From the Research
Psychosis is not common in patients with epilepsy, but it occurs more frequently than in the general population, with a point prevalence of 5.6% in unselected samples of people with epilepsy. Approximately 2-7% of epilepsy patients develop psychosis, compared to about 1% in the general population 1. Psychotic symptoms in epilepsy can manifest as postictal psychosis (occurring shortly after seizures), interictal psychosis (between seizures), or as a side effect of antiepileptic medications. Risk factors include temporal lobe epilepsy, longer duration of epilepsy, and a history of status epilepticus.
Key Considerations
- The relationship between epilepsy and psychosis likely involves shared neurobiological mechanisms, including dopamine dysregulation and structural abnormalities in temporal and frontal regions that affect both seizure activity and thought processing 2.
- When psychosis occurs, treatment typically involves optimizing seizure control with antiepileptic drugs like levetiracetam, carbamazepine, or lamotrigine, while potentially adding low-dose antipsychotics such as risperidone (0.5-2mg daily) or quetiapine (25-300mg daily) for symptom management 1.
- Clinicians should be cautious as some antipsychotics can lower seizure threshold, and the management of psychotic disorders in epilepsy is still based on individual clinical experience 1.
Management Approach
- A multidisciplinary approach with early involvement of a liaison psychiatrist associated with a neurologist is recommended for managing psychosis in patients with epilepsy 2.
- The treatment of psychotic disorders in epilepsy should be based on guidelines outside epilepsy, taking into account epilepsy-related issues including interactions with antiepileptic drugs and seizure risk 1.
- Second-generation antipsychotics, especially risperidone, can represent a reasonable first-line option because of the low propensity for drug-drug interactions and the low risk of seizures 1.