Blog #54: What Happens to Children with Epilepsy Later in Life?

 

            The complexities of living with epilepsy and questioning what the future holds are explored in the December 4, 2014 issue of Neurology Today. Jamie Talan, a journalist at the publication, reports a study presented by Dr. Anne T. Berg of Northwestern University at the American Epilepsy Society annual meeting in December, 2014. This same question—what does the future hold in epilepsy?―is juggled by the newly diagnosed third-grader Conner Golden and his family in my epilepsy novel, DINGS (ISBN 9781626463042).

            The experience of neurologists is that children who rapidly become free of seizures once an anti-convulsive medication regimen is begun usually remain seizure-free while they are on the medications. However, predictions of continued seizure cessation are less reliable once medications are stopped.

            The study reported by Dr. Berg included six hundred thirteen children aged from under one to fifteen years who had any form of epilepsy. It was carried out by researchers at Yale and Northwestern University beginning in 1993. Among the six hundred thirteen, five hundred sixteen of these children were followed at least 10 years; on average they were monitored for approximately seventeen years. A large percentage did well over the long term. About one-third of the six hundred thirteen was free of seizures within 2 years of the diagnosis and they were eventually able to stop their medications. Just one-quarter of that group which stopped medications were seizure-free for 5 years when the study ended. Twenty-five percent of the participants had seizure control, too, but only when they continued anti-convulsants. A further sixteen percent of the group continued to have seizures despite anti-convulsants but this group tended to have other neurological conditions complicating their epilepsy.

            Among the participants who were followed at least 10 years and who had been seizure-free for at least a one year period, fifty-two percent experienced a relapse. The researchers concluded that short-term remission of seizures did not guarantee long-term remission. Many reasons accounted for relapsing-remitting seizure control, including stopping anti-convulsant medications.

            Dr. Jacqueline A. French, a leader in epilepsy research, is quoted in the above Neurology Today article: “Neurologists have believed that they could stop medication if a patient was seizure-free for two years and that they would be fine for the rest of their lives […] but this is not the case. Two years may be too short [a time period] to determine whether a child will have problems with epilepsy again. We still don’t have a way to know which children will relapse.” Dr. Patrick Kwan, chair of neurology at the University of Melbourne and head of epilepsy at the Royal Melbourne Hospital in Australia commented on childhood epilepsy in the publication: “The data suggests that relapsing-remitting pattern of epilepsy control is not uncommon in children. This should be conveyed to patients when counseling them on prognosis. We need more studies […].”

            In conclusion, remission of seizures during the first two years of treatment is a favorable predictor of epilepsy-control but long-term future seizure-free life without anti-convulsants cannot be accurately foretold.

 

 

 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. DINGS is his first novel. It is a mother’s dramatic story that teaches epilepsy.

Blog #53: New Studies: When Is It Safe to Drive With Epilepsy?

(This blog was originally posted on December 26, 2014)

 

 

 

 

 

            “I get an aura, a warning before my epileptic seizure, so that protects me and I can pull my car over and avoid an accident.” That’s what some people with epilepsy believe. Can these patients truly protect themselves and the driving public? There’s not enough information to make an accurate decision.

            An article in the December 4, 2014 issue of Neurology Today reviewed studies reported at the 2014 American Epilepsy Society Annual Meeting. The article concluded that neurologists and law-makers need to rethink current recommendations about driving with epilepsy. The American Academy of Neurology previously considered auras―“warnings”—that were consistent and prolonged to be a favorable feature in sanctioning a driving license. Recent studies question this belief: the aura did NOT protect the driver from an accident. Accident rates in people who have auras were similar to patients who did not have auras.

            In their study, patients underwent continuous video-EEG monitoring at the Yale Epilepsy Center while simulating “driving” on portable computer-based driving simulators, complete with brakes, gas, and a steering wheel. Researchers found that patients with longer seizures and seizures that led to a loss of consciousness were more likely to “crash” their vehicles in the simulated test compared to patients with other types of seizures without loss of consciousness (e.g., simple partial seizures). The research showed clearly that people who lose consciousness or have serious impairments in their movements during a seizure should not drive until treatment controls their seizures. Other patients whose EEG showed epileptiform discharges (these correlate with altered brain neuron-cell function) that did not alter consciousness or have other symptoms (subclinical EEG discharges) had vague, imprecise effects on driving. However, and very significantly, many patients who had lost consciousness did not know that their awareness was impaired during the “subclinical” EEG discharges when queried by the researchers.

            Some states leave the important decision of when to allow driving in people with epilepsy up to the neurologist. But in six states, California, Oregon, Nevada, Pennsylvania, New Jersey and Delaware, the state’s Department of Motor Vehicles makes the ultimate decision utilizing the physician’s—not necessarily a neurologist―input.

            With imprecise ability to determine if consciousness is preserved or not, neurologists need to be cautious in deciding whether a person who has epilepsy can drive safely. As noted above, there is still not enough information to make a highly accurate, sound decision about this important safety issue.

 

 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. DINGS is his first novel. It is a mother’s dramatic story that teaches epilepsy.

 

Blog #52: Unrecognized Epilepsy in the Classroom

(This blog was originally posted on November 25, 2014)

 

            When I discuss my epilepsy novel, DINGS, occasionally parents or relatives of epilepsy patients have told me, “That story sounds just like what happened in our family; no one knew what was wrong with her for the longest time until a doctor finally diagnosed epilepsy.” DINGS features a mother whose bright, eight-year-old son, Conner, is failing third grade. Conner’s complex partial seizures are not recognized and he is too immature and inarticulate to complain about his confusing symptoms of blank-outs which are usually preceded by the classical (but not always present) hallucinating bad smells such as “burning rubber.” Meanwhile, the youngster’s teachers, friends and parents don’t notice the boy’s brief confusion episodes which last seconds to minutes. Since convulsive movements are not part of his epilepsy experience, his friends think he is just acting weird whenever he stares into space and makes chewing, swallowing and other small movements while he seems to be “in his own world” for the minute or two these seizures last.

            Educators can have difficulty recognizing this form of epilepsy and the other type of blank out—the petit mal seizure. Complex partial seizures are preceded by a difficult-to-describe confusing sensation in the belly—the aura―associated with a facial expression of fear. Then, awareness is lost associated with lip smacking and swallowing movements and movement of fingers such as picking at clothing. Humming and uttering short phrases or aimlessly walking can occur: none of these behaviors are recalled after the seizure and the person remains confused for a short while as the seizure slowly terminates.

            Unlike the complex partial seizure, the petit mal seizure differs in that it is not preceded by an aura. Furthermore, it lasts just 10-20 seconds during which time the patient (it is almost always a child or a teen) doesn’t fall but loses awareness with excessive blinking. The person will come out of the spell and will be immediately alert without any awareness that consciousness was lost.

            If either complex partial or petit mal seizures are frequent, concentration and learning are bound to suffer. If no one tries to interact with the child during these events teachers may incorrectly conclude that the child has a learning disorder or is daydreaming. Alternatively, educators may suspect that the child may have a hearing problem since the child may not respond when addressed. An intermittent stuttering problem may also be considered as speech may be stuttered during the spell. Finally, ADD and autism have been confused with these two types of epilepsy.

            If you are familiar with these types of seizures I recommend that these non-convulsive seizures and their mimics be brought to the attention of school personnel. Increasing teachers’ awareness can lead to earlier diagnosis and treatment resulting in more successful learning.

 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. DINGS is his first novel. It is a mother’s dramatic story that teaches epilepsy.

 

Blog #51: DINGS, My Epilepsy Novel, Came to Life and Touched a Family

(This blog was originally posted on October 26, 2014)

 

 

          I was recently invited to a local restaurant by a woman who lives in my city. The restaurant had displayed copies of DINGS, as a novel written by a local author and she purchased a copy. The woman wrote:

Hi Dr. Fogan,

I just finished your book. If I didn't know any better I'd say that story was about my mother and I.  I am now 46, so for me I'm going back about 40 years. It took different doctors to figure out that it was Epilepsy. Then there were the drugs, Dilantin, Phenobarbital and Tegretol.  No drug ever stopped them, perhaps slowed them down, I had "dings" with the funny feeling in my stomach and the fear of another one coming on -throughout the day, everyday.  Left temporal lobe epilepsy.

 

It must have been the late 80's early 90's when my mother and I walked into our Dr's office for a routine visit.  The doctor told my mother that I would be a perfect candidate for this new procedure they we're doing at UCLA and that we should look into it.... I was 23. My surgery occurred in 1993.

The change over wasn't easy though, the seizures had been my life. But today, I have been married for almost 10 years and we have 2 beautiful children. So thank you for your story.

            Our breakfast meeting was made so that her mother, who was visiting from out of town, could also meet me. When I entered tears filled the younger woman’s eyes as she rose to greet me. Her speech occasionally halted and her eyes moistened as both women related their lives and the daughter’s difficult epilepsy stories during our two and one-half hour visit. I was deeply moved. Our meeting was a valuable and touching experience for me.

            The narrative in my novel tells a mother’s story as she tries to account for her bright 8-year-old failing third grade. His learning problems were due to unrecognized complex partial seizure confusion blank outs. As the e-mail above states, my fictional characters’ experiences in DINGS were so very close to the actual life experiences of both of these women. My new friend’s complex partial seizures similarly were not recognized in school. A teacher even struck her during one of her blank out-confusion spells thinking she was on drugs. Her student-friend came over to restrain the teacher, saying, “Stop! She has epilepsy.” Hallucinating foul odors were commonly experienced by the protagonist in my novel but these were not part of her complex partial seizures. But, both the fictional character and my new friend experienced confusing, difficult to explain rising abdominal sensations and fears. She fidgeted her hands. These are classical symptoms of the complex partial seizure form of epilepsy.

            Her mother described how her daughter’s situation was continuously on her mind; she never knew when she’d get a frantic call concerning her daughter’s very frequent seizures while she ran an active business enterprise. The older woman said that she also had to be extremely alert when her daughter took baths or showers at home, and she would never take her eyes off of her daughter for a second when they visited the beach.

            DINGS highlights that successful life can be achieved while living with epilepsy. My new friend is able to drive and she has a happy family life caring for her lovely family.

 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. DINGS is his first novel. It is a mother’s dramatic story that teaches epilepsy.

Blog #50: Epilepsy Management

(This blog was originally posted on September 25, 2014)

 

 

 

 

There are four primary types of epilepsy treatment of which patients and their families need to be aware. 1) Medications. 2) Devices that stimulate the nervous system. 3) Special diets and 4) Brain surgery. These treatments need to be considered since approximately one out of every three patients with epilepsy does not respond adequately to anti-convulsant medications.

Surgery that removes the offending brain area from which seizures originate can possibly cure epilepsy. The other treatments are not curative. Neurostimulators generally reduce, but do not eliminate, the number of seizures. Such stimulators include: vagus nerve stimulators (VNS) that have a small battery-powered stimulator implanted beneath the skin in the upper chest with its stimulating wires winding up to contact the vagus nerve in the neck. Other battery-operated neurostimulators currently approved for use in the United States are surgically placed in the skull bone with its stimulating wires contacting the brain cortex. It responds if the device detects the onset of seizure activity. It “short circuits” the seizure and minimizes or prevents that seizure. Diets that favorably affect epilepsy are very specialized and for the most part aid young children whose epilepsy is uncontrolled. These diets are extremely restrictive regarding the foods that can be eaten.

I urge patients and their families to consider this information and to discuss with their neurologists if any modality is appropriate for their treatment.

 

 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. DINGS is his first novel. It is a mother’s dramatic story that teaches epilepsy.

Blog #49: Psychogenic "Fake" Non-Epileptic Seizures

(This blog was originally posted on August 27, 2014)

 

 

Experience shows that up to one-third of our patients in epilepsy clinics have involuntary, psychogenic, fake pseudoseizures. They resemble the patient’s true epileptic seizures; distinguishing between them can be very challenging.

Some of our “epilepsy” patients are misdiagnosed: they never had epilepsy to begin with. Close follow up may lead to clues that the seizures are not real, such as: poor seizure control in the face of repeatedly normal electroencephalograms (EEGs); varied physicality of the “seizures;” and they occur conveniently during emotional stress.

 Psychogenic “seizures” show no abnormalities on the EEG indicating that they do not originate in abnormal epileptogenic nerve cells in the brain. Highly sensitive EEG telemetry recordings with video pictures of patients in a hospital setting show this when patients exhibit their “seizure” activity. That pseudoseizures occur complicates care of our patients. Twenty to thirty percent of patients have poorly controlled refractory epilepsy; anti-seizure medications can’t prevent them. Neurologists must consider if the patient’s refractory seizure control could be due to involuntary, psychogenic seizures in addition to the patient’s true epileptic seizures or they do not have epilepsy at all.

So then, what is the problem? In most cases the patient is not consciously “faking” their seizures. Rather, underlying psychological problems and stresses seem to induce the “seizure.” These “seizures” could support the patient’s loss of control and augment his dependency in his life patterns without insight or understanding. This, in turn, relieves responsibility for his failings. He becomes a sick and dependent person satisfying his various psychological needs. This is called a “conversion syndrome.”

LaFrance and associates recently published a study on treatment of “refractory” seizure patients who had never showed EEG abnormalities during their “seizures.” They did not actually have epilepsy. A form of psychotherapy which his group calls “cognitive behavioral therapy,” reduced seizures by 51.4%; it also improved their quality of life, social interactions and reduction in depression and anxiety. This Cognitive Behavior Therapy is unique. It will be found in the researchers’ Taking Control of Your Seizures: A Workbook, to be published later in 2014 by Oxford University Press (1). This therapy emphasizes assertive communication. The patients learned to identify auras for their pseudoseizure so they could then act to avoid it. Some kept thought records so they could review their thoughts and moods from a different perspective. The researchers found that many of these patients had suffered abuse and trauma. This version of psychotherapy addressed their patients’ core beliefs. It helped people who felt victimhood to feel empowered and to take control of their “seizures.”

The longer the pseudoseizure condition exists without effective treatment the more difficult it is to control. Neurologists can improve psychogenic non-epileptic seizure-healing by suspecting it earlier. Ordering EEG video monitoring sooner, and which lasts hours to days after initiating care for a new poorly-controlled epilepsy patient, can reveal the true diagnosis. Then patients can discontinue their ineffective antiseizure medications and get into an effective psychiatric treatment program as identified above.

(1) LaFrance WC Jr, Baird GL, et. al. Consortium Multicenter Pilot Treatment Trial for Psychogenic Nonepileptic Seizures: A randomized clinical trial. JAMA Psychiatry, Epub 2014 Jul 2.

 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. DINGS is his first novel. It is a mother’s dramatic story that teaches epilepsy.

Blog #48: Post-Concussion Epilepsy Can Be Hard to Recognize

(This blog was originally posted on July 24, 2014)

 

Concussions are caused by a non-penetrating trauma to the head such as blows to the head and exposure to nearby explosions as in war. Symptoms of mild concussion include dizziness, blurry vision, vomiting, ear-ringing and tiredness. These may last a few minutes or continue for weeks or longer. More severe concussion results in loss of consciousness that can be followed by headaches, confusion (thinking as if in a fog), memory loss and depression. When neurons (brain cells) are injured during a serious concussion, epilepsy can develop.

          Epilepsy is defined as more than one seizure, even when they are separated by 5-10 years or more. They can be very subtle. These post-concussive seizures may not cause convulsive falling, jerking, tongue biting or incontinence that people commonly associate with epilepsy.

These subtle types of seizures are especially hard to recognize. The person may “blank out” or suddenly lose concentration for a few seconds days, months or even years after the original head trauma. Family and observers often dismiss this behavior or don’t even notice the sudden confusion, blank facial expression and cessation of speech, let alone think it might be a seizure.

Professional medical staff often misdiagnosis post-traumatic stress disorder (PTSD) when it actually is post-traumatic epilepsy. Very brief loss of contact with the person’s environment is the diagnostic clue. Loss of contact with surroundings by “blinking out” or short confusion and cessation of speech may be all that happens.

When psychiatrists evaluate people whose personalities seem changed the above symptoms may be the only clues that non-convulsive epilepsy, and not a psychiatric disorder, is the true problem. Since brain scans and EEGs can be normal in people with epilepsy neurologists are the most expert at sorting out the symptoms and giving the proper treatment.

 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. DINGS is his first novel. It is a mother’s dramatic story that teaches epilepsy.

Blog #47: Epilepsy in Developed vs. Underdeveloped Nations

(This blog was originally posted on June 25, 2014)

 

Premature death is more likely to occur in underdeveloped, low-income countries, than in the developed world. Significant causes of these early deaths include deficiencies in education, nutrition, sanitary conditions, perinatal care and access to medical services. More than 85 percent of people who have epilepsy—approximately 70 million people worldwide—reside in areas of the world with limited health-related resources (1). Epilepsy-related deaths in these countries seem to be associated with falls, burns, drowning and status epilepticus, or uncontrolled continuous seizures lasting many minutes to hours to days without stopping. 

The data is staggering. Ngugi, et al, published a study in Kenya, Africa. It showed that the death rate of those with active convulsive epilepsy is more than six times that of a comparison group without active convulsive epilepsy (2). Important factors contributing to this high mortality associated with epilepsy include lack of appropriate anticonvulsant medications and nonadherence to their anticonvulsant medication regimen (commonly associated with long distances from medical providers, traditional animistic beliefs about epilepsy and cognitive impairment). More than half of all deaths in this study were directly related to epilepsy with a high incidence of prolonged seizures and status epilepticus. The researchers concluded that access to basic medical management of seizures would have saved lives.

Conversely, death due to epilepsy is far less common in the developed world. Sudden Unexplained Death in Epilepsy (SUDEP) is a known cause occurring in approximately one out of one thousand people who have epilepsy (see my Blog # 13, November 14, 2011: Sudden Unexpected Death in Seizures). It is imperative that people with epilepsy: follow medical treatment advice; prevent drowning—do not swim alone and don’t bathe or shower unless the bathroom door is open and someone is at home, if at all possible; and don’t drive unless epilepsy is controlled.

The underdeveloped world’s tremendous challenge is to serve their populations by improving the quality of life for all of their people and to prioritize healthcare.

 

1.      Newton CR, Garcia HH. Epilepsy in poor regions of the world. The Lancet 2012; 380: 1193-1201.

2.      Ngugi AK, Bottemly C, et. al. Premature mortality in active convulsive epilepsy in rural Kenya. Neurology 2014; 82: 582-589.

 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. DINGS is his first novel. It is a mother’s dramatic story that teaches epilepsy.

Blog #46: Uncontrolled Epilepsy: New Explanation and Treatment

(This blog was originally posted on May 27, 2014)

 

Almost one-third of people who have epilepsy cannot satisfactorily control their seizures, even when they take several anti-epilepsy drugs simultaneously.

A new treatment has come to light that some of these epilepsy patients respond to drugs that reduce inflammation in the brain. Toledano, et. al, reported that immunotherapy can improve seizure control (Neurology; 82:1578-86, May 6, 2014). How can this work?

Patients’ own natural defenses can cause disease. This type of disease mechanism is known as an autoimmune process. For various, and poorly understood reasons, the body creates chemical substances called antibodies that react with, and battle against, itself. Antibodies normally are produced to fight against disease-bearing germs, such as those causing infections, and against foreign bodies. Examples of FOREIGN BODIES are livers and kidneys transplanted from one person into another. But sometimes the body uses the immune system to harm itself. Examples of AUTOIMMUNE illnesses include rheumatoid arthritis, lupus, myasthenia gravis and multiple sclerosis.

Various inflammations of the brain are also caused by autoimmune antibody mechanisms. Autoimmune diseases are treated with medications that minimize the effect of autoimmune antibodies. Steroids (prednisone, methylprednisolone, and cortisol) are examples of such medications. Other treatments involve “washing” these deleterious antibodies out of the blood by plasmapheresis, or by infusing intravenously human immune globulin (IVIG) blood products. The precise mechanism by which IVIG suppresses harmful inflammation has not been definitively established.

Testing for various known antibodies working against nervous system tissue can be considered in those patients with epilepsy whose epilepsy has no identifiable cause and is poorly controlled. Research has shown that, when appropriate, treating with a trial of immunotherapy as discussed above has been effective.

 

 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. DINGS is his first novel. It is a mother’s dramatic story that teaches epilepsy.

Blog #45: Police Sued: They Failed to Recognize Epileptic Confusion and Tasered Man

(This blog was originally posted on April 24, 2014)

 

On January 26, 2014, a Connecticut newspaper, the New Haven Register, reported that a man sued the town of Hamden and the Police Department after he was tasered by two officers because he “refused” to cooperate with their orders to exit his crashed vehicle. He claims that at the time he was suffering an epileptic seizure and was unable to follow their directions. The victim said the police require better training to recognize and deal with people having epileptic seizures.

According to the news article the man experienced a seizure while driving on city streets. His car then picked up speed and hit a stone wall and a detached garage. The passenger, his sister, told the arriving emergency services that her brother had epilepsy and that he had just had a seizure; he was unresponsive and slumped over the wheel at that time. The police ordered the man to exit the car. When he failed to comply, they tasered his neck. The man “screamed in pain” and bit the officer’s arm. He was again tasered.

The police reported a different scenario. They claimed the driver was uncooperative and would not exit the vehicle. He became confused, and after “10 minutes” of discussion, the man finally exited the car but tried to manually remove the car from the wall. An officer intervened. The driver jumped back into the car and tried to start it. The officers claimed that they tried to restrain the driver’s arms and remove him from the car, but he resisted, bit the officer’s arm and violently lashed out. The police resorted to the taser. The driver still resisted. Police were able to gain control, remove him from the vehicle and then they applied handcuffs. Following the incident, the sister said her brother “becomes violent when he has epileptic episodes and can’t control himself…a similar incident occurred when he fought with medical staff attempting to assist him.” The police officers decided against pursuing criminal charges because of the man’s “state of mind” when he resisted them.

This incident describes classical post-ictal, confusion-associated violence that often follows a complex partial seizure, a very common form of epileptic seizure. If a person is experiencing a complex partial seizure and he is physically restrained, he may savagely resist any person attempting to restrain him. Furthermore, he will have no memory of it afterward.

Since one percent of the population has epilepsy, education and training of police to deal safely and properly with this common condition is essential.

 

 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. DINGS is his first novel. It is a mother’s dramatic story that teaches epilepsy.

 

Blog #44: Epilepsy in Shakespeare's Characters

(This blog was originally posted on March 23, 2014)

My extensive study of Shakespeare’s works reveals characters that apparently had seizures and epilepsy. Based on my clinical neurological experience in the care of patients, I am certain that the great author-playwright had to have observed many seizures in its different forms.

Moving along London’s Renaissance thoroughfares, Shakespeare witnessed citizens harboring countless maladies. Epilepsy is estimated to occur in almost one percent of the population today, and there must have been at least that incidence then.  Two of the plays describe characters in the throes of a fit; others refer to altered behavior and/or responsiveness; and one makes reference to an ill-defined “epileptic” expression. 

In Othello, Othello has an actual seizure on stage following a severe emotional stress created when Iago, his trusted, but disloyal companion, famously drops Desdemona’s handkerchief for her husband, Othello, to find. This discovery causes Othello to fly into a jealous rage and an epileptic aura begins. Othello becomes confused. “It is not words that shake me thus– Pish! Noses, ears and lips? Is’t possible? – Confess? – Handkerchief? – O devil! (He falls in a trance).” (Act IV, scene 1, line 41):

Iago explains to Cassio, an observer: “…My lord is fall’n into an epilepsy. This is his second fit; he had one yesterday.” Cassio then advises: “Rub him about the temples.” Iago responds: “No, forbear. The lethargy must have his quiet course. If not, he foams at the mouth, and by and by breaks out to savage madness. Look, he stirs. Do you withdraw yourself a little while. He will recover straight.”

Anyone familiar with complex partial seizures will recognize the classical symptoms of Othello’s seizure: the aura initiated by emotional distress; the confusion and loss of awareness; and Iago’s warning to Cassio not to touch or try to restrain Othello in the midst of the seizure, which could lead to Othello reflexively assaulting Cassio, in which case he would have no recollection of doing so, afterwards.

Later in the play, Othello murders his wife in a jealous rage. In our twenty-first century, Othello’s defense lawyer could argue that his client was innocent, or at least guilty of a far less serious charge. His client, a known epileptic, was not responsible for his action because he killed in the throes of his epilepsy. This defense would be even stronger if there had been a witness who heard Desdemona crying out as she was being strangled (Act V, scene 2, line 40): “And yet I fear you; for you’re fatal then when your eyes roll so.”

 

In Julius Caesar (Act I, scene 2, line 246):    Caesar’s associates discuss Caesar’s illness. Casca says, “…for he swounded and fell down at it …He fell down in the market place and foamed at the mouth and was speechless.” Brutus says, “’Tis very like he hath the falling sickness. …What did he say when he came unto himself?” Casca replies,             “…and so he fell. When he came to himself again, he said, if he had done or said anything amiss, he desired their worships to think it was his infirmity…”

Earlier in Julius Caesar, Cassius describes Caesar in the throes of a febrile illness. Rigors of febrile chills―possibly malaria, or possibly part of another of Caesar’s convulsions―were described by Cassius in Act I, 2,119:  “…he had a fever when he was in Spain, and when the fit was on him, I did mark how he did shake. ‘Tis true, this god did shake. His coward lips did from their color fly, and that same eye whose bend doth awe the world did lose his luster. I did hear him groan…”

 

 

In Macbeth, upon hearing disturbing news, Macbeth alludes to an alteration in his well-being (Act III, 4, 21): “Then comes my fit again. I had else been perfect; whole as marble, founded as the rock…” Macbeth then experiences visual hallucinations, seeing the form of Banquo, a nobleman just murdered on his orders. Macbeth then reacts to his companions in a confused manner.  His wife makes excuses, alluding to a fit (Act II, 4, 51): Nobleman Lennox asks, “What is’t that moves your Highness?” Macbeth says, “Which of you have done this?”  Ross, a nobleman, says, “Gentlemen, rise. His Highness is not well.” Lady Macbeth says, “Sit, worthy friends. My lord is often thus, and hath been from his youth. Pray you keep seat. The fit is momentary; upon a thought he will again be well…” Macbeth’s affliction could possibly be complex partial seizures.

 

The romance comedy, The Tempest, includes Caliban, a savage and deformed slave. Shakespeare makes reference to fits, which could imply shaking chills, or possibly a seizure, in the following exchange of Stephano to Caliban; Act II, 2, 72:

• Stephano says, “He’s in his fit now and does not talk after the wisest. He shall taste of my bottle: if he have never drunk wine afore, it will go near to remove his fit….Open your mouth. This will shake your shaking, I can tell you, and that soundly (gives Caliban a drink).

 

 

The Earl of Kent, in King Lear, exclaims in anger; Act II, 2, 76: “A plague upon your epileptic visage!” This probably refers only to a face contorted in a grin but Shakespeare demonstrates his descriptive talents.

 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. DINGS is his first novel. It is a mother’s dramatic story that teaches epilepsy.

 

Blog #43: Teaching Future Teachers to Recognize Non-Convulsive Seizures in Schools

(This blog was originally posted on February 19, 2014)

 

 

Yesterday I gave a PowerPoint presentation, “Recognizing Covert, Non-convulsive Epileptic Seizures in the Classroom” to California State University, Northridge students who are aspiring to become primary school teachers. This Psychological Foundations of Learning and Teaching class is in the University’s Department of Educational Psychology and Counseling. My presentation was similar to that which I gave to the California Association of School Psychologists at their November, 2013 convention in Newport Beach, CA. At that meeting the school psychologists encouraged me to present this information to teachers since they are more closely involved with school children. Teachers knowledgeable about the common, covert non-convulsive forms of epilepsy, namely Petit Mal/Absence and Complex Partial Seizure types, can help to speed up medical evaluation, diagnosis and treatment.

I was pleased to observe their interest and their surprise at my introducing them to the non-convulsive types of epilepsy. This was a new phenomenon to most of them, i.e., the ones who did not have relatives or friends with epilepsy. Some of the one percent of the American population that has epilepsy will no doubt come into these teachers’ lives at some time. The attendees have my handouts as reference for their careers.

These future teachers now are aware that children who stare off inappropriately should be challenged with commands and questions to reveal the student’s degree of contact with his environment or his loss of awareness. School children who are thought to have some sort of “learning disorder” will be assessed more closely. Included will be those suspected of daydreaming, or intermittent hearing problems, or autism or ADD, or stuttering that can occur with a brain confused amidst a non-convulsive seizure.

Recently, a neurologist colleague read a boy’s EEG. Surprising to his parents, it showed epilepsy. My colleague said, “It was just like the youngster in your epilepsy novel, DINGS. For a year he was falling behind in school. His teachers, parents and his pediatrician didn’t know what was wrong. When I told them about the EEG and I told them the epilepsy diagnosis, the parents were encouraged that DINGS could give them a better understanding of what their child and they were experiencing.”

My presentation to student teachers at the University should minimize these delays in epilepsy diagnosis.

 

 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. DINGS is his first novel. It is a mother’s dramatic story that teaches epilepsy.