Coping With Schizophrenia and Psychosis

The Schizophrenia-free Package

What are you going to find in the Schizophrenia-FreeYour New Life Begins Today e-book: Relationships and Friends: In this chapter, I share with you my way of thinking about friends and relationships. I provide my point of view about how I see this interesting issue. I also give you some tips about how to get friends, deal with friends, and treat relationships. About Schizophrenia and Getting Well: In this chapter, I describe my way of thinking about schizophrenia and other similar mental illnesses. Living on Your Own and Being Independent: In this chapter, I share my perspective about our independence as sufferers and how to live on our own and be independent. Other Sufferers' Recovery Examples: I decided to share other sufferers' stories so you won't feel alone in your illness. Finding Your Mate and Getting Married: Having a mate is one of the most important pillars in your life as a sufferer. In this chapter, you learn some of the most important basics in this matter. Preventing Future Seizures and Getting Help: This chapter shows how to reduce the chance of having future psychotic disorder seizures and, even if you experience one, how to make it as minimal as possible. Dieting and Exercising: This chapter demonstrates how to acquire easy life habits in order to survive your years to come in the healthiest manner possible. Living by Yourself and Earning Your Own Money: This chapter shows how to earn your own money and live by yourself as a result. Ways of Getting Support: There is nothing like a good support system in order to rehabilitate in the best matter possible. This chapter discusses the most basic and powerful ways of getting support. Quitting Smoking: In this chapter, you learn the basic principles of why and how to quit smoking. Learning a Profession and Finding a Job: In this chapter, you learn the most important factors for learning a profession and finding a job.

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Postictal psychoses revisited Table 94 Patient background

Postictal psychosis (n 45) (SD) Interictal psychosis (n 126) (SD) Age at epilepsy onset (year) Duration of epilepsy (year) Age at psychosis onset (year) Latent period Low intelligence higher in patients with interictal psychosis than in those with postictal psychosis. These data agree well with the report of Umbricht et al. (1995), which confirmed lower IQ and younger age at onset of epilepsy in interictal psychosis than in postictal psychosis. Our data support the suggestion of a majority of previous studies that psychosis in epilepsy might be preferentially associated with the temporal lobe (Bruens, 1971 Edeh and Toone, 1987 Gibbs, 1951 Perez and Trimble, 1980 Toone et al., 1980). However, a direct comparison between postictal and interictal psychosis revealed that the close link between psychotic episodes and temporal lobe epilepsy was significantly more remarkable in postictal than in interictal psychosis (Table 9.5). Our data provided additional supportive evidence in this...

Chronic interictal psychoses

Because of the widespread reservation about operating on chronic psychotic patients, due to the argument that the psychoses would continue to persist anyhow, and surgery would therefore not be profitable, the number of severe psychotic patients evaluated has become small in epilepsy surgery centres. However, the argument of the positive effects of a seizure reduction in psychotic patients is relevant, and Fenwick (1988) has argued that psychotic patients without seizures could be much 'better off than patients with psychosis and seizures. Moreover there are reports of permanent remittance of psychoses after surgery (Jensen and Larsen, 1979), and enduring deteriorations on the other hand have not been found (Taylor, 1972). Nevertheless, surgical interventions in chronic psychotic patients are complicated. First, the comorbidity of psychosis and TLE may be evidence for an extended limbic dysfunction. Second we know that these patients are vulnerable and tend to experience acute...

Risk Factors for Developing Psychosis

Numerous studies have looked at the risk factors for the development of psychosis in epilepsy. Unfortunately, results are not always consistent, and studies may be biased because of selection criteria. It is widely accepted that psychosis is more common in people with TLE (14 ) compared with idiopathic generalized epilepsy (3.3 )26 however, recent studies have found no difference.27,28 It is difficult to compare studies in the field because of the varying definitions of epilepsy, psychosis, and the risk factors identified, however, it is thought that female patients with TLE (complex partial seizures), with a left-sided focus on the electroencephalogram, will more commonly suffer from psychosis of epilepsy.29 Recent studies have refuted this, with no difference being demonstrated in the sex, laterality of seizures, or age-related variables rather, the associations found were related to level of intellectual functioning (more common in people with low or borderline ID) and family...

Learning disability behavioural disorder and psychosis

The presence of a chronic interictal psychosis is also generally a contra-indication to surgery, as the psychosis can worsen dramatically after surgery. Decisions about surgical treatment should not be made by severely depressed patients. Psychosis and depression may also prevent informed consent. Again, individual decisions in this situation require a detailed assessment by an experienced practitioner.

Violence and postictal psychosis

Violent behaviour elicited in the course of postictal psychosis deserves a special comment. The argument against the view that epilepsy is closely related to a libera tion of aggressive impulses has marked modern epileptology, with the result that epi-leptologists have almost succeeded in dismissing this old view. However, in the course of our investigation of postictal psychosis, the sporadic episodes of abrupt violent behaviour that we observed impressed us greatly. In a previous study (Kanemoto et al., 1999), we compared violent attacks during episodes of postictal psychosis, acute interictal psychosis, and postictal confusion immediately following complex partial seizures in patients with temporal lobe epilepsy (TLE), and confirmed that severe violent confrontational behaviour towards surrounding people with impending danger occurred only rarely during the postictal confusions as previous studies have also pointed out (Ashford et al., 1980 Rodin, 1973 Treiman, 1991). In contrast,...

Postoperative psychoses

One question is, whether or not there are typical de novo psychoses induced by ES. According to one position, postoperative psychoses primarily occur as so-called de novo postictal psychoses (Savard et al., 1998) in patients with persistent seizures, and thus are only indirectly connected with the surgical event. Another position is that surgery only has the function of a trigger that releases a manifest psychosis, which was already latent and might have found its preoperative expression in paranoid personality traits (Ferguson et al., 1993). However, there are still good arguments for the diagnostic entity 'de novo psychosis' as aetiologically linked to the surgical intervention. Mace and Trimble (1991) consider them to be an effect related to a nondominant hemisphere hypofunction, because they predominantly occur after right nondominant resections. They further argue that the sudden inhibition of seizure activity through surgery may induce mechanisms parallel to those of 'forced...

Concluding Remarks Plural Epileptic Psychoses Should Be Understood Under Plural Hypotheses

Does the psychosis of epilepsy differ from a primary psychotic disorder Historically, several answers have been presented. As we discussed in the preceding sections, variations of the answer in the negative may be summarized as follows the coexistence of the two conditions in a single individual is only accidental epilepsy increases the vulnerability to a primary psychotic disorder and the two conditions develop from a common etiological factor, but independently. Since Slaters report 40 years ago, the first answer seems to be denied by several studies including large scale epidemiological investigations (Jalava and Sillanpaa, 1996 Bredkjaer et al. 1998 Qin et al. 2005). When focused on CP, the increased incidence of psychosis among patients with epilepsy has tended to be explained by one of the latter two answers, both of which presuppose an enhanced susceptibility to schizophrenia in patients with epilepsy. As mentioned in the introduction section, the corollary to these is that...

Alternative psychosis and forced normalization

In some patients periods of seizure control and normalized EEG appear to be associated with the development of psychoses, which is reversed when seizures recur (the phenomenon as applied to EEG is sometimes known as 'forced normalization'). However, the opposite pattern is also observed, and the true status of forced normalization is rather contentious. The exact mechanism of this pattern is unclear. Antipsychotics, antidepressants and anxiolytic drugs, as appropriate, can be used to treat these episodes. In some individuals the psychosis may be due in part to the introduction of an antiepileptic drug (associated with the remission of seizures), and the replacement of this drug by others is worthwhile. In exceptional cases it is deemed

Alternate Psychosis Or Forced Normalization

The concept of alternate psychosis was developed from observations in 1953 by Landoldt, of an inverse relationship between seizure control and psychotic symptom occurrence, in which he observed a 'normalization' of EEG recordings with the appearance of psychiatric symptoms and coined the term 'forced normalization' 56 . This antagonism between psychosis and epilepsy has been considered by some as the explanation for the therapeutic effect of ECT of psychotic disorders. Forced normalization has been reported in patients with temporal lobe epilepsy and generalized epilepsies this phenomenon is relatively rare. Forced normalization presents as a pleomorphic clinical disorder with a paranoid psychosis without clouding of consciousness being the most frequent manifestation. As with other POEs, a richness of affective symptoms has been identified.

Lucid interval recurrence and duration of postictal psychosis

Postictal psychosis has long been confused with the clouded consciousness observed following complex partial seizures. Recent studies, including ours, have proven that postictal psychosis cannot be reduced to a mere extension of postictal confusions. The primary argument in support of this is twofold (1) there is preserved orientation and memory seen during the episodes, and (2) lucid intervals occur between the end of the seizures and the start of postictal psychoses (Kanemoto et al., 1996 Levin, 1952 Logsdail and Toone, 1988 Savard et al., 1991). It is very difficult to explain the delayed manifestation of positive symptoms after a short period of normality as a psychic equivalent of Todd's paralysis, since a mere exhaustion of the nervous system would have steadily recovered without reversion, just as in postictal confusion. In 18 out of 51 patients, we confirmed the presence of a lucid interval, which lasted from 1 to 3 days in 15 out of the 18 (83 ) (Table 9.2). This agrees well...

The Psychoses of Epilepsy a Neurological Disease

A close association between psychoses and epilepsy has been known since 1854 confirmed by the fact that the early mental hospitals in Europe had special wards dedicated to epilepsy. The early proponents of psychosis of epilepsy (POE) included Kraepelin (1918) who believed that the dementia resulting from epilepsy was different from dementia praecox or schizophrenia. This was further affirmed by Vorkastner (1918) and Krapf (1928) who clarified that schizophrenialike symptoms might follow epilepsy and that these need to be differentiated from true schizophrenia. Contrary to this, Glaus (1931) and Gruhle (1963) opined that the schizophrenic symptoms of epilepsy could be true independent schizophrenia. In 1860, with the description of alternating psychosis, this relationship underwent some radical thinking, and sadly petered out until the 1950s when the term schizophrenia-like psychosis of epilepsy (SLPE) was coined by Slater et al. (1963). Throughout its history, however, POE has been...

Which Type Of Epileptic Psychosis Should Be Compared With Which Primary Psychotic Disorder

With regard to the wide-ranging clinical manifestations of epileptic psychoses and primary psychotic disorders, it is important, first of all, to determine which should be compared. Table 8.1 demonstrates the incidence of subcategories of psychosis occurring in patients with epilepsy who visited the Kansai Regional Epilepsy Center from 1983 to 1999 (Kanemoto et al, 2001), definitions of which are listed in Table 8.2. Chronic epileptic psychosis (CP), acute interictal psychosis (AIP), and postictal psychosis (PIP) together constituted 95 of all patients who had TABLE 8.1 Subcategories of epileptic psychoses (n 200) Postictal psychosis AIP as well Acute interictal psychosis evolving into CP Chronic psychosis Others Source Data recalculated from Kanemoto et al. (2001). AIP Acute interictal psychosis CP Chronic psychosis. TABLE 8.2 Definitions of subcategories of epileptic psychoses Postictal psychosis Psychosis that follows immediately after 1 or generally multiple seizures (mostly...


Looking at the most serious, yet rarest, psychiatric disorder, the psychoses, and paying attention to their frequency in generalized epilepsies in comparison to focal epilepsies, most authors of the relevant literature (Table 4.1), found that psychoses in focal epilepsies are slightly more frequent than in generalized epilepsies, but the difference proved to be significant in only one study (Onuma, 1983). Two studies using the International Classification did not find the frequencies of psychoses in IGE and in TLE to be different (Schmitz and Wolf, 1991, 1995 Sengoku et al., 1997). With regard to specific epileptic syndromes, CAE was significantly associated with the presence of psychosis. CAE occurred in 7 28 (25 ) of patients with psychosis compared with 55 669 (8 ) of patients without psychosis (Schmitz and Wolf, 1991). With regard to specific seizure types, absences in combination with GTCS are associated with an increased risk of psychosis. With this seizure combination psychosis...


The term 'psychosis' designates - globally spoken - severe psychiatric syndromes, characterized by thoughts, feelings and actions that are incomprehensible for a neutral observer. Diagnoses are often based on spectacular symptoms such as delusions and hallucinations without any further diagnostic differentiation. Given this weak assessment basis, Savard (1991) found in a meta-analysis of diverse studies, preoperative rates of psychoses between 7 and 16 , and postoperatively between 10 and 28 . The importance of an exact classification of psychoses in the context of epilepsy is emphasized by Trimble and Schmitz (1997). They distinguish between ictal, postictal, peri-ictal, interictal and alternative psychoses. Except for interictal psychoses, which require neuroleptic treatment, all other psychoses in epilepsy require a regulation of the antiepileptic drugs as the first therapeutic intervention. Thus, clear diagnoses can save patients from referrals to psychiatric hospitals.

Postictal psychoses

Poor diagnostic differentiation between the psychoses, especially between postictal and interictal ones, can have severe consequences for surgical candidates. Thus, without exact psychiatric classification, the already-mentioned tendency to exclude psychotic patients from surgery could mislead surgeons into regarding postictal psychoses as a contraindication for ES. 'Mislead' because patients with postictal psychoses can profit from surgery in two ways. If the resection is successful, they lose their seizures. However, in addition they will lose their directly seizure-related psychosis. For these reasons Fenwick (1994) has even suggested that postictal psychoses should be regarded as a psychiatric indication for ES. Table 18.2. Postictal psychoses Psychiatric outcome Psychoses The occurrence of postictal psychoses was quoted at 4 in a large study group of more than 800 patients with TLE (Kanemoto et al., 1996), but the incidence in surgical candidates is higher (between 6 and 18 )....

Postictal Psychosis

Post-ictal psychotic phenomena can present in the form of isolated symptoms or as a cluster of symptoms mimicking psychotic disorders. Post-ictal psychosis (PIP) corresponds to approximately 25 of POE. The prevalence of post-ictal psychiatric disorders in the general population of patients with epilepsy is yet to be established, but has been estimated to range between 6 and 10 54 . In a study published in 1996, we estimated the yearly incidence of post-ictal psychiatric disorders among patients with partial epilepsy who are undergoing video-EEG to be 7.9 55 . The majority, or 6.4 , presented as PIP. Common findings among the different case series of PIP include (i) a symptom-free period of several hours to several days between the onset of psychiatric symptoms and the time of the last seizure (ii) a relatively short duration, ranging from several hours to a few days, though occasionally can extend to several weeks (iii) an effect-laden symptomatology (iv) the clustering of symptoms...

Chronic psychosis

A grumbling interictal psychosis, with occasional exacerbation, is often seen in patients with severe epilepsy. Psychotic features may be quite mild, and complicated by irritability, anxiety, paranoia and dysphoria. In most cases antipsy-chotic medication is required. Sulpiride is a good drug for mild psychosis, and its additional anxiolytic effects can be helpful. During acute exacerbations of psychotic behaviour, risperidone, olanzapine or quetiapine may become necessary. Sometimes exacerbations of interictal psychosis are prolonged and non-responsive to treatment. In these cases clozapine can be used, but it can precipitate seizures and also carries a significant risk of leucopenia, and close monitoring of blood counts is necessary. Electroconvulsive therapy (ECT) has occasionally been used, and is often strikingly effective, but there is a theoretical risk of ECT-induced status epilepticus.

Are psychiatric disorders commoner in epilepsy

This question needs to be addressed from a public health perspective. Were psychiatric disorders to be commoner in patients with epilepsy, specific mental health resources would need to be created in the community for this patient group. On the other hand were there no excess in psychiatric comorbidity, when patients with epilepsy were compared with other illness groups, matched for age, sex and disability, and normal controls, such resources would not be required. Here we shall examine the evidence, to see if depression and psychosis are commoner in epilepsy. Of all the different psychiatric disorders in epilepsy, it is psychosis for which there is considerable evidence of overrepresentation. The prevalence of psychosis in epilepsy is reported to be in the order of 4 (see Manchanda et al., 1996 for example), sometimes rising as high as 10 . Psychotic disorders are 10 times more common in epilepsy than in the general population, and this is borne out in well-designed population-based...

The classification of psychiatric disorders in epilepsy

Patients with epilepsy - fourfold risk of somatic, psychosomatic and or psychiatric disorder in combination compared with population-based controls Results related to epilepsy and not antiepileptic drug administration Incidence of schizophrenia spectrum psychoses significantly increased for both men and women with epilepsy Standardized incidence ratio for the entire schizophrenia spectrum (P 10-8), nonaffective psychosis (P 10-8) and schizophrenia alone (P 0.0001) Psychiatric diagnosis in 35 of 241 epilepsy cases as compared with 30 of controls, the difference not being statistically significant Significantly higher rate of schizophrenia among men Other differences have also been reported to characterize psychopathology in epilepsy and to differentiate it from psychopathology in general. The interictal psychosis of epilepsy is reported in many studies to be characterized by the preservation of affect, religiosity and paranoid ideation, rather than the undifferentiated, or hebephrenic...

The psychiatry of idiopathic generalized epilepsy

'Temporal Lobe Epilepsy (TLE) is associated with an increase in psychiatric morbidity compared to other types of epilepsy.' This hypothesis is central to the discussion of the relationship between epilepsy and psychopathology, according to the statement of Anne Stub-Naylor, a young Danish doctor, in her thesis on 'Epilepsy and psychiatric disorder - a comorbidity study' (1996). And she continues 'Despite the scarce evidence it appears to have become a dogma that such a relationship exists. In contemporary medicine especially three schools have nourished this view, represented by Elliot Slater, David Bear and Michael Trimble'. Indeed, the description of schizophrenia-like psychoses in patients with TLE (Slater et al., 1963) - has encouraged the expectation of finding a biological-based explanation for schizophrenia. For this reason, the discussions on psychiatric disorder and especially those on psychoses in the case of epilepsy have long been dominated by the 'limbic hypothesis'.

Classification of aggression

Aggressive behaviour can be observed in the context of different medical, neurological and psychiatric disorders and diseases. It is a common problem in patients with mental retardation, possibly due to impaired social perception or deficits in expressing personal needs (Barratt et al., 1997 Gunn, 1977 Kligman and Goldberg, 1975 Saver et al., 1996). Aggressive behaviour in the context of organic brain disease like frontal or hypothalamic brain tumours, neuro-degenerative disease, delirium or drug abuse is often malstructured, defensive and tends to occur in the context of states of confusion and diffuse emotional arousal. Goal-directed and well-planned acts of aggression can occur on the background of psychiatric disorders like psychosis with delusional states, attention-deficit hyperactivity disorder (ADHA) or bipolar disorder. It is frequently observed in patients with antisocial personality disorder (APD) where it is part of the characteristic trait-like behaviour (Barratt et al.,...

Series of suicides providing neuropsychiatry data

Mendez and Doss (1992) reported on the psychiatric aspects of four patients who died by suicide out of 1611 patients with epilepsy followed in a neurology clinic over a period of 8 years two male patients with chronic psychosis and good seizure control one male patient with brief psychotic episodes associated with confusion and increased bitemporal spikes and diffuse slowing on EEG in the absence of seizures and one female patient with profound ictal and postictal depression who committed suicide after three witnessed staring spells. The patient with brief psychotic episodes and one of the patients with chronic psychosis experienced voices commanding them to commit suicide. All four patients had suffered from complex partial seizures since childhood. All four patients committed suicide by medication overdose.

Preventing suicide in epilepsy

Preventing suicide in epilepsy patients consists of effectively treating both the dysphoric disorder and the psychosis of the interictal phase (Blumer, 1997 Blumer et al., 2000 Blumer and Zielinski, 1988). We now treat both the patients with suicidal dysphoric moods and those with interictal psychoses with double antidepress-ant medication, enhanced if necessary with an atypical neuroleptic drug, e.g. with the combination of 100-150 mg imipramine, 20-40 mg paroxetine and 2-4 mg risperidone daily. The same treatment has been effective for patients with severe postictal depressive mood, although we have not had the occasion to treat a patient with ictal depression and suicidal intensity of the postictal phase. The dysphoric disorder is endogenous, and psychotherapy without pharmacotherapy leaves the patient with suicidal moods at risk. 1998) is erroneous on both empirical and theoretical grounds. As our experience over some 15 years has shown, the modest amounts of antidepressant...

Classical antiepileptic drugs

Psychoses and other complications Alternative psychoses Toxic schizophreniform psychoses, encephalopathy Aggression, depression, psychosis withdrawal syndromes ADHD, encephalopathy, alternative psychoses Rarely psychoses Psychoses possible Psychoses Phenytoin may provoke schizophrenia-like psychoses at high serum levels (McDanal and Bolman, 1975). These psychoses are dose related, thus toxic syndromes, but they are not associated with cerebellar symptoms which are the most Psychoses typically following cessation of seizures and associated with a normalization of the EEG occur in 2 of children treated with ethosuximide. The risk for 'forced normalization' is higher (8 ) in adolescents and adults treated with ethosuximide for persisting absence seizures (Wolf et al., 1984).

Psychiatric side effects of new antiepileptic drugs

Batrin, a London group had published an incidence of significant psychiatric complications in 7 of treated patients (Sander et al., 1991). Thomas et al. (1996) have analysed case records of psychiatric complications, episodes of psychoses or major depression, reported to the manufacturer of vigabatrin. With respect to psychoses the authors identified three patterns of a total of 28 psychotic patients, eleven had become seizure free with vigabatrin, six had a postictal psychosis following a cluster of seizures after initial seizure control, possibly related to tolerance, and two psychoses occurred after withdrawal of vigabatrin. Since these early reports, the clinical significance of vigabatrin-associated behavioural problems has been a matter of controversy, prompting Ferrie to perform a meta-analysis of psychoses and severe behavioural reactions leading to drug discontinuation, in seven placebo-controlled European studies (Ferrie et al., 1996). The overall incidence of these...

Summary and clinical recommendations

Psychiatric disorders in epilepsy have a multifactorial aetiology, pharmacotherapy being only one of many risk factors which are both biological and psychosocial. Among psychiatric adverse events of anticonvulsants, a variety of nonpsychotic behavioural problems are reported most commonly, followed by affective disorders, and psychosis being a relatively rare though severe complication. Psychotropic effects of anticonvulsants warrant further research because many relevant parameters related to pathomechanism, frequency, psychopathology and prognosis are not known.

How could the development of personality disorders and their neuronal basis be explained

Such a model of interaction of psychosocial and neurobiological factors could be paradigmatic for the development of all psychoses maladaptive schemata of action and behaviour, acquired by constitutional and or experiential faults, are preconditions, which emerge as personality disorders. Under special emotional stress

Pharmacokinetic interactions

The interactions between antipsychotic drugs and antiepileptic drugs have been even less studied than the antidepressants. Some psychotropics, such as haloperi-dol, mainly metabolize using the P450 system, others such as chlorpromazine use different liver mechanisms. However, decreases in the levels of some neuroleptics can occur in patients prescribed anticonvulsant drugs, and several studies have been carried out in patients with schizophrenia who have received both carbamaz-epine and a neuroleptic. Haloperidol levels can drop by up to 50 following coadministration of the antiepileptic (Arana et al., 1986). Clozapine and olanzapine primarily use the CYP1A2 isoenzyme, which may lead to interactions with some of the tricyclic antidepressants, and carbamazepine.

Treatment of aggression in epilepsy

If aggression is a problem in the clinical management of patients with epilepsy the most important point is to establish a correct diagnosis (Figure 7.5). A careful neurological, psychiatric and medical history and examination should be performed to answer the following questions 1. Is there any medical condition that contributes to the aggressive behaviour such as endocrinological or immunologi-cal diseases Is there any medication that might contribute to the aggressive behaviour 2. What is the correct neurological diagnosis Are there any other cerebral problems in addition to the epilepsy 3. Are there any psychiatric diagnoses which possibly are independent of the epilepsy, like bipolar disease or antisocial personality disorder If the epilepsy started early in life it is in fact often impossible to establish if, for example, a clinical picture that fulfils the criteria for an antisocial personality disorder has to be judged as independent of the organic brain disease indicated by...

Aggression and epilepsy

Postictal aggression is more common than ictal aggression but it is still believed to be rare (Treiman, 1991). It often occurs following a cluster of complex partial seizures or very severe secondary generalized seizures. Ictal pain or dysphoria may predispose individuals to the development of postictal aggressive behaviour (Gerard, 1998). Postictal aggression is frequently observed in the context of postictal confusional states or postictal psychosis but it also occurs without any signs of delusion or hallucination (Kanemoto, 1999 Lancman, 1999 Szabo and Lancman, 1996). If postictal aggression is part of a postictal confusional state the disruptive behaviour immediately follows the seizure without a lucid interval. The violent behaviour tends to be resistive, poorly structured and patients usually are very aroused, angry and fearful (Kanemoto, 1999 Lancman, 1999). Postictal psychosis follows a cluster of complex partial and secondary generalized seizures after a lucid interval, which...

Personality disorders a gateway to an individual understanding of patients

To recapitulate our main results on personality disorders in the surgical context First, 60 of our patients with temporal lobe resections had personality disorders second, about one-third of all patients with severe personality disorders suffered from postoperative psychiatric deteriorations third, we had no new psychoses after surgery without preexisting personality disorder (paranoid features in most cases) and finally, we had no new dissociative attacks after surgery without preexisting personality disorders (all borderline type).

Intermittent explosive disorder in epilepsy

Twenty- five patients with TLE and IED diagnosed according to the DSM-IV criteria described above and 25 control patients with TLE without any psychopathol-ogy were recruited from a tertiary referral centre (National Hospital for Neurology and Neurosurgery and the associated Chalfont Centre for Epilepsy). The clinical syndrome of interest was defined as complex partial seizures with a semiology, EEG and MRI findings compatible with TLE. On the basis of the discharge summaries patients with TLE with and without a history of aggression were identified, contacted and seen by a neuropsychiatrist (LTVE). Patients with extratemporal or generalized epilepsy were excluded as were those with a history of mental handicap or psychoses. Patients with TLE with and without a history of IED diagnosed according to DSM-IV criteria were included in the study.

Nonepileptic seizures and dissociation

Epileptologists frequently encounter patients who present with paroxysmal events that, despite resembling epileptic episodes, are actually nonepileptic. Indeed, as many as 50 of patients referred to specialist epilepsy centres may turn out not to have epilepsy (Francis and Baker, 1999). While some nonepileptic seizures may be attributable to physical causes other than epilepsy (see Gates and Erdahl, 1993), a demonstrable organic basis is absent in many such cases. Of these, some are attributable to an identifiable psychiatric illness, such as psychosis, that can produce seizure-like symptoms. In other cases, however, nonepileptic seizures4 occur as an isolated psychiatric problem in their own right. Identifying such cases represents a considerable challenge to neurologists working within this domain. At present, there are few, if any, reliable criteria for an inclusive diagnosis of nonepileptic attack disorder. As a result, current diagnostic practice is essentially based on the...

Statedependent cognitive impairment

Frequent absence seizures, by interrupting awareness, can affect both cognitive performance and behaviour. People who are having frequent absence seizures may present as having withdrawn behaviour, fragmented thought processes which may be mistaken for a psychosis, attention-deficit disorder with motor overactivity or, if the frequency of the seizures is variable, attention-seeking behaviour. The last of these behaviours tends to be seen when the person emerges from a bout of very frequent absence seizures. It is almost as if the child is 'making up for lost time' in being badly behaved when he has the opportunity of doing so, having been unable to misbehave when the absence seizures were very frequent.

Historical background

Except for the immediate effects of a seizure on mental function, such as complex partial status epilepticus and postictal confusion, modern epileptic psychoses can be categorized into three main types chronic, acute interictal and postictal psychoses. In 1953, Landolt stressed a seesaw relationship between epileptic seizures and psychoses, and proposed the concept of forced normalization. In 1963, Slater made a rather comprehensive report on chronic psychoses in patients with epilepsy (Slater and Beard, 1963). In contrast, it was as late as 1988 before the concept of postictal psychoses was revived by Logsdail and Toone. This delay in conceptual formation is all the more peculiar, when considering the very old root of the concept of postictal psychosis. In 1860, a French psychiatrist, Farlet, classified epileptic psychoses into three categories transient peri-ictal, chronic and true epileptic psychosis (Farlet, 1860 1961). As there was a lack of strict distinctions between preictal,...

Role of the interictal and periictal psychopathology in suicide

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- 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,...

Psychopathological features

The most striking differences between interictal and postictal psychoses lay in the domain of psychopathological phenomenology (Table 9.9). In a series presented by Logsdail and Toone (1988), only one of 14 patients had primary delusions or thought disorders (7 ), whereas as many as nine exhibited a markedly abnormal mood (64 ). Our previous study, comparing the psychopathological features of postictal psychoses with those of interictal psychoses, supported their data. The first-rank symptoms of Schneider, such as delusions of perception and voice commenting, occurred significantly less often in postictal psychoses than in acute interictal psychoses, whereas sexual indiscretions, religious delusions, and grandiosity, often in the setting of an elevated mood, were observed in postictal psychosis five times more often than acute interictal psychosis. Illusions of familiarity, mental diplopia, and feelings of impending death, which Jackson and Stewart (1899) described as hallmarks of the...

Temporal Gate hypothesis

In other neurological conditions associated with deterioration, the phenomenon of oxidative stress (the production of oxygen radicals beyond a threshold for proper antioxidant neutralization) has been implicated. These include Alzheimer's disease (Sims, 1996), Parkinson's disease (Jenner and Olanow, 1994), amyotrophic lateral sclerosis (Gorman et al., 1994), Pick's disease (Castellani et al., 1995J and schizophrenia (Ramchand et al., 1996). Various intracellular messenger systems involving glutamate are implicated in oxidative radical production. These systems are involved in neuronal growth, differentiation and apoptosis (Michaelis, 1998). Glutamate is also known to play an important role in epilepsy. The author has observed substantial improvement in cognitive functioning in two patients (one male 'subcortical', one female 'temporal') after using lamotrigine, a glutamate release inhibitor (Meldrum, 1994). There are various other reports, generally of an anecdotal nature, of the...

Epilepsy and behaviour disorders

Single case reports of behavioural and personality disorders in patients with severe brain lesions often appear dramatic. However, with respect to focal epilepsies, these reports nevertheless raise the question of whether there might be parallels in the behaviour when epilepsy affects the same brain regions. With the exception of rare cases of ictal aggression, postictal confusional states or psychosis (Marsh and Krauss, 2000), behaviour and personality disorders observed in patients with FLE appear less severe. Furthermore, as with TLE, one can hardly expect to find the prototypical 'frontal epileptic personality' or Wesensanderung. Personality is by definition more trait than state dependent and, particularly in epilepsy, it is quite difficult to determine whether a given behaviour has trait characteristics or not.

Peripheral mechanisms

Okuma, T., Kishimoto, A., Inoue, K., Matsumoto, H. and Ogura, A. (1973). Anti-manic and prophylactic effects of carbamazepine (Tegretol) on manic depressive psychosis. A preliminary report. Folia Psychiatr Neurol Jpn, 27, 283-97. Schmitz, E.B., Robertson, M.M. and Trimble, M.R. (1999). Depression and schizophrenia in epilepsy, social and biological risk factors. Epilepsy Res, 35, 59-68.

Pathogenesis of the psychiatric disorders of epilepsy

Upon decrease and particularly upon full control of seizures, dysphoric symptoms and psychosis tend to be exacerbated or to emerge de novo. All patients of the two series of suicides providing neuropsychiatric details (Mendez and Doss, 1992 Epi-Care patients noted above) had an onset of epilepsy in early life, with a mean duration of the seizure disorder of 25 and 29 years, respectively. This interval exceeds the mean interval from onset of epilepsy to the manifestation of interictal psychosis, reported as 14 years (Slater and Beard, 1963). Two of the three patients who committed suicide in a psychotic state were under good seizure control. The third patient showed the rare finding (Demers-Desrosiers et al., 1978) of what seems the opposite of forced normalization psychotic episodes coinciding with the presence of increased electroencephalographic epileptiform potentials in the absence of seizures, presumably resulting from the forceful engagement of inhibitory mechanisms in response...

Possible anatomic substrates of some behavioural disturbances associated with epilepsy

The behavioural disturbances most associated with epilepsy include depression and other affective disorders and personality traits, schizophrenia, aggressivity and anxiety. Schizophrenia The dopaminergic hypothesis of schizophrenia originated initially from two indirect findings except for clozapine, all effective antipsychotics are blockers of D2 dopamine (DA) receptors, and stimulants that increase DA release in the limbic system frequently induce psychosis (Farde, 1997). This hypothesis has been applied mostly to the positive symptoms of schizophrenia such as hallucinations and delusions, because typical antipsychotic medications, which act almost exclusively on D2 receptors, are not very efficient in treating negative symptoms and thought disorganization. This last fact, together with the delay in action of antipsychotic medications (although D2 antagonism is immediate), put the dopaminergic theory into In cats, kindling of the dopaminergic ventral tegmental area of the brain...

Classification of learning disorders

The prevalence of state-dependent or permanent learning disorders is not satisfactorily known. Brain damage or stable brain dysfunction is mainly associated with permanent learning disorders. Epilepsy itself or the medication used to treat it may lead to state-dependent learning disorders. The picture is further complicated by associated mood disorders or psychoses, a low level of self-perception and expectation and reduced learning opportunities. It is certainly a common experience to observe that many normally underestimated or undiagnosed severe epileptic conditions, such as some frontal lobe epilepsies with frequent specific EEG activity (including rapid activity lasting between one and one-and-a-half seconds), are subsequently associated with the onset of severe behavioural disturbances (sometimes with psychotic symptoms), or schizophrenia-like or autism-like syndromes.

Other psychotropic agents

There appear to be differences between the 1,5 and 1,4 benzodiazepines, the former being represented by clobazam. This drug was introduced initially as an anxiolytic, but was shown to have effective and sustained anticonvulsant properties. It is recommended as an adjunct treatment for the management of patients with intractible epilepsy, and may be particularly of value in patients with epilepsy with a high level of anxiety, who may also present with panic attacks. It is less cereb-rotoxic than the 1,4 equivalents such as clonazepam, and is recognized to have inherent psychotropic properties. Clobazam is of particular value in patients with intermittent clusters of seizures (such as catamenial episodes), and for the supres-sion of clusters of seizures. The latter are associated in some patients with postictal psychosis, and prevention of the cluster may well abort a potential psychosis. Ten milligrams given 4-6 hourly for 24-48 hours may be all that is required. Clobazam can also be...

Affective disorders and anxiety

As is the case for psychoses, it is also true for the affective disorders that the usual psychiatric diagnostic categories do not offer adequate classification for epilepsy Additionally, circumscribed episodes of depression occur after ES. As early as in 1957 Hill et al. described their occurrence, being independent of seizure outcome, with a remission within the first 18 months after surgery. Because of their temporary character, Trimble (1992) designates them as 'complications of surgery'. Their frequency is about 8-10 of surgically treated patients (Naylor et al., 1994). They occure more with nonlesional resections or mesio-temporal scleroses (Bruton, 1988), in nondominant resected patients (Fenwick et al., 1993 Bethel) and in preoperatively aggressive patients, who lose their aggressiveness after surgery and tend to develop depressions (Taylor, 1987). There are hints from one research group (Kanemoto et al., 1998) of correlations with dominant resections and with post-ictal...

Postoperative de novo manic depressive illness

Hill et al. (1957) were one of the first to recognize that depression could occur after a temporal lobectomy. In a series evaluated by Taylor (1972), five patients committed suicide. In another follow-up study, Taylor and Marsh (1977) reported that the mortality rate during the first 2 years postoperatively was twice as high as that in any subsequent 2-year period. Further, in a Danish series investigated by Jensen and Larsen (1979), all suicide attempts occurred within the first postoperative month. A literature search failed to find any descriptions of postoperative hypomanic or manic states, except for our own recent report (Kanemoto et al., 1998). However, we were able to confirm the presence of a substantial number of cases with postoperative transient manic or hypomanic states, and a close relationship between postoperative mood disorder and preoperative history of postictal psychoses. Considering the intrinsic interrelatedness of postictal psychosis with dramatic affective...

Clinical studies

In our work, we re-examined all of the outpatient cases from 1984 to 1999 at the Kansai Regional Epilepsy Center who were known to have had epilepsy with psychotic episodes (n 177). Epilepsy and seizure classifications were based on definitions proposed by the International League against Epilepsy (Commission on Classification and Terminology of the International League Against Epilepsy, 1981 1989). In our study, psychosis was defined according to the following ICD-10 criteria the presence of hallucinations, delusions, or a limited number of severe abnormalities of behaviour, such as gross excitement and overactivity, and catatonic behaviour (World Health Organization, 1992). However, we excluded psychomotor retardation from the original definition. Ictal psychotic episodes directly corresponding to ictal epileptiform discharge, such as nonconvulsive status epilepticus, were also excluded from psychotic episodes. Postictal psychosis was defined as one that occurred within 7 days after...

Patient background

In view of the common features that patients with interictal and postictal psychosis share, such as a comparatively long latent period between epilepsy and psychosis onset (longer than 10 years Table 9.4) and a close association with temporal lobe epilepsy, the prevailing view has been that interictal and postictal psychoses are probably similar (Savard et al., 1991). However, we have found that postictal and interictal psychoses differ in several fundamental demographic data. First, age at epilepsy onset was significantly younger in patients with interictal psychosis than in those with postictal psychosis. Second, the latent period between psychosis and epilepsy onset was still longer in postictal than interictal psychosis. Third, the proportion of those patients with reduced intelligence quotient (IQ) was significantly


The concept of forced normalization goes back to the publications of Heinrich Landolt, head of the Swiss epilepsy centre in Zurich from 1955 until 1971 (Landolt, 1958). Cases of forced normalization or alternative psychoses have been reported with all of the novel drugs but seem to be particularly common with vigabatrin. There are a number of reports with topiramate, very few with tigabine and lamot-rigine, and only one case with gabapentin (Blumer, personal communication). There seems to be a link between the incidence of these alternative syndromes with a number of drugs which happen to be more efficacious than others, when accepting the results of the meta-analysis by Elferink and Van Zwieten Boot (1997). These authors analysed drug trials and compared AEDs by looking at the number of patients which are needed to be treated in order to find one responder. According to this analysis, vigabatrin and topiramate hold relatively good positions while gabapentin and lamotrigine appear to...


Suicide in epilepsy results from the psychiatric disorder of temporal lobe epilepsy that is, from a severe dysphoric disorder, from interictal psychosis (associated with preceding and concomitant dysphoric disorder, and at times with command hallucinations), or from a severe postictal depressive state. These psychiatric disorders develop gradually as seizure-suppressing mechanisms become established or, at times, upon acute engagement of the inhibition. Suicide in epilepsy has increased with our improved ability to suppress seizures.


Edeh and Toone (1987) conducted a survey in doctor's surgeries in south London. They interviewed 88 adult patients with epilepsy drawn from doctor's surgeries in the area, using the Clinical Interview Schedule, and reported that 48 emerged as psychiatric cases. They also found that while patients with temporal lobe epilepsy (TLE) and focal non-TLE did not differ in terms of psychiatric morbidity, both groups were significantly more impaired than patients with primary generalized epilepsy. The techniques of ascertainment used in this study are commendable. Subjects with epilepsy underwent both CT scans and EEG tests, in confirmation of their diagnosis. The study also used a validated instrument for common mental disorder, the CIS-R (Lewis et al., 1992). In criticism, however, it must be said that the study failed to examine matched population-based controls, psychopathology specific to epilepsy was not examined, and while cases with psychosis were identified, no validated diagnostic...


Treatment for postictal psychosis should be directed at two different stages. First, once an episode of postictal psychosis appears, a direct shortening or alleviation of postictal psychosis should be attempted. While Kanner et al. (1996) recommend dopamine blockers, Lancman et al. (1994) advise the use of benzodiazepines and sedation with chloral hydrate. However, this difference in opinion is more apparent than real. In a typical case, postictal psychosis begins with an initial hypomanic state, which develops rapidly into a psychotic state with marked psychomotor agitation within 12-48 hours. If we succeed in making patients sleep amply during the initial hypomanic state, appearance of frank psychosis could be nipped in the bud. In this way, a certain proportion of the postictal psychosis could be prevented at the stage of the hypo-manic state, especially in the seizure monitoring unit, where trained psychiatrists could recognize the initial signs without delay. Indeed, postictal...

Antipsychotic drugs

In general, the use of intramuscular preparations, such as fluphenazine deca-noate, was not associated with any change in the frequency of reporting of seizures in patients with epilepsy who also had psychosis. There are some patients with epilepsy who are nonresponsive to neuroleptic drugs, and need clozapine. In particular there is a group of patients whose seizure frequency decreases or who become seizure-free, whose psychosis deteriorates in this setting. For them clozapine may be the drug of choice. She had been prescribed several antipsychotic drugs, including the atypical antipsychotics risperidone and olanzapine. None of these were of any help in resolving her psychosis. A dramatic improvement in her psychosis was noted, such that she is once again living independently in the community, with stable mood, infrequent auditory hallucinations, and with more insight into her paranoia. She remains on sodium valproate and clozapine (400 mg a day).

Case reports

A 28-year-old kimono shop manager had a 20-year history of paroxysmal fearful feelings of being left alone. At age 11, complex partial seizures began to follow these moments of fear. As his age advanced, his seizures increased in intensity as well as frequency, despite maximum drug therapy. At age 26, the first manifest postictal mental derangement occurred, after several bouts of complex partial seizures. One day after this cluster of seizures, he struck his father, the owner of the kimono shop, who had asked whether he was all right, out of uncontrollable rage. This peculiar dysphoric state lasted for a week, during which he was continuously prone to violent behaviour over minor matters. He reported that alien ideas had invaded him and that opposing thoughts battled each other during this state. Afterwards, he could recall perfectly the details of his violent behaviour, but could not understand why he had acted in such a manner. Such postictal episodes and repeated violent...


Fifty-one (2 ) out of 2905 patients with epilepsy treated at Kansai Regional Epilepsy Center experienced postictal psychoses that were not artificially induced (Table 9.1). It is difficult to compare our data with previous studies, as they are either multiple case reports (Lancman et al., 1994 Levin, 1952 Logsdail and Toone, 1988 Savard et al., 1991 Umbricht et al., 1995) or based on observations during Table 9.1. Incidence of epileptic psychosis Table 9.1. Incidence of epileptic psychosis Postictal psychosis* Acute interictal psychosis* Chronic psychosis* * Six patients experienced both postictal and interictal psychoses. * Six patients experienced both postictal and interictal psychoses. the seizure monitoring in preparation for epilepsy surgery (Devinsky et al., 1995 Kanner et al., 1996). However, our finding seems to have a certain reliability, because the prevalence of interictal psychosis in patients with epilepsy in the current study (5 ) agreed well with that seen in other...

AEDs For Patients wITH oTHER health CoNCERNs

Some patients may be poor candidates for specific AEDs because of their past history. For example, patients who have demonstrated hypersensitivity to AEDs may have problems with more allergenic compounds. Some AEDs have a higher likelihood of cross-reacting with each other, including phenytoin, carbamazepine, phenobarbital and lamotrigine 111 . In principle, patients who are overweight should avoid carbamazepine, gabapentin, pregabalin, valproic acid and vigabatrin as these drugs tend to increase weight, although they may be warranted in some patients. Similarly, patients who are overly thin or have eating disorders may not be ideal candidates for topiramate, felbamate or zonisamide, which suppress appetite. Drugs with greater potential for psychiatric problems such as irritability, mood disorders and psychosis include levetiracetam, topiramate and vigabatrin, whereas lamotrigine, carbamazepine and valproate may stabilize mood. Use of drugs in patients with concomitant medical...

General Prevalence Of Psychiatric Disorders

schizophrenia ( ) psychosis ( ) the study of Havlova (1990), where a review of charts was done (similar principle to ICD), the prevalence of psychiatric disorders was lower than studies using ICD codes. Studies using general practitioners ' registries such as those by Edeh and Toone (1987) and Gaitatzis et al. (2004b) report higher prevalence rates of psychiatric conditions (see Table 1.1) . The same effect is observed in the study by Stefansson et al. (1998), based on a list of patients with disability. The prevalence of psychiatric conditions in these types of studies could be higher compared with other methodologies because they are biased toward individuals seeking medical attention, for example, sicker populations. A study of 88 adult patients with epilepsy from general practices in the South of London reported a prevalence of psychosis of 4 . The ascertainment method in this study was performed using the clinical interview schedule (Edeh and Toone, 1987).

Neuronal ceroidlipofuscinosis

The neuronal ceroid-lipofuscinoses (NCLs) are a group of inherited lysosomal-storage disorders which may present with progressive myoclonic epilepsy and mental and motor deterioration. These are the most common of the hereditary progressive neurodegenerative diseases, occurring generally in about 1 in 25,000 live births, but there is marked geographical variation with a particularly high frequency in Finland. The phenotypes are categorized by age of onset infantile neuronal ceroid-lipofuscinosis (INCL), late-infantile (LINCL), juvenile (JNCL), adult (ANCL), and Northern epilepsy (NE). Myoclonic epilepsy is a feature of all types. Almost all cases are inherited in an autosomal recessive manner although an autosomal dominant form of adult-onset NCL has been described. Carriers show no symptoms. In Santavuori disease (INCL), infants are normal at birth and then develop retinal blindness and seizures by 2 years of age, followed by progressive mental deterioration, and usually death in the...

Note on Concomitant Psychiatric Disorder

It is often stated that epilepsy, especially chronic epilepsy, carries a risk of associated psychiatric disorder. This is particularly true for the association with psychosis, which according to Krishnamoorthy31 is 10 times greater than in the general population. Quite separately, people with ID are said to have higher rates of mental health problems than the rest of the population, often stated as three to five times greater than expected, with some studies showing very significantly greater risk for schizophrenia.32 As Krishnamoorthy noted in a further review,33 the literature on psychopathology among subjects with epilepsy and ID is sparse and contradictory. Nevertheless, Scandinavian population-based studies once again give the clearest picture. In the Goteborg children's study it was found that 59 of those with ID and active epilepsy had at least one psychiatric diagnosis, including 38 with autism spectrum disorders. The authors felt that these observed figures were possibly...

Genetics Of Eeg Abnormalities

Recent research using advances in genome scanning technology have shed light in characterizing structural variations in human DNA that are 1 Kb to 3 Mb in size along the human genome. These copy number variations (CNV) occur at high frequencies when compared to other classes of cytogenetically detected variations. These variants, existing in a heterozygous state, lie between neutral polymorphisms and lethal mutations. Their position may directly interrupt genes or may influence neighboring gene function by virtue of a position effect. These CNVs or copy number polymorphisms (CNPs) are capable of influencing biochemical, morphologic, physiologic, and pathologic processes, thus yielding potentially new mechanisms to explain diversity in human genetic diseases. CNVs and CNPs have been used to identify genetic susceptibility loci and potential candidate genes successfully for complex genetic disorders such as schizophrenia, autism, and severe speech and language disorder (25, 26). It is...

Effects of medications and surgical treatments

Antiepileptic medications have a striking range of effects on the presence of mood disorders, psychosis, and cognitive and personality parameters and are well reviewed in a recent monograph (Meador et al.) 2001). Some drugs with excellent efficacy in epilepsy may have relatively high discontinuation rates related to cognitive and psychiatric effects (Bootsma et al.) 2004). Vagus nerve stimulation may have some positive effects on dysphoric syndromes in epilepsy patients (Hoppe et al.) 2001). The potential effects of epilepsy surgery on cognition, mood and psychosocial adjustment are substantial. In some cases, depression or psychosis first appear or are significantly exacerbated in the postsurgical setting (Kanner, 2003). Surgical and nonsurgical treatment outcome seems to be linked to the presence of psychiatric comorbidities. In some studies, the rate of seizure freedom after a new diagnosis of epilepsy and the rate of seizure freedom after anterior temporal lobectomy was lower in...

Subsequent Seizures Seizure Exacerbations in Established Epilepsy

Apart from the first seizure (see previous section) medical attention should not be required in someone who is otherwise well, with the exception of two situations a prolonged seizure failure to recover adequately within a few minutes of a seizure or injury in the seizure. As already discussed, if the seizure is precipitated by an underlying illness, then medical attention may also be required. It is not necessary to call an ambulance or arrange for admission to hospital if the individual recovers promptly from the seizure and is conscious but simply tired. Brief postictal confusion is common. Sometimes this confusion may lead to resistive violence 4 if the person is left to recover without being approached touched, then this is unlikely to occur but if some people are approached closely or touched soon after a seizure, while still in a confused state, they may misinterpret these actions and the caregiver may be pushed away or struck. If postictal confusion is prolonged or...

What Possible Strategies Exist For The Improvement Of Psychiatric Care For Patients With Refractory Epilepsy

At each level of the spectrum of training there are possible improvements that could focus treatment on both abolishing seizures and treating the comorbidities that would facilitate the best overall health. At the resident level, clearly more didactic sessions, interdisciplinary interactions at conferences and in clinics and more exposure to the outpatient management of mood disorders, anxiety, psychosis and ADHD would be helpful in the training of a neurologist. Specifically, more emphasis on the frontal lobe-related and affective portions of the mental status examination would be helpful, and neurobehavioral rounds in an outpatient or inpatient setting can serve to better integrate the disciplines (Matthews et al., 1998) . The current moment seems an excellent time to develop a curriculum for our residents in psychiatry the residents just starting mandatory rotations and their psychiatry mentors seem ideally positioned to comment on what that experience should entail. What rotations...

Acute psychotic or depressive states induced by antiepileptic drugs

Although many antiepileptic drugs have a role in the management of bipolar disorder, virtually all these drugs have also been reported to precipitate severe adverse psychiatric reactions, notably acute psychosis or depression. The risk seems greatest in patients with a previous history of psychiatric disorders. How frequently this occurs is not clearly known, but levetiracetam, phenobarbital, topiramate and vigabatrin carry perhaps the greatest risk. These antiepileptic drugs should be used with caution in patients with concurrent psychosis, and carbamazepine or valproate might be preferred options.

The relationship of antiepileptic drugs AEDs to depression

Because the psychoses appear to be most usually related to complete cessation of seizures, whereas depression, while often related to control of seizure frequency, is not so often associated with complete cessation (Ring et at., 1993 Thomas et al. , 1996 Mula et al., 2008).

Bipolar disorder and epilepsy

It used to be confidently stated that bipolar disorder was rare in patients with epilepsy (Wolf, 1982) . Such statements were made prior to the use of standardized diagnostic manuals such as the DSM-IV, and were also based on clinical impression rather than being assessed by the use of rating scales. It was accepted however that in the context of the postictal state, patients could develop a post-ictal psychosis, the features of which were often manic or hypomanic, although more generally the presentation was one of a mixed affective state often with psychotic features. A recent study (Kanner et al, 2004) of the postictal symptoms of 100 patients noted postictal hypomanic symptoms in 22 patients, often with associated psychotic phenomenology. Nishida et al. (2006) recently showed that postictal mania has a distinct position among mental disorders observed in the postictal period. Postictal manic episodes last for a longer period than postictal psychotic episodes. They have a higher...

Examination And Investigations

The neurological examination fluctuated with proximity to a seizure. Within days of most seizures the patient showed an organic psychosis with religious preoccupation and failure to recognize place and time. At a time more than 1 week from a seizure, he was fully oriented, conversant, and without focal neurological signs, but depressed about his life circumstances. One seizure was observed in the clinic he roared and then leapt up and out of the room. He ran straight down the clinic corridor toward an open door connecting with the clinical laboratory, screaming all the way. Laboratory phlebotomists heard and saw him coming and slammed the door shut. The patient ran forcibly into the closed door, slumped to the ground, and had a tonic clonic convulsion.

Clinical use in epilepsy

Although minor dose-related side-effects are common, the frequency of idiosyncratic drug-related reactions, including cutaneous reactions, is very low, and an advantage of tiagabine over other conventional drugs is its favourable cognitive profile. It does not suffer the major side-effects encountered with vigabatrin, namely psychosis and depression, or the induction of visual-field defects.

Neurotoxic and other sideeffects

In the pooled data of three double-blind placebo-controlled studies in the USA and Europe, the incidence of adverse drug reactions was 78.1 , compared with 61.3 on placebo. Side-effects which occurred at an incidence greater than 5 in the placebo-controlled studies are listed in Table 3.27. 11.5 of the treated patients and 6.5 of the placebo group discontinued treatment because of side-effects, mainly sedation and effects on behaviour and cognition. Speech and language problems were also recorded, especially after 6 -10 weeks of therapy and at doses above 300 mg day. In the placebo-controlled studies, 2.2 of patients were hospitalized for depression and 2.2 were hospitalized for psychosis. Weight loss is a common side-effect, often welcomed by patients. Pancreatitis has been reported.

Treatment and outcome

This case clearly illustrates the complex relationships between epilepsy and psychiatric disorders, ranging from the more common and better-accepted agonistic relationship, to the less common and often hotly debated antagonistic relationship - the forced normalization of Landolt1 and the alternative psychoses of Tellenbach.2 Thirdly, even those clinicians who acknowledge the existence of the antagonistic relationship between epilepsy and psychiatric disorders often believe that the only presentation of the psychiatric disorders is with psychotic symptoms. This could not be further from the truth. The alternative psychoses, often accompanied by forced normalization of the EEG, are a spectrum of disorders that range from traditional psychosis to affective disorder, anxiety disorder and even non-organic complaints.6 In our experience, alternative psychoses can also present as discrete neuropsychiatric syndromes such as abulia and even the syndrome of episodic dyscontrol. Putative...

Clinical Manifestations

Psychiatric symptoms in young children consist of mood instability and personality disturbances, whereas slowing or arrest of psychomotor development and educational progress characterize the neuropsychological symptoms. Character problems predominate in older children, and acute psychotic episodes or chronic forms of psychosis with aggressiveness, irritability, or social isolation may occur (35). Prolonged reaction time and information processing are the most impaired of the cognitive functions (18). Kaminska et al found that the main characteristics of mental deterioration were apathy, memory disorders, impaired visuomotor speed, and perseveration (42). The major electrographic abnormalities associated with LGS may account for some of the abnormalities found in higher intellectual functions. Commonly, the epileptiform discharges are frequent and may affect the ability of the patient to engage with the surroundings (43).

Psychiatric Disorders in People with ID and Epilepsy

Four studies have suggested that the rate of psychiatric illness is lower in those with epilepsy compared to those people with ID only (numbers 4, 8, 10, and 14 from Table 10.2). When psychiatric illness was present, affective neurotic disorder was the most prevalent category both in people with and without epilepsy (studies 4 and 12). However, people with epilepsy showed more schizophrenia and delusional disorder than those without epilepsy and, interestingly, no cases of bipolar affective disorder were found among those with epilepsy (study 4). In people with epilepsy, one study demonstrated a higher rate of changeable mood, but this did not reach statistical significance.38 When people with ID and epilepsy were compared with people with epilepsy but no ID, the two most frequent psychiatric disorders in those with ID and epilepsy were psychosis and personality disorders, while neurotic and psychotic disorders were most commonly found in those with epilepsy but no ID.

General Effects from the ID

While considering the general effect of the ID it may be important to consider the following hypothesis. Poorer attention and verbal factors are described in patients with epilepsy and psychosis compared with controls this suggests that psychotic disorders in epilepsy are associated with underlying cognitive defects. Extrapolating this further, verbal dysfunction and attentional deficits may therefore result in a reduced capacity to deal with complex social problems, predisposing people with epilepsy to psychotic disorders.54

Epidemiology Of Depression And Anxiety In Epilepsy

In light of these limitations, rates for anxiety disorders are reportedly elevated among individuals with epilepsy and range from 5 to 25 (see Table 7.2). A brief summary of three of these studies follows. Silberman et al. (1994) assessed individuals with epilepsy from a tertiary care center using the Schedule of Affective Disorders and Schizophrenia Lifetime Version (SADS-L) (Endicott and Spitzer, 1978), and 15 met criteria for an anxiety disorder and 16 reported symptoms of anxiety on self-report measures. Glosser et al. (2000) utilized the SCID to assess individuals with TLE prior to surgery and reported 18 of the total sample met criteria for an anxiety disorder in the previous 12 months. Among Dutch individuals with generalized and complex partial seizures, Swinkels et al. (2001) found 30 of the sample met criteria for a lifetime anxiety disorder and 25 meet criteria in the past 12 months. Much like depression, it appears that anxiety disorders are also elevated in epilepsy.

The Effect of the Treatment

Barbiturates, especially phenobarbitone, may provoke hyperkinetic syndromes,40 and its sedating effect is known to adversely alter psychosocial functioning.51 The difficulties associated with the side effect profiles of phenobarbitone and phenytoin result in their use in people with ID and epilepsy not being recommended.67 Carbamazepine is thought to have less cognitive and behavioral side effects than other AEDs as a result of the mood stabilizing effect.43,51 However, more recent studies comparing it with modern drugs show that it is cognitively impairing and can cause significant problems on initiation.68 Modern AEDs are usually well tolerated and free of significant problems if used appropriately. There are a number of reports of behavioral effects relating to the newer drugs, but these need to be interpreted with care. Benzodiazepines are sedating and may be associated with paroxysmal released aggression. Tiagabine has been reported to have dose-related anxiety effects, and...

Psychiatric assessment

A detailed neuropsychiatric evaluation is a vital part of the pre-surgical assessment and should be carried out routinely in the early stages of the assessment process. The structured clinical interview schedule can be backed up by the use of rating scales which might include Neurobehavioural Inventory, State-Trait Anxiety Inventory, Beck Depression Inventory, Subjective Handicap of Epilepsy Scale, Quality of Life in Epilepsy Scale, and the Minnesota Multiphasic Personality Inventory. The evaluation has four purposes 1 To identify the presence of psychiatric contra-indications to surgery. Usually, surgery should not be performed in patients with ongoing interictal psychosis, severe personality disorder or psychopathy, co-morbid non-epileptic seizures, or ongoing alcohol or drug abuse. Peri-ictal psychosis is often considered to be a factor weighing on the

Aetiology And Severity Of Intellectual Disability

Our ability to recognize relatively well-defined epilepsy phenotypes in these conditions is an exciting development and is progressing alongside similar advances in understanding the physical and behavioural phenotypes. These, too, may provide clinically useful information - for example, the understanding of autonomic dysfunction in Rett syndrome where knowledge of the prevalence of hyperventilation and breath-holding allows the clinician to recognize potential diagnostic confusion with absence or complex partial seizures. Behavioural phenotypes can also be valuable when distinguishing the relative impact of seizures and their treatment on behaviour - the development of confusion with Alzheimer's disease in Down syndrome or psychosis in velocardiofacial syndrome being examples of conditions that may be attributed to a medication effect rather than to the condition itself.

Inflammatory And Autoimmune Disorders

When neurologic or behavioral symptoms are prominent, the term neuropsychiatrie lupus NPSLE is used. Juvenile-onset lupus carries greater risk of NPSLE and poorer prognosis (188). Eleven percent to 17 of patients with SLE develop seizures unrelated to renal disease, cardiac disease, or drugs. In one large series, 11.6 had seizures, with about a third experiencing seizures at the onset of the disease (189). These generalized or partial seizures usually occur early in the disease. Because a true vasculitis is uncommon, the precise cause is not defined. The pathogenesis of NPSLE is multifactorial and can involve various autoantibod-ies or immune complexes in mechanisms involving vasculopathic and autoantibody-mediated neuronal injury. Cerebral microinfarcts and subarachnoid hemorrhage have been demonstrated and may be related to antiphospholipid antibodies and lupus anticoagulant that can be present. When seizures are associated with psychiatric symptoms, a generalized vasculitis may be...

SPECT single photon emission computerized tomography scanning

Another excellent AED with multiple mechanisms of action. Good for focal and generalized seizures found helpful with Lenox-Gastaut syndrome, infantile spasm, and other seizure types. Generally very well tolerated may cause a decrease in the appetite and psychosis. At times, it may also be associated with a temporary sedative effect. For some children it may be the only medication that can completely control frequent intractable seizures. much less adverse reaction compared to ACTH (the standard treatment for infantile spasms). Sabril is one of the GABA designer medications, and the only one that effectively does what it was designed to do. Sabril blocks the degradation of GABA by blocking the effect of the enzyme GABA transaminase, thus increasing GABA concentration in the presynaptic area. Other side effects of Sabril include psychosis (rare), and some mild fatigue or gastrointestinal upset, which are related.

The interictal dysphoric disorder

Parietal Lobe

The theoretical framework suggested by Blumer goes beyond a narrow IDD profile, and he speculated that affective symptoms in epilepsy exist along a continuum, from a dysphoric disorder with fleeting symptoms, to a more severe disorder with transient psychotic features, to an even more debilitating disorder with prolonged psychotic states. This scenario is deeply influenced by classic German psychiatry, especially Kraepelin s view of the relationship between manic-depressive illness and schizophrenia (Kraepelin, 1923).

Psychiatric and cognitive outcome

Post-operative psychiatric disturbance is perhaps the biggest risk following temporal lobe surgery. Unfortunately, there are still considerable uncertainties about the extent of this problem. In early series, the incidence of schizophreniform illness following temporal lobectomy was about 15 , but in recent studies the incidence of de novo psychosis following temporal lobe surgery is much lower less than 5 . This is probably because of better patient selection, and a pre-operative chronic psychosis is usually now considered a contra-indication, in most situations, to temporal lobe surgery. A depressive illness following surgery is more common, occurring in about 35 of patients in the first year after surgery. The rate may be higher after non-dominant

Cadd And Modeling Anticonvulsant Drugs

Tricyclic Butterfly

(carbamazepine, oxcarbazepine) as well as psychosis (chlorpromazine), schizophrenia, depression (amitriptyline), headache, insomnia and chronic pain. In treating these many disorders, tricyclic drugs demonstrate an ability to bind to a plethora of different (and structurally quite distinct) receptors, including the voltage gated Na+ channel protein as well as multiple types of dopamine receptors, serotonin receptors and acetylcholine receptors.

Epilepsy training models

In smaller training programs, psychiatry residents may not have access to such integrated epilepsy programs, but they will no doubt encounter patients with epilepsy through psychiatry rotations. On the consultation-liaison service, psychiatry trainees are most often exposed to acute psychopathology or changes in mental status that are associated with delirium, psychosis, mood disorder exacerbations, danger-ousness, and medication side effects. Trainees become acquainted with peri-ictal and ictal presentations of psychopathology and the temporal relationship with the course of epilepsy. Also, they become familiar with non-epileptic seizures and underlying psychopathology, such as conversion, malingering, and factitious disorders. However, the consulting team usually has limited clinical contact with individual patients with epilepsy, and thus the learning experience may be fragmented.

Step Three Mandatory Investigations

Psychiatric disorders do not preclude a patient from epilepsy surgery, as illustrated by one study of US veterans demonstrating uniform post-surgical results in patients with and without psychiatric illness, although larger studies are needed 43 . Patients with baseline psychopathology can benefit from psychological surveillance, monitoring for any decline or improvement in function post-operatively. Early psychiatric evaluation can also help to identify patients who are at risk for post-ictal psychosis, which can be difficult to manage. Such patients can be placed on anti-psychotic medication prophylactically when admitted for video-electroencephalography.

Diagnostic approach

Spike activation during sleep is required for the diagnosis of CSWS, but investigators have varied in their use of diagnostic criteria. For example, some studies have included patients with less than the classic spike-wave index of 85 , making comparisons with other studies difficult . The spikes are often focal or multifocal during awake and rapid eye movement (REM) sleep, with anterior foci being slightly more frequent than posterior The spike-wave activity becomes more frequent and may generalize during non-REM sleep, particularly in the early stages of the sleep cycle The spike-wave index may vary during the course of the disease and with treatment Neuropsychological testing may demonstrate a variable pattern of dysfunction, although all patients exhibit declines in their IQ or developmental quotients . Language regression, visuospatial disturbances, motor impairment, and memory difficulties may be seen in patients with CSWS, and these may depend somewhat on the sites of maximal...

Seesaw Phenomenon In Epilepsy

With good reason, most contemporary physicians specializing in epilepsy may well wonder why this disease used to be regarded as one of the major psychoses along with mood disorders and schizophrenia. According to population-based studies (Krohn, 1961 Helgason, 1964 Gudmundsson, 1966 Zielinski, 1974 Jalava and Sillanpaa, 1996 Bredkjaer et al. 1998 Qin et al. 2005), the incidence of psychosis among patients with epilepsy ranges from 2 to 6 at most. Further, in our prospective study (Tadokoro et al., 2007) , only 7 (2.3 ) out of 302 patients with epilepsy (average follow-up period 4 years) newly developed interictal or postictal psychoses. Overall, except for early studies in mental hospitals or specialized centers (Gibbs, 1951 Stantage, 1973 Shukla et al. 1979) , recent reports, nearly unanimously, agree that the overwhelming majority of individuals with epilepsy have never experienced psychotic episodes, which inevitably leads to the long-disputed question if there exists an intrinsic...

Abulia in a Seizure Free Patient with Frontal Lobe Epilepsy

Alternative psychosis in a patient with frontal lobe epilepsy presenting as a frontal lobe syndrome characterized by abulia. This case clearly illustrates the complex relationships between epilepsy and psychiatric disorders, ranging from the more common and better-accepted agonistic relationship, to the less common and often hotly debated antagonistic relationship the forced normalization of Landolt1 and the alternative psychoses of Tellenbach.2 Thirdly, even those clinicians who acknowledge the existence of the antagonistic relationship between epilepsy and psychiatric disorders often believe that the only presentation of the psychiatric disorders is with psychotic symptoms. This could not be further from the truth. The alternative psychoses, often accompanied by forced normalization of the EEG, are a spectrum of disorders that range from traditional psychosis to affective disorder, anxiety disorder and even non-organic complaints.6 In our experience, alternative psychoses can also...

Treatment oF BIPoLAR DisoRDERs IN PwE

The aims of pharmacotherapy in bipolar disorders are to suppress acute major depressive, hypomanic, manic and mixed manic depressive episodes and reinstate and maintain a euthymic state. Just as in co-morbid depression in epilepsy, the treatment of bipolar disorder in PWE has to be based on data from studies done in non-epilepsy patients. The management of bipolar disorders is fraught with a significantly lower therapeutic success than (unipolar) major depressive and dysthymic disorders and with potential complications, including a higher suicidal risk, co-morbid drug abuse and the development of psychotic episodes. The pharmacologic treatment includes the use of mood stabilizing agents, such as lithium, valproic acid, carbamazepine and lamotrigine. Obviously, in the case of PWE, AEDs with mood-stabilizing properties should be considered before lithium. Furthermore, anti-depressants should be used with great caution in these patients as they increase significantly a risk of triggering...

Should a Low IQ Be a Contraindication to Epilepsy Surgery

However, some reports have suggested that the psychiatric status of epilepsy patients is either not influenced, or may even improve, following epilepsy sur-gery1314 and that even patients with chronic psychosis may have a successful outcome.15 The evidence for the psychiatric outcome in patients with ID is limited, but one of the studies examining the seizure outcome in patients with different IQ scores commented on an overall improvement in behavioral problems in patients with ID.8 A study of 226 consecutive patients who underwent epilepsy surgery at a single center showed a favorable psychiatric outcome overall1 6 but did not specifically examine patients with ID. There was a high proportion (34.5 ) of some psychiatric disturbance preoperatively, with psychosis in 16 . In 22 patients (28 ) the psychiatric symptoms resolved post surgery the main symptom was postictal psychosis, which suggests that this may be a factor favoring surgery. Thirty-nine patients (50 ) had a persistence of...


Ethosuximide has a very narrow therapeutic indication, with use limited to patients with absence seizures 41 . In most cases, it should be used as the sole agent only in patients who experience this seizure type in isolation, a condition seen primarily in childhood 42 . Occasionally, in patients with primary generalized epilepsy with seizure types other than absence, addition of ethosuximide as an adjunctive medication may improve seizure control. Ethosuximide can be started at 500 mg day, and titrated as tolerated, with weekly increments. Serum concentrations of 40-100 mg l are usually optimal. The most common side-effects noted with ethosuximide use include nausea and abdominal discomfort, drowsiness, anorexia and headache 41 . In rare cases, behavioural changes may be seen, including psychosis. Blood dyscrasias have been reported. Drug-drug interactions are minimal.

Psychiatric Issues

At the time of diagnosis of epilepsy, patients, parents and physicians tend to focus exclusively on seizure control. However, important issues such as school performance, anxiety, depression and other mental health problems must not be overlooked. Early on, physicians must ask questions about behaviour, mood, affect, aggression, anxiety, psychosis, obsessions and compulsions. Identification of psychiatric co-morbidity in its early stages, and appropriate referral to psychologists and psychiatrists, represent key interventions and may ultimately impact significantly on the patient's life 46 .


A 55-year-old woman had a history of epileptic seizures controlled since age 35. She also carried a diagnosis of chronic schizophrenia, although she had married, had children, and worked successfully for years before the appearance of a new seizure type. These events, characterized by grabbing her head in her hands, calling out Oh my, oh my, or other phrases repetitively, and thrashing about were felt to be consistent with nonepileptiform seizures. Video-EEG revealed their true epileptic nature (Figure 3.5a and b).

Adverse Effects

Knowledge of the side effect profiles of the various anticonvulsants is of importance, as the learning disabled may be both particularly susceptible to developing adverse events and less able to communicate about them effectively. Adverse effects may be acute and usually dose related, idiosyncratic, or linked to chronic administration. In the general population anticonvulsants have been linked to the precipitation of delirium, psychosis, and cognitive changes. Drugs which more are more commonly known to affect cognition, such as primidone, phenytoin, or topiramate, may require careful monitoring in people with ID.

Figure 1311

Matter demonstrates increased anisotropy in some reports (45). Among children with tuberous sclerosis, DTI studies have identified abnormalities in cortical tubers and in associated white matter lesions (46). Asymmetries in temporal anisotropy have been associated with atypical language lateralization (47). Fractional anisotropy in frontotemporal regions has been correlated with interictal psychosis (48). Generalized decreased fractional anisotropy in injured brain regions may be useful in predicting epileptogenesis in patients with traumatic brain injuries (49). Diffusion tensor imaging tractography is sensitive enough to detect both axonal fragmentation and delayed myelin degradation in patients undergoing corpus callosotomy (50). In combination with functional MRI and MR spec-troscopy, DTI provides a noninvasive window on the functional, microstructural, and biochemical characteristics of epileptogenic tissue (51).

Psychotic Phenomena

It has been noted for some time that psychosis is more common in people with epilepsy than in those without epilepsy and that within the epilepsy population it is more common in those with TLE. The prevalence of epilepsy and schizophrenia are both around 1 . It would be reasonable, therefore, to expect 1 in 100 patients with epilepsy to develop a schizophreniform psychosis however, clinical studies have suggested a prevalence of around 3 in epilepsy, suggesting more than just a random association between the two disorders.23 Psychotic phenomena related to the seizure (ictal and postictal) are fairly clearly defined. Ictal events usually present with a delirium, are related to ongoing seizure activity, and respond to antiepileptic medication. Postictal episodes are discrete psychotic events occurring 24-48 hours after a cluster of seizures they are shortlived (hours to days, sometimes up to a week) and occur in clear consciousness with hallucinations and delusions which are usually...

Neuroimaging Studies

With the advances in neuroimaging and the ability to capture some real-time data, it is hoped that this field will illuminate some of the etiological processes that are held in the relationship between epilepsy and psychosis. A magnetic resonance imaging (MRI) study in patients with TLE and psychosis has identified potential structural differences in the brains of patients with temporal lobe epilepsy and psychosis as compared with TLE patients without psychopathology and healthy con-trols.30 Twenty-six patients with psychosis in epilepsy (15 with postictal and 11 with interictal psychosis) were compared with 24 patients with epilepsy but without psychosis and 20 healthy controls. Findings in the group with psychosis showed smaller total brain volumes, significant bilateral amygdala volume enlargement (16-18 ), but no difference in hippocampal volumes. When separately reviewed there was no difference between the groups with postictal or interictal psychosis.24 A further MRI study...

Forced Normalization

Landolt described a group of patients who had productive psychotic episodes with forced normalization, the phenomenon characterized by the fact that, with the occurrence of the psychotic states, the EEG becomes more normal or entirely normal, as compared with previous or subsequent EEG findings. Tellenbach introduced the term alternative psychosis, which described psychosis in epilepsy that had become controlled, but did not rely on EEG findings. This interesting phenomenon has, ever since, led to a burgeoning number of case reports but little in the line of formal research. Newer antiepileptic drugs and the emergence of behavioral changes with seizure freedom have led to a renewed interest in the field. Research is hampered by the conflicts and requirements does the phenomenon require psychosis or will a behavioral change suffice, is near-normalization of the EEG a necessity or can the EEG findings be ignored This has led to the development of diagnostic criteria, although these are...

Psychotic Disorders

Psychotic disorders are the less frequent psychiatric co-morbidities in PWE, but their prevalence rates are still significantly higher than those of the general population (see Table 15.1). Psychosis of epilepsy (POE) can present as interictal psychosis of epilepsy, peri-ictal, of which post-ictal psychosis is the most frequently recognized, and the psychotic episodes as an expression of the phenomenon of 'forced normalization'. Interictal psychosis of epilepsy can be indistinguishable from schizophreniform disorders identified in patients without epilepsy and may present with delusions, hallucinations, referential thinking and thought disorders. However, in a significant proportion of PWE, interictal psychosis differs from that of patients with primary schizophreniform disorders. Slater coined the term of interictal psychosis of epilepsy (IPOE) to describe certain clinical characteristics of these psychotic episodes, which consist of an absence of negative symptoms, better pre-morbid...

Postictal Lethargy

The postictal state encompasses lethargy, confusion, psychosis, sleep, and coma. The elements of the postictal state have not been as well studied in a fashion that the ictal stages have been by historical data, physical examination, video electroencephalographic (EEG) monitoring, and functional neuroimaging. Family members often misinterpret the postictal period as a continuation of the ictus, leading to exaggerated estimates of the seizure duration. Many times it is even confusing to a trained clinician. The differentiation between these two states using EEG data can still remain ambiguous. The distinction is further blurred in conditions such as status epilepticus where certain EEG patterns such as periodic lateralized epileptiform discharges (PLEDs) are still debated as to whether they represent an ictal or a postictal phenomenon. Most postictal phenomena are ignored because they have poor lateralizing value. However, there are some postictal phenomena such as postictal aphasia...