Both neurology and psychiatry deal with diseases of the same organthe brain

Both neurology and psychiatry deal with diseases of the same organthe brain. Predicting interaction between neurologic and psychiatric diseases is not, therefore, unreasonable. In an editorial in the journal Neurology in 2000, Price, Adams, and Coyle explored these interactions. The clinical relationship between epilepsy and behavioral disorders remains controversial.

Some authors find a greater incidence of behavioral disorders in patients with epilepsy than in the general population. Other authors argue that this apparent overrepresentation is due to sampling errors or inadequate control groups. Mechanisms for such a relationship include the following:

Common neuropathology

Genetic predisposition

Developmental disturbance

Ictal or subictal neurophysiological effects

Inhibition or hypometabolism surrounding the epileptic focus

Secondary epileptogenesis

Alteration of receptor sensitivity

Secondary endocrinologic alterations

Primary, independent psychiatric illness

Consequence of medical or surgical treatment

Consequence of psychosocial burden of epilepsy

Because of the phenomenology of epilepsy, the close association between epilepsy and psychiatry has a long history. The traditional approach to epilepsy care has been to focus on the seizures and their treatment. Concentrating only on the treatment of the seizures, which occupy only a small proportion of the patient's life, does not seem to address many of the issues that have an adverse impact on the quality of life of the patient with epilepsy. Sackellares and Berent stated that comprehensive care of the epileptic patient requires "...attention to the psychological and social consequences of epilepsy as well as to the control of seizures."

Although undoubtedly important in the care of the patient with epilepsy, advances in neurologic diagnosis and treatment tended to obscure the behavioral manifestations of epilepsy until Gibbs drew attention to the high incidence of behavioral disorders in patients with temporal lobe epilepsy. Agreement now is general that the incidence of neurobehavioral disorders is higher in patients with epilepsy than in the general population. Many, but not all, authors also accept the proposition that the link between neurobehavioral disorders and temporal lobe or complex partial epilepsy is particularly strong. Edeh and Toone asserted that the difference is between focal epilepsies, both temporal lobe and nontemporal lobe, and primary generalized epilepsy.

Vuilleumier and Jallon estimated that 20-30% of patients with epilepsy have psychiatric disturbances. Tucker reported that one study found that 70% of patients with intractable complex partial seizures had one or more diagnoses consistent with Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R)58% had a history of depressive episodes, 32% had agoraphobia without panic or other anxiety disorder, and 13% had psychoses. Torta and Keller reported that the risk of psychosis in populations of patients with epilepsy may be 6-12 times that in the general population, with a prevalence of about 7-8% (in patients with treatment-refractory temporal lobe epilepsy, the prevalence has been reported to range from 0-16%). Differences in the rates may result from differences in populations studied, time periods investigated, and diagnostic criteria.

The psychiatric symptoms characteristic of the neurobehavioral syndrome of epilepsy (ie, Morel syndrome) tend to be distinguished in the following ways:

Atypical for the psychiatric disorder

Episodic

Pleomorphic

In studying the relationship between epilepsy and psychiatric disorders, care must be taken to differentiate between the following:

Psychiatric disorders caused by the seizures of the epilepsy - Ictal disorders, postictal disorders, and interictal disorders

Epileptic and psychiatric disorders caused by common brain pathology

Epileptic and psychiatric disorders that happen to coexist in the same patient but are not causally related

Schmitz et al found that multiple interacting biological and psychosocial factors determine the risk for development of either schizophreniform psychoses or major depression in patients with epilepsy and concluded that behavioral disorders in epilepsy had multiple risk factors and multifactorial etiology.

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PSYCHOSIS Section 3 of 7

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Author Information Introduction Psychosis Mood Disorders Anxiety Disorders Personality Disorders Bibliography

Vuilleumier and Jallon found that 2-9% of patients with epilepsy have psychotic disorders. Perez and Trimble reported that about half of epileptic patients with psychosis could be diagnosed with schizophrenia. Kanner stated that various classifications have been proposed for the psychoses associated with epilepsy. He asserted that, for the neurologist, the most useful might be that which distinguishes among psychoses closely linked to seizures (ictal or postictal psychosis), those linked to seizure remission (alternative psychosis), psychoses with a more stable and chronic course (such as interictal psychosis), and iatrogenic psychotic processes related to anti-epileptic drugs.

Ictal events: Status epilepticus (ie, complex partial status epilepticus and absence status epilepticus) can mimic psychiatric disorders, including psychosis.

Postictal events: So and colleagues distinguished between postictal psychosis, which is characterized by well-systematized delusions and hallucinations in a setting of preserved orientation and alertness, and postictal confusion, and also between self-limited postictal psychosis and the unremitting chronic interictal psychosis seen in long-standing epilepsy. Criteria proposed by Stagno for postictal psychosis include the following:

Psychotic or other psychiatric symptoms occur after a seizure or, more frequently, a series of seizures, after a lucid interval or within 7 days of the seizure(s).

The event may be psychosis, depression or elation, or an anxiety-related symptom.

The event is time limited, lasting days and rarely weeks. No significant clouding of consciousness occurs. Logsdail and Toone believe that clouding of consciousness, disorientation, or delirium may be noted and, if consciousness is unimpaired, delusions and hallucinations are present; a mixture of both also may be noted. Clouding should not be attributable to other medical or psychiatric cause (eg, drug intoxication, complex partial status epilepticus, metabolic disturbance).

Interictal psychosis: Tandon and DeQuardo reviewed the series of patients with epilepsy who developed psychosis published by Slater and Beard and found that the psychosis was usually a form of schizophrenia, most commonly paranoid schizophrenia. Stagno reported that persistent interictal psychoses of epilepsy and the "schizophrenia-like psychoses of epilepsy" are distinguishable from schizophrenia in the traditional psychiatric sense by the following:

Lack of negative symptoms of schizophrenia, particularly flattening of affect and personality deterioration

Better premorbid personality

Paranoid delusions

Delusions of reference

More benign and variable course

Risk factors for developing psychosis in epilepsy that have been found in some studies (for more details see the bibliographic entries by Trimble and Schmitz) include the following:

Partial complex seizures, especially with temporal lobe foci: Some authors have noted a predominance of left-sided foci. Frontal lobe epilepsy is also common.

The presence of "alien tissue" (eg, small tumors, hamartomas)

Mesial temporal lobe gangliogliomas

Left-handedness, especially in women

Schmitz et al studied risk factors and classified them by the following system:

Biological factors

Earlier onset of epilepsy

More severe epilepsy

More frequent temporal lobe and unclassifiable epilepsies and less frequent generalized epilepsies: No significant differences in types of epilepsies between patients with epilepsy and psychosis and patients with epilepsy without psychiatric disease have been found.

Psychosocial factors

Disturbed family background

Lack of interpersonal relationships

Social dependency

Professional failure

Trimble and Schmitz (1998) believe that the conclusions presented in the literature on risk factors are highly controversial.

Treatment Status epilepticus and ictal abnormalities are treated in the same way as nonpsychiatric epileptic events. Postictal events are treated by improving seizure control. So et al believe that postictal psychosis remits spontaneously even without treatment but the use of effective neuroleptics may shorten the duration.

Interictal psychosis is treated with antipsychotic drugs. Medications that lower seizure threshold should be avoided. Some studies indicate that risperidone, molindone, and fluphenazine may have better profiles than older antipsychotic medications; clozapine has been reported to confer a particularly high risk of seizures.

Tarulli et al (2001) have documented cases of patients who had multiple episodes of postictal psychosis before developing interictal psychosis. They concluded that a progression from postictal to interictal psychosis may be at play and that increased awareness and prompt treatment of postictal psychosis may inhibit or prevent development of some instances of interictal psychosis.

Treatment of any of the psychoses of epilepsy should take into consideration the phenomenon termed as forced normalization, which is a concept described by Landolt in the 1950s. When the EEG in psychotic patients is normalized, often with anticonvulsant medicines, the psychiatric problem worsens. Alternative psychosis, or antagonism between seizures and behavioral abnormalities (ie, worsening of behavior with improvement in seizure control) is a similar phenomenon that has been known for a longer time. Forced normalization frequently is described in patients treated with ethosuximide; anecdotally, however, forced normalization effects have been produced by treatment with most antiepileptic agents, including the newer agents. The mechanism underlying these interesting phenomena is not yet understood. Many authors consider the idea of forced normalization to be somewhat controversial.