A relationship between seizure control and psychotic symptoms in some patients with intractable epilepsies was described in the middle of the 20th century by a Swiss neuropsychiatrist and multiple reports have appeared in the literature since then. The observation that the EEG recordings of these patients normalized during the psychotic episode led some investigators to coin the term "forced normalization" to describe this phenomenon. Some believe that this antagonism between psychosis and epilepsy may explain the therapeutic effect of electroconvulsive therapy (ECT) for psychotic disorders.

This phenomenon, also known as "alternative psychosis," is by no means common. In one study, its prevalence was estimated to be 1% among 697 patients followed at a university epilepsy center.

Forced normalization has been reported in patients with both TLE and generalized epilepsies. A paranoid psychosis (a richness of affective symptoms without clouding of consciousness) has been its most frequent manifestation. It has been observed following the use of various AEDs, including phenytoin (Dilantin, Phenytek), carbamazepine (Tegretol, Carbatrol), ethosuximide (Zarontin), and levetiracetam (Keppra).

Recent observations have suggested that the phenomenon of forced normalization is not restricted to psychotic episodes, but may also present as episodes of major depression.

Adapted from: Holzer JC and Bear DM. Psychiatric considerations in patients with epilepsy. In: Schachter SC, Schomer DL, eds. The comprehensive evaluation and treatment of epilepsy. San Diego, CA: Academic Press; 1997. p. 131-148.
With permission from Elsevier (www.elsevier.com)

Authored By: 
Jacob C. Holzer MD
David M. Bear MD
Reviewed By: 
Andres M. Kanner MD
Thursday, April 1, 2004