Forced Normalization: Clinical and Therapeutic Relevance

Abstract

Summary:The phenomenon of forced normalization and its clinical counterpart, alternative psychoses, is discussed. The historical origins are briefly noted before the clinical presentation, and some associated clinical findings are given. The main part of the article is devoted to the literature on chemical and electrical kindling, in an attempt to provide some heuristic model to understand the antithetical relationship between seizures and behavior disorders. We conclude that the use of the kindling model may provide further insights into these phenomena, particularly taking into account such key neurotransmitters as glutamate, dopamine, and GABA.

Enhancement of Central Dopaminergic Activity in the Kainate Model of Temporal Lobe Epilepsy: Implication for the Mechanism of Epileptic Psychosis

“…The prevalence of this epileptic psychosis appears to be about 7-11%, which is much higher than in the general population (McKenna et al, 1985;Trimble, 1991;Torta and Keller, 1999). Since in some patients with epileptic psychosis there is an inverse correlation between the presence of epilepsy and the psychosis, this phenomenon has been labeled 'forced normalization' or 'alternative psychosis' (see review of Krishnamoorthy and Trimble, 1999). Slater et al (1963), on the other hand, reported that the emergence of epileptic psychosis was related to the duration of epilepsy and to brain damage, and was linked to temporal lobe epilepsy (TLE).…”

“…Another hypothesis is that enhanced activity of the mesolimbic dopamine (DA) system is responsible for the development of epileptic psychosis (Trimble, 1977;Krishnamoorthy and Trimble, 1999). In experimental studies, kindling-induced chronic epileptogenesis produced longlasting hypersensitivity to direct or indirect DA agonists (enhancers of DA release), such as apomorphine (Post et al, 1981;Csernansky et al, 1988a), methamphetamine (MAP, Sato, 1983), and amphetamine (Leung et al, 2000).…”

Chronic (Interictal) Psychosis and Phenomenon of Forced Normalization: Case Report

“…Olgu lar da, psi koz ve di ğer psi ki yat rik be lir ti ler or ta ya çık tı ğın da bi lin cin açık ol du ğu be lir til mek te dir. 6,12 Kli nik gi di şin ge nel de iyi ol du ğu, ken di li ğin den dü ze le bil di ği gi bi epi lep tik bir nö bet ta ra fın dan da son lan dı rı la bil di ği, nö bet ler ve ya elek tro en se fa logra fi bul gu la rı ye ni den or ta ya çık tı ğın da psi ki yat rik be lir ti le rin kı sa sü re de dü zel di ği bil di ril miş tir. 12 Has ta la rın çok az bir kıs mın da sü re ğen psi koz ge lişe bi lir.…”

“…Bu fe no men de bil di ri len psi kiyat rik has ta lık lar ço ğun luk la psi koz lar dır. 6 Genellikle kı sa psi ko tik bo zuk luk sek lin de ken di ni gös ter mek te dir. Sü re ğen psi ko zun sey rek gö rül dü -ğü bil di ril mek te dir.…”

Psychic Seizures and Their Relevance to Psychosis in Temporal Lobe Epilepsy

“…Some anticonvulsant drugs like topiramate and zonisamide are evidently more prone to induce psychiatric disturbances than others, while there has been a general concept of "forced normalization" that means the reciprocal appearance of psychotic disorders when the patient's seizures were inhibited by any drugs (Krishnamoorthy & Trimble, 1999).…”