Understanding Postictal Psychosis

PIP occurs in roughly 2% of epileptic patients. The condition can be a frightening and confusing experience for both the individual experiencing the symptoms and their loved ones. Individuals with epilepsy and their caregivers may need to be aware of the possibility of postictal psychosis and understand how to seek help if symptoms emerge. Treatment usually involves lifestyle changes, medication, and therapy.

Psychosis can be disturbing for individuals and their loved ones

Seek mental health support as a caregiver

Epilepsy overview

Chronic epilepsy is a neurological disorder typically characterized by recurrent, unprovoked seizures. The condition has several potential causes, including, but not limited to, the following:

• Traumatic brain injury or infection
• Brain structure abnormalities
• Missed doses of or misused medications
• Sleep deprivation
• Genetics
• Stroke
• Aneurysms
• Metabolic disorder
• Severe fever

There can be more than one type of epilepsy. These different forms may have differing causes or places of origin and somewhat varied symptoms. Each of these types may also involve further subcategories of epilepsy. Different types of epilepsy are outlined below.

Focal

Also known as partial epilepsy, this type of epilepsy is normally characterized by seizures that originate in a specific area of the brain but can spread widely. When complex partial seizures spread, they can cause a tonic-clonic seizure, or a generalized seizure involving the loss of consciousness. Categories of focal epilepsy seizures include those listed below:

• Temporal lobe epilepsy: Temporal lobe tends to be the most common type of epilepsy, in which seizures can range from mild (i.e., subtle but odd sensory experiences) to severe (i.e., intense fear or anxiety). 
• Frontal lobe: Frontal lobe is usually the second most common type of epilepsy. These types of seizures often occur in one’s sleep and might include thrashing movements upon waking.  
• Occipital lobe: In these types of seizures, individuals may have visual disturbances, see flickering lights, or have visual hallucinations. Other symptoms may mimic those of migraine headaches, such as partial blindness, headache, nausea, and vomiting.
• Parietal lobe: This can be considered a rare type of epilepsy in which seizures originate in the area of the brain responsible for interpreting spatial information and managing sensory experiences like touch and pain.

Generalized 

Unlike focal epilepsy, generalized seizures can be characterized by excessive, widespread electrical activities involving both brain hemispheres. Types of generalized epileptic seizures include those discussed below:

• Absence seizures: Formerly called petit mal seizures, these are typically brief and may feature sudden staring and lack of movement.
• Myoclonic seizures: Myoclonic seizures are usually characterized by sudden jerking movements, typically on both sides of the body. A subtype of myoclonic epilepsy called progressive myoclonic epilepsy can present additional symptoms of muscle rigidity, unsteadiness, and cognitive disability.
• Generalized tonic-clonic seizures: These types of seizures may cause stiffness in the body (tonic phase) followed by tremors or convulsions (clonic phase).

Reflex epilepsy

This type of epilepsy can feature seizures caused by environmental stimuli, like flashing lights or specific sounds. In some, seizures can be triggered by nonvisual stimuli involving cognitive function, like solving a math problem or reading. 

Seizure phases

Seizures usually involve different phases (or the absence of a phase) according to type. 

• Prodromal: This phase can be characterized by symptoms like headache, insomnia, agitated mood, and depression, which typically emerge hours or days before the actual seizure. 
• Aura: The aura phase normally occurs a few seconds or minutes before a seizure. Symptoms of this phase may be challenging for patients to describe and can include extreme feelings of fear and anxiety, hallucinations, unpleasant smells, and dreamlike experiences. 
• Seizure (ictus): This can refer to the active phase of the generalized or focal seizure.
• Postictal: This is the stage directly following a seizure, which can be characterized by headache, fatigue, confusion, and irritability. In some cases, individuals might vomit and have trouble with balance. Some experience postictal psychosis during this phase, which may last for several hours or days.
• Interictal: This period typically takes place in the absence of seizures, or between habitual seizures. Interictal psychosis may occur during this phase. 

Postictal psychoses: Causes and contributors

The exact cause of postictal psychosis isn’t yet fully understood, but a combination of factors related to the abnormal electrical activity in the brain that occurs during a seizure may play a role. Below are some factors identified as potential contributors to the condition.

Abnormal brain activity

The abnormal brain activity during a seizure may trigger changes in neurotransmitter levels and neural circuits, potentially contributing to the development of postictal psychiatric symptoms like depression or psychosis.

Research suggests that PIP is most often associated with frontal and temporal lobe epilepsies.

Sleep deprivation

Lack of sleep or disrupted sleep patterns have been associated with an increased risk of seizures and may also contribute to the development of postictal psychosis. 

Sleep deprivation can affect brain function and possibly increase susceptibility to psychiatric symptoms.

Stress

Stressful situations or emotional stress may trigger seizures in individuals with epilepsy, potentially increasing the risk of developing postictal psychosis.

Physiological responses to stress can impact brain activity and neurotransmitter levels, potentially exacerbating psychiatric symptoms.

Medication

Some antiepileptic medications used to manage seizures may have side effects that can contribute to psychiatric symptoms, including postictal psychosis. Changes in medication dosages or medication interactions might also influence brain chemistry and increase the risk of psychosis. 

Neurobiological factors contributing to postictal psychoses

More research may be required to understand how neurobiological factors might cause postictal psychosis, but current studies suggest that individual differences in brain structure and function may play a role.

Genetic factors could also be involved in postictal psychosis. 

Premorbid psychiatric risk factors for postictal psychotic behavior

Several preexisting psychiatric factors may contribute to an individual’s likelihood of developing PIP. These include premorbid psychotic disorders or mental health conditions featuring chronic psychosis, recent head trauma, and psychoactive substance misuse. 

Symptoms of postictal psychosis (PIP)

Postictal psychosis symptoms can vary between individuals, but they typically involve a range of psychiatric symptoms.

• Hallucinations: These can be defined as sensory experiences that are not reality-based, such as seeing, hearing, or feeling stimuli that aren’t there. Some individuals also report hallucinations associated with smell or taste. 
• Delusions: Delusions are typically described as false beliefs that are firmly held despite evidence to the contrary. These may be paranoid (believing that one is being persecuted or targeted), grandiose (believing one has special powers or importance), or bizarre (unusual or impossible beliefs). 
• Mood disturbances: These generally refer to changes in mood or emotions, such as irritability, agitation, anxiety, depression, or euphoria. Research suggests that individuals with PIP tend to experience more affective psychosis symptoms, like manic and depressive episodes, than purely psychotic symptoms. 
• Confusion: Individuals experiencing seizures and postictal psychosis may have difficulty with concentration, decision-making, memory, and disorientation. Like other psychotic disorders, confusion during postictal psychosis may emerge as disorganized thinking and speech.

Diagnosis of postictal psychosis

Postictal psychosis is included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) under the category “psychotic disorder due to another medical condition.” In general, one must meet the following criteria to qualify for a PIP diagnosis: 

• Psychotic episodes that develop within one week after a seizure
• Psychosis lasting between 15 hours and two months
• Delusions, hallucinations, bizarre or disorganized behavior, formal thought disorder, or affective changes
• No evidence of anticonvulsant toxicity, non-convulsive status epilepticus, recent head trauma, alcohol or substance intoxication or withdrawal, or prior chronic psychotic disorder

Individuals with postictal psychosis who are assessed and diagnosed early often experience more favorable treatment outcomes. Evaluation, testing, and screening for PIP detection should be performed by healthcare professionals experienced in diagnosing and treating epilepsy and psychosis. 

Treatment and coping strategies for postictal psychotic behavior

Treatment for PIP typically involves a comprehensive strategy addressing all aspects of the condition, including the underlying contributors to epilepsy and the psychiatric symptoms associated with postictal psychosis. Individuals with epilepsy may work closely with their healthcare team to develop a treatment plan that addresses both their seizure disorder and psychiatric symptoms. 

Management of underlying seizure disorders

Epilepsy management typically involves a combination of strategies tailored to the individual’s needs, potentially including the following:

• Anticonvulsant medications
• Vagus nerve stimulation therapy
• Ketogenic eating habits
• Prevention strategies like getting plenty of sleep, using head protection during activities that could result in head injury, and avoiding substances, alcohol, and nicotine
• Learning to recognize what might trigger a seizure and cope with stress

Medications for psychiatric symptoms

In addition to anticonvulsants, individuals with PIP may take other medications to manage psychological symptoms. These may include antipsychotics to control symptoms like hallucinations, delusions, and disordered thoughts and speech or mood stabilizers for symptoms like mania and manic depression. These medications may not be safe or effective for every patient and must be taken under strict medical supervision.

Psychosocial interventions

Individuals with epilepsy and psychosis may face unique challenges in daily life. They may experience difficulties with productivity, relationships, self-care, and other areas requiring extra support. Psychosocial interventions can address these challenges and, when used in tandem with medication, may be tailored to the individual’s needs. Some psychosocial treatments include those discussed below:

Individual therapy

Psychotherapy, such as cognitive behavioral therapy (CBT), can help individuals with psychosis better understand their symptoms, cope with stress, and improve their quality of life. 

Family therapy

Family therapy is recommended in many cases of psychosis. Family members in therapy can learn to manage conflict, solve problems, communicate more effectively, and better support their loved one. 

Group therapy 

Individuals who have experienced symptoms of psychosis might find it beneficial to meet with their peers. In peer-led group therapy, people can offer support to each other as they share their experiences, challenges, and successes.

Psychoeducation

Understanding how postictal psychosis works, how to recognize the condition, and how to manage PIP can lead to more favorable treatment outcomes. Psychoeducation can also diminish the stigmas and misconceptions often associated with psychosis and epilepsy.

Support services 

Services like case management, vocational rehabilitation, and housing assistance can provide individuals with practical support.

Seizure and psychosis management plan

Establishing a plan for handling seizures and postictal psychotic episodes can help individuals and their families in many ways, from maintaining seizure control to keeping everyone safe during an episode. A seizure action plan can help individuals organize medical information and communicate to others about what to do in an emergency. 

For more information about tracking and managing seizures, seizure preparedness, and how to respond to a seizure emergency, visit the Epilepsy Foundation’s website. You’ll also find resources for epilepsy specialists and centers in your area.

Psychosis can be disturbing for individuals and their loved ones

Seek mental health support as a caregiver

Seeking help as a caregiver for someone with epilepsy

Caring for others can be physically, emotionally, and mentally demanding. Participating in activities you enjoy, getting plenty of exercise, eating nutritiously, and maintaining a healthy sleep routine may be integral ways to care for yourself while you care for your loved one. 

Caregivers often prioritize the mental health of others above their own. Additionally, caring for others can present unique barriers to receiving professional mental health support. For these reasons, many don’t receive the support they deserve to maintain the compassion, patience, and resilience often required when caring for others. 

Online therapy for caregivers and people affected by postictal psychosis

The rise in popularity of virtual therapy may present individuals with an effective alternative to conventional treatment, eliminating many of the barriers caregivers experience when caring for their own mental health. 

For example, online therapy platforms frequently offer greater scheduling flexibility and a larger pool of mental health professionals with experience supporting caregivers. Attending sessions from the comfort of home can eliminate the need to travel to and from appointments. Additionally, online therapy is often more affordable than traditional therapy without insurance.