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Progressive psychosis in a non-surgically managed case of mesial temporal sclerosis- Augusta University, USA

Benjamin Casola

Thorough exploration and accurate diagnosis of patients with histories of psychosis and epilepsy can be difficult for numerous reasons. Many practitioners have to overcome disease specific problems, including not only chronology of psychosis presentation and seizure history, but also how a patient’s behavioral health can wax and wane in-between or during clusters of seizures, logistical challenges relating to differing supervising teams, and in our case, psycho-social and cultural issues. Our patient is 21-year-old male from Cameroon, who has lived in the US since 2008. The patient was diagnosed with focalized seizures at the age of 9, and the parents opted for medical management over lobectomy. During adolescence, the patient reportedly began suffering from MDD and was hospitalized at Cincinnati Children’s Hospital. The patient reported to AU Emergency Department in October of 2016 for witnessed, generalized seizures, reportedly for running out of medicine. On repeated visits, the patient’s father reported that the patient had not showered in months and had a flat, depressed affect. The patient admitted to depression with a prior suicide attempt and recent non-compliance; he was later discharged with outpatient follow-up. Ten months later, the patient was sent to an inpatient psychiatric hospital for psychotic behavior and was treated for hallucinations. He was readmitted a few days after discharge for poor sleep and staring off into space, notably displaying a high risk of aggression. He was readmitted a few days after his next discharge for persisting psychotic symptoms. The patient became non-compliant due to religious rituals and complained of seizures though his EEG was normal. Eventually, the patient was started on clozapine and improved. There exists a well-known association between epilepsy and psychosis, with temporal lobe epilepsy more closely associated with psychosis than other forms of epilepsy. In this case, there are additional risk factors including hippocampal sclerosis and early age at epilepsy onset. In this patient, there is substantial evidence to suggest interictal psychosis, given the delay in presentation between psychotic symptoms and onset of epilepsy. This is but one example that highlights the connection between seizures and psychosis not to mention the importance of an interdisciplinary course when managing such patients.