How to manage psychosis secondary to a seizure disorder?

Management of Psychosis Secondary to Seizure Disorder

The management of psychosis secondary to seizure disorder should focus on optimizing antiepileptic treatment as the primary intervention, with careful addition of antipsychotics only when necessary for persistent or severe psychotic symptoms. 1, 2

Classification of Seizure-Related Psychosis

• Psychosis in epilepsy can be categorized based on temporal relationship to seizures: ictal, postictal, and interictal psychosis 1, 2
• Postictal psychosis (PIP) typically occurs within 1 week after seizures, lasts between 15 hours and 2 months, and features delusions, hallucinations, bizarre behavior, or affective changes in clear consciousness 1
• Interictal psychosis has no temporal relationship with seizures and may resemble schizophrenia 2
• Unlike delirium, awareness and level of consciousness in psychotic patients are typically intact 3, 4

Diagnostic Approach

• Rule out medical emergencies and investigate underlying causes, including central nervous system infections and traumatic brain injury 5
• Consider neuroimaging (CT head without IV contrast or MRI head without IV contrast) to exclude intracranial processes requiring intervention 3
• Distinguish from primary psychotic disorders (schizophrenia, bipolar disorder with psychotic features) and other secondary causes of psychosis 4
• Look for risk factors for seizure-related psychosis: long-standing localization-related epilepsy, extratemporal onset, bilateral epileptiform activity, secondary generalization, slowing of EEG background activity, and personal/family history of psychiatric disorders 1

Treatment Strategy

First-Line Approach

• Optimize antiepileptic drug (AED) therapy to achieve better seizure control, which is the best prophylaxis for ictal and most postictal psychoses 1, 6
• For acute psychotic episodes, consider:
  • Oral benzodiazepines for mild symptoms 1
  • Combined oral benzodiazepines and atypical antipsychotics for moderate symptoms 1
  • Intramuscular administration of antipsychotics only for severe agitation or violent behavior 1

Antipsychotic Selection and Use

• When antipsychotics are necessary (primarily for interictal psychosis or prolonged postictal psychosis), select agents less likely to lower seizure threshold 6
• Risperidone at low doses (around 2 mg/day) is preferred due to lower risk of lowering seizure threshold 3, 6
• Olanzapine (7.5-10.0 mg/day) is another appropriate initial option 3
• Avoid high initial doses of antipsychotics as they increase side effects without hastening recovery 5
• The concern that antipsychotics lower seizure threshold has limited clinical significance in patients already on antiepileptic drugs 1

Duration of Treatment

• Implement antipsychotic treatment for 4-6 weeks before determining efficacy 5
• For postictal psychosis, symptoms typically remit within approximately one week, with or without treatment 1
• If symptoms persist after an adequate trial of two first-line atypical antipsychotics (around 12 weeks), review reasons for treatment failure 3

Psychosocial Interventions

• Include families in the treatment plan and provide them with emotional support and practical advice 3, 5
• Provide psychoeducation to patients and families about the nature of seizure-related psychosis, treatments, and expected outcomes 3
• Consider family therapy when there is high distress in the family 3
• Implement structured group programs tailored to the immediate needs of the patient 3

Long-Term Management

• Maintain continuity of care with the same treating clinicians for at least the first 18 months of treatment 3, 5
• Monitor for depression, suicide risk, substance misuse, and social anxiety, which should be identified and actively treated 3
• Balance vigilance for early signs of relapse with allowing space for recovery and resumption of normal developmental tasks 3
• Consider levetiracetam as an antiepileptic option, which has shown promising results in controlling both seizures and psychotic episodes in some cases 7

Special Considerations

• For treatment-resistant cases, consider alternative psychosis related to forced normalization (paradoxical worsening of psychiatric symptoms when seizures are controlled) 7
• Recognize that psychosis may also occur as a side effect of certain antiepileptic drugs 6
• Coordinate care between neurology and psychiatry services for optimal management 8