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At present there is no real consensus amongst doctors about the most effective way to treat someone who has non-epileptic seizures. Sometimes (though not usually in specialist epilepsy units) a very confrontational approach is used: the ‘snap out of it and stop trying to pull the wool over our eyes’ school of treatment. This does not work because it blames the person for something which is not their fault and ignores the very important fact that all seizures, whether they are organic or emotional, have a cause. Above all, it does not take into account that these non-epileptic seizures can be just as disabling and disruptive for the patient as a ‘real’ seizure.
Treatment of non-epileptic seizures needs to be carried out in a specialist unit. The first step is to start investigating the seizures. The more thorough the investigation, the less easy it will be for the patient rationally to reject the suggestion that their seizures are not due to epilepsy.
At the same time the patient will be reassured that although the attacks are not epileptic but emotional, they are nonetheless real, and are due to a build-up of tension and emotion. They are also told that non-epileptic seizures need to be treated just as do epileptic ones. But the best news as far as the patient is concerned is that the seizures are more easily cured and the patient can learn to control their own attacks.
Each patient is given a key nurse to whom they can talk at any time. The relationship between the patient and the nursing and medical staff is crucial, because it is only when trust has built up between them that the patient will feel able to talk freely about the tensions in their life and the difficulties they are having, at work or at home.
RECOGNIZING TRIGGER SITUATIONS
The next step is for the patient to be shown how to analyse the situations in which they have attacks, and to recognize that there may sometimes be emotional triggers for their attacks. This is done in very much the same way that people who have epileptic seizures are taught to recognize situations which may trigger a seizure.
They will be taught to analyse exactly what is happening to them just before an attack starts, in particular asking
themselves:
What were they doing just before the attack?
How did they feel just before the attack?
What were they thinking just before the attack?
If they can recognize and record their emotions very precisely, they may be able to identify the thoughts that make them have an attack. Maybe they were feeling very tense; perhaps someone had been angry with them or spoken sharply to them and their feelings were hurt; or maybe some memory had come into their mind that was too painful to think about.
The patient is asked to think about the consequences of the attack too, and to note down in as much detail as possible not only what happened immediately after the attack, but how it may have altered the situation for them, and how they felt. If they were very tense beforehand, for example, did they feel much better after the attack? If they had been feeling very lonely or ignored beforehand, were people comforting them or paying them attention afterwards?
Usually, if they manage this sort of analysis honestly, most people can find some sort of connection between the likelihood of an attack occurring and their feelings, what is going on in their life or their relationships with other people.
BEHAVIOURAL PROGRAMMES
They will be taught to recognize situations in which they are likely to have an attack, but to try to talk about how they feel instead of allowing their feelings to precipitate an attack. They will be taught a method of relaxation, and shown how to use relaxation whenever they feel they might have an attack. They are encouraged to admit that their attacks are emotional and not epileptic. And they are helped to talk about their problems and anxieties rather than their seizures.
Finally, they have to be helped to come to terms with an absence of seizures and decide how they are going to run their life seizure free. The family is always involved in this phase of treatment, for they too will have to decide how they are going to respond to the patient’s absence of seizures.
The success of the treatment depends a great deal on how much the person still needs their seizures. The problems that created the need for seizures do not just disappear once the attacks stop, and they still somehow have to be resolved. The sufferer has to learn how to get his or her emotional needs met more straightforwardly, and the family have to be taught how to offer the support the patient needs. If these strategies can not be worked out, non-epileptic seizures are a problem that can persist.
Non-Epileptic Seizures: A Diagnosis Checklist
Do the seizures fail to respond to drugs?
Is consciousness maintained during a seizure?
Does the person seldom hurt themselves badly during a violent seizure?
Do they feel better after a seizure rather than worse?
Do their seizures last for a very long time?
Do their seizures involve very complex bodily movements, thrashing about or waving of limbs?
If the answers to all these questions are yes then it is possible that seizures are emotional and not epileptic in origin. At any rate, this is a possibility that the doctor will want to consider.
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There is, of course, another side to this coin. If so many people have the ability to stop a seizure, it is not surprising that quite a lot find that they can make a seizure happen deliberately without too much difficulty. Many people know that they can bring on their own seizures by a direct act of will, by thinking or behaving in a certain way. Probably many more do the very same thing without realizing that they are doing so. If seizures start with a movement such as flexing a limb or turning the head, then mimicking the movement while mentally willing a seizure to occur may actually precipitate one. In one survey of people attending an epilepsy clinic about a quarter of the interviewees said they could generate a seizure at will. However, this figure is probably an over-estimate: a study of Swedish children with epilepsy found that 16 per cent could make themselves have a seizure if they tried. But, more importantly, allot these children said that they knew the circumstances in which they were likely to have a seizure.
Lucy’s father died when she was 14. At the time she was intensely miserable, and used to lie on her bed every evening crying. Lucy had epilepsy, and she found that often when she was feeling very sad she would have a seizure. She came to welcome these seizures because they meant that for a short time at least she was unconscious and therefore free of her misery.
Eventually Lucy got over her father’s death. For several years her seizures were well controlled. Then, seemingly out of the blue, one evening she started having recurrent seizures and was taken to hospital as an emergency. Afterwards, when questioned closely by her doctor, Lucy admitted that she had recently broken up with her boyfriend. The day of her hospital admission she had been lying on her bed, feeling very sad, just as she had when her father died. She had had a seizure, and felt that in the seizure she was able to escape from her sadness. Coming out of the seizure she was overwhelmed by misery once again and had allowed the sad feelings to sweep over her, knowing that it would result in another seizure . . . and another . . . and another.
People who have discovered that emotional mental states such as sadness or resentment can cause seizures, for example, can often ensure that they have a seizure by deliberately thinking about things that they know make them feel sad or resentful. It is not unheard of for children to use this kind of ploy when a parent is angry with them.
Some people find that deliberately keeping their mind blank can precipitate a seizure. You may discover quite by accident what particular movement or mental activity always seems to start a seizure off, or that you can will a seizure by manipulating your attention or thinking certain thoughts. It is very common, for instance, for people to have seizures when they are thinking or talking about seizures.
There is thus a very fine line between deliberately inducing a seizure and allowing yourself the luxury of a mental state or a behaviour that you know is likely to induce one.
It would be nice to be able to say that there is a good chance you may be able to control your epilepsy completely by using behavioural methods. Unfortunately, this is not very likely. These self-help methods are not meant to replace drugs, and you certainly should not stop taking your drugs if you practise them. But they are a useful addition to more conventional treatment.
A complete treatment of epilepsy does not involve just taking drugs. It means learning how your feelings, thinking and behaviour can all be used in the control of your seizures. You will not then be nearly so much at the mercy of your epilepsy. You will be able to gain some mastery over your seizures instead of letting them control you and dominate your life.
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What are the chances of another seizure recurring in your child? If her chances of having another seizure were 10 to 15 percent, would you consider this a high chance or a low one? The consequences of a second seizure will depend on the child’s age and the type of seizure. The consequences of a seizure could be great for older adolescents or adults if, for example, they are driving a car. The consequences of prohibiting driving are great for this age group. The younger child faces no such consequences. The consequences of everyday activities, therefore, vary with age. The toddler is unlikely to be climbing a tree, while the older child may be climbing when a seizure occurs. Risks and consequences vary dramatically with age, with activities, and also personality, as well as many other factors. Since the consequences will happen to you and your child, you (and sometimes your child) will have to be the one to evaluate their significance.
Medication is usually started to decrease the chance of another seizure. But does medication do this? It is widely believed that medication is effective in preventing seizures, and indeed, it is clearly effective in people who have frequent seizures. It is not as clear that it prevents a second seizure in a child who has had only one. A number of studies suggest that the risk of a second seizure is just as great for the child who is placed on medication as for the child who is not. Therefore, whether medication is effective in this situation remains a matter of debate.
You might want to try medicine anyway if it involved no risks or negative consequences.
Unfortunately, however, there are both risks and consequences. The cost of medication can be significant for some families. Every medication has side effects (risks and consequences). The “cost” in terms of side effects can be substantial. You have to evaluate the costs and benefits for your child.
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As mentioned above, the first choice drug should be used alone (monotherapy) and in the lowest dose to control seizures without producing any unacceptable side-effects. If the initial control of seizures is less than complete, then the dose of that drug should be increased gradually until either complete control is achieved, or side-effects develop. If unacceptable side-effects occur before control is reached, then there are two alternatives: either a different drug can be used to replace the first drug, or an additional drug can be added to the first drug. Which alternative is chosen depends on the individual patient and also on the doctor. If there has been some reasonable control with the first drug, it is our practice to add the next most appropriate

anti-epileptic drug without withdrawing the first drug. If complete seizure control is then achieved, we will attempt to withdraw the first drug after a period of two to three months free from seizures. If the initial drug has been ineffective we would simultaneously replace the first drug with the second. In some children and adults, therapy with two anti-epileptic drugs is justified, as this may result in further significant (even complete) control in an additional 5 per cent to 10 per cent of children. It is unlikely that polytherapy with three drugs will result in any further control, and there is certainly an increased risk and frequency of side-effects and toxicity due to interactions between this many drugs.

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