Epilepsy (Seizures)
Introduction Going on the road you might have observed sometimes that a person suddenly falls down unconscious and starts having convulsions, just like a sacrificial goat after its throat has been cut, and his chances of recovery look dim. People gather around him. Somebody suggests that he should be made to smell a shoe and others suggest something else. While these people are still arguing as to what should be done, that person opens his eyes, becomes conscious in a few minutes and sits up. People enquire about his well-being and ask him whether he should be taken to a hospital or a doctor to consult but he quietly gets up, cleans the dust off his clothing, gets hold of his belongings, thanks the concerned people around him and departs quietly leaving those around him astounded. Later on somebody informs that this person often has such “attacks”. In the same way there is this young girl who quarrels with her sister, suddenly takes a deep breath, lets out a scream and falls down with a bang. Her limbs become stiff and eyes turn up and she becomes unconscious for some time. Then gradually she regains consciousness and is taken to a hospital to consult some doctor. Usually by the time she arrives there she recovers almost completely except for feeling a bit weak. The doctor does not find anything wrong and thinks the girl is suffering only from “Hysteria”. Thus he assures the family too that the illness is very minor and psychological in nature and that they should try to keep the girl happy. The family feels reassured but somewhat perplexed at the same time because they cannot imagine anything else they could do for their dear girl who is already very much pampered. Anyway they feel relieved that the illness was not so serious as it seemed. After coming back home the other sister is reprimanded and told not to quarrel again. Few months pass without incident and then one day a teacher scolds her at school and suddenly the condition recurs. This time she also urinates in her clothes and thus inspite of trying to keep her happy and instructing others to improve their behavior with her, the “attacks” keep on occurring again and again, and keep the patient and her family constantly worried. However there is no other problem except the attacks. The physical and mental abilities are not hampered. This is the reason why the people think that this illness is due to some supernatural influence. There must be some “Jin” who suddenly overpowers and renders the person unconscious and the man or woman starts thrashing about their limbs and after that the male or female “Jin” leaves the person alone and the patient gets well and goes about the business of daily life normally. Some people call it “Mirgi” and sometimes it is termed as “Epilepsy”. The majority of people think that it is contagious and that doctors cannot cure it and only the faith-healers or “Aamils” can, but even after years of such “treatments”, these recurring “attacks” or “fits” of unconsciousness become a permanent feature of the patients life and often result in mishaps like the patient falling on fire resulting in severe burns, or falls from a height resulting in severe injuries and fracture of bones or even death by suddenly falling before moving vehicles. Types of Seizures The fits described above are the most common but this seizure disorder can manifest in hundreds of disguises. Let us unveil its different forms before you. 1. Convulsions with unconsciousness (Grand-Mal or Complex, Generalized) Basically these are the types of fits that have been described above. Often before the fits the patient feels restless and anxious. He then may feel fear, gas ascending from abdomen towards the throat, bad smell, hearing vague sounds and noises, feeling of visualizing shadows or pictures without reason (Aura). After such feelings the patient lets out a scream, falls down and becomes unconscious. His teeth become clenched, sometimes tongue is bitten and there is bleeding from mouth. First the limbs and neck become stiff and after this there are convulsions. Sometimes there is frothing from the mouth and there may be incontinence of urine and faeces. After sometime the convulsions stop, breathing improves and the patient slowly regains consciousness. Often after regaining consciousness the patient seems to be confused. There is also a feeling of tiredness, headache, weakness and difficulty in speaking or walking. These types of fits may occur from once or twice every year to several times during a day. 3% of patients have fits only during the night, then it is termed as “Sleep Epilepsy”. Sometimes fits occur only during or a few days before the menstrual cycle (Catamenial Epilepsy). 2. Absences (Petit-Mal or Simple and Generalized) In this type the duration of fits is very short, usually from 5 to 30 seconds. The patient suddenly starts gazing vacantly, the eyelids flutter and then just as suddenly the fit is over in a few seconds. This type is more common in children. The number of fits may vary from one in several days to more than a hundred in a single day. 3. Fits without unconsciousness and convulsions (Akinetic). The patient falls down but the body neither becomes stiff nor there are convulsions. There is no unconsciousness as well. 4. Fits without unconsciousness and partial jerks (Myoclonic). Muscles of a single part of body start twitching but there is no unconsciousness. 5. Fits with physical signs and symptoms (Autonomic). Some patients have only physical complaints and there is no unconsciousness or convulsions. These complaints may be of the following nature: Abdominal pain, vomiting, excessive sweating, hair standing on end, excessive salivation or fever etc. 6. Fits with psychological or emotional symptoms. (Psychomotor) In this type of fits there is no unconsciousness. The fits start with anxiety, abdominal disturbance, strange thoughts, feelings and emotions. The patient suddenly stops doing whatever he is engaged in and starts behaving strangely for example chewing, swallowing, sucking, moving the hands and legs aimlessly. Nausea, vomiting, hunger or abdominal pain may be complained of. Sometimes the beginning is with a feeling of bad smell. Often the fit comprises only of aimless aggression and violence. Some patients have emotional changes for example fear, anger, aimless wandering, running around or some other aimless activity. Often they experience sounds or visualize objects. Sometimes, during the fit, the patient feels as if some other person is in possession of his thoughts and mind and changing them according to his own wish. Usually the patient does not remember what he has done during the fits. 7. Status Epilepticus In this condition fits occur continuously without interval. There is no respite from the convulsions. The patient remains in a state of deep continued unconsciousness. There is stiffness of the body and convulsions, improper breathing, urinary or faecal incontinence, fever and excessive sweating. This state can persist for several days. Without prompt treatment anoxia occurs causing irreparable damage to the brain, heart and kidneys. Usually this condition occurs in patients who either stop or change the medication on their own. In some patients continued Petit-Mal fits are also seen. This is a life threatening condition therefore the patient must be admitted right away to a hospital for treatment. Precipitating causes In some patients some precipitating causes have been observed. For example bright lights, some specific scene, loud sound or some specific emotional conditions like intense fear, grief or anger. This causes the misunderstanding that this is not a mental or physical illness but has happened due to intensity of emotions. This misunderstanding is often the cause of dangerous delay in diagnosis and treatment. Condition of the patient during the period in-between the fits During the period in-between the fits usually there are no signs and symptoms and the patient performs the routine of his daily life with his usual physical and mental ability but some patients develop a fear of the illness and hopelessness about treatment. This causes sadness, irritability, lack of concentration and forgetfulness. Sometimes these complaints may be very severe manifesting in the form of some mental disorder. Basic Etiology This illness is due to an injury of the brain usually so minute that it cannot be visualised by any investigation, except at times by computerized skull X-rays or MRI. The exact nature of the fit depends upon the area of the brain effected by the lesion. Causes of brain injury These causes are as under 1. Defective brain development before birth. 2. Unusually difficult child birth during which there are greater chances of injury to the brain of the child. 3.Inadequate supply of oxygen to the child during child birth. 4.High grade fever. 5. Infection of brain (Meningitis / Encephalitis) 6. Pus discharge from ears (Suppurative Otitis Media) 7. TB of nervous system (TB Meningitis) 8. Injury of brain due to a fall accident 9. Brain tumor 10. Illness of blood vessels supplying the brain (Arteriosclerosis) 11. Severe allergy to some food or medication. 12. Physical illnesses due to which some other organs of the body may be affected for example increased level of urea in the blood due to kidney disease. 13. Effects of toxic substances Diagnosis For diagnosis the following steps are necessary. 1. Detailed information about the patient and his illness should be obtained. In this regard the doctor should gather and evaluate all the necessary information, by talking to the patient and his family, about the condition of the patient immediately before the fit, during the fit, after the fit and during the period between the fits. The patient and the family members should clearly understand that, during this interview, even the smallest detail, which may seem to them of no consequence, may be important for diagnosis and treatment. 2. Physical and psychological examination. 3. Laboratory examination including EEG, Urine, Blood C. P. glucose, urea, and electrolytes, CT scan or MRI of head may also be sometimes needed. It must be emphasized that the first EG is not positive in majority of epileptics. However with repetition abnormalities are detected in the EEG in most (not all) patients. Treatment For treating this illness usually the following medicines are used. (see the chart at the end) Which patient needs which medication and in what quantity is decided by considering
the type of fit, its severity, the age of the patient, his occupation and
social setup. In this regard the important point is that the prescribed medication
should be given to the patient in the proper dose. The patient or his family
members should not increase or decrease the dose by themselves, nor should
they stop the medication on their own, as this may have adverse and sometimes
dangerous consequences. During the treatment if it is felt that there is some
change in the nature or intensity of the illness, it should be brought to
notice of the doctor so that he may be able to suitably increase or decrease
the dose of medication or prescribe some new medication. In the treatment
of this illness compliance with the medications is so important that missing
of even a single dose may precipitate a fit. Surgical removal of the brain lesion and Vagal Nerve stimulation are also beneficial but not available in Pakistan as yet. Duration of treatment Regarding treatment, a common question asked is that for how long the medication has to be continued. The general consensus is that if with the use of medication there have been no fits for a period of three years the medication should be gradually tapered and then stopped. But often, after the medication is stopped the fits start again. In such cases the medication should be given for another two years. Fits stop in some patients but in others the medicine needs to be given for life. Restrictions Physical exhaustion and staying up late at night can precipitate fits. Psychological Treatment Patients suffering from seizure disorder have certain psychological and social problems which should be given due consideration during treatment. For treating these, in addition to medication, the patients need counseling. In some patients seizures are precipitated by emotional tension, environmental mal-adjustment, anger and fear etc. In such patients it is necessary to ascertain and treat these factors too. It has been observed that if the family and social environment can be improved a lesser amount of medication is needed. For proper treatment it is necessary to seek the cooperation of the family and school teachers. Precautions It should be understood that people suffering from this illness, with proper treatment, can effectively continue their education, chores of daily life and business activities. Due to the specific nature of this illness, the patient should avoid adopting such professions which require climbing heights without necessary protective measures, using dangerous heavy machines, working near ovens, kilns or open fire or using dangerous chemicals like acid etc. The treating psychiatrist should specifically be consulted on this aspect of treatment and his instructions should be followed. Need for hospitalization Patients suffering from Status-Epilepticus should be hospitalized immediately because delay in treatment may endanger life. Other patients suffering from severe types of this illness should also be admitted. Case Histories 1. RASHEED “Twice or thrice during the day there is a feeling of the head being heavy. It seems as if the blood vessels are expanding and will eventually burst, along with that is a feeling of sadness, hopelessness, weeping, and a wish for death. After a period of 20 - 25 minutes this feeling is relieved by itself.” 22 years old Rasheed gave this account in his first meeting with his doctor. Rasheed is a student of B.Sc. He was physically and mentally healthy before this condition. One day while sleeping, he suddenly felt as if his whole body was tied tightly and alongwith that he felt a strange fear. This condition was relieved after a short time and he was well for several days. Then became ill with typhoid fever. Considering his complaints he was diagnosed to be suffering from Seizure Disorder and following medicines were prescribed. 1. Tab. Phenobarbitone 30 mg 0+0+3 2. Cap. Vit A + D 0 + 0 + 1 After 6 days Rasheed stated that he was feeling about 80% better and that most of his complaints had disappeared. The dose of phenobarbitone was increased to 4 tablets at night. His condition kept getting better however one complaint, that of his hair standing on end several times during the day persisted. This complaint was not relieved even after increasing the dose of phenobarbitone, so Tab. Carbamazepine 200mg ½ + 0 + ½ was also prescribed. Meanwhile results of X-Ray skull and E.E.G. were available and did not reveal any abnormality. 2. SHAKEELA Shakeela is a 35 years old lady. When she came to the hospital she was unable to speak inspite of trying. Her sister-in-law stated that she had been suffering from seizures for the last 12 years. During the seizures her limbs become stiff and then start jerking and eyes roll up. These fits occur during sleep as well as while awake. During the fits she falls down and her lips are injured because of the clenching of teeth. On the average, she has two fits in one month. Five months back her 22 years old nephew died. Her condition has worsened since then. After a fit yesterday she has been unable to talk. Shakleela indicated by gestures that the jaws feel clenched from the inside therefore she is unable to speak. After admission to the hospital, Shakeela was given Inj. Diazepam 10 mg I/V. After the injection she started speaking. During her stay at the hospital she was diagnosed to be suffering from Seizure Disorder. E.E.G. was arranged for Shakeela and it confirmed the Seizure Disorder. Therefore anticonvulsant medications were prescribed which improved her condition. 3. SHEHNAZ Shehnaz is 20 years old. She is a student of B.A at a local college. She is unmarried and lives with parents, brothers and sisters. Few months back one night she had an attack of severe anxiety. Anxiety was so severe that she felt as if her heart was popping out. Her mother gave her a glass of water with some glucose. After that her eyes closed and speech also stopped. Teeth become clenched. A nearby doctor was called to the house. At that time her mouth opened but she could not speak. The doctor gave her some medication after which she went to sleep. After getting up in the morning her legs seemed paralyzed and she felt dizzy. She tried to get up but fell down and also fell drowsy. This condition persisted for about thirty minutes and after that she could not talk for three days. A doctor gave her some injection after which she was able to talk. This condition recurs six to seven times during a week. Immediately before the reappearance of these symptoms she is unable to speak and the family comes to know that the attack is about to come. During this condition the body goes limp, there is drowsiness, teeth become clenched and the face looks pale. This condition persists for about twenty minutes. Once while she was travelling by bus the condition started. She became silent and by the time she reached home she had become very drowsy. Shehnaz was diagnosed to be suffering from Seizure Disorder. She was advised investigations and prescribed appropriate medication, which improved her condition to a great extent. |
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