[Postictal psychosis syndrome: a clinical entity to be recognized]

Postictal psychosis, a cause of secondary affective psychosis: A clinical description study of 77 patients

OBJECTIVE

Postictal psychosis (PIP) is a severe complication occurring at least in 2% of patients with epilepsy. Since the 19th century, psychiatrists have reported the specificity of PIP presentation, but descriptions did not clearly distinguish PIP from after-seizure delirium. This study aimed to provide a precise description of psychiatric signs occurring during PIP, and improve recognition of PIP.

METHODS

We performed a review of clinical descriptions available in literature (48 patients), that we gathered with a retrospective multicentric case series of patients from three French epilepsy units (29 patients). For each patient, we collected retrospectively the psychiatric signs, and epilepsy features.

RESULTS

We found a high prevalence of persecutory (67.5%) and religious (55.8%) delusions, with almost systematic hallucinations (83.1%) and frequent mood disturbances (76.6%), especially euphoria. Severe consequences were not negligible (other-directed assault in 20.8%, self-directed in 13.0%). The type of delusion was associated with mood symptoms (p = 0.017). Episode onset was mainly sudden/rapid (90.9%), its duration was mostly between one and 14 days (64.9%) and the response to antipsychotic medication was good. Disorder was recurrent in more than a half of the sample (57.1% of patients with at least 2 episodes).

CONCLUSION

Considering our findings, PIP resembles more an affective psychosis, than a purely psychotic disorder. The presence of affective signs differentiates PIP from other psychotic comorbidities in epilepsy. Additionally, resemblance between PIP and psychotic manic episode might help to discuss links between epilepsy and bipolar disorder.

Psychotic Disorders in Epilepsy: Do They Differ from Primary Psychosis?

Any attempt to compare the definitions of symptoms listed for "primary psychoses" with those adopted in studies of psychoses in patients with epilepsy (PWE) will encounter problems of heterogeneity within both conditions. In this manuscript, five psychotic illnesses listed in Diagnostic and Statistical Manual of Mental Disorders-5th Edition (DSM-5), that is, brief psychotic illness, schizophreniform disorder, schizophrenia, delusional disorder, and schizoaffective disorder are compared with postictal (or periictal) and interictal psychotic disorders in PWE. After examining definitions of primary psychoses, definitions of psychoses adopted in the papers dealing with postictal and interictal psychoses are summarized. Further, diagnostic criteria of five types of psychotic disorders in PWE proposed in 2007 by Krishnamoorthy et al. are also discussed, which include postictal psychosis, comorbid schizophrenia, iatrogenic psychosis caused by antiepileptic drugs (AEDs) (AED-induced psychotic disorder: AIPD), and forced normalization. Evidently, a comparison between postictal psychosis and schizophrenia is pointless. Likewise, schizophrenia may not be an appropriate counterpart of forced normalization and AIPD, given their acute or subacute course.Based on these preliminary examinations, three questions are selected to compare primary psychoses and psychoses in PWE: Is postictal psychosis different from a brief psychotic disorder? Does epilepsy facilitate or prevent the development of psychosis or vice versa? Is interictal psychosis of epilepsy different from process schizophrenia? In conclusion, antagonism between psychosis and epileptic seizures in a later stage of active epilepsy seems not to be realized without reorganization of the nervous system promoted during an earlier stage. Both genetic predisposition and the summated effects of epileptic activity must be taken into consideration as part of a trial to explain interictal psychosis. Interictal psychosis is an aggregate of miscellaneous disorders, that is, co-morbid schizophrenia, AED-induced psychotic disorders, forced normalization, and "epileptic" interictal psychosis. Data are lacking to conclude whether differences exist between process schizophrenia and "epileptic" interictal psychosis in terms of negative symptoms, specific personal traits, and the "bizarre-ness" of delusory-hallucinatory contents. These discussions may shed light on the essence of process schizophrenia, thus allowing it stand out and receive increased focus.

Medical evaluation and triage of the agitated patient: consensus statement of the american association for emergency psychiatry project Beta medical evaluation workgroup

Numerous medical and psychiatric conditions can cause agitation; some of these causes are life threatening. It is important to be able to differentiate between medical and nonmedical causes of agitation so that patients can receive appropriate and timely treatment. This article aims to educate all clinicians in nonmedical settings, such as mental health clinics, and medical settings on the differing levels of severity in agitation, basic triage, use of de-escalation, and factors, symptoms, and signs in determining whether a medical etiology is likely. Lastly, this article focuses on the medical workup of agitation when a medical etiology is suspected or when etiology is unclear.

Relapse of postictal psychosis following 14-year symptom-free period

Neuropsychiatric sequelae in patients with epilepsy have been vastly studied and documented. These may be affective, cognitive or psychotic. Certain risk factors may predispose some epileptics more to these sequelae. In general, good epileptic control may minimize these outcomes. We present in this report, a case of postictal psychosis (PIP), superimposed on delirium, in a 68-year-old woman, with history of a single previous psychotic illness following a cluster of seizures. This report shows a collaborative management of the neuropsychiatric complications of temporal lobe epilepsy (TLE), by the neurology, geriatric medicine and psychiatry teams.

[Postictal psychosis]

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 120h. 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.