Epilepsy in intellectual disability — peri-ictal behaviour to SUDEP (MEQ)

(i) Epidemiology. Epilepsy is far more common in ID than in the general population. McGrother et al. reported roughly 26% prevalence in adults with ID in service contact, with a large fraction still having seizures despite AEDs — matching this man's treatment-resistant pattern. Severity of ID tracks higher epilepsy rates; mortality is increased when seizures are ongoing.^[1][2]

(ii) Relationships to behaviour. Map to peri-ictal timeline: pre-ictal irritability; ictal automatisms; immediate postictal confusion/aggression; postictal psychosis after cluster, often after a lucid interval (Logsdail/Toone); interictal mental illness; and AED psychiatric adverse effects (recent levetiracetam increase is highly relevant). Do not equate aggression with schizophrenia without criteria. Coexisting operant challenging behaviour may still need functional analysis.^[3][4]

(iii) Acute safety. Protect from injury; follow personal epilepsy rescue plan (e.g. buccal midazolam thresholds); exclude medical drivers and nonconvulsive status if awareness does not recover. Do not stop AEDs abruptly — status risk. If postictal psychosis is suspected, prioritise safety and treat psychosis while liaising with neurology.^[3][4]

(iv) Definitive management. Joint neurology–ID psychiatry review; seizure diary/video; rationalise AEDs; review levetiracetam for irritability before escalating antipsychotics; PBS and environmental strategies for non-psychotic behaviour; deprescribe risperidone if no mental illness indication once risk is controlled; if psychotropics needed, use seizure-aware choices and avoid high-risk agents such as bupropion; monitor metabolic effects of antipsychotics; capacity-supported decisions.^[3][5][7]

(v) Mortality counselling. Discuss excess death risk with ongoing seizures, including SUDEP (risk rises with uncontrolled tonic–clonic and nocturnal seizures) and drowning/bathing safety, adherence supports, and night supervision strategies proportionate to risk — not fear without a plan.^[2][6]