Case Report: Psychotic Disorder Due to Epilepsy

Ahmad Ashraf Ilman bin Zulbahri

Faculty of Medicine & Health Sciences, Universiti Sains Islam Malaysia
March 2016

Introduction
Psychotic disorders are more common in epilepsy patients compared to the general
population. The most common form of psychosis in epilepsy is the post-ictal psychosis, which is a psychotic disorder that follows a seizure with characteristic phenomenology lasting up to three months. Psychotic disorders are of particular importance
in terms of establishing the diagnosis, the increased risk of suicide, the risk of developing chronic inter-ictal psychosis, and the challenges in management.

Case report
Mrs K was a 45 year-old Malay lady who was currently unemployed, married with no
children, and had underlying history of epilepsy with the last fitting episode of a
month before admission was brought by her husband with the chief complaint of
low mood one week prior to admission. History was taken from the patient.

History of presenting illness

At the onset of the low mood, she noticed that her limbs became rigid and shaky. As
a result, she fell down while she was cooking and regained her posture after a few
minutes. There was no loss of consciousness. She also stopped doing her hobbies e.g.
quilting, complaining of lack of pleasure as well as inability to concentrate. She was
easily irritable. There were feelings of guilt and worthlessness. She also complained of
difficulty to fall asleep and early morning awakenings and that she was not rested.
She loss her appetite and complained of lack of energy to carry out her daily activi-

ties. She had thoughts of suicide, but she had no plan nor any previous attempt. She
said that she always feel threatened. She had feelings that her husbands ex-wife was
jealous of her and wanted to harm. Progressively, she had poor oral intake, stopped
speaking, isolated herself in the house and stopped doing her usual household chores
e.g. cooking. On the day of admission, she believed she was already dead and that
this world was a second world as the previous world was already destroyed. She was
brought by her husband to Hospital Sultan Haji Ahmad Shah for further management.
Otherwise, she denied any history of hallucinations, manic symptoms, fever, head
trauma, or substance abuse.

Past psychiatric history

She was previously well until 1990 when she developed epilepsy at the age of 19 years
old. It was preceded by her fathers death in the previous year. The seizures were tonic-clonic and generalised, with frequency ranging from one episode per week to two
episodes per day. She had multiple admissions to Hospital Jerantut and initially was
under follow up there. She then defaulted follow up and medications due to feeling
cured; however, she was unsure of the year she started to default treatment. Her
symptoms continued and the family resorted to traditional healers for many years up
until now. However, her symptoms did not improve. She claimed that she experienced
symptoms of low mood after each fitting episode since she defaulted treatment. She
was unsure of the duration of each mood episode and gave a vague duration of a
month. Otherwise, there were no other known medical or psychiatric problems.

Family history
She was the thirtd out of six siblings. Her father passed away in 1989 and she was unsure of the cause. Her mother was still alive in her 60s with multiple comorbidities
i.e. diabetes mellitus, hypertension, and ischaemic heart disease. There were no history of mental illness in her nuclear family and no family history of epilepsy. She noted
that one of her siblings had migraines.

Personal history
She was born term via standard vertex delivery; however, she was unsure of other
perinatal events. She completed her secondary education with no history of fights or
misconducts. She had good academic performance as she received Grade 2 for her Sijil
Pelajaran Malaysis (SPM). She used to work for five years as a clerk at a driving
school, which used to be her fathers company. There was no problem socially at her
workplace except that sometimes her work was interrupted by her fitting episodes.
She stopped working and became a housewife since her marriage in 2006. Her husband did not allow her to work in view of her illness. Her husband worked as a rubber

tapper, and they were not yet blessed with children. She denied any history of highrisk behaviours, smoking, alcohol, or substance abuse.

Premorbid history
She described herself as a quiet person and an introvert. She enjoyed quilting in her
past time. She was able to make friends and was a practising Muslim. She described
her premorbid mood as euthymic.

Phsyical examination
The patient was alert, conscious, and sitting comfortably on the interview chair. She
was not in respiratory distress with a respiratory rate of 12 breaths per minute. Her
pulse was of regular rhythm and good volume with a rate of 84 beats per minute. Her
peripheries were warm with capillary refill time of less than 2 seconds. There was no
jaundice, no pallor, and no cyanosis. The hydration status was good.
On neurological examination, the tone, power, and reflex of all her limbs were
normal. The cutaneous sensation and proprioception was normal. There was no gait
abnormalities.
The examination of other systems were unremarkable.

Mental state examination

The patient was an average-sized Malay female in hospital attire, wearing a headscarf.
She was comfortable and cooperative. She had good rapport, but poor eye contact.
There was no behavioural abnormalities noted.
Her speech was of average rate and volume. It was coherent, relevant, and rational. She was euthymic during the interview. There were no feelings of guilt or worthlessness. There was no suicidal ideation. Her mood was congruent to the circumstances but slightly restricted. There was no lability of the mood. There were no abnormalities thought and no formal thought disorder. She was not hallucinating.
She was oriented to place, person, and time of the day; however, she was unsure
of what day it was and how long she had been in the ward. Her short-term memory
was good; however, she had difficulties to recall dates and durations of past events
such as onset of her mood symptoms. She was able to hold the conversation well and
not easily distracted.
Her personal judgment was good. She planned to clean the house after discharge
as she had been in the ward for weeks. Her insight was partial she was aware of her
fitting and mental symptoms, she knew that those symptoms were not normal, and
she noted that her epilepsy might contribute to the mental symptoms. However, she
was partial about taking the medications and believed that traditional healing may be
the better alternative.

Summary
Mrs K was a 45 year-old Malay lady who was a housewife with underlying epilepsy
for the past 25 years with the last fitting episode one month prior to admission. She
defaulted epilepsy treatment favouring traditional healing. She complained of a oneweek history of depressive symptoms associated with nihilistic delusions and persecutory ideas. Her social and occupational (housewife) functions were impaired. Mental
state examination showed poor eye contact, restricted affect, poor long-term memory,
and partial insight in terms of treatment.

Diagnoses
Provisional diagnosis:
Psychotic disorder due to epilepsy with delusions. The patient fulfilled all criteria of the diagnosis according to DSM-5 classification. A) She had nihilistic delusion
and persecutory ideas. B) She was a long-time epilepsy sufferer who defaulted treatment. There is evidence that psychotic disorder can be caused by epilepsy (LaFrance
et al., 2008). C) Even though depressive symptoms predominate, according to
LaFrance et al. (2008), the symptomatology of psychosis in epilepsy is affect laden,
and the symptoms are clustered into delusional and affective like psychosis. D) The
last fitting episode was one month prior to onset of symptoms, and E) her social and
occupational functions were impaired by the symptoms.

Differential diagnoses:
Depressive disorder due to epilepsy with depressive features. The patient
fulfilled all nine symptoms of a major depressive episode outlined by DSM-5 (low
mood, anhedonia, loss of appetite, insomnia, psychomotor agitation, loss of energy,
feelings of guilt and worthlessness, impaired concentration, and suicidal thoughts);
however, she presented with a one-week history instead of the two weeks required to
specify with major depressive-like episode. Her delusion was congruent with depression
(nihilistic). Depression is the most frequent psychiatric disorder in epilepsy (LaFrance
et al., 2008), and she had underlying epilepsy for a long time while defaulting treatment. However, Criterion C of Depressive Disorder Due to Another Medical Condition may not be fulfilled as the presence of delusion with mood symptoms may better
be explained by a psychotic disorder, as above.
Major depressive disorder with mood-congruent psychotic features.
The patient fulfilled all nine symptoms outlined by DSM-5 for Major Depressive Disorder with nihilistic delusion; however, she presented with a one-week history instead
of the two weeks required to diagnose major depressive disorder. Her history of longstanding untreated epilepsy also justified against this diagnosis.

Formulation
The patients predisposing factors were her underlying epilepsy and her non-compliance to treatment due to stronger faith in traditional methods. The precipitating factor was her last fitting episode. The perpetuating factors were the belief in traditional
methods resulting in non-compliance to treatment.

Management
Investigations
Fundoscopy and a complete neurological examination should be performed.

Biological investigations:
- Full blood count: as baseline investigation, to rule out infection, and to
look for anaemia as the patient had poor oral intake
- Blood urea and serum electrolytes, serum calcium, and serum
magnesium: as baseline investigation and to look at her kidney function
as well as any electrolyte imbalance as the patient had poor oral intake
- Thyroid function test: to look for thyroid hormone imbalance as it may
lead to psychosis
- Liver function test: as therapeutic investigation to look at the liver
function before any antipsychotic is to be administered
- Urine toxicology: to look for any evidence of substance abuse as substance use may lead to psychosis
- Urine pregnancy test: she was of reproductive age and pregancy can
cause depressive and psychotic symptoms
- Electrocardiography: as therapeutic investigation for baseline as antipsychotics may cause prolonged QT interval
- Electroencephalography (EEG): to rule out temporal lobe epilepsy
which is highly associated with post-ictal psychosis (cite)
- Computed tomography (CT) scan of the brain: to look for any
space-occupying lesion that may cause seizures and abnormal behaviour.

Psychosocial investigations:
- Corroborative history is to be taken from her husband and if possible
from another family member regarding the presence of symptoms in between fits as well as her personal and premorbid history, especially on
changes of her behaviour after her father passed away.

- Suicidal risk assessment is to be carried out as the patient had history

of suicidal ideation.

Treatment
Biological management:
The patient is to be admitted to the ward in view of her symptoms, her suicidal
ideation, her functional impairment, and her history of non-compliance. Anti-epileptic
drug such as sodium valproate is to be administered to improve seizure control. Antipsychotic drug should be given, but care should be taken as antipsychotics lower the
seizure threshold. The best antipsychotic in this case is atypical anyipsychotic such as
sublingual olanzapine (Zydis), or typical antipsychotics that have lower proconvulsant
properties such as haloperidol, or sublingual olanzapine. A low-dose benzodiazepene
may be administered to help the patient sleep. A fit chart is to be started, and her vital signs are to be monitored. She is to be put on suicidal caution.

Psychosocial management:
Psychoeducation should be given to the patient regarding her condition and the relation between epilepsy and psychosis. There should be an emphasis on compliance to
medication. The family should be involved in the management the husband should
be stressed on the importance of pharmacological treatment despite traditional methods. Electroconvulsive therapy or cognitive behavioural therapy may be considered as
part of the management.

Discussion
Psychiatric disorders are prevalent in 2550% of patients with epilepsy, especially
among those whose epilepsy is poorly controlled (LaFrance et al., 2008). Depression
has the highest prevalence rate in patients with epilepsy, followed by anxiety and psychotic disorders (LaFrance et al., 2008). This patient was diagnosed to have psychotic
disorder due to epilepsy, which has a prevalence rate of up to 10% (LaFrance et al.,
2008).
The diagnostic criteria from DSM-5 requires evidence to show a direct pathophysiological causality between epilepsy with the psychotic features. Logsdail & Toone
(1988) devised a criteria for the diagnosis of post-ictal psychosis (PIP), which presents
with psychotic features within a week after a seizure episode, lasting at least 24 hours
up to 3 months, with the exclusion of external factors such as anticonvulsant toxicity,
history of other psychotic disorders, evidence of nonvonvulsant status epilepticus from
EEG, recent history of head trauma, or substance abuse.

Kanner et al. in 2004 found that PIP is common in patients with complex partial
seizures which later become secondarily generalised tonic-clonic seizures of increasing
frequency. This is consistent with this patients history. She also presented with psychotic features of about a month in duration characterised by delusions and predominant affective symptoms with more than 10 years of underlying epilepsy findings
that are consistent with the common features of PIP summarised by LaFrance et al.
(2008). Depression happens in 90% of patients with PIP and hypomania in 70%, with
20% of them having suicidal ideation (Kanner, 1996). Religious delusions are common
in PIP, as well as fear of impending death (Trimble et al., 2010), as experienced by
the patient.
It is important to identify and treat PIP early as recurrent PIP may progress to
inter-ictal psychosis (IIP). Diagnosis of IIP is made when the duration of the sympoms is more than 6 months (Tarulli et al., 2001). Patients with PIP and IIP are
prone to suicide. 1 out of 14 patients with PIP studied by Logsdail & Toone (2008)
attempted; and 2 out of 6 patients with IIP studied by Tarulli et al. (2001) attempted
suicide twice and both succeeded on the second attempts.
PIP is self-limiting and management is by observation and supervision (Trimble
et al., 2010) other than improving seizure control. However, any florid psychotic
episode may need intervention such as benzodiazepenes and mood stabilisers (Trimble
et al., 2010). Antipsychotics lower the seizure threshold; however it should not be a
reason to withhold it from patients who need it (LaFrance et al., 2008). When it is required, atypical antipsychotics are administered. If typical antipsychotics are indicated, haloperidol has among the lower proconvulsant properties (LaFrance et al., 2008).
Attention must also be given to the interaction between antipsychotics and antiepileptis. Antiepileptics induce liver enzymes which may increase the clearance of antipsychotics, thus reducing its effect. Discontinuation of antiepileptics may cause reduced
clearance of antipsychotics, leading to extrapyramidal syndromes (LaFrance et al.,
2008).

References
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Archives of Neurology, 53(3), 258263. doi:10.1001/archneur.1996.00550030070024
LaFrance, C. W., Kanner, A. M., & Hermann, B. (2008). Chapter 20 psychiatric
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10.1016/S0074-7742(08)00020-2

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