Psychosis

Ictal Psychoses - include non-convulsive status:

• Prolonged automatisms
• Confusion
• Episodic hallucinations  
• Mood changes
• Paroxysmal EEG changes
• Clearly episodic, rarely >1 hour

Post-ictal Psychoses- Fugues:

• Wandering
• Altered behaviour
• Amnesia
• ?“dissociative”
•  EEG usually “normal”

Twilight states:

• Abnormal subjective experience (cognitive and affective)
• Perseveration
• Subtle cognitive impairments
• Paranoid hallucinatory experiences
• May be associated with deep EEG changes or with “forced normalization”

Chronic Inter-ictal Psychoses: 

• 3% risk - especially if left temporal lobe

Chronic paranoid hallucinatory:

• “Schizophreniform”
• Onset 10-15 years after epilepsy
•  Less Family history
•  Pre-morbid personality
•  Warmer affect
•  Less personality deterioration

Affective disorder and Epilepsy

Ictal emotion:  

• Fear, also depression,                            
• Rarely elation                          
• Can be prodromal, partial status, post ictal                      
• Lack precipitant                                                                        
• Sudden onset and ending                           
• Have a primitive, unvarying quality

Inter-ictal depression and anxiety:

• 15-45% prevalence
•  Major Affective Disorder 11% (cf 4.9% gen pop)
•  62% lifetime prevalence (cf 17% gen pop)
•  High anxiety and hostility scores
•  Risk after surgery: 2yrs=10%(successful or not)
•  Multi-factorial causation (biological,  personal, family and societal factors)
•  Treatment: attend to these factors:
  SSRIs, can use ECT
  A range of interactions, mostly “academic”

Personality and Epilepsy

A long and misleading history of prejudice

• Possibly a "Temporal lobe personality syndrome”
• Bear and Fedio 1977 :
  • Humourless sobriety
  • Circumstantiality
  • Viscosity
  • Religiosity
  • Emotionality (Rt)
  • Hypergraphia (Rt)
  • Ruminative intellectual (Lt)

• However, “current data do not support or refute any consistent clustering of behavioural traits in epilepsy” Devinsky 1996
• But may show extremes and diversity.

Aggression and Epilepsy

• Aggression - ictal, possibly ictal, not ictal
• Ictal:  usually part of confusion, poor handling etc
• Very rare as part of an automatism
• Poorly directed, fragmentary, simple, brief,
• Repetitive, lack of concealment, remorse after
• Possibly ictal: ? “Episodic Dyscontrol”
• Not ictal: statistical relationship between epilepsy and
• Violence for various epidemiological reasons.