Postictal psychosis – A complex challenge

Abstract

IntroductionPatients with epilepsy have 6–12 times higher risk of suffering from psychosis, with a prevalence of about 7–8%, and the coexistence of these two conditions is associated with increased morbidity and mortality. The psychosis of epilepsy is generally split into two groups: interictal psychoses and postictal psychosis (PIP), and the latter has been estimated to represent 25% of all types. However, many of these episodes remain under-recognized and/or are often misdiagnosed.ObjectivesTo provide an overview of PIP.MethodsLiterature review based on PubMed/Medline, using the keywords “epilepsy” and “psychosis”.ResultsPIP has been recognized since the 19th century, when Esquirol described postictal “fury”. Although its etiology and pathogenesis remain poorly understood, several risk factors and etiopathogenic mechanisms have been suggested and analysed. An essential step in PIP management is its accurate and early diagnosis. Generally, before the onset of PIP there is a lucid period of one to six days after the seizure(s). PIP frequently has a polymorphic presentation, tends to be affect-laden and symptoms often fluctuate. It is of limited duration and frequently responds very rapidly to low doses of benzodiazepines and antipsychotics. However, the propensity of the antipsychotics to provoke seizures and the risk of pharmacokinetic interaction with anti-epileptics are important considerations. Recurrence rates range 25% to 50%.ConclusionsGiven the negative impact of PIP in morbidity and mortality among these patients, it is crucial that neurologists and psychiatrists are able to adequately recognize and treat this clinical condition.Disclosure of interestThe authors have not supplied their declaration of competing interest.