Evaluating consciousness and awareness during focal seizures: responsiveness testing versus recall testing

Objective: The current International League Against Epilepsy (ILAE) guidelines classify focal seizures based on awareness, defined as successful postictal recall of ictal experiences, and exclude the use of responsiveness during seizures for classification. One reason for this exclusion is that responsiveness was thought to not be commonly tested during seizures. Our goal was to determine whether, in at least some settings, responsiveness testing during seizures is relatively common. Methods: We assessed how often responsiveness and recall were each evaluated in patients with focal epilepsy undergoing surface and intracranial EEG-video monitoring. We performed this evaluation by retrospectively reviewing video recordings from 121 seizures from 48 patients during their stay in the epilepsy monitoring unit between September 2012 and November 2019. Results: We found that responsiveness during seizures was tested more frequently than recall of ictal events after seizures. Of 121 seizures in 48 patients, responsiveness was tested in 101 seizures, whereas recall was tested in only 38. Significance: Evaluating if consciousness is impaired during seizures is of critical importance for guiding recommendations for people with epilepsy, such as whether it is safe for them to drive or operate machinery. The ILAE classification guidelines are intended to be broadly useful, but our findings demonstrate that at least in one important clinical setting, responsiveness was used more commonly than recall to evaluate patients during focal seizures. Although our preliminary findings should be replicated in a larger sample and in other patient groups, they suggest that responsiveness testing during focal seizures might be relatively common in at least some clinical practice settings. With further study, this may lead to a re-evaluation of criteria for classifying focal seizures to include both responsiveness and recall of experiences during seizures, as both may provide important information to guide clinical care.

Acute Symptomatic Seizures and Provoked Seizures: to Treat or Not to Treat?

PURPOSE OF REVIEW: Acute symptomatic and provoked seizures by definition occur in close proximity to an event and are considered to be situational. The treatment implications and likelihood of recurrence of acute symptomatic and provoked seizures differ from unprovoked seizures. In this article, the authors review the literature on acute symptomatic and provoked seizures with regard to therapeutic approach and risk of recurrence. RECENT FINDINGS: In the acute period, patients who suffer from acute symptomatic and provoked seizures have higher rates of morbidity and mortality. Patients with acute symptomatic seizures in the setting of certain conditions including subdural hemorrhage, traumatic penetrating injuries, cortical strokes, neurocysticercosis, venous sinus thrombosis, and viral encephalitis have a higher rate of seizure recurrence although the rate of recurrence of seizures is less than that of patients with unprovoked seizures. In patients with acute symptomatic and provoked seizures, short-term treatment with anti-seizure medications is appropriate given the higher morbidity and mortality in the acute phase of illness. In patients with acute symptomatic seizures with persistent epileptiform activity on EEG and structural changes on imaging, longer-term treatment (i.e., a few months as opposed to 1 week) with anti-seizure medications can be considered due to high risk of seizure recurrence. If a patient subsequently has an unprovoked seizure, there is yet a higher risk of recurrence of seizures and likelihood of the development of epilepsy. In these patients, long-term seizure treatment can be considered, keeping in mind that although anti-seizure treatment may reduce risk of seizure recurrence in the short-term, it does not appear to influence long-term seizure remission rates.

Emotional bias in unaffected siblings of patients with bipolar I disorder.

BACKGROUND: Bipolar disorder (BPD) research has identified a number of neurocognitive deficits as potential vulnerability markers; however, very few studies have focused on patterns of performance on affective processing tasks (e.g. affective Go/No-Go tasks) which may be more closely tied to the pathophysiology of the illness. We previously reported that stable BPD patients demonstrate a response bias toward negative affective stimuli as compared with healthy controls and schizophrenia patients. The goal of the current study was to expand upon these prior findings to investigate these patterns in the unaffected siblings of BPD patients. METHODS: An affective Go/No-Go test was used to evaluate inhibitory response to negatively-valenced, positively-valenced, and neutral stimuli in 20 unaffected siblings of bipolar I patients versus 20 healthy controls. Accuracy (d') and response bias (beta) served as dependent variables in a series of repeated measures ANCOVAs. RESULTS: We found a non-significant main effect for group when comparing accuracy performance (d') on the affective Go/No-Go of unaffected siblings versus healthy controls. However, very similar to the pattern that we previously reported in stable BPD patients, unaffected siblings showed a response bias (beta) toward negatively-valenced stimuli versus healthy controls [F=3.81; p=0.03]. LIMITATIONS: Small sample size. CONCLUSIONS: The current results extend our recent work which suggested that stable bipolar patients attend more readily to negative target stimuli than do schizophrenic or healthy subjects. These data, indicating that unaffected siblings also demonstrate an affective processing bias, implicate this task as a potential endophenotype in BPD.

The role of general intelligence as an intermediate phenotype for neuropsychiatric disorders.

INTRODUCTION: Neurocognitive impairment is common to several neuropsychiatric disorders. The growing use of cognitive impairment as an intermediate phenotype, or "endophenotype", in psychiatry raises the issue of whether global measures of cognition, such as IQ, or assays of more specific cognitive domains, such as working memory, will best serve to enhance power in detecting susceptibility loci in molecular genetic studies. METHODS: This paper will review the research on general intelligence in schizophrenia and bipolar disorder and evaluate its strengths and weaknesses as a candidate intermediate phenotype. RESULTS: Although global measures of cognition may not be optimal as intermediate phenotypes in bipolar disorder, certain clinical traits that overlap between schizophrenia and bipolar disorder, such as psychosis, may be predictive of poor performance on global measures, regardless of DSM-IV categorisation. CONCLUSIONS: Global measures of cognition represent good intermediate phenotypes in schizophrenia. Current research does not support the use of global measures of cognition as intermediate phenotypes for bipolar disorder. Assays of specific neurocognitive domains may have greater potential to detect genetic markers for bipolar disorder.

Attention and psychomotor functioning in bipolar depression.

The objective of this study was to assess psychomotor functioning and attention in individuals with bipolar disorder during the depressed phase of illness. Measures of attention and psychomotor functioning were administered to a sample of 24 bipolar I and II patients and a matched sample of healthy controls. Relative to the healthy controls, the bipolar sample demonstrated evidence of psychomotor slowing and revealed deficits on measures of effortful attention, yet demonstrated comparable performance on measures of automatic attention. In the bipolar sample, we detected significant correlations among measures of psychomotor functioning and some aspects of attention and a strong relationship between the severity of depression and psychomotor functioning, but no direct relationship between attention deficits and depressive symptomatology. These results suggest an attentional impairment during the depressed phase of bipolar disorder that may be specific to effortful processing, while automatic processes remain relatively intact. Associations among indices of attention deficits and psychomotor slowing may be indicative of similarities in the underlying neurobiology of these frequently co-occurring symptom domains in depressed individuals with bipolar disorder.

Predictors of trait aggression in bipolar disorder.

OBJECTIVES: Although aggressive behavior has been associated with bipolar disorder (BD), it has also been linked with developmental factors and disorders frequently found to be comorbid with BD, making it unclear whether or not it represents an underlying biological disturbance intrinsic to bipolar illness. We therefore sought to identify predictors of trait aggression in a sample of adults with BD. METHODS: Subjects were 100 bipolar I (n = 73) or II (n = 27) patients consecutively evaluated in the Bipolar Disorders Research Program of the New York Presbyterian Hospital-Payne Whitney Clinic. Diagnoses were established using the Structured Clinical Interview for the DSM-IV (SCID-I) and Cluster B sections of the SCID-II. Mood severity was rated by the Hamilton Depression Rating Scale (HDRS) and Young Mania Rating Scale (YMRS). Histories of childhood maltreatment were assessed via the Childhood Trauma Questionnaire (CTQ), while trait aggression was measured by the Brown-Goodwin Aggression Scale (BGA). RESULTS: In univariate analyses, significant relationships were observed between total BGA scores and CTQ total (r = 0.326, p = 0.001), childhood emotional abuse (r = 0.417, p < 0.001), childhood physical abuse (r = 0.231, p = 0.024), childhood emotional neglect (r = 0.293, p = 0.004), post-traumatic stress disorder (t = -2.843, p = 0.005), substance abuse/dependence (t = -2.914, p = 0.004), antisocial personality disorder (t = -2.722, p = 0.008) and borderline personality disorder (t = -5.680, p < 0.001) as well as current HDRS (r = 0.397, p < 0.001) and YMRS scores (r = 0.371, p < 0.001). Stepwise multiple regression revealed that trait aggression was significantly associated with: (i) diagnoses of comorbid borderline personality disorder (p < 0.001); (ii) depressive symptoms (p = 0.001); and (iii) manic symptoms (p < 0.001). CONCLUSIONS: Comorbid borderline personality disorder and current manic and depressive symptoms each significantly predicted trait aggression in BD, while controlling for confounding factors. The findings have implications for nosologic distinctions between bipolar and borderline personality disorders, and the developmental pathogenesis of comorbid personality disorders as predisposing to aggression in patients with BD.