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Postictal Psychosis: Resolution after Electroconvulsive Therapy
Epilepsy & Behavior 2, 363–366 (2001) doi:10.1006/ebeh.2001.0223, available online at http://www.idealibrary.com on
CASE REPORT Postictal Psychosis: Resolution after Electroconvulsive Therapy Ana Pascual-Aranda,* ,1 Irene Garcia-Morales, † and Javier Sanz-Fuentenebro* *Department of Psychiatry and †Department of Neurology, 12 de Octubre University Hospital, Madrid, Spain Received February 27, 2001; revised May 3, 2001; accepted for publication June 4, 2001
The association between epilepsy and psychosis has generated considerable debate since the 19th century. Recently, diagnostic criteria for a distinct type of epileptic psychosis, postictal psychosis, have emerged. We present the case of a 23-year-old woman who was admitted to the hospital with a catatonic-like psychosis after a cluster of partial complex seizures. She received a diagnosis of postictal psychosis, and fully recovered after electroconvulsive therapy. This article once again emphasizes the association between psychosis and epilepsy, a matter of great theoretical interest, as it provides a chance for developing an organic model for psychosis. © 2001 Academic Press Key Words: postictal psychosis; epilepsy; partial complex seizures; schizophrenia.
INTRODUCTION
terized by clouding of consciousness and “organic” manifestations; interictal psychoses, with a clear consciousness, and a form that might be indistinguishable from schizophrenia; and postictal psychoses, which contain an admixture of “functional” and “organic” symptoms. Postictal psychoses have largely been ignored in the literature, and very few reports have focused on this condition (11–13). Postictal psychoses are defined by their temporal relationship to the epileptic activity. Psychosis usually occurs after an exacerbation in partial complex seizure frequency and often after a lucid interval. Phenomenology is pleomorphic, and the psychotic episode may occur either in clear or in clouded consciousness. Prognosis appears to be good; resolution is often spontaneous, although with a tendency to recur.
The association between psychosis and epilepsy had been suggested by 19th-century authors such as Morel, Falret and Jackson, and the issue has generated considerable debate and interest since then. The nature of such an association has been largely discussed. There are those, headed by Landolt (1), who support the idea of an antagonism between the two disorders. On the other hand, the “affinity” concept has been supported by other authors (2–7) who have observed that psychotic episodes occur in epileptic patients more often than chance expectation. Different authors seem to agree in that patients with temporal lobe epilepsy are at greater risk for developing psychotic episodes (4, 5, 8), and some authors, particularly Flor-Henry (9), found a greater risk among patients with left hemisphere temporal lobe foci. Psychoses associated with epilepsy can be classified into three distinct groups (10): ictal psychoses, charac-
CASE HISTORY A.A., a 23-year-old Nigerian woman, with no previous psychiatric or neurological consultation, had arrived in our country only 5 months before admission.
1 To whom correspondence should be addressed at the Department of Psychiatry, 12 de Octubre University Hospital, Avenida de Andalucia Km. 5,400, 28041 Madrid, Spain. E-mail: [email protected].
1525-5050/01 $35.00 Copyright © 2001 by Academic Press All rights of reproduction in any form reserved.
363
364 She described two short psychotic episodes in the past that had seemingly resolved with the help of a “quack.” Further information on the medical or psychiatric history of the patient was not available due to language difficulties, the different cultural setting, and a lack of reliable informants. She was admitted to the psychiatric unit of our hospital presenting with a catatonic-like psychotic episode. A cluster of partial complex seizures that sometimes became secondarily generalized could be evidenced during the previous week. The EEG tracing showed rhythmic epileptic activity in the left temporal lobe. A 4-day interval of apparent normality of mental state separated the last of these seizures from the onset of the psychotic syndrome. After a few days of treatment with phenytoin (400 mg/24 h) and carbamazepine (400 mg/8 h), the EEG abnormalities resolved, but the psychotic symptoms persisted. The patient was well aware of the environment, in a setting of clear consciousness. She displayed bizarre behaviors and disinhibition (she undressed, spat, intrusively entered other patients’ rooms, etc.). Thought disorder and language impairment, with echolalia and verbal stereotypy, were prominent. Persecutory delusions were present (she thought her food and her medicine were being poisoned, she believed a woman was trying to kill her, etc.). Vivid visual hallucinations were an outstanding feature (she “saw” a woman with a knife, spirits in the ceiling, etc.); auditory hallucinations were also present, although to a lesser degree (menacing voices in the second person, the voice of her brother, etc.). Periods of predominant catatonic-like features (mutism, opposition, repetitive stereotyped movements) alternated with other periods in which the patient showed intense anxiety and withdrawal from her surroundings. MRI scan of the brain showed a lesion compatible with a congenital cholesteatoma in the left petrous bone, but this finding could not be confirmed after CT. Cerebrospinal fluid was normal; blood serologic tests and parasites were negative. After treatment with haloperidol, up to 17 mg per day, the patient showed no improvement. A few days after admission, the patient required tube feeding as she refused to ingest food or medicine, and her physical condition was severe. Furthermore, physical restriction was often needed as she frequently became agitated. All the preceding symptoms, along with the psychopathological state of the patient, led to the choice of ECT (electroconvulsive therapy) for treatment. She underwent 11 sessions, with a bifrontotemCopyright © 2001 by Academic Press All rights of reproduction in any form reserved.
Pascual-Aranda, Garcı´a-Morales and Sanz-Fuentenebro
poral thrice-weekly stimulus. The patient showed gradual improvement, with resolution of the delusional ideas and hallucinations and progressive behavioral normalization. As she gradually recovered, she was able to discuss the lack of reality of her delusions, and cultural issues started to emerge as she tried to explain her previous pathological ideas (“evil eye,” repeated reading of the Bible, etc.). By the time of her release from the hospital (2 months after admission) she had returned to her previous normal mental state.
DISCUSSION Postictal psychosis, a relatively rare condition, has been largely ignored in the literature, particularly when compared with the better known interictal psychoses (chronic illnesses, presenting with schizophreniform or affective symptomatology, that occur without a temporal relationship to the seizures and in a setting of clear consciousness) (10). In fact, the diagnostic criteria for postictal psychosis were not specified until the late 1980s (11) (Table 1). The prevalence of postictal psychiatric disorder in patients with epilepsy is yet to be established, but has been estimated to range between 6 and 10% (14, 15). The postictal psychoses are characterized by their temporal relationship to seizure activity and they represent an intermediate state between the above-mentioned interictal psychoses and purely ictal phenomena (that abate as soon as the EEG abnormalities resolve). Furthermore, this entity can be clearly demarcated from classic postictal confusional states. Postictal psychosis usually develops following an increase in partial complex seizure frequency and after a brief lucid interval (hours or days after resolution of the postictal period and preceding the onset of psychotic symptoms, in which the patient remains asymptomatic) (11, 12). The psychotic episode may occur either in clear or in clouded consciousness. Even though first-rank Schneiderian symptoms may be present, making the episode phenomenologically indistinguishable from schizophrenia, this is not common. On the other hand, marked mood changes, mild catatonic phenomena, visual hallucinations, a clouding of consciousness, less deterioration and the lack of family history of psychosis are common features of this disease (10 –13, 15, 17) that make differential diagnosis possible. In short, as
365
Case Report TABLE 1 Diagnostic Criteria Proposed by Logsdail and Toone (11)
1. The episode of confusion or psychosis manifests immediately upon a seizure or emerges within a week of the return of apparently normal mental function. 2. The psychosis has a minimum length of 24 hours and a maximum length of 3 months. 3. The mental state is characterized by one of the following: (a) clouding of consciousness, disorientation, or delirium; (b) delusions, hallucinations in clear consciousness; (c) a mixture of (a) and (b). 4. There is no evidence of the following extraneous factors, which might contribute to the abnormal mental state: (a) anticonvulsant toxicity, based on anticonvulsant levels where possible and also physical examination for evidence of cerebellar dysfunction in each case; (b) previous history of interictal psychosis; (c) EEG evidence of minor status; (d) recent history of head injury, or alcohol or drug intoxication.
some authors affirm, postictal psychosis shows an admixture of “organic” and “functional” manifestations (10). Prognosis is considered to be good but with a tendency to recur. Some authors suggest that the occurrence of further seizure activity, after onset of the psychotic episode, would bring no changes to the mental state of the patient or could even worsen the condition (11) (therefore contradicting Landolt’s “forced normalization”); others, however, describe a remission of psychotic symptoms following the occurrence of new seizures or after treatment with ECT (1, 15). Substantial data support the safety of programmed grand mal seizures (18, 19), and in fact ECT is indicated in the treatment of intractable epilepsy. Modern programmed seizure therapy, with muscle paralysis and oxygenation, raises seizure threshold and does not cause any irreversible changes or substantial morbidity (20), and is, therefore, an option in the treatment of postictal psychoses in patients with epilepsy. We present the case of a Nigerian patient who, following a cluster of seizures, developed an episode compatible with the diagnosis of postictal psychosis. As described, there was a lucid interval between the last of the seizures and the psychotic episode. The patient presented with a catatonic-like psychosis that made the differential diagnosis with schizophrenia necessary. The temporal relationship with seizures, the fluctuating level of consciousness, the prominent visual hallucinations, and the lack of significant negative symptomatology led to the diagnosis of postictal psychosis. This episode lasted 2 months and responded quite spectacularly to treatment with ECT. We believe that this case once again supports the association between epilepsy and psychosis and the
existence of a particular type of epileptic psychosis that can be clearly demarcated from ictal and interictal psychosis and the classic postictal confusional states. Postictal psychosis should be borne in mind to ensure adequate treatment. Furthermore, the epileptic psychoses are of great theoretical interest as they provide a chance for studying the link between cerebral dysfunction and mental disorder, offering useful insights into the biology of schizophrenia. Obviously, further studies are required, and qualified specialists, psychiatrists, and neurologists alike should keep working together to gather more knowledge on this issue.
REFERENCES 1.
2. 3. 4. 5.
6.
7. 8.
Landolt H. Serial EEG investigations during psychotic episodes in epileptic patients and during schizophrenic attacks. In: Lorenz de Haas AM, editor Lectures on epilepsy, 1958. Amsterdam: Elsevier, 1958:91–133. Gibbs EL, Gibbs FA, Fuster B. Psychomotor epilepsy. Arch Neurol Psychiatry 1948; 60:331–9. Hill D. Psychiatric disorders of epilepsy. Med Press 1953;229: 473–5. Slater E, Beard AW. The schizophrenia-like psychoses of epilepsy. Br J Psychiatry 1963;109:95–150. Perez NM, Trimble MR. Epileptic psychosis: diagnostic comparison with process schizophrenia. Br J Psychiatry 1980;137: 245–9. Mendez MF, Grau R, Doss RC, Taylor JL. Schizophrenia in epilepsy: seizure and psychosis variables. Neurology 1993: 1073–7. Hyde MH, Weinberger DR. Seizures and schizophrenia. Schizophrenia Bull 1997;23:611–22. Dongier S. Statistical study of clinical and electroencephalo-
Copyright © 2001 by Academic Press All rights of reproduction in any form reserved.
366
9. 10. 11.
12.
13.
14.
Pascual-Aranda, Garcı´a-Morales and Sanz-Fuentenebro graphic manifestations of 536 psychotic episodes occurring in 516 epileptics between clinical seizures. Epilepsia 1959;1:117– 42. Flor-Henry P. Psychosis and temporal lobe epilepsy: a controlled investigation. Epilepsia 1969;10:363–95. Lishman W. Organic psychiatry. 3rd ed. Oxford: Blackwell Science, 1998:237–314. Logsdail SJ, Toone BK. Post-ictal psychoses: a clinical and phenomenological description. Br J Psychiatry 1988;152:246 – 52. Savard G, Andermann F, Olivier A, Remillard GM. Postictal psychosis after partial complex seizures: a multiple case study. Epilepsia 1991;32:225–31. Kanemoto K, Kawasaki J, Kawai I. Postictal psychosis: a comparison with acute interictal and chronic psychoses. Epilepsia 1996;37:551– 6. Kanner AM, Stagno S, Kotagal P, Morris HH. Postictal psychi-
Copyright © 2001 by Academic Press All rights of reproduction in any form reserved.
15. 16.
17. 18.
19.
20.
atric events during prolonged video-electroencephalographic monitoring studies. Arch Neurol 1996;53:258 – 63. Kanner AM. Psychosis of epilepsy: a neurologist’s perspective. Epilepsy Behav 2000;1:219 –27. Toone B. Psychosis of epilepsy. In: Reynolds EH, Trimble MR, editors. Epilepsy and psychiatry. London: Churchill Livingstone, 1981:113–37. Lancman M. Psychosis and peri-ictal confusional states. Neurology 1999;53(suppl 2):S33– 8. Coffey CE, Weiner RD, Djang WT, et al. Brain anatomic effects of electroconvulsive therapy. Arch Gen Psychiatry 1991;48: 1013–21. Lippmann S, Manshadi M, Wehry M, et al. 1250 electroconvulsive treatments without evidence of brain injury. Br J Psychiatry 1985;147:203– 4. Swartz CM. Seizure benefit: grand mal or grand bene? Neurol Clin 1993;11:151– 60.
CASE REPORT Postictal Psychosis: Resolution after Electroconvulsive Therapy Ana Pascual-Aranda,* ,1 Irene Garcia-Morales, † and Javier Sanz-Fuentenebro* *Department of Psychiatry and †Department of Neurology, 12 de Octubre University Hospital, Madrid, Spain Received February 27, 2001; revised May 3, 2001; accepted for publication June 4, 2001
The association between epilepsy and psychosis has generated considerable debate since the 19th century. Recently, diagnostic criteria for a distinct type of epileptic psychosis, postictal psychosis, have emerged. We present the case of a 23-year-old woman who was admitted to the hospital with a catatonic-like psychosis after a cluster of partial complex seizures. She received a diagnosis of postictal psychosis, and fully recovered after electroconvulsive therapy. This article once again emphasizes the association between psychosis and epilepsy, a matter of great theoretical interest, as it provides a chance for developing an organic model for psychosis. © 2001 Academic Press Key Words: postictal psychosis; epilepsy; partial complex seizures; schizophrenia.
INTRODUCTION
terized by clouding of consciousness and “organic” manifestations; interictal psychoses, with a clear consciousness, and a form that might be indistinguishable from schizophrenia; and postictal psychoses, which contain an admixture of “functional” and “organic” symptoms. Postictal psychoses have largely been ignored in the literature, and very few reports have focused on this condition (11–13). Postictal psychoses are defined by their temporal relationship to the epileptic activity. Psychosis usually occurs after an exacerbation in partial complex seizure frequency and often after a lucid interval. Phenomenology is pleomorphic, and the psychotic episode may occur either in clear or in clouded consciousness. Prognosis appears to be good; resolution is often spontaneous, although with a tendency to recur.
The association between psychosis and epilepsy had been suggested by 19th-century authors such as Morel, Falret and Jackson, and the issue has generated considerable debate and interest since then. The nature of such an association has been largely discussed. There are those, headed by Landolt (1), who support the idea of an antagonism between the two disorders. On the other hand, the “affinity” concept has been supported by other authors (2–7) who have observed that psychotic episodes occur in epileptic patients more often than chance expectation. Different authors seem to agree in that patients with temporal lobe epilepsy are at greater risk for developing psychotic episodes (4, 5, 8), and some authors, particularly Flor-Henry (9), found a greater risk among patients with left hemisphere temporal lobe foci. Psychoses associated with epilepsy can be classified into three distinct groups (10): ictal psychoses, charac-
CASE HISTORY A.A., a 23-year-old Nigerian woman, with no previous psychiatric or neurological consultation, had arrived in our country only 5 months before admission.
1 To whom correspondence should be addressed at the Department of Psychiatry, 12 de Octubre University Hospital, Avenida de Andalucia Km. 5,400, 28041 Madrid, Spain. E-mail: [email protected].
1525-5050/01 $35.00 Copyright © 2001 by Academic Press All rights of reproduction in any form reserved.
363
364 She described two short psychotic episodes in the past that had seemingly resolved with the help of a “quack.” Further information on the medical or psychiatric history of the patient was not available due to language difficulties, the different cultural setting, and a lack of reliable informants. She was admitted to the psychiatric unit of our hospital presenting with a catatonic-like psychotic episode. A cluster of partial complex seizures that sometimes became secondarily generalized could be evidenced during the previous week. The EEG tracing showed rhythmic epileptic activity in the left temporal lobe. A 4-day interval of apparent normality of mental state separated the last of these seizures from the onset of the psychotic syndrome. After a few days of treatment with phenytoin (400 mg/24 h) and carbamazepine (400 mg/8 h), the EEG abnormalities resolved, but the psychotic symptoms persisted. The patient was well aware of the environment, in a setting of clear consciousness. She displayed bizarre behaviors and disinhibition (she undressed, spat, intrusively entered other patients’ rooms, etc.). Thought disorder and language impairment, with echolalia and verbal stereotypy, were prominent. Persecutory delusions were present (she thought her food and her medicine were being poisoned, she believed a woman was trying to kill her, etc.). Vivid visual hallucinations were an outstanding feature (she “saw” a woman with a knife, spirits in the ceiling, etc.); auditory hallucinations were also present, although to a lesser degree (menacing voices in the second person, the voice of her brother, etc.). Periods of predominant catatonic-like features (mutism, opposition, repetitive stereotyped movements) alternated with other periods in which the patient showed intense anxiety and withdrawal from her surroundings. MRI scan of the brain showed a lesion compatible with a congenital cholesteatoma in the left petrous bone, but this finding could not be confirmed after CT. Cerebrospinal fluid was normal; blood serologic tests and parasites were negative. After treatment with haloperidol, up to 17 mg per day, the patient showed no improvement. A few days after admission, the patient required tube feeding as she refused to ingest food or medicine, and her physical condition was severe. Furthermore, physical restriction was often needed as she frequently became agitated. All the preceding symptoms, along with the psychopathological state of the patient, led to the choice of ECT (electroconvulsive therapy) for treatment. She underwent 11 sessions, with a bifrontotemCopyright © 2001 by Academic Press All rights of reproduction in any form reserved.
Pascual-Aranda, Garcı´a-Morales and Sanz-Fuentenebro
poral thrice-weekly stimulus. The patient showed gradual improvement, with resolution of the delusional ideas and hallucinations and progressive behavioral normalization. As she gradually recovered, she was able to discuss the lack of reality of her delusions, and cultural issues started to emerge as she tried to explain her previous pathological ideas (“evil eye,” repeated reading of the Bible, etc.). By the time of her release from the hospital (2 months after admission) she had returned to her previous normal mental state.
DISCUSSION Postictal psychosis, a relatively rare condition, has been largely ignored in the literature, particularly when compared with the better known interictal psychoses (chronic illnesses, presenting with schizophreniform or affective symptomatology, that occur without a temporal relationship to the seizures and in a setting of clear consciousness) (10). In fact, the diagnostic criteria for postictal psychosis were not specified until the late 1980s (11) (Table 1). The prevalence of postictal psychiatric disorder in patients with epilepsy is yet to be established, but has been estimated to range between 6 and 10% (14, 15). The postictal psychoses are characterized by their temporal relationship to seizure activity and they represent an intermediate state between the above-mentioned interictal psychoses and purely ictal phenomena (that abate as soon as the EEG abnormalities resolve). Furthermore, this entity can be clearly demarcated from classic postictal confusional states. Postictal psychosis usually develops following an increase in partial complex seizure frequency and after a brief lucid interval (hours or days after resolution of the postictal period and preceding the onset of psychotic symptoms, in which the patient remains asymptomatic) (11, 12). The psychotic episode may occur either in clear or in clouded consciousness. Even though first-rank Schneiderian symptoms may be present, making the episode phenomenologically indistinguishable from schizophrenia, this is not common. On the other hand, marked mood changes, mild catatonic phenomena, visual hallucinations, a clouding of consciousness, less deterioration and the lack of family history of psychosis are common features of this disease (10 –13, 15, 17) that make differential diagnosis possible. In short, as
365
Case Report TABLE 1 Diagnostic Criteria Proposed by Logsdail and Toone (11)
1. The episode of confusion or psychosis manifests immediately upon a seizure or emerges within a week of the return of apparently normal mental function. 2. The psychosis has a minimum length of 24 hours and a maximum length of 3 months. 3. The mental state is characterized by one of the following: (a) clouding of consciousness, disorientation, or delirium; (b) delusions, hallucinations in clear consciousness; (c) a mixture of (a) and (b). 4. There is no evidence of the following extraneous factors, which might contribute to the abnormal mental state: (a) anticonvulsant toxicity, based on anticonvulsant levels where possible and also physical examination for evidence of cerebellar dysfunction in each case; (b) previous history of interictal psychosis; (c) EEG evidence of minor status; (d) recent history of head injury, or alcohol or drug intoxication.
some authors affirm, postictal psychosis shows an admixture of “organic” and “functional” manifestations (10). Prognosis is considered to be good but with a tendency to recur. Some authors suggest that the occurrence of further seizure activity, after onset of the psychotic episode, would bring no changes to the mental state of the patient or could even worsen the condition (11) (therefore contradicting Landolt’s “forced normalization”); others, however, describe a remission of psychotic symptoms following the occurrence of new seizures or after treatment with ECT (1, 15). Substantial data support the safety of programmed grand mal seizures (18, 19), and in fact ECT is indicated in the treatment of intractable epilepsy. Modern programmed seizure therapy, with muscle paralysis and oxygenation, raises seizure threshold and does not cause any irreversible changes or substantial morbidity (20), and is, therefore, an option in the treatment of postictal psychoses in patients with epilepsy. We present the case of a Nigerian patient who, following a cluster of seizures, developed an episode compatible with the diagnosis of postictal psychosis. As described, there was a lucid interval between the last of the seizures and the psychotic episode. The patient presented with a catatonic-like psychosis that made the differential diagnosis with schizophrenia necessary. The temporal relationship with seizures, the fluctuating level of consciousness, the prominent visual hallucinations, and the lack of significant negative symptomatology led to the diagnosis of postictal psychosis. This episode lasted 2 months and responded quite spectacularly to treatment with ECT. We believe that this case once again supports the association between epilepsy and psychosis and the
existence of a particular type of epileptic psychosis that can be clearly demarcated from ictal and interictal psychosis and the classic postictal confusional states. Postictal psychosis should be borne in mind to ensure adequate treatment. Furthermore, the epileptic psychoses are of great theoretical interest as they provide a chance for studying the link between cerebral dysfunction and mental disorder, offering useful insights into the biology of schizophrenia. Obviously, further studies are required, and qualified specialists, psychiatrists, and neurologists alike should keep working together to gather more knowledge on this issue.
REFERENCES 1.
2. 3. 4. 5.
6.
7. 8.
Landolt H. Serial EEG investigations during psychotic episodes in epileptic patients and during schizophrenic attacks. In: Lorenz de Haas AM, editor Lectures on epilepsy, 1958. Amsterdam: Elsevier, 1958:91–133. Gibbs EL, Gibbs FA, Fuster B. Psychomotor epilepsy. Arch Neurol Psychiatry 1948; 60:331–9. Hill D. Psychiatric disorders of epilepsy. Med Press 1953;229: 473–5. Slater E, Beard AW. The schizophrenia-like psychoses of epilepsy. Br J Psychiatry 1963;109:95–150. Perez NM, Trimble MR. Epileptic psychosis: diagnostic comparison with process schizophrenia. Br J Psychiatry 1980;137: 245–9. Mendez MF, Grau R, Doss RC, Taylor JL. Schizophrenia in epilepsy: seizure and psychosis variables. Neurology 1993: 1073–7. Hyde MH, Weinberger DR. Seizures and schizophrenia. Schizophrenia Bull 1997;23:611–22. Dongier S. Statistical study of clinical and electroencephalo-
Copyright © 2001 by Academic Press All rights of reproduction in any form reserved.
366
9. 10. 11.
12.
13.
14.
Pascual-Aranda, Garcı´a-Morales and Sanz-Fuentenebro graphic manifestations of 536 psychotic episodes occurring in 516 epileptics between clinical seizures. Epilepsia 1959;1:117– 42. Flor-Henry P. Psychosis and temporal lobe epilepsy: a controlled investigation. Epilepsia 1969;10:363–95. Lishman W. Organic psychiatry. 3rd ed. Oxford: Blackwell Science, 1998:237–314. Logsdail SJ, Toone BK. Post-ictal psychoses: a clinical and phenomenological description. Br J Psychiatry 1988;152:246 – 52. Savard G, Andermann F, Olivier A, Remillard GM. Postictal psychosis after partial complex seizures: a multiple case study. Epilepsia 1991;32:225–31. Kanemoto K, Kawasaki J, Kawai I. Postictal psychosis: a comparison with acute interictal and chronic psychoses. Epilepsia 1996;37:551– 6. Kanner AM, Stagno S, Kotagal P, Morris HH. Postictal psychi-
Copyright © 2001 by Academic Press All rights of reproduction in any form reserved.
15. 16.
17. 18.
19.
20.
atric events during prolonged video-electroencephalographic monitoring studies. Arch Neurol 1996;53:258 – 63. Kanner AM. Psychosis of epilepsy: a neurologist’s perspective. Epilepsy Behav 2000;1:219 –27. Toone B. Psychosis of epilepsy. In: Reynolds EH, Trimble MR, editors. Epilepsy and psychiatry. London: Churchill Livingstone, 1981:113–37. Lancman M. Psychosis and peri-ictal confusional states. Neurology 1999;53(suppl 2):S33– 8. Coffey CE, Weiner RD, Djang WT, et al. Brain anatomic effects of electroconvulsive therapy. Arch Gen Psychiatry 1991;48: 1013–21. Lippmann S, Manshadi M, Wehry M, et al. 1250 electroconvulsive treatments without evidence of brain injury. Br J Psychiatry 1985;147:203– 4. Swartz CM. Seizure benefit: grand mal or grand bene? Neurol Clin 1993;11:151– 60.