[Pharmacological treatment of psychosis in epilepsy]

Criminal Liability and Epilepsy: A Case Report of a Postictal Attempted Homicide from Tunisia

INTRODUCTION

Epileptic patients charged with a serious offense may be referred by courts for forensic psychiatric examination, which may pose a legal challenge. Therefore, a detailed examination is necessary to assist the courts in making the right decision.

METHOD

We present the case of a 30-year-old Tunisian male with temporal epilepsy who exhibited an inadequate response to the treatment. The patient attempted to kill his neighbor after a cluster of seizures, showing apparent post-ictal aggression. An anti-epileptic treatment was reintroduced a few days after the detention followed by forensic psychiatric examination three months afterwards.

RESULTS

On the forensic examination, the patient's thought process was clear with no evidence of a thought disorder or a psychosis. Both medical and psychiatric opinions stated that the attempted homicide was due to a post-ictal psychosis. The patient was transferred to a psychiatric facility for further management as he was found not guilty by reason of insanity.Conclusion:This case report illustrates the difficulties that experts may encounter in establishing criminal liability after an aggressive behavior associated with epilepsy. It highlights some shortcomings in theTunisian law that should be addressed to ensure the fairness of the legal process.

A Case of Complex Partial Seizures Presenting as Acute and Transient Psychotic Disorder

Introduction

Complex partial seizures are focal (CPS) (i.e., start in one area of the brain) and associated with impairment in consciousness. Most of them arise in the temporal region and are characterized by aura, impaired consciousness, and automatisms. CPS that arise in temporal region are most often misdiagnosed as primary psychiatric illness.

Case Report

A 25-year-old male presented with fluctuations in consciousness, aggressive behaviour, hallucination, and delusions of grandeur lasting a few hours. He was diagnosed with acute and transient psychotic disorder according to ICD10 criteria and was treated with intramuscular haloperidol 10mg BID followed by oral olanzapine 10mg. Computed tomography of brain and electroencephalogram were normal. After 15 days he presented again to the outpatient department with complaints of aggressive behaviour and sensory misinterpretations. Video electroencephalogram was recommended, which was not done due to financial constraints. The diagnosis was reconsidered and he was started on oral carbamazepine due to high clinical suspicion, of complex partial seizures, in spite of lack of EEG evidence. He responded well to antiepileptic and symptom remission has maintained well.

Conclusion

Patients presenting with psychosis need careful diagnostic evaluation for other possibilities.

Mitochondrial Respiration Chain Enzymatic Activities in the Human Brain: Methodological Implications for Tissue Sampling and Storage

Mitochondrial respiratory chain complexes enzymatic (MRCCE) activities were successfully evaluated in frozen brain samples. Epilepsy surgery offers an ethical opportunity to study human brain tissue surgically removed to treat drug resistant epilepsies. Epilepsy surgeries are done with hemodynamic and laboratory parameters to maintain physiology, but there are no studies analyzing the association among these parameters and MRCCE activities in the human brain tissue. We determined the intra-operative parameters independently associated with MRCCE activities in middle temporal neocortex (Cx), amygdala (AMY) and head of hippocampus (HIP) samples of patients (n = 23) who underwent temporal lobectomy using multiple linear regressions. MRCCE activities in Cx, AMY and HIP are differentially associated to trans-operative mean arterial blood pressure, O2 saturation, hemoglobin, and anesthesia duration to time of tissue sampling. The time-course between the last seizure occurrence and tissue sampling as well as the sample storage to biochemical assessments were also associated with enzyme activities. Linear regression models including these variables explain 13-17 % of MRCCE activities and show a moderate to strong effect (r = 0.37-0.82). Intraoperative hemodynamic and laboratory parameters as well as the time from last seizure to tissue sampling and storage time are associated with MRCCE activities in human samples from the Cx, AMYG and HIP. Careful control of these parameters is required to minimize confounding biases in studies using human brain samples collected from elective neurosurgery.

Aspectos epidemiológicos e relevância dos transtornos mentais associados à epilepsia

Epilepsia é o mais freqüente transtorno neurológico sério, atingindo 50 milhões de pessoas no mundo, 40 milhões delas em países em desenvolvimento. Embora seja um problema predominantemente tratável, nestes países a maioria dos pacientes permanece sem tratamento. Provavelmente, uma das principais causas para isto seja o estigma que atinge as pessoas com epilepsia. Tal fato se agrava ainda mais quando à epilepsia se associam os transtornos mentais, que ocorrem com prevalência aumentada. Os pacientes com epilepsia e transtornos mentais sofrem o que chamamos de "duplo estigma", que freqüentemente os deixa sem tratamento. É provável, particularmente em países em desenvolvimento, que psiquiatras se defrontem com pacientes com epilepsia nos diferentes locais de atendimento. O presente estudo tem como objetivo revisar a epidemiologia dos transtornos mentais associados à epilepsia, determinando a lacuna de tratamento e o impacto destes transtornos na qualidade de vida dos pacientes.