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de Toffol B. Epilepsy and psychosis. Rev Neurol (Paris) 2024; 180:298-307. [PMID: 38336524 DOI: 10.1016/j.neurol.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 12/21/2023] [Accepted: 12/21/2023] [Indexed: 02/12/2024]
Abstract
Psychotic disorders are eight times more frequent in epilepsy than in the general population. The various clinical syndromes are classified according to their chronology of onset in relation to epileptic seizures: ictal psychoses (during epileptic discharge), post-ictal psychoses (PIP, after a seizure), interictal psychoses (IIP, with no chronological link) and those related to complete seizure control. Antiepileptic drugs can cause psychotic disorders in all these situations. Post-ictal psychoses (PIP) are affective psychoses that occur after a lucid interval lasting 12 to 120hours following a cluster of seizures. They last an average of 10days, with an abrupt beginning and end. PIP are directly linked to epileptic seizures, and disappear when the epilepsy is controlled. Interictal psychoses are schizophrenias. The management of psychotic disorders in epilepsy is neuropsychiatric, and requires close collaboration between epileptologists and psychiatrists. Antipsychotics can be prescribed in persons with epilepsy. Even today, psychotic disorders in epilepsy are poorly understood, under-diagnosed and under-treated.
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Affiliation(s)
- B de Toffol
- Université des Antilles, Neurology Department, Centre Hospitalier de Cayenne, CIC Inserm 1424, rue des Flamboyants, 97300 Cayenne, French Guiana.
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2
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Evers MEA, Nelissen J, Vlooswijk MCG, van Kranen-Mastenbroek VHBM, Leentjens AFG, Rouhl RPW. Risk factors for behavioral and psychotic dysregulation at the epilepsy monitoring unit in patients with intracranial electrodes. Epilepsy Behav 2023; 148:109448. [PMID: 37776593 DOI: 10.1016/j.yebeh.2023.109448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 09/13/2023] [Accepted: 09/14/2023] [Indexed: 10/02/2023]
Abstract
OBJECTIVE Aberrant behavior in patients with epilepsy (PWE) admitted to an epilepsy monitoring unit (EMU) can endanger their safety. We sought to identify predictive factors for post-ictal behavioral dysregulation and psychosis in patients with refractory epilepsy being monitored at an EMU. METHODS Retrospective data were gathered from electronic patient files of all patients with refractory epilepsy who underwent intracranial registration at our EMU. We assessed behavioral and psychotic dysregulations by reviewing clinical notes, administered emergency medication, and reports of injuries or casualties in patients and nurses. In addition, we compared patient demographic characteristics, clinical characteristics, and antiepileptic drug (AED) profiles between patients with and without behavioral and/or psychotic dysregulation. RESULTS Out of 73 admissions, 23 patients (32%) experienced behavioral dysregulation, and five patients experienced psychosis (7%). Behavioral dysregulation was only significantly associated with a previous history of interictal or postictal psychosis. Psychotic dysregulation is significantly associated with a psychiatric history, including a history of agitation or psychosis, whether or not epilepsy-related. For both types of dysregulations, there was no relation with a pre-admission frequency of seizures, clustering of seizures during monitoring, or a temporal focus of seizures. We could not report a relationship between AED use, tapering, and the occurrence of dysregulation. CONCLUSION We conclude that a psychiatric history, including a history of agitation and psychosis, is related to an increased risk of behavioral and psychotic dysregulation in patients undergoing invasive seizure monitoring at the EMU.
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Affiliation(s)
- M E A Evers
- Department of Neurology, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - J Nelissen
- Department of Neurology, Maastricht University Medical Centre+, Maastricht, the Netherlands; Academic Center for Epileptology Kempenhaeghe/MUMC+, Heeze and Maastricht, the Netherlands
| | - M C G Vlooswijk
- Department of Neurology, Maastricht University Medical Centre+, Maastricht, the Netherlands; Academic Center for Epileptology Kempenhaeghe/MUMC+, Heeze and Maastricht, the Netherlands
| | - V H B M van Kranen-Mastenbroek
- Academic Center for Epileptology Kempenhaeghe/MUMC+, Heeze and Maastricht, the Netherlands; Department of Clinical Neurophysiology, Maastricht University Medical Centre+, Maastricht, the Netherlands; School for Mental Health and Neurosciences, Maastricht University, Maastricht, the Netherlands
| | - A F G Leentjens
- School for Mental Health and Neurosciences, Maastricht University, Maastricht, the Netherlands; Department of Psychiatry and Neuropsychology, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - R P W Rouhl
- Department of Neurology, Maastricht University Medical Centre+, Maastricht, the Netherlands; Academic Center for Epileptology Kempenhaeghe/MUMC+, Heeze and Maastricht, the Netherlands; School for Mental Health and Neurosciences, Maastricht University, Maastricht, the Netherlands.
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3
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Gyimesi J. Epilepsy, violence, and crime. A historical analysis. JOURNAL OF THE HISTORY OF THE BEHAVIORAL SCIENCES 2022; 58:42-58. [PMID: 34289120 DOI: 10.1002/jhbs.22117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/24/2021] [Accepted: 07/08/2021] [Indexed: 06/13/2023]
Abstract
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.
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Affiliation(s)
- Júlia Gyimesi
- Department of Personality and Clinical Psychology, Institute of Psychology, Faculty of Humanities and Social Sciences, Pázmány Péter Catholic University, Budapest, Hungary
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Freund B, Tatum WO. Pitfalls using smartphones videos in diagnosing functional seizures. Epilepsy Behav Rep 2021; 16:100497. [PMID: 34927041 PMCID: PMC8646964 DOI: 10.1016/j.ebr.2021.100497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/26/2021] [Accepted: 10/30/2021] [Indexed: 11/17/2022] Open
Abstract
Expert review of seizure semiology looking at video recordings independent of EEG has been found to be useful for diagnosing functional seizures. Videos recorded outside the hospital containing "spells" have similar sensitivity to EEG when quality recordings are evaluated. Recently, smartphone videos were shown to serve as an adjunct to standard history and physical examination with similar diagnostic yields when compared to diagnostic video-EEG monitoring and reviewed by experts. However, caution must be exercised when interpreting videos of paroxysmal neurological events recorded by caregivers to ensure proper video quality is maintained and recorded event is representative. In this report, we present a case of initial identification of and event falsely suggesting functional seizures in a patient with epilepsy. The smartphone video of a "seizure" was recorded by his wife using her smartphone. Despite a quality recording and a history consistent with epilepsy, the smartphone video reviewed during evaluation in the clinic suggested a functional behavior in contrast to the history that suggested epilepsy manifest as convulsions. Instead of bilateral tonic-clonic motor movements, bizarre, intermittent non-clonic wild flinging movements and vocalization were identified on the smartphone video. The discordance between the clnical history and ideo prompted inpatient video-EEG monitoring. The same nonepileptic semiology was subsequently clarified to represent a physiological nonepileptic event. The event on the smartphone was typical of his agitated post-ictal state following an electroclinical tonic-clonic seizure. With treatment the seizures became controlled with antiseizure medication in long-term follow-up. We highlight the pitfalls using patient-recorded smartphone videos in patients diagnosed with epilepsy. Understanding the utility of smartphones as an adjunct to the clinical history will help in differentiating epileptic from functional seizures.
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Affiliation(s)
- Brin Freund
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, United States
| | - William O. Tatum
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, United States
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Billakota S, Devinsky O, Kim KW. Why we urgently need improved epilepsy therapies for adult patients. Neuropharmacology 2019; 170:107855. [PMID: 31751547 DOI: 10.1016/j.neuropharm.2019.107855] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 11/12/2019] [Accepted: 11/15/2019] [Indexed: 12/29/2022]
Abstract
PURPOSE Up to a third of patients with epilepsy suffer from recurrent seizures despite therapeutic advances. RESULTS Current epilepsy treatments are limited by experiential data from treating different types of epilepsy. For example, we lack evidence-based approaches to efficacious multi-drug therapies or identifying potentially serious or disabling adverse events before medications are initiated. Despite advances in neuroscience and genetics, our understanding of epilepsy pathogenesis and mechanisms of treatment-resistance remains limited. For most patients with epilepsy, precision medicine for improved seizure control and reduced toxicity remains a future goal. CONCLUSION A third of epilepsy patients suffer from ongoing seizures and even more suffer from adverse effects of treatment. There is a critical need for more effective and safer therapies for epilepsy patients with frequent comorbitidies, including depression, anxiety, migraine, and cognitive impairments, as well as special populations (e.g., women, elderly). Advances from genomic sequencing techniques may identify new genes and regulatory elements that influence both the depth of the epilepsies' roots within brain circuitry as well as ASD resistance. Improved understanding of epilepsy mechanisms, identification of potential new therapeutic targets, and their assessment in randomized controlled trials are needed to reduce the burden of refractory epilepsy. This article is part of the special issue entitled 'New Epilepsy Therapies for the 21st Century - From Antiseizure Drugs to Prevention, Modification and Cure of Epilepsy'.
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Affiliation(s)
- Santoshi Billakota
- NYU Langone Comprehensive Epilepsy Center and NYU Langone School of Medicine, New York, NY, USA.
| | - Orrin Devinsky
- NYU Langone Comprehensive Epilepsy Center and Professor of Neurology, Neurosurgery, and Psychiatry at NYU Langone School of Medicine, New York, NY, USA; Saint Barnabas Institute of Neurology and Neurosurgery, Livingston, NJ, USA
| | - Kyung-Wha Kim
- NYU Langone Comprehensive Epilepsy Center and NYU Langone School of Medicine, New York, NY, USA
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Saleh C, Reuber M, Beyenburg S. Epileptic seizures and criminal acts: Is there a relationship? Epilepsy Behav 2019; 97:15-21. [PMID: 31181424 DOI: 10.1016/j.yebeh.2019.05.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 05/08/2019] [Accepted: 05/16/2019] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Christian Saleh
- Department of Neurology, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg.
| | - Markus Reuber
- Royal Hallamshire Hospital, Academic Neurology Unit, University of Sheffield, Sheffield, UK.
| | - Stefan Beyenburg
- Department of Neurology, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg.
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Hamed SA, Attiah FA. Psychosis in adults with epilepsy and its relationship to demographic, clinical and treatment variables. Neurol Res 2019; 41:959-966. [PMID: 31280704 DOI: 10.1080/01616412.2019.1638017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Objectives: Psychiatric symptoms and disorders are commonly reported with epilepsy. This study aimed to determine the prevalence of interictal psychosis (IIP) in adults with epilepsy and its risk predictors. Methods: The study included 710 patients (mean age: 36.40 years; age at onset: 13.58 years; duration of epilepsy: 22.80 years). All underwent neurological and psychiatric interviewing, electroencephalography and brain imaging. Results: IIP was reported in 20.65%, of them 50% had temporal lobe epilepsy with impaired awareness and/or to bilateral tonic clonic, 42.47% had frontal lobe epilepsy with impaired awareness and/or to bilateral tonic clonic and 7.53% had generalized tonic-clonic seizures. Compared to patients without psychosis, patients with psychosis were older at age of examination, had earlier age at onset, frequent seizures, longer duration of epilepsy and long-term antiepileptic drugs therapy and many relatives with epilepsy. Nearly 76.71% had history of postictal psychosis (PIP). The mean age of onset of IIP was 30.45 years and its mean duration was 3.84 months. Approximately 22% of patients with IIP had family history of psychosis. Patients developed IIP 10 years or more after epilepsy onset. Multivariate logistic regression analyses showed that predictors for IIP were the age at onset and duration of epilepsy, number of seizures, family history of epilepsy or psychosis, history of PIP and different types of epilepsy. Conclusion: IIP is not infrequent with chronic epilepsy regardless to its type. These findings emphasize the importance of optimizing patients' treatment and early recognition and management of IIP. Abbreviations: IIP: interictal psychosis; PIP: post-ictal psychosis; TLE: temporal lobe epilepsy; FLE: frontal lobe epilepsy; GTC: generalized tonic clonic; AEDs: antiepileptic drugs; CBZ: carbamazepine; VPA: valproate; LEV: levetiracetam; APDs: antipsychotic drugs.
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Affiliation(s)
- Sherifa Ahmed Hamed
- Department of Neurology and Psychiatry, Assiut University Hospital , Assiut , Egypt
| | - Fadia Ahmed Attiah
- Department of Neurology and Psychiatry, Assiut University Hospital , Assiut , Egypt
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Cramer Bornemann MA, Schenck CH, Mahowald MW. A Review of Sleep-Related Violence. Chest 2019; 155:1059-1066. [DOI: 10.1016/j.chest.2018.11.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 10/19/2018] [Accepted: 11/05/2018] [Indexed: 10/27/2022] Open
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Abstract
The psychoses of epilepsy can be classified according to their temporal relationship with seizures, namely as ictal, postictal and interictal psychosis. Interictal psychosis is the most common and may resemble schizophrenia. They can be challenging to diagnose and to manage, especially given the perception that some antipsychotic drugs may exacerbate seizures, while some antiepileptic medications may worsen psychosis. The current uncertainty around their best management means that some patients may not receive appropriate care. We propose a practical stepwise approach to managing psychosis in patients with epilepsy, summarising the key clinical features. We provide a framework for diagnosis, investigation and management of psychosis in the acute and long term. We also summarise the available evidence on the risk of psychosis with current antiepileptic drugs and the risk of seizures with antipsychotic drugs.
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Affiliation(s)
| | - Jasvinder Singh
- Department of Neuropsychiatry, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Anthony Marson
- Department of Neurology, The Walton Centre for Neurology and Neurosurgery, University of Liverpool, Liverpool, UK.,The Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, Uk
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10
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de Toffol B, Hingray C, Biberon J, El-Hage W. [Psychiatric comorbidities in epilepsy]. Presse Med 2017; 47:243-250. [PMID: 29275022 DOI: 10.1016/j.lpm.2017.10.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 10/25/2017] [Indexed: 12/31/2022] Open
Abstract
Psychiatric comorbidities are overrepresented in people suffering from epilepsy in comparison to the general population. There is a two-way link between epilepsy and psychiatric disorders. Psychiatric symptomatology is specific in epilepsy, according to the chronology of symptoms in relation to the seizure (inter, pre- or postictal). Easy to use, fast and efficient self-administered questionnaires are available to evaluate depressive (NDDI-E) and generalized anxiety disorder (GAD-7) symptoms. Selective serotonin reuptake inhibitors (SSRIs) are not proconvulsant and can be safely used to treat depressive or anxious disorders.
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Affiliation(s)
- Bertrand de Toffol
- Inserm U 930, CHU Bretonneau, service de neurologie et neurophysiologie clinique, 2 bis, boulevard Tonnellé, 37044 Tours cedex, France.
| | - Coraline Hingray
- Centre psychiatrique de Nancy, pôle universitaire du Grand-Nancy, 1, rue du Dr Archambault, 54520 Laxou, France
| | - Julien Biberon
- CHU Bretonneau, service de neurologie et neurophysiologie clinique, 2 bis, boulevard Tonnellé, 37044 Tours cedex, France
| | - Wissam El-Hage
- CHRU de Tours, clinique psychiatrique universitaire, 37044 Tours cedex, France
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Gulrajani C. Epilepsy in the Courtroom. Psychiatr Ann 2017. [DOI: 10.3928/00485713-20171113-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Chen B, Choi H, Hirsch LJ, Katz A, Legge A, Buchsbaum R, Detyniecki K. Psychiatric and behavioral side effects of antiepileptic drugs in adults with epilepsy. Epilepsy Behav 2017; 76:24-31. [PMID: 28931473 DOI: 10.1016/j.yebeh.2017.08.039] [Citation(s) in RCA: 219] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 08/26/2017] [Accepted: 08/27/2017] [Indexed: 11/08/2022]
Abstract
PURPOSE Psychiatric and behavioral side effects (PBSEs) are common, undesirable effects associated with antiepileptic drug (AED) use. The objective of the study was to compare the PBSE profiles of older and newer AEDs in a large specialty practice-based sample of patients diagnosed with epilepsy. METHODS As part of the Columbia and Yale AED Database Project, we reviewed patient records including demographics, medical history, AED use, and side effects for 4085 adult patients (age: 18 years) newly started on an AED regimen. Psychiatric and behavioral side effects were determined by patient or physician report in the medical record, which included depressive mood, psychosis, anxiety, suicidal thoughts, irritability, aggression, and tantrum. Significant non-AED predictors of PBSE rate were first determined from 83 variables using logistic regression. Predictors were then controlled for in the comparison analysis of the rate of PBSEs and intolerable PBSEs (PBSEs that led to dosage reduction or discontinuation) between 18 AEDs. RESULTS Psychiatric and behavioral side effects occurred in 17.2% of patients and led to intolerability in 13.8% of patients. History of psychiatric condition(s), secondary generalized seizures, absence seizures, and intractable epilepsy were associated with increased incidence of PBSE. Levetiracetam (LEV) had the greatest PBSE rate (22.1%). This was statistically significant when compared with the aggregate of the other AEDs (P<0.001, OR=6.87). Levetiracetam was also significantly (P<0.001) associated with higher intolerability rate (17.7%), dose decreased rate (9.4%), and complete cessation rate (8.3%), when compared with the aggregate of the other AEDs. Zonisamide (ZNS) was also significantly associated with a higher rate of PBSE (9.7%) and IPBSE (7.9%, all P<0.001). On the other hand, carbamazepine (CBZ), clobazam (CLB), gabapentin (GBP), lamotrigine (LTG), oxcarbazepine (OXC), phenytoin (PHT), and valproate (VPA) were significantly associated with a decreased PBSE rates (P<0.001). Carbamazepine, GBP, LTG, PHT, and VPA were also associated with lower IPBSE rates when compared individually with the aggregate of other AEDs. All other AEDs were found to have intermediate rates that were not either increased or decreased compared with other AEDs. When each AED was compared to LTG, only CBZ had a significantly lower PBSE rate. The main limitations of this study were that the study design was retrospective and not blinded, and the AEDs were not randomly assigned to patients. CONCLUSIONS Psychiatric and behavioral side effects occur more frequently in patients taking LEV and ZNS than any other AED and led to higher rates of intolerability. Lower PBSE rates were seen in patients taking CBZ, CLB, GBP, LTG, OXC, PHT, and VPA. Our findings may help facilitate the AED selection process.
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Affiliation(s)
- Baibing Chen
- Comprehensive Epilepsy Center, Dept. of Neurology, Yale University, New Haven, CT, USA; William Beaumont School of Medicine, Oakland University, Rochester, MI, USA.
| | - Hyunmi Choi
- Comprehensive Epilepsy Center, Dept. of Neurology, Columbia University, New York, NY, USA
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Dept. of Neurology, Yale University, New Haven, CT, USA
| | - Austen Katz
- Comprehensive Epilepsy Center, Dept. of Neurology, Yale University, New Haven, CT, USA
| | - Alexander Legge
- Comprehensive Epilepsy Center, Dept. of Neurology, Columbia University, New York, NY, USA
| | - Richard Buchsbaum
- Comprehensive Epilepsy Center, Dept. of Neurology, Columbia University, New York, NY, USA
| | - Kamil Detyniecki
- Comprehensive Epilepsy Center, Dept. of Neurology, Yale University, New Haven, CT, USA
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Abstract
Behavioural changes associated with epilepsy can be challenging for patients and clinicians. Evidence suggests an association between aggression and epilepsy that involves various neurophysiological and neurochemical disturbances. Anti-epileptics have variable effects on behaviour and cognition that need consideration. Early detection and careful consideration of history, symptomatology and possible common comorbid psychiatric disorders is essential. Appropriate investigations should be considered to aid diagnosis, including electroencephalogram (EEG), video EEG telemetry and brain imaging. Optimising treatment of epilepsy, treatment of psychiatric comorbidities and behavioural management can have a major positive effect on patients' recovery and well-being.Learning Objectives• Understand the epidemiology of aggression in epilepsy• Comprehend the link between anti-epileptics and aggression, including the important role of pharmacodynamics• Be aware of the pharmacological treatments available for managing aggressive behaviour in epilepsy
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Clinique et neurobiologie des psychoses post-ictales. Encephale 2016; 42:443-447. [DOI: 10.1016/j.encep.2015.12.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 12/09/2015] [Accepted: 12/14/2015] [Indexed: 11/18/2022]
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Hilger E, Zimprich F, Pataraia E, Aull-Watschinger S, Jung R, Baumgartner C, Bonelli S. Psychoses in epilepsy: A comparison of postictal and interictal psychoses. Epilepsy Behav 2016; 60:58-62. [PMID: 27179193 DOI: 10.1016/j.yebeh.2016.04.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 04/01/2016] [Accepted: 04/02/2016] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Eva Hilger
- Department of Neurology, Medical University of Vienna, Austria.
| | | | | | | | - Rebekka Jung
- Department of Neurology, Medical University of Vienna, Austria
| | - Christoph Baumgartner
- Karl Landsteiner Institute for Clinical Epilepsy Research and Cognitive Neurology, 2nd Neurological Department, General Hospital Hietzing with Neurological Center Rosenhuegel, Vienna, Austria
| | - Silvia Bonelli
- Department of Neurology, Medical University of Vienna, Austria
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Josephson CB, Engbers JDT, Sajobi TT, Jette N, Agha-Khani Y, Federico P, Murphy W, Pillay N, Wiebe S. An investigation into the psychosocial effects of the postictal state. Neurology 2016; 86:723-30. [PMID: 26819455 DOI: 10.1212/wnl.0000000000002398] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Accepted: 10/28/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine whether postictal cognitive and behavioral impairment (PCBI) is independently associated with specific aspects of a patient's psychosocial health in those with epilepsy and nonepileptic events. METHODS We used the University of Calgary's Comprehensive Epilepsy Clinic prospective cohort database to identify patients reporting PCBI. The cohort was stratified into those diagnosed with epilepsy or nonepileptic events at first clinic visit. Univariate comparisons and stepwise multiple logistic regression with backward elimination method were used to identify factors associated with PCBI for individuals with epilepsy and those with nonepileptic events. We then determined if PCBI was independently associated with depression and the use of social assistance when controlling for known risk factors. RESULTS We identified 1,776 patients, of whom 1,510 (85%) had epilepsy and 235 had nonepileptic events (13%). PCBI was independently associated with depression in those with epilepsy (odds ratio [OR] 1.73; 95% confidence interval [CI] 1.06-2.83; p = 0.03) and with the need for social assistance in those with nonepileptic events (OR 4.81; 95% CI 2.02-11.42; p < 0.001). CONCLUSIONS PCBI appears to be significantly associated with differing psychosocial outcomes depending on the patient's initial diagnosis. Although additional research is necessary to examine causality, our results suggest that depression and employment concerns appear to be particularly important factors for patients with PCBI and epilepsy and nonepileptic attacks, respectively.
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Affiliation(s)
- Colin B Josephson
- From the Department of Clinical Neurosciences (C.B.J., N.J., Y.A.-K., P.F., W.M., N.P., S.W.), Clinical Research Unit (J.D.T.E., T.T.S., S.W.), and Department of Community Health Sciences (T.T.S., N.J., S.W.), Cumming School of Medicine, Hotchkiss Brain Institute (T.T.S., N.J., P.F., S.W.), and O'Brien Institute of Public Health (T.T.S., N.J., S.W.), University of Calgary, Canada
| | - Jordan D T Engbers
- From the Department of Clinical Neurosciences (C.B.J., N.J., Y.A.-K., P.F., W.M., N.P., S.W.), Clinical Research Unit (J.D.T.E., T.T.S., S.W.), and Department of Community Health Sciences (T.T.S., N.J., S.W.), Cumming School of Medicine, Hotchkiss Brain Institute (T.T.S., N.J., P.F., S.W.), and O'Brien Institute of Public Health (T.T.S., N.J., S.W.), University of Calgary, Canada
| | - Tolulope T Sajobi
- From the Department of Clinical Neurosciences (C.B.J., N.J., Y.A.-K., P.F., W.M., N.P., S.W.), Clinical Research Unit (J.D.T.E., T.T.S., S.W.), and Department of Community Health Sciences (T.T.S., N.J., S.W.), Cumming School of Medicine, Hotchkiss Brain Institute (T.T.S., N.J., P.F., S.W.), and O'Brien Institute of Public Health (T.T.S., N.J., S.W.), University of Calgary, Canada
| | - Nathalie Jette
- From the Department of Clinical Neurosciences (C.B.J., N.J., Y.A.-K., P.F., W.M., N.P., S.W.), Clinical Research Unit (J.D.T.E., T.T.S., S.W.), and Department of Community Health Sciences (T.T.S., N.J., S.W.), Cumming School of Medicine, Hotchkiss Brain Institute (T.T.S., N.J., P.F., S.W.), and O'Brien Institute of Public Health (T.T.S., N.J., S.W.), University of Calgary, Canada
| | - Yahya Agha-Khani
- From the Department of Clinical Neurosciences (C.B.J., N.J., Y.A.-K., P.F., W.M., N.P., S.W.), Clinical Research Unit (J.D.T.E., T.T.S., S.W.), and Department of Community Health Sciences (T.T.S., N.J., S.W.), Cumming School of Medicine, Hotchkiss Brain Institute (T.T.S., N.J., P.F., S.W.), and O'Brien Institute of Public Health (T.T.S., N.J., S.W.), University of Calgary, Canada
| | - Paolo Federico
- From the Department of Clinical Neurosciences (C.B.J., N.J., Y.A.-K., P.F., W.M., N.P., S.W.), Clinical Research Unit (J.D.T.E., T.T.S., S.W.), and Department of Community Health Sciences (T.T.S., N.J., S.W.), Cumming School of Medicine, Hotchkiss Brain Institute (T.T.S., N.J., P.F., S.W.), and O'Brien Institute of Public Health (T.T.S., N.J., S.W.), University of Calgary, Canada
| | - William Murphy
- From the Department of Clinical Neurosciences (C.B.J., N.J., Y.A.-K., P.F., W.M., N.P., S.W.), Clinical Research Unit (J.D.T.E., T.T.S., S.W.), and Department of Community Health Sciences (T.T.S., N.J., S.W.), Cumming School of Medicine, Hotchkiss Brain Institute (T.T.S., N.J., P.F., S.W.), and O'Brien Institute of Public Health (T.T.S., N.J., S.W.), University of Calgary, Canada
| | - Neelan Pillay
- From the Department of Clinical Neurosciences (C.B.J., N.J., Y.A.-K., P.F., W.M., N.P., S.W.), Clinical Research Unit (J.D.T.E., T.T.S., S.W.), and Department of Community Health Sciences (T.T.S., N.J., S.W.), Cumming School of Medicine, Hotchkiss Brain Institute (T.T.S., N.J., P.F., S.W.), and O'Brien Institute of Public Health (T.T.S., N.J., S.W.), University of Calgary, Canada
| | - Samuel Wiebe
- From the Department of Clinical Neurosciences (C.B.J., N.J., Y.A.-K., P.F., W.M., N.P., S.W.), Clinical Research Unit (J.D.T.E., T.T.S., S.W.), and Department of Community Health Sciences (T.T.S., N.J., S.W.), Cumming School of Medicine, Hotchkiss Brain Institute (T.T.S., N.J., P.F., S.W.), and O'Brien Institute of Public Health (T.T.S., N.J., S.W.), University of Calgary, Canada.
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Andrade-Machado R, Benjumea-Cuartas V, Santos-Santos A, Sosa-Dubón MA, García-Espinosa A, Andrade-Gutierrez G. Mortality in patients with refractory temporal lobe epilepsy at a tertiary center in Cuba. Epilepsy Behav 2015; 53:154-60. [PMID: 26575257 DOI: 10.1016/j.yebeh.2015.08.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 08/22/2015] [Accepted: 08/30/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES We aimed to investigate the prevalence and risk of mortality in patients with refractory temporal lobe epilepsy. METHODS Eligible patients included all adults referred to the National Institute of Neurology (NIN) in Havana, Cuba. All patients were followed up for 9 years. All analyses were made with the data available at the last follow-up. The frequency of death related to refractory TLE was analyzed taking into account the total number of patients included in the study. We analyzed the causes of death for each case. Multivariate analysis was made to determine the specific variables related to the death. All values were statistically significant if p<0.05. RESULTS Six out of 117 patients died during follow-up. Fifty percent of patients died because of suicide. Only the presence of aura, specifically experiential psychic auras, and prodromal depressive disorders were associated significantly with the deaths (p<0.05). Patients who died had a higher concern about their seizures than patients who were still alive at last follow-up (p<0.01); they also had a poor perception of the overall QOL (p<0.01); and they were more concerned about the possible medication side effects than patients who did not die (p<0.05). Logistic regression provided only one variable related to the deaths in our cohort in multivariate analysis: presence of prodromal depressive disorder. CONCLUSION The causes of death in patients with refractory temporal lobe epilepsy were similar to those documented in the general population of patients with epilepsy.
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Affiliation(s)
- René Andrade-Machado
- National Institute of Neurology, Havana, Cuba; National Institute of Neurology, Colombia.
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18
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Park SJ, Lee HB, Ahn MH, Park S, Choi EJ, Lee HJ, Ryu HU, Kang JK, Hong JP. Identifying clinical correlates for suicide among epilepsy patients in South Korea: A case-control study. Epilepsia 2015; 56:1966-72. [PMID: 26530473 DOI: 10.1111/epi.13226] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Suicide is a major cause of premature mortality in patients with epilepsy. We aimed to identify the clinical correlates of suicide in these patients. METHODS We conducted a matched, case-control study based on a clinical case registry of epilepsy patients (n = 35,638) treated between January 1994 and December 2011 at an academic tertiary medical center in Seoul, Korea. Each epilepsy patient in the suicide group (n = 74) was matched with three epilepsy patients in the nonsuicide group (n = 222) by age, gender, and approximate time at first treatment. The clinical characteristics of the patients in both groups were then compared. RESULTS In a univariate analysis, seizure frequency during the year before suicide, use of antiepileptic drug polytherapy, lack of aura before seizure, diagnosis of temporal lobe epilepsy, use of levetiracetam, psychiatric comorbidity, and use of antidepressants were all significantly higher in the suicide group than in the nonsuicide group. Multivariate analysis revealed that a high seizure frequency (odds ratio [OR] 3.3, 95% confidence interval [CI] 1.04-10.2), a lack of aura before seizure (OR 4.0, 95% CI 1.7-9.3), temporal lobe epilepsy (OR 3.7, 95% CI 1.6-8.6), and use of levetiracetam (OR 7.6, 95% CI 1.1-53.7) and antidepressants (OR 7.2, 95% CI 1.5-34.1) were all associated with a higher probability of suicide. SIGNIFICANCE Patients with temporal lobe epilepsy who experience seizures weekly or more frequently, experience a lack of aura, use levetiracetam, or take antidepressants are all at a higher risk of suicide and should be monitored closely.
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Affiliation(s)
- Sung-Jin Park
- Department of Psychology, Seoul National University, Seoul, Korea
| | - Hochang Benjamin Lee
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, U.S.A
| | - Myung Hee Ahn
- Department of Psychiatry, Asan Medical Center, College of Medicine University of Ulsan, Seoul, Korea
| | - Subin Park
- Department of Psychiatry, Seoul National University, Seoul, Korea
| | - Eun Ju Choi
- Department of Neurology, Asan Medical Center, College of Medicine University of Ulsan, Seoul, Korea
| | - Hoon-Jin Lee
- Department of Psychology, Seoul National University, Seoul, Korea
| | - Han Uk Ryu
- Department of Neurology, Asan Medical Center, College of Medicine University of Ulsan, Seoul, Korea
| | - Joong-Koo Kang
- Department of Neurology, Asan Medical Center, College of Medicine University of Ulsan, Seoul, Korea
| | - Jin Pyo Hong
- Department of Psychiatry, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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19
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Mula M, Sander JW. Suicide and epilepsy: do antiepileptic drugs increase the risk? Expert Opin Drug Saf 2015; 14:553-8. [DOI: 10.1517/14740338.2015.1010506] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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20
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Eisenschenk S, Krop H, Devinsky O. Homicide during postictal psychosis. EPILEPSY & BEHAVIOR CASE REPORTS 2014; 2:118-20. [PMID: 25667886 PMCID: PMC4307965 DOI: 10.1016/j.ebcr.2014.04.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 04/04/2014] [Accepted: 04/06/2014] [Indexed: 11/09/2022]
Abstract
Postictal psychosis is characterized by a fluctuating combination of thought disorder, auditory and visual hallucinations, delusions, paranoia, affective change, and aggression including violent behavior. We present a case of homicide following a cluster of seizures. The patient's history and postictal behavior were his consistent with postictal psychosis. Contributing factors resulting in homicide may have included increased seizure frequency associated with a change in his AED regimen seizure frequency. The AED change to levetiracetam may also have increased impulsiveness with diminished mood regulation following discontinuation of carbamazepine. There is evidence that he had a cluster of seizures immediately prior to the murder which may have resulted in the postictal disinhibition of frontal lobe inhibitory systems. This homicide and other violent behaviors associated with postictal psychosis may be avoided with earlier recognition and treatment.
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Affiliation(s)
- Stephan Eisenschenk
- Department of Neurology, University of Florida, 1149 Newell Drive, Rm L3-100, Gainesville, FL 32611, USA
| | - Harry Krop
- Community Behavioral Services, 1212 N.W. 12th Ave., Ste. B, Gainesville, FL 32601, USA
| | - Orrin Devinsky
- Department of Neurology, NYU School of Medicine, 223 East 34th Street, New York, NY 10016, USA
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21
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Adachi N, Kanemoto K, de Toffol B, Akanuma N, Oshima T, Mohan A, Sachdev P. Basic treatment principles for psychotic disorders in patients with epilepsy. Epilepsia 2013; 54 Suppl 1:19-33. [PMID: 23458463 DOI: 10.1111/epi.12102] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
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.
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Hilger E, Zimprich F, Jung R, Pataraia E, Baumgartner C, Bonelli S. Postictal psychosis in temporal lobe epilepsy: a case-control study. Eur J Neurol 2013; 20:955-61. [DOI: 10.1111/ene.12125] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 01/30/2013] [Indexed: 11/26/2022]
Affiliation(s)
- E. Hilger
- Department of Neurology; Medical University of Vienna; Austria; Austria
| | - F. Zimprich
- Department of Neurology; Medical University of Vienna; Austria; Austria
| | - R. Jung
- Department of Neurology; Medical University of Vienna; Austria; Austria
| | - E. Pataraia
- Department of Neurology; Medical University of Vienna; Austria; Austria
| | - C. Baumgartner
- 2nd Neurological Department; General Hospital Hietzing with Neurological Center Rosenhuegel; Vienna; Austria
| | - S. Bonelli
- Department of Neurology; Medical University of Vienna; Austria; Austria
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24
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Abstract
Epilepsy is a common neurological disorder that is complicated by psychiatric, cognitive, and social comorbidities that have become a major target of concern and investigation in view of their adverse effect on the course and quality of life. In this report we define the specific psychiatric, cognitive, and social comorbidities of paediatric and adult epilepsy, their epidemiology, and real life effects; examine the relation between epilepsy syndromes and the risk of neurobehavioural comorbidities; address the lifespan effect of epilepsy on brain neurodevelopment and brain ageing and the risk of neurobehavioural comorbidities; consider the overarching effect of broader brain disorders on both epilepsy and neurobehavioural comorbidities; examine directions of causality and the contribution of selected epilepsy-related characteristics; and outline clinic-friendly screening approaches for these problems and recommended pharmacological, behavioural, and educational interventions.
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Affiliation(s)
- Jack J. Lin
- Department of Neurology, University of California at Irvine, Irvine, California, USA
| | - Marco Mula
- Amedeo Avogadro University, Novara, Italy
| | - Bruce P. Hermann
- Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Buono S, Scannella F, Palmigiano MB, Elia M, Kerr M, Di Nuovo S. Self-injury in people with intellectual disability and epilepsy: a matched controlled study. Seizure 2012; 21:160-4. [PMID: 22244737 DOI: 10.1016/j.seizure.2011.10.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Revised: 10/27/2011] [Accepted: 10/30/2011] [Indexed: 11/19/2022] Open
Abstract
We aimed to identify the presence of self-injurious behavior in a sample of 158 people with intellectual disability and epilepsy as compared with a control sample consisting of 195 people with intellectual disability without epilepsy. The Italian Scale for the Assessment of self-injurious behaviors was used to describe self-injurious behavior in both groups. The groups were matched for ID degree: mild/moderate (20 and 20 respectively), severe/profound (45 in both samples) and unknown (4 in both samples). Seventy-four percent of the first sample were diagnosed with symptomatic partial epilepsy. The prevalence of self-injurious behaviors was 44% in the group with intellectual disability and epilepsy and 46.5% in the group with intellectual disability without epilepsy (difference not significant). The areas most affected by self-injurious behaviors in both samples were the hands, the mouth and the head. The most frequent types of self-injurious behaviors were self-biting, self-hitting with hands and with objects. Self-injurious behavior is frequently observed in individuals with epilepsy and intellectual disability. Our study does not suggest that the presence of epilepsy is a risk factor for self-injurious behavior in this patient group.
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Affiliation(s)
- Serafino Buono
- Unit of Psychology, IRCCS Oasi Maria SS., Troina (EN), Italy.
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26
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Woo TS, Yoon SY, Pena ICD, Choi JY, Lee HL, Choi YJ, Lee YS, Ryu JH, Choi JS, Cheong JH. Anticonvulsant Effect of Artemisia capillaris Herba in Mice. Biomol Ther (Seoul) 2011. [DOI: 10.4062/biomolther.2011.19.3.342] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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27
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Hamed SA. Psychiatric symptomatologies and disorders related to epilepsy and antiepileptic medications. Expert Opin Drug Saf 2011; 10:913-34. [PMID: 216194860 DOI: 10.1517/14740338.2011.588597] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Psychiatric comorbidities (such as depression, anxiety, psychosis, inattention, obsession, personality traits, aggression and suicide) are frequent in patients with epilepsy and have a significant impact on medical management and quality of life. AREAS COVERED A literature search was performed in MEDLINE for epidemiological, longitudinal, prospective, double-blind clinical trial studies published between 1990 and 2011 using the following words: epilepsy, antiepileptic drugs (AEDs), behavioral/emotional/psychiatric comorbidities, suicide and aggression. In this review, the author discusses: i) the characterization and prevalence of behavioral disturbances associated with epilepsy, ii) variables correlated with behavioral comorbidities which include: psychosocial-, clinical- and treatment-related variables, iii) the complex mechanisms of behavioral comorbidities associated with epilepsy, which include both psychosocial (functional) and organic; the process of epileptogenesis, neuronal plasticity, abnormalities in hypothalamic-pituitary axis and neurotransmitters and pathways are fundamental determinants, iv) the negative psychotropic effects of AEDs and their mechanisms and v) the suggested biopsychosocial model of management (pharmacological and non-pharmacological). EXPERT OPINION The relationship between psychiatric disorders and epilepsy has relevant therapeutic implications which should be directed towards a comprehensive biopsychosocial approach that focuses on the whole person rather than simply on the disease process.
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Kanemoto K, Tadokoro Y, Oshima T. Violence and postictal psychosis: a comparison of postictal psychosis, interictal psychosis, and postictal confusion. Epilepsy Behav 2010; 19:162-6. [PMID: 20727827 DOI: 10.1016/j.yebeh.2010.06.018] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Accepted: 06/17/2010] [Indexed: 10/19/2022]
Abstract
The belief that epilepsy is linked with violent behavior acquired a highly stigmatizing value in the late 19th century on the basis of degenerative theory. This widespread medical view lost general acceptance among experts in the 1990s after several large-scale studies showed that aggressive phenomena can arise during epileptic seizures, but are extremely rare. The concept of postictal psychosis (PIP) shed a new light on this old dispute. With this concept, the significance of the chronological relationship between seizures and violent behaviors in patients with epilepsy is newly stressed, which made a simple "yes" or "no" answer to the question implausible. In this review, we discuss violent behaviors at five chronological points relative to seizures and demonstrate representative cases. As shown in our previous study, well-directed violent attacks occurred during 22.8% of the PIP episodes, 4.8% of the IIP episodes, and 0.7% of the postictal confusions. Compared with the other two situations, proneness to violence stood out in the PIP episodes. Suicidal attempts showed a similar trend. Purposeful, organized violence as a direct manifestation of seizures or ictal automatism is highly exceptional. Violent acts could occur in postictal confusion as an expression of unconscious, vigorous resistance against efforts of surrounding people to prevent the affected individual from roaming or fumbling about. In contrast, some PIP episodes can be highly alarming, especially if a violent act has been previously committed in preceding episodes. Violent acts by patients with epilepsy should be treated differently according to the various pathophysiological backgrounds from which the violence arises.
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Affiliation(s)
- Kousuke Kanemoto
- Department of Neuropsychiatry, Aichi Medical University, Nagakute, Aichi, Japan.
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Abstract
Postictal behaviors and symptoms often require special assessment and treatment. We review risk factors for postictal delirium and psychosis and management of agitated and confused behaviors in patients after seizures. Medical and emergency staff require careful training to manage behaviors associated with postictal delirium and psychosis in order to protect patients while their confusion resolves. Treatment of postictal states requires recognition of underlying neurological and systemic disorders associated with seizures and delirium such as metabolic disorders and nonconvulsive seizures. There is incomplete information about the causes and optimal treatments for seizure-related psychosis, however, postictal behaviors can usually be managed safely.
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Affiliation(s)
- Gregory Krauss
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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Ito M. Neuropsychiatric evaluations of postictal behavioral changes. Epilepsy Behav 2010; 19:134-7. [PMID: 20708439 DOI: 10.1016/j.yebeh.2010.06.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Accepted: 06/17/2010] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Masumi Ito
- Department of Neuropsychiatry, Tenshi Hospital, Sapporo, Japan.
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31
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Abstract
Postictal psychoses represent a considerable clinical challenge and are often unrecognized. In this review, the clinical features of the syndromes and the underlying biological foundations, as revealed through EEG and imaging studies, are discussed. It is concluded that although the syndrome can be well recognized, it is not acknowledged in standard diagnostic manuals, hence the relative neglect in the epilepsy literature.
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Abstract
Postical psychosis often complicates chronic epilepsy, especially in patients with seizure clusters that include tonic-clonic seizures, bilateral cerebral dysfunction (e.g., bilateral epileptiform activity or history of encephalitis), and a family history of psychiatric illness. Psychosis includes delusions, auditory and visual hallucinations, mood changes, and aggressive behavior. It typically emerges after a lucid interval of hours or days after the last seizure. This treatable disorder is associated with serious morbidity and mortality.
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Affiliation(s)
- Orrin Devinsky
- Departments of Neurology, Psychiatry, and Neurosurgery, NYU Epilepsy Center New York, NY, USA.
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Abstract
BACKGROUND Aggression is a major public health issue and is integral to several mental health disorders. Antiepileptic drugs may reduce aggression by acting on the central nervous system to reduce neuronal hyper-excitability associated with aggression. OBJECTIVES To evaluate the efficacy of antiepileptic drugs in reducing aggression and associated impulsivity. SEARCH STRATEGY We searched CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, metaRegister of Controlled Trials (mRCT) and ClinicalTrials.gov to April 2009. We also searched Cochrane Schizophrenia Group's register of trials on aggression, National Research Record and handsearched for studies. SELECTION CRITERIA Prospective, placebo-controlled trials of antiepileptic drugs taken regularly by individuals with recurrent aggression to reduce the frequency or intensity of aggressive outbursts. DATA COLLECTION AND ANALYSIS Three authors independently selected studies and two authors independently extracted data. We calculated standardised mean differences (SMDs), with odds ratios (ORs) for dichotomous data. MAIN RESULTS Fourteen studies with data from 672 participants met the inclusion criteria. Five different antiepileptic drugs were examined. Sodium valproate/divalproex was superior to placebo for outpatient men with recurrent impulsive aggression, for impulsively aggressive adults with cluster B personality disorders, and for youths with conduct disorder, but not for children and adolescents with pervasive developmental disorder. Carbamazepine was superior to placebo in reducing acts of self-directed aggression in women with borderline personality disorder, but not in children with conduct disorder. Oxcarbazepine was superior to placebo for verbal aggression and aggression against objects in adult outpatients. Phenytoin was superior to placebo on the frequency of aggressive acts in male prisoners and in outpatient men including those with personality disorder, but not on the frequency of 'behavioral incidents' in delinquent boys. AUTHORS' CONCLUSIONS The authors consider that the body of evidence summarised in this review is insufficient to allow any firm conclusion to be drawn about the use of antiepileptic medication in the treatment of aggression and associated impulsivity. Four antiepileptics (valproate/divalproex, carbamazepine, oxcarbazepine and phenytoin) were effective, compared to placebo, in reducing aggression in at least one study, although for three drugs (valproate, carbamazepine and phenytoin) at least one other study showed no statistically significant difference between treatment and control conditions. Side effects were more commonly noted for the intervention group although adverse effects were not well reported. Absence of information does not necessarily mean that the treatment is safe, nor that the potential gains from the medication necessarily balance the risk of an adverse event occurring. Further research is needed.
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Affiliation(s)
- Nick Huband
- Institute of Mental HealthSection of Forensic Mental HealthNottinghamshire Healthcare Trust, Room B06, The Gateway BuildingUniversity of Nottingham, Innovation Park, Triumph RoadNottinghamUKNG7 2TU
| | - Michael Ferriter
- Nottinghamshire Healthcare NHS TrustLiterature and Evidence Research Unit (LERU), Institute of Mental HealthThe Clair Chilvers CentreRampton HospitalWoodbeckNottinghamshireUKDN22 0PD
| | - Rajan Nathan
- University of LiverpoolDivision of PsychiatryRoyal Liverpool University HospitalLiverpoolUKL69 3GA
| | - Hannah Jones
- Nottinghamshire Healthcare NHS TrustLiterature and Evidence Research Unit (LERU), Institute of Mental HealthThe Clair Chilvers CentreRampton HospitalWoodbeckNottinghamshireUKDN22 0PD
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34
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de Toffol B. [Postictal psychosis]. Rev Neurol (Paris) 2009; 165:769-73. [PMID: 19683323 DOI: 10.1016/j.neurol.2009.07.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2009] [Revised: 07/03/2009] [Accepted: 07/08/2009] [Indexed: 11/29/2022]
Abstract
In epilepsy patients, psychotic states are related to a group of psychotic disorders with a specific phenomenology in which potential pathophysiological mechanisms are believed to be closely related to the epileptic disorder itself. Postictal psychosis is a very specific syndrome in relation to seizure activity: a clear temporal relationship exists between the psychotic state of sudden onset and a precipitating bout of complex partial or generalized seizures, with a characteristic lucid interval which lasts from two to 120h. The psychotic state may be related to the withdrawal of anticonvulsants, often in connection with video-EEG monitoring. The phenomenology of the psychotic state is often pleomorphic, with abnormal mood, paranoid delusions and hallucinations, with some clouding of consciousness or no evidence of impaired consciousness. The outcome is characterized by a remission of the psychotic symptoms over several days (mean: 1 week), with or without neuroleptic treatment. The majority of the patients suffer from complex partial seizures with frequent psychic auras that secondarily become generalized. In the majority of cases, prepsychotic EEG abnormalities persist during the psychosis. Frequent bitemporal foci are recorded on the EEG and MRI abnormalities (including mesial temporal sclerosis) are seen in more than half of the cases. The results of clinical, morphologic and metabolic available studies will be briefly discussed.
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Affiliation(s)
- B de Toffol
- Clinique neurologique, CHU Bretonneau, Tours, France.
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35
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Kanner AM. Suicidality and epilepsy: a complex relationship that remains misunderstood and underestimated. Epilepsy Curr 2009; 9:63-6. [PMID: 19471611 PMCID: PMC2685880 DOI: 10.1111/j.1535-7511.2009.01294.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Suicidality in people with epilepsy is significantly more frequent than in the general population. The relation between suicidality and epilepsy is multifactorial and bidirectional. The purpose of this review is to highlight the most important psychiatric, pharmacologic, and epilepsy-related variables linked to the increased suicidal risk among these patients.
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Affiliation(s)
- Andres M Kanner
- Rush Medical College at Rush University, Rush Epilepsy Center at Rush University Medical Center Chicago, Illinois, USA.
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36
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Alper K, Kuzniecky R, Carlson C, Barr WB, Vorkas CK, Patel JG, Carrelli AL, Starner K, Flom PL, Devinsky O. Postictal psychosis in partial epilepsy: a case-control study. Ann Neurol 2008; 63:602-10. [PMID: 18481288 DOI: 10.1002/ana.21341] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Divergent findings among prior studies on correlates of risk for postictal psychosis (PIP) suggest the value of a controlled study involving a relatively large number of patients. METHODS The study population consisted of a consecutive series of 59 patients with partial epilepsy and a history of PIP, and 94 control patients with partial epilepsy and no history of PIP evaluated as inpatients with video-electroencephalography. The groups did not differ significantly regarding demographic features. Exact tests yielded a subset of variables and a tentative interpretation that were evaluated further utilizing principal components analysis and logistic regression. RESULTS PIP was associated with extratemporal versus temporal (p = 0.036) or undetermined (p = 0.001) localization of seizure onset, bilateral interictal epileptiform activity (p = 0.017), secondary generalization (p = 0.049), and history of encephalitis (p = 0.018). Interictal slow activity was more frequently absent in control patients (p = 0.045). PIP was associated with family histories of psychiatric disorders (p = 0.007) and epilepsy (p = 0.042), which themselves were significantly intercorrelated (r = 0.225; p = 0.006). Age of onset or duration of epilepsy and lateralized electroencephalographic or magnetic resonance imaging asymmetries did not differ significantly between control and PIP groups. The analysis indicated four underlying domains of risk for PIP: ambiguous/extratemporal localization, family neuropsychiatric history, abnormal interictal electroencephalographic activity, and encephalitis. Each unit increase on a simple additive scale composed of 9 dichotomous independent variables multiplied the odds ratio for PIP by 1.71 (95% confidence interval, 1.36-2.15; p < 0.0001). INTERPRETATION PIP in partial epilepsy is associated with relatively broadly and bilaterally distributed epileptogenic networks, genetic determinants of psychiatric disorders and seizures, and encephalitis.
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Affiliation(s)
- Kenneth Alper
- Department of Neurology, Comprehensive Epilepsy Center, New York, NY 10016, USA.
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37
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Verrotti A, Cicconetti A, Scorrano B, De Berardis D, Cotellessa C, Chiarelli F, Ferro FM. Epilepsy and suicide: pathogenesis, risk factors, and prevention. Neuropsychiatr Dis Treat 2008; 4:365-70. [PMID: 18728742 PMCID: PMC2518384 DOI: 10.2147/ndt.s2158] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Depression and suicide tendencies are common in chronic diseases, especially in epilepsy and diabetes. Suicide is one of the most important causes of death, and is usually underestimated. We have analyzed several studies that compare mortality as a result of suicide in epileptic patients and in the general population. All the studies show that epileptic patients have a stronger tendency toward suicide than healthy controls. Moreover it seems that some kinds of epilepsy have a higher risk for suicide (temporal-lobe epilepsy). Among the risk factors are surgery therapy (suicide tendency five times higher than patients in pharmacological therapy), absence of seizures for a long time, especially after being very frequent, and psychiatric comorbidity (major depression, anxiety-depression disorders, personality disorders, substance abuse, psychoses). The aim of the review was to analyze the relationship between suicide and epilepsy, to identify the major risk factors, and to analyze effective treatment options.
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Affiliation(s)
- Alberto Verrotti
- Department of Pediatrics, Institute of Psychiatry, University "G. d'Annunzio" of Chieti Italy.
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38
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Reuber M, Mackay RD. Epileptic Automatisms in the Criminal Courts: 13 Cases Tried in England and Wales between 1975 and 2001. Epilepsia 2008; 49:138-45. [PMID: 17727668 DOI: 10.1111/j.1528-1167.2007.01269.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To explore the relationship of epilepsy and criminal behavior. METHODS Case series based on all criminal cases found "not guilty by reason of insanity" (NGRI) because of epilepsy in England and Wales between 1975 and 2001. Data were extracted from medico-legal reports held by the Mental Health Unit at the Home Office and the Department for Constitutional Affairs in London, UK. RESULTS Thirteen cases were identified, accounting for 7.3% of all verdicts of NGRI. Charges included murder (1), attempted murder (1) assault (7), arson (2), abduction/kidnapping (3), and burglary (1). Of the defendants, 92.3% were male, 76.9% had neuropsychological impairments, 84.6%% had psychiatric comorbidity, 92.3% were unemployed at the time of the offence, and 69.2% had been convicted of criminal offences previously. Eight of 10 defendants treated with antiepileptic drugs were complying poorly with medication. A total of 61.5% offenses were committed in a state of alcohol intoxication. Psychotic symptoms may have been present when the offense was committed in 52.8% of cases. Over two-thirds of offenses probably occurred during the postictal period. CONCLUSIONS This case series suggests that it is exceptional for epileptic seizures to cause criminal acts or omissions. The relatively low standard of proof required means that some of cases found NGRI on account of epilepsy were not actually related to seizures. There were no definite examples of ictal criminal behavior. Most offenses related to seizures are likely to have occurred in the postictal phase.
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Affiliation(s)
- Markus Reuber
- Academic Neurology Unit, University of Sheffield, Sheffield, UK.
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39
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Ito M, Okazaki M, Takahashi S, Muramatsu R, Kato M, Onuma T. Subacute postictal aggression in patients with epilepsy. Epilepsy Behav 2007; 10:611-4. [PMID: 17418643 DOI: 10.1016/j.yebeh.2007.02.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2007] [Revised: 02/20/2007] [Accepted: 02/22/2007] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Masumi Ito
- Department of Psychiatry, National Center of Neurology and Psychiatry, Musashi Hospital, 4-1-1 Ogawahigashi-cho, Kodaira, Tokyo 187-8551, Japan.
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40
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Hillemacher T, Kraus T, Stefan H, Kerling F. Suicidal attempts and aggressive behaviours after temporal lobectomy in epilepsy. Eur J Neurol 2007; 14:e10. [PMID: 17355530 DOI: 10.1111/j.1468-1331.2006.01633.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Cognitive function is more frequently impaired in people with epilepsy than in the general population, and the degree of cognitive impairment varies according to the epilepsy syndrome. Behavioral disorders are also more frequent in people with epilepsy than in individuals who do not have epilepsy. Behavioral disturbance is observed more frequently in people with drug-resistant epilepsy, frequent seizures, and/or associated neurological or mental abnormalities. In children and adolescents, many data suggest a close link between behavior/cognition and some specific epilepsy syndromes. For example, aspects of mood, behavior, personality, and cognition may be related to temporal lobe epilepsy or juvenile myoclonic epilepsy. Behavioral disorders may precede, occur with, or follow a diagnosis of epilepsy; they differ between children and adults. Predictors of behavioral disorders in children with epilepsy are the epilepsy itself, treatment, the underlying lesion, and personal reactions to epilepsy. More specifically, conditions in which behavioral disorders may be associated with epilepsy include depression, psychosis, particular personality traits, aggression, anxiety, and attention deficit and hyperactivity disorder.
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42
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Rothenhäusler HB. [Clinical features, diagnosis, and treatment of dysphoric states and psychoses associated with epilepsy]. DER NERVENARZT 2006; 77:1381-91; quiz 1392. [PMID: 17061130 DOI: 10.1007/s00115-006-2186-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Although dysphoric states and psychoses represent clinically relevant psychiatric complications in patients with epilepsy, their symptomatologies are complex and therefore frequently underrecognized and undertreated in daily psychiatric routine. Detecting dysphoric states and psychoses secondary to the psychotropic effects of various antiepileptic drugs is often challenging, even for the most experienced psychiatrists. This article gives an overview of epidemiology, clinical features, diagnosis, and therapy of interictal, peri-ictal, and alternative dysphoric states and psychoses in patients with epilepsy. Further, potential drug interactions between antiepileptic and psychiatric medications are discussed.
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Affiliation(s)
- H-B Rothenhäusler
- Universitätsklinik für Psychiatrie der Medizinischen Universität Graz, Auenbruggerplatz 31, 8036 Graz.
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43
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Pompili M, Girardi P, Tatarelli G, Angeletti G, Tatarelli R. Suicide after surgical treatment in patients with epilepsy: a meta-analytic investigation. Psychol Rep 2006; 98:323-38. [PMID: 16796084 DOI: 10.2466/pr0.98.2.323-338] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Suicide is a major issue in surgically treated epileptic patients. A meta-analysis was performed comparing suicides in a sample of such patients and in the general population. The Index Medicus and the World Health Statistics Annual were searched to ascertain the suicide rates in the age groups indicated in the studies of epileptic patients for specific years and country. 11 studies were selected, comprising 2,425 patients, 24 of whom committed suicide. Data obtained for each study were processed together to calculate the mean number of suicides per 100,000 individuals with surgically treated epilepsy for each year. This meta-analysis shows that suicide in patients with epilepsy after surgical treatment is more frequent than in the general population. Results are discussed with particular attention to possible causative factors.
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Affiliation(s)
- Maurizio Pompili
- McLean Hospital, Harvard Medical School, Belmont, Massachusetts, USA.
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44
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Haller J, Kruk MR. Normal and abnormal aggression: human disorders and novel laboratory models. Neurosci Biobehav Rev 2006; 30:292-303. [PMID: 16483889 DOI: 10.1016/j.neubiorev.2005.01.005] [Citation(s) in RCA: 122] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2004] [Revised: 01/20/2005] [Accepted: 01/27/2005] [Indexed: 10/25/2022]
Abstract
We review here aggression-related human psychopathologies and propose that human aggressiveness is mainly due to three major factors: (i) brain dysfunction affecting aggression-controlling brain centers (e.g. in certain types of brain lesions, epilepsy, Alzheimer disease, etc.); (ii) hypoarousal associated with chronically low plasma glucocorticoids, which foster violence by diminishing emotional barriers that limit such behaviors (e.g. in conduct disorder and antisocial personality disorder); (iii) hyperarousal which leads to irritability and outbursts (e.g. in depression, intermittent explosive disorder, chronic fatigue, etc.). Different disorders are associated with different types of aggressiveness; e.g. hypoarousal is often associated with instrumental aggression, whereas hyperarousal is associated with uncontrollable outbursts. Many psychological disorders have been simulated in laboratory models, which were used to assess aggressiveness. Little effort was invested, however, in assessing the abnormal dimension of such aggressiveness. We present here three models that appear especially suitable to assess abnormal aspects of rodent aggression: (i) abnormal attack targeting (head, throat, and belly) that is induced by hypoarousal in rats and models violence in hypoarousal-driven human aggression (ii) 'escalated' aggression (increased aggressive response due to frustration or instigation), which models irritability and hyperarousal-driven aggressiveness; and (iii) context-independent attacks induced by hypothalamic stimulation or genetic manipulations. These three models address different aspects of abnormal aggressiveness, and can become extremely useful in three areas: in evaluating and assessing models of human psychopathologies, in studying transgenic animals, and in developing new treatment strategies. Research based on these or similar models do not address aggressiveness in quantitative terms, but follows the development of abnormal aspects, and the possibilities of their specific treatment.
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Affiliation(s)
- József Haller
- Institute of Experimental Medicine, P.O. Box 67, 1450 Budapest, Hungary.
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Haller J, Mikics E, Halász J, Tóth M. Mechanisms differentiating normal from abnormal aggression: glucocorticoids and serotonin. Eur J Pharmacol 2005; 526:89-100. [PMID: 16280125 DOI: 10.1016/j.ejphar.2005.09.064] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2005] [Revised: 06/28/2005] [Accepted: 09/23/2005] [Indexed: 11/15/2022]
Abstract
Psychopathology-associated human aggression types are induced by a variety of conditions, are behaviorally variable, and show a differential pharmacological responsiveness. Thus, there are several types of abnormal human aggression. This diversity was not reflected by conventional laboratory approaches that focused on the quantitative aspects of aggressive behavior. Recently, several laboratory models of abnormal aggression were proposed, which mainly model hyperarousal-driven aggressiveness (characteristic to intermittent explosive disorder, post-traumatic stress disorder, depression, chronic burnout, etc.) and hypoarousal-driven aggressiveness (characteristic mainly to antisocial personality disorder and its childhood antecedent conduct disorder). Findings obtained with these models suggest that hyperarousal-driven aggressiveness has at its roots an excessive acute glucocorticoid stress response (and probably an exaggerated response of other stress-related systems), whereas chronic hypoarousal-associated aggressiveness is due to glucocorticoid deficits that affect brain function on the long term. In hypoarousal-driven aggressiveness, serotonergic neurotransmission appears to lose its impact on aggression (which it has in normal aggression), certain prefrontal neurons are weakly activated, whereas the central amygdala (no, or weakly involved in the control of normal aggression) acquires important roles. We suggest that the specific study of abnormal aspects of aggressive behavior would lead to important developments in understanding the specific mechanisms underlying different forms of aggression, and may ultimately lead to the development of better treatment approaches.
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Affiliation(s)
- Jozsef Haller
- Institute of Experimental Medicine, Hungarian Academy of Science, 1450 Budapest, P.O. Box 67, Hungary.
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Tassinari CA, Tassi L, Calandra-Buonaura G, Stanzani-Maserati M, Fini N, Pizza F, Sartori I, Michelucci R, Lo Russo G, Meletti S. Biting behavior, aggression, and seizures. Epilepsia 2005; 46:654-63. [PMID: 15857430 DOI: 10.1111/j.1528-1167.2005.58404.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE To describe the semiologic features of aggressive behaviors observed in human epileptic seizures with particular reference to the act of biting a conspecific. METHODS We analyzed the biting behavior (BB) and other aggressive gestures occurring in a group of 11 patients retrospectively selected from >1,000 patients subjected to video-EEG/SEEG monitoring for presurgical evaluation of drug-resistant seizures. RESULTS Patients displaying BB showed (a) a male sex predominance, (b) heterogeneous etiologies and lesion locations, and (c) seizures involving the frontotemporal regions of both hemispheres. The act of biting was a rapid motor action, lasting approximately 600 ms, occurring in the context of strong emotional arousal, fear, and anger, with various bodily gestures with aggressive connotation. BB was mainly a "reflexive" behavior, in that biting acts were evoked (both during and after seizures) by actions of people in close contact with the patient. The sole intrusion of the examiner's hand in the space near the patient's face was effective in triggering BB. Rarely, self-directed or object-directed biting acts were not triggered by external stimuli. Intracranial data (SEEG) obtained in one subject showed that the amygdala/hippocampal region plus the orbitomedial prefrontal cortex had to be involved by ictal activity to observe BB. CONCLUSIONS Anatomic and electrophysiologic data in our patients suggest that a model of dual--temporal and frontal--dysfunction could account for the occurrence of ictal/postictal BB. Behavioral data suggest also that BB and related aggressive gestures can be considered as the emergence of instinctive behaviors with an adaptative significance of defense of the peripersonal space.
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Affiliation(s)
- Carlo Alberto Tassinari
- Division of Neurology, Department of Neurosciences, Bellaria Hospital, University of Bologna, Italy
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Dinkelacker V, Dietl T, Widman G, Lengler U, Elger CE. Aggressive behavior of epilepsy patients in the course of levetiracetam add-on therapy: report of 33 mild to severe cases. Epilepsy Behav 2003; 4:537-47. [PMID: 14527496 DOI: 10.1016/j.yebeh.2003.07.008] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Levetiracetam (LEV) was shown to be very efficacious and well tolerated as add-on therapy for refractory epilepsy. Here we report 33 patients with longstanding histories of epilepsy who experienced aggressive episodes during LEV therapy. This corresponds to 3.5% of LEV-treated patients as compared with less than 1% of patients not on LEV. Among these cases, 24 showed only moderate, partly transient irritability, with 10 patients requiring reduction or discontinuation of LEV. More strikingly, 9 patients displayed severe symptoms of aggression with physical violence and, in 2 cases, the need for psychiatric emergency treatment. One patient developed additional psychotic symptoms. We suggest that, specifically in patients with a previous history of aggression, behavioral tolerability of LEV should be carefully monitored.
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Affiliation(s)
- Vera Dinkelacker
- Department of Epileptology, University of Bonn Medical Center, Sigmund-Freud Strasse 25, 53105 Bonn, Germany.
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49
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Smith MC, Spitz MC. Treatment strategies in Landau-Kleffner syndrome and paraictal psychiatric and cognitive disturbances. Epilepsy Behav 2002; 3:24-29. [PMID: 12609317 DOI: 10.1016/s1525-5050(02)00510-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Psychiatric and cognitive disturbances of the peri-ictal period (i.e., the seizure prodrome and the postictal period) can be considered paraictal disturbances, as they are directly related to the ictal event. There are also certain interictal psychiatric and cognitive disturbances that become apparent concomitantly with the onset of a seizure disorder and remit and/or significantly improve upon its remission. Such disorders also fall under the classification paraictal disorders, and are exemplified by Landau-Kleffner syndrome (LKS), a disorder in which language and psychiatric disturbances begin with the onset of epileptic activity and improve upon its disappearance. In this article, we review the treatment of paraictal cognitive and psychiatric disorders presenting as preictal and postictal psychiatric disturbances and LKS.
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Affiliation(s)
- Michael C. Smith
- Department of Neurological Sciences, Rush Presbyterian St. Luke's Medical Center, Rush Medical College, Chicago, IL, USA
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Fukuchi T, Kanemoto K, Kato M, Ishida S, Yuasa S, Kawasaki J, Suzuki S, Onuma T. Death in epilepsy with special attention to suicide cases. Epilepsy Res 2002; 51:233-6. [PMID: 12399073 DOI: 10.1016/s0920-1211(02)00151-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
To examine clinical features of cases of death among epilepsy patients as a case-control study, with special attention to suicide, we analyzed the records of 43 deceased patients with well-classified epilepsy. The subjects were compared with 1,722 control patients who showed definite subtypes of epilepsy. As a result, among the major causes of death, 13 of the subjects suffered accidents (mostly drowning), ten experienced sudden unexpected death, seven had status epilepticus, and six committed suicide. There were no significant differences with regard to clinical variables except for psychotic episodes, which were more frequently encountered in subjects than in controls (chi(2)=6.771, P=0.009, Yates' modification). Statistically significant differences were found by epilepsy type as well (chi(2)=14.72, P=0.002), with temporal lobe epilepsy (TLE) proving to be most closely associated with death among the epilepsy patients. Further, suicide was only encountered in patients with TLE and the association was statistically significant (chi(2)=5.119, P=0.024). Half of those who committed suicide (n=3), did so by jumping in front of an oncoming train while in the midst of an episode of postictal psychosis. In conclusion, most cases of suicide in patients with epilepsy were found to be the result of an immediate causal relationship with ictal or interictal epileptic manifestations, rather than a result of augmentation of psychosocial stressors generated by a long-standing handicap derived from the severe illness.
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