Epilepsy Talk

Epilepsy and Psychosis – Is It Genetic? | September 6, 2013

Just as epilepsy is called “a storm in the brain,” psychosis might be viewed as “a lightning strike” to the brain.

Both have to do with havoc in the brain, but one’s a neurological issue and the other is a mental illness.

Totally different ballgames, right?

Maybe not, says new research which focuses on the genetic connection.

Genetics and Psychosis

Individuals with a parental history of psychosis had a 2.7-fold increase in the risk of having a diagnosis of epilepsy, compared to individuals without a parental history of psychosis.

Theories abound regarding the link between epilepsy and psychosis, but they all have one thing in common – that epilepsy has toxic effects on the brain.

Combined with prior genetic and neurodevelopmental evidence, these new findings point to a much more complex association, which likely includes a shared genetic vulnerability.

Dr. John Krystal, Editor of Biological Psychiatry, commented: “We have long known that particular types of epilepsy were associated with psychosis.

However, the finding that a parental history of psychosis is associated with an increased risk of epilepsy in the offspring strengthens the mechanistic link between the two conditions.”

“Our evidence that epilepsy and psychotic illness may cluster within some families indicates that these disorders may be more closely linked than previously thought,” said the study’s first author, Dr. Mary Clarke.

Recent research looked at the psychiatric and neurological histories of both the children and their parents. Here are their report’s main findings:

People with epilepsy had 5.5 times the usual risk of having a psychotic disorder.

Individuals whose parents had epilepsy had twice the risk of developing psychosis, compared with individuals with two non-epileptic parents.

Past studies have looked at the two disorders as a chicken-or-egg kind of thing, struggling to determine which came first.

But Dr. Clark’s study suggests that one doesn’t preclude the other, epilepsy and psychosis more likely share common origins.

An interesting fact is that the findings support the idea of mental illnesses as physical illnesses.

No one blames a person’s character when they have a seizure, but psychosis carries with it a shameful connotation, as if it’s a personal weakness.

If researchers can better pinpoint the commonalities of the two, not only will we gain better insight into the disorders individually, we’ll have further evidence to fight the stigma against mental illness.

Seizures and Psychosis

That being said, it does seem clear that some forms of psychosis are closely linked to the occurrence of seizures and differ from the psychotic disorders that affect other people.

Psychosis in people with epilepsy is most often classified according to the time when episodes occur, in relation to seizures:

Ictal psychosis typically involves a type of nonconvulsive status epilepticus. The use of an EEG is important in making the diagnosis, as ictal psychosis often involves unresponsiveness and automatic movements that also may occur in psychotic disorders that are not related to seizures.

Mood and behavioral changes can occur as direct manifestation of the seizures, including anxiety, depression, and hallucinations.

The episodes are usually brief (1-3 minutes), begin and end abruptly.

They usually occur with partial seizures, simple partial (aura) or complex partial seizures, but can also occur in generalized seizures.

Pre-ictal symptoms usually may be recognized several hours before the seizure, although it’s not rare for them to occur 48 or even 72 hours before the seizures.

As the seizure onset nears, the intensity of these symptoms may increase.

They consist typically of irritability, poor frustration tolerance, anxiety, depression, impulsive behavior or aggression and are relieved by the seizure.

These symptoms can last a few hours, and sometimes up to a few days before a seizure.

Post-ictal disturbances are more likely to occur following clusters of seizures, generalized seizures or status epilepticus.

It’s been estimated to affect between 6% and 10% of people with epilepsy.

Involved are psychiatric symptoms that occur within 7 days (usually within 1 to 3 days) after a seizure or seizure cluster in a person who does not have these symptoms at other times (or at least has them in a much milder form).

These symptoms may include delusions, depressive or manic psychosis, or bizarre thoughts and behavior, and generally disappear promptly when treated with low doses of medication.

Insomnia is usually the first sign of post-ictal psychosis, so the psychotic symptoms often can be prevented if a medication like risperidone (Risperdal) is given promptly when or, even before, the insomnia occurs.

Inter-ictal psychosis (psychosis “in between” seizures, not only around the time of seizures) is reported to occur in 4-10% in patients with epilepsy, mainly those with temporal lobe epilepsy.

It’s a chronic disorder and clinically resembles chronic schizophrenia (symptoms of delusions, hallucinations, thought disorder) but there are some reports that personality is better preserved.

What About AEDs?

An unusual type of psychosis in people with epilepsy occurs when seizures are well controlled by seizure medicines.

The psychotic symptoms are inversely related to the occurrence of seizures, generally in people who have had epilepsy for a long time.

The cause of this phenomenon, which is called alternative psychosis or forced normalization, is uncertain.

If the seizure medicines are reduced until seizures recur, the symptoms of psychosis will stop.

Some antiepileptic drugs can cause psychiatric problems, most commonly depression, anxiety, behavioral or cognitive problems and, in rare cases, psychosis.

Older antipsychotic drugs such as Thorazine (chlorpromazine) and Mellaril (thioridazine) can occasionally cause seizures and should be used at the lowest effective dosage.

Newer antipsychotic drugs, however, have minimal risk of worsening seizure control.

These drugs include: Risperidal (rispiridone), Zyprexa (olanzapine), Seroquel (quetiapine), Abilify (aripiprazole), Geodon (ziprasidone) and Moban (molindone).

Alternately, sometimes it can be difficult to distinguish between alternative psychosis and the psychosis that occasionally occurs as a side-effect of most seizure medicines.

The medication is likely to be the cause of the psychosis if the person is still having seizures or is also showing symptoms such as tremor or other movement disorders.

In conclusion, multiple psychiatric symptoms and syndromes may be experienced by people with epilepsy and are often easy to treat if recognized.

Just because you have epilepsy doesn’t mean you’re going crazy. Or else we’d all be off the rails!

Other articles of interest: With Psychosis Risk, Functioning Is Key
http://www.medpagetoday.com/Psychiatry/Schizophrenia/41404?xid=nl_mpt_DHE_2013-09-06&utm_content=&utm_medium=email&utm_campaign=DailyHeadlines&utm_source=WC&eun=g678262d0r&userid=678262&email=pfjohnson@comcast.net&mu_id=5845719

Schizophrenia and Epilepsy — The Connection
https://epilepsytalk.com/2013/09/15/schizophrenia-and-epilepsy-the-connection-2/

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Resources:
http://my.epilepsy.com/epilepsy/mood_psychosis
http://epilepsy.med.nyu.edu/living-with-epilepsy/related-disorders/psychosis-and-epilepsy
http://www.smartplanet.com/blog/rethinking-healthcare/study-supports-link-between-epilepsy-and-psychosis/8682
http://www.sciencedaily.com/releases/2012/05/120502112709.htm
https://docs.google.com/viewer?a=v&q=cache:izeOexAUtlsJ:www.epilepsysociety.org.uk/FileStorage/main_content/16-psychiatric-disorders-in-epilepsy.pdf+&hl=en&gl=us&pid=bl&srcid=ADGEESi6-FHpLngjfKGoVZ_iSIB8hyAP6S-Y5ORE1E5lp0tR9ifNolkJ0kYG1waYSbBa5jbr3UUTa84JQ_e1eaDyorf-bgBD-6JJmCqDBX975LnLhCexd5BVEfGA8ETo-jjlZ30EaLGc&sig=AHIEtbR4Z4f3rcAdXRRGsfBJHZziGLVMhg
http://www.ncbi.nlm.nih.gov/pubmed/8800660
http://en.wikipedia.org/wiki/Ictal
http://professionals.epilepsy.com/page/behavioral_influence.html

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