INT'L. J. PSYCHIATRY IN MEDICINE, Vol. 22(3)231-237,1992
ICTAL AND PSYCHIATRIC ASPECTS OF SUICIDE IN EPILEPTIC PATIENTS
MARIO F. MENDEZ, M.D., PH.D. ROBERT C. DOSS, B.S. University of Minnesota, St. Paul
ABSTRACT
Objective: To evaluate the ictal and psychiatric aspects underlying the high risk of suicide among epileptic patients. Method We surveyed the records of 1611epileptic patients seen in a neurology clinic during an eight-year period, found four who died by suicide, and characterized their ictal and psychiatric features. Results: All four epileptic patients had partial complex seizures and temporal lobe foci. Two had an associated paranoid schizophrenia with suicidal ideation, and good or improving seizure control at the tine of their deaths. Another patient killed himself during a brief psychotic episode associated with increasing epileptiform discharges. The fourth patient had ictal depression and committed suicide during a flurry of partial complex seizures. Conclusions: These findings suggest that the high suicide rate among epileptic patients has a greater association with psychotic behaviors and psychic auras than with major depression or the psychosocial burden of being epileptic. We further review other reported risk factors for suicide in epilepsy. (Inf7. J. Psychiatry in Medicine 22:231-237, 1992) Key Words: epilepsy, suicide, seizures, psychosis, depression
Epilepsy is associated with an increased risk of suicide. Among all seizure patients, the estimated risk of death by suicide is 5 percent, or about three to four times greater than the general population 111, and, among those with temporal lobe epilepsy, the risk is as much as twenty-five times greater [2]. The reasons for the increased number of epileptic suicides are not clear. Factors that could affect the rate of suicide include: a) psychosocial stressors associated with epilepsy, b) seizure type and frequency, c) psychic auras, and d) the presence of associated psychopathology. In those with epilepsy, unsuccessful suicide attempts are 231 8 1992, Baywood Publishing Co., Inc.
doi: 10.2190/7PD3-C5MM-M0GJ-WJWT http://baywood.com
232 / MENDEZ AND DOSS
frequently associated with borderline personality characteristics [3]; however, successful suicides are not the same as suicide attempts, and may differ in underlying psychopathology. Understanding the underlying seizure and psychiatric relationships of successful suicides could help reduce the high risk of suicide in epilepsy. We investigated the possible contributing factors for suicide among epileptic patients by surveying the medical records of 1611seizure patients evaluated in our neurology clinic at St. Paul-Ramsey Medical Center since January, 1984. Four patients were identified as having successfully committed suicide. CASE REPORTS Patient No. 1
A thirty-three-year-old man had partial complex seizures (PCS) and rare generalized tonic-clonic seizures (TCS) dating from age three. His usual seizure frequency was one or 2 PCS per month characterized by an alteration of consciousness without a preceding aura. During his outpatient evaluations, his mental status and neurological examinations were normal. Electroencephalograms (EEG) showed bitemporal epileptiform discharges, and cranial computerized tomography (CT)scans were unremarkable. Beginning at age seventeen, the patient experienced four or five psychotic episodes of less than two weeks’ duration. These episodes involved sudden agitation, paranoid ideation, auditory hallucinations often urging him to kill himself, and a “compulsion” to commit suicide. In a prior psychotic episode, he attempted to burn himself but sustained only minor burns. During his psychotic episodes, the patient was disoriented, confused, and had increased bitemporal spikes and diffuse slowing on EEG. There were no clear precipitating psychosocial factors for his psychotic episodes, and the patient was not treated with long-term antipsychotic medications. One week prior to his suicide, his anticonvulsant medication was changed from phenytoin to carbamazepine. Two days prior to his suicide, he became suddenly agitated and heard the voice of his dead mother telling him to commit suicide by overdosing on his medications or by jumping in front of an automobile. The patient overdosed on carbamazepine and over-the-counter drugs, was brought to the hospital in a comatose state, and had a fatal cardiorespiratory arrest. Patient No. 2
A thirty-one-year-old man had PCS with epigastric auras and secondarily generalized TCS dating from age twelve. On phenytoin therapy, his frequency of seizures was less than one PCS per month, with a rare nocturnal TCS. He was a disheveled-appearing man with a flat affect and low-average intelligence. His
SUICIDE IN EPILEPTIC PATIENTS / 233
physical examination was unremarkable, CT scan was normal, and EEG showed a right temporal epileptiform focus. The patient had a ten-year history of schizophrenia characterized by paranoid delusions, auditory hallucinations including voices commanding him to harm himself, and a deteriorating psychosocial adjustment. During his acute psychotic stages, he remained under good or improving seizure control and had therapeutic phenytoin levels. The patient had several psychiatric hospitalizations, and was treated with trifluoperazine and thioridazine. His last hospitalization followed an altercation with a co-worker whom he falsely accused of spying on him. At that time, the patient had thought insertion, thought withdrawal, and hallucinations telling him that specific people were the devil. He also reported depressive symptoms, suicidal ideation, and dreams of being in a morgue. Six months later, he was found dead after overdosing on his medications.
Patient No. 3 A thirty-seven-year-old diabetic woman had PCS since age ten, characterized by a sensation of depression followed by an alteration of consciousness with a motionless stare and occasional wandering for up to ninety minutes. These auras of depression were stereotypical, out-of-context, and profound in intensity. After a PCS,the patient had residual depression with prominent suicidal ideation and extreme fatigue. She remained on primidone and carbamazepine with fluctuations in compliance and in anticonvulsant levels. The mental status and physical examinations were remarkable only for obesity, the EEG showed epileptiform activity in the right temporal region, and the cranial CT scans were normal. On the day of her suicide, the patient had three witnessed staring spells. That night, she wandered about her apartment banging on neighbors’ doors. She was later found in a comatose state, and subsequently died. Laboratory data documented an overdose with primidone, carbamazepine, and insulin.
Patient No. 4 At the time of his suicide, a thirty-four-year-old man with childhood-onset PCS had therapeutic carbamazepine levels and a few PCS per month. His examination and cranial CT scans were unremarkable, but a recent EEG documented a left temporal epileptiform focus. Beginning at age twenty-two, the patient had several hospitalizations for paranoid schizophrenia and for suicide attempts by drug overdose. He had delusions of persecution, illogical thinking, deterioration in his work and personal life, and was managed primarily with trifluoperazine. A month prior to his suicide, the patient was hospitalized due to an overdose with a barbiturate. On recovery, he remained seizure-free, but claimed that people were laughing at him and out to get him, reported transient feelings of depression, and talked about suicide. When his suicidal ideation cleared, he was discharged with a diagnosis of schizoaffective
234 / MENDEZANDDOSS
disorder, residual stage. On the day of his suicide, he was found unresponsive with a suicide note complaining that people were ridiculing him. Empty medication bottles and blood levels proved that the patient had overdosed on carbamazepine and trifluoperazine. He remained comatose for several days and died with acute respiratory distress syndrome documented at autopsy. DISCUSSION
Out of 1611 seizure patients followed in our neurology clinic, we found four patients who had committed suicide. Although our medical center sample may not reflect the entire epileptic population, the characteristics of those who had committed suicide suggest several reasons for the increased risk of suicide among those in epilepsy. All four patients had PCS with temporal lobe foci. Two had a history of paranoid schizophreniawith variable affective features, good or improving seizure control, and therapeutic anticonvulsant levels. Tko others had increased epileptiform activity associated with brief psychotic episodes or with auras of depression (“ictal depression”). No patient had major depression or complained of the psychosocial difficulties associated with having a seizure disorder. Varied sources report a rate of suicide in epilepsy ranging from 3 to 22 percent [l,3,4-81.The psychosocial and disability effects of seizures have been important considerationsfor explaining the high suicide rate [9]. Epileptic patients are prone to low self-esteem, feelings of dependency and loss of control, stigmatization, and job and transportation difficulties [lo], but these problems have not been clearly documented to underlie the increased number of suicides. Furthermore, when the degree of disability is controlled, four to five times as many epileptic patients attempt suicide as compared to patients with other disabilities [ll]. A second consideration for the increased suicide rate is the frequency of the seizures themselves. Mitigating this is the fact that suicides occur even after temporal lobectomieswith successful control of seizures 1121. A third consideration for the high suicide rate is the associated psychopathology. Borderline personality characteristics with impulsive behavioral tendencies may be the most common predisposing factor for unsuccessful suicide attempts among epileptic patients [3]. Suicide attempts are frequently not serious efforts to commit suicide, however, and borderline personality characteristics do not necessarily account for the increased risk of death by suicide among seizure patients. In Patients No. 2 and No. 4, the main contributor to suicide was the presence of a chronic psychosis. Prior evidence has shown that psychosis is common in those with epilepsy, occurring in 7 to 12 percent of all seizure patients [13]. For example, in a thirty-year follow-up of 100 children with PCS, psychosis occurred in nine (10%)of eighty-seven non-retarded survivors [14]. And, in a review of the Minnesota Multiphasic Personality Inventory, epileptics had more elevated schizophrenia and paranoia scale scores than patients with other disabilities [151.
SUICIDE IN EPILEPTIC PATIENTS / 235
Table 1. Factors Potentially Associated with Increased Risk of Suicide Among Epileptic Patients General 1. Males, ages 25-49 [I 01 2. Structural brain lesions, mild mental retardation [I 01 3. Access to medications in large quantities [I 0, 271 4. Psychosocial stressors [lo] II. Psychopathology 1. Borderline personality characteristics [3] 2. Chronic psychosis [3,13,161 Command hallucinations Paranoia Affective features 3. Brief psychotic episodes [20-231 4. lnterictal depressive disorders [I I ] Ill. lctal Characteristics 1. lctal depression [24, 251 2. Ictally-related “depressive delirium” [26] 3. Prolonged postictal delirium [26] 4. Complex partial seizures [2, lo] 5. Many years of seizures [lo] 6. Insufficient therapy [lo] 1.
Psychosis in epilepsy often resembles schizophrenia mixed with affective and suicidal symptoms [16,17]. Although seizure control with medications or surgery does not prevent the development of this psychosis [17], patients with this interictal psychosis often have an eleven- to fifteen-year history of poorly controlled seizures [13,18]. Some patients develop psychosis after their seizures are controlled, or with improved seizure control, as suggested by Patients No. 2 and No. 4 ~91. Patient No. 1 demonstrated that brief, psychotic episodes associated with increased epileptiform discharges could result in sudden suicidal acts. Investigators have documented the presence of psychotic episodes associated with clinical seizures, with epileptiform discharges from temporal limbic structures, or with the post-ictal period [20-231. These episodes include confusional elements, agitation, hallucinations, paranoia, and impulsive behaviors [20-221. In Patient No. 1, a destabilizing change in anticonvulsant medications may have precipitated the increased epileptiform activity. In Patient No. 3, suicide probably resulted from ictal depression, given her expressed suicidal ideation during ictal depressive periods. Depression occurs as a
236 / MENDEZAND DOSS
rare ictal event that heralds a PCS,and that may persist after the seizure has passed 124, 251. Depression with suicide could also result from intermittent increased seizure activity with a “depressive delirium,” or from a prolonged postictal depressive state [26]. Moreover, interictal depression is a common psychiatric problem in epilepsy and the most common reason for the psychiatric hospitalization of epileptic patients [ll]. Other reported considerations for the increased risk of suicide in epilepsy are summarized in Table 1. One prominent risk factor worth emphasizing is the facilitation of suicide by overdose with readily-accessible anticonvulsant medications [27]. More speculative ictal causes of suicide include complex suicidal automatisms and psychic auras such as fear, “ictal command hallucinations,” forced thinking, or the destabilizing effects of derealization and depersonalization. A final consideration is the effect of anticonvulsant medications. Certain medications, such as barbiturates, can exacerbate depression [28]. This study concludes that associated psychotic symptoms and psychic auras contribute to the increased rate of suicide among epileptic patients. We did not encounter a direct suicidal reaction to the emotional burden of having a seizure disorder. Our findings have implications for preventing suicide among epileptics and deserve further exploration.
REFERENCES 1. W. S. Mathews and G. Barabas, Suicide and Epilepsy: A Review of the Literature, Psychosomatics, 22515-524,1981. 2. B. Barraclough, Suicide and Epilepsy, in Epilepsy and Psychiatry, E. Reynolds and M. Edinburgh (eds.), Churchill Livingstone, Edingurgh, pp. 72-76, 1981. 3. M. F. Mendez, D. J. Lanska, R. Manon-Espaillat, and T. 14. Burnstine, Causative Factors for Suicide Attempts by Overdose in Epileptics, Archives of Neurology, 46:1065-1068,1989. 4. J. Delay, P. Deniker, and R. Barande, Le Suicide des Epileptiques, Encephole, 46: 401-436,1957. 5. C . Prudhomme, Epilepsy and Suicide, Journal of Nervous and Mental Disease, 94~722-731,1941. 6. J. J. Zielinski, Epilepsy and Mortality Rate and Cause of Death, Epilepsia, 15191-201, 1974. 7. M. Iivanainen and J. Lehtimen, Causes of Death in Institutionalized Epileptics, Epilepsia, 30:485-492,1979. 8. W. Krohn, Causes of Death among Epileptics, Epilepsia, 4315-321, 1963. 9. Editorial, Suicide and Epilepsy, British Medical Journal, 281 530,1980. 10. L. W. Diehl, Epilepsie und Suizid, Psychiatrie Neurologie und PsychoZogie, 3 8 625633,1986. 11. M. F. Mendez, J. L. Cummings, and D. F. Benson, Depression in Epilepsy. Significance and Phenomenology, Archives ofNeurology, 43:766-770,1986.
SUICIDE IN EPILEPTIC PATIENTS / 237
12. I. Jensen, Temporal Lobe Epilepsy. Late Mortality in Patients Treated with Unilateral Temporal Lobe Resections, Acta Neurologica Scandiriavica,52:374-380,1975. 13. M. R. Trimble, The Psychosis of Epilepsy, Raven Press, New York, 1991. 14. J. Lindsay, C. Ounsted, and P. Richards, Longterm Outcome in Children with Temporal Lobe Seizures: 111. Psychiatric Aspects in Childhood and Adult Life, Developmental Medicine and Child Neurology, 21530-636,1979. 15. S. Whitman, B. P. Hermann, and A. C. Gordon, Psychopathology in Epilepsy: How Great is the Risk? BiologicalPsychiatry, 19:213-216,1984. 16. P. J. McKenna, J. M. Kane, and K. Parrish, Psychiatric Syndromes in Epilepsy, American Journal of Psychiatry, 142:895-903,1985. 17. I. Jensen and K. Larsen, Mental Aspects of Temporal Lobe Epilepsy, Journal of Neurology, Neurosurgery and Psychiatry, 42:256-265,1979. 18. E. Slater and A. Beard, The Schizophrenia-like Psychosis of Epilepsy: Psychiatric Aspects, British Journal of Psychiatry, 109:95-150,1963. 19. A. Pakalnis, M. E. Drake, K. John, and J. B. Kellum, Forced Normalization: Acute Psychosis after Seizure Control in Seven Patients, Archives of Neurology, 44289-292, 1987. 20. S. Dongier, Statistical Study of Clinical and ElectroencephalographicManifestations of 536 Psychotic Episodes Occurring in 516 Epileptics between Clinical Seizures, Epilepsia, 1:117-142,1959/60. 21. J. C. Hancock and A. R. Bevilacqua, Temporal Lobe Dysrhythmia and Impulsive or Suicidal Behavior, Southern Medical Journal, 6 4 1189-1193,1971. 22. C. E. Wells, Transient Ictal Psychosis, Archives of Gerteral Psychiatry, 32:1201-1203, 1975. 23. M. F. Mendez, The Post-ictal Psychosis of Epilepsy: Investigation in Two Patients, International Journal of Psychiatry in Medicine, 2123592,1991. 24. A. A. Weil, Depressive Reactions Associated with Temporal Lobe-uncinate Seizures, Journal ofNervous and Mental Diseases, 121505-510,1955. 25. D. Williams, The Structure of Emotions Reflected in Epileptic Experiences, Brain, 79:29-67,1956. 26. T. A. Betts, Depression, Anxiety and Epilepsy, in Epilepsy and Psychiatry, E. H. Reynolds and M. R. Trimble (eds.), Churchill Livingstone, Edinburgh, pp. 60-71, 1981. 27. A. MacKay, Self-Poisoning-A Complication of Epilepsy, British Journal of Psychiatry, 134:277-282,1979. 28. L. W. Batzel and C. B. Dodrill, Emotional and Intellectual Correlates of Unsuccessful Suicide Attempts in People with Epilepsy,Journal of Clinical Psychology 42:699-702, 1986.
Direct reprint requests to: M. F. Mendez, M.D., Ph.D. Department of Neurology St. Paul-Ramsey Medical Center St. Paul, MN 55101
ICTAL AND PSYCHIATRIC ASPECTS OF SUICIDE IN EPILEPTIC PATIENTS
MARIO F. MENDEZ, M.D., PH.D. ROBERT C. DOSS, B.S. University of Minnesota, St. Paul
ABSTRACT
Objective: To evaluate the ictal and psychiatric aspects underlying the high risk of suicide among epileptic patients. Method We surveyed the records of 1611epileptic patients seen in a neurology clinic during an eight-year period, found four who died by suicide, and characterized their ictal and psychiatric features. Results: All four epileptic patients had partial complex seizures and temporal lobe foci. Two had an associated paranoid schizophrenia with suicidal ideation, and good or improving seizure control at the tine of their deaths. Another patient killed himself during a brief psychotic episode associated with increasing epileptiform discharges. The fourth patient had ictal depression and committed suicide during a flurry of partial complex seizures. Conclusions: These findings suggest that the high suicide rate among epileptic patients has a greater association with psychotic behaviors and psychic auras than with major depression or the psychosocial burden of being epileptic. We further review other reported risk factors for suicide in epilepsy. (Inf7. J. Psychiatry in Medicine 22:231-237, 1992) Key Words: epilepsy, suicide, seizures, psychosis, depression
Epilepsy is associated with an increased risk of suicide. Among all seizure patients, the estimated risk of death by suicide is 5 percent, or about three to four times greater than the general population 111, and, among those with temporal lobe epilepsy, the risk is as much as twenty-five times greater [2]. The reasons for the increased number of epileptic suicides are not clear. Factors that could affect the rate of suicide include: a) psychosocial stressors associated with epilepsy, b) seizure type and frequency, c) psychic auras, and d) the presence of associated psychopathology. In those with epilepsy, unsuccessful suicide attempts are 231 8 1992, Baywood Publishing Co., Inc.
doi: 10.2190/7PD3-C5MM-M0GJ-WJWT http://baywood.com
232 / MENDEZ AND DOSS
frequently associated with borderline personality characteristics [3]; however, successful suicides are not the same as suicide attempts, and may differ in underlying psychopathology. Understanding the underlying seizure and psychiatric relationships of successful suicides could help reduce the high risk of suicide in epilepsy. We investigated the possible contributing factors for suicide among epileptic patients by surveying the medical records of 1611seizure patients evaluated in our neurology clinic at St. Paul-Ramsey Medical Center since January, 1984. Four patients were identified as having successfully committed suicide. CASE REPORTS Patient No. 1
A thirty-three-year-old man had partial complex seizures (PCS) and rare generalized tonic-clonic seizures (TCS) dating from age three. His usual seizure frequency was one or 2 PCS per month characterized by an alteration of consciousness without a preceding aura. During his outpatient evaluations, his mental status and neurological examinations were normal. Electroencephalograms (EEG) showed bitemporal epileptiform discharges, and cranial computerized tomography (CT)scans were unremarkable. Beginning at age seventeen, the patient experienced four or five psychotic episodes of less than two weeks’ duration. These episodes involved sudden agitation, paranoid ideation, auditory hallucinations often urging him to kill himself, and a “compulsion” to commit suicide. In a prior psychotic episode, he attempted to burn himself but sustained only minor burns. During his psychotic episodes, the patient was disoriented, confused, and had increased bitemporal spikes and diffuse slowing on EEG. There were no clear precipitating psychosocial factors for his psychotic episodes, and the patient was not treated with long-term antipsychotic medications. One week prior to his suicide, his anticonvulsant medication was changed from phenytoin to carbamazepine. Two days prior to his suicide, he became suddenly agitated and heard the voice of his dead mother telling him to commit suicide by overdosing on his medications or by jumping in front of an automobile. The patient overdosed on carbamazepine and over-the-counter drugs, was brought to the hospital in a comatose state, and had a fatal cardiorespiratory arrest. Patient No. 2
A thirty-one-year-old man had PCS with epigastric auras and secondarily generalized TCS dating from age twelve. On phenytoin therapy, his frequency of seizures was less than one PCS per month, with a rare nocturnal TCS. He was a disheveled-appearing man with a flat affect and low-average intelligence. His
SUICIDE IN EPILEPTIC PATIENTS / 233
physical examination was unremarkable, CT scan was normal, and EEG showed a right temporal epileptiform focus. The patient had a ten-year history of schizophrenia characterized by paranoid delusions, auditory hallucinations including voices commanding him to harm himself, and a deteriorating psychosocial adjustment. During his acute psychotic stages, he remained under good or improving seizure control and had therapeutic phenytoin levels. The patient had several psychiatric hospitalizations, and was treated with trifluoperazine and thioridazine. His last hospitalization followed an altercation with a co-worker whom he falsely accused of spying on him. At that time, the patient had thought insertion, thought withdrawal, and hallucinations telling him that specific people were the devil. He also reported depressive symptoms, suicidal ideation, and dreams of being in a morgue. Six months later, he was found dead after overdosing on his medications.
Patient No. 3 A thirty-seven-year-old diabetic woman had PCS since age ten, characterized by a sensation of depression followed by an alteration of consciousness with a motionless stare and occasional wandering for up to ninety minutes. These auras of depression were stereotypical, out-of-context, and profound in intensity. After a PCS,the patient had residual depression with prominent suicidal ideation and extreme fatigue. She remained on primidone and carbamazepine with fluctuations in compliance and in anticonvulsant levels. The mental status and physical examinations were remarkable only for obesity, the EEG showed epileptiform activity in the right temporal region, and the cranial CT scans were normal. On the day of her suicide, the patient had three witnessed staring spells. That night, she wandered about her apartment banging on neighbors’ doors. She was later found in a comatose state, and subsequently died. Laboratory data documented an overdose with primidone, carbamazepine, and insulin.
Patient No. 4 At the time of his suicide, a thirty-four-year-old man with childhood-onset PCS had therapeutic carbamazepine levels and a few PCS per month. His examination and cranial CT scans were unremarkable, but a recent EEG documented a left temporal epileptiform focus. Beginning at age twenty-two, the patient had several hospitalizations for paranoid schizophrenia and for suicide attempts by drug overdose. He had delusions of persecution, illogical thinking, deterioration in his work and personal life, and was managed primarily with trifluoperazine. A month prior to his suicide, the patient was hospitalized due to an overdose with a barbiturate. On recovery, he remained seizure-free, but claimed that people were laughing at him and out to get him, reported transient feelings of depression, and talked about suicide. When his suicidal ideation cleared, he was discharged with a diagnosis of schizoaffective
234 / MENDEZANDDOSS
disorder, residual stage. On the day of his suicide, he was found unresponsive with a suicide note complaining that people were ridiculing him. Empty medication bottles and blood levels proved that the patient had overdosed on carbamazepine and trifluoperazine. He remained comatose for several days and died with acute respiratory distress syndrome documented at autopsy. DISCUSSION
Out of 1611 seizure patients followed in our neurology clinic, we found four patients who had committed suicide. Although our medical center sample may not reflect the entire epileptic population, the characteristics of those who had committed suicide suggest several reasons for the increased risk of suicide among those in epilepsy. All four patients had PCS with temporal lobe foci. Two had a history of paranoid schizophreniawith variable affective features, good or improving seizure control, and therapeutic anticonvulsant levels. Tko others had increased epileptiform activity associated with brief psychotic episodes or with auras of depression (“ictal depression”). No patient had major depression or complained of the psychosocial difficulties associated with having a seizure disorder. Varied sources report a rate of suicide in epilepsy ranging from 3 to 22 percent [l,3,4-81.The psychosocial and disability effects of seizures have been important considerationsfor explaining the high suicide rate [9]. Epileptic patients are prone to low self-esteem, feelings of dependency and loss of control, stigmatization, and job and transportation difficulties [lo], but these problems have not been clearly documented to underlie the increased number of suicides. Furthermore, when the degree of disability is controlled, four to five times as many epileptic patients attempt suicide as compared to patients with other disabilities [ll]. A second consideration for the increased suicide rate is the frequency of the seizures themselves. Mitigating this is the fact that suicides occur even after temporal lobectomieswith successful control of seizures 1121. A third consideration for the high suicide rate is the associated psychopathology. Borderline personality characteristics with impulsive behavioral tendencies may be the most common predisposing factor for unsuccessful suicide attempts among epileptic patients [3]. Suicide attempts are frequently not serious efforts to commit suicide, however, and borderline personality characteristics do not necessarily account for the increased risk of death by suicide among seizure patients. In Patients No. 2 and No. 4, the main contributor to suicide was the presence of a chronic psychosis. Prior evidence has shown that psychosis is common in those with epilepsy, occurring in 7 to 12 percent of all seizure patients [13]. For example, in a thirty-year follow-up of 100 children with PCS, psychosis occurred in nine (10%)of eighty-seven non-retarded survivors [14]. And, in a review of the Minnesota Multiphasic Personality Inventory, epileptics had more elevated schizophrenia and paranoia scale scores than patients with other disabilities [151.
SUICIDE IN EPILEPTIC PATIENTS / 235
Table 1. Factors Potentially Associated with Increased Risk of Suicide Among Epileptic Patients General 1. Males, ages 25-49 [I 01 2. Structural brain lesions, mild mental retardation [I 01 3. Access to medications in large quantities [I 0, 271 4. Psychosocial stressors [lo] II. Psychopathology 1. Borderline personality characteristics [3] 2. Chronic psychosis [3,13,161 Command hallucinations Paranoia Affective features 3. Brief psychotic episodes [20-231 4. lnterictal depressive disorders [I I ] Ill. lctal Characteristics 1. lctal depression [24, 251 2. Ictally-related “depressive delirium” [26] 3. Prolonged postictal delirium [26] 4. Complex partial seizures [2, lo] 5. Many years of seizures [lo] 6. Insufficient therapy [lo] 1.
Psychosis in epilepsy often resembles schizophrenia mixed with affective and suicidal symptoms [16,17]. Although seizure control with medications or surgery does not prevent the development of this psychosis [17], patients with this interictal psychosis often have an eleven- to fifteen-year history of poorly controlled seizures [13,18]. Some patients develop psychosis after their seizures are controlled, or with improved seizure control, as suggested by Patients No. 2 and No. 4 ~91. Patient No. 1 demonstrated that brief, psychotic episodes associated with increased epileptiform discharges could result in sudden suicidal acts. Investigators have documented the presence of psychotic episodes associated with clinical seizures, with epileptiform discharges from temporal limbic structures, or with the post-ictal period [20-231. These episodes include confusional elements, agitation, hallucinations, paranoia, and impulsive behaviors [20-221. In Patient No. 1, a destabilizing change in anticonvulsant medications may have precipitated the increased epileptiform activity. In Patient No. 3, suicide probably resulted from ictal depression, given her expressed suicidal ideation during ictal depressive periods. Depression occurs as a
236 / MENDEZAND DOSS
rare ictal event that heralds a PCS,and that may persist after the seizure has passed 124, 251. Depression with suicide could also result from intermittent increased seizure activity with a “depressive delirium,” or from a prolonged postictal depressive state [26]. Moreover, interictal depression is a common psychiatric problem in epilepsy and the most common reason for the psychiatric hospitalization of epileptic patients [ll]. Other reported considerations for the increased risk of suicide in epilepsy are summarized in Table 1. One prominent risk factor worth emphasizing is the facilitation of suicide by overdose with readily-accessible anticonvulsant medications [27]. More speculative ictal causes of suicide include complex suicidal automatisms and psychic auras such as fear, “ictal command hallucinations,” forced thinking, or the destabilizing effects of derealization and depersonalization. A final consideration is the effect of anticonvulsant medications. Certain medications, such as barbiturates, can exacerbate depression [28]. This study concludes that associated psychotic symptoms and psychic auras contribute to the increased rate of suicide among epileptic patients. We did not encounter a direct suicidal reaction to the emotional burden of having a seizure disorder. Our findings have implications for preventing suicide among epileptics and deserve further exploration.
REFERENCES 1. W. S. Mathews and G. Barabas, Suicide and Epilepsy: A Review of the Literature, Psychosomatics, 22515-524,1981. 2. B. Barraclough, Suicide and Epilepsy, in Epilepsy and Psychiatry, E. Reynolds and M. Edinburgh (eds.), Churchill Livingstone, Edingurgh, pp. 72-76, 1981. 3. M. F. Mendez, D. J. Lanska, R. Manon-Espaillat, and T. 14. Burnstine, Causative Factors for Suicide Attempts by Overdose in Epileptics, Archives of Neurology, 46:1065-1068,1989. 4. J. Delay, P. Deniker, and R. Barande, Le Suicide des Epileptiques, Encephole, 46: 401-436,1957. 5. C . Prudhomme, Epilepsy and Suicide, Journal of Nervous and Mental Disease, 94~722-731,1941. 6. J. J. Zielinski, Epilepsy and Mortality Rate and Cause of Death, Epilepsia, 15191-201, 1974. 7. M. Iivanainen and J. Lehtimen, Causes of Death in Institutionalized Epileptics, Epilepsia, 30:485-492,1979. 8. W. Krohn, Causes of Death among Epileptics, Epilepsia, 4315-321, 1963. 9. Editorial, Suicide and Epilepsy, British Medical Journal, 281 530,1980. 10. L. W. Diehl, Epilepsie und Suizid, Psychiatrie Neurologie und PsychoZogie, 3 8 625633,1986. 11. M. F. Mendez, J. L. Cummings, and D. F. Benson, Depression in Epilepsy. Significance and Phenomenology, Archives ofNeurology, 43:766-770,1986.
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