Trials and tribulations of diagnosing and managing psychosis secondary to non-convulsive epilepsy

Mahmoud Awara,Matt Havenga,Joshua Smalley,Manal Elnenaei

doi:10.1192/bjo.2021.334

Abstract

ObjectiveTo highlight the importance of reviewing diagnosis and management of refractory psychosis and to share that with the scientific community; and to also shed some light on the dilemma and challenges that professionals may face to diagnose and treat organic psychosis. In addition, to look at the possible similarity/dissimilarity in psychopathology between organic and primary psychosis and differences in opinions through presenting the history and course of illness of this patient.Case reportWe present the case of a 51-year-old female who had a 28-year history of treatment-resistant schizophrenia. She did not report or display any seizure activity, and an extensive investigation was unremarkable. The unusual nature of her psychopathology, which was predominantly visual hallucinations and somatic delusions, and the difficult to treat nature of her symptoms, prompted investigation with Electroencephalograph which demonstrated bilateral temporal lobe epileptic activity.DiscussionTreatment with divalproex sodium and discontinuation of antipsychotic medication achieved an excellent response, where her visual hallucinations and somatic delusions were both remarkably ameliorated.ConclusionThe differentiation between organic/secondary and functional/primary psychosis is an area of contention between psychiatrists and neurologists and also within each of these specialties.The myriad of psychopathology and associated treatment resistant psychotic symptoms that patients with non-convulsive epilepsy may experience should result in building a long desired bridge between neurology and psychiatry to collaborate in managing such cases.

Highlights

A clinical impression of moderate depression with anxiety and panic attacks and possible emerging emotionally unstable personality traits was made and she had begun psychological sessions with the therapist before referral to the medics
There had been no recent infections or previous history or family history of tics. At this point, sertraline had helped with her motivation and she was able to come off promethazine and her sleep was improved by practising sleep hygiene with an accompanied cessation of tics
The rationale behind reporting this case is that previous studies have pointed at SSRIs, as causes of tics disorders, but promethazine is one that does a good job in improving sleep and has a side effects of movement disorder

Summary

Introduction

A clinical impression of moderate depression with anxiety and panic attacks and possible emerging emotionally unstable personality traits was made and she had begun psychological sessions with the therapist before referral to the medics. She initially refused to come off promethazine as it had helped her sleep. At this point, sertraline had helped with her motivation and she was able to come off promethazine and her sleep was improved by practising sleep hygiene with an accompanied cessation of tics.

Results

Conclusion