When you interview Ms. D she is alert but only intermittently oriented to date and location. She makes a variety of paraphasic speech errors. She is talking about heaven and angels and several times asks if you are the devil. Evaluation by the emergency physician discloses no toxic, metabolic, or infectious cause for her symptoms. Other than mental status, her neurologic examination is normal and shows no evidence of motor seizure activity. What would you suggest next?
This patient presents with complex partial seizures occurring in sequence without return to normal between seizures, followed by a continuous state of altered consciousness. This cluster of symptoms and signs is consistent with complex partial status epilepticus.
Emergency EEG is diagnostic. If the EEG is positive for status epilepticus, recommended treatment is IV benzodiazepines along with other IV antiepileptic drugs.
Complex partial status epilepticus can have a variety of triggers, including drug overdose, hyperthyroidism, brain tumor, or carcinomatous meningitis.3 In this case, the most likely trigger is medication noncompliance.
Complex partial or other forms of nonconvulsive status epilepticus occur in up to 37% of hospitalized patients with altered consciousness of uncertain etiology.3 EEG is required to confirm the diagnosis, but many hospitals do not have EEG technologists on call nights and weekends.
Table
THE FEARFUL PATIENT: PANIC ATTACK, SEIZURE DISORDER, OR PSYCHOGENIC?
| Panic attacks |
|
| Temporal lobe complex partial seizures |
|
| Psychogenic nonepileptic seizures |
|
In my experience, a patient who later was referred to me for seizure control was once admitted to a psychiatry ward for 4 days because of unidentified complex partial status epilepticus. When someone finally restarted her carbamazepine, she returned to normal in a few days. Six months after she became my patient, she presented with identical symptoms. An EEG within hours of symptom onset showed continuous EEG ictal activity from the left temporal lobe. When we administered IV lorazepam, her EEG normalized within minutes and her confusion and delusional symptoms resolved in 20 minutes.
Case 5: Seizure clusters followed by agitation
Mr. E, 32, has had complex partial and tonic-clonic seizures since age 14. He presents with chronic depressive symptoms and independent episodes of agitated behavior with psychotic features lasting hours after seizure clusters. His seizures have continued despite trials of different antiepileptic drugs, and he currently is receiving phenytoin and valproate. He is referred to you to diagnose and treat the psychiatric symptoms.
He scores a 28 on the Beck Depression Inventory, which indicates moderate depression,4 but he is not suicidal. He reports that although his depression symptoms are constant, his psychotic features occur only after a series of closely-spaced seizures. How do you approach this problem?
Based on the history, this patient has both mild interictal depression and postictal psychosis. In patients with epilepsy, psychiatric symptoms are categorized as:
- ictal (occur only during a seizure)
- interictal (may wax and wane but are present chronically, usually with no relation to seizure occurrence)
- or postictal (appear within 7 days after a lucid interval following a seizure or—more often—a series of seizures).5
Interictal psychiatric disorders include depression, bipolar disorder, and psychotic disorders. If the psychiatric disorder is truly interictal and has no clear relation to seizure occurrence, it should be treated like any other psychiatric illness with appropriate medications. One should not automatically add another antiepileptic drug (AED), because AEDs as a class have more adverse effects and more drug interactions than commonly used antidepressants.
Begin by examining the AEDs the patient is receiving. For example, phenobarbital and, to a lesser extent, phenytoin are associated with depression and should be used in patients with depression only when other AEDs have failed.
Ictal and postictal psychiatric symptoms should be treated acutely. Postictal symptoms may include psychosis, depression, mania, or anxiety. A short course of benzodiazepines is often helpful; the use of neuroleptics is dictated by the intensity and quality of the postictal symptoms.