Electroconvulsive therapy for refractory interictal psychosis in focal epilepsy

Introduction

Epilepsy and psychosis intersect through shared alterations in cortico-limbic excitability, salience attribution, inhibitory control and temporo-frontal network dynamics. Psychosis may be classified according to its temporal relationship with seizures, with interictal psychosis typically presenting as a chronic, seizure-independent syndrome. Electroconvulsive therapy (ECT) remains underused in this context because it intentionally induces a generalised tonic–clonic seizure, despite evidence that repeated ECT may raise seizure threshold and exert anticonvulsant and neuroplastic effects. We report a case illustrating the clinical reasoning, safety considerations and therapeutic value of ECT for severe pharmacoresistant interictal psychosis in focal epilepsy.

Methods

We present a case report based on longitudinal inpatient observation, review of psychiatric and neurological history, serial mental state examinations, electroencephalographic data, structural neuroimaging data, psychopharmacological treatment response, and multidisciplinary risk–benefit discussion. The discussion is supported by a targeted literature review focusing on epilpesy-associated psychosis. The clinical formulation considered the temporal relationship between psychotic symptoms and epileptic seizures, treatment resistance, tolerability of dopamine D2 receptor blockade, catatonia vulnerability and the safety requirements for ECT in the context of focal epilepsy.

Case summary:
A 46-year-old man with refractory focal epilepsy since early childhood, associated with a right posterior fronto-mesial cortico-subcortical lesion and suspected focal cortical dysplasia, had mild intellectual developmental disorder and early small-vessel cerebrovascular disease. He had been free of clinical seizures for several months, with repeated electroencephalograms showing no epileptiform activity. Over more than ten years, he developed a chronic psychotic syndrome temporally unrelated to ictal events, initially characterised by persecutory delusions and later by second- and third-person auditory verbal hallucinations. He was admitted after hiding in a municipal building because he believed he was being threatened by snipers and explosives. During a prolonged admission, complicated by recurrent infection, sepsis, Clostridioides difficile diarrhoea, extended isolation, sarcopenia and depressive-apathic symptoms, psychosis remained severe. Trials included aripiprazole, risperidone , amisulpride, olanzapine, and clozapine. Clozapine reached therapeutic plasma concentrations but produced only partial improvement. Antipsychotic titration was limited by extrapyramidal and fluctuating catatonic features. Following multidisciplinary discussion, ECT was proposed as augmentation for treatment-resistant interictal psychosis, with careful review of antiseizure medication to balance spontaneous seizure prevention, seizure threshold and ECT efficacy. An acute course of 18 treatments was delivered in an intensive-to-standard schedule. The patient showed marked global improvement: remission of hallucinations, residual low-dynamism delusional activity without behavioural impact, improved motor and affective symptoms, euthymic mood, preserved affective reactivity, coherent spontaneous speech and clinical stabilisation permitting discharge.

Conclusions

This case supports ECT as a valuable neuromodulatory option for selected patients with epilepsy-associated refractory interictal psychosis, particularly when antipsychotic optimisation is constrained by catatonia or extrapyramidal burden. Epilepsy should not be regarded as an absolute contraindication to ECT. Treatment requires explicit seizure-threshold planning, rational adjustment of antiseizure medication, EEG-informed neurological collaboration and ongoing psychiatric risk assessment. Larger prospective studies are needed to clarify predictors of response, cognitive safety and relapse-prevention strategies in this neglected neuropsychiatric population.

References

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