Organic psychosis improving after a seizure

To the Editor

This case, which to our knowledge has never been reported in the literature, concerns a 32-year old man with organic psychosis secondary to traumatic brain injury (TBI), whose index seizure led to improvement of psychosis.

Raised by a supportive family, he abused substances as a teenager but remained a productive worker, living independently.

In his 20s, he had a motor vehicle crash resulting in a TBI. Despite executive function impairment, he was able to continue working.

Two years after the crash, he became irritable, aggressive and eventually psychotic, experiencing troubling hallucinations and paranoia.

He responded well to treatment, but non-compliance led to several relapses. In the end, he was unable to work and moved back to live with his parents, where he isolated himself and became dependent on alcohol.

He was referred for admission by the Intensive Community Outreach Team. Clinically, he was thin, dishevelled and perplexed, smiling and laughing inappropriately. His speech was slurred. He was experiencing referential phenomena and multi-modal hallucinations. Insight was preserved, and there was passive suicidal ideation. Repeat magnetic resonance imaging (MRI) was identical to previous scans, showing punctate lesions in frontal and parietal regions.

Titration of amisulpride led to a gradual improvement, although he continued to isolate himself. Co-morbid depression was diagnosed, and he was treated with fluoxetine.

During a multidisciplinary meeting with his parents present, the patient suffered an index tonic–clonic seizure and was treated with clonazepam and levetiracetam.

He was moved to a medical ward for further assessment, where his mental state was found to have dramatically improved: he was sociable and interactive, speaking normally and free from perceptual disturbance. The former symptoms did recur days later but to a lesser extent. The patient was discharged not long after this with appropriate follow-up.

TBI can lead to neurological and psychiatric symptoms with impact on relationships and employment and co-morbid depression and anxiety. In all, 15% attempt suicide within 5 years of the injury (Fann et al., 2009).

Psychosis after TBI is rare compared with depression (>1% vs 25%). Treatment should include atypical antipsychotics at one-third the usual dose, titrating slowly upwards (Schwarzbold et al., 2008).

The use of electroconvulsive therapy (ECT) for psychosis of any aetiology is controversial; there are no reports of its use in TBI psychosis. It has been used safely, however, in TBI depression, with only transient side effects (Kant et al., 1999).