A grumbling interictal psychosis, with occasional exacerbation, is often seen in patients with severe epilepsy. Psychotic features may be quite mild, and complicated by irritability, anxiety, paranoia and dysphoria. In most cases antipsy-chotic medication is required. Sulpiride is a good drug for mild psychosis, and its additional anxiolytic effects can be helpful. During acute exacerbations of psychotic behaviour, risperidone, olanzapine or quetiapine may become necessary. Sometimes exacerbations of interictal psychosis are prolonged and non-responsive to treatment. In these cases clozapine can be used, but it can precipitate seizures and also carries a significant risk of leucopenia, and close monitoring of blood counts is necessary. Electroconvulsive therapy (ECT) has occasionally been used, and is often strikingly effective, but there is a theoretical risk of ECT-induced status epilepticus.
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