Temporal Lobe Epilepsy Misdiagnosed as Psychiatric Illness: A Revealing Case Study

Abstract

Temporal lobe epilepsy may present with symptoms that closely resemble psychiatric disorders hence implying late diagnosis and mismanagement. Here is a case of a 34-year-old man who initially was diagnosed to suffer from a psychiatric condition after mood swings, anxiety, and altered perceptions. The symptoms continued and worsened after psychiatric treatment. Detailed neurological examination revealed that the manifestations were due to temporal lobe epilepsy. This makes TLE a diagnostic challenge in itself, not because of the intricate presentation but also interdisciplinary cooperation to avoid misdiagnosis. Early identification and treatment of TLE will help provide better patient outcomes.

Introduction

The most common form of focal epilepsy is temporal lobe epilepsy. It often presents multiple and subtle forms that mimic psychiatric disorders. Because of its role in emotion, memory, and sensory processing, seizures from the temporal lobe can be expressed as alterations in behavior mood, and perception. Sometimes, because these manifestations are not typical of seizure activity, such as convulsions, it makes their diagnosis more challenging.

We present a 34-year-old male who initially had been diagnosed with a psychiatric disorder till a diagnosis of TLE was made. This case report also covers diagnostic pitfalls, clinical courses, and management of such cases that need recognition of atypical presentations of TLE.

Patient Information

1. Age/Gender: 34-year-old male

2. Chief Complaint: Episodes of intense anxiety, mood swings, and altered perceptions over two years

3. History: The patient had no significant medical history of neurological disorders but had been experiencing episodes of extreme emotional distress, irritability, and a sense of unreality. These episodes occurred suddenly, lasted for a few minutes, and were followed by confusion and fatigue. He had been treated for depression and anxiety but without significant improvement.

Initial Psychiatric Diagnosis

The patient, who complained of mood instability, anxiety attacks, and occasional feelings of detachment from surroundings, derealization, was first evaluated by a psychiatrist who diagnosed him with generalized anxiety disorder and major depressive disorder. He was then treated with antidepressants and anxiolytics, but his symptoms continued to worsen with time.

Further Development of Symptoms

Escalation of Symptoms

After several months, the patient's symptoms continued to change. He had episodes of visual disturbances at times, and then he would suddenly become confused and dazed. The episodes were unpredictable, occurring a few times a day. In some episodes, he suddenly would freeze, and he wouldn't be responsive to his environment. Later, he could remember only pieces of what happened.

Even with these developments, his psychiatric treatment continued with medication adjustments that did not make any difference to his condition. The patient became more frustrated by the fact that he felt misunderstood, misdiagnosed, and underestimated.

Diagnostic Revaluation

Neurological Consultation

After two years of ineffective psychiatric treatment, the patient sought a second opinion. During a comprehensive evaluation by a neurologist, the patient's history of episodic disturbances, déjà vu, and altered perception raised suspicion for a neurological cause, specifically temporal lobe epilepsy.

EEG and MRI Findings

The patient underwent an electroencephalogram (EEG), which revealed epileptiform discharges originating from the temporal lobe, confirming the diagnosis of temporal lobe epilepsy. An MRI scan of the brain showed subtle hippocampal sclerosis, a structural abnormality often associated with TLE.

Diagnosis

Based on the clinical presentation, EEG findings, and MRI results, a definitive diagnosis of temporal lobe epilepsy was made. The episodes previously described as mood swings, anxiety attacks, and dissociative states were identified as focal seizures, likely originating from the temporal lobe.

Diagnostic Criteria Met

• Seizure-like episodes with déjà vu and perceptual changes
• Epileptiform discharges on EEG
• MRI findings consistent with hippocampal sclerosis

Treatment and Management

The patient was put on an antiepileptic drug, levetiracetam, shortly after the diagnosis of TLE. Within a few months, the symptoms improved appreciably with a decrease in the frequency and intensity of seizures. The psychiatric symptoms had reduced also, which means that these emotional and perceptual disturbances were related to the seizure activity rather than being primary psychiatric disorders.

Timeline of Case

1. Year 0: Onset of anxiety, mood swings, and dissociative symptoms. Initial psychiatric consultation and treatment with antidepressants.

2. Year 1: Symptoms persist, with occasional visual distortions and episodes of déjà vu. The diagnosis remains psychiatric.

3. Year 2: Neurological consultation after escalating symptoms. EEG reveals temporal lobe epilepsy, and MRI shows hippocampal sclerosis.

4. Year 2, Month 1: Diagnosis of temporal lobe epilepsy confirmed. Antiepileptic medication was initiated.

5. Year 2, Month 4: Significant improvement in symptoms following epilepsy treatment.

Discussion

The Overlap Between Psychiatry and Neurology

Overlapping symptoms, temporal lobe epilepsy rather commonly misdiagnosed as psychiatric disorders, can have a wide range of psychiatric manifestations from mood swings and anxiety to irritability and psychosis. Such presentations more frequently result in mistakes in the form of direct psychiatric disorders, especially in clinically silent seizures or in auras that mimic manifestations of psychiatric symptoms.

The brain's temporal lobe plays a key role in processing emotions, memory, and sensory input during the life of any individual. This is the reason why seizures in this region can be so diverse and complex. Sometimes, patients with TLE are not afflicted with generalized tonic-clonic seizures but suffer focal seizures that influence their perception, mood, and cognition. This condition primarily makes it harder to diagnose since the symptoms may not necessarily point out any underlying neurological cause at first instance.

The Importance of Early Diagnosis

Delayed diagnosis of TLE may result in important morbidity. He had long years of untreated seizures that affected his quality of life and psychological well-being. What is most important in preventing protracted mismanagement is, therefore, early diagnosis, facilitated by a high index of suspicion with proper use of diagnostic tools such as EEG and MRI.

In atypical or treatment-resistant psychopathological states, alternative explanations such as medical/neurological ones must be considered. Ideally, there should be an effort to collaborate or work in conjunction with psychiatrists and neurologists when the clinical presentation remains undefined.

Treatment Strategies

The treatment of TLE typically involves antiepileptic drugs (AEDs), with medications such as levetiracetam, carbamazepine, and lamotrigine being effective in controlling seizures. In patients with refractory epilepsy or structural abnormalities like hippocampal sclerosis, surgical intervention, such as anterior temporal lobectomy, may be considered.

In this case, the patient responded well to levetiracetam, with a dramatic reduction in both his seizure episodes and psychiatric symptoms. This outcome highlights the importance of appropriate treatment in restoring normal functioning and improving patient outcomes.

Conclusion

This case points out the difficulties in diagnosing temporal lobe epilepsy, especially when the presentation is psychiatric. It may lead to misdiagnosis that could result in inappropriate treatment, prolongation of suffering, and worsening outcomes for patients. A high index of suspicion and appropriate testing are essential to avoid this pitfall in the assessment of TLE masquerading as a psychiatric condition. An early diagnosis and a better treatment of the patient for TLE will significantly prevent subsequent complications and improve the quality of life of those affected.

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