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Keywords:

  • Postictal psychosis;
  • Chronic interictal psychosis

Abstract

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

Summary:  Purpose: To describe a case series of patients with both postictal psychosis (PIP) and chronic interictal psychosis (IIP).

Methods: We retrospectively reviewed the records of 43 patients with PIP from a comprehensive epilepsy center to find evidence of both PIP and IIP in the same patient.

Results: Six (13.9%) of the 43 patients met all the criteria for both PIP and IIP. Five of our six patients had multiple documented PIPs before they became chronically psychotic. The range of length of time between PIP and IIP was 7 to 96 months. Postictal and interictal psychotic behavior was similar or identical in five of six cases.

Conclusions: The results of this study suggest a progression from PIP to IIP: there is a similarity between the symptoms of the two psychoses, a history of multiple PIPs before the first IIP, and a period of months to years between PIP and IIP onset.

Psychosis in patients with epilepsy was recognized in antiquity and described in detail in the nineteenth century by Morel and Falret (1,2). A chronic interictal psychosis (IIP) in patients with epilepsy was epidemiologically documented by Slater et al. (3). The prevalence of IIP is estimated to be 7–8%(4). Logsdail and Toone (5) first explicitly distinguished IIP and postictal psychosis (PIP), a psychosis that followed an epileptic seizure but lasted <3 months. PIP and IIP differ in their time courses but share several features: high prevalence of complex partial seizures (CPSs), bitemporal seizure foci, absence of prior febrile convulsions, similar rates of generalized seizures compared with nonpsychotic patients, and clustering of multiple seizures (4–7). The coexistence of both IIP and PIP in the same patient is not well studied. Dongier (8) found that ∼10% of patients with PIP became chronically psychotic. Logsdail and Toone (5) reported that PIP progressed to IIP in a minority of cases. Neither of these reports provided details about the association of the two psychoses. This study provides clinical data on six patients with both PIP and IIP.

METHODS

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

We retrospectively reviewed all admissions to the New York University Comprehensive Epilepsy Center between January 1990 and July 2000, including examination of data from inpatient and outpatient charts, routine EEG and video-EEG monitoring, and neuroimaging studies. Patients with prolonged postictal confusion or psychosis after a seizure captured by video-EEG monitoring study or by patient report were identified. An epileptologist and a psychiatrist used criteria adapted from Logsdail and Toone (5) to make a diagnosis of postictal psychosis:

  • 1
    Episode of psychosis developed within 1 week after a seizure or cluster of seizures.
  • 2
    Psychosis lasted geqslant R: gt-or-equal, slanted15 h, but <2 months.
  • 3
    Mental state characterized by delusions, hallucinations in clear consciousness, bizarre or disorganized behavior, formal thought disorder, or affective changes.
  • 4
    No evidence of (a) antiepileptic drug (AED) toxicity; (b) EEG findings consistent with nonconvulsive status epilepticus (NCSE); (c) recent head trauma, alcohol, or drug intoxication or withdrawal; or (d) prior chronic psychotic disorder.

An epileptologist and psychiatrist used the following criteria to make a diagnosis of interictal psychosis (IIP):

  • 1
    Psychotic symptoms for geqslant R: gt-or-equal, slanted6 months or psychotic symptoms plus the requirement for antipsychotic medication as determined by a psychiatrist for geqslant R: gt-or-equal, slanted6 months.
  • 2
    Psychosis not temporally related to seizure activity (i.e., not PIP).
  • 3
    Mental state characterized by delusions, hallucinations in clear consciousness, bizarre or disorganized behavior, formal thought disorder, or affective changes.
  • 4
    No evidence of (a) AED toxicity; (b) EEG findings consistent with NCSE; or (c) recent head trauma, alcohol, or drug intoxication or withdrawal.

We obtained information on the following variables from the patient charts: age at presentation; handedness; age at epilepsy onset; seizure type, frequency, duration, and phenomenology; palliating and precipitating factors for seizures; history of SE and NCSE; history of nonepileptic conversion seizures; history of febrile seizures, encephalitis, intracranial masses, head trauma, loss of consciousness, or alcohol- or drug-related seizures; EEG findings; results of neuroimaging studies; use of neurosurgery as a treatment for seizures; age at onset of PIP and IIP; psychotic phenomenology; presence of seizure clusters preceding PIP; number of episodes of PIP before and during IIP; interval between first and last PIP and IIP; duration of IIP; use of antipsychotic medications; history of postictal confusion, fatigue, aphasia, amnesia, headache, anxiety, or depression; history of previous psychosis or other psychiatric conditions; history of suicide attempts; and other medical conditions.

CASE REPORT

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

A 24-year-old right-handed man was referred to our center for treatment of medically refractory epilepsy in December 1990. At age 14 years, he experienced a generalized tonic–clonic seizure (GTCS) with postictal confusion, fatigue, and aphasia. After several more GTCSs and CPSs, phenobarbital (PB) and phenytoin (PHT) were started, and he remained seizure free until age 18 years. At this time, CPSs with secondary generalization resumed and remained refractory. After one flurry of CPSs, he had an episode of psychosis with religious delusions, which resolved without treatment. At age 20 years, PIPs with religious delusions recurred. He continued to have multiple CPSs and several episodes of seizure clustering followed by PIP. At age 23 years, the patient had a 2-h bout of SE. In the same year, he attempted suicide during a PIP. At his first visit to our center, the patient's seizure frequency was characterized by weekly clusters of several seizures over a period of 2–3 days followed by PIPs lasting 1–2 days.

Two months after his first visit, the patient had a cluster of three GTCSs followed by postictal religious delusions. The next day he developed disordered, delusional thinking and visual hallucinations. This episode of PIP resolved with molindone and lorazepam (LZP) treatment. In April 1991, the patient had three clusters of seizures. The third cluster was followed by disordered thinking that lasted for 1 day. Between April 1991 and November 1991, the patient experienced two seizure clusters without subsequent psychotic symptoms. He was lost to follow-up until July 1992. The patient reported one suicide attempt precipitated by unclear circumstances (possibly while in a PIP) in February 1992 and was given haloperidol by another physician. He subsequently averaged one CPS per month and experienced chronic psychoses including a decrease in sexual activity secondary to a threat of punishment by God, delusions that the devil was responsible for both his and Julius Caesar's seizures, feelings that he was Jesus Christ, ideas of a new religion based on self-healing, and visual hallucinations of seeing God. He attempted suicide for a second time in December 1992. In August 1993, his antipsychotic medication was changed from haloperidol to pimozide. This improved his psychotic symptoms, as disordered thought content was less intense and bizarre. He had two episodes of PIP after a single GTCS and two after clusters of GTCSs between April 1996 and January 1997. The patient remained chronically psychotic until committing suicide in March 1997.

RESULTS

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

Review of the files of ∼2,000 epilepsy patients yielded 43 with definite PIP. Six (13.9%) of these 43 met all the criteria for both PIP and IIP. Of the 37 patients who did not develop IIP, 29 had neither evidence of chronic psychosis nor the requirement for long-term antipsychotic medication; three patients had evidence of persistent psychosis, but were lost to follow-up; three patients required antipsychotic medication for PIP prophylaxis for geqslant R: gt-or-equal, slanted6 months, but did not demonstrate clear psychotic symptoms; one patient required antipsychotic medication for major depression with psychotic features; and one patient required antipsychotic medication for irritability and agitation.

Patient, seizure, and psychosis variables are summarized in Table 1. The temporal relationship among seizures, PIP, and IIP are summarized in Table 2. Of the six patients in this series, three (patients 2, 5, and 6) had temporal lobectomies (Table 3). All three remained psychotic after surgery despite improvement in seizure frequency. Patient 2 had new-onset IIP after surgery. The most common psychotic symptom was religious delusions (four patients). During IIP, the most common symptoms were religious and paranoid delusions, found in three patients each. Postictal psychotic features were identical to interictal psychotic features in three cases and similar in two others. Only patient 6 had a different set of PIP and IIP symptoms.

Table 1.  Seizure and psychosis variables
PtSexHandedness/seizure lateralitySeizure typeSeizure control during IIP compared with before IIPPIP psychotic featuresIIP psychotic features
  1. CPS, complex partial epilepsy; IIP, interictal psychosis; NCSE, nonconvulsive status epilepticus; PG, primary generalized epilepsy; PIP, postictal psychosis; SE, status epilepticus; SG, secondary generalized epilepsy.

1FR/LCPS, SG, PG, NCSEBetterParanoid delusionsParanoid delusions
2FR/RCPS, SGBetterReligious delusionsReligious delusions
3MR/?CPS, SG, SESimilarReligious delusionsReligious delusions, visual hallucinations
4FR/LCPS, SGWorse at onset, then seizure-freeReligious delusions, somatic delusionsReligious delusions, somatic delusions
5FR/BCPS, SGBetterSomatic delusions, paranoid delusions, persecutory delusions, ideas of reference, perseveration, affective flatteningParanoid delusions, persecutory delusions, ideas of reference
6FR/LCPS, SGBetterReligious delusionsParanoid delusions
Table 2.  Temporal relationship among seizures, PIP, and IIP
PatientAge at first seizure (yr)Age at first PIPAge at first IIPNo. of PIP before IIPNo. of PIP during IIPFirst PIP–IIP interval (mo)Duration of IIP (mo)
  • IIP, interictal psychosis; PIP, postictal psychosis.

  • a

     Remained psychotic at more recent visit.

  • b

     Committed suicide during IIP.

1late 20s494910719
2303537221713a
3141826349661b
447565720813
512222335854b
6123637211039a
Table 3.  Patients receiving temporal lobectomy
PatientIndicationSeizure frequency before surgerySeizure frequency after surgeryPsychosis outcome
  1. CPS, complex partial seizure; GTCS, generalized tonic–clonic seizure; MTS, mesial temporal sclerosis; IIP, interictal psychosis.

2R-sided MTS1–2 CPS/wk with clusters up to 2–5 seizures/day1–3 CPS/moNew-onset IIP 1 mo after surgery
5R-sided MTS2–3 CPS/wk; 1–2 GTCS/moInfrequent auras for 5 mo; six CPS over the following 8 mo; two further clusters of GTCSPersistent IIP
6L-sided MTS1–2 CPS/wk; occasional GTCSOne CPS/mo; one GTCS every 3–4 moPersistent IIP

Epilepsy risk factors included febrile seizures in patients 4, 5, and 6, and a left gyrus rectus cavernoma patient 4. Although patient 3 had a seizure after albuterol administration for asthma, no patients had drug- or alcohol-related seizures before the onset of epilepsy. Four suicide attempts were made by two patients: patient 3 during a possible PIP and then successfully during IIP, and patient 7, twice during IIP. Patient 4 had steroid-induced psychosis shortly after seizure onset and separate from any episodes of PIP or IIP. No other patients had psychosis other than PIP or IIP.

DISCUSSION

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

Chronic psychoses occurred in six (13.9%) patients of 43 who had previous PIP. This percentage is similar to previous reports that found IIP in ∼10% of patients with PIP (5, 8). The actual percentage of patients demonstrating progression may be higher, as three patients were lost to follow-up, and a fourth patient had depression with psychotic features. The presence of both these disorders in patients with epilepsy may represent progression between the two states. Five of our six patients had multiple documented PIPs before they became chronically psychotic, suggesting this possibility.

Postictal and interictal psychotic behavior were similar or identical in five of six cases. Perhaps similar mechanisms or anatomic locations generate both PIP and IIP. The similarity in PIP and IIP symptoms suggests that the mechanisms of the two psychoses are similar and that progression between the two states may occur. Alternatively, PIP in this group of patients may represent a forme fruste of IIP or the initial manifestation of IIP that is unmasked by a cluster of seizures. In a study of 30 patients with PIP and 58 independent patients with IIP, Kanemoto et al. (9) found that grandiose and religious delusions accompanied by elevated moods were more characteristic of PIPs than IIPs. This may suggest that the features of IIP after PIP differ from IIP without preceding PIP.

In our sample, four patients had better seizure control during IIP, and one had IIP during a period of seizure freedom. This finding suggests several possible pathogenic relationships between epilepsy and psychosis: (a) mechanisms independent of seizure frequency generate psychosis (e.g., genetic factors, bilateral limbic lesions); (b) seizures cause psychosis acutely but also cause cumulative neuronal changes that lower the threshold for future psychoses; (c) increased inhibitory activity or exhaustion of neuronal function after seizure clusters or chronic epilepsy contributes to psychosis; (d) neurotransmitter/modulator change associated with the postictal or interictal states contribute to psychosis; (e) the psychotic episodes represent an “alternative psychosis” (i.e., they are the manifestations of a disorder that may present at different times as either psychosis or epilepsy) (10). More than one mechanism may be relevant in a specific patient.

Three of our patients had temporal lobectomies. All showed improvement in seizure frequency; one (patient 2) developed new IIP. Surgery may, therefore, be an independent risk factor for psychosis. Temporal lobe resection did not resolve any cases of psychosis, similar to prior studies (11). New-onset psychosis is generated by temporal lobectomy in between 3.8 and 35.7% of cases with a mean of 7.6%(12). Previous studies demonstrated that a chronic psychosis can develop despite complete removal of the seizure focus. Jensen and Larsen found that five of 11 patients with preoperative psychoses had similar or worse psychoses after temporal lobectomy (13). Of nine patients in their study who developed new psychoses postoperatively, seven were either seizure free or had a marked reduction in seizure frequency.

All patients in this study had seizures for at least a year before psychosis developed, and five of the six had epilepsy for geqslant R: gt-or-equal, slanted5 years before developing PIP. Although this suggests long-standing epilepsy before the development of psychosis, others have reported that psychosis usually develops 10–15 years after epilepsy onset (3). Perhaps this difference is secondary to the small sample size in this study or reflects a particular rapidity of progression of epilepsy in patients with PIP that evolves into IIP.

The results of this study suggest a progression from PIP to IIP: there is a similarity between the symptoms of the two psychoses, a history of multiple PIPs before the first IIP, and a period of months to years between PIP and IIP onset. Our findings also highlight the significant morbidity and mortality associated in patients with PIP and IIP: four suicide attempts were made, and two were successful. The possible progression of PIP into IIP suggests that increased awareness and more prompt therapy of PIP may prevent the development of IIP in some instances.

REFERENCES

  1. Top of page
  2. Abstract
  3. METHODS
  4. CASE REPORT
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES
  • 1
    Morel BA. D'une forme de delire, suite d'une surexcitation nerveuse se rattachant a une variete non encore decrite d'epilepsie (Epilipsie larvae). Gaz Habdomad Med Chir 1860;7:7735, 819–21, 836–41.
  • 2
    Falret JP. Memoire sur la folie circulain. Bull Acad Imperiale Med 1854;19:382400.
  • 3
    Slater E, Beard A, Clitheroe E. The schizophrenia-like psychoses of epilepsy. Br J Psychiatry 1963;109:95105.
  • 4
    Trimble MR. The psychosis of epilepsy. New York: Raven Press, 1991.
  • 5
    Logsdail SJ & Toone BK. Post-ictal psychoses: a clinical and phenomenological description. Br J Psychiatry 1988;152:24652.
  • 6
    Mendez MF, Grau R, Doss RC, et al. Schizophrenia in epilepsy: seizure and psychosis variables. Neurology 1993;43:10737.
  • 7
    Savard G, Andermann F, Olivier A, et al. Postictal psychosis after partial complex seizures: a multiple case study. Epilepsia 1991;32:22531.
  • 8
    Dongier S. Statistical study of clinical and electroencephalographic manifestations of 536 psychotic episodes occurring in 516 epileptics between clinical seizures. Epilepsia 1959/1960;1:11742.
  • 9
    Kanemoto K, Kawasaki J, Kawai I. Postictal psychosis: a comparison with acute interictal and chronic psychosis. Epilepsia 1996;37:5516.
  • 10
    Tellenbach H. Epilepsy as a seizure disorder and as a psychosis: on alternative psychoses of a paranoid type with “forced normalization” (Landolt) of the electroencephalogram of epilepsies. In: TrimbleMR, SchmitzB, eds. Forced normalization and alternative psychoses of epilepsy. Petersfield: Wrightson Biomedical Publishing Ltd., 1998:4966.
  • 11
    Reutens DC, Savard G, Andermann F, et al. Results of surgical treatment in temporal lobe epilepsy with chronic psychosis. Brain 1997;120:192936.
  • 12
    Trimble MR. Behaviour changes following temporal lobectomy with special reference to psychosis. J Neurol Neurosurg Psychiatry 1992;55:8991.
  • 13
    Jensen I & Larsen JK. Mental aspects of temporal lobe epilepsy: follow up of 74 patients after resection of a temporal lobe. J Neurol Neurosurg Psychiatry 1979;42:25665.