Integrative Neurobiology of the Alcohol Withdrawal Syndrome???From Anxiety to Seizures

Promising strategies for the prevention of alcohol-related brain damage through optimised management of acute alcohol withdrawal: A focussed literature review

There is an increasing awareness of the link between chronic alcohol consumption and the development of cognitive, behavioural and functional deficits. Currently, preventative strategies are limited and require engagement in dedicated long-term rehabilitation and sobriety services, the availability of which is low. The acute alcohol withdrawal syndrome is an episode of neurochemical imbalance leading to autonomic dysregulation, increased seizure risk and cognitive disorientation. In addition to harm from symptoms of alcohol withdrawal (e.g. seizures), the underpinning neurochemical changes may also lead to cytotoxicity through various cellular mechanisms, which long-term, may translate to some of the cognitive impairments observed in Alcohol-Related Brain Damage (ARBD). Here we review some of the pharmacological and neurochemical mechanisms underpinning alcohol withdrawal. We discuss the cellular and pharmacological basis of various potential neuroprotective strategies that warrant further exploration in clinical populations with a view to preventing the development of ARBD. Such strategies, when integrated into the clinical management of acute alcohol withdrawal, may impact large populations of individuals, who currently face limited dedicated service delivery and healthcare resource.

Clinical characteristics of seizure recurrence and epilepsy development in patients with alcohol-related seizures

BACKGROUND

Alcohol withdrawal is widely recognized as a trigger for acute symptomatic seizures among individuals with chronic alcohol consumption. While most alcohol withdrawal seizures occur shortly after cessation, chronic alcohol consumption can be associated with the development of epilepsy, necessitating anti-epileptic drug (AED) therapy. This study aimed to investigate the clinical characteristics, seizure recurrence, and epilepsy development in patients with alcohol-related seizures and to identify prognostic factors for epilepsy.

METHODS

In a retrospective analysis at Ewha Womans University Mokdong Hospital, 206 patients with alcohol-related seizures were examined and 15 were excluded due to preexisting epilepsy. Demographic and clinical data, including alcohol withdrawal duration, seizure recurrence, types, and comorbidities, were investigated. Logistic regression models were used to analyze the risk factors for seizure recurrence and epilepsy development. The performance of the final models was evaluated based on the area under the receiver operating characteristic curve (AUC) and validated using calibration plots and leave-one-out cross-validation.

RESULTS

Of the 191 patients (146 males; mean age 48.3 ± 12.1 years) with alcohol-related seizures, 99 patients (51.8%) experienced seizure recurrence and 79 patients (41.4%) developed epilepsy. Factors associated with seizure recurrence included alcohol consumption levels, occurrence of focal impaired awareness seizure, anxiety, and headache. The number of recurrent seizures, semiology, status epilepticus, electroencephalogram findings, and brain imaging findings was associated with epilepsy development. The predictive models showed strong diagnostic performance, with AUCs of 0.833 for seizure recurrence and 0.939 for epilepsy development.

CONCLUSION

High alcohol consumption and specific clinical and diagnostic features are significant predictors of seizure recurrence and the development of epilepsy among patients with alcohol-related seizures. These findings underscore the importance of early identification and intervention to prevent seizure recurrence and the onset of epilepsy, emphasizing the importance of AED treatment in managing these conditions.

Protein kinase C epsilon-mediated modulation of T-type calcium channels underlies alcohol withdrawal hyperexcitability in the midline thalamus

BACKGROUND

Millions of people struggle with alcohol use disorder (AUD). Abrupt abstinence after a period of chronic alcohol use can precipitate the alcohol withdrawal syndrome (AWS), which includes hyperexcitability and, potentially, seizures. We have shown that T-type Ca2+ channels are novel, sensitive targets of alcohol, an effect that is dependent upon protein kinase C (PKC). The purpose of this study was to (1) understand midline thalamic neuronal hyperexcitability during alcohol withdrawal and its dependence on PKC; (2) characterize T channel functional changes using both current clamp and voltage clamp methods; and (3) determine which PKC isoform may be responsible for alcohol withdrawal (WD) effects.

METHODS

Whole-cell patch clamp recordings were performed in midline thalamic neurons in brain slices prepared from C57bl/6 mice that underwent chronic intermittent alcohol exposure in a standard vapor chamber model. The recordings were compared to those from air-exposed controls. T-channel inactivation curves and burst responses were acquired through voltage-clamp and current-clamp recordings, respectively.

RESULTS

Whole-cell voltage clamp recordings of native T-type current exhibited a depolarizing shift in the voltage-dependency of inactivation during alcohol withdrawal compared to air-exposed controls. A PKCε translocation inhibitor peptide mitigated this change. Current clamp recordings demonstrated more spikes per burst during alcohol withdrawal. Consistent with voltage clamp findings, the PKCɛ translocation inhibitor peptide reduced the number of spikes per burst after WD.

CONCLUSION

We found that alcohol WD produces T channel-mediated hyperexcitability in the midline thalamus, produced in part by a shift in the inactivation curve consistent with greater availability of T current. WD effects on T current inactivation were reduced to control levels by blocking PKCε translocation. Our results demonstrate that PKCε translocation plays an important role in the regulation of alcohol withdrawal-induced hyperexcitability in midline thalamic circuitry.

Trazodone Prolonged-Release Monotherapy in Cannabis Dependent Patients during Lockdown Due to COVID-19 Pandemic: A Case Series

(1) Background: During the SARS-CoV-2 (COVID-19) pandemic, cannabis use increased relative to pre-pandemic levels, while forced home confinement frequently caused sleep/wake cycle disruptions, psychological distress, and maladaptive coping strategies with the consequent appearance of anxiety symptoms and their potential impact on substance use problems. (2) Aim: Long-acting trazodone (150 mg or 300 mg daily) has a potential benefit as monotherapy in patients with cannabis use disorder. The present work aims to investigate the effectiveness of trazodone in optimizing the condition of people with cannabis dependence under pandemic conditions. (3) Methods: All cases with cannabis use disorder were uniformly treated with long-acting trazodone 150 mg or 300 mg/day; their craving and clinical status were monitored through appropriate psychometric scales. Side effects were recorded as they were reported by patients. We described the cases of three young patients—one man and two women—who were affected by chronic cannabis use disorder and who experienced lockdown-related psychological distress and sought psychiatric help. (4) Results: The described cases highlight that the once-a-day formulation of trazodone seems to have a therapeutic role in patients with cannabis use disorder and to guarantee tolerability and efficacy over time. No significant side effects emerged. (5) Conclusions: The use of long-acting trazodone (150 mg or 300 mg daily) has a potential benefit as monotherapy in patients with cannabis use disorder. Trazodone deserves to be studied in terms of its efficacy for cannabis use disorder.

Multi-modal imaging reveals differential brain volumetric, biochemical, and white matter fiber responsivity to repeated intermittent ethanol vapor exposure in male and female rats

A generally accepted framework derived predominately from animal models asserts that repeated cycles of chronic intermittent ethanol (EtOH; CIE) exposure cause progressive brain adaptations associated with anxiety and stress that promote voluntary drinking, alcohol dependence, and further brain changes that contribute to the pathogenesis of alcoholism. The current study used CIE exposure via vapor chambers to test the hypothesis that repeated episodes of withdrawals from chronic EtOH would be associated with accrual of brain damage as quantified using in vivo magnetic resonance imaging (MRI), diffusion tensor imaging (DTI), and MR spectroscopy (MRS). The initial study group included 16 male (~325g) and 16 female (~215g) wild-type Wistar rats exposed to 3 cycles of 1-month in vapor chambers + 1 week of abstinence. Half of each group (n = 8) was given vaporized EtOH to blood alcohol levels approaching 250 mg/dL. Blood and behavior markers were also quantified. There was no evidence for dependence (i.e., increased voluntary EtOH consumption), increased anxiety, or an accumulation of pathology. Neuroimaging brain responses to exposure included increased cerebrospinal fluid (CSF) and decreased gray matter volumes, increased Choline/Creatine, and reduced fimbria-fornix fractional anisotropy (FA) with recovery seen after one or more cycles and effects in female more prominent than in male rats. These results show transient brain integrity changes in response to CIE sufficient to induce acute withdrawal but without evidence for cumulative or escalating damage. Together, the current study suggests that nutrition, age, and sex should be considered when modeling human alcoholism.

Alcohol withdrawal in epileptic rats - Effects on postictal depression, respiration, and death

Patients with epilepsy are at risk of sudden unexpected death in epilepsy (SUDEP). The most common series of events in witnessed cases of SUDEP is a generalized convulsive seizure followed by terminal apnea. Risk factors for SUDEP include prolonged postictal depression (PID), as well as alcohol abuse. The present study examined these issues in a genetic epilepsy model that exhibits generalized convulsive audiogenic seizures (AGSz) but rarely exhibits seizure-induced death, the genetically epilepsy-prone rats (GEPR-9s). We evaluated the effect of ethanol withdrawal (ETX) in GEPR-9s on respiration patterns, duration of PID, and the incidence of seizure-induced death. Audiogenic seizures were induced in GEPR-9s and in normal Sprague-Dawley rats, which were subjected to a 4-day binge ethanol protocol, 18-24h after the last ethanol dose. Following the tonic seizures, all GEPR-9s exhibited PID, characterized by loss of the righting reflex and respiratory distress (RD), which were absent during ETX seizures in the normal rats. During ETX, GEPR-9s exhibited significant increases in the duration of PID and RD, compared with vehicle-treated GEPR-9s. A significant increase in the incidence of death following seizure in GEPR-9s subjected to ETX was observed, compared with that in vehicle-treated GEPR-9s and normal rats subjected to ETX. Death in GEPR-9s was preceded by prolonged seizures because, in part, of the emergence of post-tonic generalized clonus. These results indicate that ETX induced significant increases in the duration of PID and RD, which contributed to the greater incidence of mortality in GEPR-9s compared with that in vehicle-treated GEPR-9s and normal rats. These experiments observed an elevated risk of sudden death associated with alcohol withdrawal in a genetic epilepsy model that had previously been identified as a risk factor in human SUDEP.

Assessment and management of alcohol-related admissions to UK intensive care units

BACKGROUND

The critical care environment has felt the overwhelming impact of the growing problem of alcohol abuse. However, there is ambiguity concerning the assessment and management of this patient group.

AIM

The aim of this study was to explore current practice in the use of assessment and management tools for alcohol-related admissions in UK intensive care units (ICU).

METHODS

Two hundred and forty-eight lead consultants across England, Scotland, Northern Ireland and Wales were sent an electronic survey using the SurveyMonkey(®) ( www.surveymonkey.com) website.

RESULTS

A total of 103 (41·05%) lead consultants responded to the survey. Most units (67%) utilized the volume of alcohol consumed per week to assess patient alcohol use. Furthermore, 12 units (11%) used the Clinical Institute Withdrawal Assessment tool, 5 units (5%) used the Glasgow Modified Alcohol Withdrawal Scale and 79 units (73%) used no tool for the management of alcohol withdrawal syndrome.

CONCLUSION

There appears to be a diverse approach to the assessment and management of alcohol-related admissions in UK ICUs. Further research is required in this area to identify the most effective way to assess and manage alcohol-related admissions within intensive care.

RELEVANCE TO CLINICAL PRACTICE

Under recognition and poor assessment of alcohol use can have major implications for critically ill patients.

Discrete cue-conditioned alcohol-seeking after protracted abstinence: pattern of neural activation and involvement of orexin₁ receptors

BACKGROUND AND PURPOSE

The enduring propensity for alcoholics to relapse even following years of abstinence presents a major hurdle for treatment. Here we report a model of relapse following protracted abstinence and investigate the pattern of neuronal activation following cue-induced reinstatement and administration of the orexin₁ receptor antagonist SB-334867 in inbred alcohol-preferring rats.

EXPERIMENTAL APPROACH

Rats were trained to self-administer alcohol under operant conditions and divided into two groups: immediate (reinstated immediately following extinction) and delayed (extinguished and then housed for 5 months before reinstatement). Prior to reinstatement, animals were treated with vehicle (immediate n= 11, delayed n= 11) or SB-334867 (20 mg·kg⁻¹ i.p.; immediate n= 6, delayed n= 11). Fos expression was compared between each group and to animals that underwent extinction only.

KEY RESULTS

SB-334867 significantly attenuated cue-induced reinstatement in both groups. Immediate reinstatement increased Fos expression in the nucleus accumbens (NAc), infra-limbic (IL), pre-limbic (PrL), orbitofrontal (OFC) and piriform cortices, the lateral and dorsomedial hypothalamus, central amygdala and basolateral amygdala (BLA), and the bed nucleus of the stria terminalis. Following delayed reinstatement, Fos expression was further elevated in cortical structures. Concurrent with preventing reinstatement, SB-334867 decreased Fos in NAc core, PrL and OFC following immediate reinstatement. Following protracted abstinence, SB-334867 treatment decreased reinstatement-induced Fos in the PrL, OFC and piriform cortices.

CONCLUSIONS AND IMPLICATIONS

Cue-induced alcohol seeking can be triggered following protracted abstinence in rats. The effects of SB-334867 on both behaviour and Fos expression suggest that the orexin system is implicated in cue-induced reinstatement, although some loci may shift following protracted abstinence.

Long-term mortality of patients admitted to the hospital with alcohol withdrawal syndrome

BACKGROUND

Although it is well known that alcoholism increases long-term mortality, there is a paucity of data regarding long-term prognosis in alcoholic patients who have an episode of alcohol withdrawal syndrome (AWS).

METHODS

We studied a cohort of 1,265 individuals with severe AWS who were admitted to a single university hospital between 1996 and 2006. Median age was 49 years (range 18 to 89 years). A total of 1,085 (85.8%) were men. Median follow-up was 34 months (range 0 to 121 months). Survival of patients with AWS was compared with that of a reference cohort of 1,362 individuals from the same area. In addition, age- and sex-standardized mortality ratios were calculated using the general population from the region (Galicia, Spain) as the reference.

RESULTS

The risk of mortality was higher in the cohort of patients with AWS than in the reference cohort after adjusting for age, sex, and smoking (hazard ratio 12.7; 95% CI 9.1 to 17.6; p < 0.001). The standardized mortality ratio in patients with AWS was 8.6 (95% CI 7.7 to 9.7). Age, smoking, serum creatinine, serum bilirubin, and prothrombin time at baseline were independently associated with mortality among patients with AWS.

CONCLUSIONS

Long-term mortality is highly increased in patients who have a history of AWS. Liver and kidney dysfunction are independent predictors of long-term mortality in patients with AWS.

A differential role for neuropeptides in acute and chronic adaptive responses to alcohol: behavioural and genetic analysis in Caenorhabditis elegans

Prolonged alcohol consumption in humans followed by abstinence precipitates a withdrawal syndrome consisting of anxiety, agitation and in severe cases, seizures. Withdrawal is relieved by a low dose of alcohol, a negative reinforcement that contributes to alcohol dependency. This phenomenon of ‘withdrawal relief’ provides evidence of an ethanol-induced adaptation which resets the balance of signalling in neural circuits. We have used this as a criterion to distinguish between direct and indirect ethanol-induced adaptive behavioural responses in C. elegans with the goal of investigating the genetic basis of ethanol-induced neural plasticity. The paradigm employs a ‘food race assay’ which tests sensorimotor performance of animals acutely and chronically treated with ethanol. We describe a multifaceted C. elegans ‘withdrawal syndrome’. One feature, decrease reversal frequency is not relieved by a low dose of ethanol and most likely results from an indirect adaptation to ethanol caused by inhibition of feeding and a food-deprived behavioural state. However another aspect, an aberrant behaviour consisting of spontaneous deep body bends, did show withdrawal relief and therefore we suggest this is the expression of ethanol-induced plasticity. The potassium channel, slo-1, which is a candidate ethanol effector in C. elegans, is not required for the responses described here. However a mutant deficient in neuropeptides, egl-3, is resistant to withdrawal (although it still exhibits acute responses to ethanol). This dependence on neuropeptides does not involve the NPY-like receptor npr-1, previously implicated in C. elegans ethanol withdrawal. Therefore other neuropeptide pathways mediate this effect. These data resonate with mammalian studies which report involvement of a number of neuropeptides in chronic responses to alcohol including corticotrophin-releasing-factor (CRF), opioids, tachykinins as well as NPY. This suggests an evolutionarily conserved role for neuropeptides in ethanol-induced plasticity and opens the way for a genetic analysis of the effects of alcohol on a simple model system.

Calcium channel dysfunction in inferior colliculus neurons of the genetically epilepsy-prone rat

Voltage-gated calcium (Ca(2+)) channels are thought to play an important role in epileptogenesis and seizure generation. Here, using the whole cell configuration of patch-clamp techniques, we report on the modifications of biophysical and pharmacological properties of high threshold voltage-activated Ca(2+) channel currents in inferior colliculus (IC) neurons of the genetically epilepsy-prone rats (GEPR-3s). Ca(2+) channel currents were measured by depolarizing pulses from a holding potential of - 80 mV using barium (Ba(2+)) as the charge carrier. We found that the current density of high threshold voltage-activated Ca(2+) channels was significantly larger in IC neurons of seizure-naive GEPR-3s compared to control Sprague-Dawley rats, and that seizure episodes further enhanced the current density in the GEPR-3s. The increased current density was reflected by both a - 20 mV shifts in channel activation and a 25% increase in the non-inactivating fraction of channels in seizure-naive GEPR-3s. Such changes were reduced by seizure episodes in the GEPR-3s. Pharmacological analysis of the current density suggests that upregulation of L-, N- and R-type of Ca(2+) channels may contribute to IC neuronal hyperexcitability that leads to seizure susceptibility in the GEPR-3s.

Impact of Experimentally Induced Positive and Anxious Mood on Alcohol Expectancy Strength in Internally Motivated Drinkers

The effects of musically-induced positive and anxious mood on explicit alcohol-related cognitions (alcohol expectancy strength) in 47 undergraduate students who consume alcohol either to enhance positive mood states (for enhancement motives) or to cope with anxiety (for anxiety-related coping motives) were investigated. Pre- and post-mood induction, participants completed the emotional reward and emotional relief subscales of the Alcohol Craving Questionnaire - Now. The hypothesis that anxiety-related coping motivated drinkers in the anxious mood condition (but not those in the positive mood condition) would exhibit increases in strength of explicit emotional relief alcohol expectancies after the mood induction was supported. An additional, unanticipated finding was that enhancement-motivated drinkers in the anxious condition also showed significant increases in strength of explicit emotional relief (but not emotional reward) alcohol expectancies. The hypothesis that enhancement-motivated (but not anxiety-related coping motivated) participants would exhibit increases in explicit emotional reward expectancies following exposure to the positive mood induction procedure was not supported. Taken together with past research findings, the current results highlight the importance of distinguishing between subtypes of negative affect (i.e., anxious and depressed affect) in exploring the affective antecedents of explicit alcohol outcome expectancies.

Role of the amygdala in ethanol withdrawal seizures

Ethanol withdrawal (ETX) after induction of ethanol dependence results in a syndrome that includes enhanced seizure susceptibility. During ETX in rodents, generalized audiogenic seizures (AGS) can be triggered by intense acoustic stimulation. Previous studies have implicated specific brainstem nuclei in the neuronal network that initiates and propagates AGS during ETX. Although ethanol and ETX are known to affect amygdala neurons, involvement of the amygdala in the network subserving AGS is unclear. Since ethanol and ETX affect N-methyl-d-aspartate (NMDA) receptors in the amygdala, the present study evaluated the effect of focally microinjecting a NMDA antagonist into the amygdala of rats treated with a binge protocol (intragastric administration of ethanol 3 times daily for 4 days). Separate experiments examined extracellular neuronal firing in the amygdala. Cannulae or microwire electrodes were chronically implanted into the amygdala, and changes in seizure behaviors and/or extracellular action potentials were evaluated. Bilateral focal microinjection of a NMDA antagonist, 2-amino-7-phosphonoheptanoate (AP7), into either central nucleus or lateral nucleus of the amygdala (LAMG) significantly reduced AGS. The doses of AP7 and time course of effect were similar in each site, suggesting that both amygdala nuclei participate in the AGS network. Acoustic responses of LAMG neurons were significantly decreased 1 h after the first ethanol dose and also during ETX, as compared to pre-binge controls. However, LAMG neurons consistently exhibited rapid tonic firing during the generalized tonic convulsions of AGS. These findings suggest a critical role of the amygdala in the ETX seizure network in generating tonic convulsions during AGS.

A rational approach to the pharmacotherapy of alcohol dependence

The use of alcohol is widespread in the world, and although there are many regular users, some individuals drink excessively. Understanding the time course of the development and maintenance of alcohol dependence is important in assessing the potential risk/benefit of an intervention and in accurately treating the problem. Most, although not all, literature suggests that alcoholism is a chronic, relapsing disorder and that there is a general progression from less to more severe problems. Understanding the neurobiology that underlies alcohol dependence as it relates to different clinical stages may help in the development of effective targeted pharmacological treatments. Important clinical stages that may be amenable to pharmacological intervention include the transition from alcohol use to heavy drinking particularly in vulnerable individuals, the cessation of heavy drinking in individuals who want to quit, and the prevention of relapse in individuals who have initiated abstinence but may struggle with craving or the desire to resume alcohol use. Neurotransmitter systems implicated in these stages include glutamate, gamma-aminobutyric acid, opioid, and serotonin systems that may act directly or via the indirect modulation of dopamine function. The treatment implications will also be discussed.

Excitatory amino acid receptor-mediated responses in periaqueductal gray neurons are increased during ethanol withdrawal

The ventrolateral periaqueductal gray (PAG) is critical for propagation in the neuronal network for ethanol withdrawal (ETX) seizures, and ethanol is known to alter glutamate effects. This study evaluated changes in glutamate antagonist effects on PAG neurophysiology in brain slices from rats treated with ethanol in vivo. Spontaneous action potentials were rare in control PAG neurons but common during ETX. Spontaneous excitatory postsynaptic potential (EPSP) frequency was increased during ETX, and an AMPA antagonist, 6,7-dinitroquinoxaline-2,3-dione (DNQX) was more effective in suppressing this activity than an NMDA antagonist, 2-amino-7-phosphonoheptanoate (AP7). EPSPs evoked by stimulation of dorsolateral PAG were decreased by AP7 or DNQX in ETX and control neurons. EPSPs of ETX neurons were significantly less sensitive than controls to blockade by AP7 and DNQX. Paired-pulse facilitation of EPSPs was significantly increased during ETX, but paired-pulse inhibition occurred in controls. Thus, PAG hyperexcitability during ETX results from alterations of both NMDA and AMPA receptor-mediated neurotransmission, which may contribute importantly to ETX seizures. These results differ from previous findings in the seizure-initiating site for ETX seizures, inferior colliculus (IC), where NMDA receptor-mediated mechanisms dominate excitability increases during ETX. This dichotomy may be related to the different role played by IC and PAG in the ETX seizure network.

Neurons in the amygdala play an important role in the neuronal network mediating a clonic form of audiogenic seizures both before and after audiogenic kindling

Previous studies showed that neuronal network nuclei for behaviorally different forms of audiogenic seizure (AGS) exhibit similarities and important differences. The amygdala is involved differentially in tonic AGS as compared to clonic AGS networks. The role of the lateral amygdala (LAMG) undergoes major changes after AGS repetition (AGS kindling) in tonic forms of AGS. The present study examined the role of LAMG in a clonic form of AGS [genetically epilepsy-prone rats (GEPR-3s)] before and after AGS kindling using bilateral microinjection and chronic neuronal recordings. AGS kindling in GEPR-3s results in facial and forelimb (F&F) clonus, and this behavior could be blocked following bilateral microinjection of a NMDA antagonist (2-amino-7-phosphonoheptanoate) without affecting generalized clonus. Higher AP7 doses blocked both generalized clonus and F&F clonus. LAMG neurons in GEPR-3s exhibited only onset type neuronal responses both before and after AGS kindling, unlike LAMG neurons in normal rats and a tonic form of AGS. A significantly greater LAMG neuronal firing rate occurred after AGS kindling at high acoustic intensities. The latency of LAMG neuronal firing increased significantly after AGS kindling. Burst firing occurred during wild running and generalized clonic behaviors before and after AGS kindling. Burst firing also occurred during F&F clonus after AGS kindling. These findings indicate that LAMG neurons play a critical role in the neuronal network for generalized clonus as well as F&F clonus in GEPR-3s, both before and after AGS kindling, which contrasts markedly with the role of LAMG in tonic AGS.

Emergent properties of CNS neuronal networks as targets for pharmacology: application to anticonvulsant drug action

CNS drugs may act by modifying the emergent properties of complex CNS neuronal networks. Emergent properties are network characteristics that are not predictably based on properties of individual member neurons. Neuronal membership within networks is controlled by several mechanisms, including burst firing, gap junctions, endogenous and exogenous neuroactive substances, extracellular ions, temperature, interneuron activity, astrocytic integration and external stimuli. The effects of many CNS drugs in vivo may critically involve actions on specific brain loci, but this selectivity may be absent when the same neurons are isolated from the network in vitro where emergent properties are lost. Audiogenic seizures (AGS) qualify as an emergent CNS property, since in AGS the acoustic stimulus evokes a non-linear output (motor convulsion), but the identical stimulus evokes minimal behavioral changes normally. The hierarchical neuronal network, subserving AGS in rodents is initiated in inferior colliculus (IC) and progresses to deep layers of superior colliculus (DLSC), pontine reticular formation (PRF) and periaqueductal gray (PAG) in genetic and ethanol withdrawal-induced AGS. In blocking AGS, certain anticonvulsants reduce IC neuronal firing, while other agents act primarily on neurons in other AGS network sites. However, the NMDA receptor channel blocker, MK-801, does not depress neuronal firing in any network site despite potently blocking AGS. Recent findings indicate that MK-801 actually enhances firing in substantia nigra reticulata (SNR) neurons in vivo but not in vitro. Thus, the MK-801-induced firing increases in SNR neurons observed in vivo may involve an indirect effect via disinhibition, involving an action on the emergent properties of this seizure network.