Alcohol and seizures: a few questions and their answers.

One of the readers of my blog asked me a few questions. His questions and my answers to them follow.

Hello Dr Sethi! To begin with, I’d like to thank you for clarifying and educate us about seizures.(esp. rum fits, alcohol withdrawal seizures and Dts seizures)

I have some questions:

1. How would I differentiate between epilepsy and alcoholic fits? Ignoring any test(EEG,CT), i mean based on the clinical manifestation?eg. duration of fits?the sequence of occurence (pattern of seizure)?etc…

2. how would i differentiate between epilepsy and the ‘fits’ that is seen in patients with hysteria (conversion disorder)?

3. is treatment necessary for alcohol fits? or just allow the patient to relax in the recovery position and let the fit go away?

4. how would you distinguish between: alcohol withdrawal syndrome and DT? is there any special cardinal symptom that will give me a clue that the patient is in DT.?

Thank you very much Dr Sethi. looking forward to hear from you.

Dr. Ronny Gooriah (doing Internship)

Dear Dr. Gooriah,
thank you for writing in to me. I am glad you found the information presented useful. Now without further delay, let me answer your questions.

1. If I understood your question you want to know how to differentiate between seizures caused by alcohol (alcohol fits) from seizures/epilepsy caused by other conditions. As you may be well aware of, epilepsy is a condition which predisposes the patient to multiple convulsions in his/her lifetime. There are numerous causes of epilepsy. Broadly speaking epilepsy can be idiopathic , symptomatic or cryptogenic. Seizures may also occur secondary to a medical condition which may or may not involve the brain like for example a brain tumor, head trauma, meningitis or encephalitis and in the setting of multiorgan failure such as sepsis, renal or hepatic failure. There is no absolute way of differentiating a seizure caused by alcohol (excessive use or sudden stoppage) from epilepsy (whether idiopathic, symptomatic or cryptogenic) specially early in the course of the disease. One needs to take a thorough history which should include a history of alcohol intake. How much? what kind? over what time frame were the drinks consumed? were drinks mixed? were recreational drugs taken along with the alcohol and so forth. Other history which may be helpful in determining if the patient has epilepsy include: a history of febrile convulsions, family history of seizures, history of meningitis or encephalitis, history of significant head trauma and if seizures have occured in settings where the patient was not abusing alcohol. The answer to all these questions and the results of tests such as EEG and neuroimaging (MRI brain) shall help in determining whether the patient has epilepsy per se or whether all his seizures can be attributed to alcohol.

2. Nonepileptic events (pseudoseizures) may occur as a manifestation of a somatoform or conversion disorder. These patients have events that look like seizures (sudden shaking of the body and the patient may appear to suffer loss of consciousness) but there is no EEG correlate to these events. Meaning that the EEG shows the patient is not having a seizure. Patients who exhibit nonepileptic events (some doctors refer to them as hysterical convulsions) usually fall in two categories. Either they are doing this for a secondary gain (seeking attention, disability or financial compensation aka they are malingering) or these events are really not under their conscious control (usually these patients are under severe mental stress or may have history of physical or sexual abuse). A trained eye (such as a neurologist) simply by looking at the clinical event shall at times be able to determine if it is a true seizure or a pseudoseizure/ hysterical convulsion. At times though the differentiation is indeed difficult (if solely based on the description of the event). A video-EEG in these cases is extremely helpful. As the name suggests the patient is attached to a EEG machine while under video surveillance. The idea is to capture a typical seizure on the camera and look at the EEG at the same time.

3. If the patient suffers a single alcohol related seizure, no treatment may be necessary apart from simple observation and making sure the patient does not hurt himself. On the other hand if the patient suffers a flurry of seizures one after the other, you may have to give medications to stop the seizures at least acutely. Whether such patients warrant long term anticonvulsant therapy is another issue and needs careful consideration.

4. Patients who are in DT or have impending DT usually have dysautonomia. They are frequently tachycardic or have irregular heart rate, their blood pressure may be high and have wide swings, they may have profuse sweating and are disoriented, confused and agitated (hence the word delirium). DT has a high mortality and hence these patients need close supervision and aggressive treatment usually in an intensive care setting.

I hope I have answered your questions to your satisfaction.

Personal Regards,

Nitin Sethi, MD

Seizures associated with alcohol intake

In this post I thought I shall discuss the effects of alcohol on the brain especially with respect to seizures. Many people drink socially , a drink or two after work is not only relaxing but also enjoyable. But who is an alcoholic or rather when does one have a drinking problem? We doctors use the CAGE criteria as a rather simple questionaire to determine if someone has a drinking problem.

“CAGE” where each letter has a question attached to it and the person has to answer yes or no. Let me elaborate a little.

C–stands for “cutting down”–have you ever felt the need to cut down on your drinking?

A–stands for “anger”—have you ever felt angry if someone has questioned your drinking habit?

G–stands for “guilt”—have you ever felt guilty about your drinking?

E– stands for “eyeopener”–have you ever taken a drink first thing in the morning?

If the person answers yes to these questions, he or she may have a drinking problem. What though is the effect of heavy alcohol drinking on the brain? Does it actually kill brain cells (neurons)? Does it lead to dementia? Can too many drinks cause a seizure?

Alcohol contrary to popular beliefs is a CNS depressant and not a stimulant. Alcohol is rather rapidly absorbed through the lining of the stomach and enters the blood stream from where it is carried to the brain. In the brain, it acts on the neurons and initially causes a loss of inhibition. You loosen up, your speech flows more smoothly and soon you become the life of the party. Well as you continue to drink, alcohol then starts depressing the central nervous system (CNS) . People usually fall asleep soon after consuming alcohol.

But let us get back to how chronic alcohol intake affects the CNS especially with respect to seizures.

I shall discuss this one by one.

Alcohol induced seizures

 

 Heavy alcohol consumption can induce seizures. Alcohol induced seizures are of different types. One is what is commonly referred to as “rum fits”. Let me explain with an example. You are out with your friends celebrating a promotion. Your drink for the night is beer. Your normal “limit” is say 4 beers. But hey you are celebrating and so you end up binging. Before you know it you are on your 10th beer of the night. Right as you are having your 11th beer, your eyes roll up and you have a big generalized tonic-clonic convulsion (see my posts on epilepsy on my website http://braindiseases.info) . This kind of seizure which occurs at the height of binging is what has been referred to as a “rum” fit. I guess it was first described with respect to rum. Any of us can have a rum fit if we drink too much alcohol. You do not need to be an epileptic to have a rum fit, though I feel these kinds of seizures associated with alcohol binging are more common in patients who have an underlying seizure tendency. Thus if you are an epileptic you are more likely to have a rum fit if you overindulge in alcohol as regards to someone who does not have a seizure tendency. Hence I always advise my seizure patients to drink alcohol in moderation. You can drink and by all means enjoy your occasional drink but do not overindulge in this pleasure. Know when to say no and walk out of the bar.

Another type of seizure associated with alcohol is what is called “Alcohol Withdrawal Seizure”. Here the seizure occurs in a different scenario. Usually the person is one who is a chronic alcohol drinker, one who is dependent on alcohol and feels uneasy and restless if he does not drink everyday. Let us now assume he suddenly stops drinking for whatever reason. Maybe he runs out of money and cannot buy alcohol. Usually 24 to 48 hours after his last drink, this patient may have a generalized tonic clonic convulsion. As this seizure occurs in the setting of a withdrawal from alcohol, it is called alcohol withdrawal seizure. It is important that heavy and chronic alcohol drinkers keep this is mind and do not suddenly stop drinking. If a person does decide to quit alcohol he should do it under medical supervision.

Now for the third setting in which seizures might occur with alcohol. Again we have a person who is an alcoholic (heavy and chronic alcohol user). Again for some reason he suddenly stops drinking. Uusally after 72 hours, he starts becoming delirious (confused), he has autonomic dysfunction and is tachycardic, sweating profusely, his blood pressure is up. Such a patient is said to be in what we refer to as “delirium tremens” (DT) . Patient who are in DT may have a flurry of seizures one after the other. DT is a life threatening condition and a patient may die if not treated in time. Usually patients are admitted to the intensive care unit of the hospital. We hydrate them aggressively, we give them medications to calm them down. Lorazepam (Ativan) or other benzodiazepines like chordiazepoxide (Librium) are given to prevent seizures and treat acute alcohol withdrawal.

Patients who have had a rum fit, an alcohol withdrawal seizure or even DT do not warrant long term treatment with an antiepileptic drug. These patients do not have epilepsy. If they abstain from drinking in the future it is more than likely that they may never have a seizure again in their lifetime. However there are a few patients whom we feel have a high risk for seizure recurrence, in such patients we may prescribe antiepileptic drug therapy for some time (the duration of the therapy varies depending upon the history, examination findings and the results of investigations like EEG and CT scan or MRI brain)

I have tried to give an overview of the kinds of seizures associated with alcohol intake. Like I stated earlier one need not be an epileptic to have seizures associated with alcohol intake. I try to explain this to my patients as follows. The brain has a threshold for the amount of alcohol it can tolerate. This threshold varies from person to person. If you drink above that threshold, the brain does not like it and one way it reacts is by having a seizure. This “threshold” is lower in patients who have an underlying seizure tendency. In these epileptic patients, a small amount of alcohol may induce a seizure. Also if you mix your drinks or combine alcohol consumption with other recreational drugs like cocaine you are creating the ideal grounds to have a seizure. Certain medicines like antibiotics also lower your seizure threshold and hence should not be used along with alcohol.

Patients with epilepsy should discuss about alcohol consumption with their doctors because at times we doctors do not initiate this discussion of our own. If you have seizures my advise to you would be to drink in moderation and not exceed your limits.

Nitin Sethi, MD