Neurology -- Correspondence for Kanner et al., 62 (5) 708-713

Correspondence published:

Prevalence and clinical characteristics of postictal psychiatric symptoms in partial epilepsy: Mario Tombini, Loredana Pacifici, Florinda Ferreri and Paolo M. Rossini (20 May 2004)

Reply to Tombini et al: Andres M. Kanner, Arnoldo Soto, Hilary Gross-Kanner (20 May 2004)

Prevalence and clinical characteristics of postictal psychiatric symptoms in partial epilepsy 20 May 2004

Mario Tombini,
Clinica Neurologica, Università Campus Bio-Medico, Rome -Italy
Via dei Compositori, 130-132 , 00128 Trigoria - Rome, Italy,
Loredana Pacifici, Florinda Ferreri and Paolo M. Rossini
Send Correspondence to journal:
Re: Prevalence and clinical characteristics of postictal psychiatric symptoms in partial epilepsy

m.tombini{at}unicampus.it Mario Tombini, et al.

We read with interest the paper by Kanner et al [1] on postictal psychiatric symptoms (PPS) in patients affected by refractory partial epilepsy presenting as single or clusters of symptoms. Those symptoms mimic those of an anxiety, depressive, or psychotic acute disorder. [2]
We report the case of a 58-year-old male affected by complex partial seizures resistant to antiepileptic drugs. He had a prior history of febrile seizures with focal signs (right hemiparesis). Since the age of 29, he had temporal lobe epilepsy. At the time of our observation, he suffered from about six seizures per month despite treatment with carbamazepine (1200 mg/day) and lamotrigine (300 mg/day). MRI revealed a left hippocampal sclerosis.
Upon admission, he was polite which matched the description given by the referring physician. During a prolonged video-EEG monitoring (16- channels system), we observed a complex partial seizure with motor arrest and staring followed by oroalimentary automatisms and autonomic symptoms lasting about 1 minute. Electroencephalographic recordings showed epileptic activity starting from the left anterior temporal region characterized by low-amplitude fast activity, early spreading to contralateral regions and then to all the scalp recording electrodes. The ictal symptoms were followed by postictal confusion lasting about 3-4 minutes, corresponding to a moderate increase in the interictal left fronto-temporal epileptiform activity.
After this post-ictal confusion period, his behavior abruptly changed and was characterized by anxiety, depression and hypomaniac symptoms. He became agitated, rude and worried about his health. He refused further exams and quarreled loudly with technicians and nurses. EEG recording during this period showed a reduction in the interictal epileptiform activity up to nearly complete normalization.
The next day he was again polite and apologized for his previous behavior. PPS remained unclear with respect to their pathogenesis. In our case report, clinical features of PPS and their appearance shortly after postictal confusion without lucid interval led us to consider a possible hypothesis equivalent to a “Todd paralysis” engaging structures in the limbic system and prefrontal cortex. These regulate the emotional status and behavior or a “forced normalization-like” mechanism as observed in patients rapidly becoming seizure-free after introduction of a successful anti-epileptic treatment. [3]
The patient reported episodes of “nervousness and irritability” as causing trouble in his personal relationships. As previously reported (2,4), PPS are very disabling for patients and their families, often more than ictal symptoms. The prompt recognition of PPS could lead to appropriate treatment with low-dose neuroleptic drugs.
References
1. Kanner AM, Soto A, Gross-Kanner H. Prevalence and clinical characteristics of postictal psychiatric symptoms in partial epilepsy. Neurology 2004;62:708-713.
2. Kanner AM, Stagno S, Kotagal P, Morris HH. Postictal psychiatric events during prolonged video-electroencephalographic monitoring studies. Arch Neurol 1996;53:258-263.
3. Krishnamoorthy ES, Trimble MR, Sander JWAS, Kanner AM. Forced normalization at the interface between epilepsy and psychiatry. Epilepsy & Behavior 2002; 303-308.
4. Vickrey BG, Berg AT, Sperling MR, et al. Relationship between seizure severity and health related quality of life in refractory localization related epilepsy. Epilepsia 2000;41:760-764.

Reply to Tombini et al 20 May 2004

Andres M. Kanner,
Rush University Medical Center
1653 West Congress Parkway, Chicago, Illinois 60612,
Arnoldo Soto, Hilary Gross-Kanner
Send Correspondence to journal:
Re: Reply to Tombini et al

akanner{at}rush.edu Andres M. Kanner, et al.

We thank Dr. Tombini et al who report the case of a patient who, during a video-EEG monitoring study, had postictal behavioral changes that consisted of a cluster of symptoms including depression, anxiety, irritability and hostile behavior. The patient also had significant concerns about his health that appeared to reach delusional-like proportions. These symptoms lasted 24 hours and led him to request that his evaluation be stopped. He also had recurrent sudden and unpredictable changes in his personality that had resulted in interpersonal problems. This case exemplifies the behavioral changes we described in our article [1] and illustrates the pleomorphic presentation of postictal psychiatric events with more than one type of psychiatric symptoms and the negative impact that these events have on their quality of life.
The pathogenic mechanisms operant in the development of postictal psychiatric symptoms is still unclear. Dr. Tombini appropriately questions whether they may reflect a phenomenon equivalent to a Todd’s paralysis, in which “latent” interictal psychiatric disturbances surface during the postictal period. We suggested that hypothesis in our paper based on the observation of an exacerbation of interictal psychiatric symptoms during the postictal period and the significant association between the occurrence of certain types of postictal psychiatric symptoms and a past psychiatric history. [1]
However, this hypothesis does not account for all cases. The sudden changes in personality described in Dr. Tombini’s case appear to be the expression of postictal symptoms but this is not explicitly stated and no evidence of past “interictal” psychiatric disorders is reported.
Dr. Tombini raises the possibility of whether his patient’s postictal behavioral changes may be the expression of a “forced normalization-like” phenomenon, given the absence of epileptiform activity during the symptomatic period. I do not think that is the case because the duration of the psychiatric symptoms is rather short and, in forced normalization, the onset of psychiatric symptoms usually occurs after a seizure-free period. [2]
References
1. Kanner AM, Soto, A, Gross-Kanner HR. Prevalence and clinical characteristics of postictal psychiatric symptoms. Neurology, 2004; 62:5:708-713.
2. Pakalnis A, Drake JK, Kellum JB. Forced normalization: acute psychosis after seizure control in seven patients. Arch Neurol, 1987; 44:289-292.