Psychiatric Controversies in Epilepsy Review & Ratings

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Psychiatric Controversies in Epilepsy Review

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This book is a brilliant addition to the growing literature on the psychiatric aspects of epilepsy. For too long neurologists have ignored this critical aspect of the illness, much to the detriment of their patients. Additionally, psychiatrists have been loathe to deal with patients with epilepsy because they have felt that epilepsy is a disorder that is totally within the bailiwick of the neurologists. Appropriately the second chapter is titled "Why do neurologists and psychiatrists not talk to each other?" I know someone who is afflicted with this disorder and have accompanied them to appointments. So many times I have heard those discouraging words of protestation come from the mouths of people held up to be great neurologists; "why, I don't know anything about this psychosis, this co-morbidity. You need to see a psychiatrist." When I hear that, I know we have once again wasted our time. This is a neurologist who only is interested in stopping seizures, not in treating the whole disease, which includes psychosis. Equally discouraging is to hear a psychiatrist say; "I am not a neurologist" as soon as we mention that seizures are involved. This book can be a great help for neurologists and psychiatrists if they would only read it. I'm not a neurologist or a psychiatrist and I read it. My frustration level really escalates when it becomes apparent from the outset that the neurologist does not even understand the difference between interictal psychosis and postictal psychosis. All of these issues and many more are addressed in this book.
Chapter one establishes that there is a 37% prevalence of mental health problems among patients with epilepsy. It seems to me that with a number like that, neurologists would like to know a little bit more about the psychiatric problems associated with epilepsy.
The title of Chapter 3 is a question with the answer implied in the question; "Are neurologists trained to recognize and treat the comorbidities of epilepsy?" It's clear from the question that the answer is NO. The chapter title should have begun with the words "Why are neurologists not trained......" Watching someone repeatedly suffer because neurologists don't care to deal with all aspects of their patient's illness is most frustrating. This chapter has lots of suggestions. My question is why is this not happening automatically? Why are the university residencies not training neurologists to deal with all aspects of epilepsy? Could it be because of the frozen-in-stone thinking of the senior neurologists and psychiatrists. It's time for a new medical model of epilepsy. More on that later. Its time for a new medical model of the psychiatric problems associated with epilepsy. The existing DSM does not work for epilepsy. Don't treat the psychosis of epilepsy with antipsychotics because it is not the same disease as schizophrenia. Symptoms can be similar at times but it's not the same.
Chapter 4 deals with the reverse problem; i.e., training psych residents to be proficient in the neuropathology of epilepsy.
Chapter 5 is an overview of mood disorders associated with epilepsy; depression, bipolar, interictal dsyphoric disorder. Its written by two of the greatest thinkers in the world about these problems. We are getting warmer.
Chapter 6 Addresses the question of whether depression associated with epilepsy is a medical disorder. Many similarities are pointed out and the conclusion is clear. Also the dogma that antidepressants can't be used because of the possibility of increasing seizures is examined briefly.
Chapter 7 looks at the potential link between anxiety and depression in epilepsy. This is another important part of the picture.
Chapter 8 looks at the difference between the psychosis of epilepsy and primary psychotic disorders. There is a difference. This may be the most important chapter in the book. It explains the different psychoses associated with epilepsy and sets forth the hypotheses that have been proposed over the years. I read this chapter a number of times. The Japanese are far ahead of US psychiatrists and neurologists in understanding this disorder. They can teach us a lot if we will only read. The diagrams on page 123 should be studied until thoroughly understood. Then the reading will know what this chapter is about.
Chapter 9 is useful in establishing that there is a difference between psychosis of epilepsy and schizophrenia. Although I don't consider the presentation to be complete it is important none-the-less. It bears mentioning at this point that there is a huge bias against this concept to the point of misreading information. An example is an Amazon review of Mesulam's seminal text on Behavioral and Cognitive Neurology by a psychiatrist. He states that "Their opinion that these conditions "might be better termed paranoid schizophrenia or schizoaffective disorder in modern psychiatric nomenclature" is consistent with clinical observation." This would seem to imply that this condition is no different than primary schizophrenia. I have read and own Mesulam's book. That is not what the authors were implying.
Chapter 10 addresses the association of ADHD with epilepsy and looks at treatment options briefly.
Chapter 11 addresses the question of whether psychogenic seizures are a manifestation of a neurological disorder. The reading is interesting and the chapter ends with a big question mark.
Chapters 12 and 13 are by one of the editors and a world leader in this field. They address the questions about whether psychiatric illnesses predispose to the development of neurological disease among other things.
Chapter 14 deals with psychological testing.
Chapter 15 is a very important chapter and asks the question about whether patients should be screened for the disorders described in this book. Hmm? An excellent argument is made that this must be done to improve the quality of care to the patients.
Chapter 16 discusses the importance of a psychiatric evaluation prior to epilepsy surgery.
Chapter 17 is one of the most important chapters and has important implications for the treatment of interictal dysphoric disorder, or the interictal psychosis. It addresses the dogma that antidepressants must be avoided in patients with epilepsy. The author even shows that antidepressants can improve seizure control in some people. I know many readers will consider that comment to be medical heresy. Yes, this book would rightly correct of some of the misinformation that is passed off as gospel truth from generation to generation of physicians on daily teaching rounds. How do we throw out the incorrect information? Does a whole generation of physicians need to retire before new concepts can be tried, all the while patients are suffering?
Chapter 18 looks at CNS stimulants and seizure threshold
Chapter 19 looks at potential positive psychotropic effects of VNS.
Chapter 20 is interesting and is a great way to end this book. It deals with psychological treatment for epilepsy. I have reviewed Adrian Richard's book which deals with similar concepts. Its good to keep an open mind but maintain a healthy level of skepticism.
If my review seemed to have a slightly angry undertone it is because that is how I feel. Most neurologists in my experience are frozen in their approach to patients with epilepsy and give little thought to the psychiatric problems. Additionally they have no thought regarding treatment. I highly recommend this book to all neurologists and psychiatrists who treat patients with epilepsy. I recommend other books as well and may review them in time.

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