This material was presented in the 25th European Congress of Psychiatry which was organised by the European Psychiatry Association in Florence, Italy from 1-4th April 2017. I had access to the material as I attended the full Congress. Please note that this material remains the intellectual property of the European Psychiatry Association and its authors and any citation should include a full reference to it. For more information on the EPA and how to become a member, please visit: http://www.europsy.net/

1. Postictal psychosis - a complex challenge
Mariana Marinho1, João Marques2, Miguel Bragança1,3
1Clinic of Psychiatry and Mental Health of São João Hospital Centre, Portugal; 2Clinic of Psychiatry of Local Healthcare Unit of Matosinhos, Portugal
3Department of Clinical Neurosciences and Mental Health of Faculty of Medicine, University of Porto, Portugal
marianalemosmarinho@gmail.com
1. INTRODUCTION AND OBJECTIVES
Patients 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). PIP has been estimated to
represent 25% of all types. However, many of
these episodes remain under-recognized and/
or are often misdiagnosed.
Objectives: To provide an overview of PIP.
2. METHODS
Literature review based on articles published
on PubMed/MEDLINE, between January 2006
and August 2016, using the keywords
“epilepsy” and “psychosis”.
3. RESULTS
• Only temporary measures - physical restriction or medical sedation - are needed to cope with risk behaviours aimed at
protecting the safety of patients and others
• Frequently responds very rapidly to low doses of antipsychotics and benzodiazepines (lorazepam, clobazam)
• To assess the need of continuous use of antipsychotics, seeking always the lowest dose for the shortest time
The pharmacological treatment of psychosis of epilepsy has particularities
• To avoid agents associated with a relatively greater risk of lowering the seizure threshold (clozapine, chlorpromazine)
• The potential seizure-threshold lowering properties of psychotropic drugs tend to be related to dose and escalation speed
• Antipsychotics known or supposed to have low epileptogenic properties: olanzapine, risperidone, quetiapine, amisulpride
• To avoid sudden changes in the pharmacological treatment of epilepsy (reduction, increase or substitution of antiepileptics),
mainly in cases with history of psychoses
• Side-effects, toxic effects and pharmacokinetic interactions of antiepileptics and antipsychotics may be additive
4. CONCLUSION
Given 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.
5. BIBLIOGRAPHY
Kanner AM and Rivas-Grajales AM, CNS Spectrums,
2016; Weisholtz DS et al, Journal of Neurological
Disorders & Stroke, 2014; Adachi N et al, Epilepsia,
2013; Guarnieria R et al, Rev Bras Psiquiatr, 2004.
• Bilateral seizure foci in the limbic temporal regions
• Processes associated with bilateral limbic lesions
• Relative increase in seizure frequency preceding the
psychotic symptoms
• Lower verbal IQ
• Absence of febrile convulsions
• Absence of temporal mesial sclerosis
Risk factors
Symptoms are variable
• Auditory, visual or tactile hallucinations
• Persecutory, religious or grandiose delusions
• Sexual indiscretions
• Irritability, agitation, aggressiveness
• Affective symptoms
Clinical presentation
PIP is a psychiatric emergency
Management
PIP is defined by two features: chronologic relationship to seizures and nature of the mental state
PIP represents about 25% of epileptic psychosis
Episodes of psychosis that develop within 1 week after a seizure, or usually a cluster of seizures
EEG: Postictal slowing
There is often a short period of clear consciousness (12 to 72 hours) between
the end of the seizure and the onset of psychosis
PIP has been recognized since the 19th century, when Esquirol described postictal “fury”
PIP usually follows exacerbations, especially clusters, of complex partial seizures,
sometimes without, but more commonly with generalization
• Duration: generally short; days to 2 weeks; mean duration is nearly 70 hours
• PIP is essentially a benign, self-remitting condition
• In half of affected patients, PIP remains as a single episode
• In the other half, PIP episodes tend to repeat, which may occur even quasi regularly after
a cluster of complex focal seizures or secondary generalization in extreme cases
Course and Prognosis
PIP is heralded by severe
insomnia which, were it
recognised, would allow
preventive treatment of the
episode by prompt
administration of low doses of
benzodiazepines or
antipsychotics!