Role of the interictal and periictal psychopathology in suicide

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The premodern psychiatrists who established the basis for our modern classification of mental disorders noted that specific mental changes were associated with epilepsy. They had the advantage of observing institutionalized patients with chronic epilepsy over prolonged periods and were familiar with the characteristic intermittent and pleomorphic changes that have eluded the modern cross-sectional psychological assessment of patients with epilepsy. Modern assessments are usually carried out with methods that have been validated for use in patients who do not have epilepsy and that are insensitive to the task. Premodern psychiatrists had arrived at the concept of the dysphoric disorder as the most common psychiatric disorder of epilepsy, a distinct disorder that has only recently been rediscovered (Blumer et al., 1995). One of its key symptoms is associated with the episodic suicidal moods of patients with chronic epilepsy, i.e. mesial temporal lobe epilepsy (Blumer, 2000; Blumer et al., 1995; Gastaut, 1956).

Kraepelin (1923) precisely described the intermittent dysphoric disorder of patients with epilepsy. Dysphoric episodes present with depressive moods ('very frequently with utter disgust of life and suicidal bent'), irritability, anxiety, headaches, insomnia or at times with euphoric moods. These polysymptomatic dys-phoric episodes occur without external triggers with rapid onset and termination and recur fairly regularly in a uniform manner in the absence of clouding of consciousness. Dysphoric symptoms can be observed as prodromes of an attack or in the aftermath of an attack, but they most commonly appear as phenomena independent of the seizures, with a frequency varying from every few days to every few months. A patient just awakens one day dysphoric, or the dysphoria develops insidiously through the course of a day. As a rule, the dysphoric state lasts from 1 to 2 days but might dissipate after just a few hours. Based on our own observations, we have added anergia and phobic fears to Kraepelin's six key symptoms of the dys-phoric disorder and have defined it by the presence of at least three of the eight key symptoms, each present to a troublesome degree. We have noted an average of five key symptoms among our patients with dysphoric disorder (Blumer et al., 1995).

The risk of suicide in patients with epilepsy is primarily associated with the episodes of intense depressive mood that occur during the interictal phase of patients with a dysphoric disorder, and suicide in epilepsy tends to occur in a precipitate manner. As already noted by Kraepelin, the dysphoric symptoms also tend to occur peri-ictally, during the prodrome or in the aftermath of a seizure. The postictal phase in particular may be associated with marked depressive mood (Blumer, 1992). A high suicidal risk has been observed in patients who experience ictal depressive mood that extends into the postictal phase for a period of 1 hour to 3 days. Williams (1956) reported 21 such cases among his 100 patients with ictal emotional experience, and 5 of the 21 patients made suicide attempts during their postictal phase.

As noted by Kraepelin, interictal psychoses tend to develop among patients with interictal dysphoric disorder (Blumer et al., 2000; Kraepelin, 1923). The dysphoric disorder persists during the psychotic state, and intense depressive moods may occur in the course of an interictal psychosis. The presence of the hallucina-

tion of voices commanding patients to kill themselves represents a particular suicidal risk.

The psychopathology of four patients (Mendez and Doss, 1992) who committed suicide is not reported in detail beyond the psychotic episodes in three of them and the ictal and postictal depression in the fourth patient; the researchers state only that two of those with psychosis also experienced depressive episodes. Four of the five patients from the Epi-Care series had longstanding dysphoric disorders. The fifth patient who had been found free of dysphoric symptoms earlier was not examined during the 3-month interval from finally (after 20 years) becoming seizure-free to his death by suicide; it was learned, however, that he had begun to experience episodes of rage, symptomatic of a de novo dysphoric disorder.

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