TLE Complex Partial NEAD, NES - PNES including PTSD

[brain]

Complex Partial Seizures Present Diagnostic Challenge

by Richard Restak, M.D.

September 1995, Vol. XII, Issue 9

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Temporal lobe epilepsy (temporal lobe epilepsy), now more commonly called complex partial seizure disorder so as to include seizures that originate in the frontal foci, straddles the borderland between psychiatry and neurology. Since the condition may involve gross disorders of thought and emotion, patients with temporal lobe epilepsy frequently come to the attention of psychiatrists. But since symptoms may occur in the absence of generalized grand mal seizures, physicians may often fail to recognize the epileptic origin of the disorder. Indeed, misdiagnosis and failures of diagnosis are common in temporal lobe epilepsy. Fortunately, the illness is marked by certain "signature" symptoms that can aid in its identification.

John Hughlings Jackson observed in the late 1800s that seizures originating in the medial temporal lobe often result in a "dreamy state" involving vivid memory-like hallucinations sometimes accompanied by déjà vu or jamais vu (interpreting frequently encountered people, places or events as unfamiliar). Jackson wrote of "highly elaborated mental states, sometimes called intellectual aura," involving "dreams mixing up with present thoughts," a "double consciousness" and a "feeling of being somewhere else." While the "dreamy state" can occur in isolation, it is often accompanied by fear and a peculiar form of abdominal discomfort associated with loss of contact with surroundings, and automatisms involving the mouth and GI tract (licking, lip-smacking, grunting and other sounds).

Experiential Illusions

In the 1940s and '50s, Wilder Penfield, a neurosurgeon at the Montreal Neurological Institute, artificially elicited "dreamy states" by cortically stimulating the lateral temporal neocortex, the anterior hippocampus or the amygdala in awake epileptic patients prior to their surgical resections. During these operating room experiments, the patients experienced what Penfield referred to as "experiential illusions."

These illusions involved an alteration, sometimes subtle, of the person's relationship to his or her environment, as well as emotional response to it. In contrast to psychotic persons, Penfield's patients remained fully aware that their altered interpretation was an illusion. A friend's voice may sound remote, or a well-known living room may appear unfamiliar, but the meaning is preserved, the voice does not become depersonalized, nor does the living room lose its identity. Even those patients describing feelings of unreality state that they know at the same time what reality is, observed Penfield. This is an important distinction from schizophrenia and other psychotic states.

For example, a patient of mine with temporal lobe epilepsy often feels compelled to stare for brief moments at a coffee table in her living room since, as she put it, "It just doesn't look exactly like my coffee table." After a few seconds, the feeling disappears. At no time does she think that the table has actually changed; the only thing that varies is her perception and "interpretation" of it.

Altogether Penfield (Mullan and Penfield 1959) divided the illusions of interpretation into four groups:

• Auditory illusions accompanied by the perception that sounds were louder or clearer, fainter or more distinct, nearer or farther away;
• Visual illusions where things seemed clearer or blurred, nearer or farther away, larger or smaller; fatter or thinner;
• Illusions of recognition where present experience seemed familiar, strange, altered or unreal; and
• Illusions of emotion consisting of feelings of fear, loneliness, sorrow or disgust.

None of these groups of symptoms are unique to epilepsy. Migraine sufferers regularly experience illusions of sound, sight, taste and smell.

True hallucinations-those without external stimulus-may occur in complex partial seizures, especially the classic olfactory or gustatory hallucination seen with uncinate fits.

In a psychiatric or neuropsychiatric practice, the most commonly encountered illusions of interpretation are those of emotion. Typically, these are sudden in onset and unrelated to conscious experiences or anything in the environment:

A 40-year-old patient with a 20-year history of mental illness had been diagnosed at various times as having either schizophrenia or borderline personality disorder. She regularly experienced sudden episodes of dread that occurred without warning and without relationship to any inner experiences or anything happening around her.

On one occasion while waiting for a cab to come to her home to take her and her husband to an event they had both been looking forward to attending, she experienced such an overwhelming sense of dread she sank to the floor with a compulsion to hurt herself. Because of the strong visceral component to her symptoms and the inexplicable sudden change in mood, a neurological workup was ordered. An electroencephalogram (EEG) "showed the presence of an intermittent epileptiform disturbance confined to the right anterior and mid-temporal regions. EEG findings would be compatible with partial complex seizure disorder." On carbamazepine (Tegretol), she has been free of the seizures for 10 years.

In most instances, the emotion experienced as part of the seizure is a disturbing one variously described as dread or a feeling of impending doom; in others, the emotion may be experienced as pleasant or euphoric, as Dostoyevsky described. Since the feelings can arise de novo without any identifiable precipitant, an incorrect diagnosis of an acute panic attack may be entertained. Almost always, however, the patient will describe additional experiences that will help in the differential diagnosis. Included here is a strong visceral component to the symptoms: a feeling or sensation, almost always unpleasant, traveling upward from stomach to head. In an attempt to explain the experience, the patient will sweep his or her hands upward starting at the abdomen. Descriptions such as "a wave," "something flowing upward" are often employed.

Often such details must be elicited by careful, tactful questioning, because the patient will be reluctant to describe the experience; its intensity and bizarre nature arouses fears of insanity. The physician frequently can sidestep this reaction by asking: "Have your episodes ever involved anything strange?" with a lack of emphasis on the word strange, thereby suggesting that strange experiences are not at all unusual with these kinds of seizures. Another approach is to say: "On occasion persons who have experienced some of the things you have told me about have described other experiences they have been reluctant to discuss because they were afraid other people, even their doctors, might think them crazy." Questions about specific epileptic experiences should be delayed until the end of the interview to avoid suggestibility.

temporal lobe epilepsy Personality?

Controversy continues as to the validity of a so-called temporal lobe personality. Certainly, many of the patients tend to be obsessive and over-inclusive in their thinking, often satisfying some or all of the requirements for obsessive-compulsive personality: hyperphogia may be seen in some patients. Their speech and thinking is "viscous" and ponderous with a tendency toward loquacity and the insistence on the elaboration of fine and often tedious distinctions. Outbursts of irritability, rather than frank violence, are hallmarks of temporal lobe epilepsy.

When interviewing suspected temporal lobe epilepsy patients, it's important to inquire about their birth and any complications of the pregnancy. Forceps deliveries, now almost unheard of, were quite common years ago and led to compressive injuries of the brain, anoxic damage to Ammon's horn in the hippocampus and the subsequent temporal lobe epilepsy. Also ask about generalized seizures, head injuries, concussions, temper tantrums and, with males, a history of aggression, fire setting, truancy and impulsive behaviors. Has the patient experienced frequent déjà vu, jamais vu, depersonalization, autoscopy or sudden mood swings accompanied by visceral or oral sensations? Do others complain that the patient often doesn't seem to be listening, appears to be daydreaming or otherwise preoccupied? Often the patients are aware of their lapses, and almost all of them experience some form of memory disturbance, even if nothing more than a vague inability to grasp things with sufficient precision.

Other rare presentations include anorexia nervosa (Signer and Benson 1990), multiple personality (Schenk and Bear 1981) or compulsive water drinking (Remillard, et al. 1981). Spitting and embarrassment have been described as the aura of a complex partial seizure (Devinsky and colleagues 1982; Hecker and colleagues 1972).

Finally, the clinician should inquire as to a family history of migraine, since migraine is overrepresented in families with temporal lobe epilepsy and can mimic the majority of temporal lobe epilepsy symptoms.

Tactful inquiry may result in anecdotal reports of sexual disturbances in some patients with temporal lobe epilepsy. Most common is a global hyposexuality affecting both libidinal and genital arousal. In individual instances, such patients may be mistakenly diagnosed as exhibiting hypoactive sexual desire disorder. These two can be distinguished by eliciting on history other hallmarks of temporal lobe epilepsy. Although rarer than hyposexuality, a great variety of other sexual disorders may be encountered in temporal lobe epilepsy. These include fetishism, transvestic fetishism, sadomasochism, pedophilia, frotteurism and voyeurism. During the seizures, the patients may also experience genital sensations, even feelings of sexual excitement evoked by the epileptic discharges.

Episodes of frank psychosis can be the initial presentation of temporal lobe epilepsy: a 38-year-old businessman with a history of childhood staring spells and petit mal epilepsy confirmed by EEG, came under considerable work pressure and began an around-the-clock work marathon lasting two days. Suddenly, early in the morning of his second "all-nighter," he experienced a "realization" that his difficulties must be conveyed to the president of the United States. After his arrest at the White House and transfer to the psychiatric ward of a local teaching hospital, an EEG was ordered for him because clinicians uncovered a history of childhood epilepsy. It showed bursts of generalized spike/wave discharges consistent with a generalized seizure disorder.

A magnetic resonance imaging (MRI) scan showed "two foci of increased signal noted in the medial aspect of the right temporal horn associated with a widening of the right temporal horn." A neurology consult suggested the use of anticonvulsants only if the patient became "symptomatic." The psychiatrist concluded: "Since the patient had no observable physical symptoms of seizures, we would withhold the anticonvulsant at this time." On low doses of antipsychotics the patient improved, another tip-off that his psychosis was atypical in etiology. (Clinicians should note, however, that antipsychotics tend to lower the seizure threshold, thereby increasing patient's incidence of seizure.)

At discharge he left the hospital uncertain and worried about what had happened to him. When I saw him in initial consultation several months later, the psychosis had cleared and he was no longer on any medications. Nonetheless, he continued to experience difficulties with memory and "getting my thinking exactly right." Neuropsychological testing showed "deficits consistent with the local or remote effects of a right temporal lesion." When placed on carbamazepine, the patient reported improvement in thinking and memory.

In retrospect, the most likely explanation was this: The lack of sleep and food coupled with stress led to the onset of a schizophreniform episode in a person with a latent seizure disorder. Because the episode was not associated with any signs of generalized epilepsy, it was not recognized as an example of complex partial seizure disorder by either psychiatrist or neurologist . After the psychosis had cleared, the patient was still left with a problem involving memory and focus originating from the hippocampus, a secondary effect of the abnormality in the right temporal region. The memory disturbance improved with anticonvulsant administration.

temporal lobe epilepsy also may be responsible for chronic rather than just acute psychoses. While any of the symptoms of schizophrenia may be encountered, paranoid traits are the most common. temporal lobe epilepsy patients can be distinguished from schizophrenic patients by the maintenance, when not acutely ill, of warm affect and good rapport. In addition to the history, the diagnosis of complex partial seizure disorder can be aided by EEG. However, since such diagnosis remains a clinical one, it should be noted that several negative EEGs do not rule out the diagnosis of temporal lobe epilepsy in a given patient. Other diagnostic aids include MRI, single photon emission computed tomography (SPECT) and positron emission tomography (PET). Interictal SPECT of cerebral blood flow is not nearly as helpful as ictal SPECT. Even more sensitive, although not generally available, is PET imaging of interictal cerebral metabolism. PET permits greater spatial resolution and versatility. Only MRI can image the structural changes associated with the underlying epileptic process. Quantitative evidence of hippocampal volume loss is correlated with seizure onset in medial temporal structures.

The treatment of temporal lobe epilepsy is complicated by the fact that many times improved seizure control via anticonvulsants leads to deterioration of the neuropsychiatric status. Schizophrenia-like epileptic psychoses often emerge when anticonvulsants are normalizing or improving the seizure activity. If this antithesis isn't recognized, the psychosis will soon become more of a problem than the seizures. One expert, Dietrich Blumer, M.D., has gone so far as to claim: "It is probable that the modern schizophrenia-like epileptic psychoses are largely iatrogenic in nature, caused by modern ability to control seizures."

temporal lobe epilepsy management presents a conundrum. While the illness is an epileptic one and treated by neurologists, many neurologists remain unfamiliar with and even uninterested in its neuropsychiatric components. But by ignoring the experiential symptoms, the neurologist deprives the patient of the opportunity to coherently integrate all aspects of the epilepsy. It may also cement the patient's misconception that in addition to the epilepsy, he or she suffers from a "mental illness."


(to be continued)

[brain]

Total management of temporal lobe epilepsy by a psychiatrist is also not without problems. Although temporal lobe epileptic patients are particularly intriguing to psychiatrists because of the nature of the symptoms, these "psychic" seizures can generalize at any time into psychomotor status or grand mal attacks. What's more, neither the timing nor the seriousness of grand mal episodes can be predicted; the initial generalized seizure sometimes occurs many years after the first manifestations of the illness and may culminate in status epilepticus and death.

For these reasons, a physician should undertake the treatment of temporal lobe epilepsy patients only if he or she has sufficient training and experience in the overall management of epilepsy. When this isn't the case, close collaboration between psychiatrist and neurologist offers the best venue for successful management of this fascinating "bridge" between neurology and psychiatry.

Dr. Restak is a clinical professor of neurology at George Washington University and associate clinical professor of neurology at Georgetown University Medical Center.

References
1. Bancaud J, Brunet-Bourgin F, Chauvel P, Halgren E. Anatomical origin of déjà vu and vivid "memories" in human temporal lobe epilepsy. Brain. 1994(Feb);117(Pt 1):71-90.

2. Devinsky O, Hafler DA, Victor J. Embarrassment as the aura of a complex partial seizure. Neurology. 1982; 32(11):1284-1285.

3. Ellison JM. Alterations of sexual behavior in temporal lobe epilepsy. Psychosomatics. 1982;23(5):499-500, 505-509.

4. Hecker A, Andermann F, Rodin EA. Spitting automatism in temporal lobe seizures. Epilepsia. 1972;13(6):767-772.

5. Jackson JH. Brain. 1898;21:580-590.

6. Kotagal P, Luders HO, Williams G, et al. Psychomotor seizures of temporal lobe onset: analysis of symptom clusters and sequences. Epilepsy Res. 1995;20(1):49-67.

7. Markand ON, Wheeler GL, Pollack SL. Complex partial status epilepticus (psychomotor status). Neurology. 1978;28(2):189-196.

8. Meiners LC, van Gils A, Jansen GH, et al. Temporal lobe epilepsy: the various MR appearances of histologically proven mesial temporal sclerosis. Am J Neuroradiol. 1994(Sept);15(8 ):1547-1555.

9. Mullan S, Penfield W. Illusions of comparative interpretation and emotion. Archives of Neurology and Psychiatry. 1959;80:269-284.

10. Pritchard PB III, Lombroso CT, McIntyre M. Psychological complications of temporal lobe epilepsy. Neurology 1980;30(3):227-232.

11. Remillard grand mal, Andermann F, Gloor P, et al. Water-drinking as ictal behavior in complex partial seizures. Neurology. 1981;31(2):117-124.

12. Remillard grand mal, Andermann F, Testa GF, et al. Sexual ictal manifestations predominate in women with temporal lobe epilepsy: a finding suggesting sexual dimorphism in the human brain. Neurology. 1983;33(3):323-30.

13. Schenk L, Bear D. Multiple personality and related dissociative phenomena in patients with temporal lobe epilepsy. Am J Psychiatry. 1981;138(10):1311-1316.

14. Signer SF, Benson DF. Three cases of anorexia nervosa associated with temporal lobe epilepsy. Am J Psychiatry. 1990;147(2):235-238.

15. Slater E, Beard AW, Glithero E. The schizophrenia-like psychoses of epilepsy. Br J Psychiatry. 1963;109:95-150.

16. Spencer SS. The relative contributions of MRI, SPECT and PET imaging in epilepsy. Epilepsia. 1994;35 (Suppl 6):S72-89.

17. Spencer SS, Spencer DD, Williamson PD, Mattson RH. Sexual automatisms in complex partial seizures. Neurology. 1983;33(5):527-33.

18. Stoudemire A, Nelson A, Houpt JL. Interictal schizophrenia-like psychoses in temporal lobe epilepsy. Psychosomatics. 1983;24(4):331-333;337-339.

19. Umbricht D, Degreef G, Barr WB, et al. Postictal and chronic psychoses in patients with temporal lobe epilepsy. Am J Psychiatry. 1995;152(2):224-231.

Complex Partial Seizures Present Diagnostic Challenge




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Moderator's Notes:

The entire article was posted in the event if this
article ceased to exist on the web.

[KAM]

This is a very interesting article. I can relate to all of the testing I did to locate the focal point of the seizures prior to surgery. When I pressed the button to tell them when they were present and nothing would register led them to believe it was all in my mind and the diagnoses would be anxiety. From my experience with cancer, if they biopsy one location and no cancer is present, it doesn’t mean that it’s not present, they just didn’t get the correct location.

Does it work the same with an EEG? Can they possibly get each and every brain wave captured on an EEG? I recall that the auras varied from a weird taste in the mouth to fear to an electric feeling of shock that would start in the stomach and I would feel it go the arms and legs. I had the migraines as well. They are likely to put you on things like Ativan and that never truly helped, all it did was knock you out. It’s an old article, did you ever find anything else on this?

[Bee91]

I am very intrigued! -yet a little confused...I cant comprehend words today...(I think its the meds.) I do want to talk about this...Because Doctors have had a lot of trouble diagnosing me. My new doctor does think the seizures are temporal lobe. But a lot have looked like they would have been frontal lobe too..and then again I have abnormal spikes in the parital and occipital lobes yet they are not abnormal? Well...thats what one doctor told me...I dont know...Its not a good day...I'll come back and re-read this..because I am really, really, REALLY interested in this. I just am a little too "high" to think right now... I'm sorry...

[KAM]

I just found a website of Dr. Restak's called the Dana Foundation. There is a lot of info here:

Intro:
http://www.dana.org/news/author.aspx?id=842

Epilepsy in general:
http://www.dana.org/resources/brainw...l.aspx?id=5112

Complex Partial:
http://www.dana.org/Search.aspx?q=complex%20partial

[Bee91]

I'm still having a hard time comprehending words...(not to mention I have ADD ) Is a short synopiss poissible?

[Bernard]

There is overlap in the diagnosis of temporal lobe epilepsy and psychiatric disorders and many neuros and psych doctors are not sufficiently equipped to properly diagnose or address both aspects.

[brain]

Actually there's a problematic issue with
temporal lobe epilepsy and FLE (Frontal Lobe Epilepsy) AND
Psychiatric Disorders ~ which complicates
everything and makes it all a complex case.

While true some people with Epilepsy can
have psychiatric or psychological problem(s),
but there's quite a few Neuros and Epis that
are under the impression that all people who
have E have a psychiatric and/or psychological
problem(s) - which isn't the case.

For example: take a complex partial episode, which may
include some bizarre behavior, psychosis,
or abnormal behavior - to name a few, which
lasts but a brief moment; and they slam the
person with Epilepsy as psychiatric/psychological
problem. A genuine Psychiatric / Psychological
problem person would have this problem all the
time, not for a brief spell. Big difference.

Hope this post defines it more clearly. It was
a Neurologist that helped me to understand this
more clearly and that Neurologist realizes and
understands it's a severe stigma in Epilepsy.

Then there are patients who have Epilepsy and
because of F L E (not T L E) that doesn't manifest
always on EEG; the Neurologist / Epileptologist
often gives the misdiagnostic(s) of the person
to have P N E S or N E S or Pseudo-seizures and
tosses them off to the Psychiatric Care when in
fact they have Epilepsy and not a Psychiatric
or Psychological problem.

In the light of P N E S/N E S (as well as the old
terminology - Pseudoseizures) - it falls into
2 categories:

1) Psychogenic - caused by trauma experienced
in childhood including sexual abuse, physical
abuse, and emotional abuse, stress, to name a
few.

2) Physiologic- caused by physical problems
such as cardiac arrhythmias and hypoglycemia,
diabetics, and other health related issues to
name a few.


I hope this detailed and more defined clarity
assists you further in more perspective.

[Bee91]

ok yes I understand! That is really interesting!!! The brain is so complex. I don't think anyone will ever be able to figure out 100% how it works...

[brain]

I have merged an old thread plus provided an
additional newer updated information (some of
this is already mentioned in the merged thread
below)



Remember: Pseudoseizures is an OLD TERMINOLOGY
that is no longer used, but is still going around

Here's the Latest Breakdown:


1) NEAD - Non-epileptic Attack Disorder: People
who "fake" seizures to get attention, can be a
psychological or mental disorder, people who do
this for 'fun' and wants attention, et cetera.

2) N E S - Non-Epileptic Seizures: These seizures are not
faked, the people are not insane or crazy, but rather,
it's very real. However in the light of this perspective,
there is no brain wave abnormalities or activities at
all. It is divided into two divisions:

I) Physiologic - meaning there's a underlying physical
problem that's triggering the seizures, such as diabetics,
cardiac, other health issues that are provoking the
seizures. These can be treated properly under the proper
care of the Health Care Specialist of that Specialty(ies).

II) Psychogenic - meaning there's an underlying psychological
factor involved anywhere from emotional, mental, physical,
or some type of trauma or some traumatizing experience
whether from the past or current events, and can include
abuse, violence, attacks, PTSD (Post Traumatic Stress Disorder),
depression, anxiety, and much more.

[brain]

[seizingbeauty]

Matt I don't think this information was directed at any one person but just supplied as information. There is an entire forum right now discussing Muchusens by Internet but again not as a blame issue just as information. I feel your frustration that even within the medical community when they can't identify the cause they just brush it off as either faked or "stress" or "all in your head"(Sorry I don't remeber who's line this is but its a good one!)
As you know I spent years and went through many doctors before someone took the time to give me some answers.

[petero]

the info in the first two posts is very helpful
these could describe precisely what I've been experiencing
I have never heard of these correlations before
I've never had any in-depth professional explanation of epilepsy either

I have had a very bad day so far
this information has been extremely helpful

I feel so lost today - I could feel it coming on last night
and today has been laden with the bad blanket

my friend said I might have had PTSD from a year ago - I then found this information

I will try to keep this in mind. I sense the feelings today will be recurrent.
I'm guessing partial/absence seizures.
the more I find about different symptoms the more I tend to believe mine is temporal lobe epilepsy
I've never had an EEG show anything