Hartshorn, Jeanette C.; Martino Maze, Claire D.
Ms. W is a right-handed 65-year-old woman with a history of seizures since childhood. She has complex partial seizures with secondary generalization presumed to be due to a birth injury. Her seizures had been well controlled on valproic acid for many years. Over the last year, her life had changed dramatically because of the death of her husband. He died very unexpectedly one evening and was found by his wife. In addition to the trauma of the death of her husband, she was then relocated to live with her daughter and her family. Ms. W is a bright, capable woman, but her husband had always provided oversight for her care, and she was not knowledgeable about her condition and was not used to active participation in her own care.
Six months following her husband’s death, Ms. W started to notice an increase in her complex partial seizures. She described these events as losing orientation for a few minutes and being unable to talk. Neither she nor her family members identified any autonomisms. After these events, she would be very tired and had a severe headache. At this point, levetiracetam was added to her therapy. She did very well with the combination of medications and enjoyed some improvement in her seizure control.
Approximately 1 year after her husband’s death, Ms. W’s seizure control worsened. She admitted to significant feelings of sadness, so a low dosage of escitalopram was added. No major changes occurred until one day she experienced a complex partial seizure. After the seizure, she “looked wild” according to her daughter and was extremely agitated and restless. She did not recognize where she was and she did not recognize her family. The family gave her lorazepam, but there was no improvement. She became very combative and left the home. The family called the local police to help locate her. When confronted by the police, Ms. W hit the policeman in the face. She was then handcuffed and arrested.
Her family prevailed upon the police to take her to a hospital and not to jail. She was eventually transported to a local emergency room and from there to an epilepsy-monitoring unit in a metropolitan hospital. She continued to be very aggressive and disoriented. A presumptive diagnosis of postictal psychosis (PIP) was made, and she was given 4 mg of risperidone. She slowly began to relax and became less confused.
Overview of PIP
PIP can be a very serious complication as shown by Ms. W’s situation. However, it is a difficult and sometimes controversial diagnosis. In the best of all circumstances, patients at high risk for this complication from seizures should be identified and safety procedures put into place to help the family avert the psychotic event if possible, and if not, at least to help them to obtain immediate and appropriate medical intervention.
The presence of postictal psychiatric phenomena has been recognized for many years but, because of the complicated nature of presentation of symptoms, remains poorly understood (Kanner, Soto, & Gross-Kanner, 2004). Although postictal psychiatric experiences can present in a variety of ways (including anxiety and depression), psychotic symptoms are the most common.
The literature about PIP is far from conclusive. Various terms for the phenomena including “postictal aggression” (Gerard, Spitz, Towbin, & Schantz, 1998) and “interictal psychosis” (Adachi et al., 2000; Alper et al., 2001; Briellmann et al., 2000) have been used. Psychiatric literature abounds with discussions of various types of responses to seizure activity including anxiety, fear, and depression. Similarly, psychotic experiences are not uncommon, particularly in patients with temporal lobe epilepsy. Various descriptions of these phenomena including delusions, hallucinations, and other psychotic experiences can be found in the literature. These experiences/symptoms can occur at various points, including interictal and postictal periods. Differentiating between the types of symptoms and their origin is essential in proper diagnosis and treatment.
Common definitions of the postictal period do not seem to exist, and each researcher defines them differently. For example, Kanner et al. (2004) defined the time as 12–72 hours; Logsdail and Toone (1988) defined it up to 7 days, and Kanemoto, Kim, Miyamoto, and Kawasaki (2001) suggested a definition of any psychotic episode within 7 days from the last generalized tonic–clonic seizures or cluster of complex partial seizures. Sachdev (2007), after an extensive review of the literature, defined postictal as a psychosis that follows immediately after one or more commonly, multiple seizures, but certainly within 1 week of the last seizure. One of the challenges of studying PIP is determining when the end of the postictal event becomes the beginning of the ictal period (Schachter, 2011). If the psychosis develops gradually and is associated with increasing seizure frequency, it may also be referred to as peri-ictal rather than postical, but there does not seem to be a significant or clinical relevant difference in these terms (Sachdev, 2007).
What appears to be common among the definitions is that the phenomenon of psychosis occurs following a seizure or series of seizures and resolves following the event, at which point the patient returns to his or her normal baseline. From the case study, this presentation was exemplified by Ms. W.
One of the most thorough reviews of the PIP was published by Kanner et al. (2004). These researchers studied 100 patients with refractory partial epilepsy and defined “postictal” as 72 hours following a seizure. Each participant completed a 42-item questionnaire designed to identify various psychological and cognitive symptoms. In particular, this questionnaire asked the subjects to distinguish between symptoms that might occur interictally versus those that occurred postictally or even worsened during the postictal period. Participants were asked to identify the frequency and prevalence of any psychiatric or cognitive symptoms over a 3-month period. In the sample, multiple postictal psychiatric and postictal cognitive symptoms were identified, including hypomania, anxiety, depression, postictal psychotic symptoms, neurovegetative symptoms, and fatigue. Thirty-eight patients reported a worsening of interictal psychiatric and cognitive symptoms.
Among the 100 patients in this study, there was a lifetime prevalence of psychiatric disorders in 54 patients, which consisted of mood disorders in 33 patients, anxiety disorders in 16 patients (12 of whom also had mood disorders), and attention-deficit hyperactivity disorder in 5 patients (Kanner et al., 2004). Interestingly, no patient had a history of psychotic disorder.
Patients in this study also experienced a combination of postictal cognitive symptoms and psychiatric symptoms. Cognitive symptoms did not last as long as the psychiatric symptoms but were equally difficult to manage. Importantly, a history of anxiety or depression increased the risk for development of postictal symptoms. According to Kanner et al. (2004), these data demonstrate a strong relationship between a history of prior psychiatric disorders and the development of postictal psychiatric events.
Characteristics and Symptoms
In PIP, there is a clear relationship between the onset of the psychotic symptoms and the seizure activity. Most commonly, the psychotic symptoms occur following an increase in seizure activity. The type of seizures can include generalized tonic–clonic and complex partial seizures (Kanner & Barry, 2001; Savard, Andermann, Olivier, & Remillard, 1991). The psychosis is most often inclusive of delusions, hallucination, and confusion. Savard et al. found that reduction of antiepileptic drugs could trigger not only the increase in seizures but also the increase in psychotic symptoms. This suggests that noncompliance with medications is a particularly dangerous problem in this group of individuals.
The natural progression includes that the psychosis is of short duration and frequently occurs in individuals with a long history (more than 10 years) of epilepsy (Kanner & Barry, 2001). Most reports suggest that this psychosis responds quickly to treatment with antipsychotics.
Specific descriptions of the symptomatology of PIP vary in the literature. Kanner et al. (2004) identified psychiatric symptomatology including delusional psychosis in four patients; a mixed, manic depressive-like psychosis in one patient, a psychotic depression-like disorder in two, a hypomanic-like psychosis in one, and manic-like psychosis in one. Similarly, Barczak, Edmunds, and Bettes (1988) reported on the development of manic symptoms as a postictal event following complex partial seizures. The researchers also reported on a 10th patient presented with bizarre behavior associated with a thought disorder. In this study, the range of the duration of the symptoms was 24–144 hours (Barczak et al., 1988). Although most patients responded well to neuroleptic medications, some symptoms resolved without pharmacological intervention (Devinsky et al., 1995; Lancman, Craven, Adconape, & Penry 1994; Logsdail & Toone, 1988; Savard et al., 1991).
Similarly, Alper et al. (2001) reviewed 622 patients undergoing surgical evaluation for complex partial seizures and found that 29 patients developed PIP, documented through EEG. In this study, the risk factors for the development of PIP included a family history of mood disorders, but not a mood disorder in the individual with epilepsy. These researchers later compared a group of 59 patients with PIP and a group of 94 control subjects with epilepsy, but no PIP (Alper et al., 2008). Their results suggested a significant association between PIP and a history of encephalitis, bilateral interictal epileptiform activity, seizures with secondary generalization, and a family history of psychiatric disorders and epilepsy.
Adding a slightly different look at the problem, Gerard et al. (1998) described the incidence of subacute postictal aggression as a manifestation of PIP. They described a review of six patients and described a postictal aggression, which recurred repeatedly and was more likely following a cluster of seizures. All of the patients were male, had medically intractable epilepsy, and were remorseful in the interictal period. Steinert and Froscher (1995) reported that directed aggression has been reported to occur significantly more frequently during the postictal period than during interictal psychosis or during the postictal confusional state following complex partial seizures.
The ability to identify and subsequently control potential risk factors for PIP is critical. For example, premorbid psychiatric risk factors have been suggested by several authors. Alper et al. (2001) found a high prevalence of mood disorders among first- and second-degree relatives, but not in the individual with epilepsy. Others have identified that a history of depression and anxiety significantly increased the number of postictal psychotic or cognitive symptoms.
Risk factors include temporal lobe involvement, particularly bilateral, longer duration of epilepsy, a cluster of convulsive seizures, and a family or personal history of some mood disorders (Schachter, 2011). If PIP occurs frequently enough, the risk of interictal psychosis increases. Thus, the need for case finding and rapid and effective treatment is essential.
The presence of fear is an important predictor in this group of patients (Hermann, Dikmen, Schwartz, & Karns, 1982). Often the patients experience fear as an aura, and Hermann et al. (1982) found that these individuals with temporal lobe epilepsy displayed interictal psychotic profiles on the Minnesota Multiphasic Personality Inventory (Groth-Marnat, 2009). Savard et al. (1991) found similar results.
Treatment of PIP
Treatment for PIP requires careful consideration of multiple areas. The most common treatment includes prevention, control of seizures, and treatment of the psychotic symptoms. The consensus group recommends treatment with antipsychotic medications, but also careful weaning of the medication after symptoms resolve. This treatment varies from 5 days for short episodes of psychosis to 2 months for longer episodes (Kerr et al., 2011).
Adachi et al. (2007) studied 58 patients with epilepsy who had a total of 151 episodes of PIP over a period of 12.8 years. After evaluating the treatment of the psychosis, these researchers showed that antipsychotic drugs were the only variable that affected the length of PIP. Schulze-Bonhage and Tebartz van Elst (2010) reported on two patients who showed PIP after a seizure cluster. These two individuals were treated with antipsychotics and benzodiazepine, and their symptoms quickly resolved. Of interest, however, is that these individuals had depth electrodes in place (because of evaluation for surgery), and although the psychotic symptoms existed, there were no associated electrographic discharges or seizures.
The risk of suicide in people with epilepsy has been a source of concern for many years. More recently, the use of antiepileptic drugs and potential suicide risk has become another important concern. There is minimal but important evidence that suicide for individuals with PIP is a possibility. Kanemoto, Kawasaki, and Mori (1999) reported a 7% incidence of suicide in a series of patients with PIP. Fukuchi et al. (2002) reported on three patients who committed suicide during the postictal phase. Other studies have not been able to identify a close relationship between PIP and suicide (Blumer, et al., 2002; Mendez & Doss, 1992). Clearly, the incidence of suicide and depression in people with epilepsy require careful assessment and treatment. Lack of obvious symptoms is not a good approach to evaluating which patients are at higher risk for suicide.
A case report (Predergast, Spria, & Schnieden, 1999) reviewed the outcome of a 32-year-old woman who experienced PIP who was successfully treated with haloperidol at 7 mg/day. With this treatment, her symptoms resolved completely within 14 days. Other reports suggest the use of other antipsychotic medications, including the newer group of atypical antipsychotics.
Nursing care of the individual with PIP is critical to rapid diagnosis, treatment, and resolution of the event. As shown by the case study, a lack of understanding of the event can have very negative consequences for the patient. Although the literature suggests that the psychosis may resolve on its own, clearly medical treatment of the response encourages a much faster resolution and will improve the outcome for the individual patient. Ms. W did well with the treatment she received; however, if she would have been taken to jail without treatment, the resolution of the psychosis would have taken much longer and the potential for worsening of her seizure control was present.
All nurses working with individuals with epilepsy need to be aware of the potential of PIP. Specific interventions should be considered to help provide the best possible care.
An understanding of the problem of PIP will allow the nurse to better assess who is at most risk for the event. As described by Kanner et al. (2004), individuals with bifrontal independent ictal foci can be at risk. Individuals with secondarily generalized tonic–clonic seizures and those with temporal lobe epilepsy seem to be at particularly high risk. In summary, longer seizure history, bilateral brain involvement (particularly the temporal lobes), and family/personal history of psychiatric diagnoses are all potential risk factors. These factors need to be included in the nursing assessment for appropriate preventative interventions. Nurses in a tertiary setting, particularly in an epilepsy-monitoring unit, may see this disorder emerge as patients are weaned from medications.
Early recognition of the events is one of the most important nursing interventions. Calls from the family indicating a psychotic event or symptoms within this time frame need to be considered as potential for the diagnosis of PIP. Mood disorders are common in epilepsy and have been shown to preexist in individuals with PIP. However, the symptoms of the psychosis differ from the usual mood disorders in that the behavior is different and normally follows the seizure or group of seizures anywhere from 12 to 72 hours. Specific information concerning the number of seizures the individual experienced, when the psychotic symptoms begin, and whether there has been a problem with compliance with the current antiepileptic drug regimen is needed. Any patient at risk should be immediately referred to the provider or emergency room. The ability to communicate quickly with the treating neurologist and the use of antipsychotic medications may prevent the patient from a trip to the hospital or emergency room. Once a patient has experienced one episode of PIP, it may be advisable for the family to have access to antipsychotic medications to be given at the first sign of any psychotic symptoms.
The general treatment of PIP is multidimensional. The first priority is to relieve the symptoms of the psychosis. Most commonly, typical or atypical antipsychotics are used to relieve these symptoms. The older, typical rapid-acting psychotics such as haloperidol have been mentioned in multiple studies. The atypical antipsychotic risperidone was used in Ms. W’s treatment. Others that may be used include ziprasidone and olanzapine. In most cases, the behavior ceases quickly with treatment. The nurse will need to assure safety for the patient, which may include judicious use of restraints and control over stimulating environmental factors until the medications begin to resolve the symptoms.
The next priority in treatment is to assure that the seizure activity is controlled. Anticonvulsant levels should be measured, and medications should be adjusted as needed. Ideally, an electroencephalogram should also be done to document the event. Additional emergency postseizure care, such as computed tomography of the head, should be considered.
After the event has resolved, the patient is likely to have limited memory of the event. In Ms. W’s case, she had minimal memory of some of the more frightening aspects of psychosis. For example, she remembers striking the police officer because she thought he was trying to restrain her to hurt her. The details of the transport to the hospital and subsequent experiences are not available to her. As the psychotic symptoms resolve, the patient will need help in being reoriented to location and careful attention to help them to understand what has happened to bring them to this location. The family can play a critical role in this change, because they may have specific information that helps the patient to understand the entirety of their experience. Since the event, her family has helped her to recreate an understanding of the experiences.
Prevention is the next and very important part of the treatment plan. The best preventative intervention is control of seizures. In this population, additional care must be exercised to assure compliance, particularly in individuals who would be considered high risk for development of these symptoms. The patients and their families need to be reminded that if the individual alters dosages, forgets to take the medication, the potential for a seizure increases, along with an increased chance for postictal psychotic experiences. Although compliance with medications is always a top priority, when the potential for the disruption caused by the postictal event is brought into the discussion, there may be some additional encouragement of compliance.
There is controversy concerning the continuing use of antipsychotic medications following the resolution of symptoms. Most research reflects that the medication is stopped once the psychotic symptoms are relieved. This may include other symptoms such as insomnia or mood changes, which were not present prior to this episode. On the basis of the literature, there is a clear relationship between the patient’s prior mental state, family history of emotional problems, and the incidence of PIP.
Each patient will require evaluation by a psychiatrist. The nurse may be in the best position to help the patient understand this process and why it is important. Emphasis should be placed on helping the patient and his or her family to understand the unpredictable nature of this problem and that the psychiatric evaluation is intended to help identify potential treatable causes of the psychotic experience. In Ms. W’s case, the depression that had been following her for more than a year may have contributed to the onset of the postictal stage. Prompt and effective treatment of the symptoms may not only decrease the incidence of the PIP but may also improve actual seizure control. Even if the patient has no prior mood disorders, a reminder to them that research has indicated that even a family history of mental illness can serve as a risk factor for the development of a PIP can be very helpful. Importantly, help the patient and family view the psychiatric evaluation as a critical part of the healing process and one that will be essential for effective treatment and prevention of another episode.
The family needs special attention during this time. Seeing a loved one embark on a psychotic episode is very frightening. In Ms. W’s case, the family was terrified. Her 5-year-old grandson who witnessed the event needed special care because he could not reconcile the behavior he witnessed with the grandmother he knew. The family began to consider plans for the future and how they would handle another episode of this type. They began to even consider nursing home placement, if the symptoms did not disappear. Although the extreme reaction to her behavior was understandable, it was not necessary. With treatment, Ms. W quickly returned to her normal and has remained there ever since. When the family understands what they are seeing and the usual time it takes to resolve the issues, they may be more comfortable in riding the wave of the experience and not feeling forced to make long-term plans based on the current behavior. Families often react to problems with patients with epilepsy because they cannot “control” the seizures and feel “helpless” at many points in their care. The nurse can provide the family a series of steps so that they can feel into control and not at all helpless. They can be taught to early identify the symptoms, who to call at that point, or even what medication to have on hand in the event their provider recommends treatment with antipsychotics before the onset of full-blown symptoms.
Education and advocacy are essential components of the nursing role. Since the presentation of PIP is unusual, it is important for the nurse to provide education and advocacy for all patients. In Ms. W’s case, the family did not understand the situation and, therefore, were not certain how to manage the problem. Intervention with law enforcement and Emergency Medical Services can also help to provide an explanation for the abnormal and unexplained behavioral change. Because the patient can be at risk for worsening of seizure control and worsening of psychotic symptoms, rapid assessment and intervention are critical..
Summary and Conclusions
Postictal psychosis is a critical complication of epilepsy. As the case study demonstrates, certain risk factors such as increased seizures and preexisting mood disorders may be present. Ms. W noted that her depression continued to worsen, particularly as she approached the anniversary of her husband’s death. Her depression, along with the worsening seizure control, made it more possible for the development of the PIP. Advocacy for the individual is critical, and as Ms. W demonstrates, without the advocacy for proper treatment, she could have experienced much worse outcomes.
Nurses can play a pivotal role in the care of a patient with PIP. Early teaching of the patient and family about the possibility of development of PIP could help to decrease the severity of problems. For example, complaints about increased seizures associated with behavioral changes, such as insomnia or hyperactivity, may suggest the potential for development of psychotic symptoms.
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Keywords:: epilepsy; nursing; postictal events; psychosis