Texte trouvé par l’archive de documents concernant le domaine médical, Highwire
Press de la Stanford University.
Article paru dans la revue Psychosomatics, Official Journal of the Academy of
Psychosomatic Medicine.
Psychosomatics 41:31-38, February 2000
© 2000 The Academy of Psychosomatic Medicine
Special Article
The Psychiatric Perspectives of Epilepsy
Joseph M. Schwartz, M.D., and Laura Marsh, M.D.
Received August 24, 1999; accepted September 16, 1999. From the Department of Psychiatry and
Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland. Address
reprint requests to Dr. Schwartz, Meyer 121, The Johns Hopkins Hospital, Baltimore, MD 21287-7144.
ABSTRACT
Psychiatric conditions occur frequently in epilepsy, and their manifestations are diverse.
Evaluation and management require knowledge of disease processes relevant to epilepsy
and to psychiatry, as well as the role of other factors that affect the expression of
psychiatric illnesses: behaviors, temperament, cognition, and life events. This article
describes a comprehensive approach for addressing psychiatric issues in epilepsy
patients.
Key Words: Neuropsychiatric Disorders • Epilepsy
INTRODUCTION
William Osler once said of syphilis, "I often tell my students that it is the only disease
which they require to study thoroughly. Know syphilis in all its manifestations and
reactions, and all things clinical will be added unto you."1 For psychiatry, epilepsy may
play a similar role because it could be the etiology for almost any symptom. Therefore, a
review of all the psychiatric aspects of epilepsy becomes a review of the practice of
psychiatry. Because many excellent reviews of the psychiatric aspects of epilepsy are
available,2–6 we present here a method for systematically addressing psychiatric issues in
epilepsy.
THE PERSPECTIVES OF PSYCHIATRY
APPLIED TO EPILEPSY
The method we present proposes looking at psychiatric issues in every patient with
epilepsy through four perspectives, or lenses, each with particular assumptions and
implications for treatment.7 They are the perspectives of 1) diseases; 2) dimensions; 3)
behaviors; and 4) life stories. The purpose of each perspective is to provide a framework
for evaluating patient symptoms and related phenomenology (description), determining
causes of psychiatric disturbance (explanation), and formulating treatment programs.
The disease perspective assumes that the cause of a psychiatric symptom is a "broken
part;" that is, biological dysfunction involving the nervous system. In other instances,
patients are not troubled because of the disease they have but because of what they are
doing; this is the behavior perspective. The dimension perspective is based on the
recognition that human traits vary from individual to individual along a continuum. Like
height and blood pressure for physical medicine, there are psychiatric dimensions. Two of
the most important are temperament (personality) and intelligence. Understanding where
an individual lies along these dimensions provides information about how a given patient
might be prone to developing psychopathology under various life circumstances.
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.
Because there are complex interactions between psychiatric phenomena and epilepsy,
evaluating a patient with the four perspectives in mind guards against the possibility of
neglecting some important aspect of a patient's condition. The symptom of anxiety,
common in epilepsy, can be used as an example of the application of the four
perspectives. The differential diagnosis will include presumed disease states (such as
panic disorder and major depression), dimensional personality vulnerabilities (anxious
temperament), behavioral issues (the embellishment of seizure symptoms or anxiety in
order to attract medical attention or obtain medications), and life-story formulations
(apprehension about one's future in the context of recurrent seizures).
The treatment goals for each of the four perspectives vary, although the different types of
treatments are often undertaken contemporaneously. In the disease perspective, the
treatment goal is to fix, prevent, or compensate for the broken part. For problematic
behaviors, the usual goal is to stop them. The goal for managing dimensional
vulnerabilities is to educate and guide patients so that they can avoid or better cope with
situations that make them susceptible to psychiatric dysfunction. In the life-story
perspective, therapy helps assign new meanings to life events, thereby minimizing
distress and maximizing personal efficiency.
Consideration of each of the four perspectives is needed to address psychiatric issues
fully in any patient. This approach is especially salient in epilepsy, where the obvious
brain dysfunction inherent in epilepsy increases the risk of bias in the direction of the
disease perspective and neglect of the other perspectives. This is in part because
biological abnormalities associated with epilepsy can also be related to the genesis of
psychiatric phenomena, for example, the location of the seizure focus, the presence of
gross brain damage (as in head trauma or mental retardation), and the anti-epileptic
medications themselves.8 Furthermore, neurochemical changes related to neuronal
excitation and seizure inhibition may also predispose to certain psychiatric phenomena.9
However, cognitive and temperamental traits, behaviors, environmental factors, and
psychosocial issues also contribute to psychiatric disturbance. In this review, we cite
examples of psychiatric conditions that illustrate applications of each perspective, but
remind the reader that the strength of this approach is the simultaneous application of all
four perspectives.
Epidemiology, Definitions, and Etiologies The prevalence of epilepsy is approximately
0.5%, and approximately 5%–10% of the population will have a seizure at some time in
their lives.10 The incidence of epilepsy is highest in the first year of life, remains steady
through midlife, and then peaks in elderly persons because of associations between
epilepsy and vascular disease and neurodegenerative disorders. Men are affected slightly
more than women.11 Given the myriad etiologies for epilepsy, seizures are best viewed as
a symptom needing investigation rather than a diagnosis in itself.
The various terms used to denote seizure types and epilepsy syndromes can be a source
of confusion for clinicians who are not familiar with this topic. In part, this is because
classification schemes for seizures and epilepsy syndromes have evolved over time and
continue to be debated.12 The system currently accepted was developed by the
International League Against Epilepsy (Table 1). 13 A seizure is defined as an abnormal
paroxysmal discharge of cerebral neurons sufficient to cause clinically detectable events
that are apparent either to the patient or to an observer. The diagnosis of epilepsy is
reserved for a chronic neurological syndrome involving recurrent seizures, which
excludes cases in which seizures are related to isolated febrile convulsions or systemic
derangement, such as hypoglycemia. Also, the diagnosis of epilepsy is withheld when
epileptiform abnormalities on the electroencephalogram (EEG) are not accompanied by
clinical correlates. A number of factors contribute to the development of seizures and
epilepsy syndromes, including genetic disorders, inherited syndromes, acquired
conditions (traumatic brain injury), and various other situations that affect seizure
threshold and predispose to epileptogenesis.14 However, the primary mechanisms causing
epilepsy are not completely understood.
View this table: TABLE 1. Classification of seizure types
[in this window]
[in a new window]
The various epilepsy syndromes are associated with different etiologies, prognoses,
medical and surgical treatments, and seizure types. Seizure types are usually classified as
localized to a discrete portion of the brain (the focal or partial category) or generalized.
Focal or partial seizures are often, but not always, associated with localized brain
pathology. Focal seizures can be "simple," that is, without a change in the level of
consciousness, or "complex," when there is clouding of consciousness or awareness.
Auras, often mistakenly viewed as prodromal phenomena, are in fact simple partial
seizures that may or may not transition into another seizure type. For a focal seizure, the
seizure semiology (sequence of clinical manifestations) varies as epileptiform discharges
propagate and involve different brain regions. Generalized seizures involve the entire
cortex electrographically and can be convulsive or nonconvulsive. Focal seizures can
progress into generalized seizures (secondary generalization). In primary generalized
seizures, auras are usually not present.
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. Some data associate a higher
incidence of psychiatric problems with focal epilepsy, especially of temporal lobe
origin,15 although higher prevalence rates for temporal lobe epilepsy (TLE) than for other
epilepsy syndromes confounds interpretations of such reports.
Psychiatric phenomena can be associated with the seizure itself, as well as the peri-ictal
and interictal phases of epilepsy. We will focus on the interictal period, since ictal and
peri-ictal phenomena are temporally related to the seizure discharge and, therefore, once
identified as such, are best treated by optimizing seizure control. However, the different
phases are not always readily distinguished, especially since affective auras, ictal
automatisms, postictal confusion, and mood lability can confound psychiatric assessment.
EPILEPSY AND THE DISEASE PERSPECTIVE
The diagnosis of epilepsy leads to the assumption that the brain has a "broken part,"
albeit unknown in many cases, that leads to abnormal propagation of brain electrical
activity. The brain is also the substrate for psychiatric syndromes, and related disease
processes appear to contribute both to epilepsy and to psychiatric conditions.16,17
Examples are major depression and panic disorder, which are more prevalent in epileptic
patients than in the general population.4
Major Depression Reported rates for major depression in epilepsy are typically in the
range of 30%, depending on the patient population and the diagnostic methods,18,19 with
rates up to 50%.20 Although major depression is the more common problem,4 a
retrospective chart review of patients with TLE found a 20% lifetime prevalence of
mania, vs. 4% in a non-epilepsy control group.21 These rates are consistent with an
increased prevalence of mood disorders associated with other primary central nervous
system (CNS) disorders, including brain tumors, strokes, and HIV.5,22 Although sadness
might be explained by demoralization secondary to the burdens of living with epilepsy
(life-story perspective), a role for underlying brain pathology is implicated by higher rates
of depression in epilepsy relative to comparison groups with non-CNS conditions and
comparable levels of impairment.22,23
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 TLE than in other epilepsy
types, supporting a specific role for temporal–limbic dysfunction in mood regulation.23–26
This finding has not been consistent, however.27 Hemispheric location of the seizure
focus has also been an area of interest, especially in TLE. Several studies associate leftsided foci with an increased risk of depression and right-sided foci with an increased risk
of mania.25,28–31 These findings parallel laterality findings for mood disorders after
cerebrovascular events, tumors, and head injury.32–34
Mood disorders in epilepsy cause substantial morbidity and contribute to increased
mortality. Compared with mortality rates in the general population, epilepsy patients have
a fivefold higher rate of deaths secondary to suicide.35 Attempted suicides and self-injury
are also more frequent.36 Reports on patients presenting after self-injury show an
approximately sixfold overrepresentation of epilepsy patients compared with baseline
rates for the general population.37,38
Panic Disorder The lifetime prevalence of panic attacks in patients with epilepsy is
21%,39 as compared with the 1% prevalence rate in the general population.40,41 Although
this increased rate of panic attacks in epilepsy implicates underlying disease processes
involving the limbic system,42 the disease perspective is also salient because interictal
panic disorder represents a paroxysmal condition that can be misdiagnosed as an epileptic
seizure.43 Conversely, anxiety symptoms and features of panic attacks can occur during
seizures, and they need to be distinguished from interictal anxiety symptoms.44
Accordingly, failure to distinguish panic attacks from seizures can lead to inappropriate
treatment with either anti-panic medications or higher doses of anti-epileptic medications.
The disease perspective is readily applied to several other examples of psychiatric
conditions that appear inherently associated with epilepsy-related disease processes.
These include chronic and transient schizophrenia-like syndromes,45 cognitive
dysfunction,46 and adverse psychoactive effects of anti-epileptic medications.47 Sedation,
loss of energy, confusion, cognitive deficits, and delirium all warrant consideration using
the disease perspective.
One proposed mechanism for psychopathology in epilepsy is based on the observation of
"forced normalization."48 "Forced normalization" refers to an EEG phenomenon in which
better seizure control and a reduction in interictal epileptiform abnormalities are
associated with the emergence of psychotic symptoms or other psychiatric complaints
(mania or anxiety). The interictal psychiatric symptoms are usually transient, with
remission of psychiatric dysfunction as seizures return and the EEG again shows
interictal disturbances. One possibility is that neurochemical activity associated with
seizures decreases the expression of psychiatric phenomena, whereas the neurochemical
changes associated with seizure inhibition facilitate psychiatric symptoms.9 Kindling
phenomena, although confirmed only in animals, are also proposed as relevant to
temporal–limbic dysfunction and certain psychiatric complications of epilepsy in
humans.17
EPILEPSY AND THE DIMENSIONAL
PERSPECTIVE
Among the four perspectives, temperament (or personality) and intelligence are viewed as
"dimensional" in the sense that these characteristics in individuals are distributed along a
continuum.7 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 a given
temperamental or intellectual trait influences vulnerability to psychiatric disturbances
under stressful circumstances. Thus, a person's vulnerabilities are merely potentials until
exposed by some provocation. In patients with epilepsy, inherent 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.
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.5,49,50 The exception may be 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.51
This dimensional model of personality stands in contrast to the categorical classification
system of personality disorders exemplified by the Diagnostic and Statistical Manual,52
which fails to capture gradations in a population and interactions between life events and
personality vulnerabilities. With the stress-diathesis model, also referred to as the neurotic
paradigm, Eysenck used factor analysis to determine core dimensions of personality.53 Of
39 personality traits studied, there were only two independent dimensions: introversion–
extraversion and neuroticism–stability. Introversion–extraversion refers to the usual
character of a person's emotional responses. Introverted qualities include slower
emotional responses and a tendency to contemplate actions in terms of past events and
future consequences, that is, primarily punishment-avoiding. Extraverted features include
rapid but fleeting emotional responses, a focus on the present, and a tendency to be
primarily reward-seeking. Neuroticism–stability describes the strength of emotional
responses, with high neuroticism describing strong responses or potential instability. In
the general population, the distribution of these dimensions reveals a normal distribution,
or bell curve. Thus, temperamental features of most individuals are midrange between the
extremes of each dimension. Fewer individuals are at the extremes, which confer greater
vulnerability to psychopathology, especially when the individual is confronted with
psychosocial stressors.
Epilepsy and its associated burdens can expose such temperamental vulnerabilities,
especially in patients who have personality traits at the extremes of a dimension. For
example, a high-neuroticism (unstable) extravert will have a low threshold for tolerating
medication side effects and less motivation for treatment when asymptomatic. Introverts
are more likely to comply with treatment but can be more prone to anxiety. Accordingly,
the differential diagnosis for mood symptoms such as sadness and anxiety requires
consideration of the impact of life events for patients at different places on the personality
dimensions.
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. The onset of epilepsy early in life is often
related to congenital, prenatal, or postnatal factors that are also associated with mental
retardation or a range of learning difficulties. Later-onset epilepsy related to head trauma,
tumor, stroke, degenerative processes, or CNS infections can be associated with
circumscribed cognitive deficits or a global decline in cognitive functioning (dementia).
Seizure type, laterality, age at onset, treatment response, and the presence of interictal
EEG spikes are also risk factors for comorbid intellectual deficits.46,54,55 The impact of
anti-epileptic medications on cognitive functioning is less clear, in part because of
methodological problems in studies evaluating this issue.56 Some show a negative impact
whereas others show benefit, probably through successful improvement in seizure control
and subclinical EEG abnormalities. However, even though seizure control can be
associated with better cognitive functioning overall, patients still have persistent cognitive
deficits that are multifactorial in origin (e.g., inherent brain damage, effects of surgically
resected brain tissue, or higher medication dosages). A given patient's ability to cope with
these intellectual deficits is further influenced by temperament. For example, wordfinding or memory deficits may be more distressing to an anxious person (highneuroticism introvert) than to a more easygoing individual (stable extrovert).
EPILEPSY AND THE BEHAVIORAL
PERSPECTIVE
Behaviors are actions defined by their consequences: they are goal-directed.7 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 motivated and non-motivated behaviors that are maladaptive, such as
aggression, substance abuse, paraphilias, self-injury, eating disorders, and illness-related
behavior.
Aggression Aggression is a behavioral problem that is frequently attributed (rightly or
wrongly) to epilepsy.57 Earlier in the 20th century, criminality was associated with
epilepsy,58 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.
Then, classification schemes such as "latent epilepsy" and "epileptoid constitution"
reinforced a notion that criminal behavior was related to a disease process and facilitated
the separation of criminals from law-abiding citizens, a misapplication of disease
reasoning. Although sudden and violent crimes were especially likely to be attributed to
epilepsy, later studies failed to support this association after accounting for other
psychiatric comorbidities and substance abuse.59,60 It does appear, however, that
aggression is more common in epilepsy patients with generalized brain damage,57 in
which case it can be difficult to determine the relative contributions of epilepsy, social
contexts, and the underlying brain damage to the behavior.
Some studies do show a higher risk of incarceration among epilepsy patients relative to
the general population, but it is usually for nonviolent crimes such as theft.61,62 Social
factors contributing to perinatal complications or posttraumatic epilepsy are implicated.63
However, in a series of 105 murder cases, crimes without clear motivation were
associated with a higher prevalence of EEG abnormalities and a thirtyfold increase in the
diagnosis of epilepsy.64 Because the acts could not be explained by ictal automatisms or
postictal confusion, two rare but occasional causes of criminal behavior,57 the significance
of the finding is unclear. Nonetheless, extrapolations from it must be made with caution,
lest we perpetuate stereotypes associated with epilepsy.
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.65 However, these features do not
always occur during epileptic events, especially focal seizures, and the distinction
between epileptic and nonepileptic seizures can be difficult. Furthermore, patients with
actual epilepsy can manifest pseudoseizures or embellish epileptic events,66 and
psychological stress can precipitate both epileptic and pseudoseizures.67
The occurrence of bilateral limb movements in clear consciousness is almost
pathognomonic of pseudoseizures (although frontal lobe seizures are the exception68).
Documentation of elevated serum creatine kinase and prolactin levels can also help with
the differential diagnosis. The only way to definitively exclude pseudoseizures from the
diagnosis is to demonstrate a lack of correlation with EEG findings. This often requires
24-hour video EEG monitoring and is a frequent reason for admission to epilepsy
monitoring units.2
Treatment of pseudoseizures involves helping patients to resolve their conflicts in an
adaptive fashion and in not reinforcing the pseudosymptom. Factors that initiate abnormal
illness behavior may be quite different from their sustaining factors. Habit and the need to
"save face" should not be ignored in the treatment of pseudoseizures. Major mood
disorders, suicidality, and mental subnormality may also be relevant comorbid issues.65,69
EPILEPSY AND THE LIFE-STORY
PERSPECTIVE
The life-story perspective focuses not on what patients have (disease perspective), nor on
what patients are (dimension perspective), nor on what they do (behavior perspective),
but on what they encounter. The application of the life-story perspective involves getting
to know the patient as an individual. It involves a commitment of time that is becoming
more and more difficult in this age of managed care with 7 -minute-long office visits.
Sometimes the events that patients encounter in their lives lead to demoralization, a state
of helplessness, hopelessness, confusion, and subjective incompetence.70
Demoralization is typically treated through one of the various forms of psychotherapy.
Through psychotherapy, patients learn a conceptual framework that allows them to
attribute new meanings to life-events and therefore lessen demoralization.71 In its most
straightforward form, supportive psychotherapy, the aim is to help the patient to focus on
abilities instead of burdens and obstacles, and develop new coping strategies. Support
groups and advocacy organizations can also be critical in combating demoralization.
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
prohibitions 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.
In addition to the social ramifications of epilepsy, there are burdens of taking
medications, often several times a day, and enduring their side effects or consequences of
missed doses. In general, patients must be prepared to remain on anti-epileptic
medications indefinitely. Yet, phenytoin can cause gum hypertrophy that may require
surgical correction. Valproic acid can cause hair loss, acne, and weight gain. Almost all
of the anti-epileptics can cause sedation; and these are the supposedly tolerable side
effects. There are also risks of drug-induced hepatitis and blood dyscrasias from many of
the medications, necessitating frequent blood tests.
We list these examples, not to be pessimistic—quite the contrary. We list them to
encourage clinicians to spend the time to get to know their patients, understand their
burdens, and help them cope with them. It is a mistake to start someone who is sad on an
antidepressant unless there has been a thorough evaluation with consideration of the
possibility of a perspective other than disease.
TREATMENT
Many of the principles guiding psychiatric treatment in patients with epilepsy are similar
to those used for patients without epilepsy. With the methods described here, a
comprehensive treatment plan can be devised that involves all four perspectives. As an
example, we will consider the treatment of sadness in a patient with epilepsy and major
depression.
Treatment will probably include use of an antidepressant medication and possibly an
antipsychotic medication if psychotic symptoms are present interictally. This use of
medications is based on the disease perspective, and an extensive review of the
pharmacologic treatment of psychiatric comorbidity in epilepsy is available.72 The
potential role for anti-epileptic medications in the treatment and causes of
psychopathology47 and drug–drug interactions also needs to be addressed. Illness
behavior may increase during exacerbations of depression, and risk of suicidal behavior
needs to be considered. Tricyclic medications and large supplies of medications are
typically not prescribed for patients with histories of self-injury, especially if by
overdose. When selecting psychiatric medications, we need to consider the dimensional
perspective as another factor. Complicated medication regimens are best avoided in
patients who have low intelligence or temperamental vulnerabilities that increase the risk
of poor adherence. Patients with epilepsy may be contending with the stigma associated
with that diagnosis. Accepting the additional diagnosis of a psychiatric disorder may
compound the stigma. Psychotherapeutic interventions, such as cognitive–behavioral and
supportive therapies, are often necessary to address these issues, confront demoralization,
and bolster the effectiveness of antidepressant medications.
CONCLUSIONS
The four psychiatric perspectives outlined in this article provide a method for assessing
psychiatric issues in patients with epilepsy. Although not exhaustive, the examples cited
demonstrate the utility of this approach. The advantage of this method is that it ensures
that critical aspects of a case are not overlooked and that the reasoning of one perspective
is not misapplied to a problem that is best viewed through the lens of another.
ACKNOWLEDGMENTS
This work was supported by National Institutes of Health Grant MH53485 to Dr. Marsh.
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