Neurology and psychiatry have been linked together for a long period of time. One overlap demonstrated in the literature is the correlation between epilepsy with mood and psychosis. There is a big group of psychoses called the psychosis of epilepsy (POE); however, there is not much evidence about the diagnosis and management. Differentiation between POEs is difficult and is compounded by a lack of evidence-based guidelines on appropriate management. Even if you arrive at the diagnosis, POE can be difficult to manage. Some antiepileptic drugs (AEDs) cause psychiatric side effects and some antipsychotics may be epileptogenic. In this poster, we will discuss ways to diagnose and treat POE, as well as how to optimize certain AEDs in patients with POE.

Articles were chosen from multiple databases, such as MEDLINE, Google Scholar, and PsychInfo, to gather evidence about the diagnosis and management of POE. Specific keywords, such as Psychosis, Epilepsy, Antipsychotic, Antiepileptic, and Electroencephalogram (EEG) were used. Articles talking about recommendations regarding the use of AEDs and antipsychotics in POE were extracted from these databases.

POE includes preictal, ictal, postictal, and interictal psychosis. Preictal psychosis is very rare and tends to present with dissociation and déjà vu. This is correlated with temporal lobe epilepsy and resolves after the seizure. Ictal psychosis will correspond with epileptic activity on EEG and can manifest as aggression, delusions, or hallucinations. Antipsychotics are contraindicated in this POE. Postictal psychosis usually presents as a combination of mood symptoms and grandiose delusions seen with interictal sharp epileptiform discharges on EEG. Interictal psychosis can be subtyped into brief and chronic, with brief occurring during periods of increasing seizure frequency and chronic having no association with seizures. They both present similar to symptoms seen in classic schizophrenia and antipsychotics are often utilized.

Clozapine and chlorpromazine were found to have the highest seizure prevalence from second- and first-generation antipsychotics respectively, and the lowest was found with risperidone. AEDs that are commonly used in psychiatry, such as oxcarbazepine, carbamazepine, valproic acid, and lamotrigine are discussed in detail regarding their optimal dosing strategy for patients presenting with POE.

Diagnosis and management of the various types of POE can be challenging due to the lack of literature. We recommend using the antipsychotic, risperidone, as it has shown to have the lowest seizure prevalence among all antipsychotics. Both neurologists and psychiatrists should keep POE on their differential when dealing with seizure patients with psychosis. It is crucial for psychiatrists to understand how to optimize AEDs in the management of POE as these patients are often seen on the consult service.

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