Treatment for postictal psychosis should be directed at two different stages. First, once an episode of postictal psychosis appears, a direct shortening or alleviation of postictal psychosis should be attempted. While Kanner et al. (1996) recommend dopamine blockers, Lancman et al. (1994) advise the use of benzodiazepines and sedation with chloral hydrate.
However, this difference in opinion is more apparent than real. In a typical case, postictal psychosis begins with an initial hypomanic state, which develops rapidly into a psychotic state with marked psychomotor agitation within 12-48 hours. If we succeed in making patients sleep amply during the initial hypomanic state, appearance of frank psychosis could be nipped in the bud. In this way, a certain proportion of the postictal psychosis could be prevented at the stage of the hypo-manic state, especially in the seizure monitoring unit, where trained psychiatrists could recognize the initial signs without delay. Indeed, postictal psychosis is self-limited and lasts at most only for several days in a majority of cases. However, some patients tend to commit violent behaviours or even suicide during the episodes. Therefore, we strongly recommend prompt arrest of this state. Second, in contrast to the alternative psychosis of Landolt, efforts to reduce complex partial and generalized tonic-clonic seizures could prevent recurrence of postictal psychosis in a substantial number of patients. Because the direction of the treatment is opposite at times as a function of alternative and postictal psychosis, the differential diagnosis between these states is all the more important.
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