Postictal Psychosis Following Subtle Nonconvulsive Seizures: A Case Report Highlighting Diagnostic Bias in Acute Care

Authors

• Mark M. Chou, University of LynchburgFollow

Specialty

Internal Medicine

Advisor

Dr Elijah Salzer

Abstract

Postictal psychosis (PIP) is an uncommon yet clinically significant complication of epilepsy that frequently mimics primary psychiatric disorders. Diagnostic challenges are exacerbated when preceding ictal activity is subtle or nonconvulsive, leading to anchoring bias and diagnostic overshadowing in acute settings.

We report the case of a 23-year-old woman who presented to the emergency department following abrupt, paroxysmal episodes of verbal aggression and behavioral dyscontrol. These episodes occurred without observed tonic-clonic activity but were followed by stereotypical periods of exhaustion, confusion, and total amnesia. Although initial assessments by emergency responders and psychiatric consultants leaned toward a primary psychiatric etiology, a comprehensive history revealed a remote seizure disorder secondary to childhood meningioma resection and a significant lapse in antiseizure medication therapy during the transition from pediatric to adult care. Neuroimaging confirmed structural sequelae consistent with prior craniotomy, and electroencephalography identified a focal temporal seizure focus. The clinical presentation was consistent with PIP following unrecognized focal seizures with impaired awareness. Reinitiation of levetiracetam resulted in the immediate and sustained resolution of all behavioral symptoms.

This case underscores the diagnostic pitfalls of neuropsychiatric manifestations of epilepsy, the inherent risk of cognitive bias in emergency medicine, and the critical importance of maintaining a broad differential for acute behavioral disturbances, particularly during high-risk periods of care transition.

Recommended Citation

Chou MM. Postictal Psychosis Following Subtle Nonconvulsive Seizures: A Case Report Highlighting Diagnostic Bias in Acute Care. University of Lynchburg DMSc Doctoral Project Assignment Repository. 2026; 8(1).