Clinical Information Flashcards
What may be seen with the use of benzodiazepines on EEG?
Beta activity
What’s another term used for delirium?
Toxic-metabolic encephalopathy
How can an EEG distinguish between pseudo dementia and dementia?
In pseudodementia the EEG ideally would remain normal, but in dementia from almost any cause, it would show slowing to below 8 Hz
Is an EEG useful for diagnosing psychiatric illnesses?
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.
Can psychotropic medications cause changes in EEGs?
Yes, they are usually minor and nonspecific, but some are prominent and persist for up to two months after medications are withdrawn
Benzodiazepines and barbiturates typically produce what type of activity on EEGs?
Beta activity
Phencyclidine (PCP) and other excitatory drugs cause what type of activity on EEGs?
Generalized, paroxysmal discharges
What type of activity to Phenylthiazines cause on EEG?
Sharp waves
What type of activity on EEGs do lithium at toxic levels, clozapine and tricyclic antidepressants cause?
Spikes and sharp waves
Which antipsychotics generally produce the most EEG changes?
Clozapine, olanzapine and trifluoperazine
Which antipsychotics generally produce the least EEG changes?
Quetiapine, Loxapine and haloperidol
What type of activity does electroconvulsive therapy induce on an EEG?
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.
Which psychiatric illness is more prevalent in epilepsy than in any other chronic neurologic illnesses including Alzheimer’s and Parkinson’s disease?
Depression
It’s prevalence in epilepsy patients ranges between approximately 7.5% and, in intractable seizure patients, 55%
What are some seizure related risk factors for comorbid depression?
Complex partial seizures, onset of epilepsy and late adult years, and, in most studies, frequent seizures
Which four antiepileptic drugs carry a risk for depression and self-destructive behavior?
Levetiracetam (keppra), topiramate (topamax), tiagabine (gabitril), and vigabatrin (sabril)
Which three antiepileptic drugs can be used for patients who are epileptic and depressed?
Carbamazepine, lamotrigine, and valproate
These medications not only help control seizures, but they also increase serotonin levels, thus, they also have mood stabilizing properties
What’s the relationship between Wellbutrin and seizures?
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.
What’s the relationship between Clomipramine and seizures?
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
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?
They produce seizures in less than 0.3% of cases
As a general rule, can psychiatrists administer ECT to patients taking AEDs?
Yes
How did ECT originate?
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
What’s the relationship between epilepsy and bipolar disorder?
Bipolar symptoms in epilepsy patients are uncommon, but occur more frequently than in either the general population or individuals with other medical disorders.
What does mania frequently look like an epileptic patient?
Childish behavior, fluctuating moods, and rapid cycling
How often is anxiety comorbid with epilepsy?
Various studies suggest 20%-60% of cases
How should physicians treat anxiety comorbid with epilepsy?
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
What is the relationship between psychosis and epilepsy?
One can develop postictal or interictal psychosis
What is postictal psychosis?
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
In an epileptic patient, what is the greatest risk factor for postictal psychosis?
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
Interictal psychosis is also loosely called what?
Schizophreniform psychosis or schizophrenia-like psychosis of epilepsy
It’s a chronic condition
When does Interictal psychosis generally arise and epilepsy patients?
When patients are 30-40 years old and their epilepsy began in childhood, especially between 5 and 10 years of age
What are the symptoms of Interictal psychosis?
Persistent hallucinations, paranoia, and social isolation
How does Interictal psychosis compare to true schizophrenic patients?
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
What is the usual daily dose of Lamictal (Lamotrigine)?
100-500 mg per day
What is the usual daily dose of Dilantin (phenytoin)? What’s the therapeutic serum concentration range?
300-400 mg per day
10-20 mcg/mL
What is the usual daily dose of topamax (topiramate)?
400 mg per day
What is the usual daily dose of Carbamazepine (Tegretol)? What’s the therapeutic serum concentration range?
600-1200 mg per day
5-12 mcg/mL
What is the usual daily dose of neurontin (gabapentin)?
900-1800 mg per day
What is the usual daily dose of divalproex (Depakote)? What’s the therapeutic serum concentration range?
1500-2000 mg per day
50-100 mcg/mL
What is the usual daily dose of levetiracetam (keppra)?
1500-3000 mg per day
What is the usual daily dose of Ethosuximide (zarontin)? What’s the therapeutic serum concentration range?
2000 mg per day
40-100 mcg/mL
What may be seen with lithium toxicity on EEG?
Triphasic waves
Do patients with interictal psychosis exhibit neuropathological and/or clinical signs of brain damage?
Yes, their brains have large cerebral ventricles, periventricular gliosis, and focal damage
What is forced normalization? Why is this important for psychiatrist to understand?
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.
What is withdrawal-emergent psychopathology?
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.
Which antipsychotic is more likely to cause seizures in overdose than haloperidol, Thioridazine, and fluphenazine, or any of the new atypical agents?
Chlorpromazine (Thorazine)
What percentage of patients taking more than 600 mg per day of clozapine may experience seizures?
4%
Atypical antipsychotics carry a seizure risk of what percentage?
Less than 1%
How should a physician manage a patient following a medication-induced seizure?
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.
What’s the relationship between epilepsy and suicide?
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.
What are the risk factors for suicide in epilepsy?
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.
What did a landmark 2008 meta-analysis of clinical trials involving antiepileptic drugs suggest? What were the specifics?
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.
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?
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.
What may happen if valproate is added to Lamotrigine?
Lamotrigine may increase to toxic levels leading to delirium
