Postictal psychosis (PIP) can occur in 6% of epilepsy patients within a week after a seizure, presenting as delusions, hallucinations, mania or confusion. PIP is more likely to involve violence in 23% of cases compared to 5% for interictal psychosis or 1% for postictal confusion. Diagnosing postictal aggression as resulting from seizures requires ruling out other medical conditions and establishing that the aggressive behavior occurred within a week after a seizure. High risk populations for PIP include males with temporal lobe epilepsy of over 10 years and cognitive or psychiatric comorbidities.

1. Increasing Understanding of Postictal Psychosis
Lei (Linda) Kang, University of Pennsylvania – Mentor: Diane Lawrence, NBHP Service Educator
Postictal psychiatric experience can present as anxiety and depression, but psychotic
symptoms are most common and have a suicide prevalence of 7%.
Epilepsy: a tendency for having recurring seizures
Prevalence: 4% of general population
Postictal Psychosis (PIP): sudden onset of psychotic state precipitated by complex partial or
generalized seizures
Prevalence: 6% of epilepsy patients
- Delusions, hallucinations, mania, confusion
- Severity and duration of postictal delirium closely parallel the severity of their seizures
- Postictal psychosis resolves in about a week
Violence: unprovoked destructive behaviors that directly harm others
Prevalence: 23% of epilepsy patients with PIP
- Out of character
- Amnesia/impaired awareness
- Gradual return to normal consciousness
Linking epilepsy with aggression has contributed to the stigma of the disorder, so any work
that clarifies the nature of the relationship between these two factors has many potential
benefits.
Criteria to determine whether violent act was result of an epileptic seizure
1) Diagnosis of epilepsy established by a neurologist
2) Episode of psychosis within 1 week after a seizure
3) Psychosis lasts more than 15 hours and less than 2 months (including delusions,
hallucinations in clear consciousness, bizarre/disorganized behavior, formal thought
disorder, or affective changes)
4) Epileptic automatisms and aggression during epileptic automatisms documented by case
history and closed-circuit TV-EEG
5) The aggressive act is characteristic of the patient’s habitual seizures
6) A clinical judgment by the neurologist as to possibility that violent act was part of seizure
7) Eliminate all other possible differential diagnoses
(Marsh & Krauss, 2000 and de Toffol & Kanemoto, 2016)
*Difficult and sometimes controversial diagnosis
Background
Diagnostic Criteria
- Get full history in advance: identify underlying cerebral disorders
- Assess sociological and biological risk for factors of violence and context of violent act
- Details of preceding seizure
- If prolonged confusion: EEG and clinical chemistry studies
- If new deficits: cerebrospinal fluid exam to exclude infections and inflammatory disorders
- Carefully assess depression and suicidality
Evaluation
Krauss, G., & Theodore, W. H. (2010). Treatment strategies in the postictal state. Epilepsy &
Behavior : E&B, 19(2), 188–190.
Hartshorn, J. C., & Maze, C. D. M. (2013). Postictal psychosis: implications for nursing.
Journal of Neuroscience Nursing, 45(2), 71-76.
Marsh, L., & Krauss, G. L. (2000). Aggression and violence in patients with epilepsy. Epilepsy
& Behavior, 1(3), 160-168.
de Toffol, B., & Kanemoto, K. (2016). [Postictal psychoses: Clinical and neurobiological
findings]. L'Encephale.
References
- Prolonged convulsion
- Increase in seizure activity
- Cluster of seizures
- Reduction of antiepileptic drugs
- Bilateral interictal epileptiform activity
- An aura of ictal fear
- Infection
- Withdrawal state
- Electrolyte imbalance
Factors Reducing Threshold for Aggressive Behavior
- Traumatic brain injury
- Alcohol-related dementia
- Cognitive impairment
- History of fetal alcohol syndrome
- History of prolonged physical abuse
- Delusions and hallucinations in the absence of insight
- Violent crimes more likely by individuals who had CNS trauma before the age of 14
Preceding Signs and Symptoms
Prevention
- Avoid known seizure triggers: lack of sleep, flashing lights, abrupt medication changes
- Advocate for frequent medication reevaluation
Supportive care
- Reduce stimulation: Dim lighting, reduced noise/activity
- Remove dangerous objects
- Raise padded bedrails
- Restraints only if patient is at risk of harming themselves or others
- Family members can help calm and reassure
- Continuous observation and support
- Speak in direct, calm manner
Discharge Instructions
- Emphasize importance of medication compliance
- Help patient and family understand importance of psychiatric care
- Instruct family and patient to recognize onset and take appropriate measures
- Ensure access to antipsychotic medications to be taken at first sign of recurrence
- Empower patient and family by providing steps for action: 1) identify 2) seek assistance 3)
notify clinician 4) medicate
Intervention
Postictal Psychosis:
- 10% follow psychosis-free interval of hours-days or cluster of complex partial seizures
- Less than a day up to several weeks, but tendency to recur
- May develop chronic interictal psychotic syndromes with affective/schizophrenia-like features
- Delusional ideation, hallucinations, thought disorder, manic or depressive mood changes
with mood congruent delusions or hallucinations
- May motivate violent behaviors
- Greater potential for violent behavior (23%) relative to acute episodes of interictal
psychosis (5%) or postictal confusion (1%)
Postictal Aggression:
- After complex partial or generalized tonic-clonic seizures
- Linked with amygdalar seizures and diencephalic lesions and tumors
- Resistive, poorly directed violence
- Pushing and shoving
- Shouting or spitting
- Lose control of an object or knock/grab nearby objects or individuals
- Repetitive movements of limbs
- Repetitive and prolonged seizures may extend duration
- Postictal automatisms with increasingly complex and directed behavior with return of
consciousness
- For extreme violence: recurrent, after a cluster of seizures in males
Clinical Presentation
Attributed to seizures alone only after excluding all other possible medical conditions
- Complications of antiepileptic drug (AED) therapy
- Overdoses and valproic acid-induced hyper-ammonemia
- Posterior reversible encephalopathy syndrome
- Withdrawal states
- Meningitis
- Complications of metabolic or endocrine disorders
- Pontine myelinolysis, hypoglycemic injury, and phenytoin toxicity
- Previously undetected psychiatric illness
- Subtle ictal states (non-convulsive status epilepticus)
- increased cerebral blood flow
- Hyperactive delirium: wandering and reactive; aggressive behaviors if held
Differential Diagnosis
Unclear, but potentially:
- Neuronal exhaustion after hyper-excitation
- Dopaminergic hypersensitivity and GABA-mediated mechanisms
- A longer seizure might be associated with higher neurotransmitter release
- Peri-ictal changes in gonadal hormones and fluid balance
- Epileptiform discharges of temporal origin
- Structural brain injury related to trauma or encephalitis associated with the development
of epilepsy
- Especially penetrating head injuries to the ventromedial prefrontal region
- Reduced left frontal gray matter volumes
- Prefrontal regions hypoactive and left temporal and basal ganglia regions hyperactive
Physiological Basis
Male
Gross
Structural
Lesions
Temporal
Lobe
Epilepsy
>10 Years
Epilepsy
History
Cognitive
and
Psychiatric
Disorders
High Risk
Population
for PIP
- Treatment-resistant epilepsy
- Slowing of the EEG background activity
- Family history of mood disorders,
psychiatric disorders and epilepsy
- Personal history of encephalitis
- Personal history of mood disorders,
depression, febrile convulsions
Huge thank you to the amazingly knowledgeable, kind, and patient Diane Lawrence, Paul
Wong, Mary Myers, Monica Boateng and all of the fabulous 7SW staff!
Acknowledgements