EPILEPSY

DEFINITION

Epilepsy is a seizure disorder. A seizure is an event that involves loss of consciousness and motor (muscular) control. A person with a seizure disorder often experiences repetitive muscle jerking called convulsions. The condition is caused by a sudden change in electrical activity in the brain.

DESCRIPTION

The medical profession now recognizes about twenty different kinds of epilepsy. These forms of the disorder vary on the basis of severity and the parts of the body affected by the seizure. Most patients have only one form of epilepsy. About 30 percent have two or more forms of the disorder.

Experts estimate that about 2 percent of the general population has some form of epilepsy. One in ten Americans experience at least one epileptic seizure at some time in their lives. At least 200,000 Americans have at least one seizure a month.

About 125,000 new cases of epilepsy are diagnosed in the United States each year. About a quarter of those cases are diagnosed in children younger than five years old.

The two most common types of epilepsy are called tonic-clonic seizures and absence seizures. At one time, these forms of the disorder were better known as grand mal ("great illness") and petit mal ("small illness"). About 90 percent of people with epilepsy experience tonic-clonic seizures, and 25 percent experience absence seizures. Less than 20 percent of patients experience other forms of epilepsy alone or in various combinations.

CAUSES

The brain contains a mass of neurons (nerve cells) that constantly communicate with each other. They communicate in two ways: by sending certain chemicals back and forth, and by the passage of electric currents among them. Under certain conditions, those electric currents can be disrupted. Instead of traveling smoothly between neurons, they go out of control.

When this happens, messages traveling through the brain are wildly disrupted. The brain begins to send out irregular and unpredictable messages to the rest of the body. Muscles throughout the body begin to contract and relax in random patterns. These changes bring about the symptoms of epilepsy.

Epilepsy is usually classified as symptomatic or idiopathic (pronounced ih-dee-uh-PA-thik). Symptomatic epilepsy is a form of the condition for which a cause is known. For example, a person may receive a blow to the head. The injury may cause damage that leads to the development of epilepsy. Some conditions that can cause symptomatic epilepsy include:

• Serious infections of the central nervous system
• Heat stroke (see heat disorders entry)
• An abscess (open sore) in the brain
• Rabies, tetanus, and malaria (see entries)
• Toxic (poisonous) materials, such as lead or alcohol
• Damage to the brain or skull (see head injury entry)
• Drug allergy
• Stroke (see stroke entry)

Idiopathic epilepsy is epilepsy for which no specific cause has been identified. Some authorities believe that idiopathic epilepsy is caused by damage to a newborn baby's brain during delivery.

About 75 percent of all cases of epilepsy are idiopathic. Individuals with this condition usually experience their first seizure between the ages of two and fourteen. Symptomatic epilepsy usually does not appear until later in life, after the age of twenty-five.

SYMPTOMS

Symptoms vary depending on the type of seizure.

Tonic-clonic Seizures

A person who is about to have a tonic-clonic seizure often has a warning. That warning is called an aura. During the aura, the patient may emit a loud cry. The attack actually begins when the person loses consciousness and falls to the ground. His or her muscles become rigid for about thirty seconds. This period is known as the tonic phase of the disorder. The muscles then alternately contract and relax, causing the patient to thrash about. This phase of the attack is known as the clonic stage. The patient may also lose control of his or her bladder or bowels, or have trouble breathing.

A tonic-clonic attack usually lasts between two and five minutes. After the attack, the patient may be confused or have trouble talking. He or she may complain of headache or muscle soreness or weakness in the arms or legs. In some cases, the patient may fall into a deep sleep.

Absence Seizure

An absence seizure is a milder form of a tonic-clonic seizure. An absence seizure usually begins with a brief loss of consciousness. This phase of the attack lasts between one and ten seconds. Patients may become very quiet. They may stare blankly, roll their eyes, or move their lips. The whole attack is usually over in fewer than twenty seconds.

After an absence seizure, patients generally do not remember anything about the event. They just continue with whatever they were doing before the attack began. They may not realize that anything unusual has taken place. In cases of absence seizures that are not treated, a patient may experience as many as one hundred attacks a day. Eventually, the condition may progress to the tonic-clonic form of epilepsy.

DIAGNOSIS

The first goal of diagnosis is to eliminate other possible causes of the patient's symptoms. Other disorders of the brain, such as small strokes, fainting, and sleep disorders (see sleep disorders entry), can be confused with seizure disorders. A doctor needs to eliminate these possibilities before deciding how to treat the patient.

One goal of diagnosis is to distinguish between symptomatic and idiopathic epilepsy. In symptomatic epilepsy, it may be possible to provide treatment to cure the disorder. For example, a person may have had a severe allergic reaction to a food or drug. The allergic reaction may be responsible for the epileptic attack. This type of case can be treated by avoiding whatever

A woman with epilepsy sits hooked up to a brain wave monitor. Her dog, Ribbon, is an assistance dog that helps her get through her seizures safely. (Reproduced by permission of

AP/Wide World Photos

)

caused the attack in the first place. In cases of idiopathic epilepsy, where a cause is not found, other types of treatment are necessary.

The primary means of diagnosing epilepsy is the electroencephalogram (EEG, pronounced ih-LEK-tro-in-SEH-fuh-lo-gram). The EEG is a device that measures electrical activity in the brain. The results obtained from an EEG test are recorded on graph paper as a pattern of wavy lines. A doctor is able to read the lines on the paper and determine whether or not the brain is functioning normally. Seizure disorders produce characteristic patterns in an EEG test.

Doctors may try to schedule an EEG test during a seizure. They know that flashing lights (like strobe lights) or forcing the patient to breathe very deeply can trigger a seizure in patients with epilepsy. Or the patient may simply be kept in the hospital until an attack occurs. In such cases, the electrical activity of the brain during an attack can be observed and recorded.

TREATMENT

Cases of symptomatic epilepsy are treated by treating the basic cause that brought on the seizure disorder. Treatment of idiopathic epilepsy involves two steps. The first step involves protecting the patient during an attack. The second step involves the use of medications to reduce the frequency and severity of symptoms.

Patients with absence epilepsy usually require little protection. They may need help in case they lose consciousness for long enough to lose their balance and fall. Attacks of tonic-clonic epilepsy require somewhat more attention. The patient should be made comfortable during an attack by loosening clothing around the neck and providing a pillow under the head. A soft object, such as a folded handkerchief, should be placed between the teeth. The object prevents the patient from biting his or her tongue. No effort should be made to hold the tongue, however.

Several medications are now available for the treatment of epilepsy. Most of these drugs fall into the category of anticonvulsants. That is, they tend to prevent or minimize the shaking and thrashing that accompanies a seizure. Some examples of these drugs are phenobarbital (pronounced FEE-no-bar-bih-tall), primi-done (pronounced PRIM-ih-doan), trimethadione

Surgery-resection of a brain mass causing epilepsy. (Reproduced by permission of

Custom Medical Stock Photo

)

(pronounced TRI-meth-uh-DIE-own), and valproate (pronounced val-PRO-ate).

No one drug is effective for all patients or for any one form of epilepsy. In fact, effective treatment of epilepsy requires finding exactly the right dose of exactly the right drug (or combination of drugs) for each individual patient. Most patients go through a period of testing in which various drugs in various combinations are tried. Eventually, the most suitable dose and combination are determined.

Medications have made it possible for most patients with epilepsy to lead relatively normal lives. However, there is one problem with drug therapy. Many drugs have side effects that can range from mild to severe for any one patient. The most common side effects are drowsiness, nausea, lethargy, and skin rash.

An important aspect of treating epilepsy is teaching the patient and his or her family how to live with the disorder. Patients are encouraged to pursue a normal life with moderate exercise and regular social activities. Families are encouraged not to become overprotective and, insofar as possible, to treat the patient as if he or she had no disorder.

Surgery

Intractable seizures are seizures that cannot be controlled without medication or without sedation or other unacceptable side effects. Surgery may be used to eliminate or control intractable seizures. This treatment is not very common as only seizures meeting very specific criteria can be controlled this way.

Alternative Treatment

Relaxation techniques can help people with epilepsy avoid some of the pressures that may bring on an attack. Yoga, meditation, hydrotherapy, aromatherapy, and acupressure may be helpful in this regard. These approaches, however, should never be substituted for the patient's regular program of medication.

For people with symptomatic epilepsy, dietary changes may be essential. Patients may need to identify the foods to which they are allergic and then eliminate those foods from their diets.

PROGNOSIS

The prognosis for most patients with epilepsy today is good. The most severe symptoms of the disorder can usually be controlled by the proper program of medications. Educating the patient about his or her condition can increase the chance that attacks will be handled properly and will not produce unnecessary emotional upsets for the patient.

In most cases, however, epilepsy is a lifelong condition. A patient has to learn to live with its symptoms while trying to lead as normal a life as possible. One important step the patient can take is to wear a medical bracelet indicating that he or she is epileptic. The bracelet should also list any medications the patient is taking.

One serious complication of tonic-clonic epilepsy is called status epilepticus (pronounced STA-tuss EP-ih-LEP-tih-kuss). Status epilepticus is a condition in which attacks of tonic-clonic seizures follow each other closely. There is no recovery period between attacks when the patient returns to consciousness and normality. The patient may have trouble breathing and his or her blood pressure may rise to dangerous levels. The condition can cause death if not treated immediately. Fortunately, status epilepticus is a rare condition.

PREVENTION

Symptomatic epilepsy can be prevented if the cause of the disorder can be identified and eliminated. There is no way to prevent idiopathic epilepsy.

The risks posed by epileptic attacks, however, can be reduced. For example, people with the condition should try to get enough sleep and exercise, and eat properly. They should avoid hyperventilating (breathing rapidly and deeply), which can bring on an attack. Individuals should make sure that they take their medications regularly, according to the prescribed pattern. If they experience an aura, they should find a safe place to lie down until the attack passes.

FOR MORE INFORMATION

Books

Carson, Mary Kay. Epilepsy. Hillside, NJ: Enslow Publishers, Inc., 1998.

Landau, Elaine. Epilepsy. New York: Twenty First Century Books, 1995.

Lechtenbert, Richard. Epilepsy and the Family: A New Guide, 2nd edition. Cambridge, MA: Harvard University Press, 1999.

Sander, J., and Y. Hart. Epilepsy: Questions and Answers. Chicago: Merit Publishing International, 1997.

Shaw, Michael, ed. Everything You Need to Know about Diseases. Springhouse, PA: Springhouse Corporation, 1996.

Wilner, Andrew N. Epilepsy: 199 Answers: A Doctor Responds to His Patients' Questions. New York: Demos Vermande, 1996.

Organizations

American Epilepsy Society. 638 Prospect Ave., Hartford, CT 06105–4298. (205) 232–4825.

Epilepsy Concern International Service Group. 1282 Wynnewood Dr., West Palm Beach, FL 33417. (407) 683–0044.

Epilepsy Foundation of America. 4251 Garden City Dr., Landover, MD 20875–2267. (800) 532–1000.

Epilepsy Information Service. (800) 642–0500.

Web sites

"Ask NOAH About: Epilepsy." NOAH: New York Online Access to Health. [Online] http://www.noah.cuny.edu/neuro/epilepsy.html (accessed on October 25, 1999).

Epilepsy. [Online] http://www.ninds.nih.gov/healinfo/disorder/epilepsy/epilepfs.htm (accessed February 28, 1998).

Epilepsy Facts and Figures. [Online] http://www.efa.org/what/education/FACTS.html (accessed on February 28, 1998).