Psychotic Disorders Induced by Antiepileptic Drugs in People With Epilepsy
Psychotic Disorders Induced by Antiepileptic Drugs in People With Epilepsy
Psychotic Disorders Induced by Antiepileptic Drugs in People With Epilepsy
doi:10.1093/brain/aww196
| 1
1 Departments of Medicine and Neurology, The Melbourne Brain Centre, The University of Melbourne, The Royal Melbourne
Hospital, Victoria, Australia
2 Department of Neurology, The First Afliated Hospital, Sun Yat-sen University, Guangzhou, China
3 Melbourne Neuropsychiatry Centre, The University of Melbourne, The Royal Melbourne Hospital, Victoria, Australia
Received April 6, 2016. Revised May 30, 2016. Accepted June 20, 2016.
The Author (2016). Published by Oxford University Press on behalf of the Guarantors of Brain. All rights reserved.
For Permissions, please email: [email protected]
Antiepileptic drug treatment can induce psychosis in some patients. However, there are no agreed denitions or diagnostic criteria
for antiepileptic drug-induced psychotic disorder in the classication systems of either epileptology or psychiatry. In this study we
investigated the clinical spectrum of antiepileptic drug-induced psychotic disorder in patients with epilepsy. The medical records of
all patients with epilepsy who were diagnosed by a neuropsychiatrist as having a psychotic disorder at the Royal Melbourne
Hospital from January 1993 to June 2015 were reviewed. Data were extracted regarding epilepsy and its treatment, psychotic
symptoms prole and outcome. The diagnosis of epilepsy was established in accordance to the classication system of the
International League Against Epilepsy while that of psychotic disorder was made according to the Diagnostic and Statistical
Manual of Mental Disorders, 5th Edition and the proposal on neuropsychiatric disorders in epilepsy. Patients with antiepileptic
drug-induced psychotic disorder were compared to those with psychotic disorders unrelated to antiepileptic drugs assessed over the
same period (non-antiepileptic drug induced psychotic disorder group). Univariate comparisons were performed and variables with
a value of P 5 0.1 were selected for the multivariate logistic regression analysis. The records of 2630 in-patients and outpatients
with epilepsy were screened, from which 98 (3.7%) with psychotic disorders were identied. Among these, 14 (14.3%) were
diagnosed to have antiepileptic drug-induced psychotic disorder. Excluding one patient who developed psychosis after valproate
withdrawal, 76.9% in the non-antiepileptic drug induced psychotic disorder group were female and the percentage of temporal
lobe involvement was higher in the non-antiepileptic drug induced psychotic disorder group (69.2% versus 38.1%, P 5 0.05).
Current use of levetiracetam was higher in antiepileptic drug-induced psychotic disorder group (84.6% versus 20.2%, P 5 0.01)
while use of carbamazepine was higher in the comparator group (15.4% versus 44.0%, P 5 0.05). Multivariate logistic regression
conrmed four factors associated with antiepileptic drug-induced psychotic disorder: female gender, temporal lobe involvement and
use of levetiracetam, and a negative association with carbamazepine. Disorganized behaviours and thinking were more common in
the antiepileptic drug-induced psychotic disorder group (100% versus 72.6% and 76.9% versus 38.1%, respectively; P 5 0.05).
The percentage of continuous treatment with antipsychotic drugs was lower in the antiepileptic drug-induced psychotic disorder
group (15.4% versus 66.7%, P 5 0.01). No patients experienced a chronic course in antiepileptic drug-induced psychotic disorder
group whereas 40.5% did in non-antiepileptic drug induced psychotic disorder (P 5 0.05). Our ndings indicated that one in seven
patients with epilepsy who developed psychosis had antiepileptic drug-induced psychotic disorder. In these patients, female gender,
temporal lobe involvement and current use of levetiracetam were signicantly associated with antiepileptic drug induced psychotic
disorder compared to other types of psychosis, while carbamazepine had a negative association. Disorganized behaviours and
thinking were predominant in antiepileptic drug-induced psychotic disorder. Patients with antiepileptic drug-induced psychotic
disorder differed from non-antiepileptic drug-induced psychotic disorders in having better outcome.
Z. Chen et al.
Introduction
| 3
Psychotiic disorder*
Specic to Epilepsy
bstance/medicaaon induced
Sub
psychoc dissorder*
Yes
o
No
Cormorb
bid schizophren
nia
/schizophreniform disord
der#
Psycho
osis of epilepsyy
Interictal psycho
osis
Yes
Posctal psychosiis
of epilepsy#
AEED-induced psyychoc
disorder
No
Other
sub
bstance/medicaaoninduced
psycho
i
oc
disorder
Figure 1 Diagnosis scheme of psychotic disorders related to epilepsy modified from DSM-5 and the proposal by ILAE
Commission on Psychobiology of Epilepsy. *As per DSM-5 (American Psychiatric Association, 2013); #as per ILAE proposal
(Krishnamoorthy et al., 2007); zdefined in this study.
Z. Chen et al.
AIPD
Delusions, hallucinations, disorganized thinking and grossly disorganized or abnormal motor behaviour.
At least delusion or hallucination must be present.
The duration of the psychotic episodes lasted at least 1 day.
The severity reached the level that impaired patients social or occupational function.
The psychotic symptoms developed during or soon after the exposure to an AED or the withdrawal.
Delusions, hallucinations, disorganized thinking and grossly disorganized or abnormal motor behaviour.
At least delusion or hallucination must be present.
The duration of the psychotic episodes lasted at least 1 day.
The severity reached the level that impaired patients social or occupational function.
Psychotic episodes are independent with seizures.
Post-ictal psychosis
Delusions, hallucinations, disorganized thinking and grossly disorganized or abnormal motor behaviour.
At least delusion or hallucination must be present.
The duration of the psychotic episodes lasted at least 1 day.
The severity reached the level that impaired patients social or occupational function.
The psychotic episodes occur after a lucid interval following clusters of seizures.
Delusions, hallucinations, disorganized thinking and grossly disorganized or abnormal motor behaviour.
At least delusion or hallucination must be present.
The duration of the psychotic episodes lasted at least 1 month.
The severity reached the level that impaired patients social or occupational function.
No distinguishing features separate it from those seen in general population.
Delusions, hallucinations, disorganized thinking and grossly disorganized or abnormal motor behaviour.
At least delusion or hallucination must be present.
The duration of the psychotic episodes lasted at least 1 day.
The severity reached the level that impaired patients social or occupational function.
The psychotic symptoms developed during or soon after the exposure to substance/medication or the withdrawal except AED.
Statistical analysis
Data were presented as n (%) for categorical/qualitative variables
or mean standard deviation (SD) or median (interquartile
range, IQR) for continuous/quantitative variables. Cases were
patients with AIPD. Controls were the patients with epilepsy
and psychotic disorders unrelated to AEDs assessed over the
same period (non-AIPD group). Clinical variables of epilepsy
and psychotic disorder were compared between the AIPD
group and the non-AIPD group. Univariate comparisons were
performed with t-test, 2 test or Fishers exact test, as appropriate. Univariate logistic regression analyses were performed to
calculate the odds ratios of the variables. Variables with
P 5 0.1 were selected for multivariate logistic regression analysis.
P 5 0.05 was considered to be statistically signicant. Statistical
analyses were carried out using the statistical software package
SPSS 20.0.
Results
Patient characteristics
A total of 98 patients (53 male) with epilepsy who had
experienced psychotic disorders were identied, 22 of
Groups
n (%)
16 (16.3)
59 (60.3)
23 (23.5)
14 (14.3)
33 (33.7)
25 (25.5)
19 (19.4)
7 (7.1)
98 (100)
| 5
F
F
M
F
M
F
2
3
7
8
10
11
12
13
14
16
43
5
23
12
55
88
28
10
7
9
22
Age at
epilepsy
onset
29
27
58
45
23
37
55
89
28
36
36
34
38
38
Age at
psychosis
onset
Tactile
Religious
Aggressive
Aggressive
Aggressive
Auditory,
Referential
tactile
Auditory, visual Referential
somatic
Auditory
Persecutory
Aggressive
Aggressive, un- +
usual social
Persecutory
Auditory
Induced by
antihistamine
Induced by
overdose
of diet
pills
12/m
3/w
1/m
2/m
12/w
2/d
1 (3 m after
stroke)
3/y
1/m
1/612 m
24/d
12/d
1/w
No
L TPO
RT
LT
LF
No
L TFP
L TF
No
R F
R TF
R TFP
LT
Haemochromatosis
Infarction
Craniopharyngioma
Astrocytoma
Unknown
LEV
TPM,2004
LEV,2005
LMT,1996
LMT,2004
LMT
54 d
10 d
3m
33 d
68 d
21 d
1m
LEV
Adjustment
of
culprit
AEDs
600 mg to 400 mg
Olanzapine
1
1
PRM, CLZ
34 m
10 m
1m
8y
1m
6m
(continued)
Droperidol,
haloperidol
Risperidone
CLZ
CLZ
PHT
32 m
Olanzapine
5
1
1
1
2
2
Number of
present
AEDs
5
1
1
1
3
3
Number of
previous
AEDs
Duration APDs
index
psychosis
600
1000 Withdrawn
Interval DMax
to
(mg)
psychosis
onset
Melanoma
Craniopharyngioma
HS
FCD
Presumed genetic
Porencephaly
Combined
AEDs
34/w
RT
HS
Seizures
frequency
before
psychosis
Localization
of the
lesion(s)
Cause of
epilepsy
Culprit
AEDs
Seizure types
Disorganized Previous
thinking
psychotic
history
Disorganized
behaviour
Gender
Patient
ID
6
Z. Chen et al.
CBZ = carbamazepine; d = day; F = frontal; L = left; m = month; P = parietal; O = occipital; T = temporal; y = year; LMT = lamotrigine; LEV = levetiracetam; TPM = topiramate; VPA = valpropic acid.
Patient 5 experienced the relapse of psychosis 2 years after the episode of AIPD. The relapse was caused by non-compliance of AEDs and her divorce, but no epileptic seizures had been observed before the relapse.
Duration of index psychosis: 1 = 17 d; 2 = 830 d; 3 = 16 m; 4 = 46 m.
Outcome: 1 = a single episode; 2 = a relapse; 3 = a chronic course.
1
1
Cease of VPA 28 d
LEV
30 d
Visual
Visual
13
14
Persecutory
Persecutory,
referential
Unusual social
Unusual social
Auditory
Auditory
11
12
+
+
1000 Represcribed
2000 Withdrawn
Olanzapine
3
1
CBZ, LMT
CBZ, CLB
11 y
6m
1
1
2
3
Withdrawn
Withdrawn
500
100
23 d
21 d
LEV
LMT
+
+
Withdrawn
Aggressive,
unusual social
Aggressive
Unusual social
Persecutory
Auditory
10
Persecutory,
grandiose
Religious
Persecutory
Aggressive
Aggressive
Aggressive
Visual
7
8
9
+
+
+
Withdrawn
Withdrawn
Withdrawn
1000
1000
1250
150
2000
2d
9d
5d
6m
10 + d
LEV
LEV
LEV,2008
TPM,2010
LEV
+
Risperidone
3
5y
7m
1
1
2
Olanzapine
2
1
1
14 m
3m
6y
4y
6y
Risperidone
2
VPA, CLB,
PHT
VPA
VPA
VPA, LMT,
TPM, CLZ
LEV
2000 Withdrawn
13 d
LEV
Aggressive
Auditory
6
Interval DMax
to
(mg)
psychosis
onset
Disorganized
behaviour
Disorganized Previous
thinking
psychotic
history
Culprit
AEDs
Adjustment
of
culprit
AEDs
Duration APDs
index
psychosis
2m
| 7
Variables, n(%)
AIPD
(n = 13)a
Non-AIPD
(n = 84)
OR
P-value
Gender: F
Age of onset of epilepsy
Seizure types
Generalized seizures
Focal seizure with impairment
of consciousness or awareness
Focal seizures evolving to a
bilateral convulsive seizure
Aetiology
Genetic
Structural/metabolic
Hippocampal sclerosis
Brain tumour
Malformations of
cortical development
Unknown cause
Lateralization
Left involved
Right involved
Bilateral
Localization
Temporal lobe involved
Febrile convulsion
History of prior psychiatric
disorders
History of prior medication/
substance-induced psychiatric
disorders
Family history of epilepsy
Drug resistance
Brain surgery
Number of previous AEDs
Number of present AEDs
10(76.9%)
16(928)
35(41.7%)
19.5(1031.5)
4.667
1.003
0.033b
0.790
3(21.6%)
9(69.2%)
18(21.4%)
48(57.1%)
0.909
1.688
0.569c
0.549c
6(46.2%)
51(60.7%)
0.555
0.321
1(7.7%)
11(84.6%)
2(15.4%)
3(23.1%)
2(15.4%)
15(17.9%)
47(56.0%)
17(20.2%)
5(6.0%)
12(14.3%)
0.383
4.330
0.717
4.740
1.091
0.323c
0.044b,c
0.510c
0.072c
0.596c
1(7.7%)
22(26.2%)
0.235
0.181c
6(46.2%)
4(30.8%)
3(23.1%)
33(39.3%)
29(34.5%)
22(26.1%)
0.755
0.843
0.441
0.638
0.529c
0.187c
9(69.2%)
2(15.4%)
2(15.4%)
32(38.1%)
4(4.8%)
24(28.6%)d
3.656
3.636
0.455
0.035b,c
0.183c
0.504c
2(15.4%)
2(2.4%)
7.455
0.086c
0(0%)
10(76.9%)
5(38.5%)
3(25)
2(13)
9(10.7%)
55(65.5%)
25(29.8%)
2(13)
2(13)
0.569
1.475
1.336
1.415
0.258a
0.317c
0.369
0.068
0.148
a
Excluding the patient who developed psychosis after withdrawal of valproate (Case 13
in Table 3).
b
Statistically significant.
c
Fishers Exact Test.
d
Among the 24 cases, two had marijuana- or steroid-induced psychotic disorder, two
had depression, one had antisocial personality disorder and the remaining 19 had
comorbid schizophrenia/schizophreniform disorder.
Table 3 Continued
Combined
AEDs
Z. Chen et al.
AIPD
(n = 13)a
4(30.8%)
2(15.4%)
2(28.6%)
1(7.7%)
11(84.6%)
4(30.8%)
3(23.1%)
3(23.1%)
Non-AIPD
(n = 84)
29(34.5%)
37(44.0%)
24(28.6%)
2(2.4%)
17(20.2%)
17(20.2%)
9(10.7%)
7(8.3%)
OR
0.843
0.231
0.455
3.417
21.676
1.752
2.500
3.300
P-value
b
0.529
0.044b,c
0.262b
0.354b
0.001b,c
0.297
0.201b
0.130b
a
Excluding the patient who developed psychosis after withdrawal of valproate (Patient
13 in Table 3).
b
Fishers Exact Test.
c
Statistically significant.
Variables
OR
95% CI
P-value
Female gender
Structural/metabolic epilepsy
Brain tumour
Temporal lobe involvement
History of prior substance/
medication-induced
psychotic disorder
Number of previous AEDs
Current use of levetiracetam
Current use of carbamazepine
26.440
2.504
1.118
27.201
5.314
1.45779.731
0.26423.743
0.06619.069
1.65547.105
0.09014.974
0.027
0.424
0.938
0.021
0.423
0.6641.797
3.730121.431
0.0020.454
0.727
0.004
0.011
Excluding the patient who developed psychosis after withdrawal of valproate (Patient
13 in Table 3).
CI = confidence interval.
AIPD
(n = 13)a
Non-AIPD
(n = 84)
OR
P-value
37(3445)
34(2346.5)
1.018
0.290
16(127)
13.5(1.523)
1.020
0.365
1.2(0.54.3)
2.7(1.47.3)
0.858
0.127
11(84.6%)
8(61.5%)
3(23.1%)
2(15.4%)
11(84.6%)
7(53.8%)
3(23.1%)
1(7.7%)
2(15.4%)
2(15.4%)
13(100%)
67(79.8%)
58(69.0%)
15(17.9%)
2(2.4%)
69(82.1%)
52(61.9%)
21(25.0%)
4(4.8%)
6(7.2%)
4(4.8%)
61(72.6%)
1.396
0.717
1.380
7.455
1.196
0.718
0.900
1.646
2.333
3.636
0.510b
0.402
0.449b
0.086b
0.593b
0.396
0.594b
0.525b
0.295b
0.183b
0.034b,c
11(84.6%)
4(30.8%)
10(76.9%)
2(15.4%)
2(15.4%)
5(38.5%)
54(64.3%)
7(8.3%)
32(38.1%)
22(26.2%)
17(20.2%)
37(44.0%)
3.056
4.889
5.417
0.512
0.717
0.794
0.209a
0.038c
0.014b,c
0.509b
0.510b
0.473
6(46.2%)
5(38.5%)
2(15.4%)
0
1(7.7%)
19(22.6%)
13(15.5%)
23(27.4%)
29(34.5%)
7(8.4%)
0.905
0.013c
0.705b
7(53.8%)
1(7.7%)
2(15.4%)
68(81.0%)
22(26.2%)
56(66.7%)
0.275
0.235
0.091
0.030c
0.131b
0.001b,c
7(53.8%)
6(42.9%)
0
33(39.3%)
17(20.2%)
34(40.5%)
0.011c
a
Excluding the patient who developed psychosis after withdrawal of valproate
(Patient13 in Table 3).
b
Fishers Exact Test.
c
Statistically significant.
APD = antipsychotic drug.
1.093
64.672
0.030
Discussion
| 9
10
In the proposal by ILAE, clinical features of psychotic disorders in epilepsy may include auditory hallucination and/
or paranoid delusions (Krishnamoorthy et al., 2007). In
DSM-5, the diagnostic criteria of substance/medicationinduced psychotic disorder consist of delusions and hallucinations. Disorganized speech and grossly disorganized
behaviour are the diagnostic criteria of brief psychotic disorder but not specically of substance/medication-induced
psychotic disorder.
We reviewed all the four categories of symptoms in both
groups and found no differences about the two core symptoms of psychotic disorders, i.e. hallucinations or delusions.
However, the AIPD group showed higher occurrence of
grossly disorganized behaviours and disorganized thinking
compared with the non-AIPD group. This is consistent with
previous reports of high incidence of aggression, agitation
or irritability with certain AEDs, such as 2.724.4% with
topiramate (Elterman et al., 1999; Mula and Trimble,
2003; Weintraub et al., 2007), 2.312.5% with levetiracetam (Mula et al., 2003; de la Loge et al., 2010), and 1.3
6.1% with lamotrigine (Weintraub et al., 2007; Labiner
et al., 2009). In contrast, the prevalence of psychosis was
relatively low, as 1.56.3% with topiramate (Mula and
Trimble, 2003), 1.01.3% with levetiracetam (Mula
et al., 2003; Weintraub et al., 2007) and 0.4% with lamotrigine (Weintraub et al., 2007). Therefore, in case of
psychosis with prominent abnormal behaviours in patients
with epilepsy, AIPD should be taken into consideration.
Disorganized thinking was seldom reported in previous studies. In a European multicentre parallel-group double-blind
trial of zonisamide as add-on treatment, the presence of
disorganized thinking was statistically signicant compared
with placebo (Schmidt et al., 1993). Hence the presence of
disorganized thinking or speech should raise the suspicion
of AIPD.
Follow-up observation showed that AIPD had a generally
better outcome than that of the other epileptic psychoses.
Conclusion
AIPD was common among epilepsy patients who develop
psychotic symptoms. In our study one in seven patients
with epilepsy who presented with psychosis had AIPD. In
these patients, female gender, temporal lobe involvement
and current use of levetiracetam were signicantly associated with AIPD compared to other types of psychosis,
while carbamazepine had a negative association.
Disorganized behaviours and abnormal disorganized thinking were predominant symptoms of AIPD. AIPD had an
overall better outcome than that of other psychotic disorders in people with epilepsy.
Funding
Z.C. was supported by the Australian and New Zealand
Association of Neurologists (ANZAN) Bayer Asia Pacic
Region Neurology Educational Grant.
References
Adams SJ, OBrien TJ, Lloyd J, Kilpatrick CJ, Salzberg MR,
Velakoulis D. Neuropsychiatric morbidity in focal epilepsy. Br J
Psychiatry 2008; 192: 4649.
Z. Chen et al.
| 11