Antiepileptic-Induced Psychosis as a Possible Predictor of Post-Temporal Lobectomy Alternative Psychosis

By Benedict, F.; Lim, K. S. et al. | East Asian Archives of Psychiatry, September 2016 | Go to article overview

Antiepileptic-Induced Psychosis as a Possible Predictor of Post-Temporal Lobectomy Alternative Psychosis


Benedict, F., Lim, K. S., Jambunathan, S. T., Binti Hashim, A. Hanim, East Asian Archives of Psychiatry


Introduction

Epilepsy is a chronic and debilitating disease. Surgery in the form of lobectomy is often sought for patients in whom conventional antiepileptic treatment fails. Indeed, temporal lobectomy has become a recognised treatment for resistant epilepsies with remission rates post-lobectomy reported to be as high as 60 to 70%.' Nonetheless, lobectomies are not without consequences. With the reduction in or complete disappearance of seizures, other complications arise, particularly major neuropsychiatric complications such as psychosis, depression, and anxiety. A large prospective study reported that patients who underwent temporal lobectomy for refractory epilepsy developed depression (22.1%) or anxiety (24.7%) postoperatively2 and could even develop schizophrenia-like psychosis.3 The mechanism of post-lobectomy psychosis has been postulated to be through alternative psychosis, whereby psychosis emerges after the seizures have been well controlled.4 Alternative psychosis, first described by Tellenbach,5 describes the clinical phenomenon of a reciprocal relationship between seizures and psychosis, without relying on electroencephalogram (EEG) findings. A similar concept, proposed by Landolt,6 is known as forced normalisation whereby the remission of seizures and absence of epileptiform activity on the EEG leads to psychotic episodes.7 Clearly, consideration of predictors of postoperative psychiatric morbidity is vital as such neuropsychiatric complications, particularly psychosis, can be debilitating. Among the predictors that have been reported are preoperative psychiatric disease, laterality of seizure focus, and age at the time of surgery.8 It is hypothesised that preoperative psychiatric disease, particularly depression, is indicative of more diffuse cerebral disease and worse seizure control.9 Nonetheless, little is known of antiepileptic-induced psychosis as a predictor of post-lobectomy psychosis.

To the best of our knowledge, this is the first case report to detail a patient who suffered from antiepileptic drug (AED)-induced psychosis pre-morbidly, and later developed post-lobectomy psychosis, with alternative psychosis as the likely underpinning mechanism.

Case Presentation

A 36-year-old female had suffered from epilepsy since 6 years of age. She had 2 to 3 seizures per day. Seizures started with blank staring and oral automatisms, with left upper limb dystonia and right head deviation. This was accompanied by drooling, up-rolling of the eyeballs, and postictal drowsiness for approximately 30 minutes. She had been suffering from epilepsy since childhood, but was only formally diagnosed in 2002 at the age of 23 years. Surgery to reduce the occurrence of seizures was suggested but she declined. With time, the frequency of seizures decreased to 2 to 3 times a week. She was initially prescribed carbamazepine and phenytoin, but later changed to levetiracetam as her seizures were not abating. Levetiracetam was stopped and she was then switched to topiramate. Two weeks after commencement of topiramate, the patient started to experience auditory and visual hallucinations. She also had persecutory delusions whereby she believed her sister was trying to harm her and delusions of jealousy whereby she believed her husband was having an affair. While on topiramate, her seizures continued. The medication was subsequently stopped and her psychosis resolved a week later. A trial of antipsychotics was never tried at this point as her psychosis resolved with the removal of topiramate from her drug regimen.

Magnetic resonance imaging of the brain in 2002 showed right mesial temporal sclerosis. Video-EEG telemetry showed right anterior temporal interictal discharges and 9 focal seizures with right temporal ictal onset in 7 seizures. A positron emission tomographic scan of her brain showed right temporal hypometabolism. In view of her persistent and intractable seizures, a right temporal lobectomy was planned. …

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