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 epileptic psychosis is nothing but a genuine schizophrenia, which at most may become modified by the presence of epilepsy. Simply stated, Slater seemed to prefer the third alternative and advocated the view that damage to the medial temporal structures, irrespective of genetic or exogenous origin (such as epilepsy), is associated with schizophrenia. Mace pointed out that this simple causal link appears to be increasingly untenable in light of subsequent developments in psychiatry and neurology. However, Slaters fundamental idea outlived decades of dispute, and became modified and innovated by Taylors as well as Stevens' more sophisticated versions of the same line of explanation. While Taylor stressed the ontogenetic rather than anatomical impact of a common pathology leading to both epilepsy and psychosis (Taylor, 1971, 1975; , Stevens proposed that the critical factor causing predisposion to schizophrenic psychoses among some individuals with organically induced psychosis (including epilepsy) is the reactive occurrence of abnormal neuronal regeneration, especially when it coincides with a vulnerable period (Stevens, 1989, 1991; . These more sophisticated versions of the common etiology hypothesis offered some prospect of reconciliation between the second and the third line of explanations. It is important to note here that the leading authors who have discussed CP nearly unanimously presumed that CP is an organically induced schizophrenia in essence.
If we conclude that the essence of epilepsy lies in seizure activity, then the question can be paraphrased as follows: Does psychosis occurring in patients with epilepsy have an intrinsic relationship with seizure activity? While answers in the negative predominate when discussing CP, some kind of intrinsic relationship between seizure and psychosis is difficult to deny with regard to transient epileptic psychosis, especially PIP and alternative psychosis. Very recently, Sachdev (2007) provided a unifying hypothesis related to the pathogenesis of alternative and postictal psychoses, and suggested that the brain s inhibitory processes in response to seizures plays a key role in the development of the psychosis underlying the two conditions. Twenty years before Sachdev, this emphasis on the excessive inhibitory process as a cause of psychosis was suggested by Stevens (1986). Wolf (1991) attempted to explain transient epileptic psychosis in a different way, but also as a phenomenon intrinsically related to seizures, and also contended that some epileptic psychoses, especially alternative psychosis, result directly from a deviant seizure that has spread from an original epileptogenic area. Originally, some areas of the reticular activating system were proposed as the destination for this deviant seizure spread. The shifting peak of seizure activity within the limbic circuit depicted in Figure 8.3 may be regarded as a variant of this deviant seizure spread hypothesis. In this case, however, the septal area was considered as the destined area. Finally, Wiesers hypothesis of limbic status epilepticus (Wieser ;t al. ; 1985) should also be categorized as an affirmative answer to the initial question.
In Table 8.9, the major theories for epileptic psychoses and suitable models for respective theories are concisely summarized. To repeat, previous theories can be divided into two groups. In one group (Table 8.9a, b), psychotic episodes occurring concurrently with epilepsy are regarded as essentially nothing but primary psychotic disorders, while in the other (Table 8.9c, d, e), a direct casual relationship between seizure activity and resultant psychosis is presumed. Figure 8.3 is a bird; eye view, in which subcategories of epileptic psychoses are allocated as a function of association with seizures and TLE. A uniting theory covering all the epileptic psychoses does not seem to exist, and lack of awareness of the limited applicability of a single explanation or theory may lead to serious confusion. Answers to the initial question, "Does epileptic psychosis differ from a primary psychotic disorder?", cannot be given wholly, but only separately one by one. As depicted in Figure 8.3, the answers are shaded from the most notable "Yes" of PIP
Association with TLE
CP without preceding
AIP with complete remission (including alternative psychosis)
Relationship with seizure activity
Figure 8.3 Subcategories of epileptic psychosis as a function of their associations with TLE and seizure activity. CP: Chronic psychosis; AIP: Acute interictal pyschosis; PIP: Post-ictal pyschosis; TLE: Temporal lobe epilepsy.
TABLE 8.9 Major hypotheses for epileptic psychoses and corresponding models a. "Psychodynamic hypothesis" as a risk factor in individuals genetically prone to psychosis (Pond, 1962)
b. Localized pathology of strategic position as a common causative factor (Slater, 1963)
c. Deviant seizure spread (Wolf, 1991)
d. Excessive inhibitory surround (Stevens, 1983)
e. Subclinical limbic status epilepticus (Wieser, 1985)
Chronic epileptic psychosis
Acute interictal psychosis (including alternative psychosis)
Chronic epileptic psychosis
Acute interictal psychosis (including alternative psychosis)
Postictal psychosis to the approximate "No" of CP without preceding AIP, based on how close the association with seizures is. Evidently, plural epileptic psychoses should be understood under plural theories. It is possible that complex interrelationships between various sites within the limbic circuit and excessive inhibitory spread will serve as promising key concepts in future studies, at least for transient epileptic psychoses.
It is interesting that as far back as the mid-19th century, Farlet named PIP as a true epileptic psychosis (Farlet, 1860/1861). The true value of that long-forgotten statement is now becoming more apparent.
The first author is indebted to Dr. Naoto Adachi for his valuable advice and Mrs. Lumina Ogawa for her help in the literature searches.
Adachi ; N. ; Matsuura ; M.; Okubo; Y. ; Oana ; Y. ; Takei ; N. ; Kato; M.; Hara; T.; Onuma; T. (2000). Predictive variables for interictal psychosis in epilepsy. Neurology 55 ; 1310—1314 .
Adachi ; N.; Matsuura; M.; Hara ; T.; et al. (2002). Psychoses and epilepsy: are interictal and postictal psychoses distinct clinical entities? Epilepsia 43; 1574—1582 ;
Adachi, N., Ito, M., Kanemoto, K., Akanuma, N., Okazaki, M., Ishida, S., Sekimoto, M., Kato, M., Kawasaki, J., Tadokoro, Y., Oshima, T., Onuma, T. (2007). Duration of postictal psychotic episodes. Epilepsia 48, 1531-1537.
American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders 4th edition ; Washington, DC: American Psychiatric Association.
Ballard ; C. G. ; O'Brien ;J. T.; Swann ; A. G.; Thompson; P.; Neill ; D. ; McKeith ; I. G. (2001). The natural history of psychosis and depression in dementia with Lewy bodies and Alzheimer s disease: persistence and new cases over 1 year of follow-up ; J Clin Psychiatry 62 ; 46-49 ;
Bredkjaer; S. R. ; Mortensen; P. B.; Parnas ; J. (1998). Epilepsy and non-organic no-affective psychosis. National epidemiologic study; Br J Psychiatry 172 ; 235-238 ;
Bruens ; J. H. (1971). Psychosis in epilepsy Psychiatrica, Neurologica, Neurochirurgica 74 ; 174-192 ;
Bruton; C. J. ; Stevens ; J. R.; Frith ; C. D. (1994). Epilepsy, psychosis, and schizophrenia: clinical and neu-ropathologic correlations. Neurology 44, 34-42.
David ; A. S.; Prince; M. (2005). Psychosis following head injury: a critical review; J Neurol Neurosurg Psychiatry 76(Suppl 1), 53-60.
Del Ser; T.; McKeith ; I.; Anand ; R. ; Cicin-Sain ; A. ; Ferrara; R.; Spiegel ; R. (2000). Dementia with Lewy bodies: findings from an international multicentre study Int J Geriatr Psychiatry 15; 1034-1045 ;
Devinsky O.; Abramson; H. ; Alper K.; FitzGerald; L. S.; Perrine; K. ; Calderon; J. ; Luciano; D. (1995). Postictal psychosis: a case control series of 20 patients and 150 controls ; Epilepsy Res 20 ; 247-253 ;
Edeh ; J. ; Toone; B. (1987). Relationship between interictal psychopathology and the type of epilepsy; Br J Psychiatry 151, 95-101.
Farlet, J., De l'état des épileptiques. Archives Générales de Médecine 1860, 1861; 16:661-699;17:461-491;18:423-443.
Ferrey; G. ; Zebdi ; S. (1999). Evolution et prognostique des troubles psychotiqueu aigus ( ; bouffée délirante polymorphe) ; Encephale 25(Special 3); 26-32 ;
Flor-Henry P. (1969). Psychosis and temporal lobe epilepsy; Epilepsia 10 ; 363-395 ;
Gibbs ; F, A. (1951). Ictal and non-ictal psychiatric disorders in temporal lobe epilepsy; J Nerv Ment Dis 113, 522-528.
Gudmundsson; G. (1966). Epilepsy in Iceland ; Acta Neurol Scand 25(Suppl); 1
Heath, R. G. (1986). Studies with deep electrodes in patients intractably ill with epilepsy and other disorders In: What is epilepsy? (eds Trimble, M. R., Reynolds, E. H.). pp. 126-138. Edinburgh Churchill, Linvingstone.)
Helgason ; T. (1964). Epidemiology of mental disorders in Iceland: Psychoses ; Acta Psychiatry Scand 173(Suppl); 67-95 ;
Hermann; B. P.; Dikmen; S. ; Schwartz ; M. S. ; Karnes ; W E. (1982). I nterictal psychopathology in patients with ictal fear: a quantitative investigation ; Neurology 32 ; 7-11 ;
Hill ; D. (1953). Psychiatric disorders of epilepsy; The Mental Press 229; 473-475 ;
Iverson; G. L. (1993). Psychopathology associated with systemic lupus erythematosus: a methodological review; Semin Arthritis Rheum 22 ; 242-251;
Jalava ; M.; Sillanpaa; M. (1996). Concurrent illness in adults with childhood-onset epilepsy: a population-based 35-year follow-up study. Epilepsia 37, 1155-1163.
Jensen; I. ; Larsen; J. K. (1979). Psychoses in drug-resistant temporal lobe epilepsy J Neurol Neurosurg Psychiatry 42 ; 256-265 ;
Kanemoto ; K. (1997). Periictal Capgras syndrome following clustered ictal fear ; Epilepsia 38 ; 847-850;
Kanemoto , K. (2002). Postictal psychoses, revisited . In The Neuropsychiatry of epilepsy (M. Trimble ,
B. Schmitz, eds), pp. 117—131 . Cambridge . Cambridge University Press . Kanemoto, K. , Kawasaki , J. , Kawai , I. (1996). Postictal psychosis: a comparison with acute interictal and chronic psychoses , Epilepsia 37 , 551—556 , Kanemoto, K., Tsuji , T., Kawasaki , J. (2001). Re-examination of interictal psychoses; based on DSM IV
psychosis classification and international epilepsy classification , Epilepsia 42, 98—103 , Kanner, A. M., Stagno, S. , Kotagel , P., Morris , H. H. (1996). Postictal psychiatric events during prolonged video-electroencephalographic monitoring studies , Arch Neurol 53, 258—263 , Kendell , R. E. , Kemp, I. W (1989). Maternal influenza in the etiology of schizophrenia , Arch Gen Psychiatry 46, 878-882 ,
Kendrich, J. R., Gibbs, F. A. (1957). Origin, spread and neurological treatment of the psychomotor type of seizure discharge. J Neurosurg 14, 270-284. Kristensen, O. , Sindrup, E. H. (1987). Psychomotor epilepsy and psychosis. I. Physical Aspects , Acta
Neurol Scand 57 , 361-369 , Krohn, W (1961). A study of epilepsy in northern Norway, its frequency and character, Acta Psychiat
Scand 150(Suppl), 215-225 , Lancman, M. E. (1999). Psychosis and peri-ictal confusional states , Neurology 53(Suppl 2), S33-38 , Landolt, H. (1958). Serial EEG investigations during psychotic episodes in epileptic patients and during schizophrenic attacks , In Lectures on Epilepsy (A. M. Lorenz De Haas, ed.), pp. 91-133 , Elsevier : Amsterdam.
Landolt, H. (1953). Einige klinisch-elektroencephalographische Korrelationen bei epileptischen
Dämmerzuständen , Nervenarzt 24, 479 , Landolt , H. (1963). Die Damm er- und Verstimmungszustande bei Epilepsie und ihre
Elektroencephalographie, Dtsch Z Nervenheilkunde 185, 411-430 , Levin, S. (1952). Epileptic clouded states. A review of 52 cases ,J Nerv Ment Dis 116(4), 215-225 , Logsdail , S. J. , Toone, B. K. (1988). Postictal psychosis: a clinical and phenomenological description , Br J
Psychiatry 152, 246-252. Mace, C. J. (1993). Epilepsy and schizophrenia , Br J Psychiatry 163, 439-445 ,
Marneros , A., Pillmann , F., Haring , A., Balzuweit, S., Blöink , R. (2005). Is the psychopathology of acute and transient psychotic disorder different from schizophrenic and schizoaffective disorders? Eur
Psychiatry 20, 315-320 ,
Matsuura , M. , Adachi , N., Oana, Y., Okubo, Y., Kato, M., Nakano, T., Takei , N. (2004). A polydiag-nostic and dimensional comparison of epileptic psychoses and schizophrenia spectrum disorders. Schzophrenia Research 69, 189-201 , Mendez, M. F., Grau , R., Doss , R. C. , Taylor, J. L. (1993). Schizophrenia in epilepsy: seizure and psychosis variables , Neurology 43, 1073-1077, Oshima, T. , Tadokoro, Y., Kanemoto, K. (2006). A prospective study of postictal psychoses with emphasis on the periictal type, Epilepsia 47, 2131-2134, Onuma, T., Adachi , N., Ishida, S. , Katou , M., Uesugi , S. (1995). Prevalence and annual incidence of psychoses in patients with epilepsy, Epilepsia 36(suppl 3), S218 , Parnas , J. , Korsgaard , S., Krautwald , O, Jensen, P. S. (1982). Chronic psychosis in epilepsy, Acta Psychiat Scand 66, 282-293.
Perala, J. , Suvisaari, J. , Saarni, S. I., Kuoppasalmi, K., Isometsa, E., Pirkola, S., Partonen, T., Tuulio-Henriksson, A., Hintikka, J. , Kieseppa, T. , Harkanen, T. , Koskinen, S., Lonnqvist, J. (2007). Lifetime prevalence of psychotic and bipolar I disorders in a general population , Arch Gen Psychiatry
Perez, M. M., Trimble, M. R. (1980). Epileptic psychosis-diagnostic comparison with process schizophrenia , Br J Psychiatry 141, 256-261 , Pichot, P. (1986).The concept of 'bouffée délirante ' with special reference to the Scandinavian concept of reactive psychosis , Psychopathology 19 , 35-43 ,
Pillmann : F.: Haring: A.: Balzuweit: S. : Bloink: R. : Marneros : A. (2003). Bouffée délirante and ICD-10
acute and transient psychoses: a comparative study: Aust New ZJ Psychiatry 37: 327—333 : Pond : D. A. (1957). Psychiatric aspects of epilepsy: Journal of the Indian Medical Profession 3: 1441—1451: Pond, D. A. (1962) Discussion remark. Proceedings of the Royal Society of Medicine 55, 316. Pull : C. B.: Pull : M. C.: Pichot: P. (1984). Des critères empiriques français pour les psychoses : I. Position du problème et méthodologie. Encéphale 10 : 119—123 : Qin, P, Xu, H., Laursen, T. M.,Vestergaard, M., Mortensen, P B. (2005). Risk for schizophrenia and schizophrenia-like psychosis among patients with epilepsy: population based cohort study. BMJ 331, 23. Roberts : G. W. : Done: D. J . : Bruton : C.: Crow: T. J . (1990). A "mock-up" of schizophrenia: temporal lobe epilepsy and schizophrenia-like psychosis : Biol Psychiatry 28: 127—143 : SachdeV: P. S. (2007). Alternating and postictal psychoses: review and a unifying hypothesis :
Schizophrenia Bull 33, 1029—1037. Sander: J. W.: Hart: Y M.: Trimble: M. R.: Shorvon: S. D. (1991).Vigabatrin and psychosis : J Neurology
Neurosurg Psychiatry 54 : 435—439 : Savard : G.: Andermann : F.: Olivier: A. : Remillard : G. M. (1991). Postictal psychosis after partial complex seizures: a multiple case study Epilepsia 32: 225—231: Schmidt: B. : Wolf:: P. (1989). Psychosis in epilepsy:Frequency and relation to different types of epilepsy : New
Delhi, India : Presented at the World Congress of Epilepsy: Schmitz: B.: Trimble: M. R. (1998). Epilogue : In Forced normalization and alternative psychoses of epilepsy
(M. R. Trimble: B. Schmitz, eds): pp. 221—227 : Petersfield : Wrightson Biomedical Publishing : Sengoku: A.: Yagi, K.: Seino: M.: Wada: T. (1983). Risks of occurrence of psychoses in relation to the types of epilepsies and epileptic seizures : Folia Psychiat Neurol Jpn 37: 221—225 : Sherwin: I. : Peron-Magnan: P.: Bancaud : J.: Boris : A. : Talairach : J. (1982). Prevalence of psychosis as a function of the laterality of the epileptogenic lesion : Arch Neurol 39: 621—625 : Shukla: G. D.: Srivastava: O. N.: Katiyar: B. C.: Joshi : V. : Mohan: P- K. (1979). Psychiatric manifestations in temporal lobe epilepsy: a controlled study: Br J Psychiatry 135 : 411—417 : Slater: E.: Beard : A. W. (1963).The schizophrenia-like psychoses of epilepsy: Br J Psychiatry 109: 95—150 : So: N. K.: Savard: G. : Andermann: A. : Olivier: A. : Quensney L. F (1990). Acute postictal psychosis: a stereo EEG study: Epilepsia 31: 188—193 : Stantage: K. (1973). Schizophreniform psychosis among epileptics in a mental hospital : Br J Psychiatry 123:231-232:
Stantage: K.: Fenton: G. W (1975). Psychiatric symptom profile of patients with epilepsy: a controlled investigation : Psychological Medicine 5: 152—160 : Stevens, J. R. (1983) Psychosis and epilepsy. Ann Neurol 14, 348-8.
Stevens : J. R. (1988). Epilepsy, psychosis, and schizophrenia : Schizophrenia Research 1: 79—89:
Stevens : J. R. (1991). Psychosis and the temporal lobe. Neurobehavioral Problems in Epilepsy: Advances in Neurology , 55 (D. Smith : D. Treiman: M. Trimble, eds), pp. 76—96: New York: Raven Press : Stevens : J. R. (1986). Abnormal reinnervation as a basis for schizophrenia: a hypothesis : Arch Gen Psychiatry 49: 238-243 :
Sutula : T. P. (2004). Mechanisms of epilepsy progression: current theories and perspectives from neuro-
plasticity in adulthood and development : Epilepsy Res 60 : 161—167 : Tadokoro Y, Oshima T, Shimizu H, Kanemoto K. (2007). Interictal psychoses in comparison with schizophrenia; a prospective study. Epilepsia 48, 2345—2351. Takeda: Y. : Inoue: Y.: Tottori : T.: Mihara : T. (2001). Acute psychosis during intracranial EEG monitoring:
close relationship between psychotic symptoms and discharges in amygdala : Epilepsia 42: 719—724 : Taylor: D. C. (1972). Mental state and temporal lobe epilepsy. A correlative account of 100 patients treated surgically Epilepsia 13: 727—765 : Taylor: D. C. (1971). Ontogenesis of chronic epileptic psychoses: A re-analysis : Psychol Med 1: 247—253 : Taylor: D. C. (1975). Factors influencing the occurrence of schizophrenia-like psychosis in patients with temporal lobe epilepsy: Psychol Med 5 : 249—254 : Tellenbach : H. (1965). Epilepsie als Anfallsleiden und als Psychose : Nervenarzt 36: 190—202:
Toone, B. K. , Garralda , M. E., Ron, M. A. (1980).The psychoses of epilepsy and the functional psychoses . Br J Psychiatry 137, 245-249, Trimble , M. R. (1991). The Psychoses of Epilepsy, New York: Raven Press ,
Trimble, M. R. , Schmitz, B. (1997). The psychoses of epilepsy/Schizophrenia , In Epilepsy: A Comprehensive Textbook (J. Engel , Jr., T. A. Pedley, eds), pp. 2071-2081. Philadelphia, PA : LippincottRaven Publishers.
Umbricht, D. , Degreef, G., Barr, W B., Lieberman , J. A., Pollack, S., Schaul , N. (1995). Postictal and chronic psychoses in patients with temporal lobe epilepsy, Am J Psychiatry 152, 224-231, Velakoulis , D. , Wood , S. J. , Wong, M. T. , et al. (2006). Hippocampal and amygdale volumes according to psychosis stage and diagnosis: a magnetic resonance imaging study of chronic schizophrenia, firstepisode psychosis, and ultra-high-risk individuals , Arch Gen Psychiatry 63, 139-149 , Wekking, E. M. (1993). Psychiatric symptoms in systemic lupus erythematosus: an update , Psychosom Med 55 , 219-228 ,
Wieser, H. G., Hailemariam, S., Regard, M. (1985). Unilateral limbic epileptic status activity: stereo-
EEG, behavioral, and cognitive data , Epilepsia 26, 19-29, Wolf, P. (1991). Acute behavioral symptomatology at disappearance of epileptiform EEG abnormality: paradoxical or forced normalization , In Neurobehavioral Problems in Epilepsy (D. Smith , D. Treiman , M. R. Trimble, eds), pp. 127-142. New York: Raven Press. World Health Organization (1992). The ICD-10 Classification of Mental and Behavioural Disorders:
Clinical and diagnostic guidelines. Geneva. Yu, H. H., Lee, J. H. , Wang, L. C., Yang, Y H. , Chiang, B. L., Wekking, E. M. (2006). Neuropsychiatric manifestations in pediatric systemic lupus erythematosus: a 20-year study, Lupus 15, 651-657 , Zhang, Q., Sachdev, P. S. (2003). Psychotic disorder and traumatic brain injury, Curr Psychiatry Rep 5, 197-201,
Zielinski , J. J. (1974). Epidemiology and Medical—Social Problems of Epilepsy in Warsaw, Washington, DC , US Government Printing Office ,
Was this article helpful?
The comprehensive new ebook All About Alzheimers puts everything into perspective. Youll gain insight and awareness into the disease. Learn how to maintain the patients emotional health. Discover tactics you can use to deal with constant life changes. Find out how counselors can help, and when they should intervene. Learn safety precautions that can protect you, your family and your loved one. All About Alzheimers will truly empower you.