Postictal psychosis: common, dangerous, and treatable

Postictal psychosis in a 3-year-old child

A case of a 3½-year-old with clinical and correlated electroencephalographic (EEG) features of postictal psychosis is described. The clinical course and sequence of EEG changes parallel the evolution of changes well described in the adult population. Although well established and defined in the adults, postictal psychosis is rarely characterized and diagnosed in the pediatric population. The true incidence of postictal psychosis in children may be underestimated because of lack of awareness as well as biological differences in presentation of clinical symptoms. To our knowledge, this is the youngest reported case of postictal psychosis in the pediatric population.

Hippocampal temporal-parietal junction interaction in the production of psychotic symptoms: a framework for understanding the schizophrenic syndrome

A framework is described for understanding the schizophrenic syndrome at the brain systems level. It is hypothesized that over-activation of dynamic gesture and social perceptual processes in the temporal-parietal occipital junction (TPJ), posterior superior temporal sulcus (PSTS) and surrounding regions produce the syndrome (including positive and negative symptoms, their prevalence, prodromal signs, and cognitive deficits). Hippocampal system hyper-activity and atrophy have been consistently found in schizophrenia. Hippocampal activity is highly correlated with activity in the TPJ and may be a source of over-excitation of the TPJ and surrounding regions. Strong evidence for this comes from in-vivo recordings in humans during psychotic episodes. Many positive symptoms of schizophrenia can be reframed as the erroneous sense of a presence or other who is observing, acting, speaking, or controlling; these qualia are similar to those evoked during abnormal activation of the TPJ. The TPJ and PSTS play a key role in the perception (and production) of dynamic social, emotional, and attentional gestures for the self and others (e.g., body/face/eye gestures, audiovisual speech and prosody, and social attentional gestures such as eye gaze). The single cell representation of dynamic gestures is multimodal (auditory, visual, tactile), matching the predominant hallucinatory categories in schizophrenia. Inherent in the single cell perceptual signal of dynamic gesture representations is a computation of intention, agency, and anticipation or expectancy (for the self and others). Stimulation of the TPJ resulting in activation of the self representation has been shown to result a feeling of a presence or multiple presences (due to heautoscopy) and also bizarre tactile experiences. Neurons in the TPJ are also tuned, or biased to detect threat related emotions. Abnormal over-activation in this system could produce the conscious hallucination of a voice (audiovisual speech), a person or a touch. Over-activation could interfere with attentional/emotional gesture perception and production (negative symptoms). It could produce the unconscious feeling of being watched, followed, or of a social situation unfolding along with accompanying abnormal perception of intent and agency (delusions). Abnormal activity in the TPJ would also be predicted to create several cognitive disturbances that are characteristic of schizophrenia, including abnormalities in attention, predictive social processing, working memory, and a bias to erroneously perceive threat.

Postictal psychosis and its electrophysiological correlates in invasive EEG: a case report study and literature review

We identified two patients with medically refractory temporal lobe epilepsy, from whom intracranial EEG recordings were obtained at the time of postictal psychosis. Both patients had mesial temporal epilepsy associated with hippocampal sclerosis. In both patients, the postictal psychosis was associated with a continual "epileptiform" EEG pattern that differed from their interictal and ictal EEG findings (rhythmical slow wave and "abortive" spike-slow wave complex activity in the right hippocampus and lateral temporal cortex in case 1 and a periodic pattern of triphasic waves in the contacts recording activity from the left anterior cingulate gyrus). Some cases of postictal psychosis might be caused by the transient impairment of several limbic system structures due to the "continual epileptiform discharge" in some brain regions. Case 2 is the first report of a patient with TLE in whom psychotic symptoms were associated with the epileptiform impairment of the anterior cingulate gyrus.

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.

Abnormalities of cortical thickness in postictal psychosis

Postictal psychosis (PIP), the occurrence of psychotic episodes following a seizure, is a common and serious comorbidity in patients with epilepsy. Yet, the anatomical correlates remain poorly defined. Here, we used quantitative MRI morphometry to identify structural abnormalities in the cortex of patients with PIP relative to patients with epilepsy without PIP and age- and gender-matched normal healthy controls. Comparison of patients with epilepsy and PIP with patients with epilepsy without PIP revealed increased cortical thickness in the right lateral prefrontal cortex, right anterior cingulate cortex, and right middle temporal gyrus. The PIP group was distinguished from the EC and NC groups by thicker cortex in the right rostral anterior cingulate cortex and thinner cortex in the right angular gyrus and the left middle temporal region. Findings indicate that PIP is associated with thickening of the right anterior cingulate cortex, which may serve as a marker for patients at risk for developing PIP.

Violence and postictal psychosis: a comparison of postictal psychosis, interictal psychosis, and postictal confusion

The belief that epilepsy is linked with violent behavior acquired a highly stigmatizing value in the late 19th century on the basis of degenerative theory. This widespread medical view lost general acceptance among experts in the 1990s after several large-scale studies showed that aggressive phenomena can arise during epileptic seizures, but are extremely rare. The concept of postictal psychosis (PIP) shed a new light on this old dispute. With this concept, the significance of the chronological relationship between seizures and violent behaviors in patients with epilepsy is newly stressed, which made a simple "yes" or "no" answer to the question implausible. In this review, we discuss violent behaviors at five chronological points relative to seizures and demonstrate representative cases. As shown in our previous study, well-directed violent attacks occurred during 22.8% of the PIP episodes, 4.8% of the IIP episodes, and 0.7% of the postictal confusions. Compared with the other two situations, proneness to violence stood out in the PIP episodes. Suicidal attempts showed a similar trend. Purposeful, organized violence as a direct manifestation of seizures or ictal automatism is highly exceptional. Violent acts could occur in postictal confusion as an expression of unconscious, vigorous resistance against efforts of surrounding people to prevent the affected individual from roaming or fumbling about. In contrast, some PIP episodes can be highly alarming, especially if a violent act has been previously committed in preceding episodes. Violent acts by patients with epilepsy should be treated differently according to the various pathophysiological backgrounds from which the violence arises.

The postictal state: effects of age and underlying brain dysfunction

There is relatively little information on the underlying parameters that affect clinical features of the postictal period. Age-related physiological changes, including alterations in cerebral blood flow and metabolism, neurotransmitter function, and responses of the brain to seizure activity may affect postictal clinical phenomena. Some conclusions can be drawn. Elderly adults and children, particularly in the presence of diffuse cerebral dysfunction, may have more prolonged postictal confusion. Postictal dysphasia strongly suggests a dominant hemisphere focus, more often temporal, and Todd's paralysis is always contralateral to the epileptogenic zone. Much additional information could be derived from the vast amount of video/EEG monitoring data available.

Postictal headache

Postictal headache (PIH) is defined by the International Classification of Headache Disorders as "headache with features of tension-type headache or, in a patient with migraine, of migraine headache, which develops within 3 hours following a partial or generalized seizure and resolves within 72 hours after the seizure." PIHs are prevalent, moderate to severe in intensity, last many hours, and frequently have characteristics of migraine. Young adults with a history of interictal headaches are at increased risk of developing PIH. Young age at onset and long duration of epilepsy, drug-resistant seizures, generalized tonic-clonic seizures, and possibly an occipital epileptic focus are additional risk factors. Although PIH is estimated to have a significant impact on the quality of life of people with epilepsy, it is frequently undertreated. Simple analgesics may prove beneficial. Epilepsy and headache share common pathophysiological mechanisms, as suggested by clinical and investigational findings, although the exact processes underlying these conditions are still largely unknown.

[Psychotic disorder revealing epilepsy linked to a dysembryoma of the left hippocampus]

INTRODUCTION

Psychotic symptoms are a rare but well-known complication of epilepsy. The prevalence is estimated between 4 and 9%.

PATIENT

We report a case of a 40-year-old patient, unrecognized epileptic, who presented an acute psychotic syndrome which seemed to be of functional origin, the EEG performed during the episode, and the cerebral CT scan being normal. Nevertheless, the clinical presentation, especially the sudden ending of delusions, led to further investigations. Careful history taking and repeated EEG recordings allowed the diagnosis of partial epilepsy that had begun 17 years earlier and symptomatic of a dysembryoplastic tumour of the left hippocampus revealed by MRI.

DISCUSSION AND CONCLUSION

Search for an epileptic origin of an acute psychotic syndrome must always be undertaken by systematic EEG. The possibility of a symptomatic temporal tumor must not be overlooked.

[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.