In February 2009, a 19-year-old man with a history of epilepsy, diabetes and mild mental retardation secondary to a hypoxic brain injury at birth was arrested by the police following destructive actions towards his family property and uncharacteristic hostility.
On assessment in the Accident and Emergency department, it appeared that he was experiencing auditory and visual hallucinations, thought interference, delusions of control and misidentification of family members. The auditory hallucinations were commanding in nature and he believed that his father was somehow inside him and was controlling him. He misidentified his grandmother as his girlfriend and stated that he could see people possessing other people's bodies.
He was detained under section 2 of the Mental Health Act for further assessment of his mental health. He was transferred to a Psychiatric Intensive Care Unit as his level of distress was high and did not respond to verbal or medical de-escalation.
He required nursing in seclusion on multiple occasions. He became extremely hostile very quickly from being reasonable and compliant. During his time in seclusion he appeared to be emotionally labile and was aggressive towards staff and property. It was noted that he appeared to be responding to unknown stimuli—attempting to grab them and then punching the wall or ceiling. He was unable to give reasons for bizarre behaviour such as drinking his own urine and smearing blood from his wounds onto the walls. A sedative effect was noted of the antipsychotic medication but no change in the intensity of his psychotic symptoms.
During admission, other causes of psychosis were eliminated by investigation. It was noted that he had recently had an adjustment of his anti-epileptic medication from sodium valproate to topiramate in an attempt to control the frequency of his epileptic seizures. At the time of admission he was on 100 mg topiramate twice per day. There appeared to be no change to the frequency of seizures reported by the family.
The introduction of topiramate coincided with the aggressive behaviour noted by his family.
The patient was reported as having a calm and kind disposition but from January 2009, after a few days of taking topiramate, he had become more aggressive and had assaulted two members of the public during an episode of absconding from the medical ward. When assessed by the liaison psychiatry team on 14 January 2009 it was noted that he had odd beliefs of feeling like he was in a video game and ‘force fields’.
His presentation was discussed with the neurological treating team and a change to phenytoin was made due to a need for anticonvulsant cover and prompt discontinuation of the topiramate thought to be the cause of his psychosis.