Logsdail and Toone's diagnostic criteria for PP (see ) continue to be widely used (8
). The typical patient is psychiatrically well until a cluster of tonic–clonic seizures, with or without complex partial seizures, occurs (9
). After an initial postictal period marked by confusion and lethargy, the patient improves for hours to days (the lucid interval). Subsequently, psychotic symptoms develop and typically last days to weeks (8
). Although not emphasized in the literature, a degree of confusion and delirium (e.g., impaired attention, alterations in sleep–wake cycle and motor activity, and increased autonomic activity) often coexist with psychotic features. This profile frequently is seen in epilepsy monitoring units, where PP affects between 6 and 10 percent of presurgical candidates (9
). Further, PP is almost exclusively an adult disorder emerging in the setting of chronic epilepsy. The mean age of onset is 32–35 years (10
), first occurring at an average of 15–22 years after the onset of epilepsy (12
). Most patients have temporal lobe epilepsy (TLE), although case-controlled studies conflict as to whether TLE or partial epilepsy rates are significantly more common.
Logsdail and Toone's Diagnostic Criteria for Postictal Psychosis
The lucid interval is a relatively unique feature of PP. Unlike other postictal symptoms, which are maximal immediately after the seizure, as mentioned, PP emerges after seizures cease. There are no detailed studies of the lucid interval, which lasts from 2 hours to a week but usually persisting over 6 hours (8
). Present in most PP cases, the lucid interval is a diagnostic pitfall. In the monitoring unit, after sufficient seizures are recorded, AEDs are often restarted and patients discharged. Some may have a normal mental state when discharged but develop psychosis at home.
The psychosis is characterized by fluctuating combinations of thought disorder, auditory and visual hallucinations (either may predominate), delusions (grandiose, religious, persecutory), paranoia, affective change (mania or depression), and aggression. Auditory or visual hallucinations can predominate (8
). Compared to patients with interictal psychosis, those with PP are more likely to suffer visual hallucinations, grandiose and religious delusions, pressured speech, and illusions of familiarity (12
). By contrast, referential, perceptual, and persecutory delusions as well as auditory hallucinations of voices are more common patients with interictal psychosis (12
). Religious and violent behavior can be prominent in PP (15
). Most sudden religious conversions in epilepsy patients occur during the postictal period (23
). Both verbal and physical violence can occur, which may be serious and life-threatening to the patient or others. In one study of 43 consecutive deaths among patients with well-characterized epilepsy, all six suicides occurred in patients with TLE: three jumped in front of a moving train during PP (24
). Other known deaths related to PP include a suicide performed by jumping into the center of a stairwell from the 12th floor of an epilepsy center and a patient stabbing his wife.