Lithium Therapy in Comorbid Temporal Lobe Epilepsy and Cycloid Psychosis

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Oxford Medical Case Reports, 2016;12, 297–299

doi: 10.1093/omcr/omw089
Case Report

CASE REPORT

Lithium therapy in comorbid temporal lobe epilepsy


and cycloid psychosis
Paul Brown1,*, Sridhar Kashiviswanath2, Alison Huynh2, Naveen Allha2,
Ken Piaggio2, Saddichha Sahoo2 and Ankur Gupta2
1
Psychiatry, The Pierre Janet Centre, Melbourne, Australia, and 2Ipswich Hospital, Queensland, Australia
*Correspondence address. The Pierre Janet Centre, Psychiatry, Melbourne, Australia. Tel/Fax: 61 03 9527 3074; E-mail: pierrejanetcentre@gmail.com

Abstract
The treatment of post-ictal psychosis has foundered on uncertainty in diagnosis of psychotic phenotypes, and equivocal
efficacy of first and second generation antipsychotics. This article presents a case history of comorbid temporal lobe
epilepsy and psychosis, suggests the applicability of the continental, cycloid psychosis diagnostic conceptualization to post-
ictal psychoses, and demonstrates the efficacy of lithium in their treatment. Clinical studies of comorbidity of epilepsy and
psychosis offer great potential as a basis for modelling brain–mind relationships, and neuropsychiatric nosology,
pathophysiology and treatment.

INTRODUCTION stabilized on topiramate, but, on account of sedation, only took


sub-therapeutic doses. Schizophrenia was diagnosed just after
A 45-year-old woman, PG, previously diagnosed with comorbid
TLE. The most prominent symptoms were grandiose and reli-
schizophrenia and temporal lobe epilepsy (TLE), and managed
gious delusions. Between 2010 and 2016 she had an average of
with a combination of anti-epileptic and second generation
three psychiatric admissions per annum. Treatment with second
antipsychotic agents, was re-diagnosed with post-ictal, cycloid
generation antipsychotics, especially depot preparations, made
psychosis, anxiety-happiness type, and successfully treated
her feel unwell, and she averred induced seizures.
with lithium therapy. The comorbidity of epilepsy and psych-
PG suffered several fits prior to the most recent admission.
osis is well described. However, comorbidities with specifically
Her mental state alternated rapidly between excitement that
cycloid psychoses and their medical management have yet to
bordered on ecstasy, with religious delusions, and anxiety, with
be described.
irritability and low-grade paranoia. PG was thought disordered.
She said ‘2016 is the end of the world …. I keep having attacks
of God … God loves me … I was meant to rewrite the bible.’ She
CASE REPORT could be observed on the ward, praying to herself.
PG recalled religious experiences, probably auras, from her pre- The patient received her last depot injection 2 weeks previ-
teens. TLE overted in her early 20s, following childbirth. Seizures ously. PG was placed on oral olanzapine and clonazepam, without
manifested in déjà vu, lip-smacking, tonic-clonic fits and benefit. On Andreasen’s Scale for Assessment of Thought,
amnesia. Post-seizure PG was confused and irritable. Right-sided Language, and Communication, PG’s global score was 4/5.
TLE was confirmed by EEG, and changes on PET scan and MRI. Incoherence and illogicality were to the fore. ECT was offered, but
PG did not tolerate valproate, or carbamazepine. She was after one treatment, it was declined. She had had an adequate

Received: August 8, 2016. Revised: October 16, 2016. Accepted: October 23, 2016
© The Author 2016. Published by Oxford University Press.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/
licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
For commercial re-use, please contact journals.permissions@oup.com

297
298 | P. Brown et al.

Table 1: Cycloid psychosis: Leonhard classification

Psychic function Cycloid psychosis Unsystematic schizophrenia

Emotion Anxiety-happiness psychosis Affective paraphrenia


Thought Confusional psychosis Cataphasia
Psycho-motility Motor psychosis: hyperkinetic/akinetic Periodic catatonia

Table 2: Perris criteria for cycloid psychosis: A to D are necessary. abnormal hormonal status. A relationship between epilepsy
and cycloid psychosis has not, as yet, been noted.
A. onset of psychosis from within hours up to a few days. Controlled treatment studies of cycloid psychoses have yet
B. At least four of the following symptoms to be performed. Electroconvulsive therapy is often cited in
i Confusion with perplexity
preference to first generation antipsychotics. Brockington and
ii Mood incongruent, mostly persecutory delusions
Perris recommended rapid neuroleptisation followed by the
iii Overwhelming generalized anxiety
addition of lithium, ‘if required’ [6]. Second generation anti-
iv hallucinosis, often with death themes
psychotic preparations, alongside high doses of benzodiaze-
v ecstasy with religious content
pines, were recently advocated [7].
vi akinetic or hyperkinetic motility disturbances
Foucher (op. cit. [5]) recently gave a detailed description of
vii preoccupation with death
viii subclinical mood swings the cycloid form, anxiety happiness psychosis. The condition is
C. Age of onset 15–50 years polymorphous, often fluctuating, by the hour, between excita-
D. Unrelated substance abuse or brain injury tion and inhibition, fear of death and spiritual exultation, anx-
ious stupor and elation. There can be both hallucinations and
pseudo-hallucinations. Ideas of grandeur commonly have a
seizure, but complained that it ‘made my muscles sore …… I felt religious quality. Subjects are altruistic rather than narcissistic.
like I was going to die … it felt like death therapy.’ They feel called to a Divine mission, and do not attach import-
PG became violent and required seclusion. Lithium was ance to themselves. Indeed the patient is a messenger. Prior to
introduced, and at 1 g per day, her thought disorder rapidly the neuroleptic era, remission, with insight, generally occurred
remitted. Global rating was closer to three than to two. At week within half a year. Recurrence of episodes was the rule with an
three, her global rating was two, and she was discharged to the average of one episode every 2–3 years. Subjects are prone to
community team. post-psychotic depression.
At 2 months, PG was free from active psychosis. Her syntax and The spectrum of evidence-based, therapeutic application of
semantics fell short of 100%: the former closer to 10, at 8 or 9/10; lithium in neurology and psychiatry is widening. There is early
the latter, at 7–8/10. She explained that she knew she suffered evidence for lithium lowering seizure thresholds, and therefore
from psychosis, but even when psychotic, the religious themes being recommended as an anti-epileptic, adjuvant [8].
were an intensification of her everyday appeal to God. She had Perris conducted the definitive study of lithium and cycloid
taken no medication since discharge, and was against re-taking psychosis in a cohort of 30 patients [9]. The mean number of
lithium. It was too sedating. She agreed to rethink topiramate, both morbid episodes and the mean total morbidity were found to
as an anti-epileptic and as a stabilizer of her mental state. be significantly reduced.
PG suffered TLE and comorbid cycloid psychosis from early
adulthood. Antipsychotics, can lower the seizure threshold [10],
DISCUSSION
increasing fit frequency, 1 and thereby exacerbate epileptic
Leonhard [1] introduced the diagnosis, cycloid psychosis psychosis. Hence caution must be exerted in their use, which is
(Table 1). His system encompasses a spectrum of psychoses in usually essential. The introduction of lithium effected a dra-
three domains (ABC): affect (A) as anxiety-happiness psychosis; matic elimination of thought disorder, and partial insight into
behaviour (B), as motor psychosis; and, cognition (C), as confu- her delusional condition. It appears that lithium was effective
sional psychosis. Perris [2, 3] proposed a unitary syndrome with in PG, partly by eliminating the affective and psychotic compo-
operational diagnostic criteria (Table 2). nents of her comorbid TLE and cycloid psychosis, and partly by
Cycloid psychoses are excluded as a named category from raising the seizure thresholds.
the ICD and the DSM. Acute and transient psychotic disorders
(ATPD) was introduced in ICD-10 to accommodate comparable,
non-manic psychoses with acute onset and brief duration [4]. CONFLICT OF INTEREST STATEMENT
ATPD share several characteristics with cycloid conditions, None declared.
including more benign course, greater prevalence in women,
occurring more in developing countries, and high prevalence of
premorbid psychological and physiologic stressors.
FUNDING
Cycloid psychoses run a relapsing-remitting course [5], None.
which is biphasic either within, or between episodes. The latter
are relatively time-limited, but in the absence of effective treat-
ment, the condition tends to chronicity. In terms of aetiology,
ETHICAL APPROVAL
problems during pregnancy and birth are more likely to have Obtained.
occurred in mothers of subjects. There is a very low classical-
genetic, as opposed to epigenetic, hereditary burden. The most
noted precipitating and maintaining factors are environmental
CONSENT
stress, illicit drugs (especially cannabis), and in women, Obtained.
Epileptic cycloid psychosis | 299

GUARANTOR sur les Psychoses: Jack Foucher. http://www.cercle-d-excelle


nce-psy.org/fileadmin/Restreint/Anxiety-happiness_psychosis.
Dr P. Brown.
pdf
6. Brockington IF, Perris C, Kendell RE, Hillier VE, Wainwright S.
The course and outcome of cycloid psychosis. Psychol Med
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