Interictal acute psychoses in temporal lobe epilepsy during withdrawal of anticonvulsant therapy.

Abstract

S U MM ARY Acute interictal psychotic attacks during withdrawal of medication are described in two patients with temporal lobe epilepsy submitted to depth EEG study with a view to surgical treatment. The patients were on chronic treatment with clonazepam associated in one with phenobarbitone and in the other with phenobarbitone plus carbamazepine. Our observations suggest that the acute withdrawal of clonazepam, the plasma levels of which were monitored, may play a part in producing psychotic attacks characterised by dysphoric manifestations, irritability, aggressiveness, anxiety, and hallucinations. These symptoms could be interpreted as a withdrawal syndrome.A relatively high incidence of psychiatric disorders has been found in patients suffering from temporal lobe epilepsy (Bruens, 1975;Pond, 1975). These psychoses have been classified as psychotic states with and without disturbances of consciousness (Bruens, 1975;Helmchen, 1975).The first condition is a postparoxysmal state (ictal psychosis) characterised by confusion, disorientation, delusion, and hallucination. EEG recording may show generalised spikes, paroxysmal sharp waves, temporal theta and delta waves. Psychotic states with a normal level of consciousness (interictal psychoses) are brief episodic attacks (depressive and dysphoric states) sometimes prolonged by chronic manic-depressive syndromes and paranoid or schizophrenia-like patterns. Interictal epileptic EEG activity may disappear during these episodes ("forced normalisation") (Landolt, 1958). In some patients these attacks alternate with epileptic seizures, the socalled "alternative psychoses" of Tellenbach (1965) andJanz (1969).McDanal and Bolman (1975) and Wolf (1977) have drawn attention to the role of antiepileptic drugs in determining acute epileptic psychoses. They demonstrated that anticonvulsant plasma levels during psychotic attacks may be normal or low and that their aetiology is not necessary toxic,

Acute Postictal Psychosis: A Stereo EEG Study

“…The psychosis was erroneously ascribed to drug discontinuation rather than to recurrent seizures. Similar misinterpretation is found in the report of such cases from another center (Sironi et al, 1979), although their illustrations clearly showed that psychotic behavior followed bouts of seizure. Furthermore, discontinuation of AEDs not leading to clusters of seizures does not lead to psychotic episodes.…”

“…Although chronic interictal psychosis in patients with long-standing epilepsy has been much studied (Slater et al, 1963; Toone, 1981), acute postictal psychosis has received relatively little attention (Levin, 1952; Logsdail and Toone, 1988). It has often been misinterpreted as being the result of drug withdrawal (Demers-Desrosiers et al , 1978;Sironi et al, 1979). Electrographic documentation to separate psychotic disturbance from ictal confusion hitherto has relied mainly on extracranial EEG recording (Ramani and Gumnit, 1982; Logsdail and Toone, 1988).…”

Acute Psychosis During Intracranial EEG Monitoring: Close Relationship Between Psychotic Symptoms and Discharges in Amygdala

“…Therefore, the psychotic episode observed in this patient represents a postictal psychosis from the clinical point of view (2,3). In most cases reported, postictal psychoses were preceded by cessation or reduction of AEDs (5,6), although the cases reported by Logsdail and Toone (2) had postictal psychoses under stable medication. So et al (4) suggested that AED discontinuation may have a contributory role but only insofar as it promotes withdrawal seizures.…”

Postictal Psychosis After Partial Complex Seizures: A Multiple Case Study

“…Discontinuation of AEDs ir itself, when it does not result in partial complex status or in a bout of repetitive seizures, is no1 known to lead to psychosis or to delirium (Duncan et al, 1988). Two reports suggest the contrary; actually, however, all cases of psychosis included in these reports were preceded by bouts of seizures and were thus related only indirectly to reduction of medication (Demers-Desrosiers et al, 1978;Sironi et al, 1979). A recent article by So et al (1990) provides an additional case study of an acute organic delusional syndrome following a cluster of complex partial seizures.…”