Neuropsychiatric Symptoms of Epilepsy

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N. Adachi and N. Akanuma
Ictal Phenomena
Ictal psychotic symptoms per se rarely cause serious dysfunction in patients,
whereas the progression of seizures, either CPS, secondary GTC, or nonconvulsive
seizure status, can result in hazardous consequences. Particular treatment for psychosis
may not be required. When a patient presents with aggressive behavior or
self-harm conduct during seizure status, certain sedation or protective seclusion
would be required.
In the inter-ictal period, optimizing treatment for better seizure control is essential.
In patients with repeated ictal psychotic episodes, patients and carers should be
given psychoeducation; they should be taught how to notice the early warning signs
of the episodes and maintain safety during the episodes. There is no evidence that
psychotropic drugs can prevent ictal psychotic symptoms.
Post-ictal Phenomena
Acute protective measures prioritize the management of risk in the early stages of
PIP. The most important point is to notice an unusual state (e.g., elevated mood or
peculiar irritability) after a seizure or seizure clusters and to be aware of its potential
as a precursor of PIP [ 100 ]. Psychotropic agents, either benzodiazepine or antipsychotic
drugs, can be used for the purpose of sedation [ 66 , 97 , 101 ]. If the precursor
symptoms are treated successfully, the episodes can be contained within the early
stage, interrupting the progression to a full-blown episode.
Once PIP develops fully, immediate protective custody is required in many
cases when the patient becomes violent or try to commit serious self-harm [ 66 ,
69 ]. The judicious application of local mental health legislation will be necessary
[ 97 , 101 ]. Antipsychotic drugs can be used to control or reduce psychomotor
excitements [ 66 ]. Sedation and cessation of the process of the present PIP episode
should take priority over possible risks of antipsychotic drugs, such as lowering
seizure thresholds [ 97 ].
In the cases with recurrent PIP, preventative procedures are necessary, including
optimizing seizure control by adjusting AEDs or by surgical treatment [ 62 , 70 ]. Like
in ictal psychotic phenomena, patients and carers should have an opportunity of psychoeducation
to improve early detection and management of further episodes [ 97 ].
Inter-ictal Phenomena
In general, psychotic symptoms are better managed earlier rather than later [ 102 ].
In cases of mild symptoms or where the patient does not give consent to be treated
with psychotropic drugs, they can be offered psychosocial interventions, or be carefully
monitored [ 95 , 103 ]. Psychotic symptoms with serious distress and/or