Epilepsy with psychosis

Epileptic psychosis can resemble psychological psychosis as seen in schizophrenia ^[1]. Psychosis in epilepsy may be more common with certain types of epilepsy and can take on a variety of forms, such as paranoid delusions or hallucinations ^[2].

What is epileptic psychosis?

Epileptic psychosis refers to the range of psychotic symptoms that can appear in people with epilepsy. In some cases, a patient may have episodes of psychosis that occur around the same time as epileptic seizure activity. In other instances, a patient may develop chronic psychosis symptoms that mirror schizophrenia ^[2].

While the exact prevalence of epileptic psychosis is unclear, studies suggest that around 3% to 7% of those with epilepsy will develop schizophrenia, compared to just 1% of the general population. This suggests that epilepsy may increase the risk for psychotic symptoms, such as those seen in patients with schizophrenia ^[2].

While the data is not entirely conclusive, there is evidence that psychotic symptoms seem to be more likely among those with temporal lobe epilepsy when compared to idiopathic generalized epilepsy ^[2].

Types of psychotic episodes seen in epileptic patients

While epileptic psychosis can resemble psychosis seen in schizophrenia, not every case of epileptic psychosis looks the same. In fact, there can be several types of psychosis in patients with epilepsy, based upon the timing of psychosis in relation to seizure activity ^[2]:

• Postictal: This form of epileptic psychosis typically occurs after clusters of complete partial seizures. After a cluster of seizures, a person experiences a lucid period lasting 12-72 hours, after which time their mental state deteriorates. Psychotic symptoms involve confusion, in addition to emotional disturbances and features of schizophrenia. Psychotic symptoms include delusions, which are false beliefs that persist despite evidence to the contrary, as well as hallucinations, which can include hearing or seeing things that are not actually present. A person with postictal psychosis may also have abnormal thinking patterns ^[3]. While postictal psychosis usually resolves on its own, episodes are likely to reoccur.
• Ictal psychosis: This is a rare form of epileptic psychosis in which a person has transient symptoms of psychosis within the context of partial seizures, which last under three minutes. Symptoms often include auditory or visual hallucinations, alongside changes in mood, which can include fear, paranoia, and agitation. A person may also feel as if they are detached from reality ^[1].
• Interictal psychosis: Interictal psychosis is a chronic psychotic state resulting from a lengthy history of uncontrolled seizures. Symptoms are similar to those seen in schizophrenia ^[1]. This form of psychosis may be called schizophrenia-like psychosis of epilepsy (SLPE) ^[2]. Persecutory auditory hallucinations, in which a person hears voices threatening to harm them, are common in this form of psychosis. Other symptoms include isolating from others and suffering from cognitive decline, especially in those with temporal lobe epilepsy ^[1].
• Psychosis following surgery: Research suggests that around 7% of patients develop transient psychotic symptoms following a type of surgery called temporal lobectomy. Patients who are over 30 years of age at the time of surgery, who have a family history of psychosis, or who had pre-operative psychosis are at increased risk of developing psychotic symptoms after epilepsy surgery ^[1].

Dangers of psychosis in epilepsy patients

Psychosis in epilepsy patients requires early treatment and intervention, because if psychosis is untreated, it can persist. Put another way, psychotic episodes beget psychotic episodes, meaning that it’s important to intervene at the first sign of psychosis, to reduce the risk of relapse or recurrent psychotic episodes ^[1].

Patients with epileptic psychosis can also experience declines in functioning, making it difficult to care for themselves. This makes it critical for individuals with this condition to receive a range of psychosocial services to keep them linked to support ^[1].

Treatment for epileptic psychosis

Treatment of epileptic psychosis requires careful monitoring and interventions that are adapted to a patient’s unique needs, based upon their clinical presentation. There is limited research on the best treatment for psychosis of epilepsy, so the condition is generally treated utilizing the same methods used in treatment of psychosis outside of epilepsy ^[4].

Both first and second-generation antipsychotics can be used to treat psychosis, but second-generation antipsychotics are believed to come with fewer side effects. Some research suggests that olanzapine, risperidone, and quetiapine are the best choices for treating first-episode psychosis, including that which occurs with epilepsy.

However, one important consideration is the fact that some antipsychotic drugs may cause seizures. Because of this risk factor, risperidone is often the first line of treatment used for epileptic psychosis ^[4].

Beyond medication, patients living with epileptic psychosis should receive integrated treatment from a multidisciplinary team. This team usually consists of a neurologist, a psychiatrist, and a social worker.

If you have epilepsy and begin to experience symptoms of psychosis, either during, after, or between episodes, it’s important to reach out for treatment. Experiencing psychotic symptoms can be distressing, but treatment can help you to manage your symptoms.