Thank you for attending today's Ask the Expert webinar on the assessment of management of postural psychosis. Please note that this webinar does offer continuing education credit after completing the evaluation. You will be taken to an evaluation immediately after the webinar. You will receive an email when the on-demand version is available. If you do have any questions during today's webinar, feel free to go ahead and type those questions into the Q&A box on the right-hand side of your screen. I would now like to introduce today's moderator, Madonna Don-Pluger, AAS Online Educational Committee member. Madonna? Thank you. Hello and welcome to the live Ask the Expert webinar, the assessment and management of post-dictal psychosis. My name is Madonna Pluger, and I will be moderating today's webinar. I'm an adult health clinical nurse specialist at Barrow Neurological Institute in Phoenix, Arizona, and I have a special interest in behavior management of patients that address cognitive and behavioral concerns that we see with post-dictal psychosis. I have been a member of the American Epilepsy Society since 2008, being active in multiple committees. I have nothing to disclose. I am privileged and honored to introduce our speaker today, Dr. Drago Saboe. Dr. Saboe is an Associate Professor of Clinical Neurology at IU School of Medicine, as well as a Program Director of Clinical Neurophysiology Fellowship Program. One of his primary roles as a clinical epileptologist is to care for patients with drug-resistant epilepsy and patients whose seizures do not respond to pharmacological management of their epileptic symptoms and consequently undergo surgical evaluation and neuromodulation. We have specific objectives that we want our learners to accomplish today, and we're confident that we will. They are to define the prevalence of patients with epilepsy in the ambulatory space, as well as the Epilepsy Monitoring Unit surrounding peri-ictal behaviors, to advocate the need for clinical intervention management recommendations, including when to restrain and when not to restrain, and other non-pharmacological approaches, to define the need for clinical practice guidelines for the management of the peri-ictal patient, and to address pharmacological interventions available for the treatment of this agitation phenomena. It's important that we want to make sure everyone comes away with an understanding of the perspective of the patient and family members living with agitation and these behaviors. Please feel free to enter your questions in the Q&A box during Dr. Saboe's presentation, and we will have him respond to that during the Q&A portion at the end of today's presentation. Now I turn the presentation over to Dr. Saboe. I would like to thank you for the invitation to give this talk. I feel in a hot spot being called an expert. I'm not sure I consider myself an expert. I continue to learn as much as all my fellows do every year. I'm a clinical neurologist and epileptologist. I've been taking care exclusively of patients with epilepsy for almost 20 years. So a lot of what we're going to talk here is based on literature, but at the same time I'll try to integrate this with what I've seen through the years. So I don't have any relevant disclosures or conflicts in relation to this talk, and we'll start here by setting the stage for psychiatric and postictal psychosis in particular. And I'm sure the audience is familiar with William Gowers, which we can consider the father of the epileptology and the first to have treated epilepsy successfully with pharmacological means, with bromides in the 1880s. He has been also among the first to recognize postictal psychosis. And I will quote here from his book from the 1880s about a case in which occasionally after a fit or more, frequently after a series of fits, an attack of mental disturbance may come on which may last for several days. It may be simply a demented state, or there may be hallucinations with irritability or even violence. So this is a very good description of what we're going to be talking about today. Postictal psychosis was actually likely described even earlier on in one of the first psychiatric textbooks from the 1800s called Postictal Fury. So after we've set the stage, you've heard already the learning objectives, so I'm not going to repeat them. But to be able to achieve these learning objectives, we're going to cover these following topics. We'll make an attempt on classification of psychiatric phenomena in epilepsy, realizing that as of now the Diagnostic and Statistical Manual, even in the revised edition in 2022, does not talk about these specific syndromes, psychiatric, psychotic syndromes that we're going to talk today. We're going to talk about a few distinct entities, like postictal psychosis proper, postictal aggression and delirium, which is a topic that's probably equally important, but maybe less well studied. We'll talk also about alternating psychosis, or alternative psychosis. You'll find it in the literature under different, both names. The topic, we'll try to understand the epidemiology of these conditions so that we are prepared for how often we'll encounter them, and we're not going to spend too much time on the mechanism of them, as that's beyond the goal of this presentation. Finally, we will talk about management of psychiatric psychosis and postictal psychosis, as well as postictal aggression, and about anti-seizure treatment and psychosis, and as well the concerns that many of us have about anti-psychotic drugs and the risk for seizures. For that, we're going to first present three cases that I would say can be considered representative of the entities we just introduced. Towards the presentation, we'll give the keys for understanding these cases. This is case number one. This is a 39-year-old man with long-standing history of epilepsy with focal onset since childhood, secondary to viral encephalitis at the age of 5. He experienced frequent focal-to-bilateral tonic-clonic seizures as well as even more frequent focal-impaired awareness seizures, often in clusters. He's on multiple anti-seizure medication and has tried multiple others, and he's admitted to the epilepsy monitoring unit, of course, for further presurgical evaluations. Three days into the study, after withdrawing the medication, he has a cluster of focal-impaired awareness seizures and immediately becomes very agitated. He tries to get out of bed, pulls the electrodes off. He can mumble a few words, but he's not oriented. He pushes the staff around and continues to try to get out of bed and even attempts to get out of the room. He becomes even more agitated as the nurse calls for further help and tries to keep him in bed. Eventually, security is also called to help immobilize the patient and pharmacological interventions were needed before the patient eventually fell asleep. At that point, our technologies were able to connect and reattach the electrodes and the patient was found to be asleep with excessive beta activity, but no ongoing seizure activity occurs. I'm sure any of you in the audience that work on the epilepsy monitoring unit see this maybe not every week, but I'm sure with regularity at least a few times a month. So this is case number one. And now this is case number two. The case number two I adapted from a presentation by Dr. Kanner that's going to be also listed in the bibliography. This is a 43-year-old woman with mesial temporal obsclerosis and epilepsy for over 25 years. After clusters of three-to-floor convulsions, she has recurrent episodes of insomnia, which start typically a day or two after the last of the seizures. And a few hours later, she has religious delusions, hallucinations, auditory typically, displaced tangential and circumstantial speech. And these states last between two to three days and can go on up to a couple of weeks. I'm sure you all recognize this pattern as well. Again, maybe not the most common psychiatric problem you encounter in your patient with epilepsy, but common enough. And finally, case number three. This is a 27-year-old woman with drug-resistant temporal lobe epilepsy, originating from the right temporal lobe. She had mesial temporal obsclerosis. Onset of her seizure was in childhood. She has frequent focal impaired awareness seizures and occasional tonic-clonic seizures as well. And she's been evaluated for possible surgery and deemed to be an excellent candidate for it, and underwent right temporal lobectomy and became seizure-free. A few weeks after the surgery, she started making daily phone calls to the office in which she started talking tangentially, making no sense, expressing delusional ideas, even threatening suicide. And not only that, she was sending letters in which she was stating, I can't stand to live. I'm not naive. I was out to find the better part of me. I'm only a mom with a silly red knife, digging for help on this one-way street. Only a mom with a funny red knife looking for a special thing inside of me. So this is a quote from a letter we were receiving at a time from the patient. So I think that these three cases will come back to them once we identify each of these specific psychiatric psychotic syndromes in epilepsy. And we'll talk about management of all these specific cases. But before that, let's talk a little bit about attempting to classify the psychotic disorders in particular in epilepsy. As you all know, psychotic disorders are classified and characterized rather by the presence of delusions, hallucinations, disorganized thinking, and also disorganized motor behavior. It may include also negative motor symptoms. As you all know, consciousness and awareness are preserved. As I already alluded, the DSM-5, even in the 2022 reiteration, does not have a specific category for psychosis in epilepsy. And this is grouped under psychotic disorders due to another medical condition. So in order likely to be able to better research these topics of psychotic disorders in epilepsy, it will be important to have a more formal characterization and categorization of these phenomena. First, we try to link the psychotic and psychiatric phenomena in epilepsy to their relation with the seizure themselves. So there are, of course, interictal psychotic syndromes with no temporal association with seizures. And these are, of course, relatively common and everybody knows that patients, for example, with schizophrenia, have significantly higher risk for epilepsy as well. However, we also deal with the scenario in which there is an actual link between the seizure phenomena and a time-wise correlation. We talk about periictal psychotic phenomena, either preictal, postictal, or ictal. And finally, we'll talk at the end about paraictal or alternative psychopathology, first recognized in the 50s and named at the time as forced normalization. And this seems to have something to do with controlling the seizures rather than the seizures occurring. So moving on and talking first about preictal and ictal psychiatric symptoms, and here I'd like to add that these categorization and classification of psychiatric symptoms and trying to fit them nicely in a box doesn't always work very well because, after all, we don't always know when seizures happen. Seizures may go unrecognized, especially focal impaired awareness seizures. Nocturnal seizures also go unrecognized, so sometimes it's difficult to know the relation of psychotic or psychiatric phenomena in general and seizures. Now, along the potential preictal symptoms that happen before seizures, headaches, autonomic changes, et cetera, behavioral and psychiatric symptoms are actually more frequent, and I'm sure many of you that follow patients especially with disabilities have encountered some that have significant mood changes and irritability minutes to days before a seizure and then a seizure seems to almost reset them and they are then doing okay from mood-wise after the seizure. Also, I'm sure this is unfortunately taken a bigger place in the lay press, the psychiatric and psychotic events occurring during seizures. These are not particularly common. Psychosis during seizures is not that common. Usually, if it happens and it's prolonged, it is potentially during the non-convulsive status epilepticus, and in that case, it's a bit more prolonged. Ictal fear, though, it's a relatively more common symptom, and in some case series, even up to 10% of patients may experience ictal fear. However, these phenomena and seizures in general should typically be short-lived and not persist too long unless we're dealing with non-convulsive status epilepticus. We're going to now move beyond the ictal events and we're going to talk about post-ictal psychiatric symptoms, and they may begin immediately after a seizure in the immediate phase or which is more characteristic for psychotic phenomena, they may start later on in the late phase, for example, 12 hours or even several days later. In the immediate post-ictal phase, cognitive disorder and headaches, for example, are more typical in the immediate post-ictal phase, while post-ictal psychiatric symptoms like the ones listed here, ranging from psychosis to anxiety typically happen more in the delayed phase. And as you can see, anxiety and depression are more common, but psychosis is relatively common as well at the 7% in these couple of case series published by Dr. Cannon and Dr. Teixeira. So let's talk now about postictal psychosis. This is a fairly specific syndrome that has been now recognized for a while and got again in the focus of attention since maybe the 1980s in particular. It's a fairly specific syndrome that has a very clear temporal relation between the acute onset of psychotic symptoms and precipitating bout of seizures, either focal impaired awareness or convulsion. With the caveat that we don't always know that the seizure happened. The seizure could have happened in sleep or the focal impaired awareness seizures may have not been witnessed. And then this clear temporal relation is not observed. Initially there could be lethargy and confusion, but then not uncommonly there is this lucid interval which is fairly characteristic and could be also a diagnostic pitfall because you will not realize that there is a correlation between the psychosis and the seizure because the patient recovered after the seizure and they were fine potentially for hours or days. After this, then the psychotic phase arises and may go on for days or even up to weeks. What is maybe not so well recognized is the fact that there is still often an association of confusion and delirium. And also it's important to know that this is really more of an adult disorder as we're going to see later. This happens primarily in people that have had longstanding epilepsy. So criteria for this condition have been published already more than three decades ago by Longsdale and Toon. And these are the criteria that are quoted and used still in most of the literature that attempts and research that attempts to study this condition. So here are the criteria. Episode of psychosis often with confusion and delirium developing within a week of a seizure or cluster of seizures. Psychosis that lasts at least 15 hours but less than two months. Mental state can be characterized by delirium or delusions or hallucinations in clear consciousness. And at the same time, there should be no evidence of a history of a treatment with antipsychotic medication or psychosis within the past three months because that may mean that this is a person with interictal baseline psychosis. There should be no evidence of antiepileptic toxicity as some antiepileptic medications have psychiatric side effects, including encephalopathy. Also, there should be no evidence of an EEG demonstrating nonconvulsive status. In that case, we would be dealing with ictal psychosis and not postictal psychosis. And there shouldn't be a history of some other neurological problem like head trauma, alcohol or drug intoxication or withdrawal. So this lucid interval, it's a very characteristic but as I mentioned, is again, could be a pitfall because you could have a patient that you have on the epilepsy unit, you produce a cluster of seizures, they recover fine and you discharge them the next day and then over the weekend, they develop psychotic symptoms at home and you're not realizing that this is postictal psychosis because of this lucid interval. So keep in mind that this could be a pitfall in diagnosing this condition as a postictal problem. Usually, this postictal psychosis comes with a combination of a thought disorder with hallucination, more commonly visual but as you've seen with the case that we discussed, auditory hallucination can occur as well. Delusions with grandiose religious persecutory can occur and a lot of religious conversion in these patients with epilepsy have been described and likely have occurred in the setting of postictal psychosis. Paranoia can happen. Also, mood disorder, manic or depression mood can occur. For example, one of the cases I was presenting also developed manic mood change. Verbal and physical violence can occur including the risk of harm occurs and suicide can occur and in some case series published regarding consecutive deaths amongst patients with well-characterized epilepsy, there were six suicides in this case series and at least two or four of them actually occurred in the setting of postictal psychosis. So this is not necessarily a benign condition just because it's often self-limited but it can lead to risky behaviors including some increased risk in suicide. Now, looking at mechanistically and risk factors, the literature contains somewhat confusing and a little bit contradictory risk factors but a few things appear to stand out and one of them is that this happens usually in long-standing epilepsy. So it's not common to see this in pediatric. Usually in pediatric population so much even though it is possible there as well if you're been dealing with long-standing epilepsy. Also, it may be more common in focal epilepsy in patients with focal to bilateral tonic-clonic seizures. Also, in patients with bilateral and widespread CNS dysfunction injury as displayed by a background that's slow on EEG, bilateral interictal discharges, the borderline IQ, these will usually predict potentially high risk of postictal psychosis and psychotic condition in epilepsy in general. And personal or family issue of psychiatric disorder increases the risk and of course the MRI findings correlate with the fact that we're dealing usually with patients with more widespread CNS pathology. So broad bilateral epileptogenic network are often present and predisposing etiologies like head trauma and encephalitis are up there primarily because these are condition that as you would expect, they are more likely to lead bilateral and diffuse damage to the brain. Metabolic hyperactivity appears to occur in some studies that look at brain metabolism and maybe it's a rebound effect after the postictal state. Benzodiazepine withdrawal can lead to psychotic presentation in some patients with epilepsy. So these may play a role mechanistically speaking but still I think we're not yet fully understanding and at least as myself as a clinician, I'm not sure I have the best understanding of the mechanism of how these psychotic conditions occur beyond the basic. So I already alluded from Dr. Kanner's series about the presence of postictal psychosis which is around 7% and prevalence of psychosis in postictally ranges between three and 9% and it's potentially higher in presurgical candidates and certainly lower in general epilepsy population. So if you think about, if you do three, four, two, three, four presurgical evaluations in your epilepsy unit per week, you're going to see a few cases with postictal psychosis every month and potentially again, you are not going to see it in your epilepsy unit but you're going to be discharging the patients home and they'll be struggling with their families at home. The mean age of onset is in the 30s and as I mentioned, postictal psychosis typically occurs in patients that have long-standing epilepsy, 15 to 22 years has been the average in some case series published through years. So the chronic epilepsy appears to be a prerequisite of this phenomenon. So now that we've talked about postictal psychosis, let's talk about a different entity but I would argue that there is a continuum between this and the postictal psychosis and let's talk a little bit about postictal delirium and aggression and this is something that you're going to actually see in your epilepsy units where we often induce seizures. We bring patients to induce seizures and in British survey of patients with epilepsy and acute psychological disorders, 35% have complication of severe delirium and delirium affective disorders, especially postictally. So it's going to be relatively common. If this postictal delirium and aggression which starts right away after the seizure is more prolonged, then we have to think about the differential diagnosis, for example, medication side effects, other medical condition or metabolic derangements, subtle ictal states and non-convulsive status. Now this of course will be easy to sort out in the epilepsy unit where you'll know right away if a patient is still seizing or not, but not at home. So these have to be kept in mind. Typical duration is minutes, hours, it may go on for one to two days in more extreme cases. There seems to be a correlation between the severity of the seizure or the cluster of seizure and the severity of the postictal aggression and delirium. And thus maybe why we see this relatively common in the epilepsy unit as well because we often withdraw medication in these patients and as a result they have seizures that are more severe or clusters that are more severe than they would have at home. So if we look at what happens with patients after a seizure that have postictal delirium or aggression, of course the most common scenario is going to be this kind of hypoactive state, hypoactive delirium with confusion. This is your patient that's confused and sleeps. You see them after a seizure, they're tired, they're out of it. If you try to wake them up, they will be confused, may not know they're in the hospital, may not even know the seizure happened. So that's the most common. However, I'm sure every one of you has seen also the hyperactive form with agitation and unusual behavior. Usually they have reactive behaviors and aggression and resistive violence, which essentially means unintended aggression towards others when someone attempts to restrain or assist the patient. So these behaviors, this aggression, it is not very organized and not very directed except potentially to the person that tries to restrain and assist the patient. So this patient can become aggressive if held. And in the process they may injure themselves. Also they may have wandering behaviors and I'm sure unfortunately many of us have had patients that even got arrested for trespassing during this state. On a rare occasion, these postictal delirious state and aggression may progress to an excited delirium that comes not with just what I mentioned before in the hyperactive state, but even autonomic hyperactivity, cardiac complication and this can become dangerous from even the physical point of view beyond the risk of injuries. And typically we should not allow patients to reach this stage. So now that we've talked about postictal psychosis and postictal aggression, let's get back to one of the first cases, the second case, actually, one of the cases we talked, the 43-year-old man with longstanding history of epilepsy with focal onset seizures since childhood, secondary to encephalitis, who during the hospital stay had the seizure medication withdrawn and after a cluster of seizures became agitated and confused, pulling electrodes and required a team effort to be mobilized, required security for safety and eventually required medications with neuroleptic and benzodiazepine after which the patient fell asleep and each electrodes were attached and the patient was asleep. So this case was a fairly typical case of postictal aggression and delirium. Of course, some psychotic features were present, but this is not the classic postictal psychosis per se. But again, fitting things in a box may miss the fact that we're dealing more with a spectrum rather than a very simply, simple and distinct conditions. So what can we do with these patients? Well, the good thing is in most patients, this results relatively rapid in minutes or just tens of minutes. But still, it is important to provide supportive care and protective care to avoid injuries. So kind of a careful watchfulness and giving the patient space if safe, it's likely more productive than getting into the patient's face and getting too close to trigger that resistive violence or aggression. So if at home, we would counsel families to try to avoid injuries, to close windows, to close doors and to watch the patient remove dangerous objects from the room, knives, forks, sharp objects, turn off stoves, things like that. In addition, of course, in the epilepsy unit, by default, the patient should have padding in their beds, but bed rails and padding, we need to be sure they are present and raised so the patient doesn't hit themselves during these bouts of post-tumor aggression. And we should not hold them down unless they are clearly at risk for harm. In that situation, though, you are going to need a team. One person usually cannot handle very well a patient that's agitated to a higher degree. So working together, a team should intervene. And of course, we need to be careful to avoid fractures, asphyxiation, if that is the case. Now, unfortunately in some cases you may need to intervene pharmacologically but we should do so confidently in the case in which it appears to be that we're evolving to excited delirium, a state in which we're starting to see autonomic changes. At that point we should not permit to do that because it can lead to possible you know cardiovascular complications. So medications, well here are a few options. Haloperidol is often very effective. It can be given intramuscular even if you've lost the IV access. This can be given IM and it can be given orally but I would argue that will be a challenge in somebody that's agitated. So more commonly you'll be reaching to IM, haloperidol. Also benzodiazepine can be used. Usually lorazepam is used and you can use one or two milligrams and at home you can also prescribe these to patients family that can administer a benzodiazepine. These days the nasal sprays are used for stopping seizures but potentially diazepam intranasal may be an option even though I must these are all off-label use. After all postictal aggression we don't have labeled use of any of these medications. So these are off-label use I want to make it clear. So be aware though that benzodiazepine can sometimes worsen delirium. So we have to be careful with that. So summarize careful watchfulness, making sure the patient is safe and not getting into their face and if need to restrain patient postictal agitation we should be careful and do it as a team to prevent injuries and then pharmacological off-label use of drugs like haloperidol or benzodiazepines remain the mainstay. So now that we talked about this case let's move to our other case, the second case, the case of of course postictal psychosis with a 43-year-old woman with bilateral mesiotemporal lobe sclerosis that after clusters of focal to bilateral tonic-clonic seizures develops insomnia, religious delusions, hallucinations, tangential and circumstantial speech and these states last two to three days to a couple of weeks. So what can we do for this patient? Well again I think prompt recognition is critical because as we talked before if this is allowed to continue and escalate it can lead to harmful and risky behavior such as risk for suicide. So delaying the treatment may lead to high-risk behavior and we don't want that to happen and thus prompt recognition is key. So because of the lucid interval and we don't always recognize this as an ictal phenomena we should inquire when we interview patients with typical with hard to treat epilepsy if the patient has unusual behaviors after seizures a day or two or even a week later. So this should be probably part of the interviewing process because otherwise we may not recognize this promptly. Of course in the extreme cases in which this is florid and prolonged it will not be able to be managed at home and then consider admission to a mental health unit. This may be necessary and because this is a post-ictal phenomena seizure control can control and prevent post-ictal psychosis. So optimal management of the seizures is potentially curative if you want for the post-ictal psychosis problem. But not every case resolves on its own. So what should we do in these cases? Again off-label use what I'm talking to you here. In mild cases a lot of people will try benzodiazepine and most commonly it's going to be lorazepam maybe cronazepam just because of their longer duration of action as opposed to a shorter acting benzodiazepine. And only in deterioration antipsychotic drugs are used. In the more moderate to severe cases a typical usually antipsychotics are used sometimes in combination with benzodiazepine. And again as I mentioned if there seems to be a trend towards worsening admission to a mental health inpatient facility may be necessary. You should be again careful sometimes with benzodiazepines in the more severe and moderate cases because you may have paradoxical excitation of the patient as a result and you may need more potent antipsychotic to more rapidly tranquilize when patients are violent and agitated. So be aware of that. It's interesting that paradoxically there's been some case series published about ECT or even transcranial magnetic stimulation in this scenario have been published. I must say I don't have much experience with that. I've had some patients that we've used ECT for psychosis in some of my patients but with what we're going to talk next alternating psychosis but not with postictal psychosis. Now of course it's important to optimize the seizure treatment because as we talk controlling seizures can lead to control of postictal psychosis. And we want to also keep in mind that some of our seizure treatment may worsen psychiatric symptoms in our patients. So another key here I think and these days I cannot do it without using something like this a phone and with the interaction check. There are too many medications out there and I have only one brain here you know. So I always check interactions between medications that I use and the patient's medication especially psychiatric medications because there is potential for interaction. So and then of course I'm sure most of the audience is very well versed and familiar with the psychiatric negative psychiatric side effects of certain medications like levitirastam, parampaneltopyramide and brivirastam which can actually worsen psychosis in these patients. So as you all know the pharmacological treatment and management of postictal psychosis the antipsychotic medications are more useful for the positive psychotic symptoms and of course the atypical neuroleptics are preferred. And again off-label risperidone is often the first choice in the published literature and that's what I also reach personally in patients with psychosis that I treat primarily risperidone as a first choice for postictal psychosis. So you can use there are low strength one to two two to four milligrams you can break it in half you can give a dose at night potentially and some patients respond quite well to low dose of these medications. Again keep in mind the interactions between seizure drugs and antipsychotic with your usual inducers like carbamazepine phenytoin increasing the clearance of many antipsychotic. Keep in mind that phenytoin decreases risperidone clearance as we talked about risperidone. Of course I'm sure you're all familiar with valproate effect of decreasing clearance of many medications to its inhibitory effect on the cytochrome system. We should be aware of the opposite effects of some of the antipsychotic drugs we use that have an effect on inhibiting the clearance of certain medications. So this is hard to keep track let me tell you and we have 30 plus seizure drugs out there and every year we get new psychotropic medications on the market and their effect on the metabolic effects are always different from one drug to another. So just check the interactions so that we make sure we use the appropriate doses for these medications otherwise they may be ineffective. For example using too low of a dose of risperidone in somebody that has their metabolism induced may be not as effective as we are hoping. Now of course we cannot talk in the last few minutes we cannot have such a talk about psychosis and seizure patients and not at least put here a question mark or what to do with a seizure threshold. I'm sure all of you manage patients with psychiatric disorders besides seizures and then the concern of what's going to happen if we use these antipsychotic drugs and the risk of seizures and of course there is literature out there about increased risk of seizures from certain antipsychotic drugs such as clozapine and maybe to a lower degree but still present from drugs like olanzapine or even quetiapine. That said still in most patients that are on anti-epileptic treatment the effect of seizure exacerbation is not present. So the bottom line is I think there shouldn't be a major hesitation of using especially low-risk antipsychotic drugs such as risperidone, r-epiprazole, ziprasidone or even haloperidol when indicated again of course off-label use but when indicated in our patients with psychotic symptoms related to their epilepsy. Even higher risk I have patients on clozapine or olanzapine that are managed by our colleagues psychiatrists and stable seizure control. So we should not necessarily hesitate that much. Then finally in the last couple of minutes we're going to talk about what my last case was a lady with right temporal lobectomy that developed psychosis after a right temporal lobectomy. So this is the so-called alternating or alternative psychosis that Landolt has observed and called forced normalization and has been seen with various treatments whether surgical or medication in patients that respond to this treatment and most common psychiatric manifestation of this will be psychosis. There is often restlessness, anxiety and personality and psychiatric history predisposed to this problem. So it is important in our patients to elicit not if they have current depression or anxiety but also if they have any history of psychiatric disorders because that can predict many of these conditions. In a systematic review of alternating psychosis most commonly happen in patients with focal epilepsy and with high frequency of epilepsy and the symptoms are usually more persecutory, delusional, referential thinking, associated sometimes with mood disorder, either depressive or manic and dissociative disorder is less common. And as I mentioned these can happen not only from medications but even epilepsy surgery and unfortunately if it's after epilepsy surgery it's less likely to be reversible. While in patients that have it induced by medications it is more likely to be reversible. So getting back to my patient that I presented, yes we had to commit her to hospitalize her in the psychiatric unit actually and she has been treated under psychiatric care since then and she's been managed with neuroleptics through the years and she has remained completely seizure free and is currently both psychiatrically and neurologically stable. But it was a journey and it wasn't that easy. We had to actually call the police to actually commit the patient to a psychiatric clinic. So how to manage this? Well withdrawing of anti-seizure medication that may be possible, taper down sometimes anti-seizure medication but that may lead to seizure recurrence. So we are here between the rock and the hard place. And as I mentioned already it is less likely to remit easily if it's triggered by a successful surgery. And often we have to resort to using anti-psychotic drugs. And they are typically the same off-label ones I mentioned to you, a typical medication like Risperidone, like Aritiprazole, Ziprazidone, et cetera. So through the presentation today I wanted to bring to your attention the psychosis in epilepsy, especially the ones pre-postictal and paraictal psychosis, and less so the interictal psychosis. And the fact that it's important to actually start looking at having a classification that will allow us then to study these conditions better in the future in larger population now in the era of big data. And also that it's important to promptly recognize and then promptly treat if these conditions become potentially risky for the patient using methods for safety supervision but also pharmacological means. And I kept here this slide a bit longer for any of you interested in further reading. These are some amazing reviews that are very useful reads. And even the fact that you see that they range for some of them are 20 years old tell you that, you know, there should be potentially more research into this field and more attention into this field. And with this I'd like to thank you for your attention. And I hope to take some questions. I'll tell you I'm not sure I'll have answers, but I'll try. Thank you, sir. I see there's one question in the chat, and it says, is temporal epilepsy more prone to postictal psychosis compared to other lobes? Excellent question. So if we look at the literature, this is one of those that in some case series the answer was yes. The temporal lobe more likely to more likely to lead postictal psychosis. But there are been some case series in which extratemporal lobe epilepsy was maybe higher association. In those cases, for example, in which psychosis still persisted, for example, after failed epilepsy surgery, it was usually present in patients that had bilateral temporal lobe epilepsy, meaning they had recurrence of seizures contralaterally. So getting back, this is more likely to happen probably in patients with more widespread bilateral disease rather than in people with very focal disease. So yes, some series say temporal lobe epilepsy more likely to be a cause of it with a caveat that probably bi-temporal lobe epilepsy and more widespread, not just mesial, more widespread temporal lobe dysfunction has been reported in some of these case series. Thank you. Does anyone else have anything they would like to pose today? Sia, thank you. Maybe while we wait for another question, I think one parting thought is that history in this patient, taking a good history is key for two reasons. One, for recognition of lifelong history of psychiatric disorder, you know, the screening tools of, you know, inquiring of, you know, depression questionnaires and such, you know, are not very useful. If we are going, because the only, I mean, they are very useful, don't get me wrong, but they are not going to be able to identify history of psychiatric disorder. And that's strongly predictive of psychiatric complications, including psychotic disorders in patients with epilepsy. So that's one thing I always inquire in any of my new patients, if they've ever been diagnosed with a psychiatric condition, if they've ever been admitted to a psychiatric unit. And that's part of history, 100%. So I see, why is risperidone the often preferred antipsychotic for post-tumor psychosis? Well, first of all, it's a bit older than ziprasidone and arepiprazole. Two, it's in the low-risk category for risk for seizures, and then has less motor complications than older antipsychotics. So it kind of made it a drug of choice, off-label, of course, in this patient. So again, lower risk for seizures, exacerbation, less use of Haldol as a first choice in EMU settings as needed for post-tumor psychosis. If it's a severe case, Haldol is going to be the go-to-go drug if it's a very agitated person. If it's a milder case, we'll still potentially use benzos. I think in our epilepsy monitoring unit, the Haldol works because we can give it IM. And sometimes these patients are so agitated, they pull that darn IV out as quick as possible. Yeah. So then I see a question, do you prescribe antipsychotics as needed for a patient at home? Yes, I do. I do. Now, of course, if I prescribe risperidone and it doesn't work, I'd use benzos. Maybe I tried one other antipsychotic. I would reach to my colleagues psychiatrists. They are just more familiar with these drugs. But I would not hesitate to prescribe one or two antipsychotics at home. Usually it's risperidone, the one I prescribe the most. And manage the balance between managing the seizure risk and managing psychosis with antiepileptic and neuroleptics. This is always a tricky thing because even drugs with low risk, if you use them enough, you'll have the occasional patient that report an increase in seizures. And you don't 100% know if that is a true causal effect or just a correlation without causal effect. So my approach has been that if I think that the psychosis in a patient is severe enough to warrant pharmacological treatment, to use low doses first if the patient is not in a very high risk situation. And I typically start in slightly lower doses than package inserts would dictate. So I would reach for a one milligram risperidone first. But as I mentioned, I have patients that are on pretty much all the antipsychotic drugs I listed here, whether prescribed by me or psychiatrists, and we just monitor their seizures. And if they appear to worsen, I try to recommend changing the antipsychotic or working with the psychiatrist to do so. And if the seizure pattern has not changed, to keep on going. I mean, I have patients on clozapine, not one, several, because that was the only drug that controlled their psychotic disorder. Usually that's more interictal schizophrenia than interictal postictal. So when do you consider ECT? Well, as I mentioned, I had only one patient that we've used ECT for such scenario, and that was a patient with autism that was absolutely impossible to manage behaviorally. It was a patient that actually had alternating psychosis, was placed on different medications for two years, but then he was put on oxcarbazepine in combination with another medication. He became completely seizure-free, but became totally unmanageable. And he was getting ECT after multiple psychiatric hospitalizations failed to help. And over time, that has been discontinued, and I follow him now about two, three years after these months of struggle with psychosis, and the patient is back in the family's care. I would consider in such situations, these are patients that will need to be so severe that neuroleptics, admissions to psychiatric ward, you'll not be able to control their behavior and continue to be at risk for themselves or people around. Do you suggest using antipsychotic daily as compared to as needed for postictal psychosis? Well, I mean, probably not, I mean, unless, again, there is a spectrum here. If there is a patient that has a psychosis that's very common and recurrent, and the seizure that happens all the time, then maybe yes. But for postictal psychosis, I think in patients that end up having postictal psychosis so often as to require daily antipsychotic drugs, it's going to be a challenge to even say, is that true postictal psychosis, or have we moved in a more, you know, in a more psychotic state that involves both the interictal states and not only related to the seizures themselves. Thank you so much, Dr. Sabo. Well, thank you again for inviting me.

postictal psychosis

epilepsy

psychiatric conditions

seizures

postictal aggression

Dr. Drago Saboe

treatment strategies

antipsychotics

epilepsy monitoring

interdisciplinary collaboration