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TYPES OF EPOLEPTIC SEIZURE: GENERALIZED SEIZURES
The tonic clonic (grand mal) seizure
The generalized tonic clonic seizure is the best known and the most common type of generalized seizure. It is everyone’s idea of a typical epileptic fit ? what used to be called the grand mal seizure. Grand mal’ is still the name by which many people know them best, but people who have epilepsy and work with it now always call these seizures ‘tonic clonic’ and so this is the term I shall use in this book.
During a tonic clonic attack the person falls to the ground unconscious. In the first ‘tonic’ phase of the attack the muscles of the body contract, the arms and legs go straight and rigid, the mouth clenches tight and the whole body is stiff. The seizure may end at this point, or it may continue with a second, ‘clonic’ phase during which the muscles of the body jerk in unison, starting at a rate of about once a second, slowing to a rate of once every four to six seconds, and then stopping. Sometimes a convulsion consists only of this jerking phase. At the end of the seizure the muscles relax. Sometimes, but not always, bowel and bladder control are lost during the fit. If you suffer from tonic-clonic seizures you will probably find that the extent of the two phases of the fit will vary from time to time.
Usually these seizures occur quite suddenly, out of the blue, though a few people do have a vague feeling of being unwell for a few seconds immediately before a seizure. But if you suffer from grand mal seizures you will not experience any ‘aura’ or odd sensation at the beginning of an attack to warn you that it is about to occur.
Absence seizures
Another very different kind of generalized seizure is the ‘absence’ (what used to be called the petit seizure). In fact ‘absence’ describes this kind of seizure very well, and so this is the name which I shall use for these seizures throughout the book. During an absence the person – nearly always a child – has a ‘blank’ period from seconds up to half a minute or so long during which they are usually quite unaware of anything that is happening to them, though they may rarely retain a dim awareness of what is going on around them. They may look pale, and their eyes are fixed and glazed. Sometimes their head will slump forward, though usually they will stay in the same position they were in before the attack. There may be brief muscular twitches around the eyes, or jerks of the limbs, but because this is a generalized seizure, affecting the whole brain, these movements will always be symmetrical, and always affect both sides of the body. When the attack is over, the child will carry on exactly as before, as if nothing has happened, continuing with whatever they were doing or saying when they were interrupted. Usually about five or ten such attacks will occur in the course of a day, but sometimes runs of attacks occur in rapid succession.
To the onlooker it may look as though the child is simply daydreaming or not concentrating, and the attacks may even pass quite unnoticed as there are virtually no after-effects. However, an EEG recording made during one of these absences will reveal a characteristic pattern, called spike and wave. The good news about absence seizures is that they usually disappear around adolescence, though occasionally they’ll persist into adulthood or give way to tonic clonic seizures. But while they are occurring they can be very disruptive of a child’s education, as well as giving him or her an undeserved reputation for inatten-tiveness. So it is important that they are diagnosed, and that they are treated.
A few children have more complex absence seizures, which last rather longer and are accompanied by lip-smacking, chewing or fumbling movements, but the EEG still has the same characteristic spike and wave pattern.
Myoclonic epilepsy
These are sudden, very brief and uncontrollable muscle jerks which usually arise from a focus on one side of the brain, affect only one side of the body, but can be generalized and affect both sides. They look essentially the same as the myoclonic jerks which most people occasionally experience just as they are dropping off to sleep. The person may be flung off balance, or if they are holding something it may be dropped or thrown violently away.
Juvenile myoclonic epilepsy
Juvenile myoclonic epilepsy (JME) is a common generalized epilepsy, with a significant genetic component. The first seizure usually occurs in the teens, most frequently between the ages of 13 and 15. For some months or years before the first seizure, the person often has mild myoclonic jerks ? the involuntary sudden jerky movements of the limbs that everyone experiences now and again, usually when they are dropping off to sleep. These jerks are usually in one or both arms, and occur within an hour of waking. In a few children the myoclonic jerks are preceded by mild absence seizures which start around the age of ten.
Seizures are triggered by lack of sleep and alcohol. About half the children who have JME are photosensitive, and for them flashing lights are a potent seizure trigger.
The outlook is good for children with JME. Up to 90 per cent become seizure-free with medication (usually sodium valproate). Unfortunately if medication is withdrawn there is a high relapse rate, even for someone who has been seizure-free for several years.
Sixteen-year-old John was used to his mother getting irritated with him at breakfast. He was always clumsy and jittery first thing in the morning; often his arm would jerk as he was trying to drink, and coffee would go everywhere. But no one took it seriously until one Sunday morning John had his first tonic clonic seizure on waking. The night before he’d been at a party, had got home at 1 a. m. and tumbled into bed exhausted and, in his own words ‘well tanked up’. Later, when John and his parents were talking to their doctor, John wouldn’t even have thought to mention his early morning jitteriness if the doctor hadn’t specifically asked him if he ever had any twitchiness in his limbs first thing in the morning.
Drop attacks
Drop attacks affect all ages and consist of a sudden, very brief loss of consciousness and muscle tone, so that the person does, literally, drop to the ground. The real danger of these attacks is that they occur quite without warning, and so the person may be badly bruised or hurt.
Infantile spasms (West’s syndrome)
One of the most serious kinds of childhood epilepsy is also, fortunately, one of the rarest. A few infants develop what are called infantile spasms between the ages of about three months and a year. The spasms – sudden, massive contractions of all the body muscles ? occur because the normal activity of the brain is disturbed, and this can happen for a variety of reasons. As they grow older many of these babies do, sadly, have learning difficulties or develop autisms, and many continue to have seizures.
*5/193/2*

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TYPES OF EPILEPTIC SEIZURES: ABSENCES (PETIT MAL SEIZURES)
For years the term petit mal has been used to describe this form of seizure. This is no longer recommended and the term absences is preferred. The reason for this is that the term petit mal is often used incorrectly by patients to describe a whole miscellany of fits that are not grand mal, but nor are they absences. It is therefore a confusing term.
Absences are a form of generalised epilepsy. In a petit mal absence, there is either a decrease or suppression in mental function which begins and ends abruptly. Attacks may last for 5-30 seconds and occasionally longer. They often occur many limes a day. The typical features are that the patient is seen to stare, the eyes may drift upwards and the eyelids flicker. During that time it is apparent that the child is absent (not with you). For a child, recurrent absences of this sort make any form of sustained attention difficult and prevent learning. It is not uncommon for children with absences to visit the doctor with symptoms of inattention, rather than a complaint of seizures themselves.
*6/192/2*

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TYPES OF EPILEPTIC SEIZURES: GRAND MAL SEIZURES (MAJOR GENERALISED SEIZURES)
Grand mal seizures are the commonest type of seizure. About 70 – 80% of children with epilepsy have grand mal fits. A grand mal fit may begin without warning or may be preceded by an aura.
An aura is a sensation which precedes loss of consciousness mid is actually the beginning of the fit. This may be a regular event for some people, but not for others. The nature of the aura will depend on the area of the brain in which the fit begins. Some people may exhibit unusual behaviour or be somewhat out of sorts before an attack. At the start of the fit there is a sudden loss of consciousness. If at that time the patient is standing, he or she will fall to the ground. This is quickly followed by generalised rigidity (stiffening) of the body, called the tonic phase of the fit. This is then followed by a generalised jerking of the body, the clonic phase. During the clonic phase patients may bite their tongue, pass urine or pass a motion. These three events occur less often in children than in adults.
During the tonic phase, when the body is rigid, the face and lips may go blue (cyanosis) as the patient is unable to breathe because of the stiffening of the body. Thereafter, breathing becomes jerky during the clonic phase and the cyanosis (blueness) lessens. The clonic movements then gradually settle down and the patient becomes relaxed and limp. After a grand mal fit the patient may recover rapidly, but if it has been a long fit, they may go into a deep sleep. Associated with recovery there may be feelings of weakness, headache or fatigue and some people may be confused and irritable. In addition, some people may injure themselves during a fit.
When a number of grand mal convulsions follow each other in rapid succession, the situation becomes serious and is called status epilepticus. This implies that the epilepsy is continuous and will not stop spontaneously.
*5/192/2*

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PSYCHIATRIC DIMENSIONS OF MEDICAL PRACTICE: CLINICAL
ASSESSMENT-PATIENT’S PSYCHIATRIC HISTORY AND PREMORBID PERSONALITY
A personal history of psychiatric disorder can be assessed either in the review of systems or in the past medical history. Here, too, there is a smooth transition from questions about neurological symptoms to questions about psychiatric ones. In the review of systems, for example, “Do you get frequent headaches?” and “Have you been depressed or anxious?” will be regarded as parallel inquiries.
Patients sometimes report having had a “nervous breakdown.” Because the meaning of this term is so uncertain, the physician should obtain a description of symptoms at the time of the illness. Just as in the medical and surgical histories, additional informants may be needed for an accurate understanding of past diagnoses and treatments.
Premorbid personality-The goal of assessing premorbid personality is not only to learn more about the patient as an individual but also to discover traits that may shape her response to illness and her relationship to physicians and others involved in her care. A good time to evaluate the premorbid personality is following the review of systems or the past medical history: “You’ve told me a lot about your health. Now I’d like you to tell me about yourself. What kind of person would you say you are?not when you’re ill, but when you’re well?” Depending on the response, the physician may wish to inquire about traits of particular interest in the medical setting. Thus, after a patient describes herself as “a good person … a kind person … a hard worker,” the physician should ask her whether she tends to be optimistic or pessimistic; carefree or worried; trusting or suspicious; calm or irritable. Someone who knows the patient well might also be asked to characterize her, if only because we often lack the gift to see ourselves as others see us.
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WHAT TYPES OF SEIZURES ARE THERE?
The classification of epilepsy has become quite complicated with a number of suggested classifications over the past two decades. There is now a general feeling that it is better to think in terms of the epilepsies or epilepsy syndromes, rather than of epilepsy per se. Although there is not a universally accepted classification of the epilepsies, especially in childhood, there is general agreement that many are distinctive, not only in terms of their symptoms and management, but also with regard to outlook.
Thus, at present, epilepsy can be discussed in two ways:
by discussing seizure type. In other words, a person may have grand mal seizures. This however does not define precisely the sort of epilepsy that they have, as grand mal seizures may occur in more than one type of epilepsy.
by discussing the type of epilepsy, or the epilepsy syndrome, which that person has. Thus a child may have Infantile spasms as the type of epilepsy, but exhibit myoclonic Jerks and grand mal seizures as their seizure type.
This chapter discusses the various types of seizures which can occur and the next chapter will discuss the various epilepsy syndromes, especially in childhood and adolescence.
From a practical point of view, seizures can be divided into generalised and partial seizures. A generalised seizure implies that abnormal electrical activity involves both halves of the brain (cerebral hemispheres) from the outset. On the other hand, partial seizures start in one cerebral hemisphere and the electrical activity does not spread to the other side of the brain. Thus the term ‘partial seizure’ means that only part of the brain is involved.
As a working rule, a generalised seizure which involves the whole brain is associated with losing consciousness. In partial seizures, consciousness is retained to a greater or lesser extent. In some partial seizures, consciousness may be retained initially but then the fit may become secondarily generalised and the patient will become unconscious in association with a major fit.
There are a number of different types of seizures (fits) which will be discussed in some detail below. However, before doing so, a general comment is warranted. It is of considerable importance that people with epilepsy should know precisely what type of seizures and what type of epilepsy they have. It is not good enough to say “I have epilepsy”. You should be able to say, “I have temporal lobe epilepsy” or “my child has infantile spasms”. The reason that you as an epileptic, or the parent of an epileptic child should know this, is that the outlook for the various types of epilepsy differs. Equally important, from a public relations point of view, people with epilepsy or parents of epileptic children need to be advocates for epilepsy. As we have already discussed, the general public is ill-informed about epilepsy. They believe all epilepsy is a grand mal fit as they have seen on television. Only by being precise about your epilepsy will you be able to educate those around you about epilepsy and its implications.
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WHAT HAPPENS DURING AN EPILEPTIC SEIZURE?
Most people’s view of a typical epileptic fit is the major grand mal seizure in which the sufferer falls to the ground unconscious and jerking. But this is only one of the very many different types of seizure. A few people suffer from more than one kind of seizure, and the form their epilepsy takes may change, so that they may have different kinds of seizures at different stages of their life. To understand exactly what happens during the different kinds of seizure, and why they occur, we need to look a little more closely at the way the brain works.
Information is transferred within the brain in the form of electrical impulses, passed from cell to cell by chemical messengers, which can make the cells which transfer information either more or less excitable. As each brain cell ‘fires’, it stimulates a neighbouring cell and this in turn fires and excites the next cell along the pathway. Some of the cells which fire are inhibitory cells and these tend to damp down the activity, so that it does not run rampant through the brain, out of control.
How excitable the brain is depends on the balance of those chemical messengers which excite and those which inhibit cell firing. In some people the brain cells are more excitable than normal. They will fire more easily and, instead of the normal damping down by inhibitory cells, there is a sudden paroxysmal burst of electrical activity within a group or groups of cells. This is known as the ‘epileptic spike discharge’ and its presence can usually be picked up through the scalp by use of the EEG. However, even if you have these spike discharges they needn’t cause any disturbance and you will normally be quite unaware of them. It is only when the damping down activity fails more extensively that the abnormal activity spreads. Whole areas of cells become involved and start to fire in these paroxysmal bursts: a seizure (convulsion or fit) then occurs.
Sometimes, if there is an area of localized brain damage, the cells at the centre of this damaged area are so altered that they can no longer fire normally. These cells are called pacemaker cells, and they fire abnormally and continuously. Nothing stops them. However, they do not, of course, cause fits continuously. Something else must happen to make a seizure occur.
We know that before a seizure occurs the pacemaker cells all clump together and discharge in unison. As they clump together, the pacemaker cells recruit the cells surrounding the damaged area into the discharge and it is this spreading of the discharge which causes a localized or focal seizure. Yet why should this happen in the first place? What makes the pacemaker cells which are firing all the time suddenly interest the cells surrounding them in their faulty messages? The answer seems to be that some change in behaviour or thinking, or even something as simple as drowsiness, makes these neighbouring cells temporarily more excitable so that they can be drawn into the seizure discharge more easily.
These focal seizures can sometimes spread to include the whole brain ? a process called secondary generalization, which often results in a major seizure.
*3/193/2*

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SUFFERING FROM SLEEPING DISORDERS
The 1992 report of the National Commission on Sleep Disorders Research, which Dr. Dement chairs, estimates that 40 million Americans suffer from some kind of chronic sleep sickness. About half of them are plagued by a condition called sleep apnea (from the Greek, meaning “not breathing”). Such individuals actually stop breathing while asleep. As carbon dioxide builds up in the lungs, the brain senses something gone wrong and sounds its alarm, waking the person enough to activate the chest and diaphragm muscles. With a terrible snore, the lungs suck in fresh air. Sleep ends for the moment. This can happen 500 times a night, fracturing any peaceful, restorative slumber. During the day, the afflicted person, lacking a restful night, constantly dozes off.
I. M. “Rusty” Gralnik, an engineer in Santa Clara, California, tells this story: “I would go to a ball game and, instead of going in the stadium, stayed in the parking lot to sleep in the car. I didn’t know something was wrong – I just thought I was tired. I would fall asleep working at my computer or while trying to read. A year ago, my wife was complaining that I was a terrible host: I’d fall asleep in front of our guests.”
People with sleep apnea inhale with high suction. It was so high in Mr. Gralnik’s case that it caused his throat to close, waking him repeatedly. This happens most often to people who are greatly overweight, although Mr. Gralnik is thin. Scientists have developed a breathing machine for apnea patients that pushes air into the nose under positive pressure, expanding the windpipe and making breathing easier.
“I feel a little more alert now,” Mr. Gralnik says, “but I’ve been down so long, it will take a while for my body to rejuvenate.” For those not helped by the machine or unable to sleep while using it, surgery opens the throat.
Rusty Gralnik’s apnea was diagnosed at Stanford’s sleep laboratory, which boasts rooms with air and light controls, and infrared TV cameras that “see” in the dark. A microphone and wires lead from a subject’s scalp to a recording machine, so doctors can see and hear the breathing, the snores, the apnea. Now 140 medical centers have such labs.
Great progress has been made in helping insomniacs – people who can’t fall asleep easily. Many perceive, sometimes falsely, that they have not had enough sleep or have endured bad, non-restorative slumber. The National Commission on Sleep Disorders Research estimates that 60 million Americans have experienced some insomnia, 15 million of them severely and chronically.
Gina Braun, a Tucson, Arizona, homemaker and mother of three young children, bore the burden of chronic insomnia. Her worst wakefulness struck during her last pregnancy. In her 8th month, pills helped Mrs. Braun rest for a while, but their effectiveness faded.
She found Richard Bootzin, director of the Insomnia Clinic of the University of Arizona Sleep Disorders Center in Tucson. Says Dr. Bootzin, “People need to develop skills for falling asleep.”
“Dr. Bootzin got me on a schedule,” Mrs. Braun says. “Before, I’d go to bed at 9 P.M., wake up at midnight, and stay awake ’til 9 A.M., when my husband [a fireman] would come home from his 24-hour shift. I had no sleep cycle.”
Dr. Bootzin used these do’s and don’ts that sleep scientists have developed to break insomniacs’ bad habits:
? Do keep a diary of your bedding-downs and waking-ups for a week, to observe your slumber pattern.
? Do maintain a regular schedule. Go to sleep and get up at the same time daily.
? Don’t drink caffeine after noon or alcohol at any time.
? Don’t nap during the day – be active.
? Don’t go to bed until you’re drowsy. If you’re wide awake, staying in bed makes matters worse.
? Do keep your bed for sleeping and sex only. Read, sew, or watch TV elsewhere.
“Dr. Bootzin told me to get out of bed as soon as I felt anxious,” says Mrs. Braun. “At first, I was out of bed 10 to 15 times a night. Now, if I can’t sleep, I get out of bed and go read. I’m thankful things are so much better.”
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