Friday, October 26, 2018

Blog #99 : REVISITING FALSE EPILEPTIC EVENTS


I recently attended a neurology conference at UCLA about Psychogenic Non-Epileptic Seizures (PNES). The discussion highlighted persons with uncontrolled seizures (szs). If patients do not respond to two anticonvulsant drugs (AEDs), a non-epileptic cause should be considered. As these PNES are not true seizures caused by epilepsy they should be considered Non-Epileptic Events (NEE). The term “psychogenic” for these non-epileptic events colors the diagnosis in an improper light which focuses on psychiatric causes. “My doctor thinks I’m crazy.” No! Unlike epileptic seizures, though, these non-epileptic events do not have an organic cause.
People do not consciously bring on these NEE “seizure-like events”; these events are not accompanied by electroencephalographic (EEG) changes. The psychological mechanism causing the event is referred to as a CONVERSION episode. NEEs can be serious as they interfere with jobs, driving, education, and etc. If a woman is pregnant and her “seizures” are actually NEE that are misdiagnosed the ineffective AED treatment can have serious side-effects on mother and fetus.
Non-epileptic events (NEE) can be difficult to diagnose. Five to ten percent of patients with non-epileptic events (NEE) also have true epileptic szs (some of their szs are accompanied by epileptiform-EEG changes while others are not). Non-epileptic events are best diagnosed in an epilepsy monitoring unit (EMU) where video recording is accompanied by simultaneous EEG recording. These patients are especially difficult to treat: is the AED a failure? Switch to another AED? Is this seizure epileptic or a NEE? Between 30-40 percent of patients in the Epilepsy Monitoring Unit at the Santa Barbara Cottage Hospital receive a diagnosis of NEE.1  Malingering, or consciously faking “seizures” was ruled out by the medical team.
Some conditions can mimic epileptic seizures: fainting due to low blood pressure or due to heart abnormalities or due to emotional stress. Some faints can be accompanied by mild jerking that can be confused with a sz. Other mimics can be low blood sugar; breath-holding in children; and complex migraine.  

Characteristics of non-epileptic events:
1)      Eye closure at onset: present in about 80 percent of non-epileptic events. Eyes are usually open during actual epileptic szs.
2)      Crying: can occur prior to, during or after the event. Crying is rare during epileptic szs.
3)      Asynchronous movements with different timing on different sides of body are characteristic of non-epileptic events.
4)      Pelvic thrusting due to back muscle-contractions is not seen during epileptic seizures.
5)      Epileptic szs have a beginning, a middle phase and an end, e.g., they start with muscle-tightening contractions that progress to jerking before the sz ends. Absence of this progression suggests non-epileptic events.
6)      Long duration: average epileptic szs last a minute. If the “sz” lasts much longer, e.g. 30 to 60 minutes or more, it is likely to be a non-epileptic event.


                                          Characteristics of NEE Sufferers:
a)                  NEE patients are more frequently women (with mean onset age 31).
b)                  NEE in children is infrequent but there is no upper age limit.
c)            Anxiety or depression had been diagnosed in 46 percent of NEE sufferers and 57 percent of this population have at least one other medically unexplained symptom.
d)                  Post-Traumatic Stress Disorder (PTSD) has been diagnosed in 30 percent of people who have NEE.
e)                   Sexual abuse had occurred in 30 percent of people with NEE and physical abuse occurred in 25 percent.
f)   NEE is seen in a significant number of active and former military personnel who had been exposed to blast injuries.


                                  TREATMENT
A four-arm study2 for treatment of NEE included: a) patients treated only with Sertraline, a psychiatric selective serotonin reuptake inhibitor (SSRI) antidepressant medication, b) patients treated only with cognitive talk/behavioral therapy (CBT), c) patients treated with Sertraline plus CBT, d) patients treated with standard medical care (with AEDs, etc.). This study’s results showed CBT alone was most successful. No reduction in szs was seen with Sertraline only or with standard medical care.
While treatment of any psychiatric condition is often difficult, prognosis is much better if a correct diagnosis can be made early and treated. People whose NEE have been ongoing for years are less likely to respond to CBT. Education of patients and their families is paramount.

1.      Gibbs M. Differentiating between psychogenic non-epileptic and epileptic seizures. Neurotransmitter. A publication of Santa Barbara Neuroscience Institute at Cottage Health. Fall 2018; p 4.
2.       LaFrance, Curt, et.al. Management of Psychogenic Nonepileptic Seizures. Epilepsy 4 Mar. 2013 onlinelibrary.wiley.com/doi/abs/10.1111/epi 12106.



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, now available in eBook, audiobook and soft cover editions.

Tuesday, September 25, 2018

Blog #98: Highlights from the Epilepsy Symposium: University of Southern California. September 15, 2018


Ten percent of the American population will have at least one seizure in their lifetime and one in 26 Americans will develop epilepsy; epilepsy is diagnosed when more than one seizure occurs. Americans with epilepsy number 3.4 million, 65 million people world-wide have epilepsy. There are 48 newly diagnosed cases/100,000 population each year.
  • The Communicable Disease Center (CDC) found the death rate for all Americans in 2017 was 844.0 deaths per 100,000 population or 0.84 percent.1  This statistic is not that dissimilar to the 500 to 1000 deaths per 100,000 people with epilepsy that die each year. However, life-expectancy for people with epilepsy averages 19 years fewer than the general population. In 2014, SUDEP (sudden unexplained death in epilepsy) was listed as cause of death for only 2650 people. Death certificates don’t always list accurate causes of death, but SUDEP is thought to occur in one out of 75-150 Americans, or 30,000, of all ages with epilepsy annually (SUDEP is discussed in my blogs #13, #57 and #68), especially in those whose epilepsy is poorly controlled. Fifty percent of the epilepsy population have more than one seizure/year, i.e., their epilepsy is active and not in remission.
  • One-third of the epilepsy population is NOT under the care of a neurologist, the physician-specialty that is more expert in caring for epilepsy patients.
  • The greatest number of newly diagnosed patients with epilepsy currently is over 60 years of age, not the pediatric population (see LanceFogan.com blog #15).
  • Pregnant women, and those who are considering getting pregnant, should take 400 micrograms of Folic Acid vitamin daily. Folic Acid can lower the incidence of nervous system and other malformations in the fetus. Verbal abilities in children of mothers on antiepileptic drugs (AEDs) who started daily Folic Acid at least four weeks before conception exceed verbal abilities the children of mothers with epilepsy not taking Folic Acid.2
GENETICS IN EPILEPSY:
  • Genes that connect with actions of certain anticonvulsants (AED) are now being identified. If these genes are present in the patient a more effective AED can be chosen. Some of these effective medications are not even AEDs but medicines used for other diseases. To date, these genetic laboratories are rare. When two AEDs have been unsuccessful in controlling one’s epilepsy, genetic testing should be done. Genetic testing is expensive, but its use is growing and should benefit many uncontrolled patients. As of 2018, seventy percent of people with epilepsy have no identifiable cause. Genetic screening will probably result in many more identifiable causes.
SURGICAL EPILEPSY TREATMENT:
  • Epilepsy is now considered a surgical disease. Epilepsy centers evaluate patients with sophisticated equipment. If an abnormal brain area can be located as the origin of seizures, 60-70 percent are cured of their epilepsy or markedly improved. As scary as brain surgery sounds side effects, as significant thinking, memory, motor or sensory problems, are uncommon. Nonetheless, surgical treatment is underutilized, probably because of fear and expense.
OTHER DEVICES AND TREATMENTS IN EPILEPSY:
  • Vagus Nerve Stimulation: in use since 1997. Its effectiveness in decreasing seizures increases over time with its use independent of AEDs. Side effects include cough, hoarseness and shortness of breath because the vagus nerve stimulates these functions of the vocal cords and the respiratory functions. Usually an out-patient procedure.
·         Responsive Neurostimulator: a portion of the external skull surface bone is scooped out for a battery-powered computer (batteries need replacement every 3-5 years) to fit in this bone-bed, then covered with scalp tissue. Thin stimulators are placed into the area of the brain where the seizure originates via two small drill-holes through the skull. Whenever the apparatus detects the beginnings of a seizure the stimulator probes “fire.” This “short-circuits” and halts the seizure. Researchers believe cognition increases over time, probably because fewer seizures occur that interfere with thought. Over one-half of the patients decrease their seizure frequency by 60 percent.

Ketogenic Diet:
            Mostly reserved for intractable epilepsy. Not ideal for good surgical candidates. Effective across the age spectrum. In use since Mayo Clinic doctors in 1924 found this diet efficacious. It consists of 90% of calories from fat and only 10% from carbohydrates (sugars) and protein. The diet is safe and can be effective in children and adults. Ten percent of patients become seizure-free & 40 percent achieve more than 50 percent decrease in seizure frequency at one year. Forty percent remained on the diet at one year due to their successful control. Of 53 percent of the people who discontinued the diet, half was due to poor tolerance and half due to poor seizure control. Response to the diet may take a month to occur.
  • Excellent response in most genetic and primary epilepsies (Juvenile Myoclonic, brain malformations and trauma, Dravet, West and Lennox-Gastaut syndromes, infantile spasms, tuberous sclerosis, and others). The ketogenic diet should not be used when certain other conditions exist, usually metabolic diseases.
2)     Husebye ESN, Gilhus NE, Riedel B, et.al. Verbal Abilities in Children of Mothers with Epilepsy. Neurology 2018: 91:e811-e821.
3)     A. Bergqvist in Epilepsy and the Ketogenic Diet; edited  by Stafstrom & Rho, 2004



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, now available in eBook, audiobook and soft cover editions.

Sunday, August 26, 2018

Blog #97: A REMINDER: SLEEP LOSS AND EPILEPSY

Epileptic seizures and sleep cycles is a complex realm of neuroscience that will not be addressed here. 

Epileptic seizures are often precipitated by a combination of various clinical factors, but, we find that sleep loss stands out as an independent seizure-trigger in neurology clinics. This variable can be controlled by our epilepsy patients. 

Below is a representative study. It supports obtaining adequate sleep of eight hours per night. In a prospective, observational cross-over study, 179 consecutive hospital admissions for epileptic seizures were included.1 The sleep duration prior to the seizure, as well as alcohol, caffeine and drug use, were recorded.

Complete data for analysis were retrieved in 144 patients. The sleep-time during the 24 hours prior to the seizure was lower (7.3 hours) compared to follow-up (8.3 hours) longer seizure-free periods. Caffeine consumption and use of relevant non-antiepileptic drugs (AED) were not different.

I emphasize that sleep-rest is critical in helping control epilepsy. Be sure to get an adequate night’s sleep, preferably at least eight hours to support your anti-convulsant medications.



1)      Samsonsen C, Sand T, BrĂ¥then G, et.al. The impact of sleep loss on the facilitation of seizures: A prospective case-crossover study. Epilepsy Research November 2016, Volume 127, Pages 260-266.




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, now available in eBook, audiobook and soft cover editions.