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SIR: The call for integration of Neurology in Psychiatric training has a long history.1 The following case is reported from the United Kingdom where the divide between neurology and psychiatry is deepening everyday as opposed to the American model.2
Ten years ago AB presented to a child psychiatrist when she was 16 with gradual withdrawal and unprovoked attack on classmates. Her younger brother had learning difficulties and episodic behavioral dyscontrol and was suspected to have epilepsy. Her mother was worried whether AB used drugs. She claimed hearing abusive voices in third person discussing her actions. But she did not appear too distressed. She also felt that she was being watched and her food might be poisoned. She became increasingly disruptive at home, physically fighting with brother and peers. She also threatened to harm her mother. There were incidents when she appeared drunk but not smelling of alcohol. She claimed the house was being bugged and that the TV is a "special camera observing her." She was admitted informally for an assessment but later detained due to lack of diagnostic progress in wake of troublesome behavior and abuse of cannabis, amphetamines and ecstasy at hospital. She was diagnosed to have schizophrenia and treated with haloperidol which was later changed to sulpiride. Her EEG showed bilateral minor sharp waves of unknown significance especially on right side which was regarded nonspecific and insignificant. CT Brain done around this period was normal. She made a slow recovery with a high degree of non compliance and presented to adult psychiatric services with depression 4 years later when she stopped all antipsychotics. She was started on sertraline which she stopped on her own after a very short course. By this time she was married and had had another episode of depression when she was noted to wander and "going into daze." Change of antidepressants proved unhelpful and she started reporting new symptoms of déjà vu and "reading others minds." She also reported seeing flashes of events before they occur with increasing paranoia and referential ideas. During this period she would stare at space and ‘lose sense of things around her’ with electric sensations at the back of her head and spasmodic jerks of one arm or leg and facial droop. Most of her symptoms were seen as psychotic features with drug induced side effects. Switching various atypical antipsychotics proved unhelpful, increasing the frequency of her déjà vu at times. An EEG was done which picked up persistent paroxysmal right temporal lobe activity. MRI did not show any structural anomalies. The diagnosis was revisited after 8 years from initial presentation and she was started on carbamazepine after stopping atypical antipsychotic. She made a remarkable improvement from symptoms of déjà vu and "psychotic" features. Symptoms of derealisation decreased considerably and she is now under shared neurology and psychiatric care. Retrospectively, her depression seems to be an interictal phenomenon, relatively resistant to antidepressants with ictal frequency increasing on psychotropic treatment.
Some important learning points transpire from this case. Temporal lobe epilepsy has been a great disguiser at psychiatric clinics. But missing a diagnosis for nearly a decade occurs rarely.3 It is well noted that a single EEG will not rule out possible seizure disorder.4 In this case the non specific reported findings were taken for schizophrenia related variation from normal. It is clear that lack of clarity about EEG findings in a psychiatric illness and general hesitancy in utilizing repeat neurophysiological investigations could lead to potential misdiagnosis.
The importance of neurological training for a psychiatrist is clearly illustrated by this case. The time-honored approach of detailed analysis of representative cases should serve to improve our practice and convergence of neurology and psychiatry within the framework of neuroscientific clinical practice.1 Even today in some countries including U.K it is possible to qualify as a psychiatrist without spending a single day in a neurology clinic.
Inspite of increasing evidence that first-rank symptoms have a wider prevalence, their strong influence on tilting the diagnostic balance toward schizophrenia, at least in Europe, is immense as in this case.5
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