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75

Section

Organic syndromes of schizophrenia

3

Section 3

Organic syndromes of schizophrenia: epilepsy and schizophrenia

Perminder S. Sachdev

Facts box

higher in epileptic patients than in the
r
There is evidence from epidemiological as
general population.

well as clinical data that schizophrenia-like
r
It is often noted that patients who develop
psychosis is more common in patients with
psychosis have a severe form of epilepsy
epilepsy and vice versa.

involving multiple seizure types, a history of
r
Psychoses associated with epilepsy have been
status epilepticus, and resistance to drug
traditionally categorized into ictal, postictal,
treatment.

and interictal. The interictal psychoses may
r
Suggestions that psychosis in epilepsy might
be brief or chronic in duration.

be exclusively or preferentially associated
r
Ictal psychosis is generally either a partial
with temporal lobe epilepsy (TLE) are

complex (psychomotor) status or a petit mal
supported by a majority of case studies. The
status.

evidence also points to a mediobasal rather
r
Postictal psychosis begins a few hours to a
than neocortical temporal lobe abnormality
few days following a flurry (usually) of
underpinning psychosis when the focus is in
seizures and has plaeomorphic

the temporal lobes.

symptomatology, a short duration, and often
r
The laterality issue remains undecided, but
settles spontaneously.

the importance of a left-sided focus is not
r
Brief interictal psychosis has usually been
striking.

referred to as “alternating psychosis,”

r
Schizophrenia-like psychosis may develop de
suggesting that the psychosis and seizures are
novo many months or years after temporal
antithetical; when psychosis is present,
lobectomy for the treatment of intractable
seizures are usually in abeyance.

epilepsy.

r
Alternating psychosis has been associated
r
Discussion of pathogenesis of chronic
with the concept of Forced Normalization of
psychosis has centered broadly on two

EEG (electroencephalograph).

mechanisms: 1) the psychosis is due to the
r
Brief psychosis has been reported in relation
repeated electrical discharges, either directly
to the use of antiepileptic drugs.

or through the development of

Antipsychotics, on the other hand, lower the
neurophysiological or neurochemical

threshold for epileptic seizures.

abnormalities; or 2) the epilepsy and

r
Postictal and brief interictal psychoses share
psychosis share a common neuropathology

clinical features and may have similar

that may be localized (emphasis on

pathogenetic mechanisms. Bimodal

temporal lobe but also frontal lobe and the
psychosis has been described in some

cerebellum) or widespread in the brain. A
patients.

synthesis of these two mechanisms may be
r

possible.

The overall evidence suggests that chronic
schizophrenia-like psychosis is many times
79

Organic Syndromes of Schizophrenia – Section 3

The association between epilepsy and schizophrenia
of an underlying cortical neuronal abnormality that
has attracted the attention of psychiatrists since the
transiently leads to an electrical discharge in the brain.

nineteenth century
[1].
This clinically observed asso-The cause of this could be a brain malformation, an
ciation was seen as a basis for exploration of the patho-altered metabolic state, a traumatic lesion, and so on.

genesis of mental illness, with epilepsy-related psy-It is therefore appropriate to refer to the “epilepsies”

chosis as a possible model of schizophrenia. It was
rather than one disease. The relative proportion of
this relationship that prompted the exploration of con-different types of epilepsies is difficult to determine.

vulsive therapy in the treatment of psychiatric disor-For example, estimates of the proportion of epilepsy
ders. The proconvulsant nature of neuroleptic drugs
patients who have a temporal lobe focus vary from
and the occurrence of psychosis with anticonvulsants
30% to as much as 76%
[7],
and studies have dif-have further fueled the interest. We have come a con-fered in the rigor with which a temporal lobe onset
siderable distance since the first efforts of understand-was investigated. This has direct relevance to the ques-ing this association, but many aspects of this relation-tion of whether psychosis has a special relationship
ship still remain controversial
[1, 2, 3, 4, 5, 6].
This
with TLE. The diagnosis of schizophrenia poses even

greater problems. For example, the six-month crite-ship and attempts to synthesize the understanding that
rion for schizophrenia used in the Diagnostic and Sta-emerges from its examination.

tistical Manual of Mental Disorders-III (DSM-III) and
subsequent classifications had a major impact on the
Introductory caveats

prevalence rates for this disorder, with implications for
associations based on previous epidemiological data.

Any examination of the association must contend with
In examining the association, therefore, the character-a number of limitations in the literature, conceptual as
istics of the “schizophrenia” being referred to must be
well as empirical. Some of these limitations are elabo-closely examined.

rated first.

Problems with definitions

The problem of superficial similarity

Although the definition of epilepsy has been consis-A considerable proportion of the discussion on this
tent, the definitions of “psychosis” and “schizophrenia”

topic has been influenced by the similarity between
used in studies have lacked standardization. Clearly,
temporal lobe phenomena and psychotic symptoms.

the significance of a confusional postictal psychosis is
Auditory hallucinations, depersonalization, altered
different from that of a postictal manic psychosis or
bodily experiences, labile emotions, and so on are fea-an interictal schizophreniform psychosis. This prob-tures common to both disorders. This does not neces-lem has been particularly salient in the literature on
sarily imply a common origin for the two sets of symp-psychosis following the use of anticonvulsant drugs.

toms. Similar brain phenomena may be produced by
In this chapter, I restrict myself to the examina-pathology in different brain regions
[8]
. This is because
tion of psychoses that phenomenologically resemble a
the brain is massively interconnected, and there are
schizophreniform illness, in which thought and per-proximal as well as remote effects of lesions or mal-ceptual disturbances, usually in the form of delusions
function.