Annals of Indian Academy of Neurology
LETTER TO THE EDITOR
Year
: 2014  |  Volume : 17  |  Issue : 2  |  Page : 238--239

Alcohol-related seizures: Need for clarity


Raman Deep Pattanayak 
 National Drug Dependence Treatment Centre, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
Raman Deep Pattanayak
Assistant Professor, NDDTC, Department of Psychiatry, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India




How to cite this article:
Pattanayak RD. Alcohol-related seizures: Need for clarity.Ann Indian Acad Neurol 2014;17:238-239


How to cite this URL:
Pattanayak RD. Alcohol-related seizures: Need for clarity. Ann Indian Acad Neurol [serial online] 2014 [cited 2021 Apr 13 ];17:238-239
Available from: https://www.annalsofian.org/text.asp?2014/17/2/238/132660


Full Text

Sir,

With regard to the recently published article by Sandeep et al., [1] we wish to raise a few methodological issues, which can impact the study findings. Most importantly, there is a need for clarity on the criteria for seizures to qualify as alcohol-related seizures (ARS).

At the out-set of paper, [1] authors have referred to ARS as 'adult-onset seizures that occur in the setting of chronic alcohol dependence'. Contrary to that, the study did not made any attempt to establish a diagnosis of alcohol dependence in patients presenting with seizures. Authors have neither used the standard diagnostic criteria (e.g. WHO ICD-10) [2] nor any diagnostic instrument to establish the same. No criteria were set to operationally define the threshold of amount or duration of alcohol intake at which a patient can be included in the study.

The AUDIT, though used in the study, is an instrument meant to detect harmful or hazardous use (at cut-off score of 8) only. The scores over 20 on AUDIT may indicate possible dependence, [3] but it is to be noted that AUDIT was also not employed as a screening tool, rather as an instrument for assessment. Further, it appears from the AUDIT score of sample [21.9 ± 4.86; [Table 1]] that at least a proportion of the patients scored below 20, and comprised of hazardous but non-dependent users. It appears that it was an over-inclusive sample.{Table 1}

Coming to question of why it is important to establish dependence in cases of ARS, we wish to emphasize that alcohol-withdrawal seizures can occur only if there is a physical or physiological dependent state. The underlying assumption of the authors that a proportion of alcohol-related seizures may be induced by alcohol itself remains a hypothesis at best. The methodology of the current study was not geared to prove or disprove this assumption. Rather, there may be a sampling bias. It appears that the patients with new-onset epilepsy presenting to emergency or OPD were included even though the alcohol use may be an incidental or unrelated finding. Nearly 15 of 100 patients in the study did not have any withdrawal symptoms, indicating nondependent alcohol use.

Few additional methodological issues are briefly summarized. Authors have mentioned that 'patients without a prior diagnosis of epilepsy' were included. Alcohol withdrawal seizures are known to be recurrent, having occurred during the previous abstinent attempts. Whether such patients were included or not remains unclear from the available description. No objective test (e.g. urinalysis) was employed to rule out concurrent substance abuse, in particular, benzodiazepine use, which has the potential to induce withdrawal seizures similar to alcohol. It has been mentioned that all subjects gave informed written consent to participate in the study; however, some patients had delirium as reported in the paper. From an ethical perspective, a mention must be made of the consent from a legal guardian. [Table 1] shows mean time interval between alcohol intake to seizure (19.35 ± 35.94 h) where the standard deviation is quite high compared to the mean. Instead, median and range would have conveyed better information on variance or dispersion from mean.

Finally we strongly disagree with one of the inferences in study discussion '14 patients in our study had seizures within 6 h of intake of alcohol. When we analyzed this subgroup we found that 8 patients had no significant withdrawal symptoms and the mean lifetime duration of alcohol intake was significantly lower in them compared with the rest…… Hence this group of patients can potentially be considered to have alcohol induced seizures rather than withdrawal seizures'. From the aforementioned pointers, none is conclusively pointing toward a role of alcohol. A person can have seizures even when there is reduction (not necessarily complete cessation) of alcohol use compared to his usual dose. The absence of withdrawal symptoms may also be due to administration of benzodiazepines given for emergency seizure management. There is mixed and contradictory evidence in the literature regarding the role of alcohol in inducing seizures. [4],[5] While the issue may be researched further in a separate study, but the above-discussed findings in a small subset of patients should not be taken to assert the link further.

From a research perspective, the study ventures into an important area. However, it is important to study it using a rigorous methodology and refining the operational criteria for inclusion in the study.

References

1Sandeep P, Cherian A, Iype T, Chitra P, Suresh MK, Ajitha KC. Clinical profile of patients with nascent alcohol related seizures. Ann Indian Acad Neurol 2013;16:530-3.
2World Health Organization. The ICD-10 Classification of Mental and Behavioral Disorders. Geneva: WHO; 1992.
3Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG, editors. AUDIT: The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Care, 2 nd ed. Geneva: World Health Organization; 2006.
4Leone M, Bottacchi E, Beghi E, Morgando E, Mutani R, Amedeo G, et al. Alcohol use is a risk factor for a first generalized tonic-clonic seizure. The ALC.E. (Alcohol and Epilepsy) Study Group. Neurology 1997;48:614-20.
5Leone M, Tonini C, Bogliun G, Monaco F, Mutani R, Bottacchi E, et al. Chronic alcohol use and first symptomatic epileptic seizures. J Neurol Neurosurg Psychiatry 2002;73:495-9.