Postictal psychosis is a complex psychiatric complication of epilepsy that causes abnormal electrical activity in the brain. It is often misunderstood and doesn’t happen during a seizure, but occurs hours or days after the seizure, which can be described as muscle twitching or loss of consciousness.PIP is a vulnerable condition that causes one to experience hallucinations and paranoia right after a cluster of seizures. However, it often follows the lucid interval, where a person appears recovered before developing psychotic symptoms. That is why it can be mistaken for other illnesses, such as substance use, behavioral issues, or agitation. According to the National Library of Medicine, PIP affects approximately 2% of patients, particularly those with long-lasting, drug-resistant temporal lobe epilepsy. However, recognizing the condition earlier can help ensure effective treatment, as the delay can increase the risk of self-harm and hospitalization.
What is Postictal Psychosis?
Postictal psychosis is a rare but acute psychiatric complication that occurs right after experiencing seizures, when an individual seems to be recovering. Not everyone with seizures can experience the symptoms of PIP, as it primarily affects individuals with a long history of drug-resistant epilepsy, particularly temporal lobe epilepsy. Moreover, it starts within one to six days after the seizure has ended. It usually occurs at the age of 30 to 42 years. PIP can present in different ways, as the symptoms fluctuate from time to time. People in this state experience a detachment from reality, as they witness vivid hallucinations, religious delusions, or paranoia.
Case Study
An illustrative case of Postictal psychosis: “Mr. R,” a 47-year-old male with a history of 4 years of generalized seizures following a head injury from an accident 11 years back. The patient also has a history of febrile convulsions as a child, and there was no family history of seizures. However, after experiencing a cluster of four seizures, he had 24 hours of normal behavior. And after 24 hours, he suddenly developed hallucinations, religious delusions, and insomnia. The behaviour seems to be different as he was “staring, not answering, chewing, swallowing heavily, moving both hands in a swimming motion, or picking at things.
Moreover, treating Mr. R requires a dual-track approach, which means managing the acute psychiatric symptoms while stabilizing the underlying seizure disorder. Common medications that help in the healing process include atypical antipsychotics & benzodiazepines. After 5 days of medications, a repeat EEG was performed in a drowsy & sleepy condition, which was normal. The patient was discharged from the hospital on day twelve with significant improvement in his mental status.
Postictal Psychosis Vs Interictal Psychosis
There is also a condition named IIP related to epilepsy, but both are distinct. Understanding the difference between them is important as it can help in an accurate diagnosis. Postictal psychosis is an episodic condition, meaning that it has a clear start and end, which is a seizure or a cluster of seizures. In this condition, the brain undergoes a temporary physiological disruption, which leads to a break from the real world. However, PIP episodes are temporary, as individuals usually return to their psychological baseline afterwards. Whereas, Interictal Psychosis is more like a mental health condition, such as schizophrenia.
IIP is a long-term change in brain function, often seen in people who have lived with epilepsy that was difficult to control. However, it does not require a seizure to trigger.
What Causes Postictal Psychosis?
The exact cause of PIP is still not fully understood, but a combination of factors can contribute to the development of this condition. Here are some factors that are potential contributors to this condition.
1. Abnormal Brain Activity
Individuals having abnormalities in the brain, such as neurotransmitter levels and neural circuits, can contribute to the development of this condition. All these abnormalities in the brain lead to symptoms like depression and psychosis. PIP is also associated with increased blood flow in the temporal and frontal lobes. This also suggests that all these abnormal activities lead to the development of PIP.
2. Sleep Deficiency
Individuals with a lack of sleep or having issues with sleeping are also at risk of developing this condition. It is because sleep deprivation affects the brain and causes one to experience seizures or psychosis later in life.
3. Neurobiological Factors
PIP tends to run in families, which means if any of the close family members have been through this condition, there are high chances that you may also develop it. While there may be a genetic predisposition, current research also focuses heavily on structural brain changes.
4. Stress
Individuals who remain in excessively stressful situations or emotional stress may be at high risk of developing PIP. Excessive stress triggers seizures in people with epilepsy, potentially increasing the risk of developing postictal psychosis. Moreover, the extreme stress also impacts the brain activity and brain chemicals, leading to the development of this condition.
5. Medication Side Effects
Some medications that are used to treat seizures may have side effects, which may lead to psychiatric symptoms, including postictal psychosis. However, changes in medication dosages may also influence brain chemistry and increase the risk of psychosis.
The Hallmark: The Lucid Interval
Lucid Interval is considered to be the most deceptive feature of Postictal Psychosis. In this period, the person appeared to have recovered before getting the psychotic symptoms. It usually lasts between 6 hours and a week, within 24 hours to 72 hours. It is considered to be the calm before the storm! In this phase, a person usually seems to be well organized, talk well, and totally recovered. However, deep down, the brain is undergoing a complex shift towards postictal psychosis.
Furthermore, the sudden change in the brain from complete lucidity to intense paranoia comes as a shock to the family members. Recognizing this sudden behavior change can help in early diagnosis and treatment.
What are the Symptoms of Postictal Psychosis?
Every person’s experience with PIP is different, but they typically involve a range of psychiatric symptoms. Including:
- Hallucinations: It causes one to experience and feel things that are not present in the real world, such as seeing, hearing, or feeling stimuli that aren’t there. Moreover, some people and individuals also experience hallucinations connected with smell or taste.
- Religious and Paranoid Delusions: Delusions are described as false beliefs that have no evidence. People in this condition may be paranoid and have organized thoughts usual beliefs. They may feel like they have a “divine mission” or are being targeted by a specific organization.
- Pleomorphic Mood: It causes extreme shifts in mood, such as irritability, agitation, anxiety, or depression. People may experience manic and depressive episodes, and they may also flip between intense fear and intense joy.
- Confusion: Individuals may have difficulty with concentration, decision-making, and memory. Like other psychotic disorders, such as shizoaffective disorder and bipolar disorder, confusion during this condition may cause one to exhibit unorganized thinking and speech.
- Hyper-Religiosity: it’s asudden preoccupation with spiritual or mystical themes.
How to Diagnose PIP?
The diagnosis can be done by a mental health professional by using the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria. A mental health professional diagnoses the condition by noticing certain symptoms at a certain time. If the symptoms develop within one week after a seizure, or last between 15 hours and two months, it can be considered to be PIP. Moreover, the early recognition helps in better treatment outcomes.
How is Postictal Psychosis Treated?
Treatment for this condition typically involves a multidisciplinary approach addressing all aspects of the condition, such as epilepsy and psychiatric symptoms. Only a mental health professional can recommend treatment after examining the exact condition and the severity.
Management of Seizure Disorders
To manage epilepsy, a healthcare professional involves a combination of strategies tailored to the individual’s needs, which includes the following:
- Anticonvulsant medication
- Vagus nerve stimulation therapy, which helps to deliver mild electrical pulses to the left vagus nerve in the neck, regulates brain activity.
- Healthy eating habits
- Prevention strategies include getting plenty of sleep, protecting the head while doing certain activities to prevent head injuries, & avoiding substances, such as cocaine and nicotine.
- Self-recognition about what might trigger a seizure and coping with stress
Management of Psychiatric Symptoms
Although anticonvulsant medications are considered to be the best treatment for PIP, some other medications are used to manage psychological symptoms. These may include antipsychotics to control symptoms, psychotic symptoms, and mood stabilizers for symptoms like mania and depression. Note: Medications may not be safe or effective for every patient, so always take medication with your mental health professional’s recommendation.
Psychosocial Interventions
People experiencing epilepsy and psychosis symptoms may struggle with challenges in daily life. A mental health specialist designs a treatment plan by combining medications, therapies, and other strategies. Some of the common psychosocial interventions can address these challenges better when used in combination with medication. Some psychosocial treatments include:
- Individualized therapy
- Family therapy
- Group therapy
- Psychoeducation
The Role of Prevention in PIP
The most effective way to manage postictal psychosis is to begin with the treatments before the psychosis even starts. Because this condition follows a timeline, people may have a “window of opportunity” to distract the biological process. The main part of this strategy is the use of Rescue Medication Protocols.
When a person with a known history of PIP experiences a seizure or an unusually severe seizure, the brain starts to overshoot. To manage this, a mental health expert may start a short course of low-dose antipsychotics or fast-acting benzodiazepines immediately after the seizures end. These medications help in soothing the brain and stabilizing dopamine before they reach the trigger to hallucinate or delusions.
Get Help at Inland Empire Behavioral Group
If anyone around you or any of your loved ones is struggling with postictal psychosis. Help is available!
At Inland Empire Behavioral Group, we have a team of mental health professionals who provide exceptional treatments. Whether it’s psychosis, postictal psychosis, or any other psychiatric condition, we are here to help.
Our top-notch team of experts addresses the root cause and recommends treatment tailored to unique needs. We offer a safe and welcoming environment where people can talk about their issues with ease. You can also get telepsychiatric services from the comfort of your home.
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Takeaway
Postictal Psychosis is a complex condition that can profoundly impact a person’s perception of reality. Managing postictal psychosis can be challenging, but it’s often possible with the proper medications, therapy, and support. It doesn’t occur anytime; it’s a time-linked event that follows a specific pattern of seizure clusters.
Individuals experiencing this condition often lose insight and cannot recognize that they are unwell, which causes intense issues. However, the early recognition helps in treating the condition in a better way. Furthermore, family members and caregivers play a major role in the treatment process as they can explain the condition to a mental health expert in a better way.
