Epigraph Vol. 22 Issue 2, Spring 2020
Post-ictal psychosis: Identification, treatment and prevention
About 70% of people with epilepsy report post-ictal complications, ranging from fatigue to memory issues to headache. Post-ictal psychosis (PIP), while rare, is perhaps the most dramatic after-effect of seizures. It has been reported that as many as 7% of people with temporal lobe epilepsy develop PIP, which can result in suicidality or interpersonal violence. The condition requires immediate attention and treatment.
Post-ictal psychosis is commonly seen in people with a long history of drug-resistant seizures – at least 10 to 15 years, said Andres Kanner, professor of clinical neurology and director of the Comprehensive Epilepsy Center of the University of Miami’s Miller School of Medicine, USA. An episode typically follows a seizure cluster, usually of secondary generalized tonic-clonic seizures, though Kanner says he also has seen post-ictal psychosis after clusters of focal seizures with impaired awareness.
Risk factors for post-ictal psychosis
Risk factors for post-ictal psychosis include bilateral independent seizure foci and a personal or family history of psychiatric disorders. Its causes and mechanisms are unknown. MRI scans of people who experience PIP show structural abnormalities beyond the temporal lobe, and functional neuroimaging studies have shown hyperperfusion in various brain regions during an episode. However, no study has confirmed whether these changes are unique to people experiencing post-ictal psychosis.
Importantly, PIP symptoms generally do not appear immediately after a seizure; instead, they begin several hours to 1 week after the seizure cluster ends, averaging 1 to 3 days afterward.
Kanner emphasized that although post-ictal fear and confusion—which are quite common—can lead to aggressive behavior in someone with epilepsy, this behavior is not post-ictal psychosis. “In the immediate post-ictal state, people are recovering. They can be very confused or agitated,” he said. “But that is not post-ictal psychosis, though it can be misidentified as such.”
Post-ictal aggression is most often a response to a bystander or first responder. A 2005 study found that both violence and aggression are more common in post-ictal psychosis than post-ictal confusion. About 23% of post-ictal psychotic episodes involved violence directed toward others, and 7% involved suicidal behavior. In comparison, 1% of cases of post-ictal confusion resulted in violence toward others, and no suicidal behavior was observed. Violence and Epilepsy: A Close Relation Between Violence and Postictal Psychosis. Kanemoto et al
Discontinuing medications to induce seizures in an epilepsy monitoring unit also may result in post-ictal psychosis, said Kousuke Kanemoto, director of the department of neuropsychiatry at Aichi Medical University, Japan. If someone has a seizure or seizure cluster during surgical evaluation, Kanemoto recommends careful psychiatric and neuropsychological monitoring for at least three days.
Herald symptoms can warn of an oncoming episode
Post-ictal psychosis has its own form of aura: “herald symptoms” occur hours before the psychosis sets in. The person become restless and irritable. They also usually develop insomnia.
“When someone has a history of seizure clusters, and you notice these changes in them after a cluster, you must at least suspect that the person is heading into post-ictal psychosis,” said Kanner.
Post-ictal psychotic behavior includes delusional thinking and extreme agitation. The person may be a danger to themselves or others. “They can often commit suicide in this state,” Kanner said. “Or they can sometimes hear voices telling them to hurt someone. People have gone to prison for homicide or attempted homicide during a post-ictal psychotic episode, because they respond to the voices or the delusional thinking.”
Most often, someone experiencing post-ictal psychosis will not recall what they’ve said and done during an episode. “They may be interacting with you and having a logical conversation, but afterward they have no recollection,” said Kanner.
Treatment involves benzodiazepines or low-dose anti-psychotic medication, or both, though evidence to guide treatment choice is nonexistent. (Only one small (n=16) randomized trial surfaces in the literature; from 2002, it appears as a conference abstract.) Early administration of anti-psychotic medication is crucial, said Kanner, though people with PIP do not require chronic anti-psychotic medication.
Some people have only an isolated episode, but about half will have repeated episodes. A retrospective study found that on average, PIP recurred 2 to 3 times per year. Kanner works with family members to help them recognize the signs of PIP and have medication on hand to treat it. He recommends prompt use of an antipsychotic medication as soon as herald symptoms develop.
Between 10% and 25% of people who experience repeated post-ictal psychosis will eventually develop interictal psychosis, which requires chronic antipsychotic medication.
Preventing post-ictal psychosis requires eliminating seizures. Because most people with PIP have tried many anti-seizure medications to no avail, other strategies should be considered, said Kanner, such as responsive neurostimulation (RNS) or deep brain stimulation.
Surgery also may be an option.
“If the person has a psychotic episode in the epilepsy monitoring unit and you see seizures on both sides but mostly on one side, you may still want to offer surgery,” Kanner said. “You have to weigh the chances of seizure freedom and preventing further PIP and interictal psychotic disorder against the fact that the surgery may not render them seizure free.”
Though surgery outcomes data in this population are limited, a 2016 cohort study of 189 people found that epilepsy surgery reduced the prevalence of psychoses and psychotic symptoms from 17.5% before surgery to 4.2% at 24 months post-surgery. More than 90% of participants experienced at least some seizure reduction.
Each PIP episode is self limiting; most last no longer than a week. But allowing an episode to run its course is dangerous, said Kanner.
“Post-ictal psychosis is an emergency, and it must be treated as an emergency,” he said. “These are episodes of violence and suicide. You can stop them if you intervene early. We have to take this seriously.”
Further reading: Basic treatment principles for psychotic disorders in people with epilepsy (2013)
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