Clinical Information

Question 1

What may be seen with the use of benzodiazepines on EEG?

Answer 1

Beta activity

Question 2

What’s another term used for delirium?

Answer 2

Toxic-metabolic encephalopathy

Question 3

How can an EEG distinguish between pseudo dementia and dementia?

Answer 3

In pseudodementia the EEG ideally would remain normal, but in dementia from almost any cause, it would show slowing to below 8 Hz

Question 4

Is an EEG useful for diagnosing psychiatric illnesses?

Answer 4

No, EEGs do not show abnormalities consistently enough to indicate psychiatric illness. In uncomplicated psychiatric illness a normal pattern will be seen or frequently only minor, nonspecific abnormalities, such as excessive beta or theta activity, a few sharp waves or spikes, or poor organization.

Question 5

Can psychotropic medications cause changes in EEGs?

Answer 5

Yes, they are usually minor and nonspecific, but some are prominent and persist for up to two months after medications are withdrawn

Question 6

Benzodiazepines and barbiturates typically produce what type of activity on EEGs?

Answer 6

Beta activity

Question 7

Phencyclidine (PCP) and other excitatory drugs cause what type of activity on EEGs?

Answer 7

Generalized, paroxysmal discharges

Question 8

What type of activity to Phenylthiazines cause on EEG?

Answer 8

Sharp waves

Question 9

What type of activity on EEGs do lithium at toxic levels, clozapine and tricyclic antidepressants cause?

Answer 9

Spikes and sharp waves

Question 10

Which antipsychotics generally produce the most EEG changes?

Answer 10

Clozapine, olanzapine and trifluoperazine

Question 11

Which antipsychotics generally produce the least EEG changes?

Answer 11

Quetiapine, Loxapine and haloperidol

Question 12

What type of activity does electroconvulsive therapy induce on an EEG?

Answer 12

During and immediately after ECT, EEG changes resemble those of a generalized tonic-clonic seizure and its aftermath. Slow wave activity develops over the frontal lobe or the entire cerebrum and persist for up to three months. When ECT is unilateral, the slowing is less pronounced and more restricted to the treated side.

Question 13

Which psychiatric illness is more prevalent in epilepsy than in any other chronic neurologic illnesses including Alzheimer’s and Parkinson’s disease?

Answer 13

Depression

It’s prevalence in epilepsy patients ranges between approximately 7.5% and, in intractable seizure patients, 55%

Question 14

What are some seizure related risk factors for comorbid depression?

Answer 14

Complex partial seizures, onset of epilepsy and late adult years, and, in most studies, frequent seizures

Question 15

Which four antiepileptic drugs carry a risk for depression and self-destructive behavior?

Answer 15

Levetiracetam (keppra), topiramate (topamax), tiagabine (gabitril), and vigabatrin (sabril)

Question 16

Which three antiepileptic drugs can be used for patients who are epileptic and depressed?

Answer 16

Carbamazepine, lamotrigine, and valproate

These medications not only help control seizures, but they also increase serotonin levels, thus, they also have mood stabilizing properties

Question 17

What’s the relationship between Wellbutrin and seizures?

Answer 17

The incidence of seizures with bupropion immediate-release formulations at up to 400 mg daily is less than 1%, but at higher doses, the incidence rises to unacceptable levels.

Question 18

What’s the relationship between Clomipramine and seizures?

Answer 18

Clomipramine led to seizures in 1.5% of patients taking 300mg or less per day. This relatively high rate represents clomipramines most significant adverse reaction

Question 19

While Tricyclic antidepressants and heterocyclic antidepressants have relatively high rates of seizures associated with them, MAOIs, SSRIs, and SNRIs have what type of relationship with seizures?

Answer 19

They produce seizures in less than 0.3% of cases

Question 20

As a general rule, can psychiatrists administer ECT to patients taking AEDs?

Answer 20

Yes

Question 21

How did ECT originate?

Answer 21

With the observation that depressed epileptic patients mood improved after a seizure. That benefit lead to physicians inducing hypoglycemic seizures by injections of large amounts of insulin

Question 22

What’s the relationship between epilepsy and bipolar disorder?

Answer 22

Bipolar symptoms in epilepsy patients are uncommon, but occur more frequently than in either the general population or individuals with other medical disorders.

Question 23

What does mania frequently look like an epileptic patient?

Answer 23

Childish behavior, fluctuating moods, and rapid cycling

Question 24

How often is anxiety comorbid with epilepsy?

Answer 24

Various studies suggest 20%-60% of cases

Question 25

How should physicians treat anxiety comorbid with epilepsy?

Answer 25

You can be treated with benzodiazepines, as well as with antidepressants, because benzodiazepines have antiepileptic effects. However, abrupt withdrawal from benzodiazepines may precipitate seizures that lead to status epilepticus

Question 26

What is the relationship between psychosis and epilepsy?

Answer 26

One can develop postictal or interictal psychosis

Question 27

What is postictal psychosis?

Answer 27

A thought disorder which characteristically emerges after several hours to several days of clear sensorium and minimal symptoms ("lucid interval") following one or usually more seizures. It consists of hours to two weeks of hallucinations, delusions, agitation, and occasionally violence. Depending on severity, patients usually require administration of benzodiazepines or antipsychotics

Question 28

In an epileptic patient, what is the greatest risk factor for postictal psychosis?

Answer 28

A preceding flurry of seizures – tonic-clonic, complex partial seizures, or both – in patients with chronic epilepsy. Up to 7% of complex partial seizures refractory to AED's lead to postictal psychosis

Question 29

Interictal psychosis is also loosely called what?

Answer 29

Schizophreniform psychosis or schizophrenia-like psychosis of epilepsy It's a chronic condition

Question 30

When does Interictal psychosis generally arise and epilepsy patients?

Answer 30

When patients are 30-40 years old and their epilepsy began in childhood, especially between 5 and 10 years of age

Question 31

What are the symptoms of Interictal psychosis?

Answer 31

Persistent hallucinations, paranoia, and social isolation

Question 32

How does Interictal psychosis compare to true schizophrenic patients?

Answer 32

Unlike typical schizophrenia patients, epilepsy patients with interictal psychosis retain a relatively normal affect, do not deteriorate, and do not have an increased incidence of schizophrenia in their families

Question 33

What is the usual daily dose of Lamictal (Lamotrigine)?

Answer 33

100-500 mg per day

Question 34

What is the usual daily dose of Dilantin (phenytoin)? What's the therapeutic serum concentration range?

Answer 34

300-400 mg per day 10-20 mcg/mL

Question 35

What is the usual daily dose of topamax (topiramate)?

Answer 35

400 mg per day

Question 36

What is the usual daily dose of Carbamazepine (Tegretol)? What's the therapeutic serum concentration range?

Answer 36

600-1200 mg per day 5-12 mcg/mL

Question 37

What is the usual daily dose of neurontin (gabapentin)?

Answer 37

900-1800 mg per day

Question 38

What is the usual daily dose of divalproex (Depakote)? What's the therapeutic serum concentration range?

Answer 38

1500-2000 mg per day 50-100 mcg/mL

Question 39

What is the usual daily dose of levetiracetam (keppra)?

Answer 39

1500-3000 mg per day

Question 40

What is the usual daily dose of Ethosuximide (zarontin)? What's the therapeutic serum concentration range?

Answer 40

2000 mg per day 40-100 mcg/mL

Question 41

What may be seen with lithium toxicity on EEG?

Answer 41

Triphasic waves

Question 42

Do patients with interictal psychosis exhibit neuropathological and/or clinical signs of brain damage?

Answer 42

Yes, their brains have large cerebral ventricles, periventricular gliosis, and focal damage

Question 43

What is forced normalization? Why is this important for psychiatrist to understand?

Answer 43

Forced normalization follows a change in the patient's antiepileptic drug regimen that completely suppresses abnormal EEG activity and eliminates long-standing seizures. Patients, then suddenly seizure-free, occasionally developed either psychosis or depression. Some researchers propose that the seizures, while troublesome, had suppressed a thought or mood disorder, perhaps through an ECT-like mechanism. This mechanism is unclear, therefore physicians should monitor patients who rapidly achieve complete seizure control.

Question 44

What is withdrawal-emergent psychopathology?

Answer 44

This is a phenomenon that occurs after physicians or patients suddenly discontinue antiepileptic drugs and psychiatric disorders, particularly anxiety or depression, appear. Neurologists have postulated that, in patients with withdrawal-emergent psychopathology, the antiepileptic drugs had suppressed a latent psychiatric disorder along with the epilepsy.

Question 45

Which antipsychotic is more likely to cause seizures in overdose than haloperidol, Thioridazine, and fluphenazine, or any of the new atypical agents?

Answer 45

Chlorpromazine (Thorazine)

Question 46

What percentage of patients taking more than 600 mg per day of clozapine may experience seizures?

Answer 46

4%

Question 47

Atypical antipsychotics carry a seizure risk of what percentage?

Answer 47

Less than 1%

Question 48

How should a physician manage a patient following a medication-induced seizure?

Answer 48

Prescribe a different antipsychotic or slowly reintroduce the original one. If the patient requires clozapine or other seizure-inducing antipsychotic, physicians may offer some protection by simultaneously adding an antiepileptic drug.

Question 49

What's the relationship between epilepsy and suicide?

Answer 49

Suicide occurs 4-5 times more frequently in all epilepsy patients and 25 times more frequently in those with complex partial seizures than in the general population.

Question 50

What are the risk factors for suicide in epilepsy?

Answer 50

Psychotic disturbances, borderline personality disorder, and other interictal psychopathology, as well as risk factors present in the general population, including depression, poor physical health, life stress, previous suicide attempts, and access to firearms.

Question 51

What did a landmark 2008 meta-analysis of clinical trials involving antiepileptic drugs suggest? What were the specifics?

Answer 51

It's suggested an iatrogenic component It found that, among epilepsy patients, AED's represented almost a twofold risk factor for "suicidality" (suicide acts or ideation). Suicidality was greater in patients taking AED's for epilepsy than for other indications, including mood stabilization, and among individuals taking multiple AED rather than a single AED.

Question 52

Contrary to the landmark 2008 meta-analysis of clinical trials involving AEDs that suggested an iatrogenic component associated with suicide, what did other studies suggest?

Answer 52

Subsequent studies found that only certain AED's, such as those associated with causing depressive symptoms, placed epilepsy patients at risk. In sharp contrast to the 2008 study, Arana et al., in an equally credible study, determined that AED posed no risk of suicidality in patients with epilepsy.

Question 53

What may happen if valproate is added to Lamotrigine?

Answer 53

Lamotrigine may increase to toxic levels leading to delirium