Article

Postictal Psychosis in Temporal Lobe Epilepsy

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Abstract

Postictal psychosis is a well-known complication, occurring especially in patients with temporal lobe epilepsy. It usually runs a benign course. The literature on this topic is sparse, and the underlying pathogenic mechanisms are not known. We report five patients with temporal lobe epilepsy in whom postictal psychosis developed during the course of video-EEG monitoring; they were studied with hexamethyl-propyleneamine-oxime single-photon emission computed tomography (HMPAO-SPECT) during and after the psychotic event. In comparison to the interictal state, all SPECT scans obtained during postictal psychosis were remarkable for bifrontal and bitemporal hyperperfusion patterns. Some studies also demonstrated unilateral left lateral frontal hyperperfusion. These cortical blood-flow patterns appeared to be distinct from those obtained during complex partial seizures. Our data suggest that postictal psychoses in patients with temporal lobe epilepsy are associated with hyperactivation of both temporal and frontal lobe structures. This hyperperfusion may reflect ongoing (subcortical) discharges, active inhibitory mechanisms that terminate the seizure, or simply a dysregulation of cerebral blood flow.

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... Spikes and slow waves in EEG generally increase during PIP episodes [1]. Most single-photon emission computed tomography (SPECT) studies report hyperperfusion of the frontal and temporal lobes during PIP [5][6][7][8][9], and hyperperfusion of the left temporal lobe during IIP has also been reported [10]. ...
... The relation between bilateral EEG abnormalities and development of psychosis has been indicated in previous studies [1,12,15,16]. Generally, increased epileptiform discharges and slow waves on EEG are present during PIP [1], although some studies have reported that EEG is unchanged or normalized during PIP [5,6,17,18]. Scalp EEG is commonly unchanged or normalized during IIP [4]. Our case showed increased bilateral interictal discharges, especially on the left side, not only during the postictal psychotic state but also during the alternative psychotic state. ...
... Therefore, it is possible that lamotrigine inhibited epileptic activity. Most SPECT studies have reported increased perfusion in the frontal and/or temporal lobe during PIP [5][6][7][8][9]. Oshima et al. reported that perfusion was especially increased in the right temporal lobe during PIP [8], and Jibiki et al. reported that perfusion was increased in the left temporal lobe during IIP [10]. ...
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We report a patient with epilepsy who experienced interictal and postictal psychoses. Her psychiatric symptoms consisted of grandiose and fantastic delusions during both psychotic states. During remission, electroencephalography showed bitemporal epileptiform discharges that were predominant in the right temporal region. Epileptiform discharges present during the psychotic states were predominant in the left temporal region. Single-photon emission computed tomography showed hyperperfusion in the left basal ganglia during the interictal psychotic state and hyperperfusion in the right temporal lobe and left basal ganglia during the postictal psychotic state. We suggest that the occurrence of postictal and interictal psychotic states in this patient were associated with a common change in electrographic activity and blood flow.
... Risk factors reported for developing psychoses in epilepsy include a higher frequency of seizures, early epilepsy onset with a longer duration of seizures, and presence of multiple lesions [2,[15][16][17]. Other risk factors reported include localization of the epileptogenic zone within the temporal lobe and left-sided focus [18][19][20], disorders of cortical development [21,22], hippocampal sclerosis [23], and factors associated with antiepileptic treatment, such as polytherapy and the use of new-generation antiepileptic drugs [5,24,25]. ...
... More recently, a higher bilateral frontotemporal anatomical compromise of the white matter detected through diffusion tensor imaging has been reported [61]. Apart from a greater structural brain compromise, independent bilateral electrical abnormalities were reported as a risk factor for the development of postsurgical psychosis among patients with TLE who had undergone surgery [17,62,63] and during presurgical assessment in patients with postictal psychosis [26][27][28]. ...
... However, it is worth mentioning that the distribution of data was quite broad and that this study had a retrospective design. Nevertheless, a longer duration of seizure exposure in critical stages of neurodevelopment has been described as a risk factor by different authors [17,23,32,35,67]. Furthermore, psychosis onset was late in life (mean: 30 ± 10 years), in agreement with a recent report that found that patients with epilepsy developed psychoses later than patients with schizophrenia [68]. ...
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The issue of psychotic disorders in epilepsy has given rise to great controversy among professionals; however, there are not many studies in this area and the physiopathological mechanisms remain unknown. The aim of this study was to describe the spectrum of psychotic disorders in an Argentine population with refractory temporal lobe epilepsy (RTLE) and to determine the risk factors associated with psychotic disorders. Clinical variables of the epileptic syndrome were compared among a selected population with RTLE with and without psychotic disorders (DSM-IV/Ictal Classification of psychoses). Logistic regression was performed. Sixty-three patients with psychotic disorders (Psychotic Group, PG) and 60 controls (Control Group, CG) were included. The most frequent psychotic disorders were brief psychotic episodes (35%) (DSM-IV) and interictal psychosis (50%) (Ictal Classification). Risk factors for psychotic disorders were bilateral hippocampal sclerosis, history of status epilepticus, and duration of epilepsy greater than 20 years.
... Therefore, most of them are diagnosed as "postictal psychosis" (PIP) [8][9][10][11]. Postictal psychosis refers to brief psychotic episodes that follow a cluster of seizures or seizure exacerbation and has been reported in the setting of presurgical evaluation, in which antiepileptic drugs are tapered to provoke seizures [9,[12][13][14]. The psychotic symptoms may resemble positive symptoms of schizophrenia, including grandiose delusions, delusions of reference, hallucinations and religious delusions, as well as affective symptoms (such as mania and depression) [9,12,13]. ...
... Postictal psychosis refers to brief psychotic episodes that follow a cluster of seizures or seizure exacerbation and has been reported in the setting of presurgical evaluation, in which antiepileptic drugs are tapered to provoke seizures [9,[12][13][14]. The psychotic symptoms may resemble positive symptoms of schizophrenia, including grandiose delusions, delusions of reference, hallucinations and religious delusions, as well as affective symptoms (such as mania and depression) [9,12,13]. ...
... As PIP occurs frequently in the framework of presurgical video-EEG monitoring, data are, nevertheless, available in the form of both continuous EEG recording as well as neuroimaging. With respect to EEG, several studies have reported frequent interictal discharges in patients with PIP, suggesting that ictal activity in the temporal lobe is directly related to this kind of psychosis [9,12,13,24]. To the best of our knowledge, analyses of the ictal nonepileptic activity as analyzed here have never been reported. ...
Article
Religious experiences have long been documented in patients with epilepsy, though their exact underlying neural mechanisms are still unclear. Here, we had the rare opportunity to record a delusional religious conversion in real time in a patient with right temporal lobe epilepsy undergoing continuous video-EEG. In this patient, a messianic revelation experience occurred several hours after a complex partial seizure of temporal origin, compatible with postictal psychosis (PIP). We analyzed the recorded resting-state EEG epochs separately for each of the conventional frequency bands. Topographical analysis of the bandpass filtered EEG epochs revealed increased activity in the low-gamma range (30–40 Hz) during religious conversion compared with activity during the patient's habitual state. The brain generator underlying this activity was localized to the left prefrontal cortex. This suggests that religious conversion in PIP is related to control mechanisms in the prefrontal lobe-related processes rather than medial temporal lobe-related processes.
... Neuroimaging studies of PIP are rare. One functional neuroimaging study using PET has shown that patients with PIP have regional hyperperfusion in the temporal lobe ipsilateral to the seizure focus [21], while others have shown hyperperfusion of bilateral frontal and temporal regions during PIP [22][23][24]. ...
... Although this dysregulation/hyperactivity is not traditionally considered to be epileptic, intracranial recordings from a small number of psychotic patients indicate that this may be the case for some patients with epilepsy [46,78], as well as perhaps for patients even without known epilepsy [44], and it should be noted that here may be a gradient between epileptic and nonepileptic activity; this may explain in part the utility of antiepileptic medications in treating both epilepsy and psychosis [79]. SPECT studies performed during periods of psychosis showing focal hyperperfusion -a finding typically associated with active seizing -also support the idea that psychosis might be associated with deep limbic epileptic activity [21][22][23][24]. Such ongoing limbic seizures, undetectable with scalp EEG recordings, would be expected to have a profound effect on emotional and other neural processing, potentially causing psychosis. ...
Article
Psychosis is a devastating, prevalent condition considered to involve dysfunction of frontal and medial temporal limbic brain regions as key nodes in distributed brain networks involved in emotional regulation. The psychoses of epilepsy represent an important, though understudied, model relevant to understanding the pathophysiology of psychosis in general. In this review, we (1) discuss the classification of epilepsy-related psychoses and relevant neuroimaging and other studies; (2) review structural and functional neuroimaging studies of schizophrenia focusing on evidence of frontal-limbic dysfunction; (3) report our laboratory's PET, fMRI, and electrophysiological findings; (4) describe a theoretical framework in which frontal hypoactivity and intermittent medial temporal hyperactivity play a critical role in the etiopathology of psychosis both associated and unassociated with epilepsy; and (5) suggest avenues for future research.
... Clinically significant grandiosity is, of course, a form of delusion, and other types of clinically significant delusions have been studied for hemispheric differences, albeit in disorders other than mania. Significant right hemisphere hypometabolism or left hemisphere hypermetabolism, at rest, has been consistently observed with functional imaging at rest in groups or subgroups presenting religious delusions [27], autobiographic delusions [28], paranoid delusions [29,30], or delusions of unspecified nature [31][32][33][34]. This asymmetry was observed whether the cohort consisted of patients with schizophrenia [26,27,31,32], patients with Alzheimer's disease [28,29,32,33], or patients with epilepsy [34]. ...
... Significant right hemisphere hypometabolism or left hemisphere hypermetabolism, at rest, has been consistently observed with functional imaging at rest in groups or subgroups presenting religious delusions [27], autobiographic delusions [28], paranoid delusions [29,30], or delusions of unspecified nature [31][32][33][34]. This asymmetry was observed whether the cohort consisted of patients with schizophrenia [26,27,31,32], patients with Alzheimer's disease [28,29,32,33], or patients with epilepsy [34]. As far as we could determine, self-depreciation has not been studied in isolation or multivariately in the neuroscience literature at all. ...
Article
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Previously published single case reports of patients with a unilateral lesion were assembled. After the lesion, each of the 244 cases presented at least one of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) symptoms of a manic episode, namely, elated or irritable mood, grandiosity, talkativeness, flight of ideas, hyperhedonism, reduced need for sleep, agitation, or distractibility (all optional in DSM-IV). As expected, the subgroup of 59 manic patients had a right hemisphere lesion far more often than a left one. However, this was also true of various sets of the nonmanic cases. Furthermore, elation was not the symptom most strongly associated with lesion side. Elation without mania was not significantly predicted by lesion side. However, talkativeness was strongly predicted by right lesion side whether in manic or nonmanic patients or even when the symptom was the only symptom observed. Agitation was consistently and robustly associated with right lesion side, but not completely distinctly so (it fell short of significance when not accompanied by elation or other symptoms). It is proposed that prevalence of right hemisphere lesions causing mania is primarily related to mental and behavioral disinhibition rather than a shift of mood and that it consists of release of left hemisphere influence.
... Post-ictal psychosis (PIP) is a recognised psychiatric complication of temporal lobe epilepsy (TLE); usually manifesting after a cluster of complex partial or generalised seizures (Logsdail and Toone, 1988). Psychotic symptoms tend to emerge following a symptom-free (lucid) period ranging from 12 to 72 h (Kanner et al., 1996) and are transient; typically lasting several days (Leutmezer et al., 2003), but may be up to weeks (Devinsky et al., 1995). ...
... Results from functional imaging studies have implicated that widespread or diffuse brain dysfunction. Case reports using SPECT during an acute episode have found increased perfusion in contralateral basal ganglia (Fong et al., 2000); bi-temporal and bi-frontal areas (Leutmezer et al., 2003); and widespread ipsilateral fronto-temporal networks (Nishida et al., 2006). Interictal bitemporal hypometabolism has also been documented in single case studies (Seeck et al., 1999;Kuba et al., 2012). ...
... While uncommon, several studies reported violence and rage in seizure patients as a post-ictal phenomenon [3,4]. It has been described as a subacute presentation hours-to-days after seizures with patients developing aggressive behavior during post-ictal psychosis [3]. ...
... These behaviors are generally out of character for the patient, most often occur in males and typically occur after a cluster of seizures [6]. Reported risk factors for these postictal psychoses include bilateral interictal epileptiform discharges, similar to our patient, as well as other factors such as: an aura of ictal fear, a longstanding history of epilepsy prior, and brain structural lesions [4]. Post-ictal state violence is usually non-directed, and resistive violence, such as in our patient [3]. ...
Article
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We report a case of a 52-year-old man with drug-resistant temporal lobe epilepsy, with post-ictal violent aggressive behaviors. Postictal violent outbursts would occur 3-4 times per year following clusters of seizures or generalized tonic-clonic convulsions. The violent outbursts were traumatizing for his family, and lead to multiple emergency department presentations as well as conflicts with police over the course of nine years. After initiation of pindolol the patient has had no episodes of violent behavior in two years despite experiencing the same frequency and severity of seizures as before pindolol. The abrupt cessation of postictal violent outbursts after introduction of pindolol in this case provides a novel management option for the treatment of postictal violence in patients with drug-resistant epilepsy and supports the importance of the beta adrenergic and potentially serotonergic systems in postictal violent behavior.
... Ring et al. beobachteten bei der Untersuchung von TLE-Kranken, dass die depressiven Patienten doppelte Anfallsfrequenz im Vergleich zu den nicht-depressiven aufwiesen [Ring et al. 1999]. Im Gegensatz zu diesen Befunden wurde in zahlreichen früheren Studien keine Korrelation zwischen der Anfallsfrequenz [Attarian et al. 2003, Jagadheesan et al. 2003, Schmitz et al. 1999 [Blumer et al. 2004, Boylan 2002, Engel und Rocha 1992, Fisher und Schachter 2000, Leutmezer et al. 2003 [Kanemoto et al. 1996, Savard et al. 1991. Hermann et al. untersuchten systematisch Patienten mit TLE und stellten eine höhere Prävalenz von interiktalen psychotischen Störungen bei Patienten mit Angstaura als mit sonstigen Formen von Aura fest [Hermann et al. 1980]. ...
... [Schmitz et al. 1999]. Insbesondere bei Patienten mit PIP wurde gehäuft eine bilaterale epilepsiespezifische Aktivität beobachtet , Kanner und Soto 1998, Leutmezer et al. 2003, Savard et al. 1991. ...
Article
Bisher wurde die Prävalenz psychopathologischer Auffälligkeiten bei fokalen pharmakoresistenten Epilepsien und das Outcome des psychiatrischen Status nach epilepsiechirurgischen Interventionen nur in wenigen, meist kleineren Studien untersucht. Um die Prävalenz und Prognose inter- sowie periiktaler psychiatrischer Störungen bei Epilepsiekranken im epilepsiechirurgischen Procedere zu bestimmen, wurden zwischen 1999 und 2002 am Epilepsiezentrum der Universität Freiburg 154 erwachsene Epilepsiechirurgiekandidaten psychiatrisch nach einem standardisierten Protokoll präoperativ untersucht. Innerhalb der gleichen Zeitspanne unterzogen sich 84 dieser Patienten einem epilepsiechirurgischen Eingriff und wurden 3- und 12 Monate postoperativ psychiatrisch vorgestellt. In der Querschnittsanalyse der präoperativen Psychopathologie erfüllten 60% der Patienten die Kriterien einer ICD-10- oder einer epilepsietypischen psychiatrischen Diagnose. Es zeigte sich somit eine 2- bis 4-fache Prävalenzrate psychiatrischer Diagnosen im Vergleich zur Allgemeinbevölkerung. Die epilepsietypische dysphorische Störung war mit einer Prävalenz von 27% das häufigste psychiatrische Syndrom. Dabei waren Frauen signifikant häufiger betroffen als Männer. Es zeigte sich ein spezifischer Zusammenhang zwischen der dysphorischen Störung und den temporo-mesialen sowie frontalen Anfallsursprüngen. Gleichzeitig wurden positive Korrelationen zwischen der Prävalenz der dysphorischen Störung und der Frequenz der komplex-fokalen Anfälle sowie der Präsenz von Angstaura festgestellt. Diese Befunde weisen auf eine besondere Rolle der temporo-fronto-limbischen Strukturen bei der Pathogenese der dysphorischen Störung hin. Ferner ergab sich eine spezifische Assoziation der Epilepsiepsychosen mit dem Vorhandensein von Fieberkrämpfen in der Vorgeschichte, mit linksseitigen temporo-mesialen Anfallsursprüngen sowie bilateraler und multifokaler EEG- oder MRT-Pathologie. Persönlichkeitsstörungen wurden insbesondere bei den Patienten mit schweren, therapierefraktären und frühmanifesten Epilepsieformen festgestellt. In der Längsschnittsanalyse des postoperativen psychiatrischen Outcomes entwickelten 18% der Fälle „de novo“ interiktale affektive Syndrome, deren Inzidenz innerhalb der ersten drei postoperativen Monate am höchsten war und die oft mit intermittierenden, wechselnd depressiv-dysphorischen und milden euphorischen Zuständen einhergingen. Andererseits wurde bei keinem der Patienten ein „de novo“ auftretendes paranoid-halluzinatorisches Syndrom postoperativ beobachtet. Darüber hinaus beobachteten wir bis zu einem Jahr postoperativ keine weiteren klinischen Manifestationen der präoperativ festgestellten postiktalen Psychosen. Ferner kamen 48% der präoperativ diagnostizierten affektiven Syndrome bzw. 62% der präoperativ festgestellten dysphorischen Störungen zu weitgehender Remission innerhalb des ersten postoperativen Jahres. In unserer Studie war die Remission der präoperativ festgestellten Psychopathologie mit einem besseren Anfallsoutcome sowie mit einem verbesserten psychosozialen Status assoziiert. Es zeigte sich kein signifikanter Zusammenhang zwischen dem postoperativen psychiatrischen Outcome und der Lateralität oder Lokalisation der Epilepsiechirurgie.
... In addition, agitated and violent behavior typically observed during PIP episodes has discouraged investigators from performing SPECT examinations. Therefore, in the present study, we reviewed four previous SPECT findings obtained during PIP episodes (Nissenkorn et al., 1999;Fong et al., 2000;Leutmezer et al., 2003;Nishida et al., 2006) as well as our own results of five additional cases, in an attempt to answer the still open question proposed by Flor-Henry. ...
Article
To identify brain regions activated during episodes of postictal psychoses (PIP), we investigated single-photon emission computed tomography (SPECT) data obtained from five patients treated at our institutions and also reviewed four previous studies. Therefore, SPECT findings in a total of 19 cases were analyzed, including 16 patients with temporal lobe epilepsy (TLE). During nonpsychotic states, the laterality of epileptic foci was judged as left-sided in nine episodes, right-sided in six episodes, and nonlateralized in four episodes. In PIP states, 88% of the patients showed a relative increase of right temporal perfusion (increased right temporal or decreased left temporal perfusion). Regardless of whether right- or left-sided pathology was suspected during a nonpsychotic state, SPECT findings obtained during PIP episodes revealed a trend of right-sided temporal predominance.
... Episodes of postictal psychosis typically last less than 1 month 7 and run a benign course, remitting after several days without neuroleptic treatment; however, it is possible for chronic psychosis to develop, particularly in cases of recurrent postictal psychosis. 8 A retrospective study in patients with TLE estimates that around 10% of patients with postictal psychosis become chronically psychotic. 9 Previous case studies have noted that postictal psychosis can be recurrent and can transform into episodic interictal psychosis. ...
Article
Seizures may present with ictal or interictal psychosis mimicking primary psychiatric disorders. The authors reviewed EEG, brain-imaging, and clinical data of 240 patients presenting with acute psychotic episode to assess the diagnostic value of EEG in differentiating ictal psychosis from primary psychosis. Seven patients had interictal spikes, but there were no patients with ictal discharges. There were no significant associations between the tested variables except that taking neuroleptics/antidepressants was associated with abnormal EEG, and older age and taking anti-epileptic drugs were associated with abnormal CT scans. These findings do not support routine use of EEG in patients presenting with acute psychosis.
... Delusions may also arise when the left hemisphere's tendency to explain goes awry; indeed, delusional disorders are characterized by excessive inference making (Braun and Suffren, 2011) and the tendency to prematurely jump to conclusions (Huq et al., 1988;Dudley et al., 1997;Conway et al., 2002;Moritz and Woodward, 2005;Warman et al., 2007). Importantly, delusions have consistently been linked to both right hemisphere damage (Devinsky, 2009;Coltheart, 2010;Braun and Suffren, 2011) and left hemisphere overactivity (Leutmezer et al., 2003;Mucci et al., 2005;cf Luat et al., 2008;Braun and Suffren, 2011). Together, these lines of evidence suggest that the left hemisphere creates explanations that best account for available data. ...
Article
Full-text available
Converging lines of evidence from diverse research domains suggest that the left and right hemispheres play distinct, yet complementary, roles in inferential reasoning. Here, we review research on split-brain patients, brain-damaged patients, delusional patients, and healthy individuals that suggests that the left hemisphere tends to create explanations, make inferences, and bridge gaps in information, while the right hemisphere tends to detect conflict, update beliefs, support mental set-shifts, and monitor and inhibit behavior. Based on this evidence, we propose that the left hemisphere specializes in creating hypotheses and representing causality, while the right hemisphere specializes in evaluating hypotheses, and rejecting those that are implausible or inconsistent with other evidence. In sum, we suggest that, in the domain of inferential reasoning, the left hemisphere strives to reduce uncertainty while the right hemisphere strives to resolve inconsistency. The hemispheres' divergent inferential reasoning strategies may contribute to flexible, complex reasoning in the healthy brain, and disruption in these systems may explain reasoning deficits in the unhealthy brain.
... Thus, postictal aphasia may be related to transient hypoperfusion of the language cortex, and other transient postictal syndromes (e.g. postictal apraxia, postictal hemineglect, postictal hemianopsia, ataxic hemiparesis , postictal psychosis) that have been described that may have a similar pathophysiology2324252627. Indeed, postictal amnesia, which was seen in our patient, has also been well described28293031. ...
Article
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Introduction Postictal (“Todd’s”) paralysis, or “epileptic hemiplegia,” is a well-known complication of focal or generalized epileptic seizures. However, it is unclear whether the pathophysiology of Todd’s paralysis is related to alterations in cerebral perfusion. We report CT perfusion findings in a patient presenting with postictal aphasia and right hemiparesis. Methods A 62-year-old woman with a history of alcohol abuse, closed head injury and posttraumatic epilepsy, presented with acute onset aphasia and right hemiparesis. A non-contrast head CT scan demonstrated no acute hemorrhage. Left hemispheric ischemia was suspected, and the patient was considered for acute thrombolytic therapy. MRI revealed a subtle increase in signal intensity involving the left medial temporal, hippocampal and parahippocampal regions on both T2-weighted FLAIR and diffusion-weighted sequences. CT angiography and CT perfusion study were performed. The CT perfusion study and CT angiography demonstrated a dramatic reduction in cerebral blood flow and blood volume involving the entire left hemisphere, but with relative symmetry of mean transit time, ruling out a large vessel occlusion. Results Clinical resolution of the aphasia and hemiparesis occurred within a few hours, and correlated with normalization of perfusion to the left hemisphere (detected by MR perfusion). Conclusion This unique case is the first in which clinical evidence of Todd’s paralysis has been correlated with reversible postictal hemispheric changes on CT and MR perfusion studies. This is important because CT perfusion study is being used more and more in the diagnosis of acute stroke, and one needs to be careful to not misinterpret the data.
... Los estudios iniciales de Slater et al. 13 consideraron que la aparición de «esquizofrenia símil» en pacientes epilépticos tenía lugar tras 10 años de iniciada la epilepsia. Posteriormente se ha determinado que una me nor edad de comienzo y un mayor tiempo de exposición a las crisis constituyen factores de riesgo para el desarrollo de ambos tipos de psicosis [8][9][10]27,28 . ...
... Opiate receptor availability may be increased for up to 8 hours after a seizure, possibly reflecting an overshoot below basal levels after the ictal endogenous opiate released occupied available binding sites [4]. It is interesting that SPECT scans during postictal psychosis reveal bifrontal and bitemporal hyperperfusion [5]. ...
Article
There is relatively little information on the underlying parameters that affect clinical features of the postictal period. Age-related physiological changes, including alterations in cerebral blood flow and metabolism, neurotransmitter function, and responses of the brain to seizure activity may affect postictal clinical phenomena. Some conclusions can be drawn. Elderly adults and children, particularly in the presence of diffuse cerebral dysfunction, may have more prolonged postictal confusion. Postictal dysphasia strongly suggests a dominant hemisphere focus, more often temporal, and Todd's paralysis is always contralateral to the epileptogenic zone. Much additional information could be derived from the vast amount of video/EEG monitoring data available.
... Although data gathered from cases with invasive EEG recordings during PIP are highly limited (Wieser et al., 1985;So et al., 1990;Mathern et al., 1995;Kanemoto, 1997;Seeck et al., 1999;Takeda et al., 2001;Schulze-Bonhage & van Elst, 2010), it has become increasingly clear that only a limited proportion of PIP or related conditions correspond to ictal EEG correlates. Indeed, sporadic single photon emission computed tomography (SPECT) studies have suggested that early frontal and late medial temporal hyperactivities may play some role in the genesis of PIP (Fong et al., 2000;Leutmezer et al., 2003;Nishida et al., 2006;Oshima et al., 2011). However, in a substantial number of cases, these hyperactivities do not seem to be directly linked with epileptiform discharge. ...
Article
n patients with epilepsy, coexisting psychoses, either interictal (IIP) or postictal (PIP), are associated with serious disturbance in psychosocial function and well-being, and often require the care of a specialist. Unfortunately, evidence-based treatment systems for psychosis in patients with epilepsy have not yet been established. This article aims to propose concise and practical treatment procedures for IIP and PIP based on currently available data and international consensus statements, and primarily targeting nonpsychiatrist epileptologists who are often the first to be involved in the management of these complex patients. Accurate and early diagnosis of IIP and PIP and their staging in terms of acuity and severity form the essential first step in management. It is important to suspect the presence of psychosis whenever patients manifest unusual behavior. Knowledge of psychopathology and both individual and epilepsy-related vulnerabilities relevant to IIP and PIP facilitate early diagnosis. Treatment for IIP involves (1) obtaining consent to psychiatric treatment from the patient, whenever possible, (2) optimization of antiepileptic drugs, and (3) initiation of antipsychotic pharmacotherapy in line with symptom severity and severity of behavioral and functional disturbance. Basic psychosocial interventions will help reinforce adherence to treatment and should be made available. Due consideration must be given to patients' ability to provide informed consent to treatment in the short term, with the issue being revisited regularly over time. Given the often prolonged and recurrent nature of IIP, treatment frequently needs to be long-term. Treatment of PIP consists of two aspects, that is, acute protective measures and preventive procedures in repetitive episodes. Protective measures prioritize the management of risk in the early stages, and may involve sedation with or without the use of antipsychotic drugs, and the judicious application of local mental health legislation if appropriate. As for preventative procedures, optimizing seizure control by adjusting antiepileptic drugs or by surgical treatment is necessary.
... However, the difficulty in incorporating this finding into an established underlying neurobiological mechanism is the fact that seizures may separate cerebral perfusion from metabolic activity by altering cerebrovascular auto regulation. [25][26][27] Furthermore, increased perfusion can be related to increased inhibition or excitation; therefore, we remain unsure about the location of the primary disturbance. Metabolic studies, combined with neurotransmitter labelling using positron emission tomography (PET), would help to clarify these possibilities. ...
Article
Psychiatric symptoms can occur following a seizure (post-ictal) in patients with epilepsy. Here, Drs Datta and Oladinni describe the case of a man with a history of nocturnal epilepsy, who developed psychotic symptoms following two successive seizures. Copyright © 2014 John Wiley & Sons
... psychosis. 2 The thalamic deficits are consistent with amotivation, avolition, psychomotor slowing, and catatonia. Tachycardia is consistent with metabolic defects in hypothalamic circuitry. ...
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A 20-year-old man with a history of congenital central hypoventilation syndrome presented with recent-onset psychosis, catatonia, and a diagnosis of schizophrenia. Psychiatric symptoms were resistant to conventional treatment. A fluorodeoxyglucose positron emission tomography scan of the brain obtained during the hospitalization revealed a hypometabolism distribution more consistent with hypoperfusion than with primary central nervous system disease. Increased mechanical ventilation was successfully used to treat the psychiatric symptoms.
... 2 Cases were reported with postictal psychosis as a recognised complication of temporal lobe epilepsy that was shown to be associated with hyperactivation of both temporal and frontal lobe structures as evidenced on single-photon emission CT scans. 3 A study 4 involving 500 patients diagnosed with epilepsy indicated varying characteristics of psychoses occurring in epilepsy. There has also an association with epilepsy and migraine that can complicate the presentation and may cause management problems. ...
Article
A 55-year-old lady was admitted following a concern raised by family members who had noticed a change in behaviour in terms of declining mood, paranoia with expression of belief that she was being bugged, also reported smelling perfume and after shave lotion. She had a prior diagnosis of bipolar mood disorder and was on lithium but remained no-compliant with her prescribed medication in the 10 weeks before admission. Upon admission, necessary investigations were performed including CT scan and EEG. Her CT was normal but EEG was grossly abnormal. Neurology consultation was sought and a sleep deprived EEG and MRI was ordered. Meanwhile, carbamezipine was commenced in view of the change in diagnosis to that of temporal lobe epilepsy. The patient responded very well to this regime and improved in all spheres. She was finally discharged with follow-up appointments with both neurology and psychiatry clinics.
... La nosologie de ces tableaux est difficile à préciser parce qu'il s'agit d'états aigus associant des troubles de l'humeur, des hallucinations et une idéation persécutive. Une hypertrophie bilatérale des amygdales (études volumétriques en IRM) a été observée chez des sujets atteints de psychoses post-ictales par rapport aux épileptiques non psychotiques appariés (Tebartz van Elst et al., 2002) et une hyperperfusion bifrontale et bitemporale en SPECT lors de l'état psychotique par rapport à l'état non psychotique (Leutmezer et al., 2003) plaident en faveur d'un mécanisme neurobiologique spécifique. ...
Article
Psychiatric comorbidity in epilepsy refers to the coexistence of mental disorders in people with epilepsy that is more than coincidental. There is good clinical evidence suggesting that the psychiatric disorders of epilepsy are clinically distinct but they do not find a place in the current classification systems in psychiatry. Current epidemiological knowledge of psychiatric disorders in epilepsy has been reviewed both in the general population and in populations with refractory epilepsy according to a descriptive approach. The prevalence of depressive disorders is reported to be more than 30% in community-based samples and 20-70% in people with refractory epilepsy. Adequate recognition and treatment of mood and anxiety disorders is essential for patient management because of their burden in quality of life. Phenomenology, diagnosis and management of depressive, psychotic and anxiety disorders in epilepsy are reviewed.
... Epilepsy-related delusions can be attributed to activation in the focus or activation in the hemisphere containing the focus (if pre-or interictal) and to result from the non-focal hemisphere (via release) if postictal. Left hemisphere epileptic activation has been found to favour delusions (Flor-Henry, 1969;Leutmezer et al., 2003;Sherwin, 1981) as has right hemisphere postictal shutdown of the focal hemisphere (Horikawa et al., 2006;Ishii et al., 2006). ...
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Neurocognitive accounts of delusion have traditionally highlighted perceptual misrepresentation, as the primary trigger in addition to other cognitive deficits that maintain the delusion. Here, a general neurocognitive model of delusional disorder (DSM-IV) is proposed, not so much based on perceptual or cognitive deficits after right hemisphere damage as on cognitive propensities, specifically excessive inferencing (especially jumping to conclusions) and excessive reference to the self, due to left hemisphere overactivity. The functional imaging, topographic EEG, and experimental imaging literatures on delusional disorder are reviewed, and 37 previously published cases of postunilateral lesion delusion (DSM-IV type, grandeur, persecution, jealousy, erotomania, or somatic), are reviewed and analysed multivariately. Functional imaging and EEG topography data were slightly more indicative of left hemisphere overactivity in delusional disorder. In addition, 73% of the postunilateral lesion cases (χ(2)=7.8, p=.005) of delusional disorder (DSM-IV type) had a right hemisphere lesion, whereas only 27% had a left hemisphere lesion. Left hemisphere release appears to be a more primary cause of delusional disorder than right hemisphere impairment, the latter merely entailing loss of inhibition of delusional beliefs. We propose that most patients with DSM-IV diagnoses of delusional disorder could be afflicted by excessive left hemisphere activity, but further research is necessary.
... One functional neuroimaging study using PET has shown that patients with PIP have regional hyperperfusion in the temporal lobe ipsilateral to the seizure focus, 90 while others have shown hyperperfusion of bilateral frontal and temporal regions during PIP. [91][92][93] During periods of active psychosis, patients without epilepsy showed dramatic spike and slow wave activity in the septal region, as well as less prominent, perhaps propagated, epileptic activity in medial temporal structures (hippocampi and amygdalae). In contrast, actively psychotic patients who also had epilepsy (but who were not experiencing overt seizures at the time of the recording) showed a reverse pattern, with prominent spike and slow wave activity in medial temporal regions, and less prominent septal epileptic activity. ...
Article
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Psychosis of epilepsy (POE) is a term applied to a group of psychotic disorders with a distinct phenomenology in which potential etiopathogenic mechanisms are believed to be closely related to a seizure disorder. POE can present as interictal psychotic episodes, which may often differ semiologically from primary schizophrenic disorder. They may present as ictal or postictal psychotic episodes and may be the expression of an iatrogenic process to pharmacologic and/or surgical interventions.Epilepsy and POE have a complex and bidirectional relation, as not only are patients with epilepsy at greater risk of developing a psychotic disorder, but patients with a primary psychotic disorder are also at greater risk of developing epilepsy. The prevalence of POE is more than 7 times higher than the frequency of primary schizophreniform disorders in the general population. While POE has been associated with focal epilepsy of temporal and frontal lobe origin, its etiology and pathophysiology of POE have yet to be established.The treatment of all forms of POE, with the exception of ictal psychotic episodes, requires the use of antipsychotic drugs, preferably the atypical antipsychotic agents with a very low or negligible potential to lower the seizure threshold (eg, risperidone, apiprazole), starting at a low dose with stepwise increments.
... Episodes of postictal psychosis typically last less than 1 month 7 and run a benign course, remitting after several days without neuroleptic treatment; however, it is possible for chronic psychosis to develop, particularly in cases of recurrent postictal psychosis. 8 A retrospective study in patients with TLE estimates that around 10% of patients with postictal psychosis become chronically psychotic. 9 Previous case studies have noted that postictal psychosis can be recurrent and can transform into episodic interictal psychosis. ...
... The number of relevant studies is small and they usually involve the video-EEG findings of PP and IIP patients with TLE only. 2, 3 We, for the first time, investigated the clinical and video-EEG features of an unselected group with available longterm video-EEG studies including all psychosis subtypes for EP patients with frontal, temporal, and other seizures. Still, our study has certain limitations. ...
Article
Background: Studies on electrophysiological characteristics of patients with epilepsy and concomitant psychosis are limited. We aimed to investigate the clinical and video-electroencephalography (EEG) findings of patients with epilepsy-related psychosis (EP). Materials and methods: Fifteen patients diagnosed with EP, assessed at the video-EEG monitoring unit and were under follow-up at both epilepsy and psychiatry clinics, were included. A total of 67 nonpsychotic epilepsy patients, investigated at the video-EEG monitoring unit were randomly selected as the control group and compared statistically with the EP group. Results: In medical history, patients with EP had experienced significantly higher level of status epilepticus (P=0.002) and perinatal cerebral injury (P=0.04), whereas drug-resistant epilepsy was detected at a lower level (P=0.015). With respect to seizure onset zone, the EP group had significantly more seizures of unknown foci, whereas the control group had mostly temporal lobe origin (P=0.0004). EEG findings showed that slow background activity was significantly common among patients with EP (P=0.009). Although only 5 of 15 patients with EP had been operated, 43 of 67 patients had undergone epilepsy surgery (P=0.04) in the control group. However, there was no significant difference between the 2 groups with respect to postoperative seizure control as per Engel classification. Conclusions: Although our sample size could be considered small, slowed EEG background activity, and the marked frequency of initial precipitant factors such as status epilepticus, perinatal cerebral injury, and detected neuronal autoantibodies suggested that EP is associated with more extensive involvement. EP is not a contraindication for epilepsy surgery, when appropriately investigated preoperatively.
... The number of relevant studies is small and they usually involve the video-EEG findings of PP and IIP patients with TLE only. 2, 3 We, for the first time, investigated the clinical and video-EEG features of an unselected group with available longterm video-EEG studies including all psychosis subtypes for EP patients with frontal, temporal, and other seizures. Still, our study has certain limitations. ...
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Objective: Neuronal auto-antibodies (NAA) have recently been shown in some patients with chronic temporal lobe epilepsy (TLE). Psychiatric comorbidity is a significant part of the TLE course and a different profile can be a marker for “autoimmune” epilepsy. For this reason, we aimed to determine the psychiatric profiles of TLE patients associated with NAA and their differentiating features. Methods: The sera of the included TLE patients have been tested for 8 neuronal auto-antibodies. The standardized, detailed psychiatric interviews and questionnaires (International Neuropsychiatric Interview; M.I.N.I. Turkish edition, Yale – Brown Obsessive Compulsive scale (YBOCS), The Scale for the Assessment of Positive Symptoms (SAPS)) were performed by the same researcher blindfolded to the NAA status of the patients. Results: We evaluated 37 consecutive patients (12 male, 25 female) with TLE. NAAs had already been detected for research purposes in the sera of 20 included patients; the antibodies were found against contactin associated protein-2 (CASPR2) in 7, N-methyl-D-aspartate receptor (NMDAR) in 6, voltage-gated potassium channel complex (VGKC-complex) in 3, glycine receptor in 3 and glutamic acid decarboxylase in one patient. Social phobia was found remarkably common in the seronegative group (p:0.015). Other psychiatric symptoms did not show any difference between the seropositive and seronegative groups. Conclusion: We could not demonstrate an alarming psychiatric profile related to NAAs in chronic TLE patients, in our small sized study. It was important to note that depression and psychosis are more frequent in patients with NAA, whereas seronegative patients displayed social phobia more frequently.
Article
To evaluate the frequency and intensity of psychiatric disorders in a group of temporal lobe epilepsy (TLE) patients from a tertiary-care center. Clinical and sociodemographic data of 73 patients were collected and a neuropsychiatric evaluation was performed with the following instruments: Mini-Mental State Examination (MMSE), structured clinical interview (MINI-PLUS), Hamilton Anxiety Scale (HAM-A), Hamilton Depression Scale (HAM-D), Brief Psychiatric Rating Scale (BPRS). Patients with TLE showed a high frequency of lifetime psychiatric disorders (70%), the most frequent being mood disorders (49.3%). At assessment, 27.4% of the patients were depressed and 9.6% met criteria for bipolar disorder. Nevertheless, depression had not been properly diagnosed nor treated. Anxiety disorders were also frequent (42.5%), mainly generalized anxiety disorder (GAD) (21.9%). Obsessive compulsive disorder (OCD) was present in 11.0% and psychotic disorders in 5.5% of the sample. Patients with left mesial temporal sclerosis (LMTS) exhibited more psychopathologic features, mainly anxiety disorders (p=0.006), and scored higher on HAM-A and HAM-D (p<0.05 in both). TLE is related to a high frequency of psychiatric disorders, such as anxiety and depression, which are usually underdiagnosed and undertreated. Damage to the left mesial temporal lobe, seen in LMTS, seems to be an important pathogenic lesion linked to a broad range of psychopathological features in TLE, mainly anxiety disorders. The present study prompts discussion on the recognition of the common psychiatric disorders in TLE, especially on the Brazilian setting.
Article
There are only a few studies in which both preoperative psychiatric comorbidity in pharmacoresistant focal epilepsy and its outcome after epilepsy surgery have been investigated. In this study, 144 patients evaluated for epilepsy surgery received psychiatric examination, 84 proceeding to intervention were reassessed postoperatively. Preoperatively, 60% met criteria for ICD-10- or epilepsy-specific psychiatric diagnosis. Twenty-seven percent, predominantly female, suffered from dysphoric disorder (DD) associated with temporal epileptogenic foci. Prevalence of DD correlated with complex partial seizure frequency and presence of ictal fear suggesting limbic-cortical dysregulation. Psychotic syndromes were linked to a history of febrile convulsions and left-sided temporomesial epileptogenic foci. High seizure frequency and early epilepsy onset predisposed to the development of personality disorders. Postoperative assessment revealed 18% of patients with "de novo" interictal affective disorders after surgery. Symptoms in 48% of patients with preoperative affective syndromes and 60% of patients with DD remitted after surgery. Seizure freedom and improved psychosocial status predicted remission of preoperative psychopathology.
Article
Postictal behaviors and symptoms often require special assessment and treatment. We review risk factors for postictal delirium and psychosis and management of agitated and confused behaviors in patients after seizures. Medical and emergency staff require careful training to manage behaviors associated with postictal delirium and psychosis in order to protect patients while their confusion resolves. Treatment of postictal states requires recognition of underlying neurological and systemic disorders associated with seizures and delirium such as metabolic disorders and nonconvulsive seizures. There is incomplete information about the causes and optimal treatments for seizure-related psychosis, however, postictal behaviors can usually be managed safely.
Article
Postictal psychosis is a particular entity with unclear relationship to preceding epileptic seizures. In particular, the role of ongoing interictal and ictal epileptic discharges in the epileptic focus, as opposed to widespread changes in cortical networks in its generation, has remained controversial. We describe two patients with temporal lobe epilepsy who developed a schizophreniform postictal psychosis after seizure clustering during or following invasive depth EEG monitoring. EEGs were analyzed for the presence of interictal and ictal discharges, and videos were analyzed for possible precursors of postictal psychosis, with particular focus on postictal neuropsychological impairments in preceding episodes. The development of psychosis was related neither to ongoing subclinical ictal activity nor to suppression of interictal discharges in the epileptic focus. There was, however, increasing severity and duration of cognitive impairment following the seizures in the cluster preceding psychotic symptoms in that the patients progressively developed postictal aphasic symptoms and disorientation before becoming overtly psychotic. The cases suggest that the buildup to schizophreniform postictal psychosis may not be related to epileptic discharges in the focus, but may develop as a consequence of ictal activity and postictal functional impairment of extended brain regions.
Article
Gerade die zusätzlichen therapeutischen Möglichkeiten mit neuen Antiepileptika haben in den letzten Jahren unsere Möglichkeiten erweitert, im Hinblick auf eine bessere Lebensqualität neben der Epilepsie an sich auch mögliche Komorbiditäten zusätzlich positiv zu beeinflussen. Das Problem der Komorbidität rückte auch aus diesem Grunde in letzter Zeit verstärkt ins Interesse. Ziel unserer Arbeit ist es, in einer Gruppe von 399 stationär im Epilepsiezentrum Kork behandelter erwachsener Patienten klinisch relevante Komorbiditäts- Faktoren zu erfassen, wobei wir besonders Augenmerk auf psychiatrische Komorbiditäten legten. Von den insgesamt 399 erwachsenen Patienten hatten 89,5 % (n=357) die Hauptdiagnose einer Epilepsie. Keine Epilepsie hatten 10,5 % (n=42) der Gesamtpatienten. Von den Patienten ohne eine Epilepsie hatten 23 (5,8 %) rein dissoziative Anfälle. Die häufigsten Nebendiagnosen der Patienten mit einer Epilepsie waren zerebrale Lähmungen oder Lähmungserscheinungen mit 41,2 % gefolgt von internistischen Erkrankungen wie Adipositas und Kreislaufstörungen mit 10,9 %. Von den 357 behandelten Epilepsiepatienten zeigten 38,4 % (n=137) stationär psychiatrische Auffälligkeiten. Davon hatten 9,8 % (n=35) eine Depression, 3,1 % (n=11) zeigten Angststörungen und weitere 2,5 % (n=10) wiesen eine Psychose auf. Suizidale Gedanken berichteten dabei 2,5 % (n=9). Die Inzidenz der psychiatrischen Komorbidität hinsichtlich Depressionen und affektiven Störungen in dieser Arbeit ist niedriger als üblicherweise in der Literatur angegeben. Gründe hierfür dürften der hohe Anteil mehrfach behinderter Patienten im Epilepsiezentrum Kork und die Tatsache sein, dass die psychiatrische Komorbidität nicht aktiv z.B. mit standardisierten Fragebögen während der stationären Aufenthalte erfasst wurde. Letzteres sollte Gegenstand einer zukünftigen Untersuchung sein.
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Epileptic populations are generally considered inappropriate to investigate hemispheric specialization. However, (1) because hallucination occurs in the early stage of the ictus during which activation is observed in and around the focus, the former could be a direct result of the latter (hypothesis 1), and (2) the type of psychological content of ictal hallucination could depend on which hemisphere is ictally activated (hypothesis 2). It was predicted that, on the basis of quantitative analysis of previously published singles case reports, unilateral ictal hallucinations should occur in the visual field, ear or hemibody contralateral to the side of the ictal focus (test of hypothesis 1). It was also predicted that verbal ictal auditory hallucinations should result more often from left hemisphere foci, and non-verbal auditory ictal hallucinations from right hemisphere foci (test of hypothesis 2). Previously published cases (N=217) of ictal hallucination from a unilateral epileptic focus were reviewed and analyzed with multivariate statistics. Both predictions were strongly supported.
Article
The effect of surgery on the postictal state has not been studied in a systematic fashion. There is limited literature looking at the effect on postictal psychosis. The effect of surgery on this phenomenon has been varied with post ictal psychosis occurring post surgery when it has not occurred prior to surgery as well as resolution after surgery. Case reports of post ictal Kluver Bucy Syndrome and Capgas Syndrome have been reported after resective epilepsy surgery as well.
Article
Postictal psychosis (PIP) represents 25% of the psychoses seen in epileptic patients. A high frequency of bilateral independent epileptiform activity has been observed in patients with PIP. The objective of this study was to determine the frequency of PIP in patients with temporal lobe epilepsy (TLE) who underwent video-EEG monitoring and to investigate possible differences between PIP and control patients. Clinical, electroencephalographic and neuroimaging data of 5 PIP patients with TLE were compared with data of 50 patients with TLE without psychotic antecedents. Patients with a past history of interictal psychosis were excluded. From 55 patients, 5 were patients with PIP and 50 controls. 31 (62%) were men, 9 (16.4%) had a previous history of encephalitis and 6 (10.9%) of status epilepticus. The mean age was 42.2 years (S.D. 12.93). Mean age at epilepsy onset was 16.95 years (S.D. 12.93) and mean seizure frequency 5seizures/month (S.D. 1.87). The frequency of PIP was 5/55 (9.1%). Previous history of status epilepticus was more frequent in PIP patients than in controls (p: 0.019). PIP patients more frequently had a non-lateralizing ictal EEG than controls (p: 0.001). Bitemporal lobe dysfunction revealed by neuropsychological studies was greater than expected by the observed lesion on MRI studies in patients with PIP. Moreover, the presurgical study was less conclusive in PIP than in control patients (p: 0.049). PIP is observed in up to 9% of patients with TLE undergoing video-EEG monitoring and most often develops in patients with bitemporal lobe dysfunction.
Article
Any attempt to compare the definitions of symptoms listed for “primary psychoses” with those adopted in studies of psychoses in patients with epilepsy (PWE) will encounter problems of heterogeneity within both conditions. In this manuscript, five psychotic illnesses listed in Diagnostic and Statistical Manual of Mental Disorders-5th Edition (DSM-5), that is, brief psychotic illness, schizophreniform disorder, schizophrenia, delusional disorder, and schizoaffective disorder are compared with postictal (or periictal) and interictal psychotic disorders in PWE. After examining definitions of primary psychoses, definitions of psychoses adopted in the papers dealing with postictal and interictal psychoses are summarized. Further, diagnostic criteria of five types of psychotic disorders in PWE proposed in 2007 by Krishnamoorthy et al. are also discussed, which include postictal psychosis, comorbid schizophrenia, iatrogenic psychosis caused by antiepileptic drugs (AEDs) (AED-induced psychotic disorder: AIPD), and forced normalization. Evidently, a comparison between postictal psychosis and schizophrenia is pointless. Likewise, schizophrenia may not be an appropriate counterpart of forced normalization and AIPD, given their acute or subacute course.
Article
We identified two patients with medically refractory temporal lobe epilepsy, from whom intracranial EEG recordings were obtained at the time of postictal psychosis. Both patients had mesial temporal epilepsy associated with hippocampal sclerosis. In both patients, the postictal psychosis was associated with a continual "epileptiform" EEG pattern that differed from their interictal and ictal EEG findings (rhythmical slow wave and "abortive" spike-slow wave complex activity in the right hippocampus and lateral temporal cortex in case 1 and a periodic pattern of triphasic waves in the contacts recording activity from the left anterior cingulate gyrus). Some cases of postictal psychosis might be caused by the transient impairment of several limbic system structures due to the "continual epileptiform discharge" in some brain regions. Case 2 is the first report of a patient with TLE in whom psychotic symptoms were associated with the epileptiform impairment of the anterior cingulate gyrus.
Chapter
Psychopathology refers to the manifestation of behaviors or experiences that may be indicative of mental illness or psychological impairment. The term is broad, encompassing all phenomena that might, but might not, reach significance for a psychiatric diagnosis. As a result, the debate about the occurrence of psychopathology in people with epilepsy has been long and intense. If behavior is the manifest aspect of psychic life, then aberrations of behavior are usually attributed to some form of abnormal mental state1; there can be no doubt that this is a significant issue in people with epilepsy. There is further difficulty in interpreting psychopathology or behavioral disorders in people with intellectual disabilities (ID), particularly in people with severe ID. How, then, do we understand the issues surrounding psychopathology in people with ID and epilepsy? In this chapter we will seek to look at these issues in more detail, describing findings in people with ID without epilepsy, in the general population with epilepsy, and then, where possible, looking for ID-specific research in the field of epilepsy.
Article
IntroductionPost-ictal psychosis syndrome (PIP) belongs to the group of epileptic psychoses which, according to the most commonly used classification, is to be distinguished from ictal psychoses, on one hand, and from inter-ictal psychoses, on the other.Objectives The present paper aims to review recent data concerning the clinical, therapeutic and pathophysiological aspects of PIP.Methods We report four cases of PPI, which involved four patients hospitalized at the Salpêtrière hospital between 2001 and 2005, and discuss these cases in light of the relevant literature.ResultsThe PIP fit generally occurs in patients suffering from intractable temporal lobe epilepsy which started several years before. The psychiatric disorders suddenly take hold after a series of complex partial seizures with frequent secondarily generalized tonic clonic seizures. During the episode, EEG recordings do not show any epileptic activity. Psychiatric symptoms consist of persecutory delusive ideas, verbal and visual hallucinations, agitation, and aggressiveness. Mood disorders are variable from one patient to another and exhibit intraindividual fluctuation. In most patients given antipsychotic drugs, the short-term outcome of PIP is favorable . In the long-term, even if recurrence is the main long-term risk, progression to severe mood disorders or to poor prognosis inter-ictal psychosis is possible. Accordingly, the clinician must be aware of this syndrome in order to correctly diagnose PIP since effective treatment with antipsychotic drugs is available.Conclusion The short-term prognosis of PPI is usually favorable but this syndrome can potentially develop in the long-term to more severe psychiatric disorders. It is, therefore, important to recognize PIP syndromes which respond more readily to pharmacological treatments than other types of psychoses.
Article
To investigate the prevalence of postictal psychosis (PP) in patients with temporal lobe epilepsy (TLE) and to estimate the predictive value of various variables for the development of PP. By retrospectively reviewing the charts of all patients evaluated with video-electroencephalogram (EEG)-monitoring at our unit between January 1995 and February 2012, we identified 684 patients with TLE, of which 48 patients had a history of PP. Patients with TLE and PP were compared with 200 controls (patients with TLE without a psychotic history) on demographic, clinical, EEG and magnetic resonance imaging (MRI) variables. The prevalence of PP in our TLE sample was 7.0%. Aggressive behaviour during PP was present in 22.9% of the sample. Univariate analysis revealed that PP was significantly associated with early age at epilepsy onset (P = 0.007), longer duration of epilepsy (P = 0.002), presence of ictal fear (P = 0.005), impaired intellectual function (P = 0.045), and bilateral ictal and interictal epileptiform activity (both P < 0.0001). Using logistic regression analysis, ictal fear [odds ratio (OR) 2.88; P = 0.015] and bilateral interictal EEG activity (OR 6.40; P < 0.0001) were predictive of PP development. No association of PP with MRI pathology or epilepsy-relevant aetiological factors was found. PP is a frequent and potentially dangerous complication within the course of TLE. Bilateral or widespread functional central nervous system disturbances rather than distinct structural brain alterations or certain predisposing aetiologies of epilepsy appear to be a risk factor for the development of PP. Ictal fear may be a predictive clinical variable of PP in TLE.
Article
In epilepsy patients, psychotic states are related to a group of psychotic disorders with a specific phenomenology in which potential pathophysiological mechanisms are believed to be closely related to the epileptic disorder itself. Postictal psychosis is a very specific syndrome in relation to seizure activity: a clear temporal relationship exists between the psychotic state of sudden onset and a precipitating bout of complex partial or generalized seizures, with a characteristic lucid interval which lasts from two to 120h. The psychotic state may be related to the withdrawal of anticonvulsants, often in connection with video-EEG monitoring. The phenomenology of the psychotic state is often pleomorphic, with abnormal mood, paranoid delusions and hallucinations, with some clouding of consciousness or no evidence of impaired consciousness. The outcome is characterized by a remission of the psychotic symptoms over several days (mean: 1 week), with or without neuroleptic treatment. The majority of the patients suffer from complex partial seizures with frequent psychic auras that secondarily become generalized. In the majority of cases, prepsychotic EEG abnormalities persist during the psychosis. Frequent bitemporal foci are recorded on the EEG and MRI abnormalities (including mesial temporal sclerosis) are seen in more than half of the cases. The results of clinical, morphologic and metabolic available studies will be briefly discussed.
Article
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Introducción: La presencia de enfermedad somática y alteración mental de tipo psicótico permite considerar la posibilidad de una psicosis orgánica. Objetivo: Discutir el curso clínico de una paciente con psicosis orgánica asociada a una encefalopatía reversible posterior (PRES) por síndrome nefrótico. Método: Reporte de caso. Resultados: Se reseña el caso de una adolescente de 14 años de edad con síndrome nefrótico, emergencia hipertensiva y estatus convulsivo. Al recuperar la conciencia, presentó cambios agitación psicomotora y cambios comportamentales con síntomas psicóticos. Discusión y conclusiones: La sospecha de psicosis orgánica debe orientar al clínico a detectar causas potencialmente corregibles.
Article
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Objective People with epilepsy (PWE) develop complications and comorbidities often requiring admission to hospital, which adds to the burden on the health system, particularly in low-income countries. We determined the incidence, disability-adjusted life years (DALYs), risk factors, and causes of admissions in PWE. We also examined the predictors of prolonged hospital stay and death using data from linked clinical and demographic surveillance system. Methods We studied children and adults admitted to a Kenyan rural hospital, between January 2003 and December 2011, with a diagnosis of epilepsy. Poisson regression was used to compute incidence and rate ratios, logistic regression to determine associated factors, and the DALY package of the R-statistical software to calculate years lived with disability (YLD) and years of life lost (YLL). Results The overall incidence of admissions was 45.6/100,000 person-years of observation (PYO) (95% confidence interval [95% CI] 43.0–48.7) and decreased with age (p < 0.001). The overall DALYs were 3.1/1,000 (95% CI, 1.8–4.7) PYO and comprised 55% of YLD. Factors associated with hospitalization were use of antiepileptic drugs (AEDs) (odds ratio [OR] 5.36, 95% CI 2.64–10.90), previous admission (OR 11.65, 95% CI 2.65–51.17), acute encephalopathy (OR 2.12, 95% CI 1.07–4.22), and adverse perinatal events (OR 2.87, 95% CI 1.06–7.74). Important causes of admission were epilepsy-related complications: convulsive status epilepticus (CSE) (38%), and postictal coma (12%). Age was independently associated with prolonged hospital stay (OR 1.02, 95% CI 1.00–1.04) and mortality (OR, 1.07, 95% CI 1.04–1.10). Significance Epilepsy is associated with significant number of admissions to hospital, considerable duration of admission, and mortality. Improved supply of AEDs in the community, early initiation of treatment, and adherence would reduce hospitalization of PWE and thus the burden of epilepsy on the health system.
Article
Neuropsychiatric sequelae in patients with epilepsy have been vastly studied and documented. These may be affective, cognitive or psychotic. Certain risk factors may predispose some epileptics more to these sequelae. In general, good epileptic control may minimize these outcomes. We present in this report, a case of postictal psychosis (PIP), superimposed on delirium, in a 68-year-old woman, with history of a single previous psychotic illness following a cluster of seizures. This report shows a collaborative management of the neuropsychiatric complications of temporal lobe epilepsy (TLE), by the neurology, geriatric medicine and psychiatry teams.
Article
Objective: The presence of chronic neurological functional deficits in epilepsy increases susceptibility to psychiatric diseases. Especially, complex partial seizures are associated with psychiatric symptoms commonly and as many as %10-30 of patients may have psychosis. The classification has been made according to the time interval of the psychotic symptoms; ictal psychosis psychotic symptoms occur only during a seizure; postictal psychosis occurs after a short period, and seizures arising from persistent psychotic symptoms of schizophrenia-like condition are referred as interictal psychosis. Methods: A 42 year old patient with epilepsy since age 7, who had psychotic symptoms, was differentiated from schizophrenia and diagnosed with interictal psychosis based on the clinical features (ICD-10 schizophrenia like psychosis). He was treated with aripiprazole and his treatment response and 1 year follow up were discussed. An epileptic focus was determined in the right hemisphere on EEG and in left parietal lobe on PET and also left mesial temporal sclerosis (MTS) was detected on MRI. Aripiprazole 10mg/day, which is known to reduce the seizure threshold and also lower and improve the negative symptoms, was started. Treatment response was assessed by SANS, SAPS, and social- occupational functioning assesment questionnaires. First evaluations were conducted in the second week and there were dramatic changes in the scale scores. She also had significant clinical improvement especially in negative symptoms and social functioning. She was called to assess response to treatment second time after 4 weeks. Conclusion: Our case has the following features: We have offered a 1-year follow-up period and reviewed the smilarities and the differential diagnosis from schizophenia and the clinical symptoms observed in follow up of patients with interictal psychosis. Finally, our case also has a unique feature due to treatment of schizophrenia-like psychosis of epilepsy with aripiprazole. The antipsychotic treatments are known to reduce the threshold for epileptic seizures. However psychosis associated with epilepsy needs twoway thinking. Therefore we thought the so-called thirdgeneration antipsychotic aripirazole might be a good option to use. The clinical similarities and differences between idiopathic schizophrenia and schizophrenia-like psychosis of epilepsy are important to know for differential diagnosis and treatment planning.
Article
La presencia de enfermedad somática y alteración mental de tipo psicótico permite considerar la posibilidad de una psicosis orgánica.
Chapter
While seizure control is an obvious goal of epilepsy surgery, the postsurgical period can have the paradoxical effect of worsening an individual’s psychiatric function. This chapter systematically reviews the literature relating to neuropsychiatric outcomes of epilepsy surgery, revealing that there is a heightened risk for psychopathology both before and after surgery. This commonly takes the form of depression, anxiety, and psychosocial adjustment difficulties, and can emerge in patients with no prior psychiatric history. From this review a compelling case arises for the routine provision of presurgical psychiatric and psychosocial evaluation, in addition to postsurgical follow-up and rehabilitation. Pre-surgery, this evaluation can shape the team’s understanding of surgical candidacy and the patient’s capacity for informed consent. Moreover, it provides a prime opportunity for managing the sometimes-unrealistic expectations that patients and their families harbor for postsurgery life. While preexisting psychopathology is a risk factor for poor seizure and psychosocial outcomes, it is not a contraindication to surgery when the treating team has the capacity to treat it proactively. Post surgery, efficacious treatment of psychiatric comorbidity increases the likelihood of seizure freedom, as well as optimizing psychosocial functioning and quality of life. By contrast, failure to treat can allow psychiatric comorbidity to persist or escalate, and psychological difficulties to develop as the patient adjusts to life after surgery.
Chapter
Zu den gefürchteten Komplikationen der Epilepsien zählen nicht nur Verletzungen im Anfall, sondern auch psychiatrische Erkrankungen. Es gibt viele — biologische und psychologische — Gründe, die bei einem Menschen mit einer Epilepsie zu der Entwicklung einer psychischen Störung beitragen können. Zu den potenziellen Risikofaktoren gehören die epileptische Anfallsaktivität, die zugrunde liegende Hirnerkrankung, antiepileptische Behandlungsmanöver und eine genetische Prädisposition für psychiatrische Störungen. Bei Epilepsiepatienten kommt das gesamte Spektrum psychiatrischer Störungen vor. Die klinisch besonders relevanten Komplikationen Depressionen und Psychosen, Suizidalität und das Phänomen der forcierten Normalisierung sollen im Folgenden ausführlich besprochen werden.
Article
Résumé Les psychoses post-ictales correspondent à l’apparition soudaine d’un état délirant aigu de durée brève après une salve de crises épileptiques. L’existence d’un intervalle libre de pleine lucidité après la crise élimine une confusion postcritique délirante. Le syndrome psychotique est de sémiologie protéiforme, associant en proportions variables des symptômes thymiques, des hallucinations et des idées délirantes avec une conscience globalement préservée. Le risque de comportements dangereux auto- ou hétéro-agressifs est élevé. L’évolution se fait vers la régression spontanée des symptômes en une semaine en moyenne, avec ou sans traitement. Le syndrome psychotique complique une épilepsie focale réfractaire évoluant depuis plus de 10 ans. L’EEG est utile au diagnostic différentiel : enregistré lors de l’épisode psychotique, il n’est pas différent de l’EEG prépsychotique. Les travaux neurobiologiques montrent que la survenue du trouble dépend d’une vulnérabilité individuelle et s’accompagne d’anomalies structurelles sur l’imagerie morphologique de l’encéphale. La dynamique du trouble a été évaluée par les enregistrements par électrodes profondes et par l’imagerie fonctionnelle.
Chapter
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Psychopathology refers to the manifestation of behaviors or experiences that may be indicative of mental illness or psychological impairment. The term is broad, encompassing all phenomena that might, but might not, reach significance for a psychiatric diagnosis. As a result, the debate about the occurrence of psychopathology in people with epilepsy has been long and intense. If behavior is the manifest aspect of psychic life, then aberrations of behavior are usually attributed to some form of abnormal mental state; there can be no doubt that this is a significant issue in people with epilepsy. There is further difficulty in interpreting psychopathology or behavioral disorders in people with intellectual disabilities (ID), particularly in people with severe ID. How, then, do we understand the issues surrounding psychopathology in people with ID and epilepsy? In this chapter, we will seek to look at these issues in more detail, describing findings in people with ID without epilepsy, in the general population with epilepsy, and then, where possible, looking for ID-specific research in the field of epilepsy.
Article
The treatment of epilepsy extends far beyond seizure control. Many comorbidities have a significant impact on the medical management and quality of life of patients with epilepsy. In this review, we examine interactions between epilepsy and some common medical conditions. Psychiatric disorders with a high prevalence in epilepsy include mood disorders, anxiety disorders, and psychosis. Depression is common, psychosis occurs both in direct relation to seizures and interictally, and suicide rates are increased. Changes in sexual function and reduced fertility and marriage rates are described, including a discussion of polycystic ovary syndrome, which is increased in women with epilepsy. The effects of other chronic medical comorbid conditions are reviewed, including the effects of antiepileptic medications on bone health and the impact of renal insufficiency on pharmacological therapy of epilepsy.
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Postictal psychosis is a known complication of complex partial seizure in particular temporal lobe epilepsy. It usually runs a benign and self limiting course. A postictal phenomenon with focal cerebral hypofunction (similar to Todd's palsy), rather than ongoing seizure activity, has been postulated.1 2 Surface EEG is either normal or showing non-specific slow waves.3 Hence, antipsychotic medications are prescribed instead of antiepileptic drugs. Until recently, the pathogenic mechanisms have remained unknown. In this communication, we report on two patients with postictal psychosis, during which a cerebral SPECT study showed a hyperperfusion signal over the right temporal lobe and contralateral basal ganglion. As hyperperfusion in ictal cerebral SPECT is closely linked to epileptic activities,4 our findings support a contrary explanation for postictal psychosis. Interictal SPECT and SPECT performed during postictal psychosis. (Top) A SPECT study of patient 1 showing areas of relative hyperperfusion over the right temporal neocortex (red arrows) and the left basal ganglia (blue and yellow arrows) during postictal psychosis. (Bottom) SPECT study of patient 2 showing areas of hyperperfusion over the right temporal neocortex and the left basal ganglia. Arrows indicate areas of hyperperfusion. Prolonged video-EEG telemetry study was performed in patients who underwent presurgical evaluation for epilepsy surgery. Antiepileptic drugs were withdrawn …
Article
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A controlled investigation comparing a population of 50 temporal lobe epileptics with psychotic episodes with 50 randomly selected temporal lobe epileptics who had never experienced psychotic disturbances, showed that: Une étude contrôlée comparant 50 épileptiques présentant une épilepsie du lobe temporal avec épisodes psychotiques et 50 épileptiques pris au hasard présentant une épilepsie du lobe temporal mais n'ayant jamais présenté de troubles psychotiques, a montré que:
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A multipurpose three-dimensional registration technique was validated with PET, SPECT, CT and MRI scans, which had been obtained under normal clinical conditions. In contrast to fully automated procedures, this coregistration method is highly interactive, which has the advantage that it does not impose rigid restrictions by data type and by alterations in normal anatomy or brain function resulting from disease. Basically, a computer program provides a variety of tools to examine the accuracy of coregistration visually and to specify necessary translations and rotations in all three dimensions. Tools and criteria to accept coregistration were applied according to a standardized protocol. Reproducibility was assessed with five independent users on nine pairs of image sets. In two pairs of these image sets, coregistration was repeated three times by each user. Depending on the resolution of the images involved, the reproducibility of translation distances ranged from 0.32 to 2.22 mm (s.d.) and of rotation angles from 0.32 to 1.70 degrees. It was always much smaller than the point-spread full-width half maximum of the device with the lower resolution. The accuracy of coregistration was examined using two arbitrarily misplaced image sets. Interindividual and intraindividual variance were similar, which suggested that the influence of subjectivity was not significant. Average displacements after coregistration were 0.43 and 0.29 mm or less for PET and MRI data, respectively, which indicated the absence of a systematic bias. The results indicate the high reproducibility and accuracy of this three-dimensional coregistration technique, which is comparable or superior to those of automated techniques and methods based on external artificial landmarks.
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I wish to comment on the postictal psychosis related regional cerebral hyperperfusion reported by Fong et al .1 Based on the their findings of hyperperfusion on SPECT within the time frame of postictal psychosis, the authors argue against the hypothesis that postictal psychosis is a psychic manifestation of a Todd's phenomenon. Two previous studies have shown a focal increase in cerebral blood flow on brain imaging during traditional motor Todd's paresis.2 …
Article
One hundred children with temporal lobe epilepsy were followed into adult life. 85 per cent had had psychiatric problems in childhood. The occurrence of overt psychiatric disorder in adult life was low: of those survivors who were not gravely mentally retarded, 70 per cent were regarded as psychiatrically healthy. Overt schizophreniform psychosis has developed in 10 per cent of survivors. Males with continuing epilepsy and left-sided foci were at special risk: 30 per cent of such patients had become psychotic. No patient coded as having a right-sided focus in 1964 had become psychotic by 1977. Though 26 patients had had grossly disordered childhood homes, this factor had no significant relation to adult psychiatric disorder. Antisocial conduct marked the adult life of 12 patients. Their childhood codes showed that male sex, a focus contralteral to the preferred hand, and unremittent epilepsy marked this group. Low intelligence and childhood rages were also prominent. Treated neurotic and depressive illness was quite uncommon. Only five survivors have fallen into this category. Those patients escaping psychiatric ill-health are often notably extraverted and successful.
Article
During stereo-EEG on drug resistant epileptic patients "psychical seizures" such as illusions, hallucinations, strange emotions and disturbances of thinking were observed. The depth recordings of the presented cases reveal the epileptic nature of these psychic phenomena. Elementary illusions and hallucinations can often be correlated with circumscribed discharges in cortical representation areas. Larger areas of the temporal lobe are found to be involved regularly in the more complex hallucinations. Emotional changes are strongly linked to the limbic system whereas "intellectual auras" or other disturbances of thinking are attributed to paroxystic dysfunctions of mainly frontal areas. The discussion deals with the relationship between psychomotor epilepsy and psychosis as well as the relationship between the frequency of seizures and psychic and/or behavioral disturbances. In this context a possible explanation of the so-called "forced normalization" of the EEG is given.
Article
Postictal transient focal neurological deficits, i.e., Todd's paralysis, at times are correlated with early veins and/or vascular stain angiographically. Radionuclide gamma camera images show that they also may be accompanied by a relative flow hyperperfusion and a cortical rim static image uptake. Using these observations some portion of Todd's paralysis may be explained as the result of focal epileptic discharges that lead to local vasomotor and/or metabolic changes. The functional arterial venous shunting that results could contribute to cortical ischemia and the subsequent clinical deficits.
Article
Paradoxical or "forced" normalization of the EEG of patients with epilepsy was first described by Landolt in 1953. It refers to conditions where disappearance of epileptiform discharge from the routine scalp EEG is accompanied by some kind of behavioral disorder. The best known of these is a paranoid psychotic state in clear consciousness, which is also known as "alternative" psychosis. Thus, the issue is related to much older observations which indicated a "biological antagonism" between productive psychotic symptomatology and epileptic seizures, which led to the therapy of psychoses with artificially induced convulsions. Apart from psychotic episodes, the clinical manifestations of PN comprise dysphoric states, hysterical and hypochondriacal syndromes, affective disorders, and miscellanea. PN can be observed in both generalized and localization-related epilepsies as a rare complication. A subset where it is more frequently seen are in adults with persistent absence seizures when the latter become finally controlled by succinimide therapy. These seem to be the drugs with the highest hazard of precipitation of PN, but all other AEDs have also been suspected. Sleep disturbance by succinimide treatment may play a crucial role, but a variety of other factors are also involved, including psychosocial factors. The pathogenesis of this condition has given rise to some debate but remains still unresolved. Eleven of the most important hypotheses have been discussed and seem to converge into a more comprehensive hypothesis which basically assumes that, during PN, the epilepsy is still active subcortically, perhaps with spread of discharge along unusual pathways. This activity is supposed to provide energy and, possibly, some of the symptoms included in the psychotic syndrome. A critical clinical condition results, usually with a dysphoric symptomatology, where a development towards psychosis is impending but still depends on the presence or absence of a variety of risk factors. Along with neurophysiological factors such as powerful inhibition of the spread of epileptic discharge, these may also include biographic factors such as the repeated experience of ictal sudden, unexpected loss of consciousness. Because during PN there presumably is ongoing epileptic activity, the differences with respect to other psychotic conditions in epilepsy are probably subtle rather than fundamental. Thus, it could be that ictal psychosis is characterized by a direct expression of epileptic activity, whereas in postictal psychosis a momentum of exhaustion may be added; moreover, in PN the prevailing pathogenic factor could be an abnormally high level of balance between excitatory and inhibitory processes.
Article
Bouts of unusually frequent partial complex seizures originating in the temporal lobe, that sometimes became secondarily generalized, induced psychotic episodes in 9 patients. In 7, the increase in seizures occurred at a time when antiepileptic drugs (AEDs) were being reduced during intensive EEG monitoring with a view to surgical treatment of intractable epilepsy. According to DSM-III-R criteria, the postictal psychosis resembled an organic delusional syndrome which was paranoid in 7 and schizophreniform in 1 and an organic mood syndrome in 1. A high incidence of ictal fear, of bilateral independent epileptogenic discharge, and of small foreign tissue lesion were unexpected findings and appeared to represent risk factors, especially in patients otherwise handicapped by an epileptic personality disorder. Recognition of postictal psychosis in this setting and in others is important both prognostically and therapeutically. Postictal psychosis does not constitute a contraindication to surgical treatment of epilepsy.
Article
Summary An acute psychosis characterized by auditory hallucinations and paranoid delusions developed in a 19-year-old man with temporal lobe epilepsy after he had a cluster of seizures when antiepileptic drugs (AEDs) had been gradually discontinued. Continuous stereotactic depth and epidural EEG recordings confirmed that this was a postictal rather than an ictal event. Acute postictal psychosis is a self-limited condition phenomenologically distinct from ictal or postictal confusion. Une psychose aiguë caractérisée par des hallucinations auditives et un délire paranoïde s'est installée chez un homme âgé de 19 ans présentant une épilepsie temporale, à la suite d'une série de crises succédant une diminution progressive du traitement antiépileptique. Des enregistrements EEG profonds par méthode stéréotaxique et épiduraux ont confirmé qu'il s'agissait là d'un état post-critique plutôt que d'un état critique. La psychose aiguë post-critique est un tat auto-limité qui se distingue sur le Plan phénoménologique de la confusion critique ou post-critique. En un hombre de 19 años con epilepsía del lóbulo temporal mostró un cuadro de psicosis aguda caracterizado por alucinaciones auditivas y delirios paranóicos después de una serie de ataques que aparecieron una vez que se había interrumpido la medicación anti-epiléptica tras una reducción gradual. Los registros stereotácticos con EEG de superficie y epidural, confirmaron que se trataba de un acontecimiento post-ictal más que ictal. La psicosis aguda post-ictal es una situación de breve duración que difiere de la confusión ictal o post-ictal. Bei einem 19 Jahre alten Mann mit Temporallappenepilepsie entwickelte sich nach einer. Serie von Anfällen, nach dem die Antiepileptika allmählich abgesetzt worden waren, eine akute Psychose mit auditorischen Halluzinationen und paranoiden Vorstellungen. Kontinuierliche sterotaktische Tiefen und Epidural-Elektroden—EEG Ableitungen bestätigten, daß es sich um ein postiktales Ereignis und nicht um ein iktales Ereignis handelte. Die akute Psychose ist ein eigenständiger Zustand, der phänomenologisch von den iktalen oder postiktalen Konfusionszuständen absugrenzen ist.
Article
Post-ictal psychoses have so far received little attention. The clinical details of 14 cases, diagnosed according to newly formulated criteria, were examined. Psychoses were usually precipitated by a run of seizures and occurred after a lucid interval. The seizures were partial complex with secondary generalisation in 11 cases. Catego analysis of the Present State Examination confirmed pleomorphic phenomenology. Follow-up details were available in all cases, for up to eight years. Psychoses tended to recur. Similarities with chronic epileptic psychosis are discussed, and a possible organic aetiology for post-ictal psychosis is proposed.
Article
Claims have been made that epilepsy is associated with both brief psychotic episodes and persistent psychotic states. The existence of brief, nonconfusional psychotic episodes in epilepsy has received some formal support; these may be a function of temporal lobe subictal activity. Persistent psychosis is found in about 7% of patients with epilepsy; independent evidence indicates this to be a significant association. Temporal lobe seizure activity, again probably acting subictally, may be involved in the pathogenesis of these states, perhaps in interaction with other factors. Occurrence of psychotic syndromes in epilepsy may be relevant to kindling, atypical psychoses unrelated to epilepsy, and the psychotropic effect of carbamazepine.
Article
1Pre-operatively, 13 patients were considered normal in their mental state, 30 neurotic., 48 psychopathic., 16 psychotic., and 5 of “epileptic personality”. In 12 cases 2 diagnoses were made.2Post-operatively 32 patients were considered normal. Those who improved came largely from the psychopathic group. Aggressiveness was most noticeably reduced.3The mean social adjustment scores differentiated most diagnostic groups from each other both pre- and post-operatively.4“Normal” post-operative mental state was associated with good pre-operative adjustment in non-family relationships and at work, with infrequent grand mal epilepsy and “falling attacks” after the operation, and was characterised by good social adjustment post-operatively, particularly in non-family relationships.5Neurosis was associated with later age at operation, better schooling, and higher intelligence.6Psychopathy was associated with male sex, lower social class, poor work, and poor interpersonal relationships. It was also related to a younger age of onset of epilepsy and to operations on the left side.7Schizophrenia-like psychoses were intractable. Epilepsy in these patients was of late onset, social adjustment was poor, mental hospital admission frequent. There was a notable lack of psychotic deterioration. 8There was no evident relationship between the types of ictal experience or the frequency of fits and the mental state.9Minimal evidence supported the view that neuroses were commoner with right and psychopathy with left sided operations.10In temporal lobe epilepsies starting after the age of 30 only 1 in 10 patients had a normal mental state at follow-up.1137 % of patients were admitted to mental hospital at some time in the follow-up period. Half these admissions were accounted for by 19 psychotic patients - 5 patients committed suicide.12The author's interpretation of the protocols can be assessed by reference to illustrative case histories.13Other studies of mental states in epileptic patients are reviewed.14The safest theory to explain the effects of surgery on mental state is that epilepsy and its attendant social and psychological problems lead patients towards an abnormal mental reaction the precise form of which is a product of their genetic and social endowment, the nature, timing and siting of their cerebral lesion and their age. 15Correlation analysis used in this way may prove a valuable technique in identifying behavioural patterns which remain stable as against those capable of modification. 1Avant l'intervention, 13 sujets étaient considérés comme normaux en ce qui concerne leur état mental, 30 comme névrosés, 48 comme psychopathes, 16 comme psychotiques et 5 comme ayant une “personnalitéépileptique”. Dans 12 cas, 2 type de troubles étaient associés.2Après l'intervention, 32 sujets étaient considérés comme normaux. Ceux qui furent améliorés provenaient en grande partie du groupe des psychopathes. C'est l'agressivité qui fut influencée de la façon la plus remarquable.3Dans chaque groupe diagnostic., les sujets ayant une mauvaise adaptation sociale se différentaient nettement des autres par leurs caractéristiques, aussi bien avant qu'après l'intervention.4L‘état mental “normal” après intervention était associéà une bonne adaptation dans les relations extra-familiales et professionnelles avant l'intervention, à des crises Grand Mal rares et des crises avec chute après l'intervention et à une adaptation sociale bonne après l'intervention, en particulier dans les relations extra-familiales.5Les états névrotiques étaient associés à une intervention plus tardive, une scolarité meilleure, un niveau intellectuel plus élevé.6Les états psychopathiques étaient associés au sexe masculin, à une classe sociale plus basse, un contexte professionnel médiocre, des relations interprofessionnelles pauvres, ainsi qu'à une épilepsie plus précoce et des interventions sur le côté gauche.7Les psychoses de type schizophrénique ont été inaccessibles à la thérapeutique. Chez ces malades, l'épilepsie avait un début tardif, l'adaptation sociale était médiocre, l'admission en hôpital psychiatrique fréquente. Il faut remarquer l'absence de détérioration psychotique. 8Il n'y avait pas de relation évidente entre le type des expériences critiques, ou la fréquence des crises, et l'état mental.9Peu d'arguments soutenaient l'hypothèse que les névroses sont plus fréquentes après intervention du côté droit et les psychopathies après intervention du côté gauche.10Dans les epilepsies du lobe temporal ayant débuté après l'âge de 30 ans, seulement 1 malade sur 10 avait un état mental normal tout au long de l'évolution.1137 % des malades ont été admis en hôpital psychiatrique à un moment donné de leur évolution. Dans la moitié des cas, il s'agissait de psychotiques (19) - 5 malades se sont suicidés.12L'interprétation que donnent les auteurs des protocoles peut être appréciée par référence aux observations détaillées des cas.13D'autres études de l'état mental des épileptiques ont été passées en revue.14La théorie la plus valable pour expliquer les effets du traitement chirurgical sur l'état mental est que l'épilepsie et ses conséquences sociales et psychologiques conduisent les malades à une réaction mentale anormale dont la forme précise dépent à la fois de leur constitution génétique, de leur situation sociale, de la nature, de la date d'apparition et du siège de leur lésion cérébrale, ainsi que de leur âge. 15L'analyse de corrélation ainsi utilisée peut constituer une technique valable pour identificier des types de comportements qui restent généralement stables malgré certaines exceptions.
Article
Computerized axial tomography (CAT) scanning was carried out on 57 patients who had received a hospital diagnosis of psychoses associated with epilepsy, and 78 epileptic patients with psychiatric illness other than epilepsy. Abnormal scans were reported in approximately half of the cases in both groups. An excess of left hemisphere abnormality was noted in the psychotic group, but this was not significant. These findings failed to provide firm support for the hypothesis that lateralized structural damage to the cerebral hemispheres plays a major part in determining the specific pattern of associated psychotic illness.
Article
The mental states of 23 epileptic psychotic patients and 10 patients with process schizophrenia were compared, using the Present State Examination. The epileptics displayed marked heterogeneity of psychiatric diagnoses. Disturbances of affect underlying the psychosis or presenting as manic-depressive psychosis were frequent and independent of the type of epilepsy. Schizophrenic psychosis, classified with psychopathological criteria similar to those used in the non-epileptic schizophrenic group, was significantly associated with temporal lobe epilepsy. Psychoses other than schizophrenia, however, were present in 5 out of 16 patients with temporal lobe epilepsy. These results support a relationship between schizophrenic symptoms and temporal lobe pathology and emphasize the need to use reproducible methods of diagnosis in psychiatric research.
Article
Todd's post-epileptic paralysis is a well-known complication after focal or generalized epileptic seizures. The underlying pathophysiology, however, is still unknown. Commonly, it is associated with a hemiparesis, usually lasting minutes or hours, rarely as long as two days, with subsequent complete remission. We report 2 patients with unusual and variant post-epileptic syndromes which have not been previously described in the literature: first, an ideomotor limb apraxia, and second, a severe hemineglect syndrome. Each syndrome lasted up to 70 hours after the seizure and was completely reversible.
Article
This study assesses prefrontal and temporal regional cerebral blood flow (rCBF) changes in young, neuroleptic-naive schizophrenic patients with acute disease. A selected population of 10 young, never-treated schizophrenic women with acute disease was studied by two hexamethylpropyleneamine oxime (HMPAO) brain SPECT sessions, performed 48 hr apart, both at rest and during a prefrontal activation task using the Wisconsin Card Sort Test (WCST). All patients met Diagnostic and Statistical Manual of Mental Disorders, 3rd edition-revised criteria for schizophrenia or schizophreniform disorder, were neuroleptic-naive and had acute symptoms. Under resting conditions, the schizophrenic group had significantly higher rCBF in the prefrontal regions, mainly in the left side and including the anterior cingulate, than did the controls. In addition, schizophrenic patients showed significant interhemispheric differences in prefrontal and posterior temporal index values at rest (left hyperfrontality and left hypotemporality). During WCST activation, the control group showed significant increases in prefrontal blood flow, whereas the schizophrenic group did not. These results support a physiologic dysfunction of the prefrontal cortex in schizophrenia that is present at the onset of the illness prior to neuroleptic treatment. Furthermore, both left hyperfrontality and left hypotemporality may indicate a brain lateralization defect in schizophrenia.
Article
We studied 30 patients with postictal psychosis and compared them with 33 patients with acute interictal psychosis and 25 patients with chronic psychosis. All patients had either complex partial seizures (CPS) or EEG temporal epileptogenic foci. Patients with postictal psychosis had a high incidence of psychic auras and nocturnal secondarily generalized seizures. The most striking feature that distinguished postictal psychosis from both acute interictal and chronic psychoses was phenomenological: the relatively frequent occurrence of grandiose delusions as well as religious delusions in the setting of markedly elevated moods and feeling of mystic fusion of the body with the universe. In addition, postictal psychosis exhibited few schizophreniform psychotic traits such as perceptual delusions or voices commenting. Reminiscence, mental diplopia, and a feeling of impending death were also fairly frequent complaints of patients with postictal psychosis. Interictal acute psychosis and chronic epileptic psychosis were psychopathologically similar. Although acute interictal and chronic epileptic psychoses could simulate schizophrenia, postictal psychosis results in a mental state quite different from that of schizophrenic psychosis.
Article
Postictal psychiatric events presenting as postictal psychotic events and postictal nonpsychotic events are known to occur following seizure clusters. Accordingly, patients undergoing prolonged video-electroencephalographic (EEG) monitoring studies may be at increased risk of experiencing postictal psychiatric event, as they often have flurries of seizures during these studies. To determine the annual incidence and clinical characteristics of postictal psychotic events and postictal nonpsychotic events in video-EEG monitoring studies in patients with partial seizure disorders and to identify potential pathogenic factors. Thirteen patients met the criteria for a postictal psychiatric event during the 18-month study period, 10 presenting as postictal psychotic events and three as postictal nonpsychotic events. The annual incidence of postictal psychiatric events at our monitoring unit for 1988 was 7.8%, 6.4% presenting as postictal psychotic events and 1.4% as postictal nonpsychotic events. Seven patients had their first-ever postictal psychiatric event during the monitoring study. In 12 of the 13 patients, the postictal psychiatric events mimicked well-defined psychiatric entities of shorter duration (mean, 66.5 hours); they appeared 12 to 72 hours after the last seizure and remitted spontaneously or with the use of low-dose psychotropic medication. No significant differences in EEG, neuroradiologic, psychiatric, medical, or psychosocial data were found between the patients with postictal psychiatric events and a group of 13 age-matched control patients. Follow-up data of comparable duration were available in nine patients with postictal psychiatric events and nine controls. Psychiatric events were reported more frequently by patients with postictal psychiatric events than by control patients (P=.03). In three patients, postictal psychiatric events converted to interictal events. These findings suggest that monitoring studies increase the risk for postictal psychiatric events, which neurologists need to be familiar with, as they represent important morbidity associated with these studies.
Article
Studies of regional cerebral blood flow in both schizophrenic and depressed patients have yielded contradictory findings. Single photon emission computed tomography (SPECT) was used to compare brain-perfusion patterns in 17 patients with schizophrenia and 12 patients with major depression and to evaluate the relationship of the findings to psychopathology. The images were analyzed both visually and quantitatively. Twelve of the 17 schizophrenic patients and 8 of the 12 depressed patients showed a pathological blood flow pattern. Hypoperfusion of the left temporal lobe was observed in seven of the schizophrenic and five of the depressed patients. Five of the schizophrenic patients also had a hypoperfusion of the left frontal lobe. Separation of both diagnostic cohorts in two subgroups with pathological and normal cerebral blood flow patterns revealed significantly higher levels of symptomatology in the group with hypoperfusion in the SPECT image. The analysis of different cerebral regions revealed statistically significant temporal hypoperfusion was significantly related to positive symptoms in schizophrenia. Our data suggest that left-sided temporal lobe dysfunction is related both to schizophrenia and major depression. The localization of hypoperfusion seems to be associated with the type of psychopathology (positive vs. negative symptoms in schizophrenia). Thus, the results support the model of paralimbic and prefrontal dysfunction in both diseases.
Article
Studies of schizophrenia by single photon emission computed tomography (SPECT) and positron emission tomography (PET) have shown both regional cerebral hyperperfusion and hypoperfusion. The aim of this study was to examine the inter-relations between regional cerebral blood flow (rCBF), psychopathology, and effects of neuroleptic therapy. 24 never-treated patients with acute schizophrenia were examined with hexamethylpropyleneamine-oxime brain SPECT and assessed psychopathologically according to the positive and negative syndrome scale; they were studied again after neuroleptic treatment and psychopathological remission. rCBF values that deviated from those of 20 controls by more than 2 SD were regarded as abnormal. Both hyperperfused and hypoperfused patterns were found among schizophrenia patients during acute illness. The seven positive symptoms on the symptom scale showed different correlations with rCBF: formal thought disorders and grandiosity correlated positively (and strongly) with bifrontal and bitemporal rCBF; delusions, hallucinations, and distrust correlated negatively (and strongly) with cingulate, left thalamic, left frontal, and left temporal rCBF. Stereotyped ideas as a negative symptom correlated negatively (and strongly) with left frontal, cingulate, left temporal, and left parietal rCBF. After neuroleptic treatment (and reduction of positive symptoms), only negative symptoms correlated exclusively with bifrontal, bitemporal, cingulate, basal ganglia, and thalamic hypoperfusion. Different positive symptoms are accompanied by different rCBF values--some related to hyperperfusion, others to hypoperfusion. This finding may help to explain observed inconsistencies of perfusion patterns in drug-naïve schizophrenics.
Article
We performed technetium-99m-hexamethylpropylene- amineoxime (Tc-HMPAO) single photon emission computed tomography in two patients with prolonged hemiconvulsions followed by transient hemiparesis (Todd's paralysis). In both cases, a prolonged post-ictal cerebral hyperperfusion state of approximately 24 h was observed, even after the neurological deficits had resolved. The cerebral hyperperfusion in both cases was of much longer duration than that in previously reported cases of single and uncomplicated focal seizures. The prolonged cerebral hyperperfusion might have been due to impairment of the cerebrovascular autoregulation in seizures followed by Todd's paralysis.
Article
This report examined the underlying mechanism of psychosis associated with epilepsy. An adult patient with epilepsy manifesting acute psychosis during long-term EEG monitoring is presented, together with a literature review on this subject. A 25-year-old woman with intractable temporal lobe epilepsy developed acute psychosis while she underwent long-term intracranial EEG monitoring. After a clustering of seizures, she manifested psychotic symptoms including hallucination, stupor, and repeated fear. The transition of psychotic symptoms corresponded to the changes in frequency and morphology of seizure discharges restricted to the left amygdala. Improvement of psychosis coincided with disappearance of seizure discharges. This case confirmed a close relationship between psychotic symptoms and seizure discharges in the left amygdala. It is suggested that paroxysmal bombardment of the medial temporal lobe structure may be a pathogenetic factor of acute psychosis associated with epilepsy.
Article
The development of algorithms for Radionuclide Computed Tomography (RCT) is complicated by the presence of attenuation of gamma-rays inside the body. Some of the existing RCT reconstruction algorithms apply approximation formulas to the projection data for attenuation correction, while others take attenuation into account through some iterative procedures. The drawbacks of these algorithms are that the approximation formulas commonly used are generally inadequate and the iterative procedures are usually very time-consuming. The method for attenuation correction in RCT, which we propose, applied a simple, effective two-step procedure to the uncorrected image. In this procedure the filtered back-projection algorithm is used for its fast speed. A simple mathematical basis and description of the procedure together with some illustrative computer results are given in this paper.
Über die Einteilung der Nervenkrankheiten in Siegburg. Zeitschrift für die gesamte
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