The postictal psychosis of epilepsy: investigation in two patients

Patients with epilepsy have a higher incidence of psychosis. Epilepsy-related psychotic behaviors include a chronic interictal schizophreniform illness, an "alternating psychosis" which remits with seizure activity, and ictal or perictal psychotic behaviors. In addition, there is an uncommon and less understood psychosis characterized by brief psychotic episodes during the postictal period. This report describes two patients with postictal psychosis and correlates their behavior with the pattern of seizures, electroencephalographic discharges, and anticonvulsant and psychotropic medications. The findings suggest that postictal psychosis results from increased epileptiform activity and continued cerebral dysrhythmia, has a latency in onset and is not due to the immediate postictal delirium, and reflects an exacerbation of underlying psychopathological tendencies. This report further discusses the potential pathophysiological mechanisms and management of this disorder.     

A prospective study of postictal psychoses with emphasis on the periictal type

PURPOSE: To assess prospectively episodes of postictal psychosis. METHODS: We followed 108 consecutive patients with temporal lobe epilepsy, who were divided into three groups: those without psychotic episodes (n=87, N group), those with interictal psychosis (n=13, IIP group), and those with postictal psychosis (n=8, PIP group). The first episode of postictal psychosis, which was defined as a psychotic episode that occurred within 1 week after the end or within 3 days before the beginning of seizure clusters, was assessed with the Brief Psychiatric Rating Scale (BPRS) and Social Dysfunction and Aggression Scale (SDAS) during the observation period. RESULTS: The duration of illness was significantly different between the N and PIP groups (p=0.004) and between the N and IIP groups (p=0.039). The average initial BPRS score (obtained 3.0 days after the end of the seizure cluster) was 19.7, and then decreased to 5.8 after 1 week, and finally normalized at 1.5 after 1 month. A statistically significant decrease in BPRS scores was found between the initial assessment and those obtained after 1 week (p=0.011). Those who had psychotic episodes without a lucid interval tended to have episodes more often than monthly, and experienced additional seizure recurrence even during the psychotic episodes. Two patients exhibited a frank manic phase, and three patients showed excessively aggressive behavior, as determined by the SDAS. CONCLUSIONS: Postictal psychosis should be subdivided into the nuclear type, with an established clinical picture as an indirect aftereffect of seizure activity, and the atypical periictal type, which is a direct manifestation of limbic discharge.     

Les psychoses postictales

In epilepsy patients, psychotic states are related to a group of psychotic disorders with a specific phenomenology in which potential pathophysiological mechanisms are believed to be closely related to the epileptic disorder itself. Postictal psychosis is a very specific syndrome in relation to seizure activity: a clear temporal relationship exists between the psychotic state of sudden onset and a precipitating bout of complex partial or generalized seizures, with a characteristic lucid interval which lasts from two to 120 h. The psychotic state may be related to the withdrawal of anticonvulsants, often in connection with video-EEG monitoring. The phenomenology of the psychotic state is often pleomorphic, with abnormal mood, paranoid delusions and hallucinations, with some clouding of consciousness or no evidence of impaired consciousness. The outcome is characterized by a remission of the psychotic symptoms over several days (mean: 1 week), with or without neuroleptic treatment. The majority of the patients suffer from complex partial seizures with frequent psychic auras that secondarily become generalized. In the majority of cases, prepsychotic EEG abnormalities persist during the psychosis. Frequent bitemporal foci are recorded on the EEG and MRI abnormalities (including mesial temporal sclerosis) are seen in more than half of the cases. The results of clinical, morphologic and metabolic available studies will be briefly discussed.     

Psychosis in epilepsy patients

Summary   Epileptic psychoses reflect a fundamental disruption in the fidelity of mind and occur during seizure freedom or during or after seizures. The psychotic symptoms in epilepsy share some qualities with schizophrenic psychosis, such as positive symptoms of paranoid delusions and hallucinations. Psychotic syndromes in epilepsy are most common but not exclusively associated with temporal lobe epilepsy. De Novo psychosis following epilepsy surgery is rare. Forced normalization—psychosis associated with dramatic reduction of epileptiform activity or seizures is described in small series only. Ictal and postictal psychosis can be prevented with seizure control, but postictal and chronic interictal psychoses require multidisciplinary and psychopharmacologic management.     

Postictal mania versus postictal psychosis: differences in clinical features, epileptogenic zone, and brain functional changes during postictal period

PURPOSE: To clarify the differences between postictal mania (PIM) and postictal psychosis (PIP). METHODS: Five patients with PIM were compared to 17 patients with PIP, with respect to clinical, epileptological, electrophysiological, and neuroimaging features. PIM was distinguished from PIP by the symptoms observed in the postictal period based on the ICD-10 criteria. RESULTS: Postictal manic episodes lasted for a longer period than postictal psychotic episodes. Patients with PIM had more recurrent postictal episodes than patients with PIP. The age at onset of epilepsy in patients with PIM was older than that in patients with PIP. PIM was associated with frontal lobe and temporal lobe epilepsies, whereas PIP was associated with temporal lobe epilepsy. The estimated epileptogenic zone was on the language dominant side in PIM, whereas there was no predominant hemispheric laterality in PIP. Electroencephalography (EEG) performed during the early period of postictal manic and psychotic episodes showed decreased frequency of interictal epileptiform discharges in both PIM and PIP. Single-photon emission computed tomography (SPECT) during postictal manic and psychotic episodes showed increased perfusion in the temporal and/or frontal lobes in both PIM and PIP. Three patients with PIM showed increased perfusion during postictal episodes on bilateral or the language nondominant side, which were contralateral to the estimated epileptogenic zone, whereas three patients with PIP showed increased perfusion on the areas, which were ipsilateral to the estimated epileptogenic zone. CONCLUSIONS: PIM has a distinct position among the mental disorders observed in the postictal period.     

Postictal Psychosis: A Comparison with Acute Interictal and Chronic Psychoses

Summary: We studied 30 patients with postictal psychosis and compared them with 33 patients with acute interictal psychosis and 25 patients with chronic psychosis. All patients had either complex partial seizures (CPS) or EEG temporal epileptogenic foci. Patients with postictal psychosis had a high incidence of psychic auras and nocturnal secondarily generalized seizures. The most striking feature that distinguished postictal psychosis from both acute interictal and chronic psychoses was phenomenological: the relatively frequent occurrence of grandiose delusions as well as religious delusions in the setting of markedly elevated moods and feeling of mystic fusion of the body with the universe. In addition, postictal psychosis exhibited few schizophreniform psychotic traits such as perceptual delusions or voices commenting. Reminiscence, mental diplopia, and a feeling of impending death were also fairly frequent complaints of patients with postictal psychosis. Interictal acute psychosis and chronic epileptic psychosis were psychopathologically similar. Although acute interictal and chronic epileptic psychoses could simulate schizophrenia, postictal psychosis results in a mental state quite different from that of schizophrenic psychosis.     

Clinical management of recurrent postictal psychosis

Although there are numerous reports of interictal psychosis in epileptic patients, there are few studies describing the longitudinal course and treatment of postictal psychosis. The goal of this study was to define the clinical features, natural history, and possible interventional methods in a group of patients with complex partial seizures and postictal psychosis. We studied seven patients who manifested psychotic behavior following an increase in their seizure frequency. Mean follow-up was 83 months. Patients underwent neuropsychiatric testing, cranial magnetic resonance imaging, and extensive EEG evaluation. All but one patient had severe epilepsy. An increased number of seizures was followed by a brief period of lucidity and then psychosis, which lasted between 2 and 14 days and tended to recur (mean, one episode every 4 months). EEGs done during the psychotic episodes generally demonstrated a mild diffuse background slowing without evidence of ictal epileptiform discharges. Evaluation between episodes revealed no persistent psychiatric features. The patients rarely required hospitalization or neuroleptic medications. Patients usually responded to mild sedation, close observation, and a supportive environment.     

Psychosis of Epilepsy: A Neurologist's Perspective

Psychosis of epilepsy (POE) comprises a group of disorders that are closely associated with epileptic seizures. These include interictal POE, postictal psychosis, and alternative psychosis (also known as "forced normalization"). Neurologists have, in general, played a limited role in the evaluation and management of patients with POE. Yet, as reviewed in this paper, a good understanding of electrophysiologic, neuroradiologic, and neuropathologic variables associated with POE can yield valuable data in the evaluation of the seizure disorder of these patients. The purpose of this review article is to highlight the clinical, neuroradiologic, neurophysiologic, and neuropathologic aspects of POE that can assist in the evaluation and management of the associated seizure disorder and to identify the circumstances in which a timely therapeutic intervention by neurologists can avert or minimize the occurrence of a psychotic episode. Specifically, the clinical characteristics of interictal POE and ictal, postictal, and alternative psychotic episodes are highlighted together with their potential pathogenic mechanisms and the associated treatment issues. Finally, discussions of psychotic disorders following epilepsy surgery and the pharmacotherapy of psychotic disorders in patients with epilepsy are presented.     

Duration of postictal psychotic episodes

PURPOSE: To clarify duration of postictal psychosis (PIP) episodes and identify factors that influence its duration. METHODS: Fifty-eight patients with epilepsy exhibited 151 PIP episodes during a mean follow-up period of 12.8 years. Distribution of the duration of these episodes was determined, and factors potentially affecting were analyzed. Factors analyzed included PIP-related variables (i.e., antecedent seizures and the lucid interval) and patient characteristics (i.e., type of epilepsy, lateralization of EEG abnormalities, and intellectual functioning). RESULTS: The mean duration of the 58 first PIP episodes was 10.5 days, and that of all 151 PIP episodes (including multiple episodes) was 9.2 days. Approximately 95% of the PIP episodes resolved within 1 month. Most PIP-related variables, except for antipsychotic drugs administered, were not associated with duration of the episodes. Several patient characteristics, i.e., history of interictal psychosis, family history of psychosis, and intellectual functioning, were associated with duration of the PIP episodes. CONCLUSIONS: This study showed that most PIP episodes last less than 1 month. PIP episodes appear to be prolonged when individuals have an underlying vulnerability to psychosis. Clinical phenomena that can trigger PIP may not determine the course of the PIP episode.     

Characteristics of postictal psychosis in a psychiatric center

The clinical characteristics of 12 cases of postictal psychosis treated at Taipei City Psychiatric Center, Taipei, Taiwan, were retrospectively reviewed. Increased seizure frequency, especially with generalized tonic-clonic seizures, was the major risk factor predisposing to postictal psychosis. The psychotic symptoms were variable with delusions and/or hallucinations. These patients showed a much longer history of epilepsy (21.9 +/- 10.7 years) prior to the development of postictal psychosis than has been previously reported. The possible mechanisms in the pathophysiology of psychosis in epileptics were discussed.     

“God has sent me to you”: Right temporal epilepsy,left prefrontal psychosis

Religious experiences have long been documented in patients with epilepsy, though their exact underlying neural mechanisms are still unclear. Here, we had the rare opportunity to record a delusional religious conversion in real time in a patient with right temporal lobe epilepsy undergoing continuous video-EEG. In this patient, a messianic revelation experience occurred several hours after a complex partial seizure of temporal origin, compatible with postictal psychosis (PIP). We analyzed the recorded resting-state EEG epochs separately for each of the conventional frequency bands. Topographical analysis of the bandpass filtered EEG epochs revealed increased activity in the low-gamma range (30–40 Hz) during religious conversion compared with activity during the patient's habitual state. The brain generator underlying this activity was localized to the left prefrontal cortex. This suggests that religious conversion in PIP is related to control mechanisms in the prefrontal lobe-related processes rather than medial temporal lobe-related processes.     

Postictal Psychosis After Partial Complex Seizures: A Multiple Case Study

Bouts of unusually frequent partial complex seizures originating in the temporal lobe, that sometimes became secondarily generalized, induced psychotic episodes in 9 patients. In 7, the increase in seizures occurred at a time when antiepileptic drugs (AEDs) were being reduced during intensive EEG monitoring with a view to surgical treatment of intractable epilepsy. According to DSM-III-R criteria, the postictal psychosis resembled an organic delusional syndrome which was paranoid in 7 and schizophreniform in 1 and an organic mood syndrome in 1. A high incidence of ictal fear, of bilateral independent epileptogenic discharge, and of small foreign tissue lesion were unexpected findings and appeared to represent risk factors, especially in patients otherwise handicapped by an epileptic personality disorder. Recognition of postictal psychosis in this setting and in others is important both prognostically and therapeutically. Postictal psychosis does not constitute a contraindication to surgical treatment of epilepsy.     

Prolonged postictal psychosis with forced normalization (Landolt) in temporal lobe epilepsy

We report two patients with temporal lobe epilepsy who developed prolonged episodes of postictal psychosis (12 weeks) following a bout of seizures and a lucid interval. No drug toxicity was noted, and no recurrent or continuous seizures were observed during their prolonged psychotic episodes. Repeated EEGs during the period of psychosis showed that their habitual focal epileptiform abnormalities had disappeared. Responses to neuroleptic treatments were not remarkable. Their psychotic symptoms gradually dispelled after their epileptiform abnormalities reappeared. These observations may suggest possible overlapping mechanisms between a prolongation of psychosis and suppression of epileptiform discharges on a scalp EEG.     

Recurrent postictal psychosis after remission of interictal psychosis: further evidence of bimodal psychosis

PURPOSE: To ascertain whether bimodal psychosis (i.e., independent postictal and interictal psychosis) in patients with epilepsy can be characterized by postictal psychosis that develops after interictal psychosis remits. Methods: We reviewed the records of 14 patients with bimodal psychosis treated at a national center hospital.Clinical and psychopathological characteristics of the patients were examined. RESULTS: Among the 14 patients with bimodal psychosis, four initially had interictal psychosis, and 10 initially had postictal psychosis. That is, interictal-antecedent bimodal psychosis characterized four cases, and postictal-antecedent bimodal psychosis characterized 10 cases. Patients with interictal-antecedent bimodal psychosis composed 2.2% of the total patients with epilepsy and psychosis (n = 180) and 28.5% of total patients with bimodal psychosis. All four patients with interictal-antecedent bimodal psychosis had partial epilepsy with complex partial seizures, bilateral EEG abnormalities, and borderline (or decreased) intellectual functioning. Most of these clinical features are common to both types of bimodal psychosis. Among patients with interictal-antecedent bimodal psychosis, the mean age at the onset of the initial symptoms was 10.8 years (SD, 4.3 years) for epilepsy, 24.4 (6.1) years for interictal psychosis, and 33.8 (4.5) years for postictal psychosis. CONCLUSIONS: In a few patients, postictal psychosis develops after the remission of interictal psychosis. Interictal-antecedent bimodal psychosis is not likely a discrete entity because of several characteristics common to both types of bimodal psychosis. Patients may have greater vulnerability to psychosis and develop psychotic episodes easily, regardless of the presence of preceding seizures.     

Violence and Epilepsy: A Close Relation Between Violence and Postictal Psychosis

Summary: Purpose: We investigated the incidence of well-directed violent behavior and suicide attempts in patients with temporal lobe epilepsy, with special attention to postictal psychosis.
Methods: We compared 57 episodes of postictal psychosis with 62 episodes of acute interictal (or alternative) psychosis and with 134 complex partial seizures. All patients were matched for age and for age at onset of seizures.
Results: The incidence of well-directed violent behavior against human beings was significantly higher (23%) during postictal psychotic episodes than during acute interictal episodes (5%) and postictal confusion (1%). Suicide attempts were also more frequent during postictal psychosis (7%) than during either acute interictal psychosis (2%) or postictal confusion (0%).
Conclusions: Our study showed that well-directed violent and self-destructive behavior was not a feature of epileptic psychosis in general but a specific hallmark of postictal psychosis.     

Acute Psychosis During Intracranial EEG Monitoring: Close Relationship Between Psychotic Symptoms and Discharges in Amygdala

PURPOSE: This report examined the underlying mechanism of psychosis associated with epilepsy. METHODS: An adult patient with epilepsy manifesting acute psychosis during long-term EEG monitoring is presented, together with a literature review on this subject. RESULTS: A 25-year-old woman with intractable temporal lobe epilepsy developed acute psychosis while she underwent long-term intracranial EEG monitoring. After a clustering of seizures, she manifested psychotic symptoms including hallucination, stupor, and repeated fear. The transition of psychotic symptoms corresponded to the changes in frequency and morphology of seizure discharges restricted to the left amygdala. Improvement of psychosis coincided with disappearance of seizure discharges. CONCLUSIONS: This case confirmed a close relationship between psychotic symptoms and seizure discharges in the left amygdala. It is suggested that paroxysmal bombardment of the medial temporal lobe structure may be a pathogenetic factor of acute psychosis associated with epilepsy.     

Postictal psychosis in temporal lobe epilepsy

PURPOSE: Postictal psychosis is a well-known complication, occurring especially in patients with temporal lobe epilepsy. It usually runs a benign course. The literature on this topic is sparse, and the underlying pathogenic mechanisms are not known. METHODS: We report five patients with temporal lobe epilepsy in whom postictal psychosis developed during the course of video-EEG monitoring; they were studied with hexamethyl-propyleneamine-oxime single-photon emission computed tomography (HMPAO-SPECT) during and after the psychotic event. RESULTS: In comparison to the interictal state, all SPECT scans obtained during postictal psychosis were remarkable for bifrontal and bitemporal hyperperfusion patterns. Some studies also demonstrated unilateral left lateral frontal hyperperfusion. These cortical blood-flow patterns appeared to be distinct from those obtained during complex partial seizures. CONCLUSIONS: Our data suggest that postictal psychoses in patients with temporal lobe epilepsy are associated with hyperactivation of both temporal and frontal lobe structures. This hyperperfusion may reflect ongoing (subcortical) discharges, active inhibitory mechanisms that terminate the seizure, or simply a dysregulation of cerebral blood flow.     

Progression of postictal to interictal psychosis

PURPOSE: To describe a case series of patients with both postictal psychosis (PIP) and chronic interictal psychosis (IIP). METHODS: We retrospectively reviewed the records of 43 patients with PIP from a comprehensive epilepsy center to find evidence of both PIP and IIP in the same patient. RESULTS: Six (13.9%) of the 43 patients met all the criteria for both PIP and IIP. Five of our six patients had multiple documented PIPs before they became chronically psychotic. The range of length of time between PIP and IIP was 7 to 96 months. Postictal and interictal psychotic behavior was similar or identical in five of six cases. CONCLUSIONS: The results of this study suggest a progression from PIP to IIP: there is a similarity between the symptoms of the two psychoses, a history of multiple PIPs before the first IIP, and a period of months to years between PIP and IIP onset.     

Long-term significance of postictal psychotic episodes: I. Are they predictive of bilateral ictal foci?

OBJECTIVE: The aim of this study was to determine the degree to which postictal psychotic episodes (PIPE) are predictive of bilateral independent ictal foci. METHODS: This was a retrospective study of 18 consecutive adults with a partial seizure disorder and PIPE (study group) and 36 patients with a partial seizure disorder but without PIPE (control group). The two groups were compared with respect to the number and location of ictal foci identified with video/EEG monitoring, seizure type, etiology, age at seizure onset, duration of seizure disorder, MRI abnormalities, and psychiatric history prior to the index video/EEG monitoring (other than PIPE). Statistical analyses consisted of logistic regression models, one to identify the variables predictive of bilateral ictal foci and the other to identify the variables predictive of PIPE. RESULTS: The occurrence of PIPE (P<0.0001) and cryptogenic partial epilepsy (P=0.004) was predictive of bilateral independent ictal foci in univariate analyses. In multivariate analyses, cryptogenic partial epilepsy was the only significant variable (P=0.03). Conversely, bilateral independent ictal foci on video/EEG monitoring (P<0.0001) and having secondarily generalized tonic-clonic seizures (P=0.035) were independent predictors of the development of PIPE in univariate and multivariate analyses. Surgery was performed in 20 controls and 3 patients with PIPE; 17 controls and 2 patients with PIPE became seizure-free. CONCLUSIONS: The presence of PIPE appears to be a predictor of bilateral ictal foci.