Alternative psychosis

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As an alternative psychosis is called an extreme course of stage of mental abnormality in underlying epileptic condition. This stage is characterized by a transition between periods of clinically manifest seizures with usually short-term loss of consciousness - with otherwise normal psychological behavior - to other periods with no seizures, but with simultaneous presence of psychological abnormalities. This leads to a change in symptoms with freedom from seizures, but at the same time also to new psychopathological symptoms up to the development of a psychosis . There is a suspicion of an antagonism in that a deterioration in the psychological state must be accepted for the improvement of the epileptic symptoms. The mental abnormalities and disorders on the one hand and the typical seizure symptoms on the other hand are considered epileptic equivalents between which the epileptic clinical picture changes or alternates in certain cases of its course. The term alternative psychosis was coined in 1965 by the Heidelberg psychiatrist Hubertus Tellenbach (1914–1994).

history

The phenomenon of the alternating occurrence of epileptic seizures and mental disorders was already known to the Greek doctor Hippocrates of Kos (around 460-370 BC). The myth of the divine ( ancient Greek νόσημα · ἱερόν · = Latin morbus sacer ) for epilepsy was already rejected by him . Rather, he called for an explanation of this disease by studying the brain. He distinguished attacks caused by hysteria from epileptic attacks. However, these advanced concepts remained ignored by medicine for more than two millennia. It was not until the late 18th and early 19th centuries that European psychiatrists developed new hypotheses about the relationship between seizures and mental disorders. At first, however, they could only refer to the conditions of the institutional system, to the pathological anatomy and to the knowledge of psychopathology . Among them are Wilhelm Griesinger (1817–1868) and Wilhelm Sommer (1852–1900). Griesinger contributed to the systematics of epilepsy through precise descriptions by distinguishing between petit mal seizures and grand mal seizures. Sommer used the term larvated epilepsy , see also Chap. Larval epilepsy . By this he meant a "covert epilepsy" in which epileptics were free from seizures at times when mental disorders occurred. Even with the petit mal seizures described by Griesinger, there are no tonic-clonic seizures with unconsciousness. Rather, twilight states such as Sometimes with myoclonus or nesting movements. The Hungarian psychiatrist Ladislas J. Meduna (1896–1964) drew from this the therapeutic idea of ​​the induction of artificial, pharmacologically or electrically triggered seizures for the purpose of curing psychotic illnesses. He successfully put this concept into practice in the 1930s. - Methodological advances in the knowledge of basic pathophysiological facts resulted from around 1950 also through the development of the EEG . The first description of the “ forced normalization ” in the EEG by Heinrich Landolt (1917–1971) provided a closer look at the functional antagonism between psychosis and epilepsy.

Three levels of consideration

According to the current state of the art, there are three main ways of looking at epileptic seizures:

a) Clinically typical epileptic symptoms,
b) detection of typical EEG changes,
c) Observing psychopathological findings.

While a) and b) are objective symptoms and findings, psychopathological subjective and objective disorders cannot be safely assigned to epilepsy. A strict causal relationship between psychopathology and typical clinical findings is not possible, as a purely coincidental coincidence of symptoms must be considered. It is a fundamental problem of psychosomatics or the mind-body problem , since psychopathological findings are always to be assessed as unspecific. A synopsis of physical and mental findings is necessary in practical psychiatry. The certainty of diagnosing epilepsy increases when several objective parameters match. However, this makes the diagnosis of epilepsy difficult in the case of “forced normalization” (Landolt). The EEG in clinically certain (typical) cases of epilepsy (grand mal) is normal in 5–30%. Even more often, a pathological focus cannot be detected in the EEG in non-generalized epilepsies of the Jackson type or in psychomotor epilepsies.

Larval epilepsy

The concept of masked epilepsy ( synonymous term: masked epilepsy ) is based on the assumption that an epilepsy may be “hidden” behind observed unspecific psychopathological findings. The concept of masked epilepsy is similar to that of masked depression . Here the respective axis symptom is measured (seizure / depression).

According to Uwe Henrik Peters (* 1930), the concept was initially developed by the German doctor Johann Peter Frank (1745–1821), who spoke of "epileptic transformations" (1800). The French psychiatrist Bénédict Augustin Morel (1809–1873) was the first to use the term larvated epilepsy. This term was also used by the London pediatrician George Frederic Still (1868–1941). It was later adopted by the pediatrician HRE Wallis for all recurrent paroxysmal conditions not obviously of epileptic origin.

The suspicion of a masked epilepsy applies in certain cases in which typical epileptic symptoms can be observed in the later course or in the history (interval findings). Even then, however, it is not possible to clearly demonstrate a causal relationship. This is the above-mentioned fundamental problem of psychosomatics. The concept of masked epilepsy, like that of alternative psychosis, is therefore to be viewed as a theoretical construct. This also applies to the above-mentioned designation of the epileptic equivalent . Regular relationships cannot be established. Exceptions are to be emphasized insofar as there are often alternative psychoses that go hand in hand without forced normalization and in which the seizures also persist. There is therefore no strict relationship between epilepsy and psychosis. However, the theoretical notions of an antagonism are supported by the fact that alternative psychoses usually occur due to anti-epileptic medication that is too high or too quickly increased, especially when using ethosuximide . They can be favorably influenced by a reduction in anti-epileptic medication. On the other hand, it is known that antipsychotic drugs ( neuroleptics ) lower the seizure threshold, i. H. increase the tendency to cramp.

Simplifying representation of the antagonism

The antagonistic view of the clinical phenomena of alternative psychosis is illustrated by the following table. As a summary, it refers to the aforementioned sources. Two antagonistic clinical stages occurring in the interval are selected and highlighted in red and green. The EEG findings are also among these findings that occur in the interval course. However, they are not specially highlighted here. Alternative psychoses occur after having achieved freedom from seizures in generalized and partial seizures (partial seizures).

Clinically objective Mentally subjective diagnosis
sensory motorized EEG
(quantitatively complete) loss of consciousness tonic-clonic convulsions typical cramp potentials amnesia Generalized seizure
aura-like psychosensory twilight attack , absence possibly myoclonus typical b / w complexes absent-minded, partial amnesia Partial attack with elementary symptoms
actual twilight attack with vegetative symptoms, double consciousness z. B. Poriomania atypical orderly twilight state Psychomotor attack = partial attack with complex symptoms
inconspicuous inconspicuous forced normalization qualitative change of consciousness Continuity syndrome

Individual evidence

  1. ^ A b c Walter Fröscher: Alternative psychosis and forced normalization . Edited by Dt. Society for Epileptology V. ( dgfe.org accessed on September 21, 2015); (a + b) to para. pathomechanism; (c) to paragraph type of seizure.
  2. ↑ a b c d e f Walter Christian: Clinical electroencephalography. Textbook and old glass. Georg Thieme, Stuttgart 2 1977, ISBN 3-13-440202-5 ; (a) pp. 174, 176 - to the district “Alternative Psychosis”; + Pp. 165, 171, 173 f. - to tax "epileptic equivalents"; (b) p. 164 ff. - on head. “Critique of causal relationship”. (c) p. 161 ff. - on taxation “masked epilepsy”; (d) p. 161 ff. - on res. “George Frederic Still” and “HRE Wallis”; (e) p. 174 f. - Re. “Exclusion ratio epilepsy / psychosis?” (F) pp. 174, 176 - Re. “For and against the concepts of alternative psychosis, epileptic equivalents and masked epilepsy”.
  3. ↑ Hubertus Tellenbach : Epilepsy as a seizure disorder and as a psychosis. About alternative psychoses of paranoid character with "forced normalization" (Landolt) of the electroencephalogram epileptic . In: Nervenarzt , 36, 1965, pp. 190-202.
  4. ↑ a b Bettina Schmitz, Michael Trimble: Psychiatrische Epileptologie. Psychiatry for Epileptologists - Epileptology for Psychiatrists. Thieme, Stuttgart / New York, 2005; ISBN 3-13-133221-2 ; P. V-VI (preface). ( books.google.de )
  5. ^ A b Johann Kugler: Electroencephalography in clinic and practice . 1963. An introduction. 3. Edition. Georg Thieme, Stuttgart / New York 1981, ISBN 3-13-367903-1 ; (a) S. V (Preface) - on the “History of the EEG”; (b) p. 74 - on tax "inconspicuous EEG in epilepsy".
  6. ↑ a b latent epilepsy . In: Ansgar Matthes: Epilepsy. Diagnostics and therapy for clinics and practices . Georg Thieme, Stuttgart 1977, ISBN 3-13-454803-8 ; P. 84 f.
  7. ↑ Concept of causality of the disease . In: Jean Delay , Pierre Pichot: Medical Psychology . Translated and edited by Wolfgang Böcher. 4th edition. Georg Thieme-Verlag, Stuttgart 1973, ISBN 3-13-324404-3 , p. 368 f.
  8. ↑ Gerd Huber : Psychiatry. Systematic teaching text for students and doctors. FK Schattauer, Stuttgart 1974, ISBN 3-7945-0404-6 ; P. 94 - on epilepsy as a physically justifiable disorder with psychopathological symptoms - necessary synopsis of physical and mental findings.
  9. ^ FA Gibbs, EL Gibbs: Epilepsy . In: Atlas of electroencephalography . Volume II. Addison-Wesley, Reading MA 1952.
  10. ^ Ajmone Marsan, C., K. Abraham: Considerations on the use of chronically implanted electrodes in seizure disorders . In: Confinia Neurologica , 27, 1966, pp. 95-110.
  11. ↑ Normal findings in epilsepsy . In: Olga Simon: The electroencephalogram. Introduction and atlas . Urban & Schwarzenberg, Munich 1977, ISBN 3-541-08221-6 , p. 45.
  12. ↑ epilepsy, larvae . In: Uwe Henrik Peters : Dictionary of Psychiatry and Medical Psychology . 3. Edition. Urban & Schwarzenberg, Munich 1984; P. 170 f.
  13. ↑ George Frederic Still : Common Diseases and Disorders of Childhood . 2nd Edition. London 1912.
  14. ↑ HRE Wallis: Masked Epilepsy . Livingston, London 1956.
  15. ↑ Ansgar Matthes: "Masked" and latent epilepsy in childhood . In: Dtsch. Z. Nervenheilk. , 178, 1958, p. 506
  16. ↑ Walter Fröscher, T. Steinert: Alternative psychoses of epilepsy . In: Epileptologia , 15, 2007, pp. 29-40