Postictal psychiatric symptoms: A neurophysiological study

OBJECTIVE

Postictal psychiatric symptoms (PPS) are a relatively common but understudied phenomenon in epilepsy. The mechanisms by which seizures contribute to worsening in psychiatric symptoms are unclear. We aimed to identify PPS prospectively during and after admission to the epilepsy monitoring unit (EMU) in order to characterize the postictal physiologic changes leading to PPS.

METHODS

We prospectively enrolled patients admitted to the EMU and administered repeat psychometric questionnaires during and after their hospital stay in order to assess for postictal exacerbations in four symptom complexes: anger/hostility, anxiety, depression, and paranoia. Electroclinical and electrographic seizures were identified from the EEG recordings, and seizure durations were measured. The severity of postictal slowing was calculated as the proportion of postictal theta/delta activity in the postictal EEG relative to the preictal EEG using the Hilbert transform.

RESULTS

Among 33 participants, 8 demonstrated significant increases in at least one of the four symptoms (the PPS+ group) within three days following the first seizure. The most common PPS was anger/hostility, experienced by 7/8 participants with PPS. Among the 8 PPS+ participants, four experienced more than one PPS. As compared to those without PPS (the PPS- group), the PPS+ group demonstrated a greater degree of postictal EEG slowing at 10 min (p = 0.022) and 20 min (p = 0.05) following seizure termination. They also experienced significantly more seizures during the study period (p = 0.005). There was no difference in seizure duration between groups.

SIGNIFICANCE

Postictal psychiatric symptoms including anger/hostility, anxiety, depression, and paranoia may be more common than recognized. In particular, postictal increases in anger and irritability may be particularly common. We provide physiological evidence of a biological mechanism as well as a demonstration of the use of quantitative electroencephalography toward a better understanding of postictal neurophysiology.

Current practice and safety measures in epilepsy monitoring units in the Gulf Cooperation Council Countries: A cross-sectional study

BACKGROUND

An increasing number of Epilepsy Monitoring Units (EMU) display various practices and safety protocols. EMU settings should meet clear, standardized safety protocols to avoid seizure adverse events (SAE). We aim to provide the foundational framework facilitating the establishment of unified evidence-based safety regulations to address the practices and safety measures implemented within the Gulf Cooperation Council (GCC).

METHODS

In this cross-sectional study, EMU directors in the GCC were contacted directly by phone to personally complete an electronic 37-item questionnaire sent via text messages and email. From January 2021-December 2021.

RESULTS

Seventeen EMUs from six GCC countries participated in the study. All EMU directors responded to the study. Twelve (70.6%) EMUs monitored adults and children, five (29.4%) monitored adults, and none monitored children only. The number of certified epileptologists in the EMUs ranged from one to eight per unit. Fifteen (88.2%) EMUs applied a continuous observation pattern, whereas two (11.8%) performed daytime only. The precautions most commonly used in the video Electroencephalogram (EEG) were seizure pads and bedside oxygen in 15 EMUs (88.2%). For invasive EEG, seizure pads were used in 9 EMUs (52.9%), %) and IV access in 8 EMUs (47.1%). The occurrence of adverse events varied among EMUs. The most common conditions were postictal psychosis 10 (58.8%), injuries 7 (41.2%), and status epilepticus 6 (35.3%). Falls were mainly related to missed seizures or delayed recognition by video monitors in 8 EMUs (47.1%). The extended EMU stay was because of an insufficient number of recorded seizures in 16 EMUs (94.1%), poor seizure lateralization and localization in 10 (58.8%), and re-introduction of AEDs in nine (52.9%). All EMUs had written acute seizure and status epilepticus management protocols. A postictal psychosis management protocol was available for 10 (58.8%). Medications were withdrawn before admission in 6 EMUs (35.3%). The specific medication withdrawal speed protocol upon admission was available in 7 EMUs (41.2%). Pre-admission withdrawal of medication demonstrated a shorter length of stay in both video and invasive EEG, which was statistically significant (ρ (15) = -.529, p =.029; ρ (7) = -.694, p =.038; respectively).

CONCLUSION

The practice and safety regulations of EMUs in the GCC vary widely. Each EMU reported the occurrences of SAE and injuries. Precautions, protective measures, and management protocols must be reassessed to minimize the number of SAEs and increase the safety of the EMU.

Neuropsychological function in psychosis of epilepsy

OBJECTIVE

The neuropsychological profile of patients with psychosis of epilepsy (POE) has received limited research attention. Recent neuroimaging work in POE has identified structural network pathology in the default mode network and the cognitive control network. This study examined the neuropsychological profile of POE focusing on cognitive domains subserved by these networks.

METHODS

Twelve consecutive patients with a diagnosis of POE were prospectively recruited from the Comprehensive Epilepsy Programmes at The Royal Melbourne, Austin and St Vincent's Hospitals, Melbourne, Australia between January 2015 and February 2017. They were compared to 12 matched patients with epilepsy but no psychosis and 42 healthy controls on standardised neuropsychological tests of memory and executive functioning in a case-control design.

RESULTS

Mean scores across all cognitive tasks showed a graded pattern of impairment, with the POE group showing the poorest performance, followed by the epilepsy without psychosis and the healthy control groups. This was associated with significant group-level differences on measures of working memory (p = < 0.01); immediate (p = < 0.01) and delayed verbal recall (p = < 0.01); visual memory (p < 0.001); and verbal fluency (p = 0.02). In particular, patients with POE performed significantly worse than the healthy control group on measures of both cognitive control (p = .005) and memory (p < .001), whereas the epilepsy without psychosis group showed only memory difficulties (delayed verbal recall) compared to healthy controls (p = .001).

CONCLUSION

People with POE show reduced performance in neuropsychological functions supported by the default mode and cognitive control networks, when compared to both healthy participants and people with epilepsy without psychosis.

Criminal Liability and Epilepsy: A Case Report of a Postictal Attempted Homicide from Tunisia

INTRODUCTION

Epileptic patients charged with a serious offense may be referred by courts for forensic psychiatric examination, which may pose a legal challenge. Therefore, a detailed examination is necessary to assist the courts in making the right decision.

METHOD

We present the case of a 30-year-old Tunisian male with temporal epilepsy who exhibited an inadequate response to the treatment. The patient attempted to kill his neighbor after a cluster of seizures, showing apparent post-ictal aggression. An anti-epileptic treatment was reintroduced a few days after the detention followed by forensic psychiatric examination three months afterwards.

RESULTS

On the forensic examination, the patient's thought process was clear with no evidence of a thought disorder or a psychosis. Both medical and psychiatric opinions stated that the attempted homicide was due to a post-ictal psychosis. The patient was transferred to a psychiatric facility for further management as he was found not guilty by reason of insanity.Conclusion:This case report illustrates the difficulties that experts may encounter in establishing criminal liability after an aggressive behavior associated with epilepsy. It highlights some shortcomings in theTunisian law that should be addressed to ensure the fairness of the legal process.

Increased cortical thickness in nodes of the cognitive control and default mode networks in psychosis of epilepsy

OBJECTIVE

To explore the cortical morphological associations of the psychoses of epilepsy.

METHODS

Psychosis of epilepsy (POE) has two main subtypes - postictal psychosis and interictal psychosis. We used automated surface-based analysis of magnetic resonance images to compare cortical thickness, area, and volume across the whole brain between: (i) all patients with POE (n = 23) relative to epilepsy-without psychosis controls (EC; n = 23), (ii) patients with interictal psychosis (n = 10) or postictal psychosis (n = 13) relative to EC, and (iii) patients with postictal psychosis (n = 13) relative to patients with interictal psychosis (n = 10).

RESULTS

POE is characterised by cortical thickening relative to EC, occurring primarily in nodes of the cognitive control network; (rostral anterior cingulate, caudal anterior cingulate, middle frontal gyrus), and the default mode network (posterior cingulate, medial paracentral gyrus, and precuneus). Patients with interictal psychosis displayed cortical thickening in the left hemisphere in occipital and temporal regions relative to EC (lateral occipital cortex, lingual, fusiform, and inferior temporal gyri), which was evident to a lesser extent in postictal psychosis patients. There were no significant differences in cortical thickness, area, or volume between the postictal psychosis and EC groups, or between the postictal psychosis and interictal psychosis groups. However, prior to correction for multiple comparisons, both the interictal psychosis and postictal psychosis groups displayed cortical thickening relative to EC in highly similar regions to those identified in the POE group overall.

SIGNIFICANCE

The results show cortical thickening in POE overall, primarily in nodes of the cognitive control and default mode networks, compared to patients with epilepsy without psychosis. Additional thickening in temporal and occipital neocortex implicated in the dorsal and ventral visual pathways may differentiate interictal psychosis from postictal psychosis. A novel mechanism for cortical thickening in POE is proposed whereby normal synaptic pruning processes are interrupted by seizure onset.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Working toward the ideal situation: A pragmatic Epi-Psy approach for the diagnosis and treatment of psychogenic nonepileptic seizures

Medical international guidelines recommend regular psychiatric consultations for patients with epilepsy, in order to detect comorbidities. However, there is a lack of guidance about PNES that constitute both a differential diagnosis and a comorbidity of epilepsy. While waiting for the ideal collaboration between neurologists and psychiatrists, we develop a pragmatic approach. Wrong diagnosis between epilepsy and Psychogenic nonepileptic seizures (PNES) is frequent and may lead to iatrogenic consequences for patients. To limit the risk of misdiagnosis, psychiatrists and neurologists should collaborate and be more trained about epilepsy, PNES, and their comorbidities. We illustrate the aim of this collaboration through the case of a patient, initially diagnosed with epilepsy, then with PNES only and finally with comorbid epilepsy and PNES. The correct final diagnosis would not have been performed without the collaboration of psychiatrists and neurologists, trained in "Epi-Psy" approach.

Epilepsy as a key feature in two works of fantastic literature by Alfred Kubin and Hermann Weyl: With a brief review of epilepsy in fantastic literature

Among the many literary works of all styles and types referring to epilepsy, fantastic literature forms a distinct and interesting subgroup. The article draws attention to two such works belonging to early 20th century German avant-garde where epilepsy is a key feature. Of the authors, Austrian Alfred Kubin (1877-1959) was a renowned artist and illustrator whose only published (and illustrated) novel "The Other Side" (1909) can be understood as the narrative of a complex epileptic experience, perhaps a dreamy state. Of the other author, Hermann Weyl (1893-1960), very little is known. He was a Jewish neuropsychiatrist who emigrated from Nazist Germany to Argentina in 1933. His only published literary work, the novella "The Epileptic" (1927), displays high literary ambitions. The topic epilepsy provided for him the desired access to the fantastic realm, and his professionality enabled him to address with great expertise aspects as diverse as postictal psychosis and social stigmatization. Both works are, thus, valuable contributions to the tradition of epilepsy in fantastic literature. A brief review of the latter includes Edgar Allan Poe, Victor Hugo, Charles Dickens, Gustav Meyrink, Mervin Peake, Russell Hoban, Eraldo Baldini, Haruki Murakami, Adam Fawer, and Christoph Ransmayr.

Enlarged hippocampal fissure in psychosis of epilepsy

Psychosis of epilepsy (POE) can be a devastating condition, and its neurobiological basis remains unclear. In a previous study, we identified reduced posterior hippocampal volumes in patients with POE. The hippocampus can be further subdivided into anatomically and functionally distinct subfields that, along with the hippocampal fissure, have been shown to be selectively affected in other psychotic disorders and are not captured by gross measures of hippocampal volume. Therefore, in this study, we compared the volume of selected hippocampal subfields and the hippocampal fissure in 31 patients with POE with 31 patients with epilepsy without psychosis. Cortical reconstruction, volumetric segmentation, and calculation of hippocampal subfields and the hippocampal fissure were performed using FreeSurfer. The group with POE had larger hippocampal fissures bilaterally compared with controls with epilepsy, which was significant on the right. There were no significant differences in the volumes of the hippocampal subfields between the two groups. Our findings suggest abnormal development of the hippocampus in POE. They support and expand the neurodevelopmental model of psychosis, which holds that early life stressors lead to abnormal neurodevelopmental processes, which underpin the onset of psychosis in later life. In line with this model, the findings of the present study suggest that enlarged hippocampal fissures may be a biomarker of abnormal neurodevelopment and risk for psychosis in patients with epilepsy.

Pharmacotherapy in patients with epilepsy and psychosis

The recognition and treatment of psychosis in persons with epilepsy (PWE) is recommended with the apparent dilemma between treating psychosis and opening the possibility of exacerbating seizures. The pooled prevalence estimate of psychosis in PWE is 5.6%. It has been proposed that a 'two hit' model, requiring both aberrant limbic activity and impaired frontal control, may account for the wide range of clinical phenotypes. The role of antiepileptic drugs in psychosis in PWE remains unclear. Alternating psychosis, the clinical phenomenon of a reciprocal relationship between psychosis and seizures, is unlikely to be an exclusively antiepileptic drug-specific phenomenon but rather, linked to the neurobiological mechanisms underlying seizure control. Reevaluation of antiepileptic treatment, including the agent/s being used and degree of epileptic seizure control is recommended. The authors found very few controlled studies to inform evidence-based treatment of psychosis in PWE. However, antipsychotics and benzodiazepines are recommended as the symptomatic clinical treatments of choice for postictal and brief interictal psychoses. The general principle of early symptomatic treatment of psychotic symptoms applies in epilepsy-related psychoses, as for primary psychotic disorders. In the authors' experience, low doses of antipsychotic medications do not significantly increase clinical risk of seizures in PWE being concurrently treated with an efficacious antiepileptic regimen.

"God has sent me to you": Right temporal epilepsy, left prefrontal psychosis

Religious experiences have long been documented in patients with epilepsy, though their exact underlying neural mechanisms are still unclear. Here, we had the rare opportunity to record a delusional religious conversion in real time in a patient with right temporal lobe epilepsy undergoing continuous video-EEG. In this patient, a messianic revelation experience occurred several hours after a complex partial seizure of temporal origin, compatible with postictal psychosis (PIP). We analyzed the recorded resting-state EEG epochs separately for each of the conventional frequency bands. Topographical analysis of the bandpass filtered EEG epochs revealed increased activity in the low-gamma range (30-40Hz) during religious conversion compared with activity during the patient's habitual state. The brain generator underlying this activity was localized to the left prefrontal cortex. This suggests that religious conversion in PIP is related to control mechanisms in the prefrontal lobe-related processes rather than medial temporal lobe-related processes.

Psychoses in epilepsy: A comparison of postictal and interictal psychoses

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

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

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

A change in electrographic activity and blood flow during interictal and postictal psychotic states in a patient with epilepsy

We report a patient with epilepsy who experienced interictal and postictal psychoses. Her psychiatric symptoms consisted of grandiose and fantastic delusions during both psychotic states. During remission, electroencephalography showed bitemporal epileptiform discharges that were predominant in the right temporal region. Epileptiform discharges present during the psychotic states were predominant in the left temporal region. Single-photon emission computed tomography showed hyperperfusion in the left basal ganglia during the interictal psychotic state and hyperperfusion in the right temporal lobe and left basal ganglia during the postictal psychotic state. We suggest that the occurrence of postictal and interictal psychotic states in this patient were associated with a common change in electrographic activity and blood flow.

The relationship between epilepsy and religiosity illustrated by the story of the visionary mystic Wise-Knut

The story of Wise-Knut is remarkable. He was born in a poor mountain district in Norway in 1792 and lived for 84years. He had severe and untreated epilepsy with apparent ictal, postictal, and interictal religious symptoms. He heard voices and had religious delusions; a spiritual awakening after a seizure cluster was a turning point in his life. Contemporary biographers have narrated his major life events in detail, but without a precise separation between ictal and postictal spiritual symptoms. Religious and supernatural significance was attributed to his experiences; he himself believed that his extraordinary abilities were a gift from God: "The prophets have had it like myself." His story corroborates the impression that epilepsy may have had a considerable role in the history of religions. However, apart from anecdotes on visionary and healing abilities, his biographies contain nothing that is miraculous or incredible. He falls into the line of various mystics and religious figures of the past that are currently thought to have had epilepsy. Apparently, the advancing understanding of epilepsy and its complications have influenced the dynamic balance between faith, superstition, and rationalism.

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

OBJECTIVES

Temporal lobe resistant epilepsy has been associated with a high incidence of psychotic disorders; however, there are many controversies; while some patients get better after surgery from their psychiatric condition, others develop psychosis or de novo depression. The aim of this study was to determine the psychiatric and seizure outcome after epilepsy surgery in patients with a previous history of psychoses.

METHODS

Surgical candidates with temporal lobe drug-resistant epilepsy and a positive history of psychosis diagnosed during the presurgical psychiatric assessment were included. A two-year prospective follow-up was determined after surgery. The DSM-IV Structural Interview, GAF (global assessment of functionality, DSM-IV), Ictal Classification for psychoses, and Engel's classification were used. The Student t test and chi-square-Fisher tests were used.

RESULTS

During 2000-2010, 89 patients were admitted to the epilepsy surgery program, 14 patients (15.7%) presented psychoses and were included in this series. After surgery, six patients (43%) did not develop any psychiatric complications, three patients (21%) with chronic interictal psychosis continued with no exacerbation, three patients (21%) developed acute and transient psychotic symptoms, and two patients (14%) developed de novo depression. Seizure outcome was Engel class I-II in 10 patients (71%). Total GAF scores were higher after surgery in patients found to be in Engel class I-II (p<0.05).

CONCLUSIONS

Patients with comorbid psychosis and temporal lobe drug-resistant epilepsy may benefit from epilepsy surgery under close psychiatric supervision.

Homicide during postictal psychosis

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.