CASE: Unexplained unresponsiveness
One month after being hospitalized with E coli sepsis—and just after completing a course of ciprofloxacin—Mrs. D, a 79-year-old widow, becomes withdrawn and has several days of worsening fatigue, weakness, and somnolence. Within 2 hours of being admitted to the hospital, she becomes flaccid and unresponsive, although she seems to be awake. She has decreased respirations and is intubated.
The neurology team finds her unresponsive to verbal and noxious stimuli, with some resistance to eye opening. Neurologic exam is nonfocal. Cranial nerve testing is intact, muscle strength and reflexes are normal and symmetrical, and sensory function is intact to light touch. MRI, ECG, chest radiography, and laboratory tests—including metabolic and infectious screenings—do not reveal acute pathology. Within hours, Mrs. D becomes much more responsive and is successfully extubated. Her rapid improvement rules out locked-in syndrome.
The next day, Mrs. D has another episode of reduced responsiveness that lasts several minutes and resolves quickly. The neurologist observes this episode—which occurred when Mrs. D’s daughter entered the room—and recommends a psychiatric consultation.
For the past 3 weeks Mrs. D has experienced depressed mood, low energy, poor sleep, memory complaints, and feeling as if her mind was “scattered.” She has stopped attending church, is isolating to her home, and has been hiding valuables because of an irrational fear that she would lose possessions from her estate. Her primary care physician noted markedly reduced speech during recent office visits and agrees with the family that Mrs. D seems depressed.
On psychiatric exam, Mrs. D’s speech is quiet and slow but coherent. Her mood is depressed with a flat affect. Her thought process is goal-directed, and her Mini-Mental State Examination (MMSE) score is 27/30, indicating her cognition is grossly intact.
Mrs. D develops a low-grade fever. Although the physician does not suspect an infection, he prescribes a prophylactic course of levofloxacin, 500 mg/d. After 2 days of monitoring and assessments, the psychiatrist attributes Mrs. D’s presentation to depression, prescribes bupropion, 100 mg/d, and zolpidem, 5 mg at bedtime, and refers her for psychiatric follow-up.
Six days after discharge, Mrs. D’s family brings her to the psychiatric emergency room. They report that since discharge she has remained fatigued and seems confused intermittently. Her depressive symptoms—decreased appetite, anhedonia, poor sleep, and agitation—persist, and her personal care has deteriorated.
The authors’ observations
The psychiatrist attributes Mrs. D’s declining functioning to a worsening mood disorder. Major depression with psychotic features can include:
- fearfulness
- suspiciousness
- delusions of poverty.
Mrs. D’s cognitive and behavioral status fluctuated during her initial medical hospitalization, and on 1 occasion she required intubation. Her confusion worsened after discharge. These aspects of her history, along with worsening psychosis, can indicate seizures.
Psychiatric manifestations of seizures have been recognized for centuries. Partial complex seizures—one of the most common seizure types—have been called “psychosensory” or “psychomotor” seizures because they often include psychiatric symptoms.1
Psychiatric symptoms most often occur with seizures involving the temporal lobe, and limbic system activation adds an affective dimension to perceptual data processed by the temporal neocortex.2 Frontal and parietal lobe seizure foci also are associated with behavior change.
Psychiatric manifestations of seizures can include:
- cognitive problems
- anxiety
- mood/affect, psychotic, and dissociative symptoms
- personality changes (Table 1).2-6
As many as 30% of patients with seizures experience prominent psychiatric symptoms.7 Approximately one-half have comorbid psychiatric syndromes.8
Table 1
Seizure-related psychiatric symptoms: What to look for
| Symptom type | Characteristic features with seizures |
|---|---|
| Cognitive: intellectual function, memory, orientation | Episodic, fluctuating course of changes Amnesia occurs with complex—but not simple—seizures |
| Anxiety | Occurs most often with temporal lobe seizures May appear as full-blown panic attack Agoraphobia is rare Associated seizure features may include disturbed consciousness, automatisms, and hallucinations |
| Mood and affect | Change in affect is often episodic and profound, without many other symptoms associated with major depression or mania |
| Psychotic | Usually manifests as a single symptom, often described as incongruous, fragmentary, or out of context2 Occurs most often with temporal lobe seizures3 Delusions (paranoid, grandiose), forced thinking Hallucinations: auditory, visual, olfactory, tactile, gustatory Negative symptoms (emotional withdrawal, blunted affect) may be more common in frontal lobe seizures4 |
| Dissociative: depersonalization, déjà vu, jamais vu | Symptoms tend to be less extreme than in patients with dissociative identity disorder or PTSD May occur more often in context of panic symptoms with temporal lobe seizures5 |
| Personality changes (in epilepsy) | May be due to underlying frontal or temporal lobe damage Includes anancastic personality, emotionally unstable personality, and Geschwind syndrome (hypergraphia, hyperreligiosity, hyposexuality, and viscous personality style—perseverative and difficult to disengage from conversation)6 |
| PTSD: posttraumatic stress disorder | |