A study of epilepsy-related psychosis

The association of epilepsy and psychosis is studied. Among the 500 patients of epilepsy evaluated, there were 12 patients, 8 males and 4 females with epilepsy-related psychosis. Their average age was 38 years. The interval between the age of onset of epilepsy and psychotic features was 9 years. Complex partial seizures were present in 7 patients and primary generalized tonic-clonic seizure was present in 1 patient. Four patients had post-ictal psychosis, 7 had acute interictal psychosis and 1 patient had chronic psychosis. The inter-ictal and chronic psychoses were schizophreniform whereas the post-ictal psychoses were not. EEG showed a temporal focus in 7 patients with complex partial seizures and an extra-temporal focus was identified in 4 out of the other 5 patients. Imaging (CT scan/MRI) revealed abnormalities in 10 patients. This study attempts to define the characteristics of psychoses occurring in epileptics.     

Inter-ictal and post-ictal psychoses in frontal lobe epilepsy: a retrospective comparison with psychoses in temporal lobe epilepsy.

There have been few studies of the psychopathology of patients with frontal lobe epilepsy (FLE). The majority of studies of both inter-ictal and post-ictal psychoses have strongly suggested the influence of temporal lobe disturbance on psychoses. Patients with organic brain damage or schizophrenia, however, sometimes show frontal lobe dysfunction. The purpose of this study was to better understand the effect, if any, of frontal lobe disturbance and seizure on psychopathology. Patients were divided into four groups based on epilepsy type and preceding seizures; 8 with FLE/inter-ictal psychosis, 3 with FLE/post-ictal psychosis, 29 with temporal lobe epilepsy (TLE)/inter-ictal psychosis, and 8 with TLE/post-ictal psychosis. Psychopathologic symptoms were retrospectively reviewed based on case notes, using a modified brief psychiatric rating scale (BPRS). Psychomotor excitement, hostility, suspiciousness, and hallucinatory behaviour were prominent features in all four groups. Six orthogonal factors were derived by factor analysis from the original data based on the 18 BPRS items. FLE patients with inter-ictal psychosis showed marked hebephrenic characteristics (i.e. emotional withdrawal and blunted effect). Our findings suggest that patients with FLE can exhibit various psychiatric symptoms. However, their psychotic symptoms, hebephrenic symptoms in particular, may often be overlooked.     

Religious experiences in epileptic patients with a focus on ictus-related episodes

Two hundred thirty-four epileptic patients were examined for ictus-related religious experiences. Of the 234 cases, three (1.3%) were found to have had such religious experiences. All three cases had temporal lobe epilepsy with post-ictal psychosis, while one exhibited a simple partial seizure. At the same time, interictal experiences with hyperreligiosity were recognized in all three cases. The incidence of religious experiences while in a state of post-ictal psychosis was 27.3%, which is regarded as high, indicating some influence by the religions that the patients had faith in. Patients who had ictus-related or interictal religious experiences did not believe solely in Buddhism, a traditional religion in Japan, but rather in a combination of Buddhism and Shintoism, new Christian sect, contemporary Japanese religions and/or other folk beliefs. This indicates that these experiences had some connection not only with the personality characteristic of temporal lobe epilepsy, but also with the general lack of religious conviction and activity in Japan. In addition, the cases having ictus-related religious experiences also had interictal religious experiences and an interaction was seen between them. In this paper, the importance of taking bio-psycho-social aspects into consideration is pointed out in the discussion of epilepsy and religion.     

Postictal psychosis after temporal lobectomy

Three of 282 consecutive patients who had temporal resections for intractable epilepsy developed postoperative postictal psychosis. These three patients had seizure recurrence contralateral to the resection, whereas none of the patients with ipsilateral seizure recurrence developed any psychiatric symptoms after surgery. Two had left amygdalo-hippocampectomy and one right temporal lobectomy. The de novo occurrence of postoperative postictal psychosis is a well-defined complication of surgery for temporal lobe epilepsy, and may relate to contralateral epileptogenesis.     

Indication for Anterior Temporal Lobectomy in Patients with Temporal Lobe Epilepsy and Psychopathology

Summary: The chronicity and severity of epilepsy, as well as the presence of temporal lobe foci, appear to correlate with psychopathology. A high prevalence of psychopathology has been reported among patients who are candidates for anterior temporal lobectomy (ATL). A review of the literature indicates that episodic psychosis may diminish when patients become free of seizures after surgery and that chronic psychosis neither improves nor worsens after ATL. If this is the case, patients with episodic psychosis may benefit from ATL. Patients with chronic psychosis may benefit if they become free from seizures after the operation, even if the psychosis persists. Case reports of maladjustment to seizure-free life after surgery, and de novo psychopathology, underline the importance of preop-erative psychiatric evaluation and postoperative psychiatric intervention in patients undergoing epilepsy surgery. Although there is a need for each epilepsy center to state its policy with regard to patients with psychopathology who undergo epilepsy surgery, it would be unwise to make a decision on whether to reject a patient simply on the grounds of psychosis. A detailed psychiatric evaluation of each individual patient is required.     

Postictal psychosis as a risk factor for mood disorders after temporal lobe surgery

This study investigated the psychiatric consequences of 38 consecutive patients who had surgery for intractable temporal lobe epilepsy with special attention to postoperative mood disorders. Aclose interrelation between preoperative postictal psychosis andpostoperative manic or depressive episodes was suggested. Left sidedlobectomy augmented this correlation. Because the first sign ofpostoperative manic and depressive episodes appeared within 1 month and2 months respectively, cautious psychiatric follow up for severalmonths after surgery proved to be crucial to prevent postoperativesuicides. Postoperative manic depressive episodes disappeared withinthe first 2 years after operation without exception, if treatedsuitably. This suggests that we do not have to preclude patients withpostictal psychosis as surgical candidates, but measures must be takento prevent postoperative depressions.

     

Temporal lobe epilepsy: clinical semiology and age at onset.

The objective of this study was to define the clinical semiology of seizures in temporal lobe epilepsy according to the age at onset. We analyzed 180 seizures from 50 patients with medial or neocortical temporal lobe epilepsy who underwent epilepsy surgery between 1997-2002, and achieved an Engel class I or II outcome. We classified the patients into two groups according to the age at the first seizure: at or before 17 years of age and 18 years of age or older. All patients underwent intensive video-EEG monitoring. We reviewed at least three seizures from each patient and analyzed the following clinical data: presence of aura, duration of aura, ictal and post-ictal period, clinical semiology of aura, ictal and post-ictal period. We also analyzed the following data from the clinical history prior to surgery: presence of isolated auras, frequency of secondary generalized seizures, and frequency of complex partial seizures. Non-parametric, chi-square tests and odds ratios were used for the statistical analysis. There were 41 patients in the "early onset" group and 9 patients in the "later onset" group. A relationship was found between early onset and mesial temporal lobe epilepsy and between later onset and neocortical temporal lobe epilepsy (p = 0.04). The later onset group presented a higher incidence of blinking during seizures (p = 0.03), a longer duration of the post-ictal period (p = 0.07) and a lower number of presurgical complex partial seizures (p = 0.03). The other parameters analyzed showed no significant differences between the two groups. We conclude that clinical and semiological differences exist between patients with temporal lobe epilepsy according to the age at onset. [Published with video sequences].     

Psychosis after epilepsy surgery: Report of three cases

Temporal lobe epilepsy surgery has become a successful alternative in patients with refractory epilepsy. However, the outcome of epilepsy surgery may be affected by the occurrence of postsurgical psychiatric symptoms, such as psychosis. This report describes three cases of refractory temporal lobe epilepsy and hippocampal sclerosis, which, after anterior temporal lobectomy, presented with acute psychosis. One of them had a history of acute psychosis, and all of them met criteria for Cluster A personality disorder (schizoid/schizotypal) during psychiatric assessment prior to surgery. The three cases had a good seizure outcome (Engel I), but, on follow-up during the first year after surgery, developed an acute psychotic episode compatible with schizoaffective disorder; brief psychotic disorder; and a delusional disorder, respectively, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Treatment with low-dose risperidone was successful.     

Psychosis after epilepsy surgery: report of three cases

Temporal lobe epilepsy surgery has become a successful alternative in patients with refractory epilepsy. However, the outcome of epilepsy surgery may be affected by the occurrence of postsurgical psychiatric symptoms, such as psychosis. This report describes three cases of refractory temporal lobe epilepsy and hippocampal sclerosis, which, after anterior temporal lobectomy, presented with acute psychosis. One of them had a history of acute psychosis, and all of them met criteria for Cluster A personality disorder (schizoid/schizotypal) during psychiatric assessment prior to surgery. The three cases had a good seizure outcome (Engel I), but, on follow-up during the first year after surgery, developed an acute psychotic episode compatible with schizoaffective disorder; brief psychotic disorder; and a delusional disorder, respectively, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Treatment with low-dose risperidone was successful.     

VNS in patients with previous unsuccessful resective epilepsy surgery: antiepileptic and psychotropic effects

OBJECTIVES: To assess the efficacy of vagus nerve stimulation (VNS) in patients with medically and surgically intractable complex partial seizures (CPS). PATIENTS AND METHODS: Sixteen patients with previous temporal [15] and frontal [one] resections were treated with VNS between 1994 and 1999 at King's College Hospital, London, UK. Post-operative video-electroencephalogram telemetry had shown that CPS started from the operated side in 12 patients, contralaterally in three and bilaterally independently in one. RESULTS: Three patients (18.75%) had 50% or more reduction in seizure frequency, but one showed severe worsening of epilepsy, which remitted upon VNS discontinuation. The antiepileptic effect of VNS was not different with respect to the type of operation (anterior temporal lobectomy vs amygdalohippocampectomy), the side of operation, or the side of seizure onset. We observed psychotropic effects in two patients with post-ictal psychosis, in two others with depression, and in a child with severe behavioral disorder. CONCLUSIONS: VNS may have a rather limited antiepileptic role to play in patients with persistent seizures following epilepsy surgery, but may independently possess useful antipsychotic and mood-stabilizing properties.     

Postictal symptoms help distinguish patients with epileptic seizures from those with non-epileptic seizures.

The aim of the study was to assess whether post-ictal symptoms can help distinguish patients who have epileptic seizures from those with non-epileptic seizures (NES). We reviewed the spontaneous responses to the question 'What symptoms do you have after a seizure?' in 16 patients with epileptic seizures (predominantly focal with secondary generalization or generalized tonic-clonic) and 23 NES patients. Six of the 16 patients (38%) vs. only one of 23 NES patients (4.3%) noted post-ictal headache (P = 0.008). Nine epilepsy patients (56%) vs. three NES patients (13%) reported post-ictal fatigue (P = 0.004). Confusion or other symptoms did not distinguish epilepsy patients from those with NES. All epilepsy patients had at least one post-ictal symptom while 12 NES patients (52%) had none (P = 0.001). Therefore, patients evaluated for epileptic vs. non-epileptic seizures who have post-ictal fatigue or headache, are more likely to have epileptic seizures. Patients with a diagnosis of NES who note post-ictal fatigue or headache should be investigated further.     

Does antiepileptic drug withdrawal predispose patients undergoing temporal lobe epilepsy surgery to late onset of psychiatric morbidity? A report of three cases

Surgery is an established and increasingly utilized treatment option in medically refractory temporal lobe epilepsy. Many psychiatric problems are known to complicate in the postoperative period. Most studies have a follow-up period of less than 24 months. We report the cases of three patients who developed severe psychiatric problems in the late postoperative period after successful temporal lobectomy for refractory epilepsy — Psychosis, major depression with psychosis, and severe anxiety disorder, respectively. None of the patients had past or family history of psychiatric disease. All three patients had undergone anterior temporal lobectomy on the right side for intractable epilepsy. They remained absolutely seizure-free after surgery. We conclude that psychiatric morbidity may arise de novo long after temporal lobectomy. This association between temporal lobectomy for epilepsy and late onset psychiatric morbidity should be carefully studied. Mechanisms underlying this late complication require deeper understanding of the effects of epilepsy surgery.     

Postoperative psychoses in epileptic patients after temporal lobectomy

Introduction – Psychosis is the most severe psychiatric complication after epilepsy surgery. Patients and methods – We evaluated postoperatively at 1 year the psychoses of a series of 57 adult patients with intractable epilepsy who underwent temporal lobe surgery. Results – Five patients (8.8%) developed postoperative psychosis. Two (3.5%) of these 5 revealed postictal psychotic episodes in connection with persisting seizures, both of them had had similar episodes even preoperatively. Two patients (3.5%) exhibited a definite and one patient (1.8%) a probable de novo schizophrenia. Conclusion – Our findings clearly emphasize the need for careful postoperative psychiatric follow-up for patients with temporal lobectomy.     

Lateralising value of ictal features in partial seizures: effect on postsurgical outcome.

We reviewed the videotapes of 49 consecutive patients with a history of medically refractory temporal lobe epilepsy for the presence and laterality of unilateral hand posturing (UHP), unilateral hand automatism (UHA), non-forced head turning (HT), and post-ictal dysphasia (PID). All of these patients underwent temporal resections with follow-up for more than 2 years after the surgery. We examined the correlation of consistency, frequency, and laterality of each of these signs on the postsurgical outcomes. The distribution of these signs was not significantly different between patients with Engel class 1 versus Engel class 2-4. The consistency and laterality of these signs do not correlate with postsurgical outcomes.     

Surgical treatment of temporal lobe epilepsy with interictal psychosis: results of six cases

We describe the postsurgical outcome of six patients with medically intractable temporal lobe epilepsy and interictal psychosis who underwent temporal lobe resection. All patients were submitted to a comprehensive presurgical investigation, including prolonged video-EEG monitoring. Despite their psychotic disorders, all patients were able to provide informed consent and we were able to complete the investigation of all cases. Surgical complications occurred in two cases. Seizure outcome was Engel class I (free from incapacitating seizures) in all except one patient. There was no worsening of their psychoses. Until now, there has been relative improvement in the mental conditions of five patients. Although psychosis has been considered by some authors as a contraindication to epilepsy surgery, with appropriate psychiatric intervention, patients with refractory epilepsy and chronic interictal psychosis may be submitted to prolonged presurgical investigation and undergo surgery successfully.     

Schizophrenia-like psychosis arising de novo following a temporal lobectomy: timing and risk factors

OBJECTIVES: To clarify risk factors for the development of schizophrenia-like psychotic disorders following temporal lobectomy, and to explore the possibility that the early postoperative period is a time of high risk for the onset of such chronic psychotic disorders. METHODS: Patients who developed schizophrenia-like psychosis were identified from a series of 320 patients who had a temporal lobectomy for medically intractable epilepsy. The relationship of their disorders to both the operation and subsequent seizure activity was examined. Using a retrospective case-control design, risk factors for the development of schizophrenia-like psychosis were established. RESULTS: Eleven patients who developed schizophrenia-like psychosis postoperatively were identified and compared with 33 control subjects who remained free of psychosis postoperatively. The onset of de novo psychotic symptoms was typically in the first year following the operation. No clear relationship between postoperative seizure activity and fluctuations in psychotic symptoms emerged. Compared with the controls, patients who become psychotic had more preoperative bilateral electroencephalogram (EEG) abnormalities, pathologies other than mesial temporal sclerosis in the excised lobe and a smaller amygdala on the unoperated side. CONCLUSIONS: Temporal lobectomy for medically intractable epilepsy may precipitate a schizophrenia-like psychosis. Patients with bilateral functional and structural abnormalities, particularly of the amygdala, may be at particular risk for the development of such psychoses.     

Psychiatric outcome of epilepsy surgery in patients with psychosis and temporal lobe drug-resistant epilepsy: A prospective case series

ObjectivesTemporal lobe resistant epilepsy has been associated with a high incidence of psychotic disorders; however, there are many controversies; while some patients get better after surgery from their psychiatric condition, others develop psychosis or de novo depression. The aim of this study was to determine the psychiatric and seizure outcome after epilepsy surgery in patients with a previous history of psychoses.MethodsSurgical candidates with temporal lobe drug-resistant epilepsy and a positive history of psychosis diagnosed during the presurgical psychiatric assessment were included. A two-year prospective follow-up was determined after surgery. The DSM-IV Structural Interview, GAF (global assessment of functionality, DSM-IV), Ictal Classification for psychoses, and Engel's classification were used. The Student t test and chi-square–Fisher tests were used.ResultsDuring 2000–2010, 89 patients were admitted to the epilepsy surgery program, 14 patients (15.7%) presented psychoses and were included in this series. After surgery, six patients (43%) did not develop any psychiatric complications, three patients (21%) with chronic interictal psychosis continued with no exacerbation, three patients (21%) developed acute and transient psychotic symptoms, and two patients (14%) developed de novo depression. Seizure outcome was Engel class I-II in 10 patients (71%). Total GAF scores were higher after surgery in patients found to be in Engel class I–II (p < 0.05).ConclusionsPatients with comorbid psychosis and temporal lobe drug-resistant epilepsy may benefit from epilepsy surgery under close psychiatric supervision.     

Somatoform disorders after temporal lobectomy.

OBJECTIVE: Depression, anxiety, and psychosis are the most frequent psychiatric disorders after epilepsy surgery. The only new-onset somatoform disorder reported postoperatively is conversion disorder. We identified 10 patients who developed somatoform disorder other than nonconversion epileptic seizures after anterior temporal lobectomy. METHOD: We retrospectively reviewed the charts of 325 anterior temporal lobectomy and 125 extratemporal surgeries between 1991 and 2000. RESULTS: Seven of the patients developed undifferentiated somatoform disorder after anterior temporal lobectomy, 1 had pain and body dysmorphia, another had pain disorder, and another had body dysmorphia alone, but none were found after extratemporal surgeries (chi-square = 3.93; P < or = 0.05). Somatoform disorder was significantly more common in right anterior temporal lobectomy (n = 9) than left anterior temporal lobectomy (n = 1) (chi-square = 6.5; P < or = 0.025). CONCLUSIONS: Our findings suggest that right temporal resection contributes to the development of somatoform disorders in our patients and that right temporal dysfunctions may contribute to idiopathic somatoform disorders.     

Psychosis associated with epilepsy: significance of the laterality of the epileptogenic lesion.

The psychiatric histories in a group of patients who had previously undergone temporal lobectomy for intractable epilepsy, were analysed for the occurrence of psychosis. The data suggest that epileptic patients with left temporal lobe lesions are especially disposed to develop a schizophrenic-like psychosis.     

Psychomotor epilepsy and psychosis

The EEG findings in waking, sleep, and sphenoidal electrode recordings in 96 patients with partial epileptic seizures with complex symptoms, who, after a median interval of 18 years developed paranoid/hallucinatory psychosis, were compared with the findings from a group of patients without psychosis, who had had the same type of epilepsy in median 24 years. There were no significant differences between the two groups with regard to median age at onset of epilepsy or complex partial seizures, age, or duration of epilepsy at time of examination. the psychotic patients had a significant preponderance of temporal medio-basal spike foci, recorded on the sphenoidal electrode, indicating deep temporal lobe dysfunction as an important factor in the pathogenesis of psychosis. A significant higher frequency of bilateral and multiple spike foci, together with a significant frequency of slow-wave admixture to the waking background EEG activity, indicated more extensive and severe epileptogenic lesions in the psychotic patients. There was no correlation between psychosis and unilateral EEG foci in either temporal lobe.