The existence of preictal symptoms was described in the early nineteenth century by Burrows who described symptoms of irritability and depression, and grandiose
delusions (5). In the twentieth century, Blanchet and Frommer investigated the presence of preictal psychiatric symptoms in 27 consecutive patients who were asked to rate their mood on a daily basis for a period of 1 month (6). Thirteen patients recorded at least one seizure during this period. Rating scales identified the presence of dysphoric symptoms, consisting of irritability and mood changes, approximately 3 days before the seizures. These symptoms worsened in severity closer to the time of the seizure and remitted approximately 1 day after the seizure, although in some cases the symptoms persisted for up to 3 days after the seizure. It is not uncommon, therefore, for parents or family members of the patients to be able to predict the occurrence of seizures. In the case of children, they typically become more irritable, and display motor hyperactivity, impulsive behavior, and poor frustration tolerance.

As stated in the preceding text, psychiatric ictal symptomatology and episodes are the clinical expression of simple partial seizures, most of which are of mesial temporal origin, although epileptogenic zones in orbitofrontal, cingulate gyrus, and insula can also be identified in psychiatric ictal events. Jackson described a “dreamy state” in seizures originating in mesial temporal structures, consisting of vivid memory–like hallucinations, and/or the sense of having previously lived through exactly the same situation (déja vu) (7). It has been estimated that psychiatric symptoms occur in 25% of “auras,” 60% of these presenting as fear or panic, and 20% as symptoms of depression (8), whereas less frequent psychiatric symptoms include pleasurable experiences (feelings of ecstasy), and visual and auditory hallucinations (see subsequent text).

Ictal fear or ictal panic may present as a simple partial seizure or can be an aura followed by a complex partial seizure in temporal lobe epilepsy (TLE) (8,9,10). Frequently, patients fail to recognize and report associated symptoms (such as transient confusion or subtle automatisms) indicative of an ictal event, which often results in its misdiagnosis and treatment as a panic disorder, and the correct diagnosis is reached only after the patient has experienced a secondary generalized tonic-clonic seizure. Yet, a careful history can help distinguish a panic disorder occurring interictally from an ictal panic. Indeed, ictal panic is typically brief (<30 seconds in duration), is stereotypical, occurs out of context to concurrent events, and is associated with other ictal phenomena, such as periods of confusion of variable duration and subtle or overt automatisms (11). The intensity of the sensation of fear is mild to moderate and rarely reaches the intensity of a panic attack. On the other hand, interictal panic attacks consist of episodes of 5 to 20 minutes’ duration which at times may persist for several hours during which the feeling of fear or panic is very intense (“feeling of impending doom”) and associated with a variety of autonomic symptoms, including tachycardia, diffuse diaphoresis, and shortness of breath. Patients may become completely absorbed by the panicky experience to the point where they may not be able to report what is going on around them; however, there is no confusion or loss of consciousness as in complex partial seizures. It is not infrequent for patients to become extremely apprehensive about experiencing another panic attack that may then lead to the development of a full-blown agoraphobia. The misdiagnosis of ictal fear as a panic disorder may be compounded by the failure to identify an electrographic ictal pattern in simple partial seizures of mesial temporal origin, above all when the seizure focus is in the amygdala. In such cases, electroencephalographic (EEG) recordings with sphenoidal electrodes placed under fluoroscopic guidance may be necessary to demonstrate the epileptiform activity (12). Finally, patients with ictal panic may also have interictal panic attacks and other types of anxiety disorders (13).

Ictal fear may be easily missed in children; this is illustrated in the following example of a 7-year-old child who experienced recurrent nocturnal and occasional
daytime attacks consisting of intense fear and complex visual hallucinations (14). He was thought to have panic disorder, pavor nocturnus, and nightmares. Furthermore, because the attacks appeared after the divorce of his parents, an adjustment disorder was suspected, and he received psychotherapy for more than 2 years, without an effect on the attacks. Routine EEG and magnetic resonance imaging (MRI) studies had been reported to be normal, but because of persistent attacks, he underwent a prolonged video electroencephalography (VEEG) monitoring study in which two typical attacks were recorded displaying a left temporal ictal pattern. He was successfully treated with antiepileptic medication. A high-resolution MRI revealed a cortical dysplasia extending from the left anteromedial temporal lobe to the amygdala with a suspected origin of seizures in the amygdala.

Ictal symptoms of depression rank second in frequency after ictal fear (8,9,10). Such mood changes are typically brief, stereotypical, occur out of context, and are associated with other ictal phenomena. The most frequent symptoms include feelings of anhedonia, guilt, and suicidal ideation. More typically, however, ictal symptoms of depression are followed by alteration of consciousness as the ictus evolves from a simple to a complex partial seizure.

Ictal hallucinations include visual and, less frequently, auditory hallucinations. In contrast to “psychotic hallucinations,” patients are able to realize that the hallucinations reflect unreal phenomena. Ictal hallucinations of insular origin are usually associated with autonomic symptoms. For example, Insard and Mauguiere reported six patients in whom seizures were recorded with intracranial electrodes from the insula, consisting of an initial sensation of laryngeal constriction followed by paresthesia that were often unpleasant affecting large cutaneous territories and were eventually followed by dysarthric speech and/or elementary auditory hallucinations (15).

Ictal psychiatric phenomena may also consist of pleasurable experiences. For example, among 11 consecutive patients reported by Hansen and Brodtkorb, 8 experienced sensory hallucinations, 4 erotic sensations, 5 described “a religious/spiritual experience,” and several had symptoms that were felt to have no counterpart in human experience (16). The ictal onset could be localized to the temporal lobe only in four patients. Eight patients voiced their wish to experience seizures; five could induce them, and four were noncompliant with their antiepileptic drugs (AEDs).

Ictal auras can also include autoscopic phenomena, which consist of a hallucination of seeing one’s double and out-of-body experiences. Devinsky et al. reported ten patients with such ictal phenomena (17); these authors found a 6.3% incidence of ictal autoscopic phenomena in the consecutive patients they interviewed in their clinic. Among 21 patients in whom the seizure focus could be identified, seizures originated in the temporal lobe in 18 (86%) with no clear lateralization.

The only systematic investigation of the prevalence and clinical characteristics of PPSs published to date was carried out by Kanner et al. and hence will be reviewed in some detail. This study was conducted at the Rush Epilepsy Center with 100 consecutive patients who had pharmacoresistent partial epilepsy (18). Every patient was asked
to complete a 42-item questionnaire (The Rush Postictal Psychiatric Questionnaire— see Appendix) designed to identify the frequency of 26 PPSs and 5 cognitive symptoms during a 3-month period. These included symptoms of depression and of various anxiety disorders (i.e., general anxiety, panic attacks, agoraphobia, obsessions, and compulsions), hypomanic and psychotic symptoms, and neurovegetative and physical symptoms. These latter two types of symptoms are common in seizures and in depressive and anxiety disorders. Accordingly, they were recorded as separate symptom categories, so as not to erroneously increase the number of postictal symptoms of depression and anxiety. The postictal period was defined as the 72 hours that followed a seizure. The questionnaire was also developed to discriminate between interictal and postictal symptoms and to identify interictal symptoms that worsen in severity during the postictal period. Each question inquired about the frequency of the symptom and only those that were identified after more than 50% of seizures were included in this study, so as to reflect a “habitual” phenomenon.

Among the 100 patients, the authors identified a lifetime prevalence of psychiatric disorders in 54 patients, which consisted of mood disorders in 33; anxiety disorder in 16, 12 of whom also had a mood disorder; and attention-deficit hyperactivity disorder in 5. No patient had a history of a psychotic disorder. Eleven patients reported one or more hospitalizations for psychiatric disorders.

A median of eight postictal symptoms was identified (range 0 to 25) corresponding to a median of three cognitive symptoms (range 0 to 5) and five PPSs (range 0 to 22); 74 patients experienced at least one type of PPS—68 reported PPSs and cognitive symptoms, and 6 reported only PPSs. An additional 14 patients experienced only postictal cognitive symptoms, whereas 12 did not report any postictal symptoms. The prevalence of the different types of PPSs and their median duration appear in the Table 19.1.

Among the 74 patients with PPSs, 60 (81%) experienced PPSs of more than one psychiatric disorder. The most frequent combination included postictal symptoms of anxiety and depression, and neurovegetative symptoms. Notably, the existence of PPSs had been investigated in only seven patients before this study and only one was offered treatment specifically directed to the remission of habitual postictal symptoms of depression.