Alternative Psychosis in an Adolescent Girl?

This chapter examines the case of an adolescent girl diagnosed with probable frontal lobe onset seizures. Prolonged video-EEG monitoring studies with scalp and intracranial electrodes failed to identify the exact location of the ictal onset. No abnormalities were identified with high-resolution brain magnetic resonance imaging scans. The patient's seizures had failed to respond to multiple trials of antiepileptic drugs and to vagus nerve stimulation. At the age of 15, after being started on clonazepam (in combination with carbamazepine) and reaching a dose of 1.5 mg/day, her seizures stopped completely. But she developed side-effects, which affected her behavior. During a recent attempt to taper off valproate, the patient developed insomnia, pressured speech, and increased energy. Sertraline was discontinued but these symptoms disappeared only after she was placed back on higher doses of valproate. The psychotic episode that followed a complete cessation of seizure activity could be an example of the phenomenon of "alternative psychosis," but subsequent prolonged seizure-free periods have not resulted in a recurrence of psychotic symptoms or bizarre behavior. Forced normalization has been reported in patients with temporal lobe epilepsy and generalized epilepsy. The psychotic manifestations were identified after a relatively long duration of the seizure disorder.