Forced normalization phenomena in outpatient clinic for epilepsy
Trevisol-Bittencourt PC 1,2,3, Tomaselli PJ1, Nahoum RG1, Collares CF4, Bittencourt FS2, Tournier MB1, Pioner LM1.
1 Federal University of Santa Catarina, Florianópolis/SC, Brazil
2 Hospital Santa Teresa, São Pedro de Alcântara/SC, Brazil
3 Epilepsy Centre of Santa Catarina, São Pedro de Alcântara/SC, Brazil
4 Intoxication Control Center of the Sao Paulo City Hospital, Brazil
Backgrounds: Epilepsy is a syndrome complex in which the impairment include seizures, sometimes cognitive regression and psychiatric illness as well. The relationship between epilepsy and behavior disorders it’s not clear, but it had been suggested that epilepsy, especially temporal lobe epilepsy, plays an important role in the genesis of manic states. Forced normalization (FN) is an unique condition characterized by brief interictal psychosis or important mood disorders encountered in people suffering from epilepsy. It was first described in 1953 by the Swiss neuropsychiatrist Heinrich Landolt. According to Landolt’s description it is the occurrence of psychiatric symptoms in association with suppression of seizures and EEG becomes more normal or entirely normal, as compared with previously abnormal EEG. Obviously symptoms like these must be distinguished properly from to the well know anti epileptic drugs (AED) side effects.
Methods: A transversal retrospective study of epileptic individuals that presents the FN phenomena. We reviewed the medical records of 1617 patients, who have been followed up as outpatients at a multidisciplinary centre for epilepsy care in southern Brazil. All patients had established diagnosis of epilepsy based on clinical history, EEG and imaging, presented behavior disturbance after a reduction in the total number of spikes by over 50%, or complete seizure control registered associated with normalization of EEG. All patients whose symptoms were attributed to undesirable side effects of AEDs were not included as suffers of this peculiar condition. The psychoses and mood disorder were diagnosed according to criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Epileptic seizures and epileptic syndromes were classified according the proposed by the Commission on Classification and Terminology of the International League Against Epilepsy (ILAE).
Their epilepsy onset was 9,3 years, presenting FN at 34,4 years (Table 3).
The mean of years between epilepsy onset and FN was 25,1 years, stay 31,4 days without seizures or reduction in the total number before the manifestation of FN (Table 4).
The etiology were established based in the clinical history, EEG and imaging – Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) (Table 5).
Most of the patients have severe partial epilepsy. Episodic mood liability with intense aggressivity; major depression complaints and also schizophreniform were seen in the sample (Table 6).
EEG previously showed a frontal and temporal area predominance (Table 7); and during the period of psychiatric disorder showed that their focal epileptiform discharges had disappeared or became close to normal.
The epilepsy syndrome was partial in 16, symptomatic in 5 and cryptogenic in 11. The other 2 patients presented generalized syndrome. Ten patients had complex partial seizures (55,7%) as the predominant seizure type, 3 had simple partial and 2 generalized seizure. Eight (44,5%) were on polytheraphy in the moment of FN. Carbamazepine was the most used (72,2%), sodium valproato (22,2%), phenytoin (16,7%).
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Endereço para correspondência:
Dr.Paulo César Trevisol Bittencourt
Neurologia/Departamento de Clínica Médica/UFSC
88040-970 – Florianópolis/Santa Catarina/Brasil