Treatment of the Interictal Psychoses
J Clin Psychiatry 2000;61(2):110-122
© Copyright 2014 Physicians Postgraduate Press, Inc.
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Background: The interictal
"schizophrenia-like" psychoses of epilepsy
conventionally are treated with antipsychotic medication with
uncertain results. In patients with these psychoses, a preceding
and concomitant dysphoric disorder usually can be documented.
Effectiveness of the pharmacologic treatment by the combination
of drugs that is effective for severe interictal dysphoric
disorders is demonstrated in a series of patients with
Method: Patients were treated with the
combination of a tricyclic antidepressant and a selective
serotonin reuptake inhibitor, enhanced if necessary by a small
amount of the atypical neuroleptic risperidone. The series
consisted of 8 consecutive patients with interictal psychosis
seen over a 20-month period. Two additional patients seen over
the past 10 years who required a different therapeutic
intervention were also included.
Results: Five of the 8 consecutive patients
achieved full remission of their psychosis; 3 patients could not
be reached for the full treatment effort. One patient with a
malignant psychosis had been treated successfully (prior to the
series reported) by surgical removal of a left frontal
epileptogenic zone; a second patient (treated after the series)
recovered only upon elimination of the antiepileptic drug that
had suppressed clinical seizures but had resulted in an
Conclusion: Interictal psychoses can be
viewed as severe interictal dysphoric disorders with psychotic
features. The same combination of psychotropic medication that is
effective for severe interictal dysphoric disorders serves as the
primary therapy for interictal psychoses. The interictal
psychiatric disorders presumably result from seizure-suppressing
mechanisms that are the targets of the proconvulsant drugs. Upon
suppression of seizures, some patients with interictal psychosis
may require modification of the antiepileptic medication
responsible for excessive inhibition. Complete surgical removal
of the epileptogenic zone can eliminate a chronic interictal
psychosis upon postoperative fading of inhibitory mechanisms.