From epilepsy to schizoform organic delusional disorder. A case report of chronic interictal psychosis.
Independent of the definition and classification criteria and of the population or time period studied, many studies conclude that the incidence of neurobehavioral disorders is higher among epileptic patients compared to the general population (1, 11). This fact is most important due to its negative implications. Therefore, the association between neurobehavioral disorders and epilepsy increases the incidence of drug-resistant epilepsy, the cost of treatment, and, last, but not least, the number of admissions per patient (12).
Epidemiological data published in 1998 reveal that 20-30% of epileptic patients are also diagnosed with psychiatric pathology (2). More recent data estimates prevalence near to 60% of psychiatric pathology among patients with epilepsy (13). The leading three positions are occupied by depression, anxiety, and psychoses (4, 14). Regarding different forms of epilepsy, it seems that temporal lobe epilepsy with complex partial seizures is most frequently associated with psychiatric disorders. Almost 70% of patients with complex partial seizures have a psychiatric disorder (10).
The link between epilepsy and psychotic disorders has been the focus of many studies due to its importance regarding not only therapeutic management, but also elucidating the etiopathogenesis of both diseases. The risk of developing psychoses is 6 to 12 times higher in patients diagnosed with epilepsy (10). The connection between epilepsy and psychosis appears to be established in both ways. On one side, the majority of the studies conclude that epilepsy is a risk factor for developing psychosis and that the latter tends to develop after minimum ten years of seizures (15). Psychosis, on the other side, can be an indirect factor for developing seizures, if we take into consideration the fact that patients with psychosis have an increased predisposition to head injuries. Moreover, antipsychotic medication can lower the seizure threshold. However, the idea that psychosis is a risk factor for developing epilepsy is less studied.
Even though the prevalence of the co-occurrence of epilepsy and psychosis varies depending on the study (2, 10), it is generally acknowledged that there is a significant link between psychotic disorders and temporal lobe epilepsy with complex partial seizures. This association is cited in 7-25% of cases (16), compared with 2.4-9.4% of cases with psychoses and mixed epilepsy (complex partial seizures and generalized seizures) (17).
A 48 years old right-handed female patient was admitted for the first time in "Socola" Mental Institute Iasi at the age of 25 with idiopathic mixed epilepsy (generalized and complex partial seizures) with clinical and electro-encephalogram confirmation.
The mother states eventless natural delivery with normal development regarding neurological, psychiatric and motor acquisitions of the small child. She has stopped her education in the forth grade (normal school) due to economical and health reasons. At 3.5 years old, the patient begins having episodes of altered consciousness, lasting minutes. The episodes are characterized by capping gaze and verbal automatisms and are followed by postictal confusion syndrome. Until the age 20, antiepileptic medication prescribed by the paediatrician (phenobarbital 100 mg/day and sodium valproate 300 mg/day) maintains an acceptable seizure frequency (1-2 seizures/week). Subsequently, the seizures tend to vary in manifestation. At age 25, generalized seizures with postictal confusion syndrome occur approximately once per month. This fact along with increased frequency of partial complex seizures justifies the admission in mental institute for adults.
At 27 years old the patient's psychiatric examination revealed: cognitive function hyperesthesia associated with irritability and irascibility, complex auditive hallucinations with appellative and commentative analytic character ("a voice says that I am going to die"), moderate global hypoprosexia and hypomnesia, decreased and adhesive ideatic rhythm, moderate bradypsychia, decreased imagination. From the assertion of the patient and the mother, the hallucinations appear in the first 24 hours after an epileptic seizure. Affective function shows dysphoric disposition with impulsive-explosive displays, hypothymia, social and familial seclusion. Effectors function reveals bradyphemia, discontinuous muteness, illiteracy, global hypobulia, anxiety rage episodes, psychomotor agitation, hypnic disorders represented by mixed insomnia. Synthesis functions are disturbed because the patient is partially auto and allo-psychically orientated in time and space and disease insight is absent.
As the patient is growing older, she presents a linear and slow psychological degradation. Therefore, at the age of 31, the evaluation of the cognitive function reveals that the complex auditory hallucinations are no longer connected to the epileptic seizures, severe global hypoprosexia, and hypomnesia, exacerbated bradypsychia.
Affective functions: patient has abnegation displays with consequent dismiss of family and daily activities. Effector function reveals bradyphemia, transitory verbal blockages, physic and verbal heteroaggressivity, misbehaviours, global hypobulia with episodes of pathological motivation due to the psycho-productivities, decreased psycho-cognitive efficiency. Synthesis function shows auto and allo-psychically disorientation and absence of disease insight.
Various drugs were administered, with temporary improvement of the psychotic symptoms. The mother states that the seizures were in a state of remission of in the past year.
The latest psychiatric examination was at 48 years old, when the patient presented yet another psychiatric decompensation. This time, the mother could not state if this decompensation was based on an epileptic seizure or not.
Cognitive functions: to the previous clinical aspect, the patient had complex visual hallucinations (she declares she sees monsters in the room), pursuance and persecutory delusion ideation, severe global hypoprosexia and hypomnesia.
Affectivity: emotional lability, dysphoric disposition, severe anxiety because of the psycho-productivities, affective ambivalence, hypothymia. The effectors functions were severely decreased with verbal and physic heteroagressivity, autolithic attempt, misbehaviours and infantile-like manifestations. Also, the patient is auto and allo-psychically disorientated, without the insight of the disease.
During her sixteen admissions in the mental institute, metabolic, electrolytic, cardiac, kidney, and liver disorders have been eliminated as a cause for her symptoms. Two electroencephalograms were performed: the first one reveals left frontal and temporal epileptiform discharge and the second reveals generalized epileptiform discharge. Repeated neurological examination of the patient find choreiform movements present at the arms and legs associated with a bilateral extrapyramidal hypertonia. These were interpreted as a secondary effect to administration of neuroleptics. A computed tomography scan of the brain was performed and it revealed generalized symmetrical mild cerebral atrophy.
At the latest discharge, the patient was diagnosed with interictal psychosis, schizoform organic delusional disorder and idiopathic mixed epilepsy (generalized and complex partial seizures). For these disorders, both antiepileptic and antipsychotic drugs were administered: olanzapine 10 mg/ day, sodium valproate 2000 mg/day and clonazepam 3 mg/day, with an acceptable control of the symptoms. Also, 2 mg per day of trihexyphenidyl were associated in order to combat extrapyramidal symptoms.
The majority of studies published until 1970 do not state a clear prevalence of cooccurrence of epilepsy and psychotic disorders due to lack of generalized and uniform psychiatric definition criteria. For example, in 1963, the term "schizophrenia like psychosis of epilepsy" was used to define psychotic manifestations in patients previously diagnosed with epilepsy (15). Since 1970, many classifications for psychosis in epileptic patients were made in the attempt to better understand the connection. From a neurological point of view, it is most useful to classify psychotic disorders by the period of time elapsed between a seizure and the development of psychoses. Therefore, postictal and ictal psychosis occur immediately after or even during the seizure, whereas interictal psychosis occurs between seizures. Alternative psychosis is also cited which tends to aggravate as seizures are being controlled by medication, along with iatrogenic psychosis which is strongly connected with the administration of some antiepileptic drugs (18).
Postictal psychosis is characterized by religious delusions and feelings of mystic fusion with the universe (19). The psychiatric symptoms appear after a seizure or, more often, after a series of seizures, but always after a period of time (maximum seven days) characterized by normal behaviour. Also, symptoms are limited in time. They disappear spontaneously or after antipsychotic medication, in a matter of days or weeks (20). In comparison with postictal, chronic interictal psychosis is characterized by mainly auditory hallucinations (19).
In the attempt to explain the occurrence of chronic interictal psychosis, several studies concluded that it develops in patients with a history of frequent acute postictal psychosis (21). This pattern is called bimodal psychosis (22).
Even though chronic interictal psychosis resembles schizophrenia, many studies consider it a separate entity, due to its particularities: more variable and benign evolution and lack of negative symptoms (19).
In the case presented, using data collected from the mother, one can conclude that the patient initially had episodes of postictal psychosis. Despite antipsychotic treatment, in approximately four years, these episodes evolved in chronic interictal psychosis. Psychiatric symptoms of the patient are complex, both positive and scarcely negative.
In the last 30 years, many studies have tried to outline risk factors for developing chronic interictal psychosis, such as: family history of psychosis (23), early onset of epilepsy (24), temporal lobe epilepsy with complex partial seizures (25), and temporal epileptic discharge on EEG (26), borderline intelligence (27) and left-handed women (26). In addition, it seems that the risk of developing chronic interictal psychosis increases with the number of hospital admissions for seizures (23).
The patient from the present case report associates some of the risk factors mentioned in the literature. Therefore, level 1 oligophrenia, onset of complex partial seizures at 3.5 years of age and high number of admissions (16 admissions in mental institute and monthly visit at the local mental health centre) could explain the association between chronic interictal psychosis and mixed epilepsy.
Regarding brain neuroimaging, it is generally admitted that schizophrenic patients have enlarged ventricles and global brain atrophy especially in the left superior temporal gyrus (28, 29). However, there are no statistical specific neuroimaging abnormalities in patients with temporal lobe epilepsy and interictal psychosis. The patient from the present case report performed a submaximal neuroimaging investigation (computed brain tomography), but the presence of choreiform movements and the mother's refusal to sedate the patient interfere with magnetic resonance imaging.
As it was previously stated, patients with epilepsy have an increased risk of developing a neurobehavioral disorder during seizure evolution and treatment. Diagnosis of psychotic disorder at a patient with epilepsy requires complex judgement due to the fact that some epileptic symptoms can mimic it. For example, status epilepticus can mimic psychotic disorder, or temporal lobe epilepsy with auditive aura can mimic auditory hallucinations.
Taking everything into consideration, the permanent collaboration between the psychiatrist and neurologist is vital to an early diagnosis of both, epilepsy and psychosis. The key to symptom control and good life quality is not only in the patients' compliance, but also in early administration of right drug combination.
ACKNOWLEDGEMENTS AND DISCLOSURES
The authors state that they are no declared conflicts of interest regarding this paper.
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Cristina G. CROITORU--M. D., Resident in Neurology, "Prof. Dr. Nicolae Oblu" Clinical Emergency Hospital, Iasi, Romania
Ioana ROSU--M. D., Resident in Psychiatry, "Socola" Institute of Psychiatry, Iasi, Romania
Serban TURLIUC--M. D., Ph. D., Lecturer, Department of Psychiatry, "Grigore T. Popa" University of Medicine and Pharmacy Iasi, Senior Psychiatrist, "Socola" Institute of Psychiatry, Iasi, Romania
M. D., Ph. D., Lecturer Psychiatry, Senior Psychiatrist, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi, "Socola" Institute of Psychiatry Iasi, Romania No. 36 Sos. Bucium, zip code 700282, Iasi, Romania
Submission: March, 20th, 2017
Acceptance: May, 03rd, 2017
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|Title Annotation:||Case Reports|
|Author:||Croitoru, Cristina G.; Rosu, Ioana; Turliuc, Serban|
|Publication:||Bulletin of Integrative Psychiatry|
|Date:||Jun 1, 2017|
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