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LETTER TO EDITOR
Year : 2016  |  Volume : 64  |  Issue : 2  |  Page : 334-335

Postictal psychosis with self-amputation of foot in an epileptic patient: A report


1 Department of Neurology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS), Shillong, Meghalaya, India
2 Department of Psychiatry, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS), Shillong, Meghalaya, India

Date of Web Publication3-Mar-2016

Correspondence Address:
Hibu Habung
Department of Neurology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS), Shillong, Meghalaya
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.177610

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How to cite this article:
Sharma SR, Nongpiur A, Hussain M, Habung H. Postictal psychosis with self-amputation of foot in an epileptic patient: A report. Neurol India 2016;64:334-5

How to cite this URL:
Sharma SR, Nongpiur A, Hussain M, Habung H. Postictal psychosis with self-amputation of foot in an epileptic patient: A report. Neurol India [serial online] 2016 [cited 2020 Nov 28];64:334-5. Available from: https://www.neurologyindia.com/text.asp?2016/64/2/334/177610


Sir,

Postictal psychosis occurs in 6-10% of patients, particularly with temporal lobe epilepsy,[1] typically after a cluster of complex partial seizures with or without secondary generalization. Self-injurious behavior in epilepsy is uncommon but can occur with seizure activity in the frontal and temporal lobes.[2],[3]

Here we report a patient with epilepsy, who had postictal psychosis and who self-amputated his left foot following a seizure.

A 25-year-old man presented with a history of seizures for the past 7 years. A typical attack started with versive head movement toward the right, followed by unawareness and then stiffening of all four limbs, followed by jerky movements of the whole body for 1–2 minutes, and finally, postictal drowsiness and confusion for a few hours. There was a history of abnormal behavior lasting for up to 24–48 hours after the seizure and a perception of hearing voices of people during that period. In the previous year, after an episode of seizure, he had accidently burnt his left leg, and postictally, he had started running around aimlessly in a nearby jungle. On reaching home, he had severed his left foot completely with a knife and threw the amputated foot towards his mother. The following day, he had no recollection of the event.

Clinically, guilt feelings and remorse were present, but no depressive, cognitive or psychotic symptoms were apparent on mental status examination. He had an amputated stump at the left ankle joint with exposed bones and burn marks over the overlying skin [Figure 1]. His blood investigations, electrocardiogram, and chest radiographs were normal. Brain magnetic resonance imaging showed an old calcified granuloma at the left middle frontal gyrus suggestive of neurocysticercosis. His electroencephalogram showed left focal temporal discharges with generalization.
Figure 1: Amputated stump of left ankle joint with burn marks over the overlying skin

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The mechanisms of postictal psychosis are unknown but may be related to transient neurochemical changes as a result of seizures, e.g., dopamine hypersensitivity or gaba aminobutyric acid (GABA)-related mechanisms. In our patient, the semiology was suggestive of a seizure of focal origin, most probably arising as a result of the granuloma, following which he had abnormal behavior, was found wandering in the jungle, and had auditory hallucinations suggestive of postictal psychosis.

Extreme cases of self-mutilation have been reported in the postictal period.[4] Such patients have guilt and remorse, but they usually have no recollection of the events, as seen in our case.

In view of the grievous nature of the self-injurious behavior, there is a need for better psychoeducation of patients and relatives visualizing the postictal phenomenon, and a continuous observation, at least for a few hours, is necessary after a seizure to prevent such occurrences.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kanner AM, Stagno S, Kotagal P, Morris HH. Postictal psychiatric events during prolonged video-electroencephalographic monitoring studies. Arch Neurol 1996;53:258-63.  Back to cited text no. 1
    
2.
Gedye A. Extreme self-injury attributed to frontal lobe seizures. Am J Ment Retard 1989;94:20-6.  Back to cited text no. 2
    
3.
Gedye A. Anatomy of self-injurious, stereotypic, and aggressive movements: Evidence for involuntary explanation. J Clin Psychol 1992;48:766-78.  Back to cited text no. 3
    
4.
Reyazuddin M, Rizvi A, Usmani MA, Gaur RK. Penile self-amputation in epileptic patient. Delhi Psychiatr J 2014;17:496-8.  Back to cited text no. 4
    


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