Epilepsy and psychoses

Nathan J Carberry MD (Dr. Carberry of New York-Presbyterian/Columbia University Medical Center has no relevant financial relationships to disclose.)
John J Barry MD (Dr. Barry of Stanford University has no relevant financial relationships to disclose.)
Jerome Engel Jr MD PhD, editor. (Dr. Engel of the David Geffen School of Medicine at the University of California, Los Angeles, has no relevant financial relationships to disclose.)
Originally released October 16, 2017; expires October 16, 2020


Psychosis is a term used to describe an abnormal condition of the brain that involves a disruption in reality testing, often including the presence of sensory misperceptions including delusions (fixed false beliefs) and/or hallucinations without insight. Often speech and behavior may also be impaired.

Historical note and terminology

Psychotic disorders have been noted to accompany psychosis of epilepsy (POE) and were particularly observed in the French literature of the 19th century (Kanner 2011). In 1839, Esquirol described postictal “fury” that lasted hours to days, whereas Farlet classified epileptic psychosis into 3 categories; peri-ictal, chronic, and true epileptic psychosis (Kanemoto 2011). Savage and Clouston observed florid behavioral dyscontrol that most likely occurred as postictal events (Kanemoto 2011). Hughlings Jackson postulated that postictal psychiatric symptoms were the result of compensational neuronal changes that resulted from seizure activity (Kanemoto 2011). However, the literature subsequently focused on the phenomena of postictal confusion and delirium. Both “affinity” and “antagonism” hypotheses have been postulated and have formed the basis for the development of convulsive therapy to treat schizophrenia (Sachdev 1998). The phenomenological and physiological relationship between schizophrenia and psychosis of epilepsy has been the source of much speculation (Kanner and Barry 2001).

The presence of psychotic symptoms in people with epilepsy (PWE) can be evaluated by investigating the temporal relationship of symptoms to seizure activity. In a review by Hilger and colleagues, 1434 people with epilepsy were evaluated (Hilger et al 2016). The overall frequency of psychosis was found to be 5.9% with postictal psychosis (PIP) found in 3.7% and interictal psychosis (IIP) in 2.2% (Hilger et al 2016). In another review, psychosis of epilepsy was noted to occur with 7 times the frequency of primary schizophreniform disorders observed in the general population (Kanner and Rivas-Grajales 2016). Schizophrenia has a point prevalence of 0.4% to 1% in the general population. In a study involving patients from a tertiary care centers, schizophrenia-like psychosis of epilepsy was seen 6 to 12 times more than in the general population (Sachdev 1998). It must be remembered that much of these data come from a skewed population sample, which may not be representative of the epilepsy population at large.

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