Rationale: Epileptic seizures may be misdiagnosed if they manifest as psychiatric symptoms. Some temporal lobe epilepsy can be associated with fixed beliefs and hyperreligiosity. Treatment of behavioral manifestations of epilepsy is aimed at the underlying epilepsy with antiepileptic medications. We present a case of temporal lobe epilepsy with auditory hallucinations and fixed beliefs.
Methods: A chart review for case report was conducted. A 31-year-old female with history of anxiety, depression with psychosis (postpartum), previous inpatient psychiatric hospitalization, one episode of generalized tonic-clonicseizure (GTCS) as a teenager, and iron deficiency anemia presented after a manic episode with panic attacks lasting a ”few hours.” She could not clearly point to a trigger but reported that these symptoms happened every night for one and a half months. She also endorsed auditory hallucinations of her mother and grandmother. She also endorsed false fixed beliefs such as “blue and red colors being triggers for something bad happening” and described feeling “like a medium.” There were no witnessed episodes of GTCS in recent years but there were witnessed episodes of patient “blacking out” during conversations. Of note, her family history included schizophrenia, bipolar disorder, autism, depression and anxiety in her brothers and seizure disorder in paternal grandmother and maternal nephew. Patient was initially on sertraline for eightyears after which she was transitioned to aripiprazole two weeks prior to hospitalization; endorsed non-compliance and worsening of symptoms after the transition.
Results: Initial differentials were major depressive disorder with psychosis and post-partum psychosis. Patient was initially admitted to the psychiatric unit where she was restarted on the sertraline 25 mg daily and was placed on quetiapine 50 mg every six hours as needed for agitation, anxiety, psychosis. Her course was complicated by worsening paranoia, fixed beliefs, and bizarre behavior with blacking out during conversations and no recall of the events. Quetiapine dose was increased to 200 mg daily with no improvement. She underwent a brain CT which was negative for any acute intracranial abnormality and EEG for intermittent altered mental status which showed frequent epileptic discharges arising from the left temporal and frontal region and right temporal region. She received Divalproex Sodium and was admitted to medicine for further management. Neurology was consulted and patient received Divalproex Sodium 500 mg twice daily PO. There was improvement in her neuropsychiatric symptoms and repeat EEG showed some improvement. Patient was deemed stable for discharge from neurology and psychiatry stand point and was discharged on divalproex sodium with outpatient follow up.
Conclusions:
The goal of this case report is to highlight the neuropsychiatric manifestations seen in temporal lobe epilepsy including auditory hallucinations, anxiety, depression, mania and panic attacks which can often mimic psychosis and lead to misdiagnosis. Knowledge of symptomatology and high index of suspicion are crucial in preventing misdiagnosis.
Funding: None