Who Diagnoses and Treats Epilepsy in Patients With Psychiatric Symptoms?

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Erratum: In the print version of this article, "Who Diagnoses and Treats Epilepsy in Patients With Psychiatric Symptoms?" published in the June 2018 issue of Psychiatric Times, there was an error. In the third paragraph of the article, following the sentence “A few hours after his first dose of thiothixene he became mute and started throwing furniture-his first act of violence," the following should have been inserted: “Repeat EEG the next morning showed definite complex partial seizure.” Thiothixene was stopped without a second dose. In the next paragraph the EEG that was referred to as normal was the third EEG, not the second EEG.

Schizophrenia and bipolar disorder are not diagnosable if the patient has epilepsy that produces hallucinations or delusions. During my career in psychiatry, I have seen several dozen patients whose hallucinations and delusions stemmed from overlooked and untreated epilepsy. When they responded to anticonvulsant medication alone these patients and their families were happy about the change in diagnosis. This article describes how several such patients presented in psychiatric practice. Personal details were obscured to avoid identifiability.

My first patient who had epilepsy with psychiatric symptoms presented early in my residency. The patient was an adolescent from a small town, who claimed he was the leader of a large street gang that was at war with another gang that wanted to kill him. The town’s police chief dismissed that as impossible. His grades had been slipping over the past year-he had been a good student but was now failing. Two years earlier, he had been knocked unconscious by a baseball bat.

His EEG, head CT, and neurological physical examination were normal. He had been calm during the 4 days of counseling in the hospital although his delusions remained. In perplexity my attending and I said to each other “I suppose it’s schizophrenia” and agreed to start him on thiothixene. A few hours after his first dose of thiothixene he became mute and started throwing furniture-his first act of violence. Repeat EEG the next morning showed definite complex partial seizures. Thiothixene was stopped without a second dose.

Two days later, the third EEG was normal without medication. Then, given phenytoin, his delusions and tension disappeared within hours. At repeated follow ups over 2 years, he remained well and his schoolwork improved.

This case vignette demonstrates that some antipsychotics can exacerbate epilepsy so that EEG abnormalities and seizure manifestations become observable. It shows that before diagnosing a psychosis such as schizophrenia, epilepsy must be excluded; normal EEG results alone do not suffice to make this exclusion.

Some clinicians may feel that epilepsy should be assessed, diagnosed, and treated by a multidisciplinary team of epileptologists, neuropsychologist, and others. In smaller communities and in state hospitals such a multidisciplinary approach is not feasible. The common experience is that epilepsy is not considered, psychosis is diagnosed, and antipsychotics are prescribed. One psychiatrist alone can diagnose schizophrenia but overlook epilepsy. DSM too easily allows dismissing epilepsy when diagnosing schizophrenia because epilepsy is not always accompanied by specific signs or EEG findings, and EEGs are not done unless ordered.

I am not surprised that about 30% of patients with schizophrenia do not respond to antipsychotics, and patients with drug-resistant schizophrenia may respond to ECT.^1,2 Anticonvulsant activity by ECT may factor in this response.³

What is the incidence of epilepsy in a general psychiatric clinic? A recent survey of my first 98 patients in a clinic revealed previously unrecognized epilepsy in 9 patients. Six had hallucinations or delusions, previously misdiagnosed as schizophrenia or bipolar disorder. All 6 showed significant rapid improvement with anticonvulsants. This incidence seems high, but the clinic is entirely for Medicaid patients.

If the psychiatrist doesn’t recognize that epilepsy is underlying delusions or hallucinations, who will? On a teaching psychiatry ward, I saw a middle-aged man who was hospitalized for yelling in public that witchcraft is killing him. He told me that he had epilepsy for which he was being treated with carbamazepine, then he showed me an old letter from a neurologist that stated that his psychosis does not stem from epilepsy. The letter proved nothing, so I added the anticonvulsant primidone. Within a day his delusions and fears disappeared, which demonstrated an epileptic basis for the delusions. He appreciated the changes and became outgoing, cheerful, and sociable. After showing stable remission for 3 days, he was discharged; there was no known readmission.

Another middle-aged man was sent to the psychiatric ward from the emergency department complaining of episodes of unresponsiveness and confusion. Because he behaved normally outside these episodes, I suspected epilepsy. Two EEGs and 24-hour EEG showed only diffuse slowing, but his serum prolactin level was elevated (22.1 ng/mL) 25 minutes post-episode, which pointed to seizure disorder. Valproic acid 1500 mg daily quickly stopped the episodes, confirming epilepsy.

These 2 cases illustrate that a psychiatrist is needed to identify epilepsy in psychiatric patients. Who then should treat epilepsy? An answer was provided by a neurology group that sent me their young clinic secretary who was suffering with auditory hallucinations, fearful delusions, and partial complex epilepsy to treat. After initiating carbamazepine, the hallucinations and delusions disappeared, and the patient happily resumed her job. The implicit message from the neurologists was that hallucinations and delusions are to be treated by a psychiatrist, regardless of cause.

Several years ago, I inherited a stable man in his mid-thirties who had a diagnosis of bipolar 1, who was being treated with high doses of olanzapine and divalproex daily. When I decreased olanzapine to below 7.5 mg daily, he showed confusion, not a mood episode, raising suspicion of epilepsy. Then I elicited an overlooked history of severe TBI with unconsciousness for 5 days antedating psychiatric symptoms by 2 years. The new EEG I obtained was abnormal. The patient declined to see a neurologist, pleaded with me to treat him.

Likewise, a young woman presented with low mood, anxiety, and unpleasant voice hallucinations that conversed with each other, impaired concentration, and disturbed sleep. Ten years earlier, she had a serious concussion and began to have episodes of auditory hallucinations and anxiety. Suspecting epilepsy, I treated her with oxcarbazapine and the voices disappeared. Eventually, she stopped taking the medication and when the symptoms returned, she was hospitalized. She received a diagnosis of bipolar disorder, epilepsy was disregarded, and she was started on an antipsychotic. Although calmer, the voices remained. When I saw her again, I discontinued the antipsychotic and restarted her on oxcarbazapine and the voices and anxiety disappeared. The presentation had no signs or symptoms specific to bipolar disorder, only anxiety and auditory hallucinations, but epilepsy had been disregarded.

This was not the only instance of disregard of epilepsy. A woman in her mid-forties was hospitalized with visual and auditory hallucinations urging her to suicide, showing impoverished thought, anxious agitation, and melancholic sickliness. A few months earlier she had discontinued olanzapine. She described childhood-onset epilepsy, and phenytoin discontinuation 10 years earlier with no reason given for stopping the medication. During the past 10 years, she was seen in the teaching psychiatry clinic with persistent hallucinations; she received a diagnosis of schizophrenia and prescriptions for antipsychotics. A new EEG showed complex partial epileptic seizures in the left anterior temporal lobe. In response to phenytoin all symptoms disappeared in one day. After discharge, the clinic psychiatrist discontinued phenytoin, rediagnosed schizophrenia, restarted olanzapine, and disregarded epilepsy and the results of the EEG. The patient gained 30 pounds, discontinued olanzapine, and never returned to the clinic.

Behavioral or psychological distress brought these “psychiatric” patients to me. Because of possible controversy, I asked the American Psychiatric Association if evaluating and treating epilepsy is in the scope of psychiatric practice. Their Council on Psychosomatic Medicine/Consultation-Liaison Psychiatry replied that it is, particularly if associated with neuropsychiatric symptoms. Similarly, Washington State Medicaid confirmed that they pay psychiatrists for evaluating and treating epilepsy in patients with hallucinations or delusions.

With growing public awareness that head injury is common and produces neuropsychiatric symptoms and impaired cognition and performance, psychiatry is needed to do more than prescribe antipsychotics. Patients with head injury need evaluation and treatment of epilepsy, especially for temporal lobe epilepsy.⁴ Likewise these patients need to be assessed for anxiety and mood disorders, attention deficit problems, and suicide risk.^5-7 Of course, diagnosing epilepsy requires experience, and psychiatrists should refer or request consultations as needed.

Disclosures:

Dr. Swartz is Emeritus Professor of Psychiatry, Southern Illinois University School of Medicine, Springfield, and Affiliate Faculty, Oregon Health & Sciences University.

References:

1. Lally J, Gaughran F, Timms P, Curran SR. Treatment-resistant schizophrenia: current insights on the pharmacogenomics of antipsychotics. Pharmgenom Pers Med. 2016;9:117-129.

2. Tharyan P, Adams CE. Electroconvulsive therapy for schizophrenia. Cochrane Database Syst Rev. 2005;2:CD000076.

3. Ahmed J, Metrick M, Gilbert A, et al. Electroconvulsive therapy for super refractory status epilepticus. J ECT. 2018;34:e5-e9.

4. National Institute for Health and Care Excellence (NICE). Epilepsies: Diagnosis and Management; 2012. nice.org.uk/guidance/cg137. Accessed May 3, 2018.

5. Kwon OH, Park SP. Depression and anxiety in people with epilepsy. J Clin Neurol. 2014;10:175-188.

6. Ettinger AB, Ottman R, Lipton RB, et al. Attention-deficit/hyperactivity disorder symptoms in adults with self-reported epilepsy. Epilepsia. 2015;56:218-224.