Indian J. Psychiat., 1995, 37(3), 136-138.

CARBAMAZEPINE IN INTERICTAL HYPERRELIGIOSITY: THREE CASE REPORTS K.E.SADANANDAN UNNI, K.S.ANAND Three patients with manifestations of hyperreligiosity during the post ictal period are presented- The compUte clearance of these manifestations on carbamazepine monotherapy is highlighted. Key words: hyperreligiosity, mystical experience, interictal psychosis, carbamazepine.

the sake of Lord Ganapathy". Unusual behaviors INTRODUCTION were writing verses after verses propitiating dif­ Interictal manifestations most frequently en­ ferent Gods, and prostrating before all deities in countered in epileptic patients include personality which ever temple he entered. These symptoms disturbances and psychoses. Hyperreligiosity is started two days after the last episode of convulsion. described to be one of the manifestations of such He had only one such similar episode of behavior personality disturbances (Kaplan & Sadock, 1992). and thought during an interictal period four years Neppe (1988) has recommended carbamazepine ad­ ago. Only after a period of regular treatment with juvant to neuroleptic therapy in schizophrenics with both phenytoin and haloperidol for three months had temporal lobe abnormalities or aggression. Fenton he become completely asymptomatic both with (1981) quoting Hill (1953), Pond (1957) and Slater regard to seizures and abnormal thought process. He (1963) has expressed the view that schizophrenia had no family history of epilepsy. His premorbid like psychoses of epilepsy and non-epileptic religious practice was confined to visiting and pray­ schizophrenia are different. He pointed out that ing in a temple during festive occasions and auspi­ warmer effect, less personality deterioration, cious days. paranoid delusion with religious coloring, mystical His electroencephalogram and computerized delusional experience and visual hallucination are tomography scan of the brain taken just after the seen more commonly in psychosis of epilepsy. Bear present consultation were normal. His hemogram, et al (1977) have done the quantitative assessment blood sugar, serum electrolytes.liver and thyroid of interictal behavior. Valkenburg et al (1992) have function tests were normal. His blood VDRL and compared the efficacy of clonazepam, car­ ELISA for HIV antibodies were negative. Patient bamazepine, valproic acid and phenytoin in various had discontinued the phenytoin and haloperidol one psychoses. Fallon et al (1990) reported that six out year ago. He was given 600 mgs of carbamazepine of ten cases of obsessive compulsive disorder with in three divided doses. After two weeks of regular moral and religious scrupulosity responded to therapy he was seen again by the authors inde­ fluoxetine or clomipramine monotherapy. pendently. He was having none of the initial present­ ing abnormal content of thought and behavior and CASE REPORTS was seizure free. Instead, he said he was thinking Case 1: A twenty seven year old unmarried male about his difficultly in passing B,A.Economics and Hindu who had completed his bachelor degree his problems of unemployment. He has maintained course in Economics had a seven year history of improvement on carbamazepine for the subsequent episodes of generalized tonic clonic convulsions twenty months of follow up. preceded each time by lip smacking movements and Case 2: A twenty six year old Hindu unmarried depressed mood. Altogether he had sixteen such farmer who had passed his higher secondary course episodes and the last episode was four days before was seen with complaints of episodes of generalized the consultation. The presenting symptoms were tonic clonic convulsions preceded each time by un­ with unusual thought, talk and behavior. The con­ usual subjective experience of peculiar smell and tents of his thought/talk which had a mystical tinge epigastric burning sensation for the last three years. were as follows (in patient's own words): "whether The frequency of episodes were once in two months God is there or not", "all are mortal", "Muslim and altogether he had seven episodes of seizures. vandals in the village and evil spirits have done The last episode was one week before the consult­ sorcery to destroy the temples", and "I am living for ation. One day following this episode he started

136 showing increased interest in propitiating the deities this period he was seizure free. He had no family in the temples in his village. He started writing Sri history of similar complaints. But he had three Ramajayam repeatedly, pages after pages. He be­ episodes of generalized tonic clonic convulsions came more reserved, serious and secluded after the over the last three years, besides the present episode last episode of seizures. He also had the delusional of seizure and other symptoms three weeks ago. His idea that Muslim vandals are planning to destroy the premorbid personality was sociable and cheerful and village temple. He lacked insight and his mood was he used to do prayer in his own house daily in the unhappy and congruent. He had a well adjusted evening. He was admitted and observed over a premorbid personality and used to visit a nearby period of more than three weeks during which he temple on auspicious days. He had no past history or kept up his improvement with regard to seizure but three generation family history of epilepsy, al­ continued having all other symptoms. coholism, psychoses or hyperreligiosity. He was His cl;nical laboratory, radiological and physically normal. Repeated mental status examina­ electrophysiological investigations done exactly in tion showed that he preferred to chant bhajans on the same way as the former two cases, were normal. Lord Rama rather than speak to anybody .In between Sodium valproate was replaced by carbamazepine he uttered the words "God is Great" and "God is 200 mgs three times daily. After two weeks of everywhere". therapy patient became asymptomatic and seizure His electroencephalogram and computerized free. He is being followed up over the last twelve tomography of the brain at the time of adm ission was months while he has kept up his improvement and normal. His routine biochemistry laboratory tests, has rejoined his business. hemogram, liver and thyroid function tests were normal. His blood VDRL and ELISA for HIV an­ DISCUSSION tibodies were negative. He was put on phenytoin 300 One has to agree that there is normal religiosity mgs in three divided doses. After two weeks, he was which provides inner strength and well being (El­ seizure free but continued to have unusual religiosity lison, 1991) and pathological religiosity which and paranoid ideas with religious coloring. He was vanishes with drug therapy (Fallon et al, 1990; admitted and observed over a period of two weeks Valkenberg et al, 1992). In any case religiosity in the while he was on the same medication. He remained clinical description remains a relative term and there seizure free but other symptoms persisted. It was may be a gradation of religiosity in normal popula­ then decided to replace phenytoin with car- tion and a gradation of pathological religiosity in bamazepine. After two weeks of carbamazepine patients with epilepsy or mental illness. If religiosity therapy patient became completely asymptomatic. appears all on a sudden as a main part of a person's He has kept up his improvement on carbamazepine thinking and functioning, as a sharp contrast to what over the subsequent twenty months. he was premorbidly, to such an extent that it inter­ Case 3: A twenty eight year old male Hindu feres with his social and occupational functioning, unmarried BCom graduate businessman was then it becomes pathological. In all three cases referred from neurology for unusual prolonged presented there were easily identifiable pathological ritualistic behavior (for example going around the hyperreligiosity. sanctum sanctorum for more than fifty times), unex- All three patients had generalized tonic clonic plainable fear, and seclusive behavior. He started seizures with normal electroencephalogram during telling everybody that the world was coming to an the period of their hyperreligious behavior. These end soon and started indulging in philanthropic ac­ patients had brought their former electroen­ tivities with s socio-religious tinge e.g. donating cephalogram during later follow up sessions. Each money to the temples and giving alms to the poor in of these electroencephalograms showed generalized the village. There was no elation, restlessness or seizure discharges with no evidence for localization sleeplessness. of the electrophysiological abnormality or secon­ All these behaviors started two days after a dary generalization. The normal electroen­ generalized tonic clonic convulsion for which he cephalogram during hyperreligious behavior could was put on sodium valproate 200 mg three times be due to 'forced normalization'. Lishman (1978) daily by a general practitioner. It took more than had described normalization of electroen­ three weeks for the family members to realize that cephalogram during interictal psychosyndromes the presenting symptoms were abnormal. During (Lishman, 1978, quoting Landolt, 1958). In the first

137 SADANANDAN UNNI two cases the seizures were preceded by lip smack­ ing movements and epigastric sensation, unlike the REFERENCES third case. The authors classified these cases ac­ American Psychiatric Association (1987) Diag­ cording to DSM ni-R (American Psychiatric As­ nostic and Statistical Manual of Mental Disor­ sociation, 1987) as organic personality syndrome ders, (3rd edn, rev.) (DSM III-R). Washington, (310.0); another possible diagnosis considered was DC: American Psychiatric Association. organic delusional disorder (293.81). These two Bear, D. & Fedio, P. (1977) Quantitative analysis classificatory codes were thought of as these are the of interictal behavior in temporal lobe epilepsy. ones under which interictal psychosyndromes are Archives ofNeurology, 34, 454-467. mentioned in DSM III-R. Ellison, C.G. (1991) Religious involvement and Similar sociodemographic profile make the subjective well being. Journal of Health and present cases comparable. The first two cases go at Social Behavior, 32,80-99. par with Valkenberg's (1992) findingo f superiority Fallon, BA., Liebowitz, M.R., Hollander, E., of carbamazepine over phenytoin in interictal Sender, F.R., Campeas, R.B., Fairbanks, J., psychosis. Valkenberg (1992) found carbamazepine Papp, LA., Hafferer, JA. & Sandbeg, D. and valproic acid equally effective in interictal (1990) The pharmacotherapy of moral and psychosis. But with the third patient, the superiority religious scrupulosity. Journal of Clinical of carbamazepine over valproic acid in the same Psychiatry, 51,2,517-521. regard is illustrated. For interictal psychiatric disor­ ders, it is traditionally taught that the treatment is the Fenton, G.W. (1981) Psychiatric disorders of same as it would be for a non epileptic patient with epilepsy, classification and phenomenology. In the caution that many psychotropic drugs can in­ Epilepsy and Psychiatry, (Eds. E.H.Reynolds & creases seizure frequency (Gelder et al 1990). In the M.R.Trimble). London: Churchill Livingstone. first two cases, delusional ideas had a religious Gelder, M., Gath, D. & Mayou, R. (1990) Organic coloring. One will be tempted to start a neuroleptic Psychiatry. In Oxford Textbook of Psychiatry, along with anticonvulsant. (2nd edn). London: English Language Book Society/Oxford University Press. Lishman (1978), quoting Pond (1957) had drawn attention to psychotic features following generalized Kaplan, I. & Sadock, BJ. (1991) Synopsis of convulsions; these psychotic features were reported Psychiatry: Behavioral Sciences, Clinical to respond to anticonvulsant alone. In all the three Psychiatry, 6th edn. Baltimore: Williams & cases presented, the hyperreligious thought and be­ Wilkins. havior completely vanished after two weeks of car­ Lishman, WA. (1978) Epilepsy. In Organic bamazepine therapy. Psychiatry. London: Blackwell Publications. Considering the present clinical experience it is Neppe, V.M. (1988) Carbamazepine in non-respon­ felt that the psychiatrists should administer car­ sive psychosis. Journal of Clinical Psychiatry, bamazepine alone in recommended antiepileptic 49, suppl, 22-30. dosage for a sufficient period of time during which Valkenberg, C.V., Kluznik, J.C. & Merrill, R, the patient with hyperreligiosity is observed for al­ (1992) New uses of anticonvulsant drugs in leviation of mental symptoms.' psychosis. Drugs, 44,3,326-335.

KESadanandan Unni DNB(Psy), DPM, Assistant Professor of Psychiatry; K.SJinattd DM(Neuro), Associate Professor ofNeurology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondkherry 605 006. $u

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