Postictal Psychosis in Frontal Lobe Complex Partial Seizures

Dear Editor:

Episodes of psychosis in patients with epilepsy have been well documented in neurology and psychiatry literature; however, it is uncommon to see such cases in regular psychiatric practice. We present a case of postictal psychosis in frontal lobe complex partial seizures.

Case report. A 14-year-old Caucasian boy was admitted to the child-adolescent psychiatry unit with a four-day history of decreased sleep, auditory hallucinations (elementary and verbal), persecutory delusions, and disorganized thought process. He was oriented to time, place, and person.

History was marked by episodes of nausea-vomiting, palpitations, headaches, confusion, and behavioral disturbances. These episodes started six months previously and lasted from minutes to hours. Between episodes he returned to baseline functioning without any residual impairment. Extensive medical workup, including computed tomography of the head, magnetic resonance imaging of the brain, and cerebral spinal fluid analysis was normal, except for electroencephalogram, which revealed epileptiform discharges in right frontal lobe. The patient was evaluated by epileptologist and diagnosed with complex partial seizures with focus in right frontal lobe.

On admission, the patient was on lamotrigine 200mg, orally, twice daily. Based on epileptologist recommendation, divalproex was added (500mg orally, twice daily) and the lamotrigine was tapered down (100mg orally, twice daily), as divalproex elevates plasma concentration of lamotrigine. The patient was commenced on risperidone (0.5mg orally, twice daily). Within three days, there was a complete turnaround in his mental state. He denied hallucinations, did not appear delusional, and displayed organized thought process. The parents stated that he was back at his baseline, and he was discharged home with outpatient neurology/psychiatry follow-up.

Discussion: Chances of experiencing psychotic symptoms is 6 to 12 times higher in patients with epilepsy than in the general population. Risk factors include earlier age of onset of seizures, complex partial seizures, evidence of temporal lobe lesion, and a prior history of psychosis, head trauma, or encephalitis.[1]

Psychosis in epilepsy is arbitrarily classified into the following: 1) ictal psychosis with active epileptiform discharges; 2) postictal psychosis occurring after one or a cluster of seizures (last seizure 1 week) with symptoms lasting from days to weeks; and 4) chronic psychosis (symptoms >3 months), which is difficult to distinguish from primary psychotic illness but is associated with preservation of affect and lack of negative symptoms.[2]

Theories based on neuroscience research to explain psychosis in epilepsy include the following: 1) subictal discharges in temporal lobe; 2) neuronal exhaustion in cortex similar to Todd’s paralysis; 3) transient neurotransmitter/modulator dysfunction involving dopamine, GABA, glutamate, acetylcholine, serotonin, adenosine, endogenous opiates, and nitric oxide; and 4) plastic regenerative changes resulting in “miswiring.”[2]

Management is mainly based on empirical evidence. Incomplete seizure control is considered to underlie postictal psychosis, hence the need to optimize anticonvulsants and limit antipsychotics to short-term use. Interictal psychosis is postulated to be due to “over-inhibition of brain,” and tapering down of anticonvulsants or adding antipsychotic medication is advised. Chronic psychosis in epilepsy needs a balance of anticonvulsant and antipsychotic medications. This scenario is complicated as anticonvulsant medications can induce psychotic symptoms and most of the antipsychotics have proconvulsant effect.[3]

References

1. Morrow EM, Lafayette JM, Bromfield EB, Fricchione G. Postictal psychosis-presymptomatic risk factors, need for further investigation of genetics and pharmacotherapy. Ann Gen Psychiatry. 2006;5:9.
2. Sachdev PS. Alternating and postictal psychosis: review of a unifying hypothesis. Schizophr Bull. 2007;33(4):1029–1037.
3. Matsuura M. Psychosis and anticonvulsant drug treatment: epileptic psychosis and anticonvulsant drug treatment J Neurol Neurosurg Psychiatry. 1999;67(2):231–233.

With regards,
Durga Prasad Bestha, MD
Psychiatry Residency Program, University of Nebraska, Omaha, Nebraska

Monica Arora, MD
Assistant Professor, Creighton University, Omaha, Nebraska

A Perspective on Soldier Suicide

Dear Editor:
Much attention has been given to the recent increase in the number of soldier suicides. It has been proposed that combat is one of many causes of the suicide crisis. I suspect that there are other factors involved in this increase.

I anecdotally noted that soldiers mobilized from the Army Reserve underwent a change in mindset. There is some loss of individuality, loss of sole control of one’s physical self, and an inability to reliably plan for future events, such as return to civilian life. Reserve soldiers change from being relatively independent individuals to becoming part of a subteam and a larger team. In doing so, some are particularly affected by the loss of control of self and individuality.

I hypothesize that the loss of control of one’s life might be associated with feelings of helplessness and hopelessness. The traditions and machismo associated with military life do not encourage discussion of these feelings. This milieu potentially can be associated with suicidal ideation.

The current emphasis in the military for peers and superiors to be cognizant of depression and suicidal ideation should reduce the incidence of suicide. Preliminary screening for symptoms of depression may also help.

With regards,
Iverson Bell Jr., MD, DFAPA, LTC. USAR (ret)
Child, Adolescent, and Adult Psychiatry, Atlanta, Georgia