Recurrent postictal psychosis after remission of interictal psychosis: further evidence of bimodal psychosis

PURPOSE: To ascertain whether bimodal psychosis (i.e., independent postictal and interictal psychosis) in patients with epilepsy can be characterized by postictal psychosis that develops after interictal psychosis remits. Methods: We reviewed the records of 14 patients with bimodal psychosis treated at a national center hospital.Clinical and psychopathological characteristics of the patients were examined. RESULTS: Among the 14 patients with bimodal psychosis, four initially had interictal psychosis, and 10 initially had postictal psychosis. That is, interictal-antecedent bimodal psychosis characterized four cases, and postictal-antecedent bimodal psychosis characterized 10 cases. Patients with interictal-antecedent bimodal psychosis composed 2.2% of the total patients with epilepsy and psychosis (n = 180) and 28.5% of total patients with bimodal psychosis. All four patients with interictal-antecedent bimodal psychosis had partial epilepsy with complex partial seizures, bilateral EEG abnormalities, and borderline (or decreased) intellectual functioning. Most of these clinical features are common to both types of bimodal psychosis. Among patients with interictal-antecedent bimodal psychosis, the mean age at the onset of the initial symptoms was 10.8 years (SD, 4.3 years) for epilepsy, 24.4 (6.1) years for interictal psychosis, and 33.8 (4.5) years for postictal psychosis. CONCLUSIONS: In a few patients, postictal psychosis develops after the remission of interictal psychosis. Interictal-antecedent bimodal psychosis is not likely a discrete entity because of several characteristics common to both types of bimodal psychosis. Patients may have greater vulnerability to psychosis and develop psychotic episodes easily, regardless of the presence of preceding seizures.     

Postictal mania versus postictal psychosis: differences in clinical features, epileptogenic zone, and brain functional changes during postictal period

PURPOSE: To clarify the differences between postictal mania (PIM) and postictal psychosis (PIP). METHODS: Five patients with PIM were compared to 17 patients with PIP, with respect to clinical, epileptological, electrophysiological, and neuroimaging features. PIM was distinguished from PIP by the symptoms observed in the postictal period based on the ICD-10 criteria. RESULTS: Postictal manic episodes lasted for a longer period than postictal psychotic episodes. Patients with PIM had more recurrent postictal episodes than patients with PIP. The age at onset of epilepsy in patients with PIM was older than that in patients with PIP. PIM was associated with frontal lobe and temporal lobe epilepsies, whereas PIP was associated with temporal lobe epilepsy. The estimated epileptogenic zone was on the language dominant side in PIM, whereas there was no predominant hemispheric laterality in PIP. Electroencephalography (EEG) performed during the early period of postictal manic and psychotic episodes showed decreased frequency of interictal epileptiform discharges in both PIM and PIP. Single-photon emission computed tomography (SPECT) during postictal manic and psychotic episodes showed increased perfusion in the temporal and/or frontal lobes in both PIM and PIP. Three patients with PIM showed increased perfusion during postictal episodes on bilateral or the language nondominant side, which were contralateral to the estimated epileptogenic zone, whereas three patients with PIP showed increased perfusion on the areas, which were ipsilateral to the estimated epileptogenic zone. CONCLUSIONS: PIM has a distinct position among the mental disorders observed in the postictal period.     

Progression of postictal to interictal psychosis

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.     

Interictal psychotic episodes in epilepsy: duration and associated clinical factors

Purpose: There have been few reports showing the distribution of the duration of interictal psychosis (IIP) episodes and their association with clinical characteristics. To clarify the nature of IIP, we studied the duration of IIP episodes and their related factors. Methods: One hundred fifty‐five patients with epilepsy exhibited 320 IIP episodes during our follow‐up period (mean 16.9 years). The duration of all the episodes and the longest episode in each patient during the follow‐up periods were studied. Characteristics of the patients (e.g., epilepsy type, age of onset, and family history of psychosis) and episode‐specific factors (e.g., age of the episode, seizure frequency, administrations of antiepileptic drugs [AEDs] and antipsychotic drugs [APDs]) were analyzed in association with the duration of the episodes. Key Findings: Mean duration of the 320 IIP episodes was 82.7 weeks and that of the longest IIP episodes was 150.1 weeks. During the follow‐up period, 17 patients (11.0%) showed all episodes remitting within a month and 54 (34.8%) showed all episodes lasting for 6 months or longer. The IIP episodes that occurred at a younger age were often prolonged. Patients with a family history of psychosis or with early onset of psychosis tended to have more prolonged IIP episodes. Among the episodes treated with APDs, early administration of APDs was significantly associated with shorter IIP duration. Significance: The distribution of the duration of IIP episodes indicated the broad spectrum and heterogeneity of the IIP phenomena. The individual vulnerability to psychosis may be associated with prolonged episodes. Administration of APDs soon after onset of the episodes appeared to be effective in controlling them. These findings support empirical treatment principles for IIP to administer APDs at an early stage of its development.     

SPECT findings during postictal psychoses: predominance of relative increase of perfusion in right temporal lobe

To identify brain regions activated during episodes of postictal psychoses (PIP), we investigated single-photon emission computed tomography (SPECT) data obtained from five patients treated at our institutions and also reviewed four previous studies. Therefore, SPECT findings in a total of 19 cases were analyzed, including 16 patients with temporal lobe epilepsy (TLE). During nonpsychotic states, the laterality of epileptic foci was judged as left-sided in nine episodes, right-sided in six episodes, and nonlateralized in four episodes. In PIP states, 88% of the patients showed a relative increase of right temporal perfusion (increased right temporal or decreased left temporal perfusion). Regardless of whether right- or left-sided pathology was suspected during a nonpsychotic state, SPECT findings obtained during PIP episodes revealed a trend of right-sided temporal predominance.     

Subacute postictal aggression in patients with epilepsy

Three men with epilepsy (age range, 38-62) who exhibited brief episodes of violent behavior during the postictal period are described. Disease duration ranged from 27 to 44 years. Patients had both complex partial seizures and secondarily generalized tonic-clonic seizures, which were refractory to antiepileptic drugs. Postictal aggression occurred shortly after a seizure and lasted 5-30 minutes. The patients displayed physically and verbally aggressive behavior toward others, but regained consciousness promptly and showed regret afterward. Interictal EEGs revealed temporal spikes, SPECT showed hypoperfusion in the temporal and frontal areas in two patients, and neuropsychological examination revealed poor frontal lobe function in two patients. Characteristics of our cases are consistent with subacute postictal aggression (SPA) reported previously. Epilepsy of prolonged duration and brain dysfunction involving a broad area including the temporal and frontal lobes may be associated with the occurrence of subacute postictal aggression.     

Clinique et neurobiologie des psychoses post-ictales

Psychosis in epilepsy can be categorized in relation to seizures in two main categories: interictal psychosis and postictal psychosis. Postictal psychosis (PIP) is a specific syndrome in relation to seizure activity: a clear temporal relation exists between the psychotic state of sudden onset and a precipitating bout of complex partial or generalized seizures. However, this very specific syndrome is not included as such within the DSM-5, and PIP belongs to the category “Psychotic disorder due to another medical condition”. Diagnostic criteria are: (1) episode of psychosis within 1 week after a seizure(s); (2) psychosis lasts more than 15 hours and less than 2 months; (3) delusions, hallucinations in clear consciousness, bizarre, or disorganized behavior, formal thought disorder, or affective changes; and (4) no evidence AED toxicity, non-convulsive status epilepticus, recent head trauma, alcohol, or drug intoxication or withdrawal, prior chronic psychotic disorder. The presence of a lucid interval between the last seizure and start of changes rules out a simple postictal delirium. The outcome is characterized by a remission of the psychotic symptoms over several days (mean: 1 week), with or without any treatment. Prepsychotic EEG abnormalities persist during the psychosis. Risk factors for PIP include: long standing localization-related epilepsy, extratemporal onset, bilateral epileptiform activity, secondary generalization, slowing of the EEG background activity and personal or family history of psychiatric disorders. Brain MRI frequently shows structural abnormalities. Several functional neuroimaging studies have shown hyperperfusion in various cerebral regions during PIP, suggesting an excessive activation of particular structures of the brain rather than a postictal depression of cerebral activity. Implanted electrode studies have shown that the EEG correlate of psychotic symptoms differs from the ictal EEG correlate of epileptic seizures. The value of antipsychotic treatment in PIP requires further studies. Despite their role in symptomatic relief, there is no clear effect of neuroleptics on duration or prognosis of PIP. Different combinations of pharmaceutical interventions can be tried on a case by case basis: (1) oral administration of benzodiazepine; (2) combined oral administration of benzodiazepine and atypical neuroleptics; (3) intramuscular administration of dopamine-blockers for rapid tranquilization of violent or agitated patients. The notion that neuroleptic drugs lower the seizure threshold has no clinical significance: there is no evidence that antipsychotic drugs increase seizure frequency in epileptic patients treated with antiepileptic drugs.     

Clinical factors associated with postictal headache in Chinese patients with partial epilepsy

PurposeTo investigate the incidence of postictal headache (PIH) and the factors potentially related to the occurrence of PIH in a Chinese epileptic center.MethodsConsecutive adult patients with epilepsy, referred to the outpatient clinic of the Epilepsy Center of the PLA General Hospital between February 01, 2012, and May 10, 2013, were recruited to this study. 854 patients with partial epilepsy completed a questionnaire regarding headache, 466 patients with temporal lobe epilepsy (TLE), 82 patients with occipital lobe epilepsy (OLE) and 306 patients with frontal lobe epilepsy (FLE). A semi-structured interview was performed in those who confirmed headache.ResultsPIH occurred in 328 (38.41%) of the subjects. By type of epilepsy, PIH was found in 164 (35.19%) of the patients with TLE, 46 (56.01%) of the patients with OLE, and 118 (38.56%) of the patients with FLE. The incidence of PIH in OLE was significantly higher than in TLE and FLE (P < 0.05). It occurs more frequently after generalized tonic–clonic seizures than other seizure types. Logistic regression analysis revealed that age at onset, type of seizure and classification of epilepsy were each significantly related to the occurrence of PIH.ConclusionThe results of our study revealed possible relationships between PIH and the region of epileptic focus and area of spread of epileptic discharges.     

癫痫发作后状态及其临床意义

癫痫发作后状态(PIS)是指癫痫发作停止到恢复至发病前水平的异常状态,包括认知、运动、感觉、自主神经和精神行为等异常,症状多样,严重程度不一,持续数秒至数天不等,对患者的健康和生活质量产生很大影响。然而,目前国内外相关的研究较少,临床医生对此缺乏正确认识,容易误诊误治。本文将从PIS的定义、病理生理机制、临床表现、诊断和鉴别诊断、临床意义以及干预策略等进行综述,以提高临床医生的认识,并为今后临床研究提供参考。     

精神分裂症未治期及其影响因素研究

目的 了解精神分裂症患者首次正式开始治疗前的疾病未治疗期间(duration of untreated illness, DUI)和精神病未治疗期间(duration of untreated psychosis,DUP)及其影响因素.方法 应用诺丁汉起病症状量表(Nottingham onset schedule, NOS)调查上海市精神卫生中心的精神分裂症患者,共收集117例.同时,应用自编问卷对患者家属进行访谈,调查可能影响患者及时就诊的因素.结果 ① 精神分裂症患者DUI中位数是181天, DUP中位数是84天.② 首发非特异性精神症状以失眠和情绪障碍最为常见,出现频度超过50%;首发精神病性症状以幻听和被害妄想最为常见,出现频度达到47%.③ 影响患者就诊的主要因素是家属不认识精神病和患者不愿接受诊治.④ 以DUI中位数181天将患者区分为长DUI组和短DUI组,发现:长DUI组中回答家庭成员意见不一致是延误就诊因素的比例显著高于短DUI组(χ2=3.9,P<0.05).结论 精神分裂症患者从发病到开始治疗的疾病未治疗期间较长.影响DUI和DUP的因素是多方面的,值得进一步深入研究.     

Short bursts of weak pulses break postictal inhibition in the neocortex of Wistar rats

PURPOSE: Postictal inhibition (PI) is a decrease in excitability that follows an epileptic seizure and decreases probability of new seizure occurrence. PI may involve both increased inhibition and persisting elevated excitation. Our experiments tested whether shorter trains of weak stimuli are able to unmask this residual increase of excitability during the PI. METHODS: Four epileptic afterdischarges (ADs) were evoked by intense electrical stimulation (20 s, 8 Hz, current intensity at 5x threshold) of the neocortex in two groups (A, B) of Wistar rats. Before the first AD and during the 10-min interictal period, 8-Hz trains of four weak pulses (half of the intensity used for the AD triggering; 4P) were applied every 20 s in group B and a single pulse with similar parameters in group A. RESULTS: The number of interictal epileptiform events evoked by 4P in the group B was significantly higher than that in the group A (evoked by single pulses) except after the second AD. Epileptic events were triggered by 4P also immediately after the AD termination. CONCLUSIONS: It is apparent that weak stimulation can trigger epileptic phenomena during PI. Our results indicate that it is no longer possible to perceive PI only as persisting extreme and active inhibition. An appropriate stimulation can reveal more subtle (but important) excitatory events contributing to the functional status during the postictal period.     

Retrospective audit of postictal generalized EEG suppression in telemetry

Sudden unexpected death in epilepsy (SUDEP) has on rare occasions occurred during electroencephalography (EEG) telemetry, and in such cases postictal EEG suppression (PI EEG-SUP) was frequently observed. More recently a retrospective case-control study reported this pattern as a risk factor for SUDEP. We retrospectively audited frequency and electroclinical features of this pattern as well as immediate management following tonic-clonic seizures during telemetry. Forty-eight patients with tonic-clonic seizures were identified from 470 consecutive EEG-videotelemetry reports. Thirteen patients (27%) with PI EEG-SUP (mean duration 38.1 s, range 6-69 s, median 38 s) were compared to 12 randomly selected controls. One seizure was analyzed per individual. Those with PI EEG-SUP were significantly more likely to be motionless after the seizure and have simple nursing interventions performed (suction, oxygen administration, placed in recovery position, vital signs checked). This pattern is relatively common and requires further study as a potential marker for increased mortality in epilepsy.     

A prospective study of postictal psychoses with emphasis on the periictal type

PURPOSE: To assess prospectively episodes of postictal psychosis. METHODS: We followed 108 consecutive patients with temporal lobe epilepsy, who were divided into three groups: those without psychotic episodes (n=87, N group), those with interictal psychosis (n=13, IIP group), and those with postictal psychosis (n=8, PIP group). The first episode of postictal psychosis, which was defined as a psychotic episode that occurred within 1 week after the end or within 3 days before the beginning of seizure clusters, was assessed with the Brief Psychiatric Rating Scale (BPRS) and Social Dysfunction and Aggression Scale (SDAS) during the observation period. RESULTS: The duration of illness was significantly different between the N and PIP groups (p=0.004) and between the N and IIP groups (p=0.039). The average initial BPRS score (obtained 3.0 days after the end of the seizure cluster) was 19.7, and then decreased to 5.8 after 1 week, and finally normalized at 1.5 after 1 month. A statistically significant decrease in BPRS scores was found between the initial assessment and those obtained after 1 week (p=0.011). Those who had psychotic episodes without a lucid interval tended to have episodes more often than monthly, and experienced additional seizure recurrence even during the psychotic episodes. Two patients exhibited a frank manic phase, and three patients showed excessively aggressive behavior, as determined by the SDAS. CONCLUSIONS: Postictal psychosis should be subdivided into the nuclear type, with an established clinical picture as an indirect aftereffect of seizure activity, and the atypical periictal type, which is a direct manifestation of limbic discharge.     

Duration of untreated psychosis: Impact of the definition of treatment onset on its predictive value over three years of treatment

BackgroundWhile reduction of DUP (Duration of Untreated Psychosis) is a key goal in early intervention strategies, the predictive value of DUP on outcome has been questioned. We planned this study in order to explore the impact of three different definition of “treatment initiation” on the predictive value of DUP on outcome in an early psychosis sample.Methods221 early psychosis patients aged 18–35 were followed-up prospectively over 36 months. DUP was measured using three definitions for treatment onset: Initiation of antipsychotic medication (DUP1); engagement in a specialized programme (DUP2) and combination of engagement in a specialized programme and adherence to medication (DUP3).Results10% of patients never reached criteria for DUP3 and therefore were never adequately treated over the 36-month period of care. While DUP1 and DUP2 had a limited predictive value on outcome, DUP3, based on a more restrictive definition for treatment onset, was a better predictor of positive and negative symptoms, as well as functional outcome at 12, 24 and 36 months. Globally, DUP3 explained 2 to 5 times more of the variance than DUP1 and DUP2, with effect sizes falling in the medium range according to Cohen.ConclusionsThe limited predictive value of DUP on outcome in previous studies may be linked to problems of definitions that do not take adherence to treatment into account. While they need replication, our results suggest effort to reduce DUP should continue and aim both at early detection and development of engagement strategies.     

Interictal and postictal language testing accurately lateralizes language dominant temporal lobe complex partial seizures

PURPOSE: Noninvasive tests that accurately localize seizure onset provide great value in the presurgical evaluation of patients with intractable epilepsy. This study examined the diagnostic utility of three expressive language disturbances in lateralizing language-dominant (DOM) temporal lobe complex partial seizures: (1) the postictal language delay (PILD; time taken to correctly read a test phrase out loud immediately following seizures); (2) the production of postictal phonemic paraphasic errors (PostPE); and (3) interictal phonemic paraphasic errors (InterPE). METHODS: All 60 subjects underwent inpatient video/EEG monitoring and had surgically confirmed temporal lobe epilepsy (TLE). We determined the presence and number of PostPE and, PILD times (in s) for 212 seizures, and InterPE on the Boston Naming Test (BNT). Each technique's diagnostic usefulness was evaluated via logistic regression and ROC curve analysis. Sensitivity, specificity, positive predictive value and negative predictive values were computed. RESULTS: PILD, PostPE and InterPE production were equally effective and accurate in lateralizing DOM seizure onset. Patients with DOM TLE had a longer PILD and committed more PostPE and InterPE than those with nondominant (NDOM) TLE. Respective sensitivity and specificity values were as follows: PILD (84%, 86%), PostPE (94%, 64%), and InterPE (97%, 86%). No single predictor was significantly better but a combination model yielded enough incremental utility to collectively outperform each separate predictor model. CONCLUSIONS: Interictal language testing is as accurate as postictal language testing in predicting DOM lateralization of TLE. Clinicians should also attend to the quality of errors produced during interictal and postictal language testing.     

Characteristics of postictal psychosis in a psychiatric center

The clinical characteristics of 12 cases of postictal psychosis treated at Taipei City Psychiatric Center, Taipei, Taiwan, were retrospectively reviewed. Increased seizure frequency, especially with generalized tonic-clonic seizures, was the major risk factor predisposing to postictal psychosis. The psychotic symptoms were variable with delusions and/or hallucinations. These patients showed a much longer history of epilepsy (21.9 +/- 10.7 years) prior to the development of postictal psychosis than has been previously reported. The possible mechanisms in the pathophysiology of psychosis in epileptics were discussed.     

青海省藏族精神分裂症未治期及影响因素分析

目的探讨藏族精神分裂症患者精神病未治期(duration of untreated psychosis,DUP)的影响因素。方法采用精神分裂症患者精神卫生服务利用调查问卷及精神分裂症首发症状评定量表对188例藏族精神分裂症患者的社会人口学资料、精神疾病家族史、家庭类型、起病形式、医疗付款方式、居住地、自评家庭收入水平、首发症状出现的时间等进行调查,分析DUP影响因素。结果患者DUP呈偏态分布,中位数375 d(QL=4 d,QU=1661 d)。将患者分为短DUP组(DUP≤375 d)90例和长DUP组(DUP375 d)98例,不同DUP组患者的起病形式、婚姻状况、文化程度、家庭类型、居住地的组间差异有统计学意义(P0.05)。DUP影响因素的logistic回归分析显示,结构缺失的家庭(OR=2.340,95%CI:1.130~4.847,P=0.022)、慢性起病(OR=2.136,95%CI:1.172~3.891,P=0.013)、居住在农牧区(OR=2.239,95%CI:1.097~4.571,P=0.027)与长DUP相关联。结论藏族精神分裂症DUP较长,受多种因素影响,主要的危险因素有结构缺失的家庭、慢性起病、居住在农牧区。     

Duration of untreated psychosis may predict acute treatment response in first-episode schizophrenia

There is growing evidence for a relationship between the duration of untreated psychosis (DUP) and the prognosis in schizophrenia. The objective of this study is to evaluate whether DUP and premorbid level of social functioning are related to treatment response in acute treatment of first-episode schizophrenia. Seventy-nine first-episode schizophrenia patients were assessed with BPRS, SAPS, and SANS on admission and discharge during their first hospitalisation. Percentage of the difference between admission and discharge in total scores of all scales were taken as measures of absolute symptom reduction. The median DUP was 6 months (mean=8.6). DUP was correlated with reduction in BPRS and SAPS scores but not SANS scores. Patients with a short DUP (n=41) also showed a higher reduction in BPRS, and SAPS scores than those with a long DUP. Premorbid Adjustment Scale (PAS) scores were inversely correlated with age at onset and positively correlated with BPRS scores at admission. We did not find any relationship between PAS scores and response to treatment. Our findings suggest that DUP may be an important predictor of response in acute treatment of first-episode schizophrenia and thus, attempts for early diagnosis may also have a positive effect on acute treatment response.     

Obstetric complications as a risk factor for first psychotic episodes in childhood and adolescence

There are reports of significant association between obstetric complications (OC) and childhood psychosis. Authors conducted a case-control study of 102 children and adolescents with a first episode psychosis (FEP) and 94 healthy controls (HC), using the obstetric complications scale (OCS) and their medical records, to examine the risk of FPE. Patients were recruited from child and adolescent psychiatry units at six university hospitals and controls from publicly-funded schools of similar characteristics and from the same geographic areas. A logistic regression was performed to quantify the risk of psychosis in childhood and adolescence, based on OC, adjusting for potential confounding factors like socio economic status (SES) and family psychiatric history (FPH). OC appeared more frequently in the records of patients. Significant differences between patients and controls were found in Prenatal OC (15.7% vs. 5.3%, P < 0.05) and among them, bleeding in pregnancy showed the greatest difference between groups (12.7% vs. 2.1%, P < 0.01). In the logistic regression, bleeding in pregnancy showed a crude odds ratio (OR) of 6.7 (95%CI = 1.4–30.6) and 5.1 (CI 95% = 1.0–24.9) adjusted for SES and FPH. Therefore, bleeding in pregnancy is a likely risk factor for early-onset psychosis.