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 relationship between epilepsy and psychosis. A paper published in 1963 by Slater and colleagues of the venerable Maudsley Hospital (Slater and Beard, 1963} represents a milestone in this discussion. They concluded that the incidence of comorbidity between epilepsy and psychosis is far above the level of chance. Together with the report of Gibbs (1951), most fundamental clinical features of interictal psychosis among populations with epilepsy, such as a close link with temporal lobe epilepsy (TLE) and a long interval (greater than 10 years) until the onset of psychosis, have been suggested in this epoch-making paper, which many authors later confirmed (Flor-Henry, 1969 ; Bruens, 1971; Stantage and Fenton, 1975 ; Jensen and Larsen, 1979 ; Shukla et al.; 1979 ; Perez and Trimble, 1980; Parnas et al.; 1982; Sengoku et al., 1983 ; Edeh and Toone, 1987; Kristensen and Sindrup, 1987; Mendez et al.,

Psychiatric Controversies in Epilepsy

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1993 ; Onuma et al, 1995 ; Adachi et al, 2000) . Indeed, those phenomena are rather rare among patients with epilepsy, though most recent large scale population-based studies (Jalava and Sillanpaa 1996 ) Bredkjaer et al, 1998 ) Qin et al, 2005) have found a higher prevalence of psychotic disorders in patients with epilepsy than in the general population. Less widely noticed, Slater and colleagues suggested that this link between epilepsy and psychosis is non-specific, and that psychosis in patients with epilepsy occurs not as a result of epileptic activity itself, but rather indirectly as a sequel to non-specific damage to a vulnerable portion of brain tissue. In other words, psychosis in epilepsy is nothing but a sign of a damaged strategic portion of the cortex (equal to the temporal lobe in Slater's context), impairment of which prepares brain milieu predisposed to psychosis.

This idea is in sharp contrast with that of Landolt (Landolt, 1953 ' Landolt 1958 ' Landolt 1963) , another pioneer of the modern concept of epileptic psychosis. As an experienced psychiatrist, who dedicated his life to people with mental illness, Landolt spent nearly his entire life within a psychiatric ward. In the midst of such devoted activity, he found a paradoxical normalization of the electroencephalogram (EEG) in patients with epilepsy while psychotic episodes became manifest. Strikingly, simultaneous with the disappearance of psychotic symptoms, epileptic seizures and accompanying EEG abnormalities recurred. In an ensuing study, Tellenbach extended Landolt 's concept by focusing on the clinical side of the seesaw phenomenon between seizures and psychosis, and proposed the concept of alternative psychosis (Tellenbach, 1965). While Slater's psychosis should be understood properly as symptomatic psychosis resulting from temporal lobe insufficiency rather than epileptic psychosis, alternative psychosis is a genuine epileptic psychosis, because of the essential link with epileptic activity. To consider this critical but unsolved discrepancy of opinions concerning the nosological positioning of epileptic psychosis in the present report, attention is initially focused mainly on the clinical picture. After reviewing phenomenological and demographic differences between the two conditions, we will return to this potential schism between two founders of the modern concepts of epileptic psychosis.

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