The Psychiatric Perspectives of Epilepsy

Tinjauan Pustaka The Psychiatric Perspectives of Epilepsy Harsono Department of Neurology, Faculty of Medicine Gadjah Mada University/ Dr. Sardjito ...
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Tinjauan Pustaka

The Psychiatric Perspectives of Epilepsy

Harsono Department of Neurology, Faculty of Medicine Gadjah Mada University/ Dr. Sardjito Hospital Yogyakarta, Indonesia

Abstract: There are four perspectives of psychiatry in every patient with epilepsy. Those are diseases, dimensions, behaviors, and life-stories. The disease perspective assumes that the cause of a psychiatric symptom is a “broken part”; that is, biological dysfunction involving the nervous system. The dimension perspective is based on the recognition that human traits vary from individual to individual along a continuum. Behavioral presentations in epilepsy can be caused by the epilepsy itself (pre and peri-ictal: prodromal/aura/automatisms, postictal especially frontal disinhibition, focal discharges), anti-epileptic drugs, underlying brain dysfunction, personal/parental reaction or response to having epilepsy, and idiopathic. Individuals also experience problems because of what they encounter in life and the meanings they attribute to these life events. These meaningful connections form the basis of the life-story perspective. Key words: psychiatry, epilepsy, behavioral presentation, anti-epileptic drugs, brain dysfunction

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The Psychiatric Perspectives of Epilepsy

Berbagai Perspektif Psikiatrik pada Epilepsi Harsono Bagian Ilmu Penyakit Saraf, Fakultas Kedokteran Universitas Gadjah Mada / SMF Penyakit Saraf RS. Dr. Sardjito Yogyakarta Indonesia

Abstrak: Ada empat perspektif psikiatrik di setiap pasien epilepsi, yaitu penyakit, dimensi, perilaku dan riwayat hidup. Perspektif penyakit mengandung pengertian bahwa penyebab munculnya gejala psikiatrik merupakan bagian terpisah, yaitu disfungsi biologik di sistem saraf. Perspektif dimensi berdasarkan pemahaman bahwa human traits bervariasi, dari individu satu ke individu lain yang merupakan suatu kontinum. Terjadinya perubahan perilaku pada epilepsi dapat disebabkan oleh epilepsinya itu sendiri (pre- dan peri-ictal yang meliputi prodroma /aura / automatisme, postictal khususnya disinhibisi frontal, bangkitan fokal), maupun oleh faktor lain misalnya obat anti-epilepsi, penyakit otak yang mendasarinya, reaksi atau tanggapan personal/ orang tua terhadap epilepsi, dan idiopatik. Sementara itu, pasien epilepsi juga mempunyai pengalaman yang khas dalam menjalani kehidupannya yang merupakan basis terbentuknya perspektif pengalaman hidup. Kata kunci: psikiatri, epilepsi, obat anti-epilepsi, disfungsi otak

Introduction All illness has both psychological and physical dimensions. This may seem a startling claim, but on reflection it is uncontroversial. Diseases donot come to doctors, patients do–and the processes by which patients detect, describe, and ponder their symptoms are all eminently psychological. This theoretical point has practical implications. If we adopt a “bio-psycho-social” approach to illness generally, one which recognizes the biological, psychological, and social aspects of our lives, we become less likely to neglect the treatable psychological origins of many physical complaints (from globus hystericus to full blown conversion disorder) and the treatable psychological consequences (such as depression and anxiety) of much physical disease.1 Psychiatric conditions occur frequently in epilepsy and their manifestations are diverse. Evaluation and management require knowledge of disease processes relevant to epilepsy and psychiatry, as well as the role of other factors that affect the expression of psychiatric illnesses such as behaviors, temperament, cognition, and life events.2 People who have epilepsy seem particularly liable to certain major psychiatric disorder i.e., a chronic interictal psychoses that closely resembles schizophrenia; and episodic psychotic states, some of which many arise in close temporal relation with seizure activity. These disorders are conventionally referred to as the psychoses of epilepsy although some of the episodic forms would be more accu-

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rately described as acute confusional states. These conditions have for long puzzled and intrigued psychiatrists and neurologist, but in recent years this interest has quickened especially among biologically minded psychiatrists in search of a neurological model for schizophrenia.3 In the postwar year of the 20th century, the division between neurology and psychiatry seemed nearly complete. Such a separation between the “organic” biologically based disorders with florid neurological physical signs, and the “functional” mentally ill behaviorally, affectively or psychotically disturbed with minimal physical neurological abnormalities on examination would have seem extraordinary a couple of centuries earlier. For pediatric neurologists it has been the rare psychiatrist who has been a regular participant in their meetings and whose writings have proved educational and inspirational. Similarly, it is rare for neurologists to be involved in teaching child psychiatrists and few have had training in the psychosocial aspects of patient management. It is to be hoped that pediatric neurology and child and adolescent psychiatry will come even closer with a new generation of neuropsychiatrists.4 There are four perspectives or lenses concerning the psychiatric issues in epilepsy; those are diseases, dimensions, behaviors and life stories.2 The purpose of the following discussion on such perspectives is to provide a framework for evaluating patient symptoms and related phenomenology (description), determining causes of psychiatric dis-

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The Psychiatric Perspectives of Epilepsy turbance (explanation), and formulating treatment programs. Diseases Perspective The diseases perspective assumes that the cause of psychiatric symptom is a “broken part” that is, biological dysfunction involving the nervous system. In this context, the brain is also substrate for psychiatric syndromes and related disease processes appear to contribute both to epilepsy and to psychiatric conditions. Examples are major depression and panic disorder, which are more prevalent in epileptic patients than in the general population.2,5 Schizophrenia Over the past four decades a consensus has begun to take shape - namely, that certain forms of epilepsy may act as risk factors for the subsequent development of a chronic interictal psychosis, a syndrome sometimes referred to as the schizophrenia-like psychoses of epilepsy (SLPE). This psychosis does resemble schizophrenia in its phenomenological manifestations, pursues a similar course, is a responsive to antipsychotic medication, and is largely uninfluenced by concurrent seizure activity. Epilepsy and psychosis may each arise out of some form of cerebral dysfunction common to both; or psychosis may be a consequence of seizure activity. The first seems more likely. Most forms of epileptic psychosis occur more commonly in the partial epilepsies, especially complex partial seizures. Within the surgical series patients with developmental lesions may be at particular risk.3 Depression Depression in epilepsy may be linked temporally to seizures, but the most common disorder is that of interictal depression. In addition to the recognized symptoms of anhedonia (lack of enjoyment), reduced appetite, poor energy, and sleep disturbance, interictal depression or dysphoria is more likely to be associated with agitation and psychotic features or impulsive self harm than is depression in people without epilepsy; a fact worth remembering when faced with a restless or truculent patient in the clinic. Pre-ictal depression may appear hours before a seizure; if this pattern can be recognized a short acting benzodiazepine such as clobazam may be used to abort seizures. Ictal depression is rare, much less common than ictal fear or anxiety, but can be profound.6 Multiple epidemiological studies have shown that depression is the most frequent comorbid psychiatric disorder in patients with epilepsy. Prevalence rates range from 20% to 55% in patients with recurrent seizures and 6% to 8% in patients with well-controlled seizures. In addition, suicide is one of the most common causes of death in patients with epilepsy; it was found to be almost 10 times more frequent in these patients than in general population.7 In a study carried out in a groups of patients with refractory epilepsy admitted to a video-EEG monitoring unit, 50% of the patients were Maj Kedokt Indon, Volum: 58, Nomor: 4, April 2008

depressed, 19% had suicidal ideation, and only 17% were being treated with antidepressant medications. Despite the high prevalence of depression and suicide risk, depression often goes unrecognized and untreated in this patients.8 Many investigators have tried to find an association between depression and epilepsy with respect to age of onset and seizure type, frequency, and duration. Depression has been identified more frequently in patients with seizures involving limbic structures (predominantly temporal and frontal lobes) and less often in patients with generalized seizure disorders. Laterality of seizure focus also has been considered as a possible risk factor, with seizure disorders of left hemispheric origin being more likely to be associated with depression. This association has been questioned by several investigators, however. There is evidence that seizures originating in or propagating to the frontal lobes increase risk of depression. For instance, patients with left temporal focus and depression have been found to display bilateral inferior frontal hypometabolism on both positron emission tomography (PET) and single proton emission computed tomography (SPECT) studies. In fact, decreased frontal metabolism on PET and SPECT has been found in primary depression.8,9 Epilepsy and depression may share common pathogenic mechanisms mediated by abnormal serotonergic, noradrenergic, GABA-ergic and dopaminergic secretion in the central nervous system. In primary depression, decreased activity of these neurotransmitters has been identified as one of the pivotal pathogenic mechanisms and the basis for antidepressant pharmacologic treatment.8 The location of the seizure focus is also relevant to the development of affective illnesses. Some studies report a higher prevalence of mood disorders in temporal lobe epilepsy (TLE) than in other epilepsy types, supporting a specific role for temporal-limbic dysfunction in mood regulation. This finding has not been consistent, however. Hemispheric location of the seizure focus has also been an area of interest, especially in TLE. Several studies associate left-sided foci with an increased risk of depression and right-sided foci with an increased risk of mania. These findings parallel laterally findings for mood disorders after cerebrovascular events, tumors, and head injury.2 The etiology of depression in epilepsy is multifactorial, encompassing both neurobiologic and psychosocial risk factors. Among the potential neurobiologic determinants, special interest has focused on epilepsy variables, such as age at epilepsy onset, type of seizures, their frequency and severity, presence of status epilepticus, medication, and the laterality of temporal lobe spike focus. Among patients with chronic temporal lobe epilepsy, adequacy of neuropsychological functioning seems to be adversely affected by comorbid interictal depression. Although there is no greater incidence of depression in left compared with right temporal lobe epilepsy, the hypothesis is raised that neuropsycho125

The Psychiatric Perspectives of Epilepsy logical performance may be more adversely affected in patients with left temporal lobe epilepsy.10, 11The psychosocial factors include mainly social stigma, adverse life events, fear, poor self esteem, lack of mastery, low rate of marriage and high unemployment, and a history of personal and family depressive illness.10 Panic Disorder The lifetime prevalence of panic attacks in patients with epilepsy is 21%, as compared with the 1% prevalence rate in the general population. Although this increased rate of panic attacks in epilepsy implicates underlying diseases processes involving the limbic system, the disease perspective is also salient because interictal panic disorder represents a paroxysmal condition that can be misdiagnose as an epileptic seizure. Conversely, anxiety symptoms and features of panic attacks can occur during seizures, and they need to be distinguished from interictal anxiety symptoms. Accordingly, failure to distinguish panic attacks from seizure can lead to inappropriate treatment with either anti-panic medications or higher doses of anti-epileptic medications.12-14 Anxiety As with depression, anxiety can be seizure related or interictal. Fear is a common manifestation of partial seizures originating in the temporal lobe and it can sometimes be difficult to distinguish between these and panic attacks. Panic disorder consists not only of discrete panic attacks but also an anticipatory fear of them and their consequences which in itself can be disabling; this, together with the short duration and lack of situational triggers in seizures, usually provides the diagnosis, but occasionally panic attacks can coexist with epilepsy. The symptoms of generalized anxiety disorder are excessive worry and anxiety in association with the somatic symptoms of restlessness, poor concentration, sleep disturbance, fatigue, irritability, and muscle tension. As with depression, asking open ended questions about a patient’s wellbeing may elicit these symptoms or they can be sought more actively by the use of screening questionnaires. Phobic disorders are common in epilepsy and are often the result of poor seizure control leading to agoraphobia and social phobia. Anxiety is often a dominant symptom of the adjustment disorder which most patients go through when first diagnosed with epilepsy.6 Dimensions Perspective Temperament or personality and intelligence are viewed as dimensional in the sense that these characteristics in individuals are distributed along a continuum. In any individual, these characteristics are composed of assets and liabilities that, in their interactions with life circumstances, yield normal as well as abnormal emotional and behavioral responses. Where a person falls on the continuum of given temperamental or intellectual trait influences vulnerability to 126

psychiatric disturbances under stressful circumstances. Thus, a person’s vulnerabilities are merely potential until exposed by some provocation. In patients with epilepsy, inherent central nervous system (CNS) pathology and the direct effects of anti-epileptic medications and seizures or postictal states affect intellectual and, potentially, temperamental attributes. However, the psychological experience of recurrent seizures can also be a significant stressor that brings out vulnerabilities.2 Temperament The notion of an “epileptic personality” has prevailed for many years, even though most patients with epilepsy are no more vulnerable to emotional problems due to their temperament than members of the general population. Some argue that descriptions of unique personality features among epilepsy patients were based on actual seizure phenomena or the effects of cognitive impairment, institutionalization, social stigma, intensified observation, medication side effects, and unrecognized comorbid psychiatric illnesses. The exception may in some patients with seizures of temporal lobe origin whose personalities are classically described as “viscous” or “sticky”, in reference to a ponderous, overly detailed, and circumstantial mode of communication that listeners tend to find tedious. This same style is evident in extensive written communication, referred to as hypergraphia. Decreased sexual interest (and, on rare occasions, increased sexual interest or fetishism) and religiosity are also observed in some patients with TLE.1,15 Intelligence The other important psychiatric dimension, intelligence, has special significance in the treatment of patients with epilepsy. Cognitive deficits in epilepsy related to brain damage reflect a “broken part” and should be viewed as the impact of a disease process on a psychiatric dimension.2 Cognitive deficits are common in people with epilepsy, but it is difficult to identify the causes in any individual because many interrelated factors may be involved. These include a) the occurrence of seizures of various types, b) the pathophysiology underlying epilepsy, c) possible cerebral pathology, either causative or secondary to the epilepsy, d) anti-epileptic drugs (AEDs), e) social stigma and educational deprivation, f) genetic factors, g) disruption of sleep by seizures and by discharges, and h) subclinical discharges causing transitory cognitive impairment (TCI). It is often unclear which of these interrelated factors contribute to the cognitive problems of an individual. By contrast, the presence of TCI in a given patient can be reliably determined. The individual is his own control: function during discharges can be compared with that when they are absent.16 Epilepsy is the most common serious neurological disorder affecting people with intellectual disabilities (mental retardation) with prevalence ranging from 20-40%, 30 times Maj Kedokt Indon, Volum: 58, Nomor: 4, April 2008

The Psychiatric Perspectives of Epilepsy higher than the general population rate. Three-quarter of the latter become seizure free on anti-epileptic drug therapy. Epilepsy in people with intellectual disabilities is more difficult to manage, although clinical guidelines have recently been developed by a working group of the International Association for the scientific Study of Intellectual Disability.17 All established AEDs have been reported to be associated with absolute cognitive side effects (i.e., all the investigated drugs have effects when compared with no treatment). These effects are definitely large for phenobarbital and possibly larger for phenytoin than for carbamazepine or valproic acid. But even these last two drugs, generally considered to be drugs with a safe cognitive profile, have cognitive effects, mostly resulting in a mild general psychomotor slowing. The respective differences between the four investigated AEDs can be considered as small, with the exception of the cognitive effects of phenobarbital, which has positively a less favorable cognitive profile when compared with phenytoin, valproic acid, and carbamazepine.18 Behavioral Perspective Behaviors are actions defined by their consequences: they are goal-directed. For example, with the behavior of eating, the goal is ingestion of food. The details of how the food is obtained, prepared, and brought to the mouth vary widely from person to person. In the end, however, the consummatory act is fairly stereotyped. Some behaviors, such as eating, sex, and addictive drug use, are further motivated by underlying drive states that pose special challenges during treatment. There are also “non-motivated” behaviors, such as self-injury and abnormal illness behavior (hysteria). The behavioral perspective is concerned with the motivated and non-motivated behaviors that are maladaptive, such aggression, substance abuse, paraphilias, selfinjury, eating disorder, and illness-related behavior.2,19 Behavioral disorders that have been consistently seen in children with epilepsy are hyperactivity, attention disorders, social withdrawal, conduct problems, and aggression. Biological, psychosocial, demographic, and medication factors contribute to behavior disorders.19 Behavioral problems need to be considered separately form psychiatric disorder because general factors, more closely associated with disability, are stronger predictors of their occurrence.15,19 Epilepsy in children is often accompanied by behavioral disorders. In an epidemiological study, behavioral disorders are found 4.7 times higher prevalence in children with epilepsy compared with healthy children. The prevalence is also higher than in children with other chronic illnesses such as cardiac disease or diabetes.20,21 Surgery in children with pharmacoresistant focal epilepsies is not only followed by successful seizure control, but is also accompanied by an early improvement of behavioral disorders. These behavioral improvements are assumed

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to result directly from the removal of epileptic focus. They are not predictable on the basis of preoperatively available information and the site of surgery, but depend on the seizure outcome.20 Aggression Aggression is a behavioral problem that is frequently attributed (rightly or wrongly) to epilepsy. Earlier in the 20th century, criminality was associated with epilepsy, an assumption that was probably related more to existing theories of criminality. Although it was known that not all epileptics were criminals, the diagnosis of epilepsy was considered in many criminals, even in the absence of a history of seizures.2 Abnormal Illness Behavior The primary goal of abnormal illness behavior is to assume the sick role inappropriately in order to address some conflict or achieve some secondary gain, for example, attention or reduced expectations. Pseudoseizures, usually regarded as a form of conversion disorder, are a type of abnormal illness behavior that involves mimicking the behaviors of an ictal event. They tend to, but do not always, lack the usual features of epileptic seizures, such as a brief duration (30 to 90 seconds), tongue-biting or other injuries, incontinence, or postictal confusion.22 Life-Story Perspective Life-story perspective focuses not on what the patients have (disease perspective), nor on what the patients are (dimension perspective), nor on what they do (behavior perspective), but on what they encounter. The application of life-story perspective involves getting to know the patient as an individual. Sometimes the events that patients encounter in their lives lead to demoralization, a state of helplessness, hopelessness, confusion, and subjective incompetence.23 Many burdens and obstacles confront the patient with epilepsy. Stigma associated with epilepsy and the seizures themselves can interfere with social contacts. Classmates can become frightened if they witness a seizure at school. Unpredictable loss of control over bodily functions can be embarrassing, and adolescents may find it difficult to develop friendships; for example, patients may fear having a seizure while on a date. The prohibition on driving and other burdens during this stage of life (adolescence) become obvious. Such disruptions in social development can continue throughout life, with difficulties achieving intimate relationships and problems with employment. Patients miss work because of seizures, postictal symptoms, and doctor appointments. Even without prejudice in the workplace, certain careers may not be available, (e.g., airline pilot) particularly those in which seizures create a dangerous risk to the patient or others.2

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The Psychiatric Perspectives of Epilepsy Treatment The patients’ perceptions of their ability to change their own seizure behavior may be an important factor and this has not been investigated with a view to predicting success or failure of psychological treatments for epilepsy. Psychological approaches, by contrast with pharmacological and neurosurgical techniques, place particular ones on the patient to bring about change that will result in seizure reduction, rather than simply relying on external agents (drugs) or techniques (neurosurgery). It may be, for example, unwise to investigate a patient’s suitability for neurosurgical treatment of their seizures and to explore psychological interventions at the same time. Psychological interventions imply that seizures can be brought under control by change on the part of the patient. The possible use of neurosurgical interventions implies the patients would not otherwise achieve control of their seizures. Simultaneous psychological and physical investigations may reduce the motivation of the patient to make sufficient effort for psychological treatment to have a maximum of success.24 Among patients with chronic temporal lobe epilepsy, adequacy of neuropsychological functioning seems to be adversely affected by comorbid interictal depression. Although there is no greater incidence of depression in left compared with right temporal lobe epilepsy, the hypothesis is raised that neuropsychological performance may be more adversely affected in patients with left temporal lobe epilepsy. Depression in epilepsy seems to be underrecognized, or at least undertreated, and greater attention should be directed to early recognition and treatment of depression given its adverse effects on quality of life.11 Many of the principles guiding psychiatric treatment in patients with epilepsy are similar to those used for patients without epilepsy. A comprehensive treatment plan can be devised that involves all four perspectives. Treatment will probably include use of an antidepressant medication and possibly an antipsychotic medication if psychotic symptoms are present interictally. This use of medication is based on the disease perspective, and an extensive review of the pharmacologic treatment of psychiatric comorbidity in epilepsy is available. The potential role for anti-epileptic medications in the treatment, causes of psychopathology and drug-drug interactions also needs to be addressed. Complicated medication regimens are best avoided in patients who have intelligence or temperamental vulnerabilities that increase the risk of poor adherence.2 Summary There are complex interactions between psychiatric phenomena and epilepsy. Psychiatric phenomena can be associated with the seizure itself, as well as the peri-ictal and interictal phases of epilepsy. Patients with epilepsy may be contending with the stigma associated with the diagnosis. Accepting the additional diagnosis of psychiatric disorder 128

may compound the stigma. Assessment of psychopathology in epilepsy requires knowledge of the patient’s specific epilepsy syndrome and whether there are special vulnerabilities to psychiatric dysfunction related to that particular epilepsy syndrome. Treatment should be based on a comprehensive evaluation with regard to the effectiveness and avoidance of the adverse effects of medications. References 1.

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Butler C, Zeman AZJ. Neurological syndromes which can be mistaken for psychiatric conditions. J Neurol Neurosurg Psychiatry 2005;76(Suppl 1):i31-8. Schwartz JM, Marsh L. The psychiatric perspectives of epilepsy. Psychosomatics 2000;41:31-8. Toone BK. The psychoses of epilepsy. J Neurol Neurosurg Psychiatry 2000;69:1-4. Baird G, Santosh PJ. Interface between neurology and psychiatry in childhood. J Neurol Neurosurg Psychiatry 2003;74 (Suppl.1):i17-22. Smith PF, Darlington CL. Neural mechanisms of psychiatric disturbances in patients with epilepsy, in McConell HW, Snyder PJ (eds): Psychiatric Comorbidity in Epilepsy” Basic Mechanisms, Diagnosis, and Treatment. Washington DC, American Psychiatric Press 1998;pp.15-35. Jackson MJ, Turkington D. Depression and anxiety in epilepsy. J Neurol Neurosurg Psychiatry 2005;76(Suppl 1):i45-7. Balabanov A, Kanner AM. Unrecognized and untreated: preventing and treating depression in patients with epilepsy. Psychiatric Times 2004;XXI (13). URL http://www.psychiatrictimes.com/ showArticle.jhtml?articleId=175802494. Boylan LS, Flint LA, Labovitz DI, Jackson SC, Starner K, Devinsky O. Depression but not seizure frequency predicts quality of life in treatment-resistant epilepsy. Neurology 2004; 80(6):909-17. Bromfield EB, Altshuler L, Leiderman DB, Balish M, Ketter TA, Devisnky O, et al. Cerebral metabolism and depression in patients with complex partial seizures. Arch Neurol 1992;49(6):61723. Piazzini A, Canger R. Depression and anxiety in patients with epilepsy. Epilepsia 2001;42(Suppl.1):29-31. Paradiso S, Hermann BP, Blumer D, Davies K, Robinson RG. Impact of depressed mood on neuropsychological status in temporal lobe epilepsy. J Neurol Neurosurg Psychiatry 2001; 70:1805. Katerndahl DA, Realini JP. Lifetime prevalence panic states. Am J Psychiatry 1993;150:246-9. Eaton WW, Kessler RC, Winchen HU, Magee WJ. Panic and panic disorder in the United States. Am J Psychiatry 1994; 151:413-20. Genton P, Bartolomei F, Guerrini R. Panic attacks mistaken for relapse of epilepsy. Epilepsia 1995;36:48-51. Lishman WA. Organic psychiatry: the psychological consequences of cerebral disorder. Oxford UK: Blacwell Science;1998. Espie CA, Watkins J, Curtice L, Espie AE, Duncan R, Tyan JA, et al. Psychopathology in people with epilepsy and intellectual disability; an investigation of potential explanatory variables. J Neurol Neurosurg Psychiatry 2003;74:1485-92. Binnie CD. Cognitive performance, subtle seizures, and the EEG. Epilepsia 2001;42(Suppl.1):16-8. Aldenkamp AP. Effects of antiepileptic drugs on cognition. Epilepsia 2001;42(Suppl.1):46-9. McHugh PR, Slavney PR. The perspectives of psychiatry. Baltimore MD: John Hopkins University Press; 1998. Lendt M, Helmstaedter C, Kuczaty S, Schrammb J, Elgera CE. Behavioral disorders in children with epilepsy: early improve-

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The Psychiatric Perspectives of Epilepsy ment after surgery. J Neurol Neurosurg Psychiatry 2000;69:73944. 21. McDermot S, Mani S, Krishnaswami S. A population-based analysis of specific behavior problems associated with childhood seizures. J Epilepsy 1995;8:110-8. 22. Peguero E, Abou-Khalil B, Fakhoury T, Mattews G. Self-injury and incontinence in psychogenic seizures. Epilepsia 1995;36:58691.

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23. Frank JD, Frank JB. Persuasion and healing. Baltimore MD: The John Hopkins University Press; 1991. 24. Goldstein LH. Effectiveness of psychological interventions for people with poorly controlled epilepsy. J Neurol Neurosurg Psychiatry 1997;63:137-42. SS

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