Erratum: In the print version of this article, "Who Diagnoses and Treats Epilepsy in Patients With Psychiatric Symptoms?" published in the June 2018 issue of Psychiatric Times, there was an error. In the third paragraph of the article, following the sentence “A few hours after his first dose of thiothixene he became mute and started throwing furniture—his first act of violence," the following should have been inserted: “Repeat EEG the next morning showed definite complex partial seizure.” Thiothixene was stopped without a second dose. In the next paragraph the EEG that was referred to as normal was the third EEG, not the second EEG.
Schizophrenia and bipolar disorder are not diagnosable if the patient has epilepsy that produces hallucinations or delusions. During my career in psychiatry, I have seen several dozen patients whose hallucinations and delusions stemmed from overlooked and untreated epilepsy. When they responded to anticonvulsant medication alone these patients and their families were happy about the change in diagnosis. This article describes how several such patients presented in psychiatric practice. Personal details were obscured to avoid identifiability.
My first patient who had epilepsy with psychiatric symptoms presented early in my residency. The patient was an adolescent from a small town, who claimed he was the leader of a large street gang that was at war with another gang that wanted to kill him. The town’s police chief dismissed that as impossible. His grades had been slipping over the past year—he had been a good student but was now failing. Two years earlier, he had been knocked unconscious by a baseball bat.
His EEG, head CT, and neurological physical examination were normal. He had been calm during the 4 days of counseling in the hospital although his delusions remained. In perplexity my attending and I said to each other “I suppose it’s schizophrenia” and agreed to start him on thiothixene. A few hours after his first dose of thiothixene he became mute and started throwing furniture—his first act of violence. Repeat EEG the next morning showed definite complex partial seizures. Thiothixene was stopped without a second dose.
Two days later, the third EEG was normal without medication. Then, given phenytoin, his delusions and tension disappeared within hours. At repeated follow ups over 2 years, he remained well and his schoolwork improved.
Dr. Swartz is Emeritus Professor of Psychiatry, Southern Illinois University School of Medicine, Springfield, and Affiliate Faculty, Oregon Health & Sciences University.
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