Epileptic peri-ictal psychosis, a reversible cause of psychosis.

Neurologia. 2012 Jun 13. [Epub ahead of print]
[Article in English, Spanish]


Servicio de Neurología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España.



Epileptic psychoses are categorised as peri-ictal and interictal according to their relationship with the occurrence of seizures. There is a close temporal relationship between peri-ictal psychosis and seizures, and psychosis may present before (preictal), during (ictal) or after seizures (postictal). Epileptic psychoses usually have acute initial and final phases, with a short symptom duration and complete remission with a risk of recurrence. There is no temporal relationship between interictal or chronic psychosis and epileptic seizures. Another type of epileptic psychosis is related to the response to epilepsy treatment: epileptic psychosis caused by the phenomenon of forced normalisation (alternative psychosis), which includes epileptic psychosis secondary to epilepsy surgery. Although combination treatment with antiepileptic and neuroleptic drugs is now widely used to manage this condition, there are no standard treatment guidelines for epileptic psychosis.


We present 5 cases of peri-ictal epileptic psychosis in which we observed an excellent response to treatment with levetiracetam. Good control was achieved over both seizures and psychotic episodes. Levetiracetam was used in association with neuroleptic drugs with no adverse effects, and our patients did not require high doses of the latter.


Categorising psychotic states associated with epilepsy according to their temporal relationship with seizures is clinically and prognostically useful because it provides important information regarding disease treatment and progression. The treatment of peri-ictal or acute mental disorders is based on epileptic seizure control, while the treatment of interictal or chronic disorders has more in common with managing disorders which are purely psychiatric in origin. In addition to improving the patient’s quality of life and reducing disability, achieving strict control over seizures may also prevent the development of interictal psychosis. For this reason, we believe that establishing a treatment protocol for such cases is necessary.

Copyright © 2010 Sociedad Española de Neurología. Published by Elsevier Espana. All rights reserved.


Schizophrenia-like psychosis and epilepsy: the status of the association.

Am J Psychiatry. 1998 Mar;155(3):325-36.


Neuropsychiatric Institute, Prince Henry Hospital and School of Psychiatry, University of New South Wales, Sydney, Australia.



Current knowledge of the relationship between epilepsy and schizophrenia-like psychosis is examined, and the proposed pathogenetic mechanisms are evaluated.


The author provides an overview of the published literature on epilepsy and schizophrenia-like psychosis.


The schizophrenia-like psychoses of epilepsy are inadequately categorized by the current classifications. Their categorization into ictal, postictal, and interictal psychoses is clinically useful, but it does not imply distinct pathophysiology for each. The recent interest in postictal psychoses has opened an important avenue for research. Brief interictal psychoses, involving alternation between epilepsy and psychosis and accompanied by forced normalization, are uncommon. Many aspects of the relationship with chronic interictal psychosis remain controversial. The majority of investigators support a special but not exclusive relationship with mediobasal temporal lobe epilepsy, and left temporal bias receives only limited support. The chronic psychosis resembles schizophrenia phenomenologically. Some suggested risk factors are severe and intractable epilepsy, epilepsy of early onset, secondary generalization of seizures, certain anticonvulsant drugs, and temporal lobectomy. Different neuropathological studies suggest the presence of cortical dysgenesis or diffuse brain damage.


There are many mechanisms by which epilepsy may be associated with schizophrenia-like psychosis. It is likely that structural brain abnormalities, e.g., cortical dysgenesis or diffuse brain lesions, underlie both epilepsy and psychosis, and that the seizures modify the presentation of the psychosis, and vice versa, thus producing a clinical picture of both an affinity and an antagonism between the two disorders.

[PubMed – indexed for MEDLINE]

Rasmussen’s encephalitis

Uploaded by on Feb 18, 2011

At the age of just three, six-year-old Cameron Mott developed a devastating and progressive brain disorder called Rasmussen’s encephalitis. This rare disease attacks the right side of the sufferer’s brain, causing a rapid decline in mental faculties and, if left untreated, eventually leading to partial paralysis. Cameron’s condition has left her with extreme epilepsy. Her daily life is plagued by sudden and frequent fits forcing her to wear a protective helmet at all times. She is only free from the fits for a precious 30 minutes at the beginning of every day, before she collapses and falls victim once more to the relentless cycle of seizures.

Uploaded by on Feb 18, 2011

Part 2

Ethosuximide-induced mania in a 10-year-old boy.

Epilepsy Behav. 2011 Aug;21(4):483-5.


Psychosis and suicidal ideation have been reported as side effects of ethosuximide treatment, but previous reports seldom place these symptoms in the context of mania. Given the recent renewed interest in ethosuximide as first-line therapy in children and adolescents, it is important for clinicians to be aware of the potential psychiatric complication of mania with this medication. Described here is the case of a 10-year-old boy who developed acute mania, as well as psychotic symptoms and suicidal ideation, on ethosuximide.

Copyright © 2011 Elsevier Inc. All rights reserved.

Misdiagnosis of epileptic seizures as manifestations of psychiatric illnesses.

Can J Neurol Sci. 2011 May;38(3):487-93.

Mirsattari SM, Gofton TE, Chong DJ. SourceDepartment of Clinical Neurological Sciences, The University of Western Ontario, London, Ontario, Canada Department of Medical Biophysics, The University of Western Ontario, London, Ontario, Canada Department of Medical Imaging, The University of Western Ontario, London, Ontario, Canada Department of Psychology, The University of Western Ontario, London, Ontario, Canada.

Abstract Background: Epileptic seizures may be misdiagnosed if they manifest as psychiatric symptoms or seizures occur in patients with known psychiatric illness. Methods: We present clinical profiles of six patients with epilepsy (three male, mean age 39 ± 12 years) that presented with prominent psychiatric symptoms. Results: Two patients had pre-existing psychiatric illnesses.

Three patients were initially diagnosed with panic attacks, two with psychosis, and one with schizophrenia. Five patients had temporal lobe epilepsy (TLE) while the sixth patient was subsequently found to have absence status epilepticus (SE). Cranial computed tomogram (CT) including contrast study was unremarkable in five patients and showed post-traumatic changes in one patient. Cranial magnetic resonance imaging (MRI) revealed dysembryoplastic neuroepithelial tumour (DNET) in one patient, cavernous hemangioma in one, and post-traumatic changes plus bilateral mesial temporal sclerosis in another patient but it was normal in two TLE patients.

Routine electroencephalography (EEG) revealed absence SE in one patient but it was non-diagnostic in the TLE patients. Video-EEG telemetry in the epilepsy monitoring unit (EMU) was necessary to establish the diagnosis in four TLE patients. None of the patients responded to medications aimed at treating psychiatric symptoms alone. Two patients required surgery while the other four required treatment with anti-epileptic drugs. All the patients had favorable response to the treatment of their epilepsy.

Conclusions: This case series illustrates that epileptic patients may experience non-convulsive seizures that might be mistaken as primary psychiatric illnesses. In this subset of patients, evaluation by an epileptologist, MRI of the brain, and/or video-EEG telemetry in an EMU was necessary to confirm the diagnosis of epilepsy if routine EEGs and cranial CT are normal. PMID: 21515510 [PubMed – in process]

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