Abstracts

Rationale:
Peri-ictal Psychosis is a well studied phenomenon in the neuro-psychological literature with first reports dating to the 1800’s with patients found in “post ictal fury” or “epileptic mania”. It is defined as psychosis in epilepsy patients not in ictus. The prevalence of psychoses in epilepsy (particularly in temporal lobe epilepsy) ranges from 2-6% amongst cited case reports. Sub-types of peri-ictal psychosis include post-ictal (PIP), inter-ictal (IP) and antecedent (AP) psychosis. The temporal relationship between seizure and psychosis symptoms is a key feature. Although not an official diagnosis in ICD10 or DSMV, its presentation had been consistent across case studies with classification in 1988 of PIP, the most common form. The presentation of peri-ictal psychosis can share parallel symptomatology to the positive symptoms of schizophrenia which is more profound than the auras or psychosomatic presentation found in temporal lobe seizures alone. Studies have even shown a strong shared genetic susceptibility between the two. More than one diagnosis can exist in a patient, but the management pathway is crucial as each can precipitate the other. Given the rarity of this phenomenon, patients are at risk of being misdiagnosed as a pure psychotic disorder or psychogenic non epileptic seizures which can lead to suboptimal treatments.
Method:
We reviewed the case histories of 4 patients, who we followed at Stonybrook University Hospital, between Sept2019-Feb2020 and whose disease course was highly suspicious of antecedent and inter-ictal psychoses.
Results:
Three of the four patients had no prior psychological history and the fourth patient’s psychological history was “second-hand information” as we could not access records. All patients had positive psychotic symptoms. Three of the four patients lived alone and history was sparse as there were no witnesses to recent or prior events. They were only found due to wandering in the streets and brought in by police. Three of four patients were older than 50 years of age with either remote or no history of prior seizures. Schizophrenia was a guarded diagnosis in these older patients as they were not in a typical age range for this disease. The fourth individual was a young male with no prior arrests, but past months with multiple altercations and imprisoned for aggressive behavior outbursts and wandering from his group home. On exam, all were lucid with disorganized speech, flat effect and one with hypoactive delirium. All four patients seized after admission with similar EEG patterns characteristic of other patients in the literature. MRI brain, labs, (including LP’s in some) were unremarkable. There were no other seizure risk factors. All received antiepileptic management which improved both the EEG and clinical status.
Conclusion:
Symptoms of peri-ictal psychosis are similar to positive symptoms of schizophrenia. Although peri-ictal psychosis is a rare etiology for the “wandering patient”, we followed four patients with this suspected diagnosis in a 6 month time frame.  One must carefully procure a good history with collateral sources and a workup which could possible help identify more patients at risk. Psychoses and epilepsy share common roots and we must not anchor to one or the other in certain patients.  With more patients we can hopefully propose an updated comprehensive diagnostic criteria and see if it warrants an ICD-10 or DSMV diagnosis on its own to better serve these patients in and outside the hospital.
Funding:
:None