Ictal (and Postictal) Psychiatric Disorders

14

He who is faithfully analysing many different cases of epilepsy

is doing far more than studying epilepsy […] A careful study of
the varieties of epileptic fits is one way of analyzing this kind of
representation by the ‘organ of mind’
John Hughlings Jackson, On a particular variety of epilepsy (‘intellectual aura’): One case
with symptoms of organic brain disease (1888)

Both ictal and postictal disorders are characterised by symptoms that are temporally
related to the epileptic seizure. The acute disruption of cerebral activity that occurs
with the seizure discharge can disrupt cortical function sufficiently to provoke acute
alterations in consciousness, as well as specific behavioural syndromes. Although
these behavioural manifestations have been described in the medical literature since
the nineteenth century, they often go unrecognised. Specifically, subtle alterations in
the mental state can be obscured by the more dramatic motor manifestations that
characterise multiple types of epileptic seizures (Fig. 14.1).
Preictal behavioural symptoms can herald a seizure and typically present as dys-
phoric affect (changes in mood associated with symptoms of anxiety and irritability,
short attention span, and impulsive behaviour). These symptoms can precede a sei-
zure by a period ranging from hours to up to 3 days. The behavioural manifestations
typically worsen during the 24 hours prior to the seizure and remit postictally,
although persistence for a few days after the seizure can occur.
Ictal behavioural symptoms are the direct clinical expression of seizure activity.
There is a possible link between ictal behavioural symptoms and temporal lobe
epilepsy, as seizure-induced alterations of the contents of consciousness are the
classic expression of epileptic auras of temporal lobe seizures. The epileptic aura is
a subjective ictal phenomenon caused by focal epileptic discharges that may pre-
cede the observable clinical features of a seizure. Ictal behavioural symptoms are a

© Springer International Publishing AG, part of Springer Nature 2018 141

A. E. Cavanna, Motion and Emotion, https://doi.org/10.1007/978-3-319-89330-3_14
142 14  Ictal (and Postictal) Psychiatric Disorders

Fig. 14.1  An epileptic or sick person having a fit on a stretcher, two men try to restrain him (ink
drawing attributed to Jean Jouvenet, 1644–1717). © https://commons.wikimedia.org/wiki/
File:An_epileptic_or_sick_person_having_a_fit_on_a_stretcher,_two_Wellcome_V0016630.jpg

Table 14.1  Possible ictal alterations of the contents of consciousness during focal-impaired
awareness seizures of temporal lobe origin and corresponding behavioural manifestations
Ictal alterations of the contents of Behavioural manifestations
consciousness
Affective symptoms Ictal emotions (usually unpleasant)
Cognitive symptoms Altered speed of thought, dissociation, forced thinking
Dysmnesic symptoms Flashbacks, illusions of memory
Perceptual symptoms Illusions, hallucinations

common presentation of experiential auras and can include perceptual, cognitive,

dysmnesic, and affective phenomena (Table 14.1).
Ictal psychotic symptoms often take the form of perceptual abnormalities, with
structured hallucinations and illusions involving all sensory systems (most com-
monly complex visual or auditory hallucinations and illusions with distortion of
body image). Ictal psychosis typically represents an obvious organic brain syndrome
with a variety of hallucinatory and delusional experiences in association with a dis-
turbed electroencephalogram. Patients might report seeing complex scenes or faces
or hearing voices or musical tunes being played for the duration of the seizure. Of
note, the contents of seizure-induced hallucinations usually appear familiar, although
it is not always possible to identify them with precision. Patients are typically able to
realise that these experiences are not real. In addition to altered speed of thoughts and
14  Ictal (and Postictal) Psychiatric Disorders 143

inability to voluntarily control their thoughts (forced thinking), patients often report
dissociative symptoms. These include depersonalisation (alteration in an individual’s
sense of personal reality and experience of self) and derealisation (alteration in one’s
sense of external reality), occasionally accompanied by out-of-body experiences and
autoscopy (seeing one’s double). Patients might recall past events or situations (flash-
backs), usually in a more vivid and intrusive way compared to commonplace recol-
lections. Moreover there might be feelings of recognition or familiarity or
reminiscence, which are often inappropriately attached to the present, creating the
illusion that the present is the reenactment of a past situation or event: so-called déjà
vu, literally ‘already seen’, or déjà vécu, ‘already lived’, and the opposite experience
of jamais vu, ‘never seen’, or jamais vécu, ‘never lived’. Overall, paramnesias (false
recollections) are not rare ictal phenomena, in particular in the context of temporal
lobe seizures. The most commonly reported ictal affective symptoms are unpleasant
emotions (fear, terror, anxiety, guilt, sadness, depression, anger, and embarrassment).
Investigators have estimated that ictal fear or panic is the most frequently reported
symptom, comprising around 60% of experiential auras, followed by ictal depression
(15%). There are important clinical implications, as ictal fear can be misdiagnosed as
panic attack disorder. Ictal fear as a manifestation of an epileptic aura is typically
brief (less than 30 seconds in duration) and stereotypical, occurs out of context to
concurrent events, and may be followed by other ictal phenomena such as periods of
confusion of variable duration, autonomic symptoms (especially salivation), and
motor automatisms. The sensation of fear typically is of mild to moderate severity.
Conversely, panic attacks consist of episodes of longer duration (5–20  minutes,
which at times may persist for several hours) during which the feeling of fear or
panic is extremely intense, characteristically associated with a variety of autonomic
symptoms, including tachycardia, diffuse diaphoresis, and shortness of breath (but
not excessive salivation). Ictal symptoms of depression are the second most frequent
ictal psychiatric manifestations. Patients characteristically report feelings of anhedo-
nia, guilt, and suicidal ideation that are of short duration and stereotypical, occur out
of context, and are associated with other ictal phenomena. In rarer cases, patients can
experience positive or pleasant emotions (exhilaration, mirth, blissful happiness,
euphoria, ecstasy, and sexual excitement) during their epileptic seizures. Famously,
it has been suggested that Russian writer Fyodor Dostoevsky (1821–1881) might
have experienced so-called ecstatic seizures as part of his temporal lobe epilepsy and
might have described his own ictal alterations of consciousness through the character
of Prince Myshkin in his novel The Idiot (1868). A vivid description of the onset
(epileptic aura) of Prince Myshkin’s seizure in the novel reads as follows: ‘his sensa-
tion of being alive and his awareness increased tenfold […] his mind and heart were
flooded by a dazzling light […] culminating in a great calm, full of serene and har-
monious joy and hope, full of understanding and the knowledge of the final cause’
(Fig.  14.2). British neurologist John Hughlings Jackson made the first systematic
study of seizure-induced alterations of the contents of consciousness and wrote of
‘psychical states which are much more elaborate than crude sensations’. Ictal mani-
festations of temporal lobe epilepsy are still among the most fascinating and poorly
understood neurological phenomena. Dreamy states define brief alterations of the
144 14  Ictal (and Postictal) Psychiatric Disorders

Fig. 14.2 Fyodor
Dostoevsky (1821–1881).
© https://commons.
wikimedia.org/wiki/
File:Dostoevsky.jpg

contents of consciousness that can occur in a variety of psychological states and, as

decribed by Hughlings Jackson, in certain types of epileptic seizures originating in
the temporal lobe (uncinate fits). Hughlings Jackson’s articles contain unparalleled
richness of clinical descriptions of dreamy states: ‘It is not very uncommon for epi-
leptics to have vague and yet exceedingly elaborate mental states at the onset of
epileptic seizures […] The elaborate mental state, or so-called intellectual aura, is
always the same, or essentially the same, in each case. “Old scenes revert”. “I feel in
some strange place”. “A dreamy state”’.
Canadian neurosurgeon Wilder Penfield (1891–1976) made the important dis-
covery that seizure-induced subjective symptoms could be reproduced by electri-
cal stimulation of the temporal lobe in patients with epilepsy undergoing surgical
procedures for their intractable seizures (Fig.  14.3). Based on the results of his
brain stimulation experiments, Penfield concluded that local neuronal activity at
the level of an epileptogenic zone can produce higher-­order experiences, and called
them experiential phenomena, because they had a compelling immediacy similar
to or sometimes more vivid than the patients’ recall of their own past experiences.
While these responses were originally reported following stimulation of the tem-
poral neocortex, subsequent studies suggested that they are more prevalent during
14  Ictal (and Postictal) Psychiatric Disorders 145

Fig. 14.3  Wilder Penfield

(1891–1976). © https://
commons.wikimedia.org/
wiki/File:Wilder_Penfield.
jpg

stimulation of the limbic structures located within the mesial aspect of the tempo-
ral lobe.
Importantly, Penfield’s work opened new pathways to our understanding of the
so-far elusive neural correlates of conscious experience. In 1954 Wilder Penfield
and his colleague Herbert Jasper (1906–1999) openly addressed this issue and its
clinical relevance: ‘no doubt consciousness is never twice exactly the same thing.
‘We are from moment to moment differently conscious’. This renders definition
difficult. Nevertheless, as clinicians, we must not allow this embarrassment to be an
insurmountable obstacle. […] It is necessary for us to judge, at least, when a patient
is conscious and when he is unconscious, and we must surmise the returning stages
of consciousness’. In addition to their clinical significance, seizure-induced altera-
tions of the contents of consciousness (experiential phenomena) raise interesting
questions concerning the brain mechanisms involved in the production of some the
most familiar human experiences, which contemporary philosophers of mind refer
to as subjective qualia. Specifically, it has been suggested that the investigation of
the neural processes taking place at the level of the limbic structures of the mesial
temporal lobe during focal impaired awareness seizures might yield useful insights
146 14  Ictal (and Postictal) Psychiatric Disorders

Table 14.2  Characteristic ictal alterations of the level and contents of consciousness during dif-
ferent types of seizures
Dimension of Example of seizure
consciousness Behavioural measure type Main neural correlates
Level (objective) Responsiveness Absence seizure Thalamus,
frontoparietal cortices
Contents (subjective) Awareness Focal-impaired Temporal lobe, limbic
awareness seizure system

into the neural correlates of epileptic qualia. The neuropsychiatric approach to epi-
lepsy is therefore key to both the improvement of patient’s health-related quality of
life and the ultimate search for the neural correlates of the qualitative texture of
experience, which is the essence of the subjective dimension of consciousness.
Ictal consciousness is most severely affected by generalised seizures, which are
characterised by a transient blackout with impairment of the level of consciousness,
behaviourally expressed by unresponsiveness and amnesia for the duration of the
widespread epileptic discharge. Recently developed instruments such as the
Consciousness Seizure Scale (CSS) and the Responsiveness in Epilepsy Scale
(RES) can assist neuropsychiatrists in the assessment of the level of consciousness
during different types of epileptic seizures, whereas self-report psychometric tools
such as the Ictal Consciousness Inventory (ICI) capture ictal changes in both the
level of the contents of consciousness. The recent observation that complete loss of
consciousness is accompanied by transient disruption in diffuse thalamo-cortical
projections and selective deactivation of the frontoparietal cortices has contributed
novel insights into the neural mechanisms subserving consciousness (Table 14.2).
Interestingly, there is a considerable degree of overlap between the conscious-
ness system in epilepsy and selected brain structures that are part of the so-called
default mode network. The default mode network is a set of interconnected brain
structures which activate during passive rest and mind-wandering and deactivate
during external goal-oriented cognitive tasks. Specifically, a functional hub of the
default mode network, which comprises the posteromedial parietal cortex (precu-
neus, retrosplenial cortex, and posterior cingulate cortex) and the medial prefrontal
cortex, has been referred to as the neurological basis for the self. This intercon-
nected network has been shown to be involved in autobiographical and self-­reference
information processing, as well as reflection about own emotional states. Mind-­
wandering usually involves thinking about one’s self in relation to others, remem-
bering the past, and projecting into the future. The default mode network could
therefore play a key role in linking the level of consciousness to self-processing
taking place as part of mind-wandering during restful wakefulness (Fig. 14.4).
Epileptic seizures affecting consciousness are typically followed by postictal
confusion, usually with ongoing disruption of the electroencephalographic activity,
mainly with diffuse slow activity. Postictal behavioural symptoms characteristically
present after a symptom-free period ranging from several hours to up to 7 days (usu-
ally after 24-48 hours, the so-called lucid interval) after a seizure (clusters of
14  Ictal (and Postictal) Psychiatric Disorders 147

Fig. 14.4  Posteromedial parietal cortex and medial prefrontal cortex: a hub of the brain’s ‘default
mode network’ playing a key role in self-consciousness. © https://commons.wikimedia.org/wiki/
File:Default_mode_network-WRNMMC.jpg

Table 14.3 Comparison of main clinical characteristics of ictal, postictal, and interictal

psychosis
Feature Ictal psychosis Postictal psychosis Interictal psychosis
Relative frequency About 15% About 60% About 25%
Consciousness Usually impaired Impaired or normal Normal
Clinical features Automatisms Lucid interval Schizophrenia-like
Duration Minutes Days to weeks Months
Electroencephalogram Epileptic changes Slowing, epileptic Unchanged
changes
Treatment Seizure control Seizure control Antipsychotics
(AEDs) (AEDs),
benzodiazepines
Abbreviations: AEDs antiepileptic drugs

seizures, more rarely single seizures). Postictal symptoms are more frequently
reported by patients with treatment-refractory focal epilepsy. The symptom-free
period between the seizure and the onset of behavioural symptoms can lead to their
misdiagnosis as interictal psychiatric disorders. Table  14.3 summarises the main
clinical features of ictal, postictal, and interictal psychosis. Postictal psychotic epi-
sodes can last from a few days to several weeks but usually remit spontaneously
after 1–2 weeks. Postictal psychosis is typically reported by patients with a seizure
disorder lasting for more than 10  years and is often associated with secondarily
generalised tonic-clonic seizures. Postictal psychosis characteristically presents
148 14  Ictal (and Postictal) Psychiatric Disorders

Table 14.4  Most commonly reported postictal behavioural symptoms in epilepsy

Affective symptoms Anhedonia
Excessive energy
Feelings of guilt and self-deprecation
Helplessness
Hopelessness
Irritability
Poor frustration tolerance
Suicidal thoughts
Tearfulness
Thought racing
Anxiety symptoms Agoraphobia
Compulsions
Excessive worrying
Panicky feelings
Self-consciousness
Psychotic symptoms Auditory and visual hallucinations
Paranoia
Referential thinking
Religious delusions

with affect-laden psychotic symptomatology, often with paranoid delusions with

religious themes. Affective features, erratic behaviours, as well as visual and audi-
tory hallucinations may also be present. Confusion and amnesia have occasionally
ben reported in association with these behavioural symptoms. Other postictal
behavioural symptoms include depression, anxiety, and autonomic manifestations
(Table 14.4). These symptoms can last for 24 hours or more and can overlap with
other psychiatric symptoms. Of note, only postictal psychosis has been found to
potentially respond to pharmacological interventions, whereas symptoms of depres-
sion, anxiety, irritability, and impulsivity have proven refractory to treatment inter-
ventions. Both ictal and postictal behavioural symptoms should initially be treated
by optimising antiepileptic therapy. Complete remission of seizure-related behav-
ioural symptoms can only be achieved with full remission of the underlying
epilepsy.

Suggested Reading

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Laureys S, Tononi G, editors. The neurology of consciousness. Oxford: Academic Press; 2013.
Zeman A, Kapur N, Jones-Gotman M, editors. Epilepsy and memory. Oxford: Oxford University
Press; 2012.
Suggested Reading 149

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