A Case Report of Psychosis as an Expression of Focal Impaired Awareness Seizure (FIAS) In Elderly Patient

Azeem NC, Saiveri NFA, Izanini ABM and Muhamad-Norie MH

Published on: 2026-03-18

Abstract

Formerly known as complex partial seizures, focal impaired awareness seizures (FIAS) are defined as focal seizures that originate in one hemisphere of the brain and are associated with an impairment of consciousness. FIAS is frequently misdiagnosed as a functional psychiatric disorder due to its affective, behavioral, and cognitive symptoms, especially when there is absence of motor manifestation of seizure or that part of history was omitted. This case portrayed a case of a geriatric patient with FIAS presenting as psychotic and behavioral disturbance.

This case illustrates a 68-year-old lady with a background history of hypertension and hyperlipidemia presented with acute behavioral disturbance associated with auditory hallucinations and persecutory delusion. Detailed history revealed that she has been experiencing recurrent fitting episodes which was described as tonic-clonic seizure with impaired awareness 2 to 3 times a month since about 20 years ago. Notwithstanding, her recurrent episodes of fitting she was still able to fully function independently as well as managing the household. There were no episodes of affective or behavioral disturbance. This year though, the fitting episode became more frequent in which she was also reported to have cognitive decline with episodes of riotous behavioral disturbance and psychosis that lead her to first medical and psychiatry contact.

A thorough clinical assessment is crucial, especially in geriatric patients that exhibits symptoms of psychosis, altered mental state, with concomitant chronic medical conditions. For patients with atypical presentations of seizure disorders, a high index of suspicion is necessary to effectively manage and avoid future seizure episodes, especially when there is no conclusive diagnostic instrument available at the time of seizure activity

Keywords

Focal impaired awareness seizure; Psychosis; Elderly

Introduction

Epilepsy in the elderly has a prevalence of 10.8 per 1,000, with 24% of new-onset epilepsy cases occurring after age 60 [1]. The International League against Epilepsy (ILAE) 2017 classification divides seizures based on three key features: the location of seizure onset, the level of awareness during the seizure, and other accompanying characteristics. Focal impaired awareness seizures (FIAS), previously known as complex partial seizures, begin in one hemisphere of the brain and are marked by impaired consciousness. Focal seizures are further categorized into motor onset (such as automatisms, atonic, clonic, myoclonic, tonic, epileptic spasms, hyperkinetic movements) and nonmotor onset (including autonomic, emotional, sensory, cognitive, and behavior arrest symptoms) [2].

FIAS-type epilepsy affects around 36% of epileptic patients. Although it can afflict persons of any age, children and older adults have the highest incidence [3]. FIAS usually occur in the temporal lobe; however, extratemporal origin has been observed in at least 10% to 30% of patients [4]. The cognitive or psychiatric characteristics of FIAS include deja vu, dissociation, de-personalization or de-realization, and aphasia or dysphasia. Emotional or affective symptoms in FIAS include agitation, hostility, rage, worry, fear, and paranoia, pleasure, sobbing, or laughing [5]. The symptoms may vary depending on which area of the brain they originate from. Simple reactions, such as eye tracking, may be unaffected by FIAS, while higher- order cognitive skills, such as verbal response decision-making, are considerably impaired. The hallmark of FIAS is impaired awareness, resulting in reduced arousal, responsiveness, and alertness.

It has been estimated that 20% to 30% of patients with seizures present with mental disturbance [6]. FIAS is frequently misinterpreted as a functional psychiatric disease because of its affective, behavioral, and cognitive symptoms. These symptoms are frequently associated with other symptoms that are atypical for primary psychiatric disorder, such as macropsia, micropsia, gustatory and olfactory hallucinations, severe, short-lived delusions, and the déjà vu phenomenon [7]. FIAS can be challenging to diagnose in the elderly. This case report describes a distinctive encounter that involved an elderly patient who had FIAS and was experiencing psychosis, significant behavioral disorder, and a state of confusion.

Case Presentation

A 68-year-old woman was brought to the hospital by her family due to sudden onset of an abnormal and aggressive behavior that had begun a week prior. She reported experiencing visual hallucinations, such as seeing a woman walking in her house, and auditory hallucinations, including hearing knocking sounds at night. She responded to these hallucinations, and her behavior progressively worsened. Notably, she engaged in dangerous actions such as pouring boiling water onto the wooden floor, slapping her son, and hitting him with a stick. On the day of presentation, she attempted to stab her son with a knife, leading her family to restrain her before bringing her to the emergency department. Her relatives emphasized that this behavior was entirely out of character, as she had no previous history of such actions. Prior to this, she had been independent, working as a rubber tapper, and managing household responsibilities without issue.

Further history revealed a previously undiagnosed history of recurrent episode of seizures for the past 20 years. According to her caregiver, she had experienced multiple seizure-like episodes, characterized by up-rolling of eyeball, body stiffening, and jerky movements of the limbs. These episodes were typically preceded by lethargy, depersonalization, and dizziness, lasted under five minutes, and resolved spontaneously. Postictal symptoms included drowsiness, but she generally returned to her baseline afterward. There had been no association with psychosis or significant behavioral disturbances during these earlier episodes. Initially occurring two to three times per month, the seizures had become more frequent over the past year, with the patient developing cognitive impairment, mood changes, irritability, and episodic psychosis. The family had not sought treatment earlier due to logistical challenges and the seizures not severely disrupting daily life.

Upon her initial presentation at the emergency department, the patient was agitated and continued to experience visual hallucinations, seeing people laughing at her and believing the doctor was toying with his feet. She was sedated with tranquilizers for agitation control and admitted to the psychiatric ward for stabilization. On the first day of admission, she was excessively sedated from the high dose of Midazolam given prior to her transfer to the ward. As a result, the tranquilizer was withheld, and an antipsychotic was administered. By the second day, she was able to communicate normally but had no recollection of the events leading up to her admission. She was, however, able to explain and identify her previous seizure episodes. Upon regaining consciousness, she was uncertain about what had occurred beforehand, often experiencing drowsiness and body aches. At this point, she is diagnosed with possible peri-ictal psychosis, with a possible neurocognitive disorder. She was been co-managed with medical team. Her antipsychotic medication was tapered down, and she was discharged in a stable condition on a low dose of antipsychotic (Olanzapine 5 mg nightly) and antiepileptic medication (Sodium Valproate 200 mg twice daily), under the care of her family.

Unfortunately, one week after discharge, the patient was readmitted with similar symptoms. Her caregiver reported that after discharge, she had returned to her premorbid state. However, within a few days, she began exhibiting paranoid delusions, especially directed at her husband, and again attempted to stab him. She also wandered around the village and caused disturbances, accusing neighbors of trying to harm her. Two days prior to her readmission, she had two generalized tonic-clonic seizures, with eye-rolling, body stiffness, and jerky limb movements, each lasting under five minutes and resolving spontaneously. Her condition worsened, and her aggression escalated, prompting the family to bring her back to the hospital. Despite claims of medication adherence, her Sodium Valproate level on admission was only 19.62 µg/ml.

During her second admission, which lasted nearly a month, the patient displayed episodic behavioral changes, including irritability without obvious triggers, disorganized behaviors such as spitting, urinating on the floor and bed, and pacing aimlessly. She exhibited paranoid delusions toward the staff, claiming they were detaining her against her will, and spoke irrelevantly at times, displaying disorientation. Her symptoms fluctuated throughout her stay, and during periods of consciousness, she was unable to recall these events. Between the episodic behaviors, the patient did not fully return to her premorbid state. She was observed to be confused and drowsy, appearing sedated most of the time. When fully conscious, some recent memory impairment and attention deficits were noted, although her MMSE score was borderline at 25/30. During the admission, the patient was co-managed with the medical team, as she required medical attention for her co-morbidities in addition to the treatment for Focal Impaired Awareness Seizures (FIAS). Her condition improved significantly once her antiepileptic medications were optimized, in combination with a temporary prescription of benzodiazepines and a low dose of antipsychotics.

In addition to her seizure history, the patient had untreated hypertension and hyperlipidemia. She was also diagnosed with hypertensive cardiomyopathy during this admission, supported by findings of cardiomegaly on chest X-ray, a mildly reduced ejection fraction on echocardiogram, and ECG changes. Given her age and multiple comorbidities, a dementia workup was performed, along with other relevant investigations to see other possible treatable causes of cognitive issues. Serial MMSE will be performed during outpatient follow up to monitor and address the cognitive concerns. Baseline blood tests, including a full blood count, renal and liver function tests, were within normal limits. A dementia workup, including vitamin B12 and folate levels, as well as infectious screenings for HIV, Hepatitis B and C, and syphilis, were all negative or normal. A contrast-enhanced CT brain scan showed multifocal old infarcts in the frontal lobe, left corona radiata, and thalamus, along with extensive periventricular hypodensity consistent with leukoaraiosis. An EEG performed approximately two weeks after discharge revealed a normal awake EEG with a posterior dominant alpha rhythm of 9-10 Hz. The MRI of the brain has been scheduled, but the report is not yet available. During the subsequent clinic visit, the patient was maintaining well with good level of functioning with the treatment provided.

Discussion

The case of this 68-year-old woman highlights the complex and atypical presentation of psychosis in the context of focal impaired awareness seizures (FIAS), particularly in elderly patients. Her 20-year history of undiagnosed seizure-like episodes might initially suggest a benign course. However, seizure semiology can evolve over time, and new symptoms do not preclude a diagnosis of FIAS. Psychotic symptoms in older adults are often attributed to dementia, delirium, mood disorders, or less commonly late-onset schizophrenia, especially when epilepsy has not been diagnosed [8]. Nonetheless, in the presence of a history suggestive of seizure-like episodes, psychosis related to epilepsy should not be ruled out.

Based on a systematic review and meta-analysis, approximately 6% of epilepsy patients have comorbid psychotic illnesses, with an 8-fold increased risk of psychosis compared to the general population [9]. Factors influencing the development of psychosis in individuals with epilepsy include inadequately managed seizures, early onset of epilepsy, structural brain lesions, a left temporal epileptogenic focus, hippocampal sclerosis, neurodevelopmental abnormalities, history of status epilepticus, and familial predisposition to psychosis or affective disorders [10].

Psychosis of epilepsy can manifest as an ictal, postictal, or chronic interictal phenomenon [11]. Psychotic features such as hallucinations, paranoia, and delusional thinking are not uncommon in individuals with epilepsy. These symptoms can occur as postictal psychosis, typically arising after a seizure cluster and lasting for days to months, or as interictal psychosis, which occurs independently between seizure episodes, resembling schizophrenia-like patterns [12]. Ictal psychosis occurs during the seizure itself, presenting with changes in cognition, mood, or psychosis, particularly in focal impaired awareness seizures, often involving the temporal lobe [11]. Notwithstanding, forced normalization is considered, as this theory proposes that psychosis may arise when seizure activity diminishes, possibly as a result of a compensatory mechanism in the brain [11]. In this case, the episodic nature of the patient's hallucinations, delusions, and affective disturbances, which correlate with seizure activity, strongly suggests that her psychiatric symptoms are linked to FIAS.

Epilepsy is the third most common neurological condition in the elderly and is often idiopathic, but it can also result from post-stroke sequelae, dementia, or space-occupying lesions [13]. FIAS, formerly known as complex partial seizures, commonly occurs without secondary generalization in elderly patients, often due to temporal lobe epilepsy, although it can originate from other regions such as the frontal, occipital, or parietal lobes [3]. In elderly patients, epilepsy may present more subtly compared to younger individuals, with cognitive, sensory, and behavioral disturbances, and less commonly with orofacial or hand automatisms. However, post-ictal confusion tends to last longer in the elderly, adding to diagnostic challenges [13]. In this case, the marked disturbances in behavior, paranoia, and possible orofacial automatisms further support the diagnosis of FIAS.

Leukoaraiosis, commonly observed in elderly imaging, is frequently associated with cerebrovascular risk, however, prolonged exposure to untreated seizures can also trigger excitotoxic cascades and neuroinflammatory processes, damaging white matter and disrupting brain plasticity mechanisms [14]. These changes can hinder the brain’s ability to compensate for white matter damage. The patient’s structural brain changes, vascular insults, and neurodegenerative changes likely contributed to the evolution of her seizure semiology. Given the presence of leukoaraiosis, the prognosis is unfavorable, with an increased risk of further cognitive, functional, and behavioral deterioration [15].

The normal EEG findings in this patient do not exclude the presence of epilepsy. Routine EEGs typically capture interictal activity, and FIAS involves transient disruptions in brain network function during seizures, which may not present as overt abnormalities on standard EEGs. The electrical activity of FIAS can be subtle, with brief discharges or rhythmic patterns that may be missed or misinterpreted due to the limitations of scalp electrodes [16]. In a study on late-onset focal epilepsy, standard EEG monitoring captured epileptic changes in only 15-20% of cases, whereas prolonged modalities such as ambulatory EEG detected epileptic activity in 60-70% of cases [15].

Given this patient's history of long-standing untreated seizures, structural brain changes, and co-morbidities, diagnosing and managing her condition is indeed challenging. Cognitive and behavioral changes associated with aging can obscure seizure activity, leading to misdiagnosis of dementia, delirium or psychiatric disorders [17]. However, the likelihood that her psychosis is a manifestation of epilepsy, rather than a primary psychiatric condition, is strengthened by the clear correlation between her psychiatric symptoms and seizure activity. Furthermore, her significant improvement with the optimization of antiepileptic drug therapy suggests that the psychosis is epilepsy-related, underscoring the importance of considering epilepsy in the differential diagnosis of psychiatric symptoms in elderly patients with a history of untreated seizures. It is crucial to ensure that the treatment provided did not expose the patient to additional complications from side effects or drug-drug interactions, given her age and comorbidities.

Conclusion

In conclusion, this case emphasizes the complex interplay between epilepsy and psychiatric symptoms, particularly in elderly patients. The patient’s presentation of psychosis, aggressive behavior, and impairment of awareness, in the context of focal impaired awareness seizures (FIAS), highlights the importance of recognizing epilepsy as a potential cause of psychiatric disturbances. The presence of medical comorbidities adds challenges to the case, requiring a holistic approach in which balances the treatment of psychosis, epilepsy, and comorbidities, while minimizing the risks and ensuring the prevention of recurrence in order to improve patient outcomes and quality of life.

International Journal of Neurobiology