LEVETIRACETAM-ASSOCIATED PSYCHOGENIC NON-EPILEPTIC SEIZURES: A HIDDEN PARADOX
Main Article Content
Keywords
Depression-anxiety stress scales, intelligence quotient, Levetiracetam, psychogenic non-epileptic seizures, video electroencephalogram
Abstract
Objectives
To study the clinical profile and outcome in patients with epilepsy who developed psychogenic non-epileptic
seizures (PNES) associated with levetiracetam (LEV) use.
Methods
In this prospective observational study, conducted over 1 year, 13 patients with epilepsy and PNES, documented by video electroencephalogram (VEEG) while on LEV, were included. Those with past history of psychiatric illnesses were excluded. VEEG, high-resolution magnetic resonance imaging, neuropsychological and psychiatric evaluation were performed. Patients in Group I (07) were treated with psychotherapy, psychiatric medications and immediate withdrawal of LEV while, those in Group II (06) received psychotherapy, anxiolytics and LEV for initial 2 months after which it was stopped. Follow-up period was six months.
Results
Mean (±SD) age of patients was 25 ± 12.28 years; there were 11 (84.62%) females. All were on antiepileptic
agents which included LEV >1000 mg/day, except one. Mean dose of LEV was 1269.23 ± 483.71 mg/day.
Three patient’s scores were suggestive of depression or anxiety; one had both depression and anxiety. Eight
patients had mood disorders; three had a history of emotional abuse or neglect. PNES subsided in all
patients within 1–3 months, only after withdrawal of LEV and did not recur in any after stopping LEV.
Conclusion
LEV can induce PNES in susceptible populations. Awareness of this association is crucial for timely withdrawal of triggering factor and appropriate management. This will reduce inadvertent additional prescription of antiepileptic agents.
To study the clinical profile and outcome in patients with epilepsy who developed psychogenic non-epileptic
seizures (PNES) associated with levetiracetam (LEV) use.
Methods
In this prospective observational study, conducted over 1 year, 13 patients with epilepsy and PNES, documented by video electroencephalogram (VEEG) while on LEV, were included. Those with past history of psychiatric illnesses were excluded. VEEG, high-resolution magnetic resonance imaging, neuropsychological and psychiatric evaluation were performed. Patients in Group I (07) were treated with psychotherapy, psychiatric medications and immediate withdrawal of LEV while, those in Group II (06) received psychotherapy, anxiolytics and LEV for initial 2 months after which it was stopped. Follow-up period was six months.
Results
Mean (±SD) age of patients was 25 ± 12.28 years; there were 11 (84.62%) females. All were on antiepileptic
agents which included LEV >1000 mg/day, except one. Mean dose of LEV was 1269.23 ± 483.71 mg/day.
Three patient’s scores were suggestive of depression or anxiety; one had both depression and anxiety. Eight
patients had mood disorders; three had a history of emotional abuse or neglect. PNES subsided in all
patients within 1–3 months, only after withdrawal of LEV and did not recur in any after stopping LEV.
Conclusion
LEV can induce PNES in susceptible populations. Awareness of this association is crucial for timely withdrawal of triggering factor and appropriate management. This will reduce inadvertent additional prescription of antiepileptic agents.
References
1. Krumholz A, Niedermeyer E. Psychogenic seizures: a clinical study with follow-up data. Neurology 1983;33:498–502.
2. Nash JL. Pseudoseizures: Etiologic and psychotherapeutic considerations. South Med J 1993;86:1248–52.
3. Leis AA, Ross MA, Summers AK. Psychogenic seizures: ictal characteristics and diagnostic pitfalls. Neurology 1992;42:95–9.
4. Direk N, Kulaksizoglu IB, Alpay K, Gurses C. Using personality disorders to distinguish between patients with psychogenic nonepileptic seizures and those with epileptic seizures. Epilepsy Behav 2012;23:138–41.
5. Hendrickson R, Popescu A, Ghearing G, Bagic A. Thoughts, emotions, and dissociative features differentiate patients with epilepsy from patients with psychogenic nonepileptic spells (PNESs). Epilepsy Behav 2015;51:158–62.
6. O’Brien FM, Fortune GM, Dicker P, et al. Psychiatric and neuropsychological profiles of people with psychogenic nonepileptic seizures. Epilepsy Behav 2015;43:39–45.
7. Helmstaedter C, Fritz NE, Kockelmann E, Kosanetzky N, Elger CE. Positive and negative psychotropic effects of levetiracetam. Epilepsy Behav 2008;13:535–41.
8. Mula M, Trimble MR, Sander JW. Are psychiatric adverse events of antiepileptic drugs a unique entity? A study of topiramate and levetiracetam. Epilepsia 2007;48:2322–26.
9. Nakken KO, Eriksson A-S, Lossius R, Johannessen SI. A paradoxical effect of levetiracetam may be seen in both children and adults with refractory epilepsy. Seizure 2003;12:42–6.
10. Anzellotti F, Franciotti R, Zhuzhuni H, D’Amico A, Thomas A, Onofrj M. Nonepileptic seizures under lev-etiracetam therapy: a case report of forced normalization process. Neuropsychiatr Dis Treat 2014;10:959–64.
11. Ignatenco A1, Arzy S, Ghika J, et al. Nonepileptic seizures under levetiracetam therapy. Epilepsy Behav 2010;19:526–7.
12. LaFrance WC, Keitner GI, Papandonatos GD, et al. Pilot pharmacologic randomized controlled trial for psychogenic nonepileptic seizures. Neurology 2010;75:1166–73.
13. Hamilton M. A RATING SCALE FOR DEPRESSION. J Neurol Neurosurg Psychiatr 1960;23:56–62.
14. Hamilton M. The assessment of anxiety states by rating. Br J Med Psychol 1959;32:50–55.
15. [No author listed]. Wechsler Adult Intelligence Scale-Revised. LIST OF TESTS Available from the CPS Testing Library. Center for Psychological Studies at Nova Southeastern University. http://cps.nova.edu/~cpphelp/WAIS-R.html.
16. Malin AJ. Indian adaptation of Weschler's intelligence scale for children. Indian J Mental Retard 1979;4:15–25.
17. Valente KD, Rzezak P, LaFrance WC Jr. Standard medical care for psychogenic nonepileptic seizures in Brazil. Epilepsy Behav 2015;45:128–35.
18. Goyal G, Kalita J, Misra UK. Utility of different seizure induction protocols in psychogenic nonepileptic seizures. Epilepsy Res 2014;108:1120–7.
19. Hubsch C, Baumann C, Hingray C, et al. Clinical classification of psychogenic non-epileptic seizures based on video-EEG analysis and automatic clustering. J Neurol Neurosurg Psychiatr 2011;82:955–60.
20. Bodde NM, Brooks JL, Baker GA, et al. Psychogenic non-epileptic seizures-diagnostic issues: A critical review. Clin Neurol Neurosurg 2009;111:1–9.
21. O’Sullivan SS, Spillane JE, McMahon EM, et al. Clinical characteristics and outcome of patients diagnosed with psychogenic nonepileptic seizures: a 5-year review. Epilepsy Behav 2007;11:77–84.
22. Benbadis SR, Agrawal V, Tatum WO 4th. How many patients with psychogenic nonepileptic seizures also have epilepsy? Neurology 2001;57:915–7.
23. Ramsay RE, Cohen A, Brown MC. Coexisting epilepsy and nonepileptic seizures. In: Gates JR, Rowan AJ, eds. Nonepileptic Seizures. Stoneham, MA: Butterworth-Heinemann;1993.
24. Alsaadi TM, Marquez AV. Psychogenic nonepileptic seizures. Am Fam Physician 2005;72:849–56.
25. Krumholz A, Hopp J. Psychogenic (nonepileptic) seizures. Semin Neurol 2006;26:341–50.
26. Reuber M, Pukrop R, Bauer J, Helmstaedter C, Tessen-dorf N, Elger CE. Outcome in psychogenic nonepileptic seizures: 1 to 10-year follow-up in 164 patients. Ann Neurol 2003;53:305–11.
27. Chabolla DR, Krahn LE, So EL, Rummans TA. Psychogenic nonepileptic seizures. Mayo Clin Proc 1996;71:493–500.
28. Noe KH, Grade M, Stonnington CM, Driver-Dunckley E, Locke DE. Confirming psychogenic nonepileptic seizures with video-EEG: sex matters. Epilepsy Behav 2012;23:220–23.
29. LaFrance WC Jr, Baird GL, Barry JJ, Blum AS, Frank Webb A, Keitner GI, et al. Multicenter pilot treatment trial for psychogenic nonepileptic seizures: a randomized clinical trial. JAMA Psychiatr 2014;71:997–1005.
30. Thompson AW, Hantke N, Phatak V, Chaytor N. The Personality Assessment Inventory as a Tool for diagnosing psychogenic non-epileptic seizures. Epilepsia 2010;51:161–4.
31. Oto M, Espie C, Pelosi A, Selkirk M, Duncan R. The safety of antiepileptic drug withdrawal in patients with non-epileptic seizures. J Neurol Neurosurg Psychiatr 2005;76:1682–5.
32. Moore PM, Baker GA. Non-epileptic attack disorder: a psychological perspective. Seizure 1997;6:429–34.
33. Awad H, Softi? J. Psychical and psychological characteristics of patients with nonepileptic seizures. Med Glas (Zenica) 2011;8(2):224–8.
34. Cherian A, Baheti NN, Menon R, et al. Atonic variant of benign childhood epilepsy with centrotemporal spikes (atonic-BECTS): A distinct electro-clinical syndrome. Brain Dev 2012 Jun;34(6):511–9.
35. Cherian A, Jabeen SA, Kandadai RM, et al. Epilepsy with myoclonic absences in siblings. Brain Dev 2014 Nov;36(10):892–8
36. Galimberti CA, Ratti MT, Murelli R, Marchioni E, Manni R, Tartara A. Patients with psychogenic nonepileptic seizures, alone or epilepsy-associated, share a psychological profile distinct from that of epilepsy patients. J Neurol 2003;250:338–46.
37. Brown RJ, Syed TU, Benbadis S, LaFrance WC Jr, Reuber M. Psychogenic nonepileptic seizures. Epilepsy Behav 2011;22:85–93.
2. Nash JL. Pseudoseizures: Etiologic and psychotherapeutic considerations. South Med J 1993;86:1248–52.
3. Leis AA, Ross MA, Summers AK. Psychogenic seizures: ictal characteristics and diagnostic pitfalls. Neurology 1992;42:95–9.
4. Direk N, Kulaksizoglu IB, Alpay K, Gurses C. Using personality disorders to distinguish between patients with psychogenic nonepileptic seizures and those with epileptic seizures. Epilepsy Behav 2012;23:138–41.
5. Hendrickson R, Popescu A, Ghearing G, Bagic A. Thoughts, emotions, and dissociative features differentiate patients with epilepsy from patients with psychogenic nonepileptic spells (PNESs). Epilepsy Behav 2015;51:158–62.
6. O’Brien FM, Fortune GM, Dicker P, et al. Psychiatric and neuropsychological profiles of people with psychogenic nonepileptic seizures. Epilepsy Behav 2015;43:39–45.
7. Helmstaedter C, Fritz NE, Kockelmann E, Kosanetzky N, Elger CE. Positive and negative psychotropic effects of levetiracetam. Epilepsy Behav 2008;13:535–41.
8. Mula M, Trimble MR, Sander JW. Are psychiatric adverse events of antiepileptic drugs a unique entity? A study of topiramate and levetiracetam. Epilepsia 2007;48:2322–26.
9. Nakken KO, Eriksson A-S, Lossius R, Johannessen SI. A paradoxical effect of levetiracetam may be seen in both children and adults with refractory epilepsy. Seizure 2003;12:42–6.
10. Anzellotti F, Franciotti R, Zhuzhuni H, D’Amico A, Thomas A, Onofrj M. Nonepileptic seizures under lev-etiracetam therapy: a case report of forced normalization process. Neuropsychiatr Dis Treat 2014;10:959–64.
11. Ignatenco A1, Arzy S, Ghika J, et al. Nonepileptic seizures under levetiracetam therapy. Epilepsy Behav 2010;19:526–7.
12. LaFrance WC, Keitner GI, Papandonatos GD, et al. Pilot pharmacologic randomized controlled trial for psychogenic nonepileptic seizures. Neurology 2010;75:1166–73.
13. Hamilton M. A RATING SCALE FOR DEPRESSION. J Neurol Neurosurg Psychiatr 1960;23:56–62.
14. Hamilton M. The assessment of anxiety states by rating. Br J Med Psychol 1959;32:50–55.
15. [No author listed]. Wechsler Adult Intelligence Scale-Revised. LIST OF TESTS Available from the CPS Testing Library. Center for Psychological Studies at Nova Southeastern University. http://cps.nova.edu/~cpphelp/WAIS-R.html.
16. Malin AJ. Indian adaptation of Weschler's intelligence scale for children. Indian J Mental Retard 1979;4:15–25.
17. Valente KD, Rzezak P, LaFrance WC Jr. Standard medical care for psychogenic nonepileptic seizures in Brazil. Epilepsy Behav 2015;45:128–35.
18. Goyal G, Kalita J, Misra UK. Utility of different seizure induction protocols in psychogenic nonepileptic seizures. Epilepsy Res 2014;108:1120–7.
19. Hubsch C, Baumann C, Hingray C, et al. Clinical classification of psychogenic non-epileptic seizures based on video-EEG analysis and automatic clustering. J Neurol Neurosurg Psychiatr 2011;82:955–60.
20. Bodde NM, Brooks JL, Baker GA, et al. Psychogenic non-epileptic seizures-diagnostic issues: A critical review. Clin Neurol Neurosurg 2009;111:1–9.
21. O’Sullivan SS, Spillane JE, McMahon EM, et al. Clinical characteristics and outcome of patients diagnosed with psychogenic nonepileptic seizures: a 5-year review. Epilepsy Behav 2007;11:77–84.
22. Benbadis SR, Agrawal V, Tatum WO 4th. How many patients with psychogenic nonepileptic seizures also have epilepsy? Neurology 2001;57:915–7.
23. Ramsay RE, Cohen A, Brown MC. Coexisting epilepsy and nonepileptic seizures. In: Gates JR, Rowan AJ, eds. Nonepileptic Seizures. Stoneham, MA: Butterworth-Heinemann;1993.
24. Alsaadi TM, Marquez AV. Psychogenic nonepileptic seizures. Am Fam Physician 2005;72:849–56.
25. Krumholz A, Hopp J. Psychogenic (nonepileptic) seizures. Semin Neurol 2006;26:341–50.
26. Reuber M, Pukrop R, Bauer J, Helmstaedter C, Tessen-dorf N, Elger CE. Outcome in psychogenic nonepileptic seizures: 1 to 10-year follow-up in 164 patients. Ann Neurol 2003;53:305–11.
27. Chabolla DR, Krahn LE, So EL, Rummans TA. Psychogenic nonepileptic seizures. Mayo Clin Proc 1996;71:493–500.
28. Noe KH, Grade M, Stonnington CM, Driver-Dunckley E, Locke DE. Confirming psychogenic nonepileptic seizures with video-EEG: sex matters. Epilepsy Behav 2012;23:220–23.
29. LaFrance WC Jr, Baird GL, Barry JJ, Blum AS, Frank Webb A, Keitner GI, et al. Multicenter pilot treatment trial for psychogenic nonepileptic seizures: a randomized clinical trial. JAMA Psychiatr 2014;71:997–1005.
30. Thompson AW, Hantke N, Phatak V, Chaytor N. The Personality Assessment Inventory as a Tool for diagnosing psychogenic non-epileptic seizures. Epilepsia 2010;51:161–4.
31. Oto M, Espie C, Pelosi A, Selkirk M, Duncan R. The safety of antiepileptic drug withdrawal in patients with non-epileptic seizures. J Neurol Neurosurg Psychiatr 2005;76:1682–5.
32. Moore PM, Baker GA. Non-epileptic attack disorder: a psychological perspective. Seizure 1997;6:429–34.
33. Awad H, Softi? J. Psychical and psychological characteristics of patients with nonepileptic seizures. Med Glas (Zenica) 2011;8(2):224–8.
34. Cherian A, Baheti NN, Menon R, et al. Atonic variant of benign childhood epilepsy with centrotemporal spikes (atonic-BECTS): A distinct electro-clinical syndrome. Brain Dev 2012 Jun;34(6):511–9.
35. Cherian A, Jabeen SA, Kandadai RM, et al. Epilepsy with myoclonic absences in siblings. Brain Dev 2014 Nov;36(10):892–8
36. Galimberti CA, Ratti MT, Murelli R, Marchioni E, Manni R, Tartara A. Patients with psychogenic nonepileptic seizures, alone or epilepsy-associated, share a psychological profile distinct from that of epilepsy patients. J Neurol 2003;250:338–46.
37. Brown RJ, Syed TU, Benbadis S, LaFrance WC Jr, Reuber M. Psychogenic nonepileptic seizures. Epilepsy Behav 2011;22:85–93.
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Published
Jul 11, 2018
Article Details
How to Cite
Jabeen, S. A., Gaddamanugu, P., Cherian, A., Mridula, K. R., Kumar, D. U., & Meena, A. kanikannan. (2018). LEVETIRACETAM-ASSOCIATED PSYCHOGENIC NON-EPILEPTIC SEIZURES: A HIDDEN PARADOX. Journal of Population Therapeutics and Clinical Pharmacology, 25(2), e1-e11. https://doi.org/10.22374/1710-6222.25.2.1
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Author Biography
Shaik Afshan Jabeen, Deptartment of Neurology Nizam’s Institute of Medical Sciences, Hyderabad, India.
Assistant Professor
How to Cite
Jabeen, S. A., Gaddamanugu, P., Cherian, A., Mridula, K. R., Kumar, D. U., & Meena, A. kanikannan. (2018). LEVETIRACETAM-ASSOCIATED PSYCHOGENIC NON-EPILEPTIC SEIZURES: A HIDDEN PARADOX. Journal of Population Therapeutics and Clinical Pharmacology, 25(2), e1-e11. https://doi.org/10.22374/1710-6222.25.2.1