Postictal psychosis concealed during long-term video-electroencephalographic monitoring and unmasked after discharge: A case report.

Background: Postictal psychosis (PIP) is a serious complication that can follow seizure clusters, including those provoked during long-term video-electroencephalographic monitoring (LTVEM). Early detection and appropriate treatment of PIP are crucial to implement LTVEM safely. However, managing PIP becomes challenging when patients conceal symptoms, and psychotic symptoms are ambiguous. Case Presentation: A female patient in her 30s with drug-resistant mesial temporal lobe epilepsy due to right hippocampal sclerosis underwent LTVEM at an epilepsy center. After seizure clusters occurred on hospital Days 2 and 3, she remained superficially stable apart from subtle psychotic symptoms beginning on hospital Day 4. Despite a thorough psychiatric assessment, she denied any psychotic experiences and was discharged as scheduled on hospital Day 7. Immediately after discharge, however, she displayed overt psychotic symptoms, necessitating emergency involuntary psychiatric admission. Her psychotic symptoms resolved within 16 days of psychiatric hospitalization. Upon recovery, she disclosed that she had concealed her symptoms during LTVEM because auditory command hallucinations had discouraged her from discussing the symptoms with her physicians, and her persecutory delusions, which were directed specifically toward the hospital and medical staff, had fostered a profound mistrust. Conclusion: The present case highlights a diagnostic pitfall caused by overlooking PIP occurring during LTVEM, particularly in patients in whom the psychotic content is directed against the hospital and medical staff. The absence of overt behavioral disturbances does not exclude PIP. Close multidisciplinary collaboration between epileptologists and psychiatrists is essential to ensure the patient's safety.