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Keywords:

  • Manic episode;
  • Epilepsy;
  • Bipolar I disorder;
  • Rapid cycling;
  • Mood disturbance

Abstract

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

Summary: Purpose: To determine whether the manic episode of patients with epilepsy has different characteristics from manic episode of patients with bipolar disorder.

Methods: Interictal manic episodes in patients with epilepsy (epilepsy group) were compared with mood disorders in patients with bipolar I disorder (bipolar group), as defined by the DSM-IV. There were 13 patients (five women and eight men) in each group.

Results: Five epilepsy patients had relatives with epilepsy and/or convulsions, and four bipolar patients had relatives with mood disorders. In the epilepsy group, two had substance-related or organic factors associated with the episodes besides epilepsy, and two exhibited a postictal manic state that had the same symptoms as those of their interictal manic episodes. Ten patients of the epilepsy group had dependent–childish behavior. The epilepsy group had fewer severe mood episodes than the bipolar group. Ten epilepsy patients had fluctuating mood disturbances, and eight had rapid cycling of mood episodes. The epileptogenic zone was in the frontal and/or temporal lobes of eight patients and in multiple lobes of two others; it could not be localized in the three remaining patients.

Conclusions: The clinical features of the interictal manic episodes in the epilepsy group were different from those in the bipolar group. The manic episodes of the epilepsy group appeared heterogeneous in their causal factors. An epileptogenic zone in the frontal and temporal lobes seems to play an important role in the mood episodes of the majority of patients with epilepsy.

Mood and affective disturbances are often observed in patients with epilepsy (1). Manic episodes, however, are rarely reported (2–5), which leaves unanswered such questions as whether manic episodes in epilepsy are truly rare, whether antiepileptic drugs (AEDs) suppress manic episodes, or how well manic episodes are documented (3,6). Conversely, temporal lobe epilepsy is reported to be a major cause of organic (secondary) mania (7), and brief, fluctuating mood disturbances and epileptic dysphoria are not rare in patients with epilepsy (5,6,8–10). At present, we have no reliable information about the prevalence of manic episodes in patients with epilepsy.

It has been suggested that epilepsy, especially temporal lobe epilepsy, plays an important role in the genesis of manic states (5,6,11). For instance, manic states may appear during ictal or postictal epileptic events and after increased epileptic activity or seizure suppression by AEDs (3,4,12,13). Consistent with the reports of manic episodes in temporal lobe epilepsy are findings that manic episodes develop secondarily after injury of the temporal and frontal lobes (14). Even if there is some correlation between manic episodes and epilepsy (3,7,15), there remains the question of whether the manic episode is related to the brain damage, the epileptogenic zone, or the epileptogenic seizure. Answers to these and other questions must be sought by studying manic episodes in patients with epilepsy without regarding the events as the accidental coincidence of bipolar I disorder in epilepsy.

No studies compared interictal manic episodes of an epilepsy group with mood disturbances of a control group, and few studies exist of the relation between interictal manic episodes and the location of epileptogenic zones (15). Therefore, in the present study, we compared the clinical features of interictal manic episodes with those of bipolar I disorder, which was diagnosed by using the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (16), and examined the relation of interictal manic episodes to the location of epileptogenic zones.

METHODS

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

Patients

Thirteen patients who had interictal manic episodes developing after the onset of epilepsy (epilepsy group) were compared with 13 patients with bipolar I disorder (bipolar group). The manic episodes and mood disorders were diagnosed, and the symptoms, course, and severity of the mood episodes were identified, according to criteria in the DSM-IV. We compared the symptoms, severity, and course of the mood episodes, and also clinical features and interictal behavior between two groups. We also studied the relation of the interictal manic episodes to the location of the epileptogenic zones in the patients with epilepsy.

Epilepsy group

The epilepsy group consisted of five women and eight men; 11 were right-handed, and two, left-handed. The patients' mean age was 37.7 ± 12.0 years at the time of the examination (Table 1). The family history, past history, and clinical course of their epilepsy and mood disorder were confirmed by asking patients and their family members directly in all patients. The symptoms and severity of the mood episodes of all patients were assessed in more episodes than one according to the criteria of DSM-IV, and behaviors of all patients were observed under direct observation during the patients' admission to our hospital or participation in our rehabilitation program. Epileptic seizures and epilepsy syndromes were classified according to the proposals of the Commission on Classification and Terminology of the International League Against Epilepsy (17,18). The category of unclassifiable epilepsy was used to designate epilepsy that could not be classified owing to lack of necessary information. Each patient had electroencephalography (EEG), neuroimaging, including computed tomography (CT), magnetic resonance imaging (MRI), single-photon emission computed tomography (SPECT) of the brain, and neuropsychological evaluation with intelligence quotient measurement. Interictal EEG recording, which necessarily included sleep recordings, was performed ≥10 times in each patient, and the ictal EEG was recorded in five patients. The laterality of the epileptogenic zone was determined from the seizure manifestations, EEG, and neuroimages.

Table 1.  Clinical features of epilepsy group
Patient no.SexHandednessAge (yr)Duration from epilepsy to mood disorder (yr)Family historyCause of epilepsyOrganic or substance-related factors for mood disorderPostictal manic state
   ExaminationEpilepsy onsetMood disorder onset     
1MRight48124230NoneUnknownNone
2MLeft3973124NoneUnknownNone
3MRight2122117Epilepsy or febrile  convulsion in 2 cousinsUnknownClobazam
4MRight37163519NoneUnknownNone+
5FRight3212UnknownUnknownPsychosis and epilepsy  in a brotherUnknownNone
6MRight3731354Febrile convulsion  in 2 sistersUnknownNone
7MRight56113524NoneUnknownNone
8MRight53165135Epilepsy in a brotherUnknownStatus epilepticus
9FRight2111198NoneEncephalitisNone+
10FLeft2312186NoneUnknownNone
11FRight26122311NoneUnknownNone
12FRight4644642NoneUnknownNone
13MRight5133128Convulsion in a sisterUnknownNone
Mean ± SD  37.7 ± 12.011.5 ± 7.132.3 ± 10.320.7 ± 11.5    

Bipolar group

The bipolar (control) group also consisted of five women and eight men, all of whom were outpatients of the Shizuoka Prefectural Mental Care and Rehabilitation Center. Patients were selected consecutively in the order of the day they visited the outpatient clinic from October 1, 1999. Eight of the 13 patients had been admitted to the center at least once for treatment of bipolar I disorder. The patients' mean age was 52.2 ± 9.7 years (range, 32–70 years) at the time of examination and 31.3 ± 8.7 years (range, 16–45 years) at the onset of bipolar I disorder.

The family and past histories; the symptoms, severity, and clinical course of the bipolar I disorder; and behavioral traits were assessed retrospectively using the medical records described by psychiatrists, psychologists, and nurses. Almost all symptoms, severity, and clinical course of the bipolar disorder were assessed according to DSM-IV. However, feelings of worthlessness and depressive mood–congruent delusion, which were two items of the depressive mood episode, were assessed only in five patients and one patient, respectively, because the two items in other patients were not able to be assessed because of lack of information.

Statistical analysis

Fisher's exact probability test and the Mann–Whitney U test were used for statistical analysis of the data. The standard deviation was calculated for all mean values.

RESULTS

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

Clinical feature

The clinical features of the patients with epilepsy are described in Table 1. Their epilepsy began at a mean age of 11.5 ± 7.1 years, and there was a mean of 20.7 ± 11.5 years between the onset of the epilepsy and the onset of the mood disorder. There was no significant difference in the patients' mean age at the onset of the mood disorder between the epilepsy group (32.3 ± 10.3 years) and the bipolar group (31.3 ± 8.7 years).

Five patients with epilepsy had a family history of epilepsy and/or convulsion (Table 1), and one had a family history of a schizophrenia-like psychosis (epileptic psychosis), but none had relatives with mood disorders. In contrast, the bipolar group had a family history of mood disorders in relatives (one grandfather, two mothers, three sisters, and one brother) of five patients, but no relatives with convulsive disorders. The incidence of epilepsy and/or convulsion in relatives of the epilepsy group was significantly greater (p < 0.05) than that in the bipolar group, and the incidence of mood disorders in relatives of the bipolar group was significantly greater (p < 0.05) than that in the epilepsy group.

Organic or substance-related factors were associated with the onset of the interictal manic episodes in two patients with epilepsy. The use of clobazam (CLB) for suppression of seizures was the factor in patient 3. Convulsive status epilepticus, resulting in brain damage of the mesial and lateral parts of the bilateral temporal lobes that extended to the lateral part of the right frontal lobe, was implicated in patient 8 (Table 1). The intelligence quotient (IQ) on the Wechsler Adult Intelligence Scale was subaverage in seven patients of the epilepsy group (Table 2). None of the bipolar group had organic or substance-related factors associated with their mood episodes, and none of the bipolar group was judged clinically to have an intelligence deficit, although none was given an intelligence quotient test.

Table 2.  Behavioral features and intelligence of epilepsy group
Patient no.Behavioral featureAffective instabilityIntelligence quotientb
  • a

     See text for description of dependent–childish behavior in 10 patients and change of behavioral pattern in patient 8.

  • b

     Verbal IQ (VIQ), performance IQ (PIQ), full-scale IQ (FSIQ) on the Wechsler Adult Intelligence Scale.

1Dependent–childish behaviora+VIQ, 91; PIQ, 98; FSIQ, 93
2Dependent–childish behavior+VIQ, 64; PIQ, 53; FSIQ, 54
3Dependent–childish behavior+Not tested
4Reserved, kindVIQ, 80; PIQ, 89; FSIQ, 83
5Dependent–childish behavior+VIQ, 57; PIQ, 60; FSIQ, 55
6Cheerful, tolerantVIQ, 78; PIQ, 68; FSIQ, 70
7Geschwind syndromeVIQ, 81; PIQ, 81; FSIQ, 80
8Dependent–childish behavior+VIQ, 81; PIQ, 68; FSIQ, 73
9Dependent–childish behavior+VIQ, 54; PIQ, 53; FSIQ, 45
10Dependent–childish behavior+VIQ, 66; PIQ, 67; FSIQ, 61
11Dependent–childish behavior+Not tested
12Dependent–childish behavior+VIQ, 68; PIQ, 62; FSIQ, 65
13Dependent–childish behavior+VIQ, 62; PIQ, 61; FSIQ, 57
Mean ± SD  VIQ, 71.09 ± 11.20; PIQ, 69.09  ± 13.81; FSIQ, 66.91 ± 13.76

Behavioral features

Behavior of 10 patients of the epilepsy group showed conspicuously disordered traits. The predominant trait was a dependent–childish behavior. They were capricious, unstable, imprudent, dependent, and lacking in patience or impulse control, and they behaved innocently, living from hand to mouth without worrying about their future (Table 2).

In patient 8, convulsive status epilepticus not only caused the interictal manic episodes, but also changed his behavioral pattern from one with the traits of seriousness, exactness, perfectionism, and enthusiasm, to dependent–childish behavior with marked recent memory disturbance, but without a marked deficit of IQ. Patient 7 exhibited behavioral features of Geschwind syndrome (19): religiosity, hyposexuality, hypergraphia, and viscosity (Table 2). In contrast, none of the patients with bipolar I disorder showed a markedly deviant behavior in the recovery period between mood episodes.

Mood disturbances

There was no marked difference in types of mood episodes between the epilepsy group and the bipolar group (Table 3). In the manic mood episodes (Table 4), the epilepsy group had a significantly lower incidence of both manic mood–congruent delusions (p < 0.001) and severe manic-mood episodes (p < 0.05) than that of the bipolar I disorder group. In depressive mood episodes (Table 5), the epilepsy group had a significantly lower incidence of feelings of worthlessness or excessive guilt (p < 0.05) and suicidal ideation or attempt (p < 0.001) than the bipolar group. None of the epilepsy group was in the severe class of severity of major depressive episode.

Table 3.  Mood disturbance in patients with epilepsy and bipolar I disorder
Mood disturbanceEpilepsy group (n = 13)Bipolar group (n = 13)
  • a

     p < 0.001 for the comparison with the bipolar group.

Mood episodes  
 Manic and depressive episodes9 (69%)12 (92%)
 Manic episode only3 (23%)1 (8%)
 Manic episode and dysthymic disorder1 (8%)0
Fluctuating mood disturbance10 (77%)a0
Rapid cycling of mood episodes8 (62%)a0
Table 4.  Manic episodes in patients with epilepsy and bipolar I disorder
Manic episodeEpilepsy group (n = 13)Bipolar group (n = 13)
  • a

     Severity of the manic episode was analyzed statistically by combining the three grades of severity and comparing the two groups with the Mann Whitney U test.

  • b  p < 0.05 and cp < 0.001 for the comparison with the bipolar group.

Euphoric, elevated and expansive13 (100%)13 (100%)
Dysphoria, irritability13 (100%)13 (100%)
Inflated self-esteem or grandiosity13 (100%)13 (100%)
Decreased need for sleep13 (100%)13 (100%)
Talkativeness13 (100%)13 (100%)
Flights of ideas13 (100%)13 (100%)
Distractibility13 (100%)13 (100%)
Psychomotor agitation12 (92%)13 (100%)
Excessive absorption in pleasure  activities12 (92%)13 (100%)
Manic mood–congruent delusion4 (31%)c13 (100%)
Manic mood–incongruent delusion4 (31%)1 (8%)
Hallucination3 (23%)0
Severitya  
 Mild4 (31%)]b0
 Moderate7 (54%)6 (46%)
 Severe2 (15%)7 (54%)]
Table 5.  Depressive mood episodes in patients with epilepsy and bipolar I disorder
Depressive mood episodeEpilepsy group (n = 9)aBipolar group (n = 11)a
  • a

     Only patients whose symptoms could be confirmed were included in the analysis; hence, the number of patients in each group differs from the original population of 13 patients.

  • b

     The symptoms could be confirmed in detail with the medical records of only five patients.

  • c

     The symptoms could be confirmed in detail with the medical records of only one patient.

  • d  p < 0.05 and ep < 0.001 for the comparison with the bipolar group.

Depressive mood9 (100%)11 (100%)
Diminished interest, activity, pleasure9 (100%)11 (100%)
Decrease in appetite9 (100%)11 (100%)
Insomnia or hypersomnia9 (100%)11 (100%)
Psychomotor retardation9 (100%)11 (100%)
Fatigue or loss of energy9 (100%)11 (100%)
Feeling of worthlessness or  excessive guilt2 (22%)d5/5b (100%)
Diminished ability to think  or concentrate, indecisiveness9 (100%)11 (100%)
Suicidal ideation or attempt0e10 (91%)
Hypochondria7 (78%)11 (100%)
Depressive mood–congruent delusion01/1c (100%)
Depressive mood–incongruent delusion02 (18%)
Severity  
 Mild4 (44%)2 (18%)
 Moderate5 (56%)5 (45%)
 Severe04 (36%)

Ten patients in the epilepsy group had recurrence of interictal manic and depressive episodes. Noteworthy is the rapid cycling of depressive and manic episodes in the epilepsy group; eight patients (three women and five men) had more than four mood episodes in a year (Table 3). The rapid cycling of mood episodes in seven epilepsy patients (patients 1, 2, 4, 7, 9, 11, and 12) was directly confirmed. That is, the interictal manic episodes, lasting from 2 to 8 weeks, and the interictal depressive episodes, lasting from 2 to 4 weeks, recurred alternately from 4 to 8 times within a year during the patients' admission to our hospital or participation in our rehabilitation program. Furthermore, 10 patients in the epilepsy group, but none in the bipolar I group, showed mood disturbances of short duration, which fluctuated between euphoria, irritability, dysphoria, anxiety, and lack of energy (Table 3). Two patients in the epilepsy group also had postictal manic states with symptoms resembling those of their interictal manic episodes (Table 1).

Epilepsy syndrome and epileptogenic zone

The epilepsy syndrome was symptomatic localization-related epilepsy in 10 patients and idiopathic generalized epilepsy (juvenile myoclonic epilepsy), symptomatic generalized epilepsy, or unclassifiable epilepsy in the three remaining patients (Table 6). In patients with symptomatic localization-related epilepsy, the epileptogenic zones were judged to be in the frontal and/or temporal lobes (eight patients) and in the occipital lobes extending to the frontal and/or temporal lobes (two patients). The epileptogenic zones in symptomatic localization-related epilepsy were in the left hemisphere of six right-handed patients and one left-handed patient, and in the right hemisphere of one right-handed patient. The MRI of patient 8 showed no definite abnormality before convulsive status epilepticus occurred at the age of 51 years.

Table 6.  Clinical and electroanatomic findings and epileptogenic zones in patients with epilepsy
Epilepsy syndrome Patient no.Seizure manifestationEEG epileptogenic dischargesCT and/or MRIInterictal SPECT hypoperfusionEpileptogenic zone
InterictalIctal
  1. Epileptogenic discharges on EEG consisted of sharp waves, spikes, and spike-and-wave discharges.

  2. Bi, bilateral; L, left; R, right; GTC, generalized tonic–clonic convulsion; SGTC, secondarily generalized tonic–clonic convulsion; CT, computed tomography; MRI, magnetic resonance imaging; SPECT, single-photon emission CT.

Symptomatic localization-related epilepsy      
 1Versive, impaired  consciousness, SGTCL frontal areaL hemisphereGeneralized atrophyL frontal and  temporal lobesL frontal lobe
 2Focal motor, SGTCL frontal areaNoneL lateral ventricle  enlargementL frontal and  temporal lobesL frontal lobe
 3Postural, SGTCBi frontal areaL hemisphereL frontal and temporal  lobes atrophyL frontal and  temporal lobesL frontal lobe
 4Dysmnesia, impaired  consciousness, SGTCL frontal areaNoneL temporal lobe atrophyL temporal lobeL temporal lobe
 5Autonomic, impaired  consciousness, SGTCL temporal areaNoneNormalL temporal lobeL temporal lobe
 6Autonomic, impaired  consciousness, SGTCBi temporal areaNoneL hipppocampal  atrophyL temporal lobeL temporal lobe
 7Postural, SGTCL frontal and temporal  areasL hemisphereGeneralized atrophyNoneL frontal and/or  temporal lobes
 8Focal motor, SGTCR frontal and temporal  areasNoneBi temporal lobe  atrophyR frontal and  temporal lobeR frontal and/or  temporal lobes
 9Visual, versive, complex  gestural automatismBi occipital and parietal  areas, bi frontal and  temporal areasBi occipital area  and bi frontal areaGeneralized atrophyNoneMultilobular
 10Visual, impaired  consciousnessBi occipital and parietal  areas, bi frontal area,  bi diffuseNoneNormalNormalMultilobular
Idiopathic generalized epilepsy      
 11Myoclonia, GTCBi diffuseNoneNormalNormalUnknown
Symptomatic generalized epilepsy      
 12Tonic, drop attack, GTCBi diffuseBi diffuseGeneralized atrophyNormalUnknown
Unclassifiable epilepsy      
 13GTCBi diffuse, L hemisphere,  bi frontal and temporal  areasNoneNormalNoneUnknown

DISCUSSION

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

Clinical features

In contrast with the bipolar group, the epilepsy group had no patients with a family history of a mood disorder, but it had epilepsy and/or convulsions in relatives of five patients. The interictal manic episode of epilepsy patients is considered to be “secondary mania,” occurring subsequent to brain injury (14,20). Secondary mania is reported to have a late onset (14,20), but there was no significant difference in the patients' ages at which the mood disturbances began between the epilepsy and bipolar groups. The two epilepsy patients with interictal manic episodes had substance-related or organic causative factors besides epilepsy. The interictal manic episode of patient 3 was caused by CLB, which can have adverse effects such as alternating psychosis (21), and that of patient 8, by convulsive status epilepticus, which resulted in extensive injury of the medial and lateral parts of the bilateral temporal lobes extending to the lateral parts of the right frontal lobe. Conversely, two patients also had not only the interictal manic episodes, but also postictal manic states. The symptoms were almost the same between the postictal manic state and the interictal manic episode in the two patients, suggesting that their interictal manic episodes were related to their epileptogenicity. The remaining nine patients with epilepsy had interictal manic episodes, but they had no causative factor and no postictal mania. Even though the number of patients studied is too small for the drawing of definite conclusions, it appears that some of the interictal manic episodes in patients with epilepsy have different genetic and causal factors than the mood episodes in patients with bipolar I disorder, and the interictal manic episodes are heterogeneous in cause.

Interictal behavioral traits

In strong contrast with the bipolar patients, none of whom had a markedly deviant behavior, 10 (77%) of the 13 patients with epilepsy had obviously dependent–childish behavior. All patients with dependent–childish behavior also had unstable or fluctuating emotions. The IQ of all patients with dependent–childish behaviors, except in two patients, was subnormal. In patient 8, the interictal manic episodes and the change to dependent–childish behavior, which were caused by bilateral temporal damage extending to the frontal lobe, occurred simultaneously. Childish and capricious personality traits have been observed in patients with frontal lobe damage (22) and with awaking epilepsy (juvenile myoclonic epilepsy) (23). The dependent–childish behavior in the epilepsy group seemed to overlap with the hypomanic traits of the “cycloid”(24). Therefore emotional deficits, subabnormal IQ, brain damage, epilepsy, and manic states seem to participate multifactorially in the dependent–childish behavior of the epilepsy group. Further research is needed to decide whether the dependent–childish behavior is due to personality disorder, designated by DSM-IV as a disorder of an enduring pattern of inner experience and behavior.

Symptoms of mood episodes

The manic episodes were less severe in the epilepsy group than in the bipolar group. The depressive episodes also were judged less severe in the epilepsy group, because the number of patients with excessive guilt and suicidal ideation or attempt was significantly smaller, and no patients had a severe class of severity in the epilepsy group (Table 5). Rapid cycling of manic and depressive episodes occurred in 62% of the patients with epilepsy who also had brief emotional and affective deficits. Rapid cycling is reported to appear in 15% of patients with bipolar mood disorders, and occurs more often in women, in mentally retarded patients, and in patients treated with antidepressant drugs (25–29). In the present study, however, rapid cycling did not occur more often in women than in men, and the mood episodes rapidly cycled in the absence of antidepressant drug therapy in the epilepsy group. Consistent with our results are reports that emotional and affective deficits occur in patients with epilepsy (6,29), and that the rapid cycling of mood disorders is apt to occur in patients with bipolar disorder and epileptogenic factors (30) and in patients with bipolar disorder and mental retardation (28). Our results suggest that epilepsy and mental retardation may be related to emotional instability and the rapid shift of manic or depressive episodes to the opposite poles in patients with epilepsy.

Periodic dysphoria was reported to appear with sudden onset and short duration in patients with epilepsy (10), and recently an epileptic dysphoria was described (6,9). The epileptic dysphoria appears interictally, has a characteristic of sudden onset and brief duration, which is from a mere few hours to a couple of days, and shows a variety of affective symptoms (9). Conversely, our patents showed manic episodes lasting >1 week and major depressive episodes lasting >2 weeks. Furthermore, mood episodes cycled from manic episodes to major depressive episodes in nine patients. These features are quite distinct from fluctuating mood disturbance with short duration and are thought to be different from epileptic dysphoria. However, because fluctuating mood disturbance with brief duration, which presumably is epileptic dysphoria, was observed in 10 patients and rapid-cycled mood episodes in eight patients, it is necessary to clarify in future whether there is a connection between mood disorder consisting of mood episodes and epileptic dysphoria in patients with epilepsy.

Manic episodes and brain-related factors

Two patients in the epilepsy group had postictal mania in addition to interictal manic episodes. Ictal and postictal mania is known to occur in temporal lobe epilepsy and is thought to be a functional disturbance caused by epileptic seizures (4,12,13). The symptoms of the postictal manic state were nearly the same as those of the interictal manic episode in the two patients. This suggests that the two patients' interictal manic episodes may have an important causal connection with the epileptogenic zone, which involved the temporal lobe or multiple lobes. Because the number of patients with postictal mania is too small to make a definite conclusion in this study, and postictal psychosis is reported to have quite different features from interictal psychosis (31), further study is necessary to clarify the relation of the interictal manic episode to the postictal manic state.

In eight patients, the epileptogenic zones involved the frontal and/or temporal lobes. “Secondary mania” is thought to be caused by a disturbance between the limbic system and the deep midline hemispheric structures, including the basal ganglia, thalamus, hypothalamus, and midbrain (20), or between the limbic or limbic-related areas, such as the orbitofrontal and basotemporal cortex and the head of the caudate and thalamus, and the frontal lobe (14). These reports suggest that not only in the two patients who had both interictal and postictal mania, but also in the eight patients whose seizures originated from the frontal and/or temporal lobes, the epileptogenic zones may be related to the interictal manic episodes. Our speculations are supported by reports that the affective deficits observed in epilepsy are caused by disturbance of the temporolimbic system (5,11,32). In the epilepsy group, five patients had multilobular epilepsy, idiopathic generalized epilepsy, symptomatic generalized epilepsy, or unclassifiable epilepsy. Our speculation that the disturbance of the frontal and temporal lobes is connected with the interictal mood disorder is applicable to three patients with multilobular epilepsy or juvenile myoclonic epilepsy. In the two patients with multilobular epilepsy, it appeared clinicoelectroanatomically that their frontal and temporal lobes may have been involved in the epileptogenic zones as well as the posterior parts of the brain (33), and dysfunction of the frontal lobe is reported in juvenile myoclonic epilepsy (34,35). However, so far, in the remaining two patients with symptomatic generalized epilepsy or unclassifiable epilepsy, no valid findings explain alteration of the limbic system or the frontal lobe as the causative factor for interictal mood disorders.

The relation between mood disorders and the hemispheric laterality of the epileptogenic zones is controversial (2,6,15). Our results suggest that the interictal manic–depressive episodes are related to epileptogenic zones in the left hemisphere. However, the number of patients examined is insufficient for a definite conclusion, and a study involving a large number of patients with both epilepsy and affective disorder is needed to establish the relation between mood disorder and laterality of epileptogenic zones.

REFERENCES

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES
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