P0900 - Temporal lobe epilepsy and Psychosis: An atypical case of Post-ictal Psychosis

Background: Postictal psychosis (PIP) is a rare but potentially serious complication in patients with seizure disorders and is part of a group of psychotic disorders known as psychosis of epilepsy (POE). PIP often complicates chronic epilepsy, especially in patients with seizure clusters that include tonic–clonic seizures, bilateral cerebral dysfunction (e.g., bilateral epileptiform activity or history of encephalitis), and a family history of psychiatric illness. Psychosis includes delusions, auditory and visual hallucinations, mood changes, and aggressive and violent behavior.

Case Presentation: We present the case of a 16-year-old female previously diagnosed with adjustment disorder with depression and recurrent episodes of suicidal ideation with suicide attempts refractory to depression medication. She presented with altered mental status after intentional Tylenol overdose secondary to suicidal ideation. Midway during the hospitalisation, she exhibited numerous episodic bursts of aggression that spontaneously resolved without intervention. Her behavioural outbursts were accompanied by periods where she was very interactive and well appearing as well as periods of minimal interaction and excessive sleeping. Her mother also noted concern about three distinct personalities she seemed to be exhibiting over the last 3 months. Additional history revealed seizure disorder diagnosed as a child in Cuba, for which she was being treated with carbamazepine until the age of 8 when medication was discontinued after EEG reportedly showed no seizure activity. Since discontinuation of her medications she no longer had clinically evident seizures but developed personality changes that patient’s mother state were not present when she was on carbamazepine. EEG was obtained to further investigate given the personality changes and the history of possible seizure disorder. The EEG revealed right posterior temporal epilepsy and she was started on Tripletail prior to transfer to inpatient psychiatry facility for further management of suicide attempt.

Discussion: The relationship between epilepsy and POE is bidirectional, as patients with epilepsy are at greater risk of developing a psychotic disorder and vice versa. Psychiatric changes are an under recognized symptom group associated with seizure activity. PIP is an emerging subclass of POEs therefore manifestations of the condition are not well established. Current literature most commonly noted psychoses occurring following period of lucidity after recurrent clinical seizure episodes. However, our patient’s psychosis manifested via aggressive outbursts and split personalities, during a period of subclinical seizures. Therefore, patients who present with psychiatric disorders, notably well‐directed violent and self‐destructive behavior, should be considered for evaluation of seizures especially with a history of possible previous seizure activity.

Keywords: Postictal psychosis, epilepsy and psychosis, psychosis of epilepsy