CPCP: Zonisamide and Psychosis by Resident Drs. Michele Morais and Nudrat Tasneem

Dr. Michele Morais, MD on the left and Dr. Nudrat Tasneem, MD on the right
Dr. Michele Morais, MD on the left and Dr. Nudrat Tasneem, MD on the right

Coming at you with another killer Clinical Problems in Consultation Psychiatry (CPCP), this time on Zonisamide (Zonegran) and psychiatric side effects with special emphasis on psychosis including manic psychosis. This was presented by resident physicians: Dr. Michele Morais, MD in Psychiatry and Dr. Nudrat Tasneem, MD from Neurology. They’re both doing an extraordinary job on their psychiatry consult rotation and having a good time doing it.

In consultation psychiatry we see many people with secondary psychiatric symptoms as a result of medical syndromes such as delirium, exposure to certain drugs such as corticosteroids and even anticonvulsants. Secondary mania from causes like these look like the primary mental disorder in almost every detail.

Zonisamide is uncommonly associated with secondary psychotic symptoms, and a case report or two described secondary mania. However, it’s also clear from the literature that epilepsy itself can be comorbid with a variety of psychiatric syndromes, probably depression more commonly than anything else.

Psychosis as a side effect from zonisamide may be more likely if it’s combined with other anticonvulsants but it’s hard to be sure because of the relative rarity of the phenomenon. It’s probably wise to be alert for this adverse effect in any person on multiple anticonvulsants with intellectual disability and comorbid psychiatric illness.

I thought the mention of paradoxical normalization was also very interesting. This used to be called forced normalization and referred to the development of psychotic symptoms that could be similar to schizophrenia in the setting of, unfortunately, excellent seizure control.

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