(060) A case of recurrent postictal mania in a patient with refractory epilepsy

Abstract:

Background:

Postictal mania is a rare clinical entity characterized by symptoms of mania occurring after a seizure. It can be indistinguishable from other causes of mania, such as cyclic mood disorders, and may be severe enough to require psychiatric hospitalization (Schmitz, 2005). Few reports of this condition exist in medical literature (Rizvi, 2018; Nishida, 2005) and none were identified that hypothesized a strategy for prevention of postictal mania in cases of refractory epilepsy. This poster discusses a case of recurrent episodes of postictal mania in a patient with epilepsy.




Case:

The patient is a 27-year-old male with bihippocampal epilepsy referred by neurology to our outpatient psychiatry clinic for management of episodes of postictal mania in the setting of recurring seizure clusters. Symptoms were typically so severe that the patient required psychiatric hospitalization. After seizure clusters, he experienced decreased sleep, excess energy, racing thoughts, increased goal-directed activity, and visual hallucinations of demons. Symptoms lasted 2 to 7 days and began 1-24 hours after a seizure cluster. He denied history of manic or psychotic symptoms outside of the postictal period. He suffered a cluster once per month and his epilepsy was managed with a vagal nerve stimulator and four anti-epileptic drugs: valproic acid, zonisamide, pregabalin, and lacosamide.



Management and Outcome:

This patient could not tolerate higher doses of valproic acid and was experiencing polypharmacy, thus was considered optimized with regards to mood stabilizing medications. He was prescribed risperidone 1mg BID with the aim to prevent future manic episodes. Following this change, the patient had two psychiatric hospitalizations and experienced no improvement of manic symptoms.




Discussion:

Often in consultation-liaison psychiatry we are asked for recommendations for management of psychiatric symptoms of neurological diseases. This case highlights a postictal syndrome which may present with psychiatric complaints. After the addition of scheduled atypical antipsychotic this patient continued experiencing severe episodes of mania, suggesting this approach may not prevent postictal mania. This is similar to literature describing management of postictal depressive states (Kanner, 2010). The goal for a postictal affective disorder is remission of seizures, however in refractory cases other strategies may need to be explored. Expanded knowledge of postictal mania in C/L literature could lead to improved recognition and management in the future.




References:

Kanner, A. M., Trimble, M., & Schmitz, B. (2010). Postictal affective episodes. Epilepsy & Behavior, 19(2), 156–158. https://doi.org/10.1016/j.yebeh.2010.06.024

Nishida, T., Kudo, T., Nakamura, F., Yoshimura, M., Matsuda, K., & Yagi, K. (2005). Postictal mania associated with frontal lobe epilepsy. Epilepsy & Behavior, 6(1), 102–110. https://doi.org/10.1016/j.yebeh.2004.11.009

Rizvi, S., Farooq, F., Shagufta, S., Khan, A. M., Masood, Y., & Saeed, H. (2018). Postictal Mania Versus Postictal Psychosis. Cureus. https://doi.org/10.7759/cureus.3338

Schmitz, B. (2005). Depression and Mania in Patients with Epilepsy. Epilepsia, 46, 45–49. https://doi.org/10.1111/j.1528-1167.2005.463009.x