At Home Drug Withdrawal

Sobriety Success

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Drug Withdrawal and Seizure Relapse

Of the patients on AED treatment, 70-80 will eventually become seizure free.1 Because of the possibility of long-term side effects of drugs, it is good practice to consider drug withdrawal after a substantial remission period. There are risks of relapse, however, in doing so and several studies have addressed this issue.13-17 The probability of relapse has varied between 11 and 41 . Most studies in children have reported figures at the lower end of the spectrum while studies in adults tend towards the higher end. A number of risk factors for seizure recurrence after discontinuation of treatment have been identified.14,15 These include a long history of

Alcohol and Sedative Drug Withdrawal

Seizures can occur upon sudden alcohol and sedative drug withdrawal, particularly when these drugs have been used for prolonged periods. Although this is much more common in people with epilepsy, seizures in this context can also occur in people without epilepsy. When planned in advance, the period of alcohol withdrawal should be accompanied by the temporary administration of benzodiazepines, which will control not only the anxiety state induced by alcohol discontinuation, but will also increase seizure threshold. The approach to the safe discontinuation of sedative drugs is different, and requires decrease of dosages over a long period of time. In people with epilepsy, rapid withdrawal of barbiturates or benzodizepines are well known seizure precipitants, and the discontinuation of these drugs should be done over weeks or months. When epilepsy is more severe, there is a definite risk of an increase in seizures even with slow discontinuation of barbiturates, and thus small dosages of...

Drug withdrawal

The sudden reduction in dose of an antiepileptic drug can result in a severe worsening of seizures or in status epilepticus, even if the withdrawn drug was apparently not contributing much to seizure control. Why these happen is not clear. Experience from telemetry

Routine Laboratory And Neuroimaging Tests

Index of suspicion based on the clinical history. Spells thought to be related to alcohol or drug abuse can be investigated by toxic screens of blood or urine. An impression of vestibular disease can be investigated with quantitative calorics and nystagmography. No blood tests or special diagnostic studies are presently widely accepted for the diagnosis of complicated migraine, although provocative tests, such as the histamine challenge, have been advocated by some. In general, routine laboratory studies and neuroimaging should be performed selectively in diagnosis of spells, based on a suspicion for particular etiologies.

Classification of aggression

Aggressive behaviour can be observed in the context of different medical, neurological and psychiatric disorders and diseases. It is a common problem in patients with mental retardation, possibly due to impaired social perception or deficits in expressing personal needs (Barratt et al., 1997 Gunn, 1977 Kligman and Goldberg, 1975 Saver et al., 1996). Aggressive behaviour in the context of organic brain disease like frontal or hypothalamic brain tumours, neuro-degenerative disease, delirium or drug abuse is often malstructured, defensive and tends to occur in the context of states of confusion and diffuse emotional arousal. Goal-directed and well-planned acts of aggression can occur on the background of psychiatric disorders like psychosis with delusional states, attention-deficit hyperactivity disorder (ADHA) or bipolar disorder. It is frequently observed in patients with antisocial personality disorder (APD) where it is part of the characteristic trait-like behaviour (Barratt et al.,...

Psychostimulants and Epilepsy

Summary Researchers performed a review of studies examining the effects of psychostimulants on seizure frequency in epilepsy patients. The following drugs are included Cocaine, amphetamine and related agents, caffeine, cannabinoids, and psychedelic drugs. Few epidemiologic studies examining the prevalence of drug-induced seizures have been conducted. Among individual drugs, cocaine use is clearly associated with seizures. The frequency ranged from 1 to 40 percent, depending on the type of study conducted. Amphetamines and related drugs rarely induce epileptic seizures at therapeutic doses, but seizures may occur after the first doses. Caffeine may cause seizures at high doses its seizure-inducing activity is attributed to its adenosine receptor antagonizing properties. Marijuana, unlike other psychostimulants, has been shown experimentally to produce a serotonin-mediated anticonvulsant action. Psychedelic drugs such as lysergic acid diethylamide (LSD), seldom cause seizures. Ingestion...

How to withdraw therapythe importance of slow reduction

When a decision to withdraw therapy is made, the drugs should be discontinued one at a time slowly. Fifty per cent of patients who are going to experience a recurrence of seizures on withdrawal do so during the reduction phase, and 25 in the first 6 months after withdrawal this should be explained carefully to the patient. Because of this, the UK driving licence authority recommends that driving be avoided during drug withdrawal and for 6 months afterwards this (non-binding) advice should be given to patients. Table 2.23 Mathematical basis of model predicting risk of recurrence of seizures after drug withdrawal (from MRC drug withdrawal study).

Vocabulary Builder

Cocaine An alkaloid ester extracted from the leaves of plants including coca. It is a local anesthetic and vasoconstrictor and is clinically used for that purpose, particularly in the eye, ear, nose, and throat. It also has powerful central nervous system effects similar to the amphetamines and is a drug of abuse. Cocaine, like amphetamines, acts by multiple mechanisms on brain catecholaminergic neurons the mechanism of its reinforcing effects is thought to involve inhibition of dopamine uptake. NIH

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Elude organ failure, ischaemia hypoxia, electrolyte and endocrine disturbance, drugs and drug withdrawal, cancer and systemic disease affecting the CNS 10 , The underlying cause may be reversible, although provoked seizures do heighten the risk of later (spontaneous) seizures. Typically, reversible brain insults do not result in parenchymal damage. By contrast, when cortical damage follows the insult, the risk of subsequent symptomatic seizures increases. Chronic seizures that follow brain insults are categorized as remote symptomatic.

Withdrawing Medication

The 1991 MRC drug withdrawal study8 demonstrated that ID should not necessarily be a barrier to anticonvulsant withdrawal. Forty percent of seizure-free patients were successfully able to withdraw therapy. However, because of the comparatively high incidence of refractory epilepsy among this population, many patients will require lifelong treatment. The decision to begin the slow withdrawal of medication must be based upon an evaluation of the potential benefits of anticonvulsant freedom versus risk of seizure recurrence. The potential benefits to medication withdrawal may be difficult to quantify, and assessments of individuals and their particular circumstances are required. Similarly, the potential impact of seizure recurrence may vary widely between patients and necessitate debate. It is estimated that withdrawing treatment probably doubles the risk of further seizures, with the greatest risk of recurrence in the two years post withdrawal. The risk of further seizures may vary...

The Obvious Cause Of Seizures May Not Be The Underlying Cause

The patient is a 48-year-old man with a previous history of alcohol and drug abuse. He presented to the emergency department following a generalized tonic-clonic seizure. He had no history of seizures and no history of head trauma, but he did have a recent history of alcohol abuse with decreasing amounts over the last several days, although he had not totally stopped drinking.

A bidirectional relationship

Another finding which has been replicated is that the link between depression and epilepsy is not necessarily unidirectional, namely that patients with the comorbidity always present with the seizure disorder before the emergence of the depression. Thus, it has been noted in epidemiological studies that having a prior mood disorder can be associated with an increased risk of epilepsy (Forsgren and Nystrom, 1990 Hesdorffer et al., 2000). There may be a number of reasons for this, including perhaps the development of epilepsy following suicidal attempts, following drug abuse or following some other kinds of trauma such as head trauma. However, the findings may reflect on an underlying common pathogenesis, which may relate to some as yet unknown genetic factor, or some link with neurotrans-mitter function (e.g., related to transmitters that are known to play a role in both epilepsy and depression such as serotonin or GABA).

Epilepsy in the Teen Years

Peers need to be educated about what to expect if a person has a seizure and how to handle an episode, so that they become less afraid to include the teen with epilepsy on social occasions. Driving can be a problem, so teens often learn to get rides from friends and contribute gas money. Students with epilepsy need support, understanding, and people to react to them as normal people. A social worker who leads a teen support group on epilepsy speaks about the effectiveness of such groups. Teens in support groups can discuss coping problems, depression, skills, medication side effects, and other concerns. Adolescents with epilepsy must learn that alcohol and other drugs, especially cocaine, can trigger seizures so it is best to avoid them. Learning what other conditions precipitate seizures is also helpful teens must learn to get adequate rest, adhere to a good diet, and take medications on time. This gives them more responsibility for their own care and helps them learn to...

Neurotoxic sideeffects

The sedative side-effects typical of antiepileptic drugs also occur with valproate, severely so in about 2 of patients, and sometimes associated with other neurological symptoms such as confusion and irritability. Tremor occurs in about 10 of patients on valproate, and is dose-related but usually mild. Parkinsonism seems to be another uncommon but unusual side-effect of vaproate therapy, usually developing on long-term treatment and reversible on drug withdrawal. The mechanism is unclear.

Clinical use in epilepsy

Side-effects remain a problem, and it is because of these that enthusiasm for valproate has waned in recent years. Weight gain is common and often problematic. Other side-effects, such as the neurotoxic effects and effects on hair growth, are also common, but often are only slight and usually are not a reason for drug withdrawal. In female patients, the hints that valproate increases the frequency of poly-cystic ovaries, causes menstrual irregularities, and reduces fertility are enough for many to avoid its use. Scientific evidence on these points, however, is generally slight, and has tended to come from one (potentially unreliable) source nevertheless, this and a marketing onslaught from valproate's competitors have reduced its usage, particularly in partial epilepsy. Valproate teratogenicity is a major concern and is a further reason for avoiding valproate in female patients where pregnancy is an issue. Its use in young children, especially those under 2 years of age, carries a...

Monitoring Patients May Be More Important Than Their Laboratory

The patient's past medical history was significant for diabetes mellitus, mild congestive heart failure following three-vessel coronary artery bypass graft surgery 4 years previously, chronic obstructive pulmonary disease, depression, rheumatoid arthritis and colostomy for resected colon cancer. Medications included phenytoin as above, insulin (Humulin 70 30) 20 units subcutaneously in the morning and 10 units in the evening, clopidogrel 75 mg day, amitriptyline 25 mg day at bedtime and sertraline 100 mg day in two divided doses. Her only known allergy was to penicillin. She had a previous history of smoking, no history of alcohol or drug abuse and a strong family history of diabetes and coronary artery disease in middle age.

Seizures In Intensive Care Units

In the ICU setting, seizures are a common neurological manifestation in medical or surgical patients. According to Bleck et al., 12.3 of patients admitted to the medical ICU for non-neurological primary problems had neurological complications, with seizures being the second-leading complication (28.1 , after metabolic encephalopathies, 28.6 ). Cerebrovascular insults were the most common cause of seizures, as illustrated in Figure 12.1, indicating aetiologies of seizures and number of patients in each diagnostic category 15 . In a separate series of patients in medical or surgical ICUs who had at least one generalized tonic-clonic seizure, one-third had seizures attributed to abrupt drug withdrawal, usually of a medication given for pain management, such as morphine. One-third had underlying metabolic aetiologies with hyponatraemia and hypocalcaemia being the most frequent 16 .

Clinical features of tonicclonic status epilepticus

Tonic-clonic status epilepticus is defined as a condition in which prolonged or recurrent tonic-clonic seizures persist for 30 minutes or more. The annual incidence has been estimated to be approximately 18 -28 cases per 100,000 persons, with the highest rates in children, the learning-disabled, and in those with structural cerebral pathology, especially in the frontal lobes. About two-thirds of cases develop de novo, without a prior history of epilepsy, and such cases are almost always due to acute cerebral disturbances common causes are cerebral infection, trauma, cerebrovascular disease, cerebral tumour, acute toxic or metabolic disturbances, or childhood febrile illness. In patients with pre-existing epilepsy tonic-clonic status can be precipitated by drug withdrawal, intercurrent illness, metabolic disturbance or the progression of the underlying disease, and is more common in symptomatic than in idio-pathic epilepsy (Table 4.2). About 5 of all adult patients attending an...

Pharmacotherapy Of Anxiety Disorders In

Buspirone is a 5-HTJA agonist agent that has been found to be effective for the treatment of GAD 43 . It is favoured over the use of benzodiazepines because it does not cause drug dependence or withdrawal with long-term use and it lacks any significant pharmacokinetic interactions with other agents. Its onset of efficacy is delayed by several weeks, like that of anti-depressant drugs.

Psychiatric assessment

A detailed neuropsychiatric evaluation is a vital part of the pre-surgical assessment and should be carried out routinely in the early stages of the assessment process. The structured clinical interview schedule can be backed up by the use of rating scales which might include Neurobehavioural Inventory, State-Trait Anxiety Inventory, Beck Depression Inventory, Subjective Handicap of Epilepsy Scale, Quality of Life in Epilepsy Scale, and the Minnesota Multiphasic Personality Inventory. The evaluation has four purposes 1 To identify the presence of psychiatric contra-indications to surgery. Usually, surgery should not be performed in patients with ongoing interictal psychosis, severe personality disorder or psychopathy, co-morbid non-epileptic seizures, or ongoing alcohol or drug abuse. Peri-ictal psychosis is often considered to be a factor weighing on the

Corticotropinreleasing factor modulation

Glucocorticoids are reported to significantly facilitate the development of cocaine-induced kindled seizures15 and to increase the severity of handling-induced convulsions during ethanol withdrawal.16 Neural circuits that mediate the pro-convulsant actions of glucocorticoids likely include brain stress neuropeptide pathways that initiate pituitary-adrenocortical activation. In particular, available evidence implicates the excitatory stress neuropeptide, corticotropin-releasing factor, as a seizure trigger during the post-natal period of development.17 In adult rodents, low doses of cortico-tropin-releasing factor given intracerebroventricularly arouse electrographic activity,18 whereas higher doses induce electrographic and behavioral signs of seizure activity indistinguishable from those which occur following electrical kindling of the amyg-dala.19 If one postulates that persistent neuroadaptations arise in the brains of stressed organisms, then the emergence of seizure pathology can...

Articles in scientific journals

Chadwick D, Taylor J, and Johnson T. 1996. Outcomes after seizure recurrence in people with well-controlled epilepsy and the factors that influence it. The MRC Antiepileptic Drug Withdrawal Group. Epilepsia, 37 1043-50. Medical Research Council Antiepileptic Drug Withdrawal Study Group. 1991. Randomized study of antiepileptic drug withdrawal in patients in remission. Lancet, 337 1175-80. Medical Research Council Antiepileptic Drug Withdrawal Study Group. 1993. Prognostic index for recurrence of seizures after remission of epilepsy. Br Med J, 306 1374-8.

Frequency and Provoking Factors

Illicit Drug Abuse and Other Habits Illicit use of central nervous system-active drugs is a universal phenomenon. Drug producing and poorly enforced drug-restricting regulations lead to major drug-related casualties in developing countries. Large-scale drug availability leads to high rates of drug use and abuse, which in turn may produce both seizures related to overdose and secondary brain lesions, causing subsequent epilepsy. Furthermore, persons who already have epilepsy may experience periods of seizure recurrence or increase in frequency when using illicit drugs. Alcohol use, abuse, and withdrawal can cause similar problems. History should clarify whether drug-related seizures in a given individual represent the overuse of a stimulant drug or the sudden withdrawal of a sedative drug in someone who is known to have epilepsy, or if the seizures are an acute reaction of a normal brain. In the latter case, a diagnosis of epilepsy is unwarranted, but in either situation, counseling...

Illicit and abused drugs

In a US national household survey on drug abuse (NHSDA) performed in 1994, 10 of people older than 12 years reported non-medical use of prescription drugs, 38 had used an illicit drug, and 85 had drunk an alcoholic beverage in their lifetime (Rouse, 1996). Little systematic information exists in this regard in patients with epilepsy (Devinsky, 2003) . One of the current debates pertains to the therapeutic use of marijuana in patients with seizures. A survey performed in a tertiary center in Canada showed that 21 of patients had smoked marijuana in the last year in order to decrease the frequency of seizures, the majority of whom reported benefits. Further, 24 of the entire sample believed it to be beneficial (Gross et al., 2004). The effects of marijuana on seizure activity are not fully understood, and some studies suggest some beneficial effect on seizures (Consroe et al., 1975 ) Wada et al., 1975 ) Gross et al., 2004), but other reports state the opposite (Brust et al., 1992)...

Man With Shoulder Twitching

The past medical history was unremarkable. There was no recent history of head trauma, fever or headache. There were no risk factors for stroke except for a history of heavy cigarette smoking, and no past history of transient ischemic attack or cerebral infarction. There was no history of alcohol or drug abuse. He had never experienced a similar type of event in the past.

And Etiological Profile in Developing Countries

Acute symptomatic seizures may be single or repetitive. Single seizure may be brief or prolonged. Repetitive seizures may be serial, clustered, or crescendo. Status epilepticus may be the presenting feature. In our study, of the 572 patients, 7 had single seizure, 90 had two or more seizures and 3 developed status epilepticus. Repetitive seizures included seizure clusters.5 Seizure type can be simple partial, complex partial (CPS) with or without secondary generalization, or generalized tonic-clonic seizures (GTCS). The most common seizure type is GTCS (including secondary generalization). In particular, alcohol or drug withdrawal, drug toxicity, or systemic metabolic disorders typically present as GTCS. Whereas patients with acute primary CNS insult may trigger simple or complex partial seizures depending on the site of pathology.

Possible anatomic substrates of some behavioural disturbances associated with epilepsy

In cats, kindling of the dopaminergic ventral tegmental area of the brain stem, which projects to the nucleus accumbens of the basal forebrain, does not produce seizures, but alters behaviour in a way that has been interpreted to resemble aspects of schizophrenia (Stevens, 1973). The nucleus accumbens and the ventral tegmen-tal area both receive input from the mesial temporal limbic system, and are thus subject to kindling-like afferent input from seizures originating from the hippocampus or perihippocampal regions. An enduring effect of limbic seizures on dopaminergic function has been demonstrated experimentally by the fact that amygdala kindling in cats enhances methamphetamine-induced stereotypy, suggesting upregulation of DA receptors (Sato, 1983), although the location of these receptors has not been identified.

Management Of Provoked Seizures

Seizures can be provoked by acute metabolic disturbances, treatment with certain drugs (see Section 3.13) and drug withdrawal (eg alcohol, benzodiazepines, barbiturates). Provoked seizures may occur in the context of drug abuse (heroin, cocaine, methadone, amphetamine, ecstasy). The risk of recurrence of such provoked seizures can be reduced by correction or withdrawal of the provocative factor. The risk of seizures related to acute alcohol withdrawal can be reduced by short term treatment with lorazepam.121 Commencement of longer term AED treatment is only indicated if unprovoked seizures occur.

Seizures versus Epilepsy

As described in Chapter 1, not all seizures indicate the presence of epilepsy. Epilepsy is the chronic persistence of a brain dysfunction, which leads to recurrent epileptic seizures. Some individuals may have a single epileptic seizure, while others may have a few recurrent seizures during life, always related to a specific transient provoking factor. These people do not have epilepsy. Examples include generalized seizures in susceptible individuals under conditions of alcohol withdrawal or prolonged sleep deprivation, or excessive use of illegal stimulant drugs such as cocaine or amphetamines. Still others may harbor specific lesions, such as cortical tumors or parasitic cysts, which may clinically present with a few seizures, but whose tendency to further episodes is eliminated by resection or medical treatment of the lesion.

Treatment oF BIPoLAR DisoRDERs IN PwE

The aims of pharmacotherapy in bipolar disorders are to suppress acute major depressive, hypomanic, manic and mixed manic depressive episodes and reinstate and maintain a euthymic state. Just as in co-morbid depression in epilepsy, the treatment of bipolar disorder in PWE has to be based on data from studies done in non-epilepsy patients. The management of bipolar disorders is fraught with a significantly lower therapeutic success than (unipolar) major depressive and dysthymic disorders and with potential complications, including a higher suicidal risk, co-morbid drug abuse and the development of psychotic episodes. The pharmacologic treatment includes the use of mood stabilizing agents, such as lithium, valproic acid, carbamazepine and lamotrigine. Obviously, in the case of PWE, AEDs with mood-stabilizing properties should be considered before lithium. Furthermore, anti-depressants should be used with great caution in these patients as they increase significantly a risk of triggering...

Basic Mechanisms

There are many more provoked seizures in neonates and infants than in adults. Their causes may involve trauma, hypoxic-ischemic encephalopathy, hypertension, metabolic abnormalities (amino acid disturbances, hypocalcemia, hypoglycemia, and electrolyte imbalance), infections, drug withdrawal, pyridoxine dependency, and toxins (4). Similarly, a genetic predisposition to epilepsy may be expressed in infancy. Genetic factors may involve congenital cerebral malformations and familial seizures such as neurocutaneous syndromes, genetic syndromes, and benign familial epilepsy (4). Additionally, several intractable seizure syndromes occur in early infancy or childhood and not later on (5). In children, focal dysfunction may often produce multifocal seizures and status epilepticus, suggesting less effective barriers for seizure spread and generalization (6).

Adults

A history of a generalized tonic-clonic convulsion following sleep deprivation, alcohol or sedative drug withdrawal, or other well-known precipitating factors in an otherwise healthy person with a normal history, physical, or neurologic examination, and routine laboratory findings suggests a provoked event which is not likely to recur as long as precipitating stimuli are avoided. An electroencephalogram (EEG) and CT (or MRI) scan are still indicated to look for some predisposing abnormality, but where resources

Druginduced seizures

Patients prospectively monitored for drug toxicity. As many as 15 of drug-related seizures present as status epilepticus. In a population-based survey from Richmond, Virginia, drug overdose was the reported cause in 2 of children and 3 of adults with status epilepticus. Drugs can cause seizures due to intrinsic epileptogenicity, patient idiosyncrasy, antiepileptic drug interactions, impairment of the hepatic or renal drug metabolism, drug withdrawal phenomena, and direct cerebral toxicity (especially in intentional overdosage). Recreational drugs can cause seizures. The greatest risk is with the stimulant drugs such as cocaine, amphetamine and 'ecstasy' (3,4-methylenedioxymethamphetamine, MDMA). The hallucinogens such as phencyclidine ('angel dust') and lysergic acid diethlyamide (LSD) less commonly cause seizures. The opiates and the organic solvents are least epileptogenic, although past or present heroin use has been shown to be a risk factor for provoked and unprovoked seizures...

Neurocysticercosis

Netic resonance imaging (MRI) are available, it can be used to assist antiepileptic treatment. Resolution of epileptogenicity is often accompanied by disappearance of the active cyst. Less than one-quarter of patients experience seizure recurrence on drug withdrawal when active cysts are no longer present on imaging. After the acute stage, dead cysts can appear on CT as small calcifications. Therefore, the finding of such calcifications on CT at the time of seizure onset suggests a chronic condition, and prognosis for drug withdrawal is poorer than when active cysts are seen. If seizures recur with drug withdrawal, chronic pharmacotherapy is necessary. When pharmacotherapy fails to control seizures, and an epilepsy surgery center is available, surgical excision of the epilepto-genic granuloma is indicated.

Neonatal Seizures

Neonatal seizures are more often provoked (acute symptomatic) seizures due to an acute neurological insult or systemic illness. The etiological factors include perinatal hypoxic-ischemic encephalopathy, infections (meningitis, encephalitis), intrac-ranial hemorrhage (intraventricular, intracerebral, subarachnoid), cerebral infarcts, metabolic disorders (hypoglycemia, hypocalcemia, hypomagnesemia), inborn errors of metabolism, congenital brain anomalies, drug and drug withdrawal.29,47-49 Severity of CNS insult and probably the underlying genetically determined lowered seizure threshold determine the severity of acute seizures. The etiological factors for acute symptomatic seizure may later predispose to epilepsy. Prolonged seizures or status epilepticus may result in further brain damage and later epilepsy,50 although still controversial.29,47,49

Mechanisms

There are a number of theoretical mechanisms linking antiepileptic drugs and psychiatric disorders. These are (1) dose-related drug toxicity, (2) dose-unrelated or idiosyncratic effects in vulnerable individuals, (3) drug withdrawal and (4) effects related to antiepileptic efficacy ('forced normalization'). The most important mechanisms both from an epidemiological and a theoretical point of view are idiosyncratic side effects and alternative syndromes associated with the phenomenon of forced normalization.

Figure 171

No other seizure types are usually seen in the course of BMEI, except simple febrile seizures, and afebrile GTCS the latter occur very late, usually during adolescence, and are often ascribed to drug withdrawal at that age. VPA may still be withdrawn without recurrence of GTCS in some, but has to be maintained in others, for example, because of persisting photosensitivity. Photosensitivity can indeed appear after the cessation of myoclonic jerks and persist into adulthood (13, 25, 26). Some patients may present with other seizure types two patients had typical absences at age 10 and 11 years, after several years of seizure freedom off VPA (14). A multicen-tric study reported that, among 34 BMEI cases diagnosed between 1981 and 2002, there were two who later developed JME (27), but such findings need confirmation.

Stimulant Drugs

Stimulant drugs can facilitate seizure occurrence in people both with and without epilepsy. Even small doses of cocaine or crack, and drugs such as amphetamines, methylphenidate, or sympathomimetic drugs for asthma can decrease seizure threshold sufficiently to cause seizures in susceptible individuals. Should an increase in seizure frequency occur in these contexts, preventive measures, including discontinuation of the precipitating drug or increase of AED dosages, should be taken. In some highly sensitive patients, even the use of caffeine should be discouraged. There are some regions of developing countries in which the ingestion of stimulants is a routine, including chewing or brewing coca leaves in the Andes and drinking mate (a stimulant herb)

Comment

Epilepsy is a common episodic neurological condition which is heterogeneous in clinical presentation and is characterized by recurrent paroxysmal episodes. Epileptic seizures occur suddenly and nearly always terminate spontaneously, without a need of pharmacological intervention. The cessation of epileptic activity at the end of an ordinary epileptic seizure is remarkable. All mechanisms participating in seizure termination are not fully understood, but sophisticated synaptic and ionic mechanisms rather than energetic failure are responsible for stopping epileptic seizures. In contrast, status epilepticus (SE) is a unique pathological state during which seizures are unremitting and tend to become self-sustained. SE may occur in epileptic patients for various reasons, but frequently it develops in patients with no previous history of epilepsy. In fact, epilepsy can follow SE in some patients. Thus, SE might be a precipitating factor for epileptogenesis, even though it is frequently...

Clinical features

Menstruation, and alcohol and drug withdrawal, but not usually photic stimulation or overbreathing as in typical absence status. The onset and offset are usually less well defined than in absence status, and the response to intravenous therapy more gradual. Complex partial status may typically follow a secondary generalized tonic-clonic seizure (or cluster of seizures), but is rarely terminated by a generalized convulsion, in contrast to the case in typical absence status. Episodes of complex partial status are usually recurrent, and in a few patients there is a remarkable periodicity. Complex partial status can arise in focal epilepsies of widely varying aetiologies.

Seizure outcome

It is important not to take an over-optimistic view of temporal lobectomy, nor to assume that it guarantees long-term seizure control. The short-term outcome of temporal lobectomy has been carefully studied, but there is a serious lack of longer-term information, in spite of the fact that the operation has been performed now for over 50 years. At 1 year post-surgery, in published studies, 'seizure freedom' rates have generally ranged between 50 and 80 (median 70 ), and at 5 years, rates have ranged between 50 and 70 . 'Seizure freedom' in these studies includes patients who continue to have auras (or other 'non-disabling' seizures) or seizures occurring only on drug withdrawal, and the rates for true 'complete seizure freedom' are lower. Furthermore, the quoted 5-year rates include patients who had been free from seizures for a year or more at the time of follow-up (only 50-55 of quoted patients had been seizure free for the whole of the 5-year period). Longer-term data are largely...

Psychosocial needs

Attending to the psychosocial, cognitive, educational and vocational aspects is an important part of caring for people with epilepsy. The implications of the diagnosis and the treatment rationale should be discussed with the patient and family to dispel any misconceptions and to ensure good adherence to medication. Support should be offered if lack of knowledge in society or stigma is an impediment for the use of the patient's full capacity and provokes job discrimination. Patients should be advised to refrain from activities that may precipitate the occurrence of seizures, e.g. sleep deprivation, excessive alcohol intake and illicit drug use. Counselling should be provided to women of childbearing potential about the effects of their epilepsy and its treatment on fertility, contraception and pregnancy. Clinicians should make their patients with epilepsy familiar with the laws regulating driving in their country.

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