by Robert S. Fisher, M.D., Ph.D.
Editor-in-Chief

The following quote is from a 22 year-old ski instructor with epilepsy.

For the following two days after that seizure, I just kinda feel out of it, although physically I continue with my daily duties. I cannot, for those two days, remember to call friends, to do things like I normally would, and I just kinda stay at home and perform things at home. The ideas don't come in as fast as they normally would to do things. Energy level during those two days is way down. My mood is kind of just down and I kinda enjoy being by myself.

Definition: In the ancient Greek language, a seizure was called "ictal," and so the time period after a seizure is "postictal." For some people with epilepsy, the aftermath of a seizure is worse than the seizure itself. The seizure may last a minute, but the recovery to normal functioning can take hours or even days. The quote above illustrates three possible aspects of the postictal state: physical, cognitive (thinking) and psychiatric problems.

Physical problems are the most obvious. Tonic-clonic (grand mal) seizures often produce muscle soreness, bruises and other injuries, or a bitten tongue. Complex partial and other seizures can lead to headaches, dizziness, stomach upset and fatigue. A prolonged seizure in one part of the body, for example, the right arm, can leave that arm partly paralyzed for hours or days. This phenomenon is called Todd’s paralysis, after a 19th century British physician who described it. A seizure and resulting paralysis rightly cause patients, doctors and families to worry about an underlying stroke; yet, the temporary paralysis can result from a seizure alone, in which case it will have no lasting consequences.

Postictal thinking problems come on suddenly and resolve over time. In the immediate aftermath of a seizure, a person may not be able to speak, recognize his/her own name or follow instructions. Fortunately, this severe disability usually lasts only minutes. Then the person seems to be mentally recovered. But are they? A less obvious impairment of thinking may in fact continue for days. The head seems "fuzzy," words are elusive, level of absent-mindedness is high. Some patients have likened it to having a hangover. For those who have prolonged postictal impairment of thinking, it must take a great effort to function well at work or school.

Postictal psychiatric problems are least often recognized. These include delirium, depression, mania and postictal psychosis. Postictal psychiatric symptoms can be very debilitating, even when temporary. Delirium is a condition of disorientation, sometimes with agitation and occasionally aggressive behavior. It is common immediately after a complex partial or generalized tonic-clonic seizure. Postictal depression is under-recognized. Brain chemistry changes produced by a seizure and affecting the system of neurotransmitters and receptors also contribute to postictal depression. The mood can be low for days. A component of postictal depression may be a reaction to problems caused by having the seizure, for example, suspension of driving, or the need to take more medicines. For poorly understood reasons, some people develop postictal hypomania, the opposite of depression. Mood may be inappropriately happy or excited, words and ideas, not all of which are logical, may come in a torrent. Sleep is near impossible. Beneath this increased energy often lies irritability and a temper on a short fuse. The mood may swing between depression and hypomania.

Postictal Psychosis: The most mysterious and troublesome seizure aftermath is a condition called postictal psychosis. In psychosis, a person is out of touch with reality, experiencing illogical thinking, sometimes paranoid suspicions, delusions (false ideas) or hallucinations (false perceptions, visions, sounds, voices, skin sensations or smells). Onset of a postictal psychosis is delayed for a few days after a seizure, providing a so-called "lucid interval." Postictal psychosis typically persists for a few days to a few weeks. It can be treated symptomatically with antipsychotic medications, sedatives and lot of reassurance that it will go away.

As a rough estimate based on personal experience and review of literature, about 75 percent of people with seizures will after at least one of their seizures experience postictal delirium, 50 percent some element of postictal depression or hypomania and 3 percent postictal psychosis.

What can be done? The first need is to recognize the existence of a postictal condition. You are not necessarily to blame for acting and feeling the way you do after a seizure. It is part of your medical condition. Second, know your own pattern, and adapt your routine to allow time for recovery. Don't make that Grand Canyon climb right after a seizure. Take a break from work or school rather than turning in a befuddled performance. Third, get help from your medical team if you have injuries, ongoing pain, extreme or prolonged confusion (in this case, the seizures may not yet be fully over), or any symptoms of psychosis. So far, the treatment for postictal problems is symptomatic. We have no drug to safely and reliably reverse the condition, and this is a subject in much need of more research. Lastly, do your best to control your seizures: no seizures — no postictal state.

The unintentional philosopher and baseball catcher, Yogi Berra, pointed out "It ain’t over till it's over." The effects of seizures may not be over for a long time.

Submitted 7/31/2009