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.
For excellent patient education resources, visit eMedicine's Brain and Nervous
System Center. Also, see eMedicine's patient education article Epilepsy.
PSYCHOSIS

Section 3 of 7

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
o Earlier onset of epilepsy
o More severe epilepsy
o 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
o Disturbed family background
o Lack of interpersonal relationships
o Social dependency
o 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.