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Levetiracetam-Associated Psychogenic Non-Epileptic Seizures

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Levetiracetam-Associated Psychogenic Non-Epileptic Seizures Original Research DOI: 10.22374/1710-6222.25.2.1 LEVETIRACETAM-ASSOCIATED PSYCHOGENIC NON-EPILEPTIC SEIZURES: A HIDDEN PARADOX Shaik Afshan Jabeen,1 Padmaja Gaddamanugu,1 Ajith Cherian,2 Kandadai Rukmini Mridula,2 Dasari Uday Kumar,1 Angamuttu kanikannan Meena1 1Deptartment of Neurology Nizam’s Institute of Medical Sciences, Hyderabad, India. 2Department of Neurology, Sree Chitra Tirunal Institute of Medical Sciences. Thiruvananthapuram, India. Corresponding Author: [email protected] Submitted: August 16, 2017. Accepted: May 31, 2018. Published: June 15, 2018. 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, docu- mented by video electroencephalogram (VEEG) while on LEV, were included. Those with past history of psychiatric illnesses were excluded. VEEG, high-resolution magnetic resonance imaging, neuropsychologi- cal 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 psy- chotherapy, 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. J Popul Ther Clin Pharmacol Vol 25(2):1-11; June 15, 2018. This article is distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International License. Author Retained Copyright e1 Levetiracetam-Associated Psychogenic Non-epileptic Seizures 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 withdrawl 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 with- drawal of triggering factor and appropriate management. This will reduce inadvertent additional prescrip- tion of antiepileptic agents. Psychogenic non-epileptic seizure (PNES) is an METHODS observable abrupt paroxysmal change in behaviour or consciousness that are similar to an epileptic seizure, Patients but not accompanied by changes in the electroen- This prospective study was undertaken by the De- cephalogram (EEG) that accompany an epileptic seizure. partment of Neurology, Nizams Institute of Medical An epileptic seizure is a clinical diagnosis, based on Sciences, Hyderabad, India, a tertiary referral centre. the entirety of the clinical and para-clinical findings. The study group consisted of a series of patients diag- Generally, positive evidence or strong suspicion for nosed to have PNES causatively associated with LEV psychogenic factors that may have caused are noted use, treated by a single neurologist between January in PNES.1–3 Presence of an underlying personality 2015 and December 2015. disorder is suggested to be a significant predictor of Diagnosis of PNES was as defined by LaFrance et 12 the disease.4 Emotional dysregulation, dissociations, al. Patients were included if they had a definite past abuse and cognitive disturbances are more frequently history of epilepsy and PNES documented by video seen in patients with PNES.5,6 electroencephalogram (VEEG) while receiving LEV Use of levetiracetam (LEV) is increasing in the either as a monotherapy or as an adjuvant with other management of epilepsy. Though it has a better antiepileptic drugs. Patients having a strong correla- safety profile, physicians need to be aware of its tion between the onset of PNES during addition or consider-able association with behavioural recent increase in the dose of LEV and those in whom changes, which may manifest as psychosis.7,8 A there was subsidence of PNES after discontinuation paradoxical effect of LEV with exacerbation of of LEV were also included. Patients with past his- true seizures is well documented9but very few case tory of psychiatric illness, PNES and those in whom reports of emergence of non-epileptic seizures are detailed neuropsychological functions could not be available.10,11 There is a high incidence of PNES in performed were excluded. patients treated with LEV. In such patients, PNES All patients underwent VEEG, high-resolution could either be stopped, or reduced significantly magnetic resonance imaging (MRI), neuro-psycho- after discontinuation of the drug along with logical and psychiatric evaluation. Details of seizure supportive psychiatric treatment. semiology of both true and PNES, including dura- PNES is a condition where diagnosis is more tion, type, medications, patient & family history, and challenging and delay in diagnosis may result in clinical response to treatment (stoppage of LEV and further addition of antiepileptic agents. Early diag- psychiatric medications) were recorded. Detailed nosis and withdrawal of precipitating drug is crucial neuropsychological evaluation performed by clinical in the management as under recognition may result psychologist included Intelligence Quotient (IQ) as- in unwarranted investigations and treatment. In this sessment and Hamilton depression and anxiety stress 13,14 study, we describe the occurrence of PNES in a cohort scores (DASS). Weschler adult intelligence scale 15 of patients with epilepsy while on LEV therapy and was administered for adults. Malin’s Intelligence subsidence after the drug withdrawal. Scale for Indian children, which is a validated Indian J Popul Ther Clin Pharmacol Vol 25(2):1-11; June 15, 2018. This article is distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International License. e2 Levetiracetam-Associated Psychogenic Non-epileptic Seizures adaptation of Wechsler’s Intelligence Scale for children, mean ± Standard Deviation (SD), percentage and was used to assess the IQ of children.16 range. Assessments and outcomes were explained Seven patients (patients 1–7, Group I) were treated using descriptive analysis. by a psychiatrist and prescribed psychiatric medica- RESULTS tions (a combination of escitalopram or sertraline with clonazepam). LEV was gradually withdrawn over We included 13 patients with LEV induced PNES. the ensuing two weeks. There were 11 females (86 %) and two males (14%). A different strategy was applied to the next 8 patients Mean (±SD) age of patients was 25.75 ± 12.28 years (patients 8–13, Group II). These patients received psy- with a range of 12–54 years. Mean duration of true chiatric consultation for the initial two months along seizures was 10.77 ± 6.47 years, (range 1–22 years). with anxiolytics but LEV was continued. After two The duration of PNES was short in all these patients months, LEV was gradually withdrawn. All with a mean of 7.66 ± 5.28 months (range 2-18 months). patients were followed up for six months and PNES was classified using the Hubsch classifica- monitored for relapse of PNES. tion system.19 Five (39%) patients each belonged to Class 3 and 4; There were one patient (7%) each in Assessments Class 1, Class 2 and Class 5 (Table1). In all these pa- Video Electroencephalography tients, PNES were frequent (daily in four patients) All recordings were carried out on a 16-channel and manifested only when they were awake. None of VEEG acquisition system (NicVue, Nicolet-Viking, these patients suffered injuries. All were subjected USA) with the scalp electrodes placed according to 1.5 Tesla MRI brain scan and 11 (84.62%) to the International10–20 system. VEEG was demonstrated the respective abnormalities (Table recorded for 40 minutes (20 minute awake and 20 1). minute sleep record), included 3 minutes of hyper- All received antiepileptic agents along with LEV. ventilation and photic stimulation in wakefulness. All were prescribed ≥1000mg/day except one patient A partial sleep deprivation protocol was used. All who was using 500 mg/day of LEV (Table 2). Mean patients with referral diagnosis of PNES underwent dose of LEV received by our patients was 1269.23 ± induction for precipitation of PNES with the help of 483.71mg/day. a vibrating tunic fork.17,18 Relationship to Levetiracetam Therapy The distribution of interictal epileptiform discharges In group II, patients in whom LEV was continued (IEDs) was assessed by visual analysis of EEG samples. for two months after the diagnosis of PNES, all The background activity was assessed for evidence continued to have PNES though psychiatric of any focal slowing defined as the presence of local- treatment was given. They had complete remission of ized slow waves not present in the other homotopic PNES only after the withdrawal of LEV. Mean regions. IEDs were categorized as either diphasic/ time taken for subsidence of PNES in group II triphasicsharp-wave/spike or a spike-wave complex was 1.08 (± 0.50) months, after discontinuation pattern. Any activation of IEDs in sleep was noted. of LEV. In group 1, patients in whom LEV was The standard method of inducing a PNES was withdrawn initially, after the diagnosis of PNES, used in which patients were hypnotized using vibrat- there was resolution of PNES in 1 to 2 months, with ing tuning fork. The EEG correlate was noted.
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