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

Psychiatric comorbidities among people with epilepsy: A population-based assessment in disadvantaged communities

Psychiatric disorders are frequent among people with epilepsy but often under-recognized. The diagnosis and treatment of these disorders in low- and low-middle-income countries (LMICs) are challenging.

METHODS

This cross-sectional survey included people recruited during a community epilepsy screening program involving 59,509 individuals from poor communities in Ludhiana in Northwest India. Adults (age ≥18 years) with confirmed epilepsy on antiseizure medications were screened for depression and anxiety using the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) and Generalized Anxiety Disorder-7 (GAD-7) twice over two years of follow-up. They were later interviewed for symptoms using the Brief Psychiatric Rating Scale, which was then confirmed by assessments by an experienced psychiatrist.

RESULTS

Of the 240 people with confirmed epilepsy, 167 (70%) were adults, of whom, 116 (70%) eventually participated in the study. The NDDI-E with a cut-off of 15 identified depression in 14 (12%) of 116 people after one year of follow-up and 17 (15%) at two years. The GAD-7 using a cut-off of 6 identified 22 (19%) at one year and 32 (28%) with anxiety at two years. The area under the curves for NDDI-E was estimated as 0.62 (_95%CI, 0.51-0.73; SE: 0.06; p = 0.04) and for GAD-7 as 0.62 (_95%CI, 0.46-0.78; SE: 0.08; p = 0.12). Brief Psychiatric Rating Scale identified 63 (54%) people with psychiatric symptoms, for whom, a psychiatric diagnosis was confirmed in 60 (52%). A psychiatric diagnosis was associated with education below high school [Odds Ratio (OR): 2.59, _95%CI, 1.12-5.1; p = 0.03], later age of seizure onset (OR, 1.05, _95%CI: 1.0-1.10; p = 0.04), seizure frequency of at least one/year at enrolment (OR, 2.36, _95%CI: 1.0-5.58; p = 0.05) and the use of clobazam (OR, 5.09, _95%CI, 1.40-18.42; p = 0.01).

CONCLUSION

Depression and anxiety are common in people with epilepsy. Our findings underscore the low yields of screening instruments, NDDI-E and GAD-7, and comparatively better professionally-administered diagnostic assessments in resource-limited settings in LMICs. Moreover, previously established cut-offs do not apply to the community studied.

Frontal Lobe Epilepsy in a Pediatric Population: Characterization of Clinical Manifestations and Semiology

Purpose: Frontal lobe epilepsy (FLE) has various clinical presentations depending on the anatomy involved. Seizures are brief and can mimic psychiatric conditions, and patients often cannot describe the aura. Therefore, it is difficult to characterize the semiology, especially in pediatric patients. This study investigated the characteristics of pediatric FLE.Methods: We retrospectively reviewed the data of pediatric patients with FLE who underwent long-term video-electroencephalography (EEG) monitoring between January 2010 and June 2020. Patients’ demographic data, seizure-related clinical presentations, semiology, brain magnetic resonance imaging (MRI), and EEG data were analyzed.Results: Fifty-six patients were included (31 males, 25 females). The age of seizure onset varied from 1 month to 14 years (mean±standard deviation, 6.1±4.4 years). Seizures were classified into nine categories, including focal tonic (30/56), aura (22/56), hypermotor (17/56), focal clonic (15/56), versive (13/56), and bilateral asymmetric tonic (4/56). Seventeen patients (30.4%) had abnormal MRI results, including focal cortical dysplasia, heterotopic gray matter, and neuroepithelial tumors. Ictal EEG changes were commonly observed in the dorsolateral premotor and central cortices. In focal tonic seizures, EEG changes often originated in the premotor cortex. The location of the lesions on MRI and EEG coincided in six cases.Conclusion: In pediatric FLE, various seizure types occur depending on the ictal anatomic origin, and individual patients had multiple semiologies. Brain MRI was normal in two-thirds of patients, and interictal EEG did not reveal epileptiform discharges in approximately 25%. Semiology reported on the basis of home videos and interictal EEG will help localize the ictal onset zone.

Quantitative psychopathology of interictal psychosis in epilepsy; interaction between epilepsy-related and psychosis-general effects

OBJECTIVE

There is a historical debate whether psychopathology of epilepsy psychosis is unique to epilepsy or common to other psychoses. However, a large comprehensive studies on this issue are scarce. To clarify the characteristics of interictal psychosis (IIP), we evaluated psychopathology quantitatively.

METHODS

This study included 150 patients with IIP (epilepsy+/psychosis+), 187 patients with schizophrenia (SC: epilepsy-/psychosis+), 182 patients with epilepsy (EP: epilepsy+/psychosis-), and 172 non-clinical individuals (NC: epilepsy-/psychosis-). The IIP group comprised 127 chronic and 23 brief psychoses. Age, sex, and years of education, onset and duration of psychosis, and onset and duration of epilepsy were matched among the groups. The psychopathology was evaluated using the 16-item Brief Psychiatric Rating Scale (BPRS), which comprises three symptom factors namely negative symptoms (NS), positive symptoms (PS), and anxiety-depressive symptoms (ADS).

RESULTS

For overall 16-BPRS and NS factor scores, there were significant interactions between epilepsy-related (epilepsy+/-) and psychosis-general (psychosis+/-) effects. The EP exhibited higher scores than did the NC, whereas the IIP exhibited lower scores than did the SC. For PS and ADS factor scores, the IIP and SC exhibited a significant psychosis-general effect. Chronic IIP was associated with more serious psychopathologies than was brief IIP. However, limited with chronic IIP, there was a significant interaction between epilepsy-related and psychosis-general effects on the overall 16-BPRS and NS factor scores.

CONCLUSION

These findings demonstrate the first large quantitative evidence on the unique psychopathology of IIP which has been only narratively described. The psychopathology is associated with the interaction between epilepsy-related and psychosis-general effects.

Cingulate-basal ganglia-thalamo-cortical aspects of catatonia and implications for treatment

The catatonic syndrome is an example of a multifactorial neurobehavioral disorder that causes much morbidity and mortality but also has the potential to unlock the mystery of how motivation and movement interact to produce behavior. In this chapter, an attempt is made to understand better the catatonic syndrome through the lens of neurobiology and neuropathophysiology updated by recent studies in molecular biology, genomics, inflammasomics, neuroimaging, neural network theory, and neuropsychopathology. This will result in a neurostructural model for the catatonic syndrome that centers on paralimbic regions including the anterior and midcingulate cortices, as they interface with striatal and thalamic nodes in the salience decision-making network. Examination of neurologic disorders like the abulic syndrome, which includes in its extreme catatonic form, akinetic mutism, will identify the cingulate cortex and paralimbic neighbors as regions of interest. This exploration has the potential to unlock mysteries of the brain cascade from motivation to movement and to clarify catatonia therapeutics. Such a synthesis may also help us discern meaning inherent in this complex neurobehavioral syndrome.

Fantastic confabulation in right frontal lobe epilepsy

Background

Interictal behavioral symptoms in frontal lobe epilepsy (FLE) are variable and often difficult to discriminate from other localization-related epilepsies.

Methods and results

We report two female patients with right FLE who exhibited fantastic confabulations. One of the patients had a 14-year history of hypermotor seizures, and the other had a 10-year history of dyscognitive seizures with automatism. Their fantastic confabulations arose in the context of moderate-to-severe cognitive impairment and of a variety of behavioral abnormalities, including emotional withdrawal and compulsive behaviors.

Conclusion

Fantastic confabulations are rare but may be a relatively specific behavioral marker for FLE-associated psychosis.

Psychoses in epilepsy: A comparison of postictal and interictal psychoses

We retrospectively analyzed data of patients with epilepsy (n=1434) evaluated with prolonged EEG monitoring in order to estimate the prevalence of postictal psychosis (PP) and interictal psychosis (IP), to investigate a potential association of psychosis subtype with epilepsy type, and to assess differences between PP and IP. The overall prevalence of psychosis was 5.9% (N=85); prevalence of PP (N=53) and IP (N=32) was 3.7% and 2.2%, respectively. Of patients with psychosis, 97.6% had localization-related epilepsy (LRE). Prevalence of psychosis was highest (9.3%) in patients with temporal lobe epilepsy (TLE). When comparing PP with IP groups on demographic, clinical, and psychopathological variables, patients with IP were younger at occurrence of first psychosis (P=0.048), had a shorter interval between epilepsy onset and first psychosis (P=0.002), and more frequently exhibited schizophreniform traits (conceptual disorganization: P=0.008; negative symptoms: P=0.017) than those with PP. Postictal psychosis was significantly associated with a temporal seizure onset on ictal EEG (P=0.000) and a higher incidence of violent behavior during psychosis (P=0.047). To conclude, our results support the presumption of a preponderance of LRE in patients with psychosis and that of a specific association of TLE with psychosis, in particular with PP. Given the significant differences between groups, PP and IP may represent distinct clinical entities potentially with a different neurobiological background.

[The relationship between schizophrenia and epilepsy: the history and current state of the problem]

The review deals with the background and current state of the relationship between schizophrenia and epilepsy. The author presents results of recent epidemiological, neuropsychological, neurophysiological and genetic studies, indicating that these diseases may be different clinical variants of a common etiologic process (neurodevelopmental brain abnormalities), while epilepsy with chronic psychotic symptoms can be considered as an experimental model of schizophrenia pathogenesis.

Pitfalls in the diagnosis of new-onset frontal lobe seizures

We reported the case of a young woman who received an antiepileptic drug after a first possible generalized tonic-clonic seizure with no clear inter-ictal epileptic paroxysms in the routine electroencephalogram. Her stereotypical movements decreased but did not disappear with treatment. Then a diagnosis of PNES was considered by neurologist after witnessing a stereotypical motor episode. While AED treatment was decreased and stopped, epileptic seizure frequency and severity increased with secondary generalized tonic-clonic seizures. Then she presented postictal psychotic features that combined with video-EEG findings led to the final diagnosis of new onset pre-frontal lobe epilepsy.

Effects of antipsychotic drugs on the duration of interictal psychotic episodes in patients with epilepsy

Treatment protocols for interictal psychosis (IIP) of patients with epilepsy have not yet been established. We aimed to clarify the effects of antipsychotic drugs (APDs) on duration of IIP episodes. We studied 393 IIP episodes in 200 patients with epilepsy in accordance with our empirical treatment protocol. The duration of all the episodes and APD treatments were reviewed. Antipsychotic drugs were used in 338 episodes and not used in 55 episodes (non-APD group). The APDs used in the treatment of IIP episodes were divided into the following three groups: first-generation APDs (FAPD, n=252), second-generation APDs (SAPD, n=44), and the combination of first- and second-generation APDs (CAPD, n=42). The non-APD group showed a significantly shorter episode duration than did the APD group (F=6.05, p=0.014). Among the 3 APD groups (FAPD, SAPD, and CAPD), there was a significant difference in duration of IIP episode (F=8.65, p=0.000). Whereas the duration of episodes was significantly longer in the CAPD group than in the other two groups, it was not significantly different between the FAPD and SAPD groups. Our findings further to clarify the nature of IIP and add further perspectives on treatment protocols for IIP.

Basic treatment principles for psychotic disorders in patients with epilepsy

In patients with epilepsy, coexisting psychoses, either interictal (IIP) or postictal (PIP), are associated with serious disturbance in psychosocial function and well-being, and often require the care of a specialist. Unfortunately, evidence-based treatment systems for psychosis in patients with epilepsy have not yet been established. This article aims to propose concise and practical treatment procedures for IIP and PIP based on currently available data and international consensus statements, and primarily targeting nonpsychiatrist epileptologists who are often the first to be involved in the management of these complex patients. Accurate and early diagnosis of IIP and PIP and their staging in terms of acuity and severity form the essential first step in management. It is important to suspect the presence of psychosis whenever patients manifest unusual behavior. Knowledge of psychopathology and both individual and epilepsy-related vulnerabilities relevant to IIP and PIP facilitate early diagnosis. Treatment for IIP involves (1) obtaining consent to psychiatric treatment from the patient, whenever possible, (2) optimization of antiepileptic drugs, and (3) initiation of antipsychotic pharmacotherapy in line with symptom severity and severity of behavioral and functional disturbance. Basic psychosocial interventions will help reinforce adherence to treatment and should be made available. Due consideration must be given to patients' ability to provide informed consent to treatment in the short term, with the issue being revisited regularly over time. Given the often prolonged and recurrent nature of IIP, treatment frequently needs to be long-term. Treatment of PIP consists of two aspects, that is, acute protective measures and preventive procedures in repetitive episodes. Protective measures prioritize the management of risk in the early stages, and may involve sedation with or without the use of antipsychotic drugs, and the judicious application of local mental health legislation if appropriate. As for preventative procedures, optimizing seizure control by adjusting antiepileptic drugs or by surgical treatment is necessary.

Neuroimaging of frontal-limbic dysfunction in schizophrenia and epilepsy-related psychosis: toward a convergent neurobiology

Psychosis is a devastating, prevalent condition considered to involve dysfunction of frontal and medial temporal limbic brain regions as key nodes in distributed brain networks involved in emotional regulation. The psychoses of epilepsy represent an important, though understudied, model relevant to understanding the pathophysiology of psychosis in general. In this review, we (1) discuss the classification of epilepsy-related psychoses and relevant neuroimaging and other studies; (2) review structural and functional neuroimaging studies of schizophrenia focusing on evidence of frontal-limbic dysfunction; (3) report our laboratory's PET, fMRI, and electrophysiological findings; (4) describe a theoretical framework in which frontal hypoactivity and intermittent medial temporal hyperactivity play a critical role in the etiopathology of psychosis both associated and unassociated with epilepsy; and (5) suggest avenues for future research.

Sample size requirements for the internal validation of psychiatric scales

The ratio of subjects to variables (N/p), as a rule to calculate the sample size required in internal validity studies on measurement scales, has been recommended without any strict theoretical or empirical basis being provided. The purpose of the present study was to develop a tool to determine sample size for these studies in the field of psychiatry. First, a literature review was carried out to identify the distinctive features of psychiatric scales. Then, two simulation methods were developed to generate data according to: (1) the model for factor structure derived from the literature review and (2) a real dataset. This enabled the study of the quality of solutions obtained from principal component analysis or Exploratory Factor Analysis (EFA) on various sample sizes. Lastly, the influence of sample size on the precision of Cronbach's alpha coefficient was examined. The N/p ratio rule is not upheld by this study: short scales do not allow smaller sample size. As a rule of thumb, if one's aim is to reveal the factor structure, a minimum of 300 subjects is generally acceptable but should be increased when the number of factors within the scale is large, when EFA is used and when the number of items is small.

Relapse of postictal psychosis following 14-year symptom-free period

Neuropsychiatric sequelae in patients with epilepsy have been vastly studied and documented. These may be affective, cognitive or psychotic. Certain risk factors may predispose some epileptics more to these sequelae. In general, good epileptic control may minimize these outcomes. We present in this report, a case of postictal psychosis (PIP), superimposed on delirium, in a 68-year-old woman, with history of a single previous psychotic illness following a cluster of seizures. This report shows a collaborative management of the neuropsychiatric complications of temporal lobe epilepsy (TLE), by the neurology, geriatric medicine and psychiatry teams.

Thalamic T-type Ca²+ channels mediate frontal lobe dysfunctions caused by a hypoxia-like damage in the prefrontal cortex

Hypoxic damage to the prefrontal cortex (PFC) has been implicated in the frontal lobe dysfunction found in various neuropsychiatric disorders. The underlying subcortical mechanisms, however, have not been well explored. In this study, we induced a PFC-specific hypoxia-like damage by cobalt-wire implantation to demonstrate that the role of the mediodorsal thalamus (MD) is critical for the development of frontal lobe dysfunction, including frontal lobe-specific seizures and abnormal hyperactivity. Before the onset of these abnormalities, the cross talk between the MD and PFC nuclei at theta frequencies was enhanced. During the theta frequency interactions, burst spikes, known to depend on T-type Ca(2+) channels, were increased in MD neurons. In vivo knockout or knockdown of the T-type Ca(2+) channel gene (Ca(V)3.1) in the MD substantially reduced the theta frequency MD-PFC cross talk, frontal lobe-specific seizures, and locomotor hyperactivity in this model. These results suggest a two-step model of prefrontal dysfunction in which the response to a hypoxic lesion in the PFC results in abnormal thalamocortical feedback driven by thalamic T-type Ca(2+) channels, which, in turn, leads to the onset of neurological and behavioral abnormalities. This study provides valuable insights into preventing the development of neuropsychiatric disorders arising from irreversible PFC damage.

Neuropsychiatric evaluations of postictal behavioral changes

Postictal behavioral changes (PBCs), including psychosis, aggression, and mood change, are commonly observed in patients with epilepsy. Recognition and description of the clinical manifestations of PBCs would help in understanding and treating patients. Additionally, various quantified objective scales that are widely available in clinical psychiatry could be used to assess the clinical symptoms of PBCs. There are few reports in which objective rating scales have been used to assess neuropsychiatric symptoms in patients with epilepsy. However, there have been a small number of studies on interictal psychosis and depression in which either the Brief Psychiatric Rating Scale or the Hamilton Depression Scale was used. These inventories are likely to be useful for the assessment of PBCs. Other rating scales used for schizophrenia, depression, mania, and aggressive behavior are reviewed here. The author suggests that cross-sectional and longitudinal neuropsychiatric measurement combined with other modalities, including functional neuroimaging, could provide clues to the pathophysiology of PBCs.

Catatonia in encephalitis and nonconvulsive seizures: a case report and review of the literature

A 20-year-old woman was admitted for psychosis. On further investigation, she was found to be have viral encephalitis and generalized nonconvulsive seizures. After the seizures were controlled, she remained in a prolonged catatonic state. Repeated intravenous benzodiazepine administration, improved her cognition dramatically. This case emphasizes that catatonia may occur after encephalitis and nonconvulsive seizures.

Neurological disorders in schizophrenia

Schizophrenia (SZ) is a complex, heterogeneous, and disabling psychiatric disorder that impairs multiple aspects of human cognitive, perceptual, emotional, and behavioral functioning. SZ is relatively frequent (prevalence around 1%), with onset usually during adolescence or early adulthood, and has a deteriorating course. The rapidly growing area of neuroimaging research has has found clear evidence of many cortical and subcortical abnormalities in individuals with SZ. In this article the most recent findings from multiple studies on neurological disorders in SZ are reviewed, and the authors make a strong argument for a neurological basis of the schizophrenic process.

Ring chromosome 20 syndrome: a link between epilepsy onset and neuropsychological impairment in three children

PURPOSE

Ring chromosome 20 [r(20)] syndrome is a well-defined chromosomal disorder characterized by epilepsy, mild-to-moderate mental retardation, and lack of recognizable dysmorphic features. Epilepsy is often the most important clinical manifestation of the syndrome, even if its appearance is not constantly precocious. Seizures are frequently drug resistant.

METHODS

We describe three children with [r(20)] syndrome in whom the onset of epilepsy (age at onset range: 4 years and 6 months to 9 years and 4 months) determined a kind of epileptic status (age at onset range: 6 years and 10 months to 9 years and 8 months) with dramatic neuropsychological deterioration. This epileptic status lasted for several months because of refractoriness to most antiepileptic drugs (AEDs), but it was treated successfully with a combination of valproate and lamotrigine in two children.

RESULTS

As soon as seizures stopped, the children showed prompt recovery with partial restoration of the neuropsychological impairment.

CONCLUSION

This clinical picture can be described as abrupt epileptic encephalopathy.

Delusions, illusions and hallucinations in epilepsy: 2. Complex phenomena and psychosis

In this second paper the clinical features and electrophysiological underpinnings of more complex psychotic states associated with epilepsy are reviewed. (a) Complex partial status epilepticus, in particular of temporal lobe origin, may result in mental states remarkably similar to those seen in the primary psychoses. This non-convulsive state is associated with prolonged epileptic discharges on intracranial stereoelectroencephalography (SEEG) in hippocampal and other mesial temporal structures, sometimes without abnormalities on the scalp EEG. Where hallucinatory or psychotic symptomatology does occurs, it can be considered an examples of an ictal psychosis. The phenomenology and electrophysiological features of this condition are reviewed. (b) Postictal psychosis is noted for its similarity to schizophrenia-like/paranoid and affective psychoses and there is convincing SEEG evidence that, for some cases at least, the psychosis is not in fact postictal but rather an ictal psychosis due to ongoing limbic seizure activity and a form of non-convulsive status epilepticus. It has been suggested that postictal psychosis should be divided into two sub-groups: the classical 'nuclear' postictal type and an atypical periictal type. (c) Interictal hallucinosis in epilepsy has been poorly studied, but is probably commoner than appreciated. To what extent it represents subclinical epileptic discharges (i.e. auras) is not known. It may interestingly also be associated with abnormal affective states in epilepsy. (d) The interictal psychosis of epilepsy is often indistinguishable from primary schizophrenia. It occurs more commonly in temporal lobe (limbic) epilepsy, in those with frequent seizures and only in patients with a long history of epilepsy (usually over 10 years). There is convincing SEEG evidence of frequent, semi-continuous and sometimes continuous epileptic activity in limbic structures at the time of psychotic and hallucinatory ideation and behaviour, suggesting that in some cases at least, the epileptic activity is the cause of the symptoms. Whether the psychosis is directly 'driven' by subclinical electrographic activity or is indirectly a consequence of function change induced by such activity is not clear. An intriguing question also arises as to whether similar electrophysiological changes could underpin psychosis in patients without epilepsy but evidence on this point is sparse. The effects of temporal lobe surgery on the psychoses of epilepsy are described and these might throw light on the mechanisms of epileptic psychosis. The principles of pharmacological therapy of epileptic hallucinosis and psychosis are outlined.

Schizophrenia and epilepsy: is there a shared susceptibility?

Individuals with epilepsy are at increased risk of having psychotic symptoms that resemble those of schizophrenia. More controversial and less searched is if schizophrenia is a risk factor for epilepsy. Here we review overlapping epidemiological, clinical, neuropathological and neuroimaging features of these two diseases. We discuss the role of temporal and other brain areas in the development of schizophrenia-like psychosis of epilepsy. We underline the importance of ventricular enlargement in both conditions as a phenotypic manifestation of a shared biologic liability that might relate to abnormalities in neurodevelopment. We suggest that genes implicated in neurodevelopment may play a common role in both conditions and speculate that recently identified causative genes for partial complex seizures with auditory features might help explain the pathophysiology of schizophrenia. These particularly include the leucine-rich glioma inactivated (LGI) family gene loci overlap with genes of interest for psychiatric diseases like schizophrenia. Finally, we conclude that LGI genes associated with partial epilepsy with auditory features might also represent genes of interest for schizophrenia, especially among patients with prominent auditory hallucinations and formal thought disorder.

Neurocognitive and behavioral functioning in frontal lobe epilepsy: a review

Frontal lobe epilepsy (FLE) is a seizure disorder with a lower prevalence than temporal lobe epilepsy (TLE). Despite its consequences on cognitive and emotional well-being, the neuropsychology of FLE has not been well studied. By contrast, TLE has been studied meticulously, leading to a relevant understanding of memory and the functional characteristics of the temporal and limbic circuits. The neuropsychological studies on FLE report deficits in motor coordination and planning, reduced attention span, and difficulties in response inhibition in complex cognitive tasks. This review aims to illustrate the most relevant neurocognitive dimensions, psychiatric comorbidity, and postoperative neuropsychological outcome of FLE. Methodological suggestions for future research are also included by critically reviewing the existing literature.

[Postictal psychosis syndrome: a clinical entity to be recognized]

INTRODUCTION

Post-ictal psychosis syndrome (PIP) belongs to the group of epileptic psychoses which, according to the most commonly used classification, is to be distinguished from ictal psychoses, on one hand, and from inter-ictal psychoses, on the other.

OBJECTIVES

The present paper aims to review recent data concerning the clinical, therapeutic and pathophysiological aspects of PIP.

METHODS

We report four cases of PPI, which involved four patients hospitalized at the Salpêtrière hospital between 2001 and 2005, and discuss these cases in light of the relevant literature.

RESULTS

The PIP fit generally occurs in patients suffering from intractable temporal lobe epilepsy which started several years before. The psychiatric disorders suddenly take hold after a series of complex partial seizures with frequent secondarily generalized tonic clonic seizures. During the episode, EEG recordings do not show any epileptic activity. Psychiatric symptoms consist of persecutory delusive ideas, verbal and visual hallucinations, agitation, and aggressiveness. Mood disorders are variable from one patient to another and exhibit intraindividual fluctuation. In most patients given antipsychotic drugs, the short-term outcome of PIP is favorable . In the long-term, even if recurrence is the main long-term risk, progression to severe mood disorders or to poor prognosis inter-ictal psychosis is possible. Accordingly, the clinician must be aware of this syndrome in order to correctly diagnose PIP since effective treatment with antipsychotic drugs is available.

CONCLUSION

The short-term prognosis of PPI is usually favorable but this syndrome can potentially develop in the long-term to more severe psychiatric disorders. It is, therefore, important to recognize PIP syndromes which respond more readily to pharmacological treatments than other types of psychoses.

Postictal catatonia in a schizophrenic patient and electroconvulsive treatment

Catatonic state has been related to variable medical, neurological, and psychiatric disorders. Although it is commonly associated with schizophrenia, epilepsy presenting as catatonialike seizures or ictal catatonia was rarely reported. Moreover, the coexistence of schizophrenia and epilepsy in a patient complicates the diagnosis and management. Here we report a case of postictal catatonia in a patient with schizophrenia who was successfully treated by electroconvulsive treatment, and in this context, we aimed to review the therapeutic effect of electroconvulsive treatment in postictal catatonia.

Psychosis with frontal lobe epilepsy responds to carbamazepine

Frontal lobe epilepsy is an unusual form of complex partial seizures associated with behavioral changes including fear, agitation, kicking, and screaming. The seizures are often missed or mistaken for psychiatric problems or sleep disorders. We report 2 unusual patients presenting with psychosis who were found to have frequent frontal lobe seizures. Treatment of the seizures with carbamazepine resulted in complete resolution of their psychiatric symptoms. The relationship between frontal lobe seizures and psychosis is explored.

Alternative psychosis and dysgraphia accompanied by forced normalization in a girl with occipital lobe epilepsy

An 11-year-old girl who had been given antiepileptic drugs (AEDs) for occipital lobe epilepsy was hospitalized with alternative psychosis and dysgraphia accompanied by forced normalization of the EEG. Her epileptic seizures and psychosis disappeared after administration of carbamazepine. She developed dysgraphia for Kanji words (Japanese morphograms). The EEG showed sporadic spikes predominantly in the left occipital region, and [123I]iomazenil single-photon-emission computed tomography (IMZ-SPECT) imaging revealed an area of hypoperfusion in the left occipital lobe. Interestingly, the left posterior inferior temporal area is known to play an important role in writing Kanji words. It is assumed that abnormal discharges in the left occipital lobe were projected into the left posterior inferior temporal area and that a functional disorder in that area led to dysgraphia; however, further exploration is needed.

Psychosis as a manifestation of frontal lobe epilepsy

A 7-year-old girl presented with a cluster of seizures occurring in one day and followed by the development of paranoid delusions. Her electroencephalogram (EEG) revealed a psychomotor variant. Cranial MRI was normal, but the 2-deoxy-2-[(18)F]fluoro-D-glucose (FDG) positron emission tomography (PET) scan showed hypometabolism in the left inferior frontal cortex. Her psychotic symptoms occurred episodically. Three years later, she developed hypermotor seizures associated with a fearful look. Video/EEG monitoring captured seizures of left frontotemporal onset. Her seizures became drug resistant and she underwent epilepsy surgery. Intracranial electrocorticography captured spontaneous and electrically induced seizures with onset in the left inferior frontal region, which was resected. She became seizure-free and her psychosis resolved. This case illustrates that frontal lobe epilepsy can present solely with psychotic symptoms, which may delay the diagnosis of epilepsy. We suggest that these cases may be underdiagnosed. When epilepsy is suspected and if MRI fails to demonstrate an abnormality, FDG PET scanning and video/EEG monitoring should be considered.

Activation of GABA(B) receptors reverses spontaneous gating deficits in juvenile DBA/2J mice

RATIONALE

Gamma-amino-butyric acid (GABA)(B) receptors play a key role in the pathophysiology of psychotic disorders. We previously reported that baclofen, the prototypical GABA(B) agonist, elicits antipsychotic-like effects in the rat paradigm of prepulse inhibition (PPI) of the startle, a highly validated animal model of schizophrenia.

OBJECTIVES

We studied the role of GABA(B) receptors in the spontaneous PPI deficits displayed by DBA/2J mice.

MATERIALS AND METHODS

We tested the effects of baclofen (1.25-5 mg/kg, intraperitoneal [i.p.]) in DBA/2J and C57BL/6J mice, in comparison to the antipsychotic drugs haloperidol (1 mg/kg, i.p.) and clozapine (5 mg/kg, i.p.). Furthermore, we investigated the expression of GABA(B) receptors in the brain of DBA/2J and C57BL/6J mice by quantitative autoradiography.

RESULTS

Baclofen dose-dependently restored PPI deficit in DBA/2J mice, in a fashion similar to the antipsychotic clozapine (5 mg/kg, i.p.). This effect was reversed by pretreatment with the GABA(B) antagonist SCH50211 (50 mg/kg, i.p.). In contrast, baclofen did not affect PPI in C57BL/6J mice. Finally, quantitative autoradiographic analyses assessed a lower GABA(B) receptor expression in DBA/2J mice in comparison to C57BL/6J controls in the prefrontal cortex and hippocampus but not in other brain regions.

CONCLUSIONS

Our data highlight GABA(B) receptors as an important substrate for sensorimotor gating control in DBA/2J mice and encourage further investigations on the role of GABA(B) receptors in sensorimotor gating, as well as in the pathophysiology of psychotic disturbances.

Alternating and postictal psychoses: review and a unifying hypothesis

A comparison of the clinical and pathophysiological features of postictal psychosis and brief interictal or alternating psychosis was undertaken to examine if the underlying mechanisms are distinct in these 2 conditions. A selective review of the published literature in English on epilepsy and brief psychosis was carried out. The literature indicates that even though brief postictal and alternating psychoses are considered to be separate syndromes, they have a number of similarities. It can be argued that the underlying pathomechanisms are common, with the brain's inhibitory processes in response to seizures playing a key role in the development of the psychosis. These homeostatic mechanisms manifest as electrophysiological, cerebral blood flow, and neurotransmitter and receptor changes. Both syndromes are likely to be associated with prolonged inhibition in limbic circuits, with further seizures modifying the psychosis depending upon whether it is associated with disinhibition or hypersynchrony involving enhanced inhibition. The neurotransmitter with a key role is GABA, although ionic currents, catecholamines, opiates, adenosine, glutamate, and nitric oxide play a role. Brief postictal and alternating psychoses provide an opportunity to understand the complex relationships between epilepsy and schizophrenia-like brief psychotic episodes, and this understanding can assist in their management.

Orbitofrontal seizures presenting with ictal visual hallucinations and interictal psychosis

Hallucinations are commonly believed to reflect temporal lobe dysfunction. This report presents the clinical, electroencephalographic, and neuroimaging findings in an 8-year-old male who experienced the acute onset of ictal auditory and visual hallucinations associated with epileptic activation of the right orbitofrontal region. Right frontal lobe surgery resulted in seizure freedom and disappearance of his psychotic symptoms. Histologic tissue examination revealed non-balloon cell Taylor type cortical dysplasia.

Catatonia induced by levetiracetam

Levetiracetam (Keppra) is a novel antiepileptic drug approved as adjunctive treatment for adults with partial onset seizures. Although the drug is generally well tolerated, behavioral side effects have been reported in variable frequency. Most behavioral problems are mild in nature (agitation, hostility, anxiety, emotional lability, apathy, depression) and quickly resolve with discontinuation of medication. However, serious psychiatric adverse events may also occur with rare cases of psychosis and suicidal behavior. We report here the case of a 43-year-old woman who developed symptoms compatible with catatonia after being exposed to levetiracetam for the treatment of epilepsy. To our knowledge, it is the first reported case of catatonia induced by levetiracetam. We review the difficulties that may be encountered in the differential diagnosis of medical catatonia.

Meta-analysis of the brief psychiatric rating scale factor structure

A meta-analysis (N=17,620; k=26) of factor analyses of the Brief Psychiatric Rating Scale (BPRS) was conducted. Analysis of the 12 items from Overall et al.'s (J. E. Overall, L. E. Hollister, & P. Pichot, 1974) 4 subscales found support for his 4 subscales. Analysis of all 18 BPRS items found 4 components similar to those of Overall et al. In a 5-component solution, a 5th activation component emerged but was best supported among samples of schizophrenic patients. The first 4 components appear to form the core of the BPRS factor structure. Results of the meta-analysis suggest 5 subscales (with items in parentheses): Affect (anxiety, guilt, depression, somatic); Positive Symptoms (thought content, conceptual disorganization, hallucinatory behavior, grandiosity); Negative Symptoms (blunted affect, emotional withdrawal, motor retardation); Resistance (hostility, uncooperativeness, suspiciousness); and Activation (excitement, tension, mannerisms-posturing).

The psychiatric comorbidity of epilepsy

Several studies have assessed the prevalence of psychiatric disorders in epilepsy. They are characterized by considerable heterogeneity, because of differences in the population setting and type of study. A non-systematic review of the literature allows us to draw some useful, although not definite, conclusions. Six per cent of people with epilepsy in the general population appear to suffer from a psychiatric disorder, while this rises to 10-20% in populations with temporal lobe and/or refractory epilepsy. Mood disorders are the most common culprit (24-74%), particularly depression (30%), followed by anxiety disorders (10-25%), psychoses (2-7%) and personality disorders (1-2%). This comorbidity appears to be related to endogenous and exogenous (including iatrogenic) factors and to the severity and chronicity of epilepsy. Conditions such as schizophrenia-like psychosis of epilepsy and interictal dysphoric disorder are represented only in epilepsy. Adequate recognition and treatment of psychiatric conditions in epilepsy is essential for patient management because of their considerable burden in morbidity and quality of life.

Psychotic symptoms in patients with medical disorders

Psychotic symptoms frequently occur in patients with comorbid medical disorders and present a diagnostic and treatment challenge. They may be a part of an independent psychiatric illness associated with the underlying medical condition or induced by substance use or medications. The presence of psychotic symptoms can contribute to misdiagnosis or complicate the management of the comorbid medical illness. Psychiatrists must be familiar with the assessment and management of psychotic disorders in patients with comorbid medical disorders. Medications that may be used to treat psychosis include antipsychotic agents, benzodiazepines, or possibly certain anticonvulsants. Selecting the appropriate medication requires knowledge of the pharmacokinetics of different agents and their side effect profile. Understanding the neuropsychiatric effects of medications and drug-drug interactions may help in preventing psychotic symptoms.

Medical comorbidities in the treatment of epilepsy

The treatment of epilepsy extends far beyond seizure control. Many comorbidities have a significant impact on the medical management and quality of life of patients with epilepsy. In this review, we examine interactions between epilepsy and some common medical conditions. Psychiatric disorders with a high prevalence in epilepsy include mood disorders, anxiety disorders, and psychosis. Depression is common, psychosis occurs both in direct relation to seizures and interictally, and suicide rates are increased. Changes in sexual function and reduced fertility and marriage rates are described, including a discussion of polycystic ovary syndrome, which is increased in women with epilepsy. The effects of other chronic medical comorbid conditions are reviewed, including the effects of antiepileptic medications on bone health and the impact of renal insufficiency on pharmacological therapy of epilepsy.

Psychoses and epilepsy: are interictal and postictal psychoses distinct clinical entities?

PURPOSE

To evaluate further the relevance of designating psychotic episodes as either postictal or interictal, we compared several biologic variables between epilepsy patients with and without psychosis.

METHODS

The study subjects comprised 282 patients with psychosis (36 with postictal psychosis, 224 with interictal psychosis, and 22 with both postictal and interictal psychoses, i.e., bimodal psychosis), and 658 epilepsy patients without psychosis. The clinical characteristics of these patients were reviewed retrospectively by experienced neuropsychiatrists. Factors predicting the development of each type of psychosis were determined by serial multivariate logistic regression analyses.

RESULTS

Factors that were comparable between postictal and interictal psychoses were intellectual function, family history of psychosis, epilepsy type, and the presence of complex partial seizures. In contrast, age at the onset of epilepsy and at the onset of psychosis and the presence of generalized tonic-clonic seizures differed for the three types of psychosis. Patients with bimodal psychosis showed characteristics associated with both postictal and interictal psychoses.

CONCLUSIONS

This study documented conditions, including both general factors and epilepsy-related factors, common to epilepsy patients with psychosis, regardless of chronologic distinctions. Certain epileptic processes appear to have equal influence on postictal and interictal psychoses. However, some differences between postictal and interictal psychoses suggest that these chronologic descriptors are valid. Our findings confirmed that psychosis associated with epilepsy should not be defined as a single, simple condition but rather as a complex condition with several possible subcategories.

Peri-Ictal Behavioral and Cognitive Changes

Peri-ictal behavioral and cognitive changes contribute substantially to disability and distress among people with epilepsy. Psychosis, depression, and suicide may all occur as complications of seizures. Greater appreciation and understanding of the peri-ictal period is clinically important and might open novel therapeutic windows. At the same time this period provides a model for understanding basic mechanisms underlying mood and thought disorders and the substrates of cognition, volition, emotion, and consciousness. This review will discuss behavioral and cognitive antecedents of seizures, including the preictal milieu, reflex seizures, and self-induced seizures. Behavioral and cognitive treatment approaches that have been undertaken are reviewed. Both acute and delayed postictal emotional, behavioral, and cognitive changes will be discussed. Finally, possible mechanisms by which epileptic brain activity and behavior may modify each other are considered.

Amygdala pathology in psychosis of epilepsy: A magnetic resonance imaging study in patients with temporal lobe epilepsy

Psychosis of epilepsy (POE) has been recognized as a severe complication of chronic intractable epilepsy for more than a century. Most of the clinical symptoms of POE are reminiscent of schizophrenia. Nevertheless, there is general agreement that the phenomenology of POE differs from classical schizophrenia. The temporal lobe hypothesis of schizophrenia put forward in the 1960s notes that episodes with paranoid psychoses are more prevalent in temporal lobe epilepsy (TLE). However, the aetiology and pathogenesis of POE are poorly understood. One of the strongest biological findings in schizophrenia is volume loss of temporal lobe structures and the hippocampus in particular. In order to test the hypothesis that atrophy of the hippocampus and the amygdala is found in patients with TLE and POE, we performed a retrospective study of all patients with TLE who were admitted to the assessment unit of the Chalfont Centre for Epilepsy from 1995 until 1999. Twenty-six (2.6%) of these 1008 patients fulfilled inclusion criteria and were compared with 24 patients with TLE without psychopathology and 20 healthy volunteers. All patients underwent extensive MRI investigations, including volumetric data sets and quantitative T(2 )relaxometry. We found that patients with TLE and POE differed from patients with TLE alone and healthy volunteers in that the total brain volumes were significantly smaller. While there were no differences in hippocampal volumes between the three study groups, there was a significant 16-18% enlargement of the amygdala on both sides in patients with POE. Our findings support the notion that POE is a distinct nosologic entity differing from schizophrenia not only in clinical details but also in neurobiological aspects. The finding of amygdala enlargement agrees with the observation of an association between dysphoric disorders of epilepsy and POE described nearly 100 years ago.

Frequency and age-related variables in interictal psychoses in localization-related epilepsies

PURPOSE

Several studies have described that patients with temporal lobe epilepsy (TLE) develop psychoses more frequently than patients with extra-temporal localization-related epilepsy (LRE). However, few controlled studies have demonstrated an increased susceptibility to psychosis in TLE patients. As one of a series of multi-center studies on psychosis in epilepsy, we investigated whether the frequency of interictal psychosis differs between types of LRE.

METHODS

We reviewed some biological characteristics of 197 PE patients with interictal psychosis and of 456 LRE patients with no history of psychosis. Type of PE was determined as TLE, frontal lobe epilepsy, parietal lobe epilepsy, occipital lobe epilepsy, and multi-lobar epilepsy/undifferentiated lobar epilepsy by clinical symptoms, EEG findings, and neuroimaging. The frequency of psychosis for each type of LRE was compared. Ages at onset of epilepsy and psychosis and the time interval between onset of each were also analyzed.

RESULTS

There was no significant correlation between psychosis and epilepsy type (P=0.211). Age-related variables also failed to show any significant differences between LRE types (age at onset of epilepsy, P=0.369; age at onset of psychosis, P=0.852; the time interval, P=0.893).

CONCLUSIONS

Patients with LREs as well as with TLE are susceptible to interictal psychosis. The mean ages at onset of symptoms and the interval between onset of epilepsy and onset of psychosis that we observed suggest that patients with LREs, regardless of focus, may share similar processes in the development of psychiatric symptoms.

Organic psychosis: Insight into the biology of psychosis

Psychotic symptoms--delusions, delusional misidentifications and hallucinations--are observed in a variety of organic or nonorganic conditions, and are, therefore, diagnostically nonspecific. Common patholophysiologic denominators of different organic diseases may offer insights into the origin of psychotic symptoms. This article reviews some of the clinical and neuroimaging findings in organic psychoses present in various organic disorders. It attempts to extract a number of hypotheses about underlying biologic factors contributing to the development of psychotic symptoms of organic origin.