Neuropsychiatric Symptoms of Epilepsy

5 Delusions and Hallucinations
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functional disturbance inevitably need pharmacological treatment in outpatient or
inpatient settings [ 97 ].
Any mainstream APD can be used for inter-ictal psychotic symptoms; the choice
of APD should be due to a balance between pharmacological profiles, efficacy, and
adverse effects [ 97 , 98 ]. Among the readily available APD, there appears to be no
significant difference in the psychotropic effects for IIP when the dosage of equivalent
antipsychotic strength is used [ 104 – 106 ]. In patients treated with AED, most
APD can be safely administered without seizure exacerbation [ 107 ]. General rules
of APD titration are: to commence at low dose, titrate slowly to a minimum therapeutic
dose, and continue at a fixed therapeutic dose for a sufficient period of time
[ 91 , 97 ]. When the patients have particular conditions, such as distinct brain damage
and impaired hepatic/renal function, a smaller initiation dose with slower titration is
recommended [ 108 ].
In addition to pharmacological interventions, psychoeducation, self-help, and
reframing may be provided. As well as patients, family and carers often need
support. The existing therapeutic relationship helps ensure that epilepsy patients
with psychoses are more likely to be cooperative with their treating doctors than
are patients with first-episode psychosis who are treatment-naïve [ 96 ].
Prognosis
Ictal Phenomena
Ictal hallucinations or delusions per se are short lasting, and rarely result in harmful
consequences. Psychotic episodes during nonconvulsive seizure status last a longer
period, depending on the duration of the status. Secondary risks may exist due to
clouded consciousness (e.g., accidents), or self-harm due to psychotic symptoms
(e.g., delusions of guilt and voices commanding killing oneself).
There is no evidence on the long-term prognosis of ictal psychotic symptoms,
either during a single seizure or seizure status. It should be linked with the prognosis
of their seizures. The long-term prognosis of nonconvulsive seizure status is related
to the cause and the type. Most patients with absence status have a single episode,
while some have a marked tendency to recur despite AED treatment [ 55 ].
Unprovoked CPS status, or CPS status as part of chronic epilepsy, is very likely to
recur [ 53 , 109 ].
Post-ictal Phenomena
PIP episodes are generally benign because of their self-remitting nature. In a seizure
monitoring setting [ 66 , 110 ], PIP episodes tend to resolve within 1 week in an overwhelming
majority of patients. In the community and standard inpatient settings