Ictal Fear Research Articles

Ictal fear and affective disorders in complex partial seizure patients

Ictal fear and affective disorders in complex partial seizure patients

Postictal Elevation of Prolactin Levels After Psychic Auras‐Evidence for Seizure Discharges Involving Mesolimbic Structures

Purpose: The postictal elevation of prolactin (PRL) levels results from the spread of ictal discharges involving mesolimbic structures (amygdala and hippocampus), via the ventral amygdalofugal pathway to the hypothalamus. To determine whether the mesolimbic structures are involved, we measured postictal PRL levels after simple partial seizures (SPSs) with psychic symptoms (psychic auras), and compared them with those after complex partial seizures (CPSs), 80% of which have been reported to show significant postictal elevations of PRL. Methods: Serum PRL levels were measured 15, 30, and 60 min after each ictus. Samples were obtained for the baseline values when patients had been seizure free for 12 h. We regarded motionless stares followed by automatisms as CPSs, and we depended on the patient's description for the occurrence of psychic auras. Results: Seven patients with temporal lobe epilepsy (four men and three women; mean age, 41.4 years; range, 25–70 years; laterality of focus, right: left: bilateral = 4:1:2) were studied. Six CPSs (in five patients) and six SPSs (in three patients) were detected. In one patient, both types of seizures were analyzed on separate occasions. The CPSs observed were either gestural or oral automatisms. The described psychic auras consisted of types such as complex visual hallucinations (n = 4), ictal fear (n = 4), deja vu (n = 2), depersonalization (n = 2), macropsia (n = 1), and distortion of sense of time (n = 1). The total number of psychic aura types was greater than six (the number of SPSs with psychic symptoms) because any single episode had multiple types of auras. That is, the sequences of psychic aura types were as follows: ictal fear→depersonalization→complex visual hallucination; ictal fear→depersonalization; ictal fear→deja vu; deja vu→complex visual hallucination; macropsia→complex visual hallucination→distortion of time sense; and ictal fear‐complen visual hallucination. Postictal PRL levels invariably reached their peaks at 15 min. Mean 15‐min postictal PRL levels (for CPSs and SPSs with psychic symptoms, 45.6 and 46.7 ng/ml, respectively) were significantly higher than the mean baselines (9.6 and 9.9 ng/ml, respectively; p < 0.02. paired t test). Conclusions: In this study, the mean 15–min postictal PRL levels for SPSs with psychic symptoms (4.9 times as high as the baseline) were significantly increased to the same extent as those for CPSs (4.6 times as high as the baseline). Although some investigators assert that ictal discharges confined to the temporal neocortical region can elicit psychic auras, our results are indicative of seizure discharges involving mesolimbic structures in the development of psychic auras.

Relationship between atrophy of the amygdala and ictal fear in temporal lobe epilepsy.

Viscerosensory and affective manifestations are often elicited by temporal lobe seizure discharges. They have been reproduced by amygdaloid stimulation in awake patients during stereotaxic exploration or neurosurgical procedures. They are not exclusively reproduced by stimulation of the amygdala, though most commonly they are evoked from it. Ictal fear is frequently, but not invariably, associated with a rising epigastric sensation, palpitations, mydriasis and pallor. We studied 50 patients (mean age 33 years) with intractable temporal lobe epilepsy (TLE): MRI volumetric measurements of amygdala and hippocampus were performed using a protocol previously described by our group (Watson et al., Neurology 1992; 42: 1743-50). All patients had extensive EEG investigation and at least two seizures recorded by video-EEG monitoring. Seventeen patients (34%) had a clear history of fear accompanied by a rising epigastric sensation as the initial manifestation of their habitual attacks. The amygdala volumes in this group were significantly (P = 0.001) smaller (mean 2131.6 mm3) compared with the volumes of the 33 patients without these symptoms (mean 2561.5 mm3). Both patient groups had smaller mean amygdala volumes compared with normal controls (mean 2828.2 mm3). Postoperative pathology correlated well with volumetric atrophy. In addition, we found that patients with more pronounced amygdaloid atrophy more commonly had prolonged febrile convulsions in early childhood and also more frequently secondarily generalized seizures. Results support the finding that ictal fear is related to pathology of the amygdala and that it, like the hippocampus, is an important substrate of TLE.

The neuroanatomy of panic disorder: The emerging role of the right parahippocampal region

Recent brain imaging and case report data suggest that a right temporal lobe abnormality, specifically involving the right parahippocampal region, may play an important role in the pathogenesis of some forms of panic disorder. The authors explore the interesting link between ictal fear in complex partial epilepsy, case reports of panic patients with focal temporal lobe pathology, and cocaine-induced panic. This is systematized into a proposed neuroanatomic theory of the pathogenesis of panic disorder involving the right temporal lobe and other brain regions.

Postictal Psychosis After Partial Complex Seizures: A Multiple Case Study

Bouts of unusually frequent partial complex seizures originating in the temporal lobe, that sometimes became secondarily generalized, induced psychotic episodes in 9 patients. In 7, the increase in seizures occurred at a time when antiepileptic drugs (AEDs) were being reduced during intensive EEG monitoring with a view to surgical treatment of intractable epilepsy. According to DSM-III-R criteria, the postictal psychosis resembled an organic delusional syndrome which was paranoid in 7 and schizophreniform in 1 and an organic mood syndrome in 1. A high incidence of ictal fear, of bilateral independent epileptogenic discharge, and of small foreign tissue lesion were unexpected findings and appeared to represent risk factors, especially in patients otherwise handicapped by an epileptic personality disorder. Recognition of postictal psychosis in this setting and in others is important both prognostically and therapeutically. Postictal psychosis does not constitute a contraindication to surgical treatment of epilepsy.

Ictal fear in temporal lobe epilepsy: Association with interictal behavioral changes

We studied 40 patients with temporal lobe epilepsy to determine if ictal fear was associated with changes in cognition, personality, or psychopathology. Patients with ictal fear scored higher ( p < 0.10) than those without ictal fear on the Minnesota Multiphasic Personality Inventory (MMPI) Social Introversion and Psychasthenia subscales, MMPI-derived scales including depression, poor morale, and delinquency and on the Spielberger Trait Anxiety Scale. These differences were not even marginally significant with Bonferoni correction for multiple comparisons. No differences were found between these groups in the Temporal Lobe (Bear-Fedio) Questionnaire, Buss-Durkey Hostility Inventory, or history of psychiatric hospitalization. However, a history of paranoid psychosis and anxiety disorder, as well as current treatment with a neuroleptic medication, were more common in patients with ictal fear. This study provides limited support for the thesis that ictal fear is associated with behavioral changes in epilepsy, particularly symptoms of anxiety, introversion, and paranoia.

Fear responses in patients with epilepsy.

Ictal fear was found equally with left- and right-sided temporal lobe foci, suggesting that basic components of fear may be bilaterally represented. With regard to interictal fear, patients with left-sided foci reported more fear of social and sexual situations, but not of animals and physical injury, compared with other groups. Men with foci in the right temporal lobe reported less fear than men with left-sided foci. It is conceivable that the two hemisphere contribute differently in the cognitive elaboration of fear responses. Alternatively, differential patterns of self-report of fearfulness may be secondary responses to cognitive or sensorimotor loss. Finally, the present study not only demonstrates differences between right and left temporal lobe epileptics, but also between these groups and those with and without other CNS dysfunction.

Interictal psychopathology in patients with ictal fear

Interictal psychopathology in patients with ictal fear

Interictal psychopathology in patients with ictal fear: a quantitative investigation.

We assessed the hypothesis that psychopathology is overrepresented in patients with temporal lobe epilepsy (TLE) who experience ictal fear. Eleven such patients were matched with two control groups: patients who had TLE without ictal fear and patients who had generalized epilepsy. On several MMPI scales, the TLE-ictal fear group scored significantly higher than the two control groups, which did not differ significantly from each other. Furthermore, the TLE-ictal fear group had more MMPI clinical scales that were pathologically elevated, had significantly more patients with histories of admission to psychiatric hospitals, and had more MMPI profiles that were psychotic than either of the control groups.