Psych · Consultation-liaison psychiatry
Epilepsy and psychiatry
Also known as Postictal psychosis · Peri-ictal psychosis · Interictal psychosis · Forced normalisation · Forced normalization · Alternative psychosis · Epilepsy and depression · Psychiatric comorbidities of epilepsy · AED psychiatric side effects
Exam-exhaustive fellowship topic on the epilepsy–psychiatry interface: peri-ictal and postictal psychosis, interictal depression, forced normalisation, AED psychiatric adverse effects, psychotropics and seizure threshold, screening, suicide risk, and joint CL–neurology management. FRANZCP-primary, globally tagged.
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Target exams
Red flags
- Seizure cluster followed by a lucid interval then new psychosis — treat as postictal psychosis until proven otherwise; high violence and self-harm risk
- Behavioural change without clear recovery of awareness — exclude nonconvulsive status epilepticus with EEG, not psychiatry alone
- New psychiatric symptoms after sudden seizure freedom or EEG normalisation — consider forced normalisation
- New irritability, aggression, or depression after starting levetiracetam, perampanel, topiramate, or zonisamide — review the AED before only escalating psychotropics
- Active suicidal ideation in a person with epilepsy — depression is common, often under-recognised, and a major mortality pathway
- Do not start bupropion or high-dose clozapine in active epilepsy without a deliberate seizure-risk plan with neurology
- Never abruptly stop AEDs for 'behaviour' without a neurology-agreed plan — risk of status epilepticus
Meet the patient
A 34-year-old man with fifteen years of temporal lobe epilepsy is admitted after a cluster of four seizures in a day. He recovers, talks normally to his mother, eats dinner, and sleeps.[1][3]
Thirty-six hours later the night nurse calls: he is convinced the ward is a testing facility, that his mother has been replaced, and that God has instructed him to leave. He is frightened, physically strong, and looking at the fire door.[1][15]
The gap between the seizures and the psychosis is the diagnosis. That lucid interval is the highest-yield discriminator in this entire topic, and it is also the thing a tired registrar records as "seemed fine yesterday" and then never mentions again.[1][3]
References16ShowHide
- [1]Logsdail SJ, Toone BK Post-ictal psychoses. A clinical and phenomenological description Br J Psychiatry, 1988.PMID 3167343
- [2]Tellez-Zenteno JF, Patten SB, Jetté N, Williams J, Wiebe S Psychiatric comorbidity in epilepsy: a population-based analysis Epilepsia, 2007.PMID 17662062
- [3]Clancy MJ, Clarke MC, Connor DJ, Cannon M, Cotter DR The prevalence of psychosis in epilepsy; a systematic review and meta-analysis BMC Psychiatry, 2014.PMID 24625201
- [4]Krishnamoorthy ES, Trimble MR, Sander JW, Kanner AM Forced normalization at the interface between epilepsy and psychiatry Epilepsy Behav, 2002.PMID 12609326
- [5]Hesdorffer DC, Hauser WA, Olafsson E, Ludvigsson P, Kjartansson O Depression and suicide attempt as risk factors for incident unprovoked seizures Ann Neurol, 2006.PMID 16217743
- [6]Hesdorffer DC, Ishihara L, Mynepalli L, Webb DJ, Weil J, Hauser WA Epilepsy, suicidality, and psychiatric disorders: a bidirectional association Ann Neurol, 2012.PMID 22887468
- [7]Barry JJ, Ettinger AB, Friel P, et al. Consensus statement: the evaluation and treatment of people with epilepsy and affective disorders Epilepsy Behav, 2008.PMID 18502183
- [8]Gilliam FG, Barry JJ, Hermann BP, Meador KJ, Vahle V, Kanner AM Rapid detection of major depression in epilepsy: a multicentre study Lancet Neurol, 2006.PMID 16632310
- [9]Kerr MP, Mensah S, Besag F, et al. International consensus clinical practice statements for the treatment of neuropsychiatric conditions associated with epilepsy Epilepsia, 2011.PMID 21955156
- [10]Alper K, Schwartz KA, Kolts RL, Khan A Seizure incidence in psychopharmacological clinical trials: an analysis of Food and Drug Administration (FDA) summary basis of approval reports Biol Psychiatry, 2007.PMID 17223086
- [11]Pisani F, Oteri G, Costa C, Di Raimondo G, Di Perri R Effects of psychotropic drugs on seizure threshold Drug Saf, 2002.PMID 11888352
- [12]Mula M Epilepsy and Psychiatric Comorbidities: Drug Selection Curr Treat Options Neurol, 2017.PMID 29046989
- [13]Maguire MJ, Marson AG, Nevitt SJ Antidepressants for people with epilepsy and depression Cochrane Database Syst Rev, 2021.PMID 33860531
- [14]Lu E, Pyatka N, Burant CJ, Sajatovic M Systematic Literature Review of Psychiatric Comorbidities in Adults with Epilepsy J Clin Neurol, 2021.PMID 33835737
- [15]de Toffol B, Trimble M, Hesdorffer DC, et al. Pharmacotherapy in patients with epilepsy and psychosis Epilepsy Behav, 2018.PMID 30241054
- [16]Mula M Suicidality and antiepileptic drugs in people with epilepsy: an update Expert Rev Neurother, 2022.PMID 35394392