Homicide during postictal psychosis

A medico-legal perspective on postictal violence: A case study and systematic review of postictal delirium

Detailed descriptions of violent postictal episodes are rare. We provide evidence from an index case and from a systematic review of violent postictal episodes that demonstrates the encephalopathic features of some violent postictal behaviors. We discuss how these cases may fit in the legal framework of culpability. The data support the view that some episodes of violent postictal behavior are more accurately classified as a neurological delirium or encephalopathy rather than as a postictal psychosis. Current medical terminology may present unwarranted (and presumably unintended) barriers to exculpation for patients who exhibit post-ictal violence during an episode of delirium during which the patient was unaware of his or her violent conduct.

The Emerging Role of Toll-Like Receptor-Mediated Neuroinflammatory Signals in Psychiatric Disorders and Acquired Epilepsy

The new and evolving paradigms of psychiatric disorders pathogenesis are deeply inclined toward chronic inflammation that leads to disturbances in the neuronal networks of patients. A strong association has been established between the inflammation and neurobiology of depression which is mediated by different toll-like receptors (TLRs). TLRs and associated signalling pathways are identified as key immune regulators to stress and infections in neurobiology. They are a special class of transmembrane proteins, which are one of the broadly studied members of the Pattern Recognition Patterns family. This review focuses on summarizing the important findings on the role of TLRs associated with psychotic disorders and acquired epilepsy. This review also shows the promising potential of TLRs in immune response mediated through antidepressant therapies and TLRs polymorphism associated with various psychotic disorders. Moreover, this also sheds light on future directions to further target TLRs as a therapeutic approach for psychiatric disorders.

Seizure semiology: ILAE glossary of terms and their significance

This educational topical review and Task Force report aims to address learning objectives of the International League Against Epilepsy (ILAE) curriculum. We sought to extract detailed features involving semiology from video recordings and interpret semiological signs and symptoms that reflect the likely localization for focal seizures in patients with epilepsy. This glossary was developed by a working group of the ILAE Commission on Diagnostic Methods incorporating the EEG Task Force. This paper identifies commonly used terms to describe seizure semiology, provides definitions, signs and symptoms, and summarizes their clinical value in localizing and lateralizing focal seizures based on consensus in the published literature. Video-EEG examples are included to illustrate important features of semiology in patients with epilepsy.

Postictal psychosis, a cause of secondary affective psychosis: A clinical description study of 77 patients

OBJECTIVE

Postictal psychosis (PIP) is a severe complication occurring at least in 2% of patients with epilepsy. Since the 19th century, psychiatrists have reported the specificity of PIP presentation, but descriptions did not clearly distinguish PIP from after-seizure delirium. This study aimed to provide a precise description of psychiatric signs occurring during PIP, and improve recognition of PIP.

METHODS

We performed a review of clinical descriptions available in literature (48 patients), that we gathered with a retrospective multicentric case series of patients from three French epilepsy units (29 patients). For each patient, we collected retrospectively the psychiatric signs, and epilepsy features.

RESULTS

We found a high prevalence of persecutory (67.5%) and religious (55.8%) delusions, with almost systematic hallucinations (83.1%) and frequent mood disturbances (76.6%), especially euphoria. Severe consequences were not negligible (other-directed assault in 20.8%, self-directed in 13.0%). The type of delusion was associated with mood symptoms (p = 0.017). Episode onset was mainly sudden/rapid (90.9%), its duration was mostly between one and 14 days (64.9%) and the response to antipsychotic medication was good. Disorder was recurrent in more than a half of the sample (57.1% of patients with at least 2 episodes).

CONCLUSION

Considering our findings, PIP resembles more an affective psychosis, than a purely psychotic disorder. The presence of affective signs differentiates PIP from other psychotic comorbidities in epilepsy. Additionally, resemblance between PIP and psychotic manic episode might help to discuss links between epilepsy and bipolar disorder.

Epilepsy, violence, and crime. A historical analysis

In the 19th and early 20th century, epilepsy was one of the most investigated disorders in forensic psychiatry and psychology. The possible subsidiary symptoms of epilepsy (such as temporal confusion, alterations of consciousness, or increased aggression) played pivotal roles in early forensic and criminal psychological theories that aimed to underscore the problematic medical, social and legal status of epileptic criminals. These criminals were considered extremely violent and capable of committing sudden, brutal acts. Although the theory of "epileptic criminality" was refuted due to 20th-century developments in medicine, forensic psychiatry, and criminal psychology, some suppositions related to the concept of epileptic personality have lingered. This paper explores the lasting influence of the theory of epileptic personality by examining the evolution of the theories of epileptic criminality both in the international and the Hungarian context. Specifically, it calls attention to the twentieth-century revival of the theory of epileptic personality in the works of Leopold Szondi, István Benedek and Norman Geschwind. The paper shows that the issue of epileptic personality still lingers in neuropsychology. In doing so, biological reductionist trends in medical-psychological thinking are traced, and attention is drawn to questions that arise due to changing cultural and medical representations.

Epileptic seizures and criminal acts: Is there a relationship?

BACKGROUND

The relation between epilepsy and criminal acts has been debated for over a century. The general perception persists that epileptic seizures can be associated with violent behavior. Some studies have provided evidence for such an association; however, it remains uncertain whether it really exists. This review critically evaluates the scientific literature on the possible relation between epileptic seizures and criminal acts.

METHODS

A PubMed search was undertaken using the search terms "epilepsy and crime", "epilepsy and automatism", "epilepsy and law", and "epilepsy and dyscontrol syndrome" with the aim of identifying studies examining the possible association between epileptic seizure and crime.

RESULTS

The combined keywords "epilepsy and crime" yielded 495 articles, the keywords "epilepsy and automatism" 402 results, the keywords "epilepsy and law" 969 articles, and the keywords "epilepsy and dyscontrol syndrome" resulted in 22 search results. After removing publications such as reviews and opinion pieces, we identified and analyzed a total of 24 research articles with relevant original data. These included single case reports. The reviewed literature suggests that there are very rare occasions when criminal acts are committed during the ictal or postictal period, mostly by patients with focal epilepsy.

CONCLUSION

The literature on the relation between epileptic seizures and criminal acts is not conclusive. Behavioral disturbances often seem more closely related to comorbidities of epilepsy than particular seizures characteristics. These comorbidities are often not well-described. There is an urgent need for more systematic and detailed data gathering and reporting, in order to allow a more detailed investigation of the relation between epileptic seizures and criminal acts.

Signs and symptoms of the postictal period in epilepsy: A systematic review and meta-analysis

OBJECTIVE

The postictal period has many physical, behavioral, and cognitive manifestations associated with it. These signs and symptoms are common, can be quite debilitating, and can have a continued impact long after the seizure has ended. The purpose of this systematic review was to quantify the occurrence of postictal signs and symptoms, along with their frequency and duration in persons with epilepsy.

METHODS

Cochrane Database of Systematic Reviews, CINAHL, EMBASE, MEDLINE, PsycINFO, Web of Science, and Scopus were searched from inception to November 29, 2017. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting standards were followed. Search terms included subject headings and text words such as convulsion, epilepsy, seizure, postictal, post seizure, seizure recovery, seizure end, Todd's paresis, and Todd's paralysis. Standardized forms were used to collect various study variables. Abstract and full-text review, data abstraction, and quality assessment were all done in duplicate. Study heterogeneity was assessed using the I-squared test, and a random effects model was used to determine estimates. Publication bias was evaluated using funnel plots.

RESULTS

From 7811 abstracts reviewed, 78 articles met eligibility criteria, with 31 postictal manifestations (signs and/or symptoms) described and 45 studies included in the meta-analysis. The majority of studies described postictal headaches, migraines, and psychoses, with mean weighted frequency of 33.0% [95% confidence interval (CI) 26.0-40.0], 16.0% [95% CI 10.0-22.0], and 4.0% [95% CI 2.0-5.0], respectively. The mean weighted proportions of manifestations ranged from 0.5% (subacute postictal aggression) to 96.2% (postictal unresponsiveness) with symptom duration usually lasting <24 h but up to 2 months for physical and cognitive/behavioral symptoms respectively.

SIGNIFICANCE

Examining data on the various signs and symptoms of the postictal period will have practical applications for physicians by raising their awareness about these manifestations and informing them about the importance of optimizing their prevention and treatment in epilepsy.

Mechanisms Underlying Aggressive Behavior Induced by Antiepileptic Drugs: Focus on Topiramate, Levetiracetam, and Perampanel

Antiepileptic drugs (AEDs) are effective against seizures, but their use is often limited by adverse effects, among them psychiatric and behavioral ones including aggressive behavior (AB). Knowledge of the incidence, risk factors, and the underlying mechanisms of AB induced by AEDs may help to facilitate management and reduce the risk of such side effects. The exact incidence of AB as an adverse effect of AEDs is difficult to estimate, but frequencies up to 16% have been reported. Primarily, levetiracetam (LEV), perampanel (PER), and topiramate (TPM), which have diverse mechanisms of action, have been associated with AB. Currently, there is no evidence for a specific pharmacological mechanism solely explaining the increased incidence of AB with LEV, PER, and TPM. Serotonin (5-HT) and GABA, and particularly glutamate (via the AMPA receptor), seem to play key roles. Other mechanisms involve hormones, epigenetics, and “alternative psychosis” and related phenomena. Increased individual susceptibility due to an underlying neurological and/or a mental health disorder may further explain why people with epilepsy are at an increased risk of AB when using AEDs. Remarkably, AB may occur with a delay of weeks or months after start of treatment. Information to patients, relatives, and caregivers, as well as sufficient clinical follow-up, is crucial, and there is a need for further research to understand the complex relationship between AED mechanisms of action and the induction/worsening of AB.

Epilepsy, Antiepileptic Drugs, and Aggression: An Evidence-Based Review

Antiepileptic drugs (AEDs) have many benefits but also many side effects, including aggression, agitation, and irritability, in some patients with epilepsy. This article offers a comprehensive summary of current understanding of aggressive behaviors in patients with epilepsy, including an evidence-based review of aggression during AED treatment. Aggression is seen in a minority of people with epilepsy. It is rarely seizure related but is interictal, sometimes occurring as part of complex psychiatric and behavioral comorbidities, and it is sometimes associated with AED treatment. We review the common neurotransmitter systems and brain regions implicated in both epilepsy and aggression, including the GABA, glutamate, serotonin, dopamine, and noradrenaline systems and the hippocampus, amygdala, prefrontal cortex, anterior cingulate cortex, and temporal lobes. Few controlled clinical studies have used behavioral measures to specifically examine aggression with AEDs, and most evidence comes from adverse event reporting from clinical and observational studies. A systematic approach was used to identify relevant publications, and we present a comprehensive, evidence-based summary of available data surrounding aggression-related behaviors with each of the currently available AEDs in both adults and in children/adolescents with epilepsy. A psychiatric history and history of a propensity toward aggression/anger should routinely be sought from patients, family members, and carers; its presence does not preclude the use of any specific AEDs, but those most likely to be implicated in these behaviors should be used with caution in such cases.

Hospital care for mental health and substance abuse in children with epilepsy

BACKGROUND

Reducing the burden of pediatric mental illness requires greater knowledge of mental health and substance abuse (MHSA) outcomes in children who are at an increased risk of primary psychiatric illness. National data on hospital care for psychiatric illness in children with epilepsy are limited.

METHODS

We used the Kids' Inpatient Database (KID), the Healthcare Cost and Utilization Project (HCUP), and the Agency for Healthcare Research and Quality from 2003 to 2009 to examine MHSA hospitalization patterns in children with comorbid epilepsy. Nonparametric and regression analyses determined the association of comorbid epilepsy with specific MHSA diagnoses and examined the impact of epilepsy on length of stay (LOS) for such MHSA diagnoses while controlling for demographic, payer, and hospital characteristics.

RESULTS

We observed 353,319 weighted MHSA hospitalizations of children ages 6-20; 3280 of these involved a child with epilepsy. Depression was the most common MHSA diagnosis in the general population (39.5%) whereas bipolar disorder was the most common MHSA diagnosis among children with epilepsy (36.2%). Multivariate logistic regression models revealed that children with comorbid epilepsy had greater adjusted odds of bipolar disorder (AOR: 1.17, 1.04-1.30), psychosis (AOR: 1.78, 1.51-2.09), sleep disorder (AOR: 5.90, 1.90-18.34), and suicide attempt/ideation (AOR: 3.20, 1.46-6.99) compared to the general MHSA inpatient population. Epilepsy was associated with a greater LOS and a higher adjusted incidence rate ratio (IRR) for prolonged LOS (IRR: 1.12, 1.09-1.17), particularly for suicide attempt/ideation (IRR: 3.74, 1.68-8.34).

CONCLUSIONS

Children with epilepsy have distinct patterns of hospital care for mental illness and substance abuse and experience prolonged hospitalization for MHSA conditions. Strategies to reduce psychiatric hospitalizations in this population may require disease-specific approaches and should measure disease-relevant outcomes. Hospitals caring for large numbers of children with neurological disease (such as academic centers) may have inaccurate measurements of mental health-care quality unless the impact of key comorbid conditions such as epilepsy is considered.

"Le grand mal intellectuel" by Jules Falret (1861), the first complete description of postictal psychosis

This paper presents the first complete description of postictal psychosis, made by the French psychiatrist Jules Falret. This description, written in 1861, was the first to fulfill modern diagnostic criteria. We will examine why this syndrome, well defined in the 19th century, was forgotten for over a century.