By: Annemarie DeChellis
What is the Postictal State?
Symptoms and Prevalence
The postictal state is the recovery period following a seizure where the patient may experience cognitive deficits, behavior changes, and psychiatric symptoms (Pottkamper et al., 2020). Headaches and cognitive impairment, such as problems with attention and trouble thinking clearly are reported most often. On average about 75% of people with epilepsy experience postictal psychiatric symptoms, and about 82% experience cognitive impairments during the postictal state (Fisher & Schachter, 2000; Josephone et al., 2016; Kanner, Soto, & Gross-Kanner, 2004; Krauss & Theodore, 2010; Pottkamper et al., 2020). Additional symptoms include depression, fatigue, neurovegetative states, anxiety, confusion, memory problems, and postictal psychosis (Devinsky, 2008; Fisher & Engel, 2010; Fisher & Schachter, 2000; Kanner, Soto, & Gross-Kanner, 2004; Kiriakopoulos & Shafer, 2017). Postictal psychosis is a relatively common and treatable mental state characterized by hallucinations, delirium, paranoia, mood disturbances, and disordered thoughts developing after a seizure or cluster of seizures (Morrow, Lafayette, Bromfield, & Fricchione, 2006; Logsdail & Toone, 1988).
Causes and Risk Factors
The postictal state is thought to occur due to changes that take place in the brain following a seizure. These changes can be in electrophysiology (e.g., “neural exhaustion”), cerebral blood flow, and neurotransmitter systems and receptors (Fisher & Schachter, 2000; Gursahani & Gupta, 2012). The different neural chemical and electrical reactions that take place as a seizure progresses into the postictal state become apparent with the onset of symptoms. Interestingly, the specific set of symptoms may provide insight to seizure localization in the brain (Fisher & Schachter, 2000).
Genetic predispositions to psychiatric disorders may increase the likelihood of developing postictal psychiatric symptoms such as depression and psychosis (Devinsky, 2008; Kanner, Soto, & Gross-Kanner, 2004). If you have epilepsy and are aware of a psychiatric history in your family, it may be beneficial to discuss this with your doctor.
Duration
On average, postictal symptoms persist for about 24 hours. However, there have been difficulties creating a standard definition for postictal state in general due to the variation in symptom duration and severity. Some patients report no postictal symptoms, while others have reported symptoms lasting days after a seizure (Fisher & Schachter, 2000; Kanner, Soto, & Gross-Kanner, 2004). While the majority of literature concerning the length of postictal symptoms is derived from self-reported data, one study found attention deficits, measured by reaction time, persisted for about 24 hours after a seizure (Aldenkamp & Bodde, 2005). Furthermore, determining the onset of the postictal phase can be difficult in seizures with subtle symptoms such as complex partial seizures. Sometimes the presence of postictal symptoms may be the only indicator that someone had a seizure (Fisher & Schachter, 2000; Fisher & Engel, 2010).
Physical, Psychological, and Social Recovery
While psychiatric and cognitive postictal symptoms are common for all types of seizures, people who have seizures that involve muscle spasms and contractions (e.g. tonic-clonic seizures) may have to recover physically after a seizure. For example, after a tonic-clonic seizure, a person may experience muscle soreness, injury from biting the tongue or cheeks, and/or injuries from falling or collapsing (John Hopkins, n.d; Kiriakopoulos & Shafer, 2017). Additional medications, e.g., benzodiazepines, are administered if a seizure does not resolve on it’s own or there is risk of recurrent seizures (Kodankandath, Theodore, & Samanta, 2021; Shafer & Hoerth, 2019). Benzodiazepines can have adverse side effects such as drowsiness, confusion, amnesia, and cognitive impairment, which the patient will need additional recovery from(Riss et al., 2008).
People with epilepsy may find themselves having to recover socially as well. People often feel embarrassed after having a seizure in public among friends, colleagues, or classmates (John Hopkins, n.d.). Reports of depression increase after a seizure not only due to the impact on neurotransmitter systems but also to the social consequences of having a seizure (Fisher & Schachter, 2000).
The Long-Term Impact of Postictal Symptoms
Postictal symptoms can interfere with all aspects of daily life from work, school, and social activities to household chores and personal hygiene. Postictal psychiatric and cognitive symptoms can also hinder someone’s ability to live independently and find employment (Josephson et al., 2016). Moreover, the risk of negative social outcomes, cognitive distress, and poor quality of life increases with the time it takes for someone to fully recover and feel “back to normal” following a seizure (Vickrey et al., 2000).
Conclusion
Further research and educating the public are two necessary steps that will help combat the negative outcomes associated with prolonged seizure recovery. Research aimed to understand the postictal state could provide insight to when it is safe for people to return to normal activities after a seizure. In addition, research highlighting the neurological mechanisms responsible for positcal cognitive and psychiatric symptoms may provide support for people in need of workplace and academic accommodations. Finally, bringing attention to the unseen challenges people with epilepsy face at both the neurological and social level, will enable others to respond with compassion and understanding when someone is recovering from a seizure.
References
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Fisher, R.S. & Schachter, S.C. (2000). The postictal state: A neglected entity in the management of epilepsy. Epilepsy & Behavior, 1(1), 52-9.
Gursahani, R., & Gupta, N. (2012). The adolescent or adult with generalized tonic-clonic seizures. Annals of Indian Academy of Neurology, 15(2), 81-88.
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