Perhaps no condition throughout history has generated more fear and paranoia than epilepsy. Myths have surrounded this neurologic condition for centuries and have promulgated physical, economic, and emotional issues. But despite its negative image, most people with epilepsy live normal lives with well-controlled symptoms and minimal restrictions.
Jack has simple partial seizures, occasional brief bouts of muscle twitches in his right arm. About once a month, Carla suffers intense recurrent feelings of fear. Rob has grand mal seizures that cause him to lose consciousness and fall to the ground with jerking movements and muscle spasms. Ted has temporal lobe seizures. About once a month, he goes into a dream-like trance, relentlessly smacks his lips and appears to be drunk or "high."
Although dissimilar in their symptoms and their severity, these four people all share a diagnosis of epilepsy.
Epilepsy is a neurologic disorder characterized by chronic, recurrent disturbances in the normal electrical activity of the brain. These disturbances are caused by sudden, uncontrolled bursts of electrical energy called seizures. They may block or alter consciousness and affect body movements, sensations, and/or emotions for a short time.
Approximately 2,500,000 people in the United States have epilepsy. Anyone can develop epilepsy at any time. However, 20% of cases develop before age five and 50% before age 25. But the true incidence is hard to assess, because there is still general reluctance on the part of the patient or the physician to report the problem, and because of the confusion as to when seizures constitute epilepsy. The incidence of epilepsy is higher in the children of people with epilepsy compared with the general population, and relatives of patients with epilepsy exhibit abnormal brain waves more frequently than do control groups.
There are many types of seizures, which are divided into two main categories:
- generalized seizures
- partial seizures
Generalized seizures occur when the electrical disturbance affects the whole brain. They cause loss of consciousness, convulsions, and falls. They used to be called "grand mal" seizures, and are typical of the seizures that people associate with epilepsy.
Partial seizures occur when the disturbance begins in only a single part of the brain. They affect only the physical or mental functions controlled by that area. Partial seizures are very common, occurring in six of 10 adults with epilepsy and four of 10 children with epilepsy. However, they often go unrecognized and may be misunderstood or mistaken for another condition.
Partial seizures are divided into simple and complex, depending on whether awareness is affected. People usually remain fully aware during simple partial seizures. However, movement, sensations, and emotions may be affected in unusual ways. For example, Carla experiences a sudden feeling of fear, which is a simple, partial seizure. Simple partial seizures may also manifest as strange sounds, smells, or tastes; or distortions in the way things look. Sudden nausea, stomach pain, sweating, flushing, or loss of color may also occur.
Complex partial seizures affect a larger portion of the brain than simple partial seizures and cause changes in awareness. Ted, for example, has epilepsy caused by complex partial seizures. When a seizure hits, he appears to be conscious, but is actually in a dream-like state. He claps his hands or smacks his lips, slurs his speech, and appears to be drunk, out of control, or socially inappropriate. When he "comes to," he is usually exhausted. Because complex partial seizures often occur in the temporal lobes, this disorder is sometimes called temporal lobe epilepsy.
In most patients, seizures occur unpredictably and without any relationship to ongoing activities. However, they may occur as a result of certain stimuli such as lack of sleep, missed meals, emotional
stress
, menstruation,
alcohol
ingestion, or certain drugs. In some patients, seizures are provoked by flashing or flickering lights, such as the lights on a police car or a strobe.
In about 50% of cases, the cause of epilepsy is not known. In the other cases the cause may be brain scarring or damage caused by head trauma, especially from accidents and falls; tumors or strokes; some poisons; infections, such as meningitis or encephalitis; or maternal illness that affects the brain of the fetus. Epilepsy may also be inherited.
A medical history that includes a description of the seizures is the most important tool for diagnosis. An electroencephalograph (EEG) is also used to study electrical signals from the brain cells. Imaging techniques such as magnetic resonance imaging (MRI) and computerized tomography (CT) scans are used to look for factors in the brain that may be causing the seizures, such as tumors or scars.
Anti-convulsant medications, such as phenytoin (Dilantin), phenobarbital, and many others, are used to treat the majority of epilepsy cases. Medications are chosen on the basis of seizure type. Anti-convulsants prevent or control seizures, but do not cure them. They also have significant side effects, including drowsiness, lethargy, skin rash, headache, and gastric distress.
Historically, a combination of drugs was used to treat epilepsy. The theory behind this was that lower doses of each drug could be used, thus decreasing the side effects. Today, many neurologists prefer to use a single-drug approach (monotherapy), both to minimize the number of drugs used and to decrease the possibility of dosage errors.
According to Daniel Hoch, M.D., co-director of the Epilepsy Service at Massachusetts General Hospital in Boston, "in the last four years, several new medications have been introduced, and several more are on the horizon. The advantage of the new medications is that the side effects are often better tolerated."
Careful assessment and frequent clinical monitoring of drug levels are often critical to patient management. Drugs are metabolized at different rates in different people, so it is important to measure drug levels in relationship to seizure control and side effects.
Drug therapy is prescribed with the goal of having no new attacks, and is usually continued until there have been no seizures for at least four years. When a patient has been seizure-free for four years, medication withdrawal is often considered. The dose is usually reduced gradually over a period of weeks or months. If seizures recur, treatment is re-instituted with the same drugs as used previously. Seizures are usually no more difficult to control after a recurrence than before.
There are several other treatments that may be used when medication fails. Surgery on brain tissue is becoming more sophisticated due to new imaging techniques. Vagal nerve stimulation is a type of electrical stimulation that helps prevent seizures through a device placed under the skin in the neck. A special diet, called the ketogenic diet can prevent seizures in some people with epilepsy, especially children. However, it is a very rigid diet and is quite difficult to follow. There is a brand new treatment available for women with epilepsy that uses hormones to control seizures that worsen with the menstrual cycle.
It is important to diagnose seizure disorders early and correctly. Undiagnosed, uncontrolled seizures can lead to learning, behavior, and social problems. They can also cause safety risks when awareness is altered or lost. However, most people with epilepsy who receive proper treatment are able to live full, productive lives.
People with epilepsy should be encouraged to wear some form of medical identification. This has been resisted in the past because of the lingering social stigma associated with epilepsy. Epilepsy associations offer many programs to help people with epilepsy, especially children and their families, cope with both the physical and the psychosocial issues. It is important that all people in contact with children who have epilepsy including teachers, sports coaches, babysitters, and social club leaders be aware of the condition and know what to do if a seizure occurs.
If the person is falling, try to support or ease the fall and lay him down gently. Clear a space around him. If possible, loosen clothing around the neck and place something soft under the head. When convulsions stop, place him in the recovery position (laying on his side with knees bent) This position ensures an open airway because the tongue cannot fall to the back of the throat, and the head and neck remain in an extended position so that the air passage is widened, and any vomit or fluid will drain freely.)
DO NOT move or lift the patient unless in danger. DO NOT forcibly restrain. DO NOT put anything in his mouth or try to open it. DO NOT try to wake him. Seek medical aid immediately.
