Questions Re: Seizure Disorder
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Q:  Questions Re: Seizure Disorder

I read your archived reply on the subject "Temporal Lobe Epilepsy or Bipolar Disorder?" with great interest. I have another question on that subject. 

My son, 12, diagnosed with bipolar disorder (at age 3.5) and Aspger's syndrome (at age 9), has been displaying symptoms of TLE/TLS all his life - migraines with vomiting, aphasia, hyperlexia, hypergraphia, vision problems or rising sensations like vertigo, need for sleep following a "rage" of irritability, etc. We have never seen a neurologist, though we have an appointment in 3 weeks with a child neurologist at Scottish Rite in Atlanta.

As per your reply to the archived question, he negatively reacted (with rages and uncontrollable behaviors) to several antidepressants (as could be expected) and also to every antipsychotic he's tried. He started with Mellaril at age 3.5 and we've been through Thorazine, Trilafon, Haldol, Zyprexa, Risperdal, Seroquel, Geodon and Abilify. All of these brought on very manic or aggressive behaviors and some even brought on psychosis. We just discontinued Abilify per pdoc's advice and he is still on a small dose of Haldol along with Lamictal (300mg).

Since we discontinued the Abilify, he is still irritable but has not raged, and even more impressive, the migraines have stopped. He has been psychosis-free for 2 years now except when febrile (had symptoms of menengitis and/or cellulitis recently that have cleared up with antibiotics - head CT was fine and no spinal tap was done).

My question is this: could his reaction to these antipsychotics (and, for the record, he did not respond well to lithium either) be indicative of a seizure disorder? Would TLE show up if it's not being induced or exacerbated by the Abilify currently? What can be added to Lamictal to deal with the extraneous spurts of irritability / melt-down behavior if antipsychotics cannot be used? (Our psychiatrist is considering adding Keppra, since we've already trialled Depakote, Tegretol and Trileptal with no success - but all were prescribed along with various antipsychotics.)

Thanks for any guidance,

Dear Ms W' -- 
You've got the idea, all right:  antipsychotics can "lower seizure threshold", i.e. make it easier to have an overt seizure if there is a pre-existing tendency in that direction; and, therefore any anticonvulsant tried with an antipsychotic on board may not have been effective because it was "working uphill" against the antipsychotic, so might be effective if tried alone -- all of that being "in theory", of course. 

However, can we reason the other way around?  As you ask, could his reactions to these medications be indicative of a seizure disorder?  Basically I think most neurologists would likely answer no -- it's just stretching the theory too far.  

Would TLE show up if not "induced"?  Depends on how bad it is, right?  It might be a tendency waiting for a "lower threshold", or it might just be over that threshold already. 

What can be added to Lamictal?  As your neurologist is thinking, the answer there is likely to be "more antiseizure medications".  The trick is to find a combination of several or maybe a higher dose of a single agent that might get complete symptom control without too much in the way of side effects.  Good luck with the search.  (In case somebody mentions it at some point, lithium too can "lower seizure threshold". )

Dr. Phelps

Published October, 2004


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