Temporal Lobe Epilepsy or Bipolar?
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Q:  Temporal Lobe Epilepsy (TLE) or Bipolar?

I am confused and frustrated...My seven year old son was diagnosed with bipolar by a psychiatrist and several therapists; the neurologist has diagnosed him with temporal lobe epiliepsy.  Do both conditions appear they same on a SPECT scan and who should make the determination what he has?  I feel like I am stuck in the middle and I don't know which diagnosis to believe.  My son is on Zoloft, Remeron, Rispedel and has several violent rages in a week.  He has been hospitalized twice in the last month and now attends a partail hospitlazation program for school.  I need to know what I should do, he has been seen by so many doctors and no on seems to agree on a diagnosis.  One of the biggest problems is that he was being abused by his father and he has problems from that but everyone seems to agree that there is an underlying condition.  Where else can I go for help?

Dear Sandy -- 
Sounds very confusing and frustrating, all right.  And yet there's an unfortunate irony here:  the treatment for both conditions is very similar, in some ways nearly identical.  In both conditions you'd want to rely on anti-seizure medications ("anticonvulsants").  They are standard medications for the treatment of bipolar disorder (here's a list of the
"mood stabilizers" we use; notice Depakote, Tegretol, lamotrigine are on that list.  In many cases they act like lithium, the old standard for bipolar disorder). 

In addition, medications that make seizure disorders worse (though only slightly in most cases) can make bipolar disorder worse also (more than slightly in many cases).  These include antidepressant medications and antipsychotic medications, because they "lower seizure threshold"; that is, they make it slightly easier for an underlying seizure condition to express itself.  And the antidepressants at least are widely recognized to have the potential to make bipolar disorder worse -- not always, and in some versions of bipolar disorder they're the standard thing to use, so your son may well have been treated in a very standard way.  However, it is possible, and needs to be considered, that the antidepressant medications (Zoloft, Remeron) could be making things worse, even at the same time as they are making things better, perhaps, in terms of less depressive symptoms (I presume they're doing something good or being examined for discontinuation, given the known risk that they present in bipolar disorder).  

The Risperdal (risperidone) is trickier but the same logic might apply to some degree.  Risperidone can occasionally make bipolar disorder worse (it acts too much like an antidepressant, bringing on cycling or manic-side symptoms -- perhaps even at the same time as it's helping treat some other aspect of the illness).  And risperidone can lower seizure threshold (not as much as some other antipsychotics, but some, e.g. Hedges et al 2003.  If you use this reference, here are some thoughts on talking to doctors about what you've learned). 

The thing is, temporal lobe epilepsy and bipolar disorder are indeed very much alike.  In fact, there is so much overlap between the two conditions, it sure seems like there must be some direct relationship there -- e.g. severe TLE, coming from just the right spot in the temporal lobe, could effectively "be" bipolar disorder, if we knew more about exactly how bipolar disorder works, which as you've probably learned, we don't.   Here's the most recent article I could find on how researchers are looking at the relationship of TLE and bipolar, finding them similar yet distinguishable (at least in this article, which to me also shows how little we know, i.e. the best we can do is assemble 13 patients and try to tell who's who?)

Sounds like it's time to move past diagnostic labels and treat the symptoms (the usual next step in situations like this).  His treatment team could have arrived at the current medications very carefully and selectively for reasons I'm not aware of.  And, I think it would be okay to wonder out loud (read that essay on talking with doctors...) as to whether perhaps some of the current medications might have the capacity to make things worse and how have they taken that into account in choosing these med's and what their next strategy will be.  Be cautious with my thoughts, though; I'm an outsider looking in through a very small window and could have this all wrong.  Good luck trying to help your son. 

Dr. Phelps

Published February, 2004


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