Lithium-Treated Mood Disorders, Paroxysmal Rhinorrhea, and Mesial Temporal Lobe Epilepsy

Case 1. A 48-year-old woman was seen for a rapid-cycling bipolar II disorder, which was partially responsive to 2 years of lithium. Lithium was effective in controlling shoplifting and major discrete cycles. Residual problems were mild cycling, anergia, anhedonia, 30-pound weight gain, intense body dysmorphia with occasional bulimia, and poor concentration.

Her full history suggested partial epilepsy. Sensations of or actual postural instability occurred suddenly 1 or 2 times a week and usually lasted 4 to 6 seconds. If standing at the time, she would sit down; however, often these experiences would occur while she was in bed. Nausea attacks, constipation, and unilateral headache were frequent. Along with numerous gaps in her childhood memories, she was frequently troubled by vague and bizarre improbable dreams of sexual abuse by her mother in her childhood. For 10 years she had experienced 3- to 5-second periods when she would read or hear a common word and would be unable to recognize its meaning. Her EEG was reported as abnormal secondary to irregular slowing, sometimes sharply contoured, in the left temporal area. MRI was unremarkable.

Lithium discontinuation immediately led to a reduction in the frequency of a previously unreported, unexplained paroxysmal rhinorrhea. Treatment with carbamazepine (augmented with low-dose valproic acid) has essentially eliminated presenting symptoms over 1 year of follow-up. Occasionally, perhaps monthly, the patient will experience a brief 2- to 3-hour period with rhinorrhea, restlessness, mood elevation, and logorrhea.

Evidence for intermittent rhinorrhea as a manifestation of mesial temporal lobe epilepsy has been accumulating recently, based on observations of nose-wiping behavior during video-monitored ictal events.^1,2 Consistent with our experience, lithium clearly has proconvulsive effects in case series of temporal lobe epilepsies.^3,4 The hypothesis needing to be examined is whether paroxysmal vasomotor rhinitis, with or without interictal epileptiform discharges on the surface EEG,⁵ implies the need for anticonvulsant treatment.