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After reading this article you will learn about:- 1. Subject-Matter of Epilepsy 2. Classification of Epilepsy 3. Diagnosis 4. Personality Disturbances 5. Aetiology 6. Treatment.
Contents:
- Subject-Matter of Epilepsy
- Classification of Epilepsy
- Diagnosis of Epilepsy
- Personality Disturbances of Epilepsy
- Aetiology of Epilepsy
- Treatment of Epilepsy
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1. Subject-Matter of Epilepsy:
Having the oldest history among all mental disorders, and most widely known and found throughout the history of human beings, epilepsy refers to a group of brain disorders, the chief symptoms of which are partial or complete loss of consciousness with or without convulsive behaviour or psychomotor disturbances.
Epilepsy is caused by brain lesions or other disorders leading to a disturbance of the rhythm of electrical discharges of brain cells.
In the middle age epileptics were considered as the curse of God. But later on it was believed to be mainly the result of chronic brain pathology having its origin in the cerebrum. Epilepsy is also called falling disease, fits, or convulsions.
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As a result of chronic brain pathology there are unpredictable seizures and frequent states of delirium which of course remain for a short duration. Epilepsy, in-fact, does not denote a specific disease, but a symptom.
Epilepsy constitutes an important mental health problem. It is the most common chronic neurological disease having a prevalence of about 1 per cent in the general population. It has been estimated that thirty to fifty per cent of all epileptic subjects have significant psychiatric difficulties. Although the incidence of psychoses is high in epilepsy, personality disturbances lead to a lot of psychiatric problems.
Epilepsy include a chronic condition of recurrent or repeated seizures. A seizure is a transient, paroxysmal, pathophysiological disturbance of cerebral function caused by a spontaneous excessive discharge of cortical neurons.
A seizure may be abnormal movements or an arrest of movement, a disorder of sensation or perception or a disturbance of behaviour or an impairment of consciousness. Almost any required or genetic pathological process involving the brain may cause epilepsy. The symptoms of epilepsy include falling down, shaking of hands, legs and bodies, biting the teeth, foaming in the mouth etc.
Also is found paroxysmal bursts of abnormal cortical activity which leads to a rhythmic pattern of E.E.G. showing abnormalities in the rate and voltage of these currents. Though epilepsy is irreversible, it on the whole does not involve the progressive deterioration and dementia commonly found in the syphilitic, presenile and senile dementias.
The epileptic seizures involve loss or distortion of consciousness and psychological and physical symptoms. Though about 20 per cent of these epileptic fits may be attributed to chronic brain disorders such as tumours, inflammation or trauma in the brain, more than 75 per cent of the epileptic fits are called idiopathic epilepsy as they do not have any known cause.
Incidence:
Recent report indicates that the incidence of epilepsy is found in about 1 person in 100 in the U.S.A. which tentatively affects between 2 and 3 million people.
Age:
Though epilepsy is not limited to any age group, it is more common in children and adolescents than adults. About 50 per cent of the recorded epileptic cases belong to the age under 15 years. The epileptics continue their normal life otherwise and usually do not need hospitalization; unless there is serious complication.
Sex:
Chances are equal for both the sexes though it is more frequent in males.
Epilepsy and Brain Waves:
Jackson (1931) defined epilepsy as “the name for occasional, sudden, excessive, rapid and local discharges of grey matter.” This view of Jackson has been amply confirmed by the E.E.G. or brain waves of epileptic patients. Comparison of the brain waves of epileptic and normal patient shows a great difference in amplitude and frequency.
The normal people show a constant brain system such as a mean frequency of 10 waves per second while the E.E.G. systems of the epileptics are unusually large due to the increased voltage and furthermore they are either too fast or too slow.
Though rhythm disturbances are most marked in actual attack even during the periods when there is no attack, in 85 per cent of the patients, transient disturbances of rhythm are observed.
Frequency of Attacks:
Great individual differences occur so far as the frequency of attack is concerned. Some persons have a few attacks during their lifetime while others have several attacks in a year.
2. Classification of Epilepsy:
Seizures are broadly characterised as partial seizures (caused by a focal lesion) and generalized seizure (caused by diffuse brain dysfunction). The psychiatricmanifestations of epilepsy are divided into those associated with seizures itself and those occurring between seizures (intericpally).
According to Ervin (1967) the epilepsy may be categorized on the basis of the type of seizure manifested. Kolb (1963) and Ervin (1967) hold that in some cases the type of seizure manifested may depend upon the heredity, though the exact nature of the hereditary defect is yet unknown.
Kolb (1977) has broadly categorized epilepsy into:
(1) Symptomatic or acquired epilepsy and
(2) Idiopathic or essential epilepsy.
Symptomatic or acquired epilepsy:
It is called symptomatic epilepsy as it is the function of brain damage caused by factors other than epilepsy. Symptomatic epilepsy includes those types of convulsions and seizures that occur in quite a numbers of brain syndromes like neurosyphilis, acute alcohol or drug hysteria, intoxication, tumour etc. or other toxic condition.
Idiopathic epilepsy:
Idiopathic epilepsy is due to some constitutional defect. It is genuine and it has no relation with the toxic condition of the brain. Certain cases have no known cause for the convulsive disorder. Idiopathics epileptics have usually early onset.
They occur at anytime, at any place and are different from hysterical fits in this regard. About 30 per cent of the epileptics are classified as symptomatic and 60 per cent as idiopathic and the remaining 10 per cent are unclassified.
Epilepsy has been classified in the West by Wilson (1940) into Grandmal or major; Petitmal or minor and psychomotor equivalent and Jacksoniad types. This classification is based on the area and the degree of brain damage.
Grandmal — (Great Illness):
In the words of Coleman (1981) it is the most prevalent and spectacular form of the epileptic seizure and it occurs in some 60 per cent of the cases.
Grandmal has four stages:
(a) The aura or warning,
(b) Tonic phase or attack proper,
(c) Colonics phase,
(d) Coma phase.
(a) The aura or warning:
In the aura or warning stage the initial sign of seizure occurs. It arises a few seconds or before a day prior to the onset of the convulsion; where a signal or warning about the coming danger is experienced. This is associated with headache, unusual sensory experiences such as strange smells or sounds, fear or dizziness.
It may also consist of numbness, tingling, a sense of distress in the stomach, hallucinated light flashes, voices, stiffness, choking, sensation and feeling of strongest.
(b) Tonic phase:
Next comes the tonic phase. Here actual convulsion is experienced. It is the onset of fit proper. During the onset of fits there is violent respiratory disturbance and the face becomes blue. In this stage the body of the victim becomes rigid. Air is suddenly expelled from the lungs producing a crying sound. He looses consciousness and falls on the ground. The arms and trunks are flexed and legs are stretched.
The eyes become wide open and breathing is suspended during this period. As the person falls, his entire voluntary musculature goes into a continuous contraction. This period fortunately lasts for about 20 to 30 seconds. The generalized spasm includes the muscles of the chest, abdomen and the larynx.
(c) Colonics phase:
The colonics phase follows the tonic phase. This period is characterised by contraction and relaxation leading to jerking movements which continue for about one to several minutes. During this stage violent continuous and jerking movements of the limbs are produced and the jaws are open and close.
He can seriously wound his tongue by biting it at this stage. In the colonics phase the EEG spikes of the tonic stage continues but there is decrement in frequency to one per second and increase in amplitude. Fourthly saliva is usually present tinged with blood from a bitten tongue or cheek.
(d) Coma phase:
After the colonics phase the coma phase starts where the individual still continues to remain in unconscious stage but there is a complete stop of convulsions. The person during the coma stage sleeps deeply for a long period.
Some persons sleep for a few hours or may awaken immediately and when they gain consciousness, they have no memory for the events immediately preceding the convulsions and experiences involved therein.
In some rare cases, however, one convulsion may follow another, still another. Such cases are rare but when occur pose danger to the life of the patient. It will cause death if not treated at once. In the post conversant period some patients become so much confused that they forget about the attack or are even not conscious of their action. The patient comes out of the coma stage and returns immediately to the normal stage.
He may either complain of headache or may feel relaxed. In certain cases, attack proper is accompanied by emotional pathology. The external physical signs of the coma stage are very few. Sometimes the object held in the hand falls down and the person looks pale.
Petitmal—(Small Illness):
It is a small or incomplete grandmal convulsion. In this type of seizure there is a loss of consciousness for 5 to 30 seconds. In this category, there is no aura or warning signal and the patient does not fall down. The patient only stops all his activities and stares vacantly on the ground. But nevertheless, he resumes his activity after a few seconds. He may however throw the thing which he is holding.
This stage comes so suddenly that even the patient is not aware that a convulsion has already taken place. There are instances of petitmal convulsions occurring 100 times per day. This type of convulsion begins early in life between 4 and 8 years and decreases with the increase in age.
The E.E.G. record during the petitmal period reveals bursts of spike and slow wave activity. In other words, the brain wave is slow and fast alternatively. In this type of seizure there are fair chances of recovery. It is said that this attack occurs because of a decreased carbon dioxide content of the breath.
Psychomotor seizures:
The attacks of the psychomotor equivalent are same as the post conversant period. There is great loss of consciousness. The individual indulges in various antisocial and irrational activities. Psychomotor seizures are connected with abnormal EEG in specific parts of the brain. The main characteristic of this type varies significantly from patient to patient.
However, it is said to produce changes in perception, self awareness, thought patterns and mood. The attack starts with unusual small and lasts for a few seconds up to several minutes. There is loss of consciousness but the person continues with his work at that time.
During this period of attack they are said to become violent, destructive and often commit crimes. But experimental studies do not confirm this view. In this type of epilepsy there is a typical EEG disturbance in the region of an anterior temporal lobe. So this type of epilepsy is quite difficult to treat.
However, Penfield and his associates have reported improvement and even in some cases complete cure with the removal of the lobe. There is excessive anger and emotional outbursts. Attempts for suicide and homicide are found in some cases.
Focal seizures:
This type of epilepsy was first described by the English neurologist Hiegh Lings Jackson and so it is also called Jacksonian epilepsy. Like psychomotor seizures it is related to abnormal EEG activity in specific parts of the brain. The attack first starts in one part of the body with a tingling or numbing sensation around the corner of the mouth or in a thumb along with muscle switches and burning sensations.
Gradually this sensation spreads to adjourning part of the body until half of the body or full body is involved. The variation in sensation depends upon the area of the brain affected. There is gradual loss of consciousness. The attack then becomes similar to grandmal epilepsy.
3. Diagnosis of Epilepsy:
When the clinical manifestations of epilepsy are more emotional or psychotic and when changes in level of consciousness and level of cognition are not apparent difficulty relating to diagnosis arises in distinguishing an organic mental disorder of epileptic origin from a psychiatric disorder.
This is type of episodic psychiatric dysfunction should always be suspected to be epileptic provided it occurs in patient in whom epilepsy has been diagnosed previously. Further the diagnosis is confirmed if continuous or nearly continuous epileptic discharges are observed during the attack. Unfortunately, the diagnosis of epilepsy becomes more difficult in patients who are not known to have epilepsy earlier.
In such cases, if he following four clinical features is noticed in the patient, it can be said to have the possibility of epilepsy:
1. Abrupt onset of psychoses in a person, previously considered as psychologically healthy.
2. Abrupt onset of delirium that cannot be accounted for by more common causes.
3. A history of similar episodes with abrupt and spontaneous onset and remission.
4. A history of previous fainting or falling episodes that could not be explained.
4. Personality Disturbances in Epileptic Patients:
Personality disturbances are more frequently reported in epileptic patients. These disorders are more likely to occur in patients with epilepsy of temporal lobe origin. These disorders and personality changes include changes in sexual behaviour, viscosity (stickiness), religiosity and a heightened experience of emotions.
Viscosity is most noticeable in the conversation of the patient which is mostly slow, serious, pedantic, overly replete with detail, and full of nonessential matters, this tendency is also reflected in the writing and drawing of the patient.
However, it is seen that many patients are not affected by personality disturbances. Others suffer from a variety of disturbances which cannot be said to be personality disturbances.
5. Aetiology of Epilepsy:
Organic Explanation:
The causes of epilepsy have been attributed to hereditary factors by many investigators. Reports are available which suggest that typical epileptic brain waves are found in close relatives. About one-third of the institutionalized, one fifth of the non-institutionalized epileptic patients have a family of epilepsy.
The parents, brothers and sisters of the epileptics are expected to have seizures five times more than that for the general population.
When one of the identical twin has epileptic fit, in 61 to 67 per cent of the cases, the other twin has also fits, 86 per cent of the cot wins of idiopathic patients have also fits. In cases of fraternal twins, when one child suffers from epilepsy in 11 per cent of the cases the other twin is affected by epilepsy.
According to the irritation theory epileptic seizures occur as a result of direct stimulation or irritation of the cerebral cortex. This neurological theory argues that injury makes the neural tissues of the cortex hyper sensitive to the stimulation.
Cerebral dysrhythmia, which predisposes an individual to have seizures, is present in about 85 per cent of the epileptic patients during periods when even they are free from attacks and in 53 per cent of their close relatives and 10 per cent of the unselected general population.
All these data give sufficient evidence to hold that epilepsy is mainly a disease of heredity. In the opinion of Page (1976) “Seizure prone individuals apparently inherit a somewhat unstable nervous system whose faulty functioning is revealed by abnormal brain waves.”
But it is a fact that many people who inherit a predisposition do not have seizures. Moreover, the nervous system of identical twins is derived from the same genes and the recorded electrical discharges of the brain cells are practically identical.
From that point of view, all the cot wins of identical epileptic twins should have convulsions but only 61 to 86 per cent are affected. What about the rest ? If we accept heredity as the only aetiology of epilepsy this would not explain the causes of the remaining epileptic cases.
If epilepsy is cent per cent inherited all cases of twins should have been epileptics because they are derived from the same genes and same nervous system. This is, however, not a fact, E.E.G. records also show inconsistencies.
Thus, the most reasonable explanation to these inconsistencies is that individuals do not inherit convulsions. What is in reality inherited is the physical constitution (and not the seizure or fits) which has a high or low potentiality for having epileptic attacks. If a person is highly predisposed, he is expected to have an attack.
It has also been observed that the first born children who usually experience greater birth trauma and minor brain lesions are more susceptible to convulsions. Similarly, certain percentage of epileptic fits may be accounted to differences in order of birth, difficulty in delivery and head injuries in later life.
Difference in precipitating causes such as injury in the brain and biochemical disturbances make the constitution more predisposed to fits.
Head Injuries and Toxins:
Keeping the heredity sound, head injuries, brain lesions and biochemical disturbances also are likely to produce convulsions. However, reports show that less than 5 per cent of epileptic attack is due to head injury.
Emotional Stress:
It is true to some extent that a few cases of epilepsy are caused by emotional stresses. Studies at the same time however indicate that the importance of emotional stress in epilepsy has been over-emphasized.
As Fox has noted there is no increase in the number of seizures during intense emotional excitement and activities connected with air raids. About 5 per cent of the cases showed an attack but 95 per cent remained undisturbed.
Psychosocial Causes:
Studying a number of epileptic patients, Clark (1933) has reported four important personality traits present in the epileptics. They are eccentricity, poverty of emotions, hypersensitivity and rigidity. Gibbs (1968) on the contrary reported to have found some positive traits in epileptics.
They are intellectually bright with pleasant personal experiences, courage to face problems of life without getting depressed and losing competency in work.
6. Treatment of Epilepsy:
Petitmal attacks are very mild and hence may not require any attention, but with respect to grandmal attack, it is desirable to protect the patient from injury by keeping a pillow or some soft object under his head during the attack. Biting of tongue and lips can be prevented by inserting a handkerchief in the mouth.
Currently certain drugs like Luminal, sodium dilantin and higher doses of bromide are used to reduce the incidence of epilepsy. It has been noted that these drugs raise the convulsion threshold and have a normalizing effect on the brain rhythms.
According to Coleman (1981) “Fortunately drug medication and other treatment measures make it possible to prevent seizures in 80 per cent or more epileptics”. But unfortunately, drugs do not always help. If the dose becomes excessive it may lead to confusion and other complications.
In case of violent attacks accompanied by excitement, confusion and various psychotic symptoms, it is advised to institutionalize the patient.
Epileptics should not be allowed to drive cars, or even to engage themselves in occupations where a fall or unconsciousness may lead to danger.
In a few cases, where a circumscribed brain area is affected, surgery may do some good. Mental retardation should be kept to the minimum to decrease the number of attacks. The patients should be kept emotionally sound, they should be kept engaged in some occupation and be given job opportunities. Regular work keeps the patient engaged and reduces the number of attacks.
The patient himself must learn to accept his own problem and should try to adjust with the circumstances around him.
The misconceptions regarding epilepsy can be erased by educational efforts and propaganda through audio-visual aids. This can help the epileptics to boost their self confidence, to change their self image in a positive direction and finally to live normal lives. Current laws permit the seizure free epileptics to drive motor vehicles.
In a few cases, a diet rich in fats and poor in starch and proteins has been found helpful. The water intake should also be kept at a minimum. This is popularly known as dehydration treatment.
Steps should be taken to maintain a healthy and cheerful personality of the patient. Traits like egocentricism, bad temper and hyper sensitiveness should be avoided to reduce the frequency of attacks. Proper personal and social adjustment is desirable. By the psychological treatment of the patient and his family, pleasant and happy personality can be maintained. He must accept the disease openly.
Parents should also learn to accept it. They should never resent it. Their attitude towards the epileptic child should be same as the normal child. The patient should not develop any complex for his disease.
Special workshops should be introduced for the epileptics which at-least develops the sense of self-esteem of the patient and improve his outlook towards life. Finally the altitude towards the epileptic patient should be one of understanding and sympathy rather than disgust, fear and ridicule.