A Case of Ictal Fear with Various Psychiatric Manifestations and Memory Disturbance in Interictal Stages.Purpose:Ictal emotion corresponds to“affective seizures,” according to the Proposal for Revised Clinical and Electroencephalographic Classification of Epileptic Seizures by the International League Against Epilepsy (ILAE; 1981), and is characterized by the appearance of affective disorders such as fear, depression, pleasure, and anger. In particular, the ictal emotion, in which fear is the most commonly noted emotion, is referred to as“ictal fear.” In the present study, we report a patient with temporal lobe epilepsy, who showed ictal fear associated with various psychiatric manifestations including memory disturbance in the interictal stage that promptly subsided with antiepileptic drug (AED) administration.Case Report:A 24-year-old woman had recurrent episodes fear and anxiety. Family risk factors consisted of major depression in the maternal grandmother, but no familial history of epilepsy. The patient had a history of mumps with fever of 38°C at age 6 years without febrile convulsion. The present illness began around April 1997, when the patient became aware of swelling of the left ear membrane and a tinnitus-like noise, with an occasional feeling of her entire body floating in air. On March 6, 2000, severe giddiness suddenly developed, and from April of that year, she had pronounced drowsiness and hypersomnia. From January 2001, her giddiness and feeling of dizziness became marked, and she was overcome by an unpleasant feeling from January 16 to 17. From January 18 to 19 and on February 7 and 8 she manifested emotional lability. She had a depressive mood on February 22 and reversed to an elated mood the following day. On March 6, she experienced sudden severe left ear pain, which was diagnosed as migraine at a department of neurosurgery in another hospital. In addition, from about this time, anxiety and vague feeling of panic developed. From around April, she experienced autonomic seizures lasting 20 s, characterized by abnormal sensations of gooseflesh and coldness extending from the left posterior neck to cheek. These seizures occurred at a frequency of 20 to 30 times a day. Furthermore, she showed increased anxiety, depressive mood, and palpitations with feeling of left chest constriction in the interictal period. On May 25 and 26, autonomic seizures consisted of sudden severe nausea, and from June were characterized by a feeling of gooseflesh and coldness extending from the upper to lower arms bilaterally. The duration of these seizures was 10–20 s, and the frequency was 10 times/day. From the same period, she had various psychiatric symptoms such as hypobulia, declining activity, and a sense of guilt in the interictal period. From around August, her unpleasant feeling gradually worsened, and her voice became low, and her actions became slow. Furthermore, hypochondriacal and depressive symptoms became more marked, and appetite decreased, with the appearance of insomnia and suicidal ideation. On August 28, generalized tonic–clonic seizures (GTCSs) occurred twice, and after the first GTCS, she had ictal fear lasting 60–120 s, which occurred at a frequency of 4 to 5 times per day. The experience of ictal fear was engendered by the patient imagining a scene in which she was enveloped in the dark by some fearful thing and pursued by something of an unknown nature. Subsequently, her parents witnessed her screaming during the ictal fear. On September 21, she was admitted to our hospital for detailed examinations and treatment.Both the ictal and interictal symptoms improved with increasing doses of carbamazepine (CBZ). Clinical examinations revealed no particular hematologic or biochemical abnormalities, and the neurologic examination was normal. Psychometric examination showed FIQ, 87[verbal IQ (VIQ) 94; performance IQ (PIQ), 82] on the WAIS-R, with procedural memory showing a learning effect in both mirror drawing and tower of Hanoi puzzle. Interictal EEGs showed generalized high-amplitude slow-burst 6- to 7-Hz train, which disappeared after CBZ administration. Fluid-attenuated inversion recovery (FLAIR) images of sagittal magnetic resonance imaging (MRI) revealed high signal intensity areas in bilateral amygdala and hippocampal regions.[99mTc]-HMPAO single-photon emission computed tomography (SPECT) images depicted hypoperfusion findings in the right medial temporal lobe.Discussion:This case had onset of epilepsy at age 20 years, and her symptoms were initially diagnosed as migraine and anxiety disorder. At the time of admission to our hospital, memory disturbance and various psychiatric symptoms such as a sensation of fear, anxiety, and depression were noted, so that the presence of anxiety disorder and dissociative disorder was suspected. However, based on the EEG and brain-imaging findings, a diagnosis of epilepsy was made. The notable features in this case are summarized as follows: (a) simple partial seizures consisting primarily of ictal emotions associated with the experience of fear; (b) interictal symptoms including various psychiatric manifestations such as manic–depressive and anxiety symptoms and memory disturbance; (c) abnormal MRI and SPECT images in the medial temporal lobes, possibly compatible with hippocampal sclerosis; and (d) rapid amelioration of the ictal and interictal symptoms with CBZ administration, accompanied by the disappearance of the generalized high-amplitude slow waves on the EEG.Conclusions:These findings suggest that ictal emotion is induced by localized focal seizures in the hippocampus and the adjacent limbic system including the amygdala. Moreover, the fact that CBZ administration ameliorated the interictal symptoms comprising various psychiatric manifestations and memory disturbances suggests that functional dysfunction associated with enhanced interictal discharges in the limbic system caused the interictal symptoms. Etiologic Analysis of Epilepsy in Children.Purpose:A population-based neuroepidemiologic survey of childhood epilepsy was conducted in the Okayama Prefecture on December 31, 1999, as the prevalence day. We analyzed the presumptive causes in this survey to clarify the causes of childhood epilepsy in the general population.Methods:The segment of the population younger than 13 years in the Okayama Prefecture on the prevalence day was 250,997. The lists of children with epilepsy were collected from the medical records of 84 hospitals and clinics in and around Okayama Prefecture, and 2,220 cases were identified; the prevalence rate was 8.8 per 1,000. In this study, EEGs were examined in 99.3% of the cases. The 2,220 cases, however, included 889 cases with single seizures or seizures induced by fever, because they were diagnosed as epilepsy by definite EEG abnormalities. Generally, cases of single seizures or seizures induced by fever are excluded from epileptic seizures in epidemiologic studies. When the 889 cases are excluded, the prevalence rate for the 1,331 cases decreased to 5.3 per 1,000. The former 2,220 cases and the latter 1,331 cases were designated as group A and group B, respectively. An etiologic analysis was carried out in the two groups.Results:Group A: (a) Presumptive causes were identified in 816 (37.8%) cases, and 1,341 (60.4%) cases had unknown etiology. The other 63 (2.8%) cases were excluded from the total because of a lack of etiologic information. (b) Predisposition to convulsions or epilepsy within second-degree relatives was found in 20.3%. (c) Prenatal causes consisted of genetic neurologic diseases in 1.4%, chromosomal aberrations or malformations in 2.0%, cerebral dysgenesis in 2.0%, intrauterine infection in 0.1%, and congenital hydrocephalus in 0.4%. (d) Perinatal causes consisted of premature birth with a low birthweight in 3.2% and neonatal asphyxia or abnormal delivery in 4.8%. (e) Postnatal causes consisted of encephalitis or meningitis in 2.7%, intracranial hemorrhage or vascular disorder in 0.9%, head trauma in 0.6%, and brain tumor in 0.2%. Group B: (a) Presumptive causes were identified in 562 (42.2%) cases, and 735 (55.2%) cases had unknown etiology. The other 34 (2.6%) cases were excluded from the total because of a lack of etiologic information. (b) Predisposition to convulsion or epilepsy within second-degree relatives was found in 18.9%. (c) Prenatal causes consisted of genetic neurologic diseases in 2.1%, chromosomal aberrations or malformations in 2.8%, cerebral dysgenesis in 2.6%, intrauterine infection in 0.2%, and congenital hydrocephalus in 0.6%. (d) Perinatal causes consisted of premature birth with a low birthweight in 3.9%, and neonatal asphyxia or abnormal delivery in 6.8%. (e) Postnatal causes consisted of encerder in 1.4%, head trauma in 0.8%, and brain tumor in 0.3%. (f) No significant differences in the prevalence of etiologic factors were noted between groups A and B.Conclusions:These findings indicate the etiologic distribution of childhood epilepsy in the general population. Comparison of Neuropsychological Findings Before Temporal Lobectomy Between Patients with Both Amygdalohippocampal Seizures and Psychotic Manifestations and Patients with Only Seizures.Purpose:The objectives of the study were to classify patients with amygdalohippocampal seizures into two groups according to the status of psychotic manifestations such as delusion and hallucination and to compare the neuropsychological findings.Subjects and Methods:We reviewed the neuropsychological findings of 28 patients (14 male, 14 female patients) who underwent temporal lobectomy and classified them into patients with psychotic manifestations such as hallucination and delusion (group P) and patients without them (group N). All patients underwent neuropsychological examinations including the Japanese Wechsler Adult Intelligence Scale–Revised (WAIS-R), Minnesota Multiphasic Personality Inventory (MMPI), Japanese Wechsler Memory Scale–Revised (WMS-R), verbal paired-associates learning test, story recall test, Benton's visual retention test, Rey-Osterrieth's complex figure test, Kana pick-out test, Japanese Raven's colored progressive matrices, and Japanese western aphasia battery.Results:The 28 patients who underwent anterior temporal lobectomy had a mean age at surgery of 36.0 years and mean age at seizure onset of 13.8 years. They were composed of 15 patients with right-sided temporal resection and 13 patients with left-sided temporal resection. According to psychotic manifestations, we classified them into the groups P and N. Group P group consisted of seven patients (25% of all patients) whose mean age at surgery was 39.6 years and mean age at seizure onset was 10.9 years. Group N consisted of 21 patients (75%) whose mean age at surgery was 34.8 years and mean age at seizure onset was 14.8 years. No statistically significant differences were found in the ages at surgery and seizure onset. The scores, determined by using Benton's visual retention test (fail), were higher (p<0.05) in group P than in group N. The scores determined by using the depression (D), psychopathic deviation (Pd), paranoia (Pa), psychasthenia (Pt), schizophrenia (Sc) scales of MMPI were higher (p<0.05) in group P than in group N. The scores of the WMS-R attention/concentration test, verbal paired-associates learning test, story recall test, and Benton's visual retention test (pass) (p<0.05) were higher in group N than in group P. The patient background of group P was as follows: Group P consisted of one male and six females; three of whom had febrile seizures. One patient had right-sided temporal resection, and six patients had left-sided temporal resection. The mean age of psychotic manifestation development was 33.4 years. The psychotic manifestations were characterized by visual hallucinations in three patients, and delusion of reference and persecution in seven patients. The average number of antiepileptic drugs (AEDs) used was 2.9, and the major AEDs were phenytoin, carbamazepine, zonisamide, and clonazepam. Four patients were married, two patients were unmarried, and one patient was divorced. The educational level was junior high school in two patients, high school in three patients, and technical college in two patients. The WAIS-R IQ was 81.9; verbal IQ was 82.6; and performance IQ was 84.6.Conclusions:Group P was distinguished from group N by the clinical scales such as the D (p<0.05), Pd (p<0.05), Pt (p<0.05), Pa (p<0.01), and Sc (p<0.01) scales of the MMPI. Thus the MMPI is a useful tool for determining patients with psychotic manifestations. The attention/concentration results in the WMS-R, verbal paired-associate learning test (hard), story recall test, and Benton's visual retention test findings revealed that patients with both amygdalohippocampal seizures and psychotic manifestations had more severe memory and attention impairments than did the patients with only seizures. Epilepsy: The Clinical Profile, Outcome, and Epilepsy-Related Psychosis.Purpose:This prospective study was conducted to evaluate the clinical profile and the prognostic factors in 1,000 epilepsy patients attending a tertiary care hospital from the year 1996 to 2001.Methods:The evaluation in all cases included clinical assessment, intelligence testing with the Stanford–Binet scale, metabolic workup, EEG, and computed tomography (CT) scan. Magnetic resonance imaging (MRI) and MR angiography (MRA) were done in selected patients. Patients were classified as per the International League Against Epilepsy (ILAE) classification and were followed up with the primary end point of a 1-year seizure-free period. Epilepsy-related psychosis was included as a study parameter in the final 3 years of the study period (500 patients). The psychoses were classified into postictal (immediately after seizures, distinct from the delirious, confusional state after seizures), interictal (with a lucid interval of normal mentation of≥24 h between seizure and psychosis), and chronic psychosis (of>3 months' duration, present all the time). Statistical analysis was done with aχ2 test wherever relevant.Results:The ages of the patients ranged from 7 months to 74 years, with a mean of 30± 8 years; 55% of them were male patients. Of the cases, 59% had localization-related epilepsy, whereas 41% had generalized epilepsy. Myoclonic epilepsy was seen in 5%, and absence seizures, in 3%. On analyzing the etiology of seizures, 66% were cryptogenic or idiopathic, 16% had neurocysticercosis, 8% had tuberculosis, 3% were postinfective, 3% had a vascular etiology, 2% had congenital abnormalities, and 2% were posttraumatic. Twelve (2.4%) patients were diagnosed as epilepsy-related psychosis, of whom eight were male patients. The majority (seven of 12) had complex partial seizures. Postictal psychosis was diagnosed in four patients; seven had acute interictal psychosis, and one patient had chronic psychosis. The interictal and chronic psychoses were schizophreniform, whereas the postictal psychoses were nonspecific. EEG showed a temporal lobe focus in all seven of the complex partial seizures with psychosis and an extratemporal focus in three patients. Two of the patients had normal EEGs. Neuroimaging abnormalities seen in 10 patients included gliosis (three), calcified granulomas (three), medial temporal sclerosis (two), and nonspecific findings (two). Two patients had normal imaging studies.Conclusions:No significant difference was seen in seizure control between the subgroups of patients with generalized and localization-related epilepsy. Our results are in agreement with the recent studies that suggest that the types and causes of seizures are not significantly related to the seizure control. The most predictive factors for good outcome were younger age (p<0.05) and good intellectual development (p<0.05). Earlier studies found 0.5–9% of patients with epilepsy to have epilepsy-related psychosis. Epilepsy-related psychosis was seen in 2.4% of our patients. This factor should be kept in mind by the caregivers of patients with epilepsy. Occupational Ability of Patients with Intractable Epilepsy.Purpose:To examine the occupational ability including interpersonal skills of patients with intractable epilepsy and to identify factors relevant for employment.Methods:Forty-eight patients (36 men, 12 women) with intractable epilepsy were studied. The mean age was 26.6 years (range, 18–49). Average IQ by Wechsler Adult Intelligence Scale–Revised was 61.4 (range, 38–95). Epilepsy diagnoses were symptomatic partial epilepsy, 41; symptomatic generalized epilepsy, six; and idiopathic generalized epilepsy, one. Seizure types were generalized tonic–clonic seizure, 13; complex partial seizure, 29; simple partial seizure, 11; and other seizures, 10. Twenty-one patients had more than one seizure per week. Nineteen patients had seizures with falling that might cause injury. We evaluated the occupational abilities of the patients through observation during occupational therapy and by vocational aptitude tests. At the same time, their employment status 6 to 18 months after leaving the hospital was surveyed. We then compared the abilities of employed patients (Employed) with those of unemployed patients (Unemployed). Fisher's exact test and Mann–WhitneyUtest were used for statistical analyses.Results:(a) Work habits, comprehension, practicality (quickness at work, workmanship), and interpersonal skills were evaluated as normal only in 40%, 6%, 10%, and 23%, respectively, of the patients through observation. The results of vocational aptitude test were generally low. Subsequent employment status was employed, 15; community workshop, five; day care, three; unemployed, 14, and others (including housewife, student), 11. (b) Intelligence scores (IQ; mean± S.D.) were 63.8± 11.1 in the Employed and 63.8± 16.7 in the Unemployed (NS). Comprehension and practicality were evaluated as normal in 13% of the Employed and none of the Unemployed (NS). Overall work habits were evaluated as normal in 67% of the Employed and 7% of the Unemployed (p<0.01). The subitem“asking therapists, greeting” was evaluated as sufficient in 80% of the Employed and 21% of the Unemployed (p<0.01). Interpersonal skills were evaluated as normal in 53% of the Employed and none of the Unemployed (p<0.01); 13% of the Employed and 79% of the Unemployed had a tendency to be isolated from others (p<0.01). As for vocational aptitude tests, the Employed performed better in tests of motor coordination, skilled finger movements, and sorting coins than the Unemployed (p<0.05). Concerning seizure control, none of the Employed and 29% of the Unemployed had seizures with falling during the daytime (NS).Conclusions:Good seizure control, preserved work habits, good interpersonal skills, and skilled motor coots with intractable epilepsy. [ABSTRACT FROM AUTHOR]