Chapter41

Ictalandpostictalpsychiatricdisturbances
MICHAELR.TRIMBLE InstituteofNeurology,UniversityCollege,London,NationalHospitalfor NeurologyandNeurosurgery,QueenSquare,London,andNationalSocietyfor Epilepsy,ChalfontStPeter,Bucks

Thetrueincidenceandprevalenceofpsychiatricdisordersinpeoplewithepilepsyis not known, with most studies carried out in referral centres or conducted retrospectively.However,noonewholooksafterpatientswithepilepsycandoubta direct link between psychopathology and epilepsy when it comes to the ictally relatedbehaviourchanges. Traditionally,psychiatricdisturbancesinepilepsyhavebeenclassifiedintothose thatareperiictal,andthosethatareinterictal.Thelatterareintheoryunrelatedin timetoanyseizureoccurrence.Periictaldisturbancesincludepreictaldysphorias, ictalsyndromesofdepressionandpsychosis,andpostictalsyndromes.Inclinical andeventheoreticalpracticethetermperiictalispreferredandisoftenusedto defineexactlywhatismeantbyaseizure,todeterminewhenaseizureends,andto determinewhattheelectrophysiologicalcomponentsofthepostictalstateare. Using traditional psychiatric nomenclature, this review will discuss periictal affectiveandpsychoticdisorders. Affectivedisorder Preictal depression. Prodromal moods of depression and irritability that occur hoursordaysbeforeaseizure,andwhichmayberelievedbytheconvulsion,are well known. Patients tend to report more depression on the days immediately preceding their seizures than on interictal days. The length of the preictal dysphoriacanlastfromtenminutestoseveraldays. Ictaldepression. Depressivemoodscanoccuraspartofanaura,rarely(about1%), andaremorecommoninwithpatientswithtemporallobeepilepsy.Typicallythey are of sudden onset and can range in severity from mild sadness to profound helplessnessordespair.Noclearlateralityeffecthasbeennoted. Postictal depression. Postictal depression is not uncommon although its prevalencehasneverbeenestimated.Itcanlastfromhourstodaysandhasfeatures typicalofadepressivesyndrome.Thedensityofthedepressioncanbeseverewith some patients expressing suicidal thoughts. Suicide itself is not common unless associated with psychotic thinking (see below). Again, no laterality effect has

consistently been reported. There are a group of patients in whom postictal depressioncontinuesintoaprolongeddepressiveillnessandisessentiallyaninter ictaldepressionthatrequiresantidepressanttreatment. In many settings, postictal depression accompanies the existential despair of patientswhohaveintractableseizures,althoughbiologicalcomponentsareclearly contributory,asaredrugrelatedeffects. Anxietydisorders Ictalfearandanxietyhavebeendescribedandcanbemistakenforpanicdisorder. Conversely,panicdisorderisoftenmisdiagnosedasanepilepticdisorder,especially iftherearenonspecifictemporallobeepileptiformEEGabnormalitiesorthereisa historyofepilepsy.Ingeneral,ictalanxietyorfearisusuallyverystereotyped,with arapidonsetandofshorterdurationthanpanicattacks.Patientswithpanicattacks oftenreportsymptomssuchasstaringblanklyintospace,orbeingoutoftouchwith theirenvironment,whilepatientswithtemporallobeepilepsyoftenrevealevolution ofthesimplepartialseizureintoacomplexpartialseizurewithsomeconfusionand disturbanceofconsciousnessandautomatisms. Postictal anxiety, like postictal depression, is not uncommon. Often it is biologically driven, as a feature of the temporal lobe syndrome, but it is also intertwinedwithfearofhavingfurtherseizures,andthelossofconfidencethatgoes withseizuresinpatientswithintractableepilepsy.Aselfreinforcingsituationcan occurinwhichapatient,onaccountofseizures,isfearfulofleavingthehousein case theyhaveaseizure,theybecome anxious andhyperventilate, andthiscan increasethechancesofhavingfurtherseizures. Periictalpsychoses Ictalpsychoses. Psychoticsymptomswhichoccurasadirectreflectionoftheictus becomeprolongedincasesofnonconvulsivestatusepilepticus,wheretheEEG revealsthediagnosis.UsuallyEEGstudiesperformedduringgeneralised(absence) statusshowgeneralisedbilateralsynchronousspikeandwaveactivity,between14 Hz. With complex partial seizure status, the EEG may show focal or bilateral epileptiformpatternswithaslowingofthebackground.Inthesestates,awiderange ofpsychopathologymaybeseen,includingamixtureofaffectiveandperceptual experiences,accompaniedbyautomatisms,andfluctuatingimpairedconsciousness. Amnesiawouldusuallyfollowtheepisode. Twotypesofcomplexfocalstatusepilepticusaredistinguished,acontinuousform and a discontinuous orcyclical form.Thelatter consistsoffrequentlyrecurring complex partial seizures. In between the seizures patients may or may not experiencesimplefocalseizuresymptoms,andconsciousnessmayrecovertonear normalstates.

Asimplefocalstatus,orauracontinua,mayleadtocomplexhallucinations,thought disorderandaffectivesymptoms.Insuchcases,thecontinuousepilepticactivityis oftenrestricted,andmaynotevenbedetectedwithEEGrecordings. Inanictallydrivenpsychosis,theclinicalpicturemayrevealfluctuatinglevelsof consciousness,andarangeofparanoidandschizophrenialikesymptoms. Postictalpsychosis.Thishastobedistinguishedfromthedeliriawhichoccurpost ictally. In the latter, patients may often appear confused for up to 30 minutes followingaseizure.Theyalsosometimesreporthallucinationsbutrarelydelusions. Thisisanorganicbrainsyndromewhichusuallyresolvesspontaneously,butduring whichtimethepatientmaybecomecombativeandmayneedsubtlerestraint. The most common and best investigated periictal psychosis, however, is that occurringpostictally withasmanyas18%ofpatients withintractableseizures reportedasexperiencingoneormoreevent. Theoperationalcriteriaforpostictalpsychosisareasfollows: 1. Onsetofconfusionalpsychosiswithinaweekofthereturnofapparentlynormal mentalfunction 2. Durationofbetweenonedayandthreemonths 3. Amentalstatecharacterisedbya)cloudingofconsciousness,disorientationor delirium;b)delusions,hallucinationsinclearconsciousness;c)amixtureofa andb 4. Noevidence offactors whichmayhavecontributed tothe abnormal mental state:a)anticonvulsanttoxicity;b)aprevioushistoryofinterictalpsychosis;c) EEGevidenceofstatusepilepticus;d)recentheadinjury,oralcoholordrug intoxication. ThemostquotedseriesisthatofLogsdailandToone(1988)whodescribed14 patients,themajoritywithcomplexpartialseizuresandsecondarygeneralisation,in whomthepsychosisdevelopedafteranexacerbationoftheseizureactivity,usually followingaclusterofseizures. Mosthadalucidintervalofupto12days,butsometimeslonger,betweenthe restoration of an apparently normal mental state following the seizure, and the beginningofthepsychosis.TheEEGduringthepostictalpsychosisisvariable, sometimes appearing relatively normal, in others showing an increase in abnormalities. Therangeforthelengthofthepsychosiswasupto90days,andmanypatients requiredpsychotropicmedication.

In their series, Logsdail and Toone followed patients for up to eight years and observedthatthepsychosistendedtorecur.About20%ofpatientswillgoonto developachronicpsychosisovertime. Ofmostinterestisthelucidintervalbetweenthecessationoftheseizuresandthe onsetofthepsychosis.Relativesoftendescribethisasthecalmbeforethestorm. The psychosis, when it emerges, can be sudden and the behaviour can be extravagant. Typically, hallucinations and delusions are noted; prominent are persecutoryandreligiousphenomena.Mostpatientshaveatleastpartialrecallfor their psychotic experiences, and because the mental state is often not one of confusion,suicidalideas,whichoccurinaboutonefifthofpatients,maybeacted upon.Welldirectedviolentattacksareseeninabout25%ofepisodes. Treatment of ictally related psychiatric disorders. A number of the psychopathologiesdiscussedaboveareselflimiting,oftenwithnodirectpsychiatric intervention required. The most problematic states are the postictal psychoses whichcangoonseveraldays.Sincethesepatientscanbecomesuicidalandexpress paranoid delusions of considerable intensity, it is often important to prescribe psychotropicmedication.Generally,itisbettertoavoidneuroleptics ifpossible, since they can lower the seizure threshold leading to further seizures and exacerbation of the psychosis. In the first instance, benzodiazepines are recommended. Clobazam can be used either to abort a cluster of seizures, by administeringitimmediatelyaftertheinitialseizureofacluster,orafteracluster, withthefirstwarningofanypsychopathology.Relativesgettoknowthewarning signs, which include irritability, sensitivity, mood lability and sleeplessness. If neuroleptic medications are to be used, those that lower the seizure threshold minimallyaretobepreferred.Theseincludehaloperidol,sulpirideandrisperidone. Obviously,crucialtothepreventionofpostictalpsychosisisbettercontrolofthe seizures.Postictalpsychosesoccurringinthesettingofunilateraltemporallobe pathologyarenotacontraindicationforepilepsysurgery. Forcednormalisation Finally,inconsideringpsychopathologicalstatesthatseemlinkedtoseizures,the conversestate,whereapsychopathologyemerges whenseizures aresuppressed, needstobeincluded. ItwasLandoltwhonotedthatcertainpatientsbecamepsychoticwhenprescribed antiepilepticdrugs(AEDs)whichsuppressedtheirseizures.Duringtheperiodof psychosistheEEGparadoxicallynormalised,losingitsepilepticfeatures.Withthe return of seizures, the EEG became abnormal again and the psychosis would resolve.Landoltusedthetermforcednormalisationtodescribethisphenomenon. Paradoxicalnormalisationisanotherterm.TheseareEEGterms;theaccompanying clinical picture is better referred to as alternative psychosis, a name given by Tellenbach.ItisnowacknowledgedthatduringthesestatestheEEGdoesnothave tofullynormalise,orseizurescompletelycease.

These phenomena have become more frequent in recent times following the introductionofpowerfulAEDswhicharegiventopatientswithintractableseizures, and can render them seizure free. The clinical pictures vary from paranoid psychoses resembling schizophrenialike states, to episodes of irritability and conductdisturbanceinchildren,topresentationswithnonepilepticseizures.The majorityofcases,however,areproductiveparanoidstates,andrequireintervention. Affectivesymptomsarefrequentlyintermingledwiththepsychoticsymptoms. TreatmentiseitherbyremovaloftheAEDwiththeresumptionofseizures,orby neuroleptic or antidepressant medication, depending upon the clinical picture. Patients who have had an episode of alternative psychosis with one drug are susceptibletohavingitagainwithotherdrugs.Inthesecasesitisadvisabletostart anynewdrugatloworaldosesandincreasethedoseslowly,askingthepatientor relativetoreportanydevelopingpsychopathology. Furtherreading

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