psychiatric morbidity after surgeryfor epilepsy: short term ...in the danish epilepsy surgery...

Journal ofNeurology, Neurosurgery, and Psychiatry 1994;57:1375-1381

Psychiatric morbidity after surgery for epilepsy:short term follow up of patients undergoingamygdalohippocampectomy

Anne Stub Naylor, Bjarke a Rogvi-Hansen, Lars Kessing, Christian Kruse-Larsen

AbstractThe aim was to assess the occurrence andtype of psychiatric disorders of patientswith medically intractable epilepsy inrelation to surgical treatment, with spe-cial reference to amygdalohippocampec-tomy (AHE). The design was aretrospective psychiatric interview study,including Present State Examination(PSE) and diagnostic classificationaccording to the InternationalClassification of Diseases-8th revision(ICD-8) and ICD-10.Forty seven (94% of total) patients

operated on between 1987 and mid-1991in the Danish epilepsy surgery pro-gramme were studied. The main group ofinterest included 37 patients treated byAHE. The presence of psychiatric disor-ders before and after operation wasassessed by PSE (including the Categoclassification) and by ordinary clinicalprocedures, making use of all availableinformation (hospital case notes andpresurgical psychiatric assessments inde-pendent ofthe study).Four patients in the AHE group devel-

oped depressive disorders of variousdurations and severity after operation (inthree (8%) patients these occurred denovo). One other patient with AHE with apresumed personality disorder whounderwent AHE developed a severedepression, as did one patient after alesionectomy. No patients developed newparanoid hallucinatory psychoses. Noassociation was found between presenceof psychiatric disorders and neither rightsided cerebral dominance nor histo-pathological findings.

In conclusion, the postoperative psy-chiatric morbidity in this sample ofpatients treated with AHE is of the samemagnitude as described in recent seriesof patients undergoing temporal loberesection for medically intractableepilepsy. Likewise, affective disorders(depressive conditions) constitute themost prominent psychiatric problemafter surgery for epilepsy.

( Neurol Neurosurg Psychiatry 1994;57: 1375-138 1)

Large scale surgical treatment of patients withmedically intractable epilepsy has been per-formed over the past 50 years. Resection ofthe anterior part of the temporal lobe is-together with "tailored" resection-the pre-

dominant operation in the treatment ofpatients with a temporal lobe focus, but insome centres amygdalohippocampectomy(AHE) is performed as a first choice opera-tion. Both procedures are known to carry ahigh success rate in terms of freedom fromseizures,' 2but it has been argued that AHEleads to fewer side effects, notably less neuro-psychological and psychiatric complications,due to removal of less tissue.3 At present,however, only limited studies have dealt withthese aspects of AHE.45The main purpose of the study is to

describe short term changes in psychiatricstate in patients treated surgically forintractable (partial) epilepsy. Special attentionis paid to AHE.

This is a follow up study with all the limita-tions inherent in such a design. Because of thesparse previous documentation of psychiatricaspects ofAHE, however, we consider it to beworthwhile to convey our findings.

Subjects and methodsCLINICAL INVESTIGATIONSSince 1987 activity in surgery for epilepsy inDenmark has been centred around theEpilepsy Surgery Group, based on HvidovreHospital and the Epilepsy Hospital inDianalund with affiliations to a number ofspecialised units in the Copenhagen area.Up to mid-1991 69 adults (patients 18 or

older at the time of follow up) who had med-ically intractable epilepsy with partial seizureswith or without secondary generalisation hadentered a stepwise evaluation that ultimatelyled to surgical treatment. Localisation of focuswas determined by a standard evaluation withinterictal and ictal video monitored scalpEEG, SPECT, CT and MR, Wada test, rou-tine psychiatric evaluation, and neuropsycho-logical testing.

SUBJECTSAll 69 patients were invited to participate in apostoperative evaluation with a one year mini-mum follow up period. In 50 patients theevaluation led to operation, and 19 patientswere dismissed from the programme for vari-ous reasons (for example, the presence ofbilateral foci, divergent findings concerninghemispheric localisation of focus, psychiatricdisturbances incompatible with surgicaltreatment, or simply because of the patients'own resistance towards the treatment). Fortyseven (94%) operated and nine (47%)non-operated patients agreed to participate.

Department ofPsychiatry,Rigshospitalet,CopenhagenA S NaylorL KessingDepartment ofNeurology, HvidovreHospital, CopenhagenB a Rogvi-HansenDepartment ofNeurosurgery,Glostrup Hospital,CopenhagenC Kruse-LarsenCorrespondence to:Dr Anne Stub Naylor,Department of Psychiatry,Rigshospitalet, Blegdamsvej9, DK-2100 Copenhagen 0,Denmark.Received 28 October 1993and in revised form8 March 1994.Accepted 16 June 1994

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Naylor, Rogvi-Hansen, Kessing, Kruse-Larsen

Among operated patients one refused to par-

ticipate and two patients could not be reachedfor geographical reasons (they lived on theFaroe Islands and Greenland). The group ofnon-operated patients was small, less than50% were willing to participate, and severalwere excluded from operation for psychiatricreasons, which made it a less suitable group

for comparison in a study of psychiatric out-come. Thus we have chosen to limit the pre-

sentation to available data on patients whohave been operated on within the frameworkof the Epilepsy Surgery Group.The study was approved by the scientific

ethical committee for the Copenhagen andFrederiksberg Districts. Written informedconsent was obtained from all participants.

OPERATIONThe standard surgical procedure was selectiveAHE via entrance through the hippocampaluncus. This was performed as the only opera-

tion in 37 patients, in whom no focal lesionswere found during the preoperative evalua-tion. The remaining 10 patients formed a het-erogenous group: two patients, initiallytreated with AHE, underwent temporal loberesection and one patient had an additionalextratemporal resection performed. Sixpatients had a lesion on MRI (five patientshad a tumour and one had a vascular malfor-mation with a calcified haemorrhage), ofwhom three had a lesionectomy, two an ante-rior temporal lobe resection, and one an

AHE. Finally, one patient, who eight yearsearlier had had a temporal lobe resection,underwent a frontal and temporal tailoredcortical resection.

PSYCHIATRIC METHODS

The clinical part of the study consisted of a

clinical and a psychiatric interview using thePresent State Examination (PSE), version 9,6carried out by one of two authors (ASN or

LK) who were both trained in the use of PSE.Information about former psychiatric disor-ders were acquired through an interview, thepreoperative psychiatric assessment notesand-when obtainable-from hospitalrecords. The psychiatric evaluation before theoperation was done by one of several psychia-trists at the local psychiatric department andwas not standardised for the purpose of thepresent study. The aim of this evaluation was

to disclose psychiatric contraindications.

At follow up, psychiatric diagnoses or syn-

drome profiles were formulated along twolines. Psychiatric disorder or symptomatologypresent at the time of the follow up interviewwas assessed according to the rules laid downin the PSE interview and its related Categoprogram. An additional procedure of classifi-cation followed ordinary clinical practice,making use of all available information.Thereby all patients were assigned none, one,

or more psychiatric diagnoses before and afteroperation, with the criteria laid down in theInternational Classification of Diseases- 10threvision (ICD-10, chapter V).7

STATISTICAL METHODS

Non-parametric statistics were used through-out, except for an approximative t test forindependent groups for comparing estimatedtotal number of seizures. Categorical datawere treated with ordinary x2 test or Fisher'sexact test for contingency tables, and data on

interval scales were analysed with the Mann-Whitney test for two independent groups. Asignificance level ofp < 0 05 is used through-out the study.

ResultsThe data on 47 operated patients is pre-

sented, with special attention paid to the core

group of 37 patients who underwent AHE.The remaining 10 patients are referred to as

"others". The 47 patients represent 94% of a

total of 50, who were operated on within theperiod of interest (1987 to mid-1991).

EPILEPSY, DEMOGRAPHIC, AND SOCIAL

VARIABLES

Table 1 describes the basic characteristics ofthe sample. In the entire sample, 26 patients(55%) were completely free from seizures atthe time of follow up (Engel's classification ofoutcome stage 1'). Most still receivedantiepileptic medication. Of 21 patients stillhaving seizures at follow up, 11 (24%) hadhad a reduction in seizure frequency (Engelstages 2-3), and seizure frequency was

unchanged in the remaining 10 (22%; Engelstage 4).The distribution of sex, age at follow up,

duration of follow up after operation, age atonset of epilepsy, duration of epilepsy, andage at operation did not differ significantlybetween seizure free and non-seizure free

Table 1 Basic epilepsy related characteristics ofsubjects included in the studyAHE Others Total

Subjects (n) 37 10 47Men/Women (n(%)) 22/15 (59 5/40 5) 4/6 (40/60) 26/21 (55 3/44-7)Age at onset of epilepsy

(y, mean (SD)) 11-5 (10-3) 13-7 (7 2) 12-0 (9 7)Duration of epilepsy (y (SD)) 17-6 (8-2) 14-8 (8-1) 17-0 (8-2)Total estimated number of seizures

(mean (SD)) 5938 (8580) 6559 (9679) 6070 (8718)Age at (last) operation (y, mean (SD)) 29-1 (9 1) 28-5 (8 4) 29-0 (8 9)Duration of follow up

(months, mean (SD)) 23-5 (11 9) 20-2 (8 0) 22-8 (12-1)Age at follow up (y, mean (SD)) 31-3 (9 1) 30 7 (8 0) 31-2 (8 8)Surgical outcome

(seizure free/non-seizure free, n (%)) 17/20 (46/54) 9/1 (90/10) 26/21 (55-3/44 7)

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Psychiatric morbidity after surgery for epilepsy

Table 2 Civic and employment state before and after surgical treatment

AHE Others Total

Subjects (n) 37 10 47Civic state before/after operation (n (%)):

Single 17/16 (46-0/43 2) 4/4 (40 0/40-0) 21/20 (44 7/42 5)Married/cohabiting 17/14 (46-0/37 8) 5/4 (50 0/40-0) 22/18 (48 8/38 3)Divorced 3/7 (8-0/19-0) 1/2 (10 0/20-0) 4/9 (8-5/19-2)

Employment state before/afteroperation (n (%))

Full time paid or in education 22/22 (59 4/59-4) 7/7 (70-0/70-0) 29/29 (61-7/61-7)Unemployed, sick leave, or pension 15/15 (40 6/40 6) 3/3 (30 0/30 0) 18/18 (38 3/38 3)

patients in the AHE group. Estimated totalnumber of seizures (seizure frequency beforeoperation multiplied by duration of illness)was lower in the seizure free group (mean3134 (SD 2575)) compared with the non-seizure free group (mean 8321 (10 995)), butthis difference was not statistically significant(t test for independent groups p = 0-055).Minor changes in civic and employment

state took place after operation (table 2). Inthe AHE group, four patients becamedivorced (two seizure free and two non-seizure free), as did one patient in the groupof "others". The proportion of full timeemployed subjects remained unchanged afteroperation. As well as four patients whoreceived a disablement pension before opera-

Table 3 PSE subscores

Amygdalohippocampectomy

Seizure free Non-seizure free Others

Subjects (n) 17 20 10Delusional and hallucinatory syndromes 0 0 (0 09) 0-4 (1-2) 0 0 (0 0)

(mean (SD)) (NS)*Behaviour, speech, and other syndromes 0-6 (1-5) 1-5 (2 6) 0-2 (0-4)

(mean (SD)) (NS)*Specific neurotic syndromes 1-4 (3 8) 2-7 (3-1) 0-8 (1-4)

(mean (SD)) (NS)*Non-specific neurotic syndromes 3-5 (6-6) 6-2 (5-6) 2-2 (2-6)

(mean (SD)) (NS)*Total score 5-5 (11-4) 10-8 (9 7) 3-2 (4 2)

(mean (SD)) (p < 0 05)*

* Mann-Whitney test, seizure free v non-seizure free groups.

Table 4 Catego diagnosis atfollow up

Amygdalohippocampectomy


Subjects (n) 17 20 10295-3 Paranoid schizophrenia 2296-2 or 300 4Psychotic or neurotic depression 1 4300 4 Neurotic depression 1300-2 Phobic neurosis 3

Table 5 Presence ofpsychiatric disorder before and after operation

Amygdalohippocampecwmy


Subjects (n) 17 20 10Psychiatric disorder present only

before operation 2 0 2Psychiatric disorder present only

after operation 1 2 1Psychiatric disorder present

before and after operation 2 9* 0No evidence of psychiatric disorder 12 9 7

* p < 0 05, non-seizure free group v seizure free group(Fisher's exact test).

tion, three other patients were applying for orhad been granted a pension at the time of fol-low up.

PSYCHIATRIC DIAGNOSTIC FORMULATIONSPresent State Examination and Catego classifica-tionsAs well as the Catego diagnoses from ICD-8,we have chosen also to report the subscoresderived from the PSE interview and Categoclassification.The PSE subscores are derived by adding

the scores of a number of related PSEsyndromes. Thus five different scores areobtained: delusional and hallucinatory syn-dromes, behaviour, speech and other syn-dromes, specific neurotic syndromes,non-specific neurotic syndromes, and thetotal PSE score. From table 3 it is seen thatonly the total score differed significantlybetween groups of seizure free and non-seizure free patients who underwent AHE, thepatients who had AHE obtaining the highestscores. Included in the specific neurotic syn-dromes subscore are the PSE symptoms:depressed mood, obsessional syndrome, gen-eral anxiety, situational anxiety, hysteria, andspecial features of depression. The non-specific neurotic syndromes subscore com-prises depersonalisation, ideas of reference,tension, lack of energy, worrying, irritability,social unease, loss of interest and concentra-tion, hypochondriasis, and somatic symptomsof depression.

Eleven patients reached the PSE-9 thresh-old level of an Index of Definition of 5 orabove, which is the minimum required by theCatego program if it is to suggest a possiblediagnosis. Level 1 is defined by the absence ofPSE symptoms, levels 2 and 3 by a low totalscore and presence of only non-specific neu-rotic symptoms, and ratings at level 4 do notcontain enough information to provide a diag-nosis. One seizure free (2 7%), nine non-seizure free (24%) AHE patients, and one"others" group (10%) reached the thresholdlevel of an index of definition >5. Table 4shows the distribution of Catego diagnoses.Depressive and neurotic disorders dominatedat the time of follow up.

CLINICAL PSYCHIATRIC DIAGNOSIS (ICD- IO)When all available information was used, psy-chiatric disorder was judged to have been pre-sent at some time in 19 patients (table 5).Thus in the AHE group two patients had had apsychiatric disorder at some time only before

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operation. In three patients, who wereassigned a diagnosis postoperatively, no evi-dence for previous psychiatric morbiditycould be found. A total of 1 1 patients hadpsychiatric problems before as well as after thetreatment, whereas the remaining 21 patientsapparently enjoyed good mental health bothbefore and after operation. In the group of"others" three patients had or had had a psy-chiatric problem at some point.

In the AHE group a higher proportion ofnon-seizure free patients were found to haveone or more psychiatric disorders before andafter operation, but the difference was statisti-cally significant only after operation (Fisher'sexact test, p < 0.05).The disorders in question covered a broad

spectrum of psychiatric disorders-fromacute psychotic disorder (F23), mood disor-ders of various degrees of severity (F30-39),

Table 6 Psychiatric findings in patients operated on

Age at Operation Cerebral Psychiatic disorder Psychiatric disorderPatient Sex operation performed dominance Histopathology Outcome before operation after operation

M 35 Left AHE

F 32 Right AHE

Left (H)

Left (W)

Reactive Non-sf (2)

Reactive Non-sf (4)

F07-0 Organicpersonality disorderF32-0 Mild depressivedisorder

3 M 21 Right AHE Left (W) Reactive Non-sf (4) F60-2 Dissociatedpersonality disorderF10 2 Alcoholdependence syndrome

4 F 57 Left AHE Left (H) Reactive Non-sf (4) F06-8 Epilepticpsychosis unspecifiedF02-8 Dementia

5 F 20 Right AHE Left (W) Reactive Non-sf (2) F06-2 Organicdelusional disorder obs

6 M 34 Right AHE Left (W) Gliosis sf (1) F60-9 Personalitydisorder unspecified

7 M 27 Left AHE Left (H) Reactive Non-sf (3) F06-2 Organicdelusional disorderF05-0 Delirium, notsuperimposed on dementia

8 M 26 Left AHE Left (W) Reactive sf (1) F07-0 Organicpersonality disorder

9 F 17 Right AHE Left (W) Reactive Non-sf (4) F60-9 Personalitydisorder unspecified

10 F 34 Left AHE Right (W) Gliosis Non-sf (2) F60-1 Schizoidpersonality disorderF60-5 Anankasticpersonality disorderF50- 1 Atypical anorexianervosa

11 F 27 Right AHE Left (W) Gliosis Non-sf (2) F71-0 Moderate mentalretardation

(B):12 M 33 Left AHE Left (W) Reactive sf (1)

13 M 26 Right AHE Left (W) Reactive sf (1)

F34 1 DysthmiaF60-7 Dependentpersonality disorderF60 2 Dissociatedpersonality disordertentativeF10-2 Alcohol dependencesyndrome tentativeF12 2 Cannabis dependencesyndrome tentative

F07-0 Organicpersonality disorderF06-0 Organic hallucinosisF41 -1 Generalised anxietydisorder orF06-4 Organic anxietydisorderF60-2 Dissociatedpersonality disorderF10-2 Alcoholdependence syndromeF55-2 Abuse of analgesicsF06-8 Epilepticpsychosis unspecified

F06-2 Organicdelusional disorder obsF32-2 Severe depressiveepisode without psychoticsymptomsF41 -1 Generalisedanxiety disorderF06-2 Organicdelusional disorderF32- 1 Moderate depressiveepisodeF07-0 Organicpersonality disorderF60-9 Personalitydisorder unspecifiedF60-1 Schizoidpersonality disorderF60-5 Anankasticpersonality disorderF50- 1 Atypical anorexianervosaF71-0 Moderate mentalretardation

None

None

33 Right AHE Left (W) Reactive sf (1) None

39 Left AHE Left (H) Reactive Non-sf (4) None

16 M 28 Right AHE Left (W) Gliosis

34 Left sidedlesionectomy

46 Right sidedlesionectomy

19 F 32 Right AHEand TLR

Left (W)

Left (H)

Left (W)

Non-sf (4) None

Tumour sf (1)(oligodendroglioma)Calcified sf (1)vascularmalformation

sf (1)

F33-9 Recurrentdepressive disorderNone

F23-9 Acute and transientpsychotic disorder

F34-9 Persistent mooddisorder, unspecifiedF07-0 Organicpersonality disorderF06-4 Organicdepressive disorderF34-1 Dysthymia

None

F32-2 Severe depressiveepisode

None

(A)1

2

(C):14 M

15 M

(D):17 F

18 M

Patients were judged to have had a psychiatric disorder at some time. TLR = temporal lobe resection; sf = seizure free; non-sf = non-seizure free; Engel's classifica-tion in parentheses. Cerebral dominance was determined by Wada test (W) or according to handedness (H). (A) = AHE patients with no or minor changes in psy-chiatric findings; (B) = AHE patients with a history of psychiatric disorders in whom none were found at follow up. (C) AHE patients without a history ofpsychiatric disorders who developed such a disorder after surgery. (D) Patients in the group "others" with a psychiatric disorder at some point.

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personality disorders (F60), organic halluci-natory or delusional disorder (F06) andorganic personality disorder (F07), to demen-tia (F02-03); table 6 shows the changes indiagnosis.Thus major changes in psychiatric diagno-

sis took place in eight patients after operation,five in the AHE group. In two patients no evi-dence of a previously described psychiatricdisorder was found at follow up (table 6(B)).Three patients without psychiatric problemsbefore operation developed a mood disorder,which in one patient was secondary to a

severe personality change (table 6(C)). Onepatient, who had previously sought treatmentfor a mild depressive disorder, had an organichallucinosis and a generalised anxiety disorderat follow up, and another patient, who proba-bly had a personality disorder before opera-tion, developed a severe depressive disorder(table 6(A)). In the group of "others" (table6(D)) one patient had previously had recur-

rent depressions and another an acute andtransient psychotic disorder, but neither ofthem displayed any psychiatric disorders atfollow up. One patient, however, developed a

severe depression immediately after the opera-tion.Of the five patients who developed mood

disorders of various severities and duration,four patients were operated on on the rightside (in three patients AHE and in one patienta lesionectomy with removal of a calcified vas-

cular malformation); one patient underwent a

left sided AHE.

CEREBRAL DOMINANCE, HISTOPATHOLOGY,AND PSYCHIATRIC FINDINGSTo determine cerebral dominance, a one

sided amytal test (Wada test) was performedin 31 patients. In four patients the result ofthe test was inconclusive. In the remainingpatients cerebral dominance was determinedby handedness. In one patient no informationwas available. Thus the left hemisphere was

found to be the dominant hemisphere in 37patients and the right hemisphere was domi-nant in five patients (table 7). Of the 19patients who had a psychiatric disorder before

Table 7 Psychiatric findings and cerebral dominance

Cerebral dominance

Right sided Left sided Inconclusive or no information

Psychiatric disorder ever 1 18*Psychiatric disorder never 4t 19t 5

p < 0 35, Fisher's exact test.An amytal test was performed on 32 patients. In the other cases determination of cerebral domi-nance was based on handedness only: *Five cases; ttwo cases; teight cases.

Table 8 Psychiatric findings and histopathology

Histopathology

Reactive changes Gliosis Alien tissue

Psychiatric disorder ever 15 2 2abPsychiatric disorder never 14 7 4ce

a = Oligodendroglia; b = calcified vascular malformation; c = astrocytoma grade 2; d = astrocy-toma (juvenile type); e = astrocytoma. There was no significant difference in presence of alientissue between psychiatric disorder ever and psychiatric disorder never groups.

or after operation, only one patient had a rightsided cerebral dominance (table 6(A), patient10).The histopathology of removed tissue was

described as gliosis in nine cases, reactivechanges in 29, and alien tissue in six (table 8).In one case no abnormalities were found, andin the remaining two cases no information wasavailable. Alien tissue was found in two of 19psychiatric cases (table 6(D), patients 17 and18), and the histopathological findings in theremaining 17 cases were reactive changes in15 and gliosis in two.

DiscussionThe purpose of this study was to describeshort term changes in psychiatric state inpatients treated by AHE because of medicallyintractable seizures. The study has somemethodological drawbacks, the most impor-tant being the uncertain reliability of presurgi-cal psychiatric conditions and diagnosis.

It can be argued that the duration of thefollow up period was too short to identify allpossible changes in psychiatric state. It hasbeen suggested, however, that most psychi-atric disorders appear within the first year ortwo after operation.8The choice of PSE-9 as the only diagnostic

instrument can be questioned, so we decidedto implement a second line of diagnosis, withordinary clinical procedures and making useof all available information. When PSE isstrictly followed, major areas of psychopathol-ogy are not considered, most notably aspectsof personality, and problems also arise whendealing with previous or long lasting psychi-atric disorders. In these cases, PSE classifica-tion and diagnoses will not necessarilycoincide with the appropriate clinical diag-noses because much relevant clinical informa-tion will be left out. Finally, the Categoprogram generates diagnoses only in ICD-8terms. On the other hand, the PSE interviewand the Catego program have the advantagesof being structured and standardised instru-ments, which, as well as the diagnostic formu-lation, offer psychopathology profiles onvarious levels.Most of the medical literature concerning

psychiatric aspects of surgery for epilepsystems from a time when the presence of psy-chiatric problems among candidates for surgi-cal treatment seemed to be the rule ratherthan the exception.9-"2 Thus in earlier studiesit is not uncommon to find that two thirds ormore of the patients with temporal lobe resec-tion disclosed one or more psychiatric disor-ders before operation. Bearing in mind thatpatients were often referred for surgery forepilepsy from psychiatric institutions, this isnot surprising. Changes and variations inmethodology and diagnostic classificationmake comparisons between studies difficult,but several attempts have been made to deter-mine the prevalence of various psychopatho-logical findings in series of patientsundergoing temporal lobe resection. Thus in arecent review of the medical literature an

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attempt was made to average across studies.'3Disturbances of general psychiatric and psy-chological adjustment are said to be present in67% of patients in whom improvement occursin two thirds after operation. More specificpsychiatric disorders are described in terms ofpsychoses in about 15% of patients bothbefore and after operation, depression, anxi-ety, or suicidal tendencies in 20% beforeoperation, aggression in 37% with improve-ment in about half, sexual dysfunction in 50%with improvement in 60%, and major difficul-ties in work adjustment in most patients, withpostoperative improvement in 60%. Only afew of the quoted studies (about 10%) havebeen published within the past decade.The level of psychiatric morbidity found

before and after operation in the present studyis of the same magnitude as described in othermore recent follow up studies of patientstreated with temporal lobe resection. Thusthree of 37 AHE patients developed a psychi-atric disorder for the first time after operation(8%).14 16

The psychiatric morbidity reported in thisand other newer series of psychosocial out-come after temporal lobe resection is muchlower both before and after operation thandescribed in earlier studies. This discrepancyis likely to reflect differing criteria for selectionof candidates for operation, and that thesources of referral have moved away from psy-chiatric institutions. The role of AHE com-pared with temporal lobe resection withrespect to psychiatric findings is uncertain,but it has been presumed that removal of lesstissue could lead to fewer neuropsychologicaland psychiatric side effects. Considering theimportance of the amygdaloid-hippocampalcomplex in the regulation of emotions andaffect, however,'7 it would not be surprising ifdifferences between the two treatment modal-ities were negligible, and in a recent compara-tive study of neuropsychological aspects of thetwo procedures, no major differencesappeared.4The psychiatric morbidity is still relatively

high in this and other series, however, andwithin the past 15 years especially, the poten-tial risk of developing a postoperative psy-chosis de novo has been focused on.8 1820Thus in a previous Danish follow up study,2'more than 10% of patients developed delu-sional disorders after the operation, and an upto date figure of severe psychiatric disorderoccurring postoperatively in 7% has been sug-gested. Whereas focus has previously been onthe occurrence of paranoid-delusional psy-choses, it has become clear that the occur-rence of affective disorders may be of equal oreven greater importance,22 which again mightreflect changes in the selection of candidatesfor operation.

In the present study no patients developedparanoid-delusional psychoses within the fol-low up period. Our finding of affective disor-ders as the predominant psychiatric problemafter operation is in accordance with otherrecent studies. The relevance of right sided

operations in (four of five) patients who devel-oped a depressive disorder is uncertain.

In an earlier study the presence of alientissue (by contrast with mesial sclerosis) andleft handedness were found to be associatedwith a high level of psychiatric morbidity (par-ticularly schizophrenia-like psychosis) aftertemporal lobe resection.23 Our findings do notsupport an association between these factorsand the presence of psychopathology ingeneral. The number of cases in this series islimited, however. Furthermore, the histo-pathological examination was hampered bythe operational procedure, whereby the tissueis sucked out from the operational cavity,rather than removed en bloc.The influence of outcome in terms of free-

dom from seizures on psychiatric morbiditycannot be assessed from the present study,although more psychiatric cases were found inthe group of patients who did not becomeseizure free.

In the medical literature and among centresoffering surgical treatment for drug resistantepilepsy there is no consensus about thenecessity of psychiatric evaluation before andafter operation, or which instruments shouldbe used for assessing psychopathology.24 Inour opinion a psychiatric assessment-and ifnecessary, intervention-should be as naturala part of the assessment before and after oper-ation as, for example, neuropsychologicalevaluation, as we consider it to be an equallyimportant aspect in the total picture of psy-chosocial outcome. We chose to follow theEuropean tradition in the choice of ICD fordiagnostic classification and its related instru-ment, PSE. At the time of the study onlyPSE-9 was available, which is why the initialformulations were done with ICD-8. In futurestudies we would recommend the use of PSE-10, and a thorough assessment of personalityfeatures and disorders. Also, a prospectivedesign including presurgical evaluation shouldbe mandatory.

It has been suggested that studies of psychi-atric consequences and psychosocial outcomeideally should include all patients entering aprogramme for surgery for treatment ofepilepsy.25 In the present study we chose toexclude the non-operated patients. We didnot find this group to be suitable for compari-son because of a high prevalence of psychi-atric disorders, this being the reason forexclusion from operation in some patients.

In conclusion, the present findings ofsevere psychopathology arising in threepatients (8%) after AHE for medicallyintractable epilepsy, is in line with the findingsfrom a recent survey among centres offeringtemporal lobe surgery (mainly resection). Oneaim for future psychiatric research shouldbe-in collaboration with other disciplines-to delineate the group of patients who carrythe greatest risk of developing psychiatriccomplications (especially lasting ones) afteroperation. Thus necessary preventive pre-cautions can be taken, either by abstainingfrom carrying out the operation or providing

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sufficient postoperative social, psychological,and psychiatric care and treatment. In thatway the proportion of psychiatric cases andpsychosocial problems arising postoperativelymay gradually diminish fuirther.We thank the Ivan Nielsen's foundation for the study of spe-cific brain disorders for making the study economically possible.

1 Engel J. Outcome with respect to epileptic seizures. In:Engel J, ed. Surgical treatment of the epilepsies. New York:Raven Press 1987:553-71.

2 Wieser HG. Selective amygdalohippocampectomy: indica-tions, investigative technique, and results. Adv TechStand Neurosurg 1986;13:40-133.

3 Wieser HG. Selective amygdalo-hippocampectomy fortemporal lobe epilepsy. Epilepsia 1998;29(suppl2):S100-13.

4 Goldstein LH, Polkey CE. Short term cognitive changesafter unilateral temporal lobectomy or unilateral amyg-dalohippocampectomy for the relief of temporal lobeepilepsy. JT Neurol Neurosurg Psychiatry 1993;56: 135-40.

5 Wieser HG. Behavioural consequences of temporal loberesections. In: Trimble MR, Bolwig TG, eds. The tempo-ral lobe and the limbic system. Petersfield: WrightsonBiomedical Publishing Ltd, 1992:169-88.

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