A 44-year-old female patient, without a personal or family history of psychiatric illness, was admitted to a psychiatric ward for a psychotic episode which has started three days before, characterized by perplexity, self-referent and mystical delusions, irritability, disorganized behavior, and aggressiveness, that had emerged shortly after a cluster of nocturnal GTC seizures. Neither Schneider's first-rank symptoms nor negative symptoms of schizophrenia were present. Additionally, some degree of mental confusion with temporal disorientation, as well as sustained, divided attention and memory deficits were noticed during psychiatric hospitalization. Past medical history was relevant for epilepsy since her early thirties, which had developed after a moderate-to-severe traumatic brain injury (TBI). She did not regularly attend follow-up neurology appointments and had poor adherence to antiepileptic treatment. Ancillary tests undergone during a previous hospitalization in a neurology ward (seven years before the hospitalization in psychiatry) had documented a focal slowing activity in the left frontotemporal topography on electroencephalogram (EEG) and a right cortico-subcortical parietooccipital lesion of encephalomalacia (Figure 1) on magnetic resonance imaging (MRI). Additionally, she presented an amnestic mild cognitive impairment, possibly secondary to both the poorly controlled epilepsy and the prior TBI.
During the hospitalization in the psychiatric ward for the index psychotic episode, haematological and biochemical screening, thyroid function, folic acid, and cyanocobalamin were normal, serologies for VDRL, HIV, and B and C hepatitis were negative, and valproic acid levels were subtherapeutic. She underwent a computed tomography (CT) scan, which did not reveal additional neuroimaging findings to those evidenced by the previous MRI, and an EEG, which was unremarkable.
Psychotic symptoms subsided in the first 36 hours after admission upon treatment with aripiprazole 10 mg/day, valproic acid 1000 mg/day, and diazepam 10 mg taken as required. Aripiprazole was tapered off in the following months. There was no recrudescence of psychotic symptoms with the improvement of seizure control in the outpatient follow-up of neurology appointments.