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Running Head: EPILEPSY: FROM THE DEPTHS OF FEAR
Epilepsy: From the Depths of Fear to the Heights of Understanding
Epilepsy: From the Depths of Fear to the Heights of Understanding
The human brain is a highly complex structure that controls a wide range of functions within the body. Millions of nerve cells, known as neurons, make up the brain. The neurons are responsible for the processing of these functions. Neurons send messages from the brain to other parts of the body through each other. When these messages are interrupted frequently the result may be the disorder known as epilepsy. Although there have been many misunderstandings about epilepsy throughout history, today's medical research is beginning to identify the neurological problems that cause epilepsy, along with the most effective treatment for the disorder.
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Epilepsy is one of the oldest disorders known to man. It can occur in all races, in both men and women, and it can begin at any age. Epilepsy affects approximately "one person in every two to three hundred persons"(Long and Phipps, p. 385, 1985). The definition of epilepsy is "a group of neurological disorders characterized by the repeated occurrence of any of the various forms of seizures" (Chipps et. al, p. 102, 1992). It was one of the first brain disorders to be described in historical texts.
The strange behavior caused by some seizures has contributed through the ages to many superstitions and prejudices. The ancient Babylonians mentioned epilepsy more than 3000 years ago. A Babylonian medical textbook that contained 40 tablets had a detailed account of epilepsy. (Temkin, 1994). It accurately recorded many of the different seizure types that we recognize presently. The Babylonian concept also emphasized the supernatural nature of epilepsy, with each seizure type associated with the name of a spirit or god – usually an evil god. Today these tablets are seen in the British Museum.
In 400 B.C., the early physician Hippocrates suggested that epilepsy was a disorder of the brain, which today we know is true. His view of epilepsy as a brain disorder did not take root until the 18th-19tth centuries. However many people in early times believed those with epilepsy were under demonic possession or directed by the gods. Some Biblical accounts now seem to indicate that some of the people that appeared to be possessed by demons might really have been epileptics.
In the Gospel of Mark 9: 17 – 27 of the New Testament, one of those accounts are recorded that presents a classic description of an epileptic having a seizure. The passage reads,
"A man in the crowd answered, "Teacher, I brought my son to you because he has an evil spirit in him and cannot talk. Whenever the spirit attacks him, it throws him to the ground, and he foams at the mouth, grits his teeth, and becomes stiff all over." "The spirit screamed, threw the boy into a bad fit, and came out. The boy looked like a corpse, and everyone said, "He is dead!" But Jesus took the boy by the hand and helped him rise, and he stood up."(Good News Bible, Mark 9, 1979).
Because the disorder was misunderstood, it was convenient to blame the behaviors on demonic possession. Since most seizures did not last long it would appear that the victim was cured when probably the duration of the seizure was over.
The word "epilepsy" is derived from the Greek word "epilepsia" which means "to take hold of" or "to seize" indicating the idea of supernatural possession. History is full of leaders, composers and others that had epilepsy. Because of the times, many of these people were thought to be possessed either by demons or by acting out behaviors brought on by the gods. A few of those that are known to have had epilepsy, either by early diagnosis or by doctors who have studied texts that describe these historical figure's behavior, are: a. Julius Caesar - Roman statesman (100-44 B.C.), b. George Fredrick Handel – composer (1685-1759),
c. Fyodor Dostoevski – writer (1821-1881), d. Peter the Great - Russian czar (1682 – 1725),
e. Napoleon Bonaparte - Emperor of France (1769 – 1821), f. Vincent van Gogh – Painter (1853-1890) g. Pius IX – Pope (1792 –1878) and h. Lord Byron – Poet (1788 – 1824).
The concept of understanding epilepsy as a brain disorder came about in the 19th century when neurology developed as a new discipline identified apart from psychiatry especially in Europe and the United States. In 1857, a hospital for the "paralysed and epileptic" was established. Colonies grew for the care and employment of epileptics as a more humanitarian approach was taken toward the disorder. Some examples of these colonies were Bielefeld-Bethel in Germany, Heemstede in Holland and Zurich in Switzerland.
The latter part of the 19th century opened the understanding that today is common knowledge about epilepsy. Hughlings Jackson, a London neurologist in 1873, made proposals concerning the disorder's seizures. He recognized that epilepsy consisted of different disorders of function-sensory as well as motor-and mental as well as physical. And he recognized that epilepsy consisted of an electrical discharge in the nerve cells of the brain.
. Scientists have come along way since ancient Greece and even those that pioneered advances in the understanding of epilepsy in the 19th century. Despite these advances, many myths about epileptics and their behavior still persist. One myth suggests that epilepsy can lead to mental illness. Another indicates that the disorder can cause aggression that can lead to serious crime. Some of the more ridiculous claims are that epileptics are contagious and their predicament developed from immoral behavior. It is also known that epilepsy does not worsen with age, as many believed, its severity depends on the kind of epilepsy the individual has and the type of seizures that are produced.
Physiological myths have also abounded about the epileptic. An epileptic does not swallow his/her tongue during a seizure. It is also a myth that each time a seizure occurs brain cells are destroyed and permanent damage can occur.
Today, it is known that epilepsy is a complex disorder because of its many variations. These variations fall under two broad groups. These two groups are known as Idiopathic Epilepsy and Symptomatic Epilepsy
Idiopathic epilepsy is classified as epilepsy "without central nervous system pathology" (Leppik, p.18, 1998). It is known to be the result of predominately genetic factors rather than environmental factors. In the case of this type of epilepsy, there are often little or no handicaps and electroencephalograph (EEG) readings are normal between the seizures. Many times idiopathic epilepsy can be treated with medications
Symptomatic epilepsy usually develops as a result of an abnormality in the brain structure. This abnormality can be present from birth or may be discovered later. This type of epilepsy can be caused by a trauma to the head and/or brain, brain tumors, abscesses, etc. Common handicaps with Symptomatic epilepsy can be physical, intellectual, and even psychiatric. Treatments for symptomatic epilepsy depend on several factors such as the type of abnormality, personal history, etc.
. Both of these groups can be broken down into the various types of seizures.
The main characteristic of epilepsy is seizures. Seizures are "episodes involving sudden often violent, involuntary contractions of muscles and disturbances in consciousness, behavior, sensation and other functions of the brain" (Chipps et al., p. 102, 1992). Seizures are classified in several ways
Seizures can be identified as either partial, generalized, unilateral, or not classified, according to the International Classification of Epileptic Seizures. Partial seizures do not generally involve the whole brain. They usually produce some form of loss of consciousness. Many times the person will not be able to remember the seizure even if consciousness is not totally lost. Generalized seizures generally consist of the sudden loss of consciousness and can involve muscle contraction, although there can be times muscle contractions do not occur. A unilateral seizure occurs when clinical signs appear only on one side of the body. Finally, an unclassified seizure is any other form of seizure unclassified under any of the other four categories.
The classification of seizures based on clinical features involves five main groups. These groups are Grand Mal, Grand Petit, Psychomotor, Jacksonian-focal, and Miscellaneous. Grand Mal is characterized by loss of consciousness for several minutes while petit mal is known for its sudden loss of consciousness with little or no movement. Psychomotor is a sudden change in awareness associated with distorted feelings and thinking and some movements. Jacksonian-focal seizures are dependent upon the location of the seizure. They usually occur in patients with structural brain damage or disease. Miscellaneous seizures are seizures that have not been classified in other categories (Long and Phipps, p.386, 1985).
Although there are a number of different seizures and other classification of epilepsy, patients often have a similar pattern before, during and after the seizure. Often a person has some form of aura before the seizure strikes. An aura is a peculiar sensation immediately preceding the onset of the seizure (Chipps et. al, p. 102, 1992). Auras range from particular smells, sensations, and /or the simplest "strange feelings". There is also a stage that some people suffer while others do not, known as prodrome. Prodrome is made up of symptoms such as headaches, depression, etc. that can occur hours or even days before the seizure itself. Next, there are the tonic, clonic, and postictal phases. The tonic phase is a state of muscle contraction with excessive muscle tone (Chipps et. al, 1992). The clonic phase is the actual state of muscle contractions, and the postical phase is the time immediately following the seizure in which the person regains consciousness and the muscle contractions come to a stop.
The generalized tonic-clonic seizure is another type of epilepsy. This convulsive seizure can be accompanied by crying out, falling to the floor unconscious, uncontrollable twitching or moving, drooling, or even loss of bladder control. The attack is over within minutes and the person is exhausted and dazed as they become conscious. This type of seizure represents the image most people have of an epileptic seizure although there are various symptoms and behaviors that can accompany a seizure.
Several causes have been connected with epilepsy over the years. One factor is genetic inheritance, which means it is passed on from parent to offspring through the genes or your Deoxribonucleic Acid (DNA). Epilepsy can, however, be caused by damages done to the brain through accidents, drugs and other events that may cause damage to the brain.
Epilepsy can be diagnosed only through testing and other investigating techniques. Some of the tests most commonly used in diagnosing epilepsy are blood tests, brain scans, and an EEG. The blood tests check over the general health of the person to eliminate other causes of seizures. Brain scans, computed tomography (CT) and magnetic resonance imaging (MRI), only help in determining if there is an abnormality of some sort or even structural damage. EEG's help patients by measuring the electrical activity of the brain. However, these tests do not always make the diagnosis of epilepsy.
Epilepsy, depending on the severity of the case, can cause some impairment intellectually. Approximately 5 – 10% of children with a learning disability also have some form of epilepsy. (Pueschel, Scola, Weidenman, and Bernier,1995). It is important to know, however, that the learning disabilities associated with epilepsy are often the result of brain damage or other under developments in the brain caused by the epilepsy any person living with epilepsy, or any handicap caused by epilepsy, can live a normal, healthy life. People that suffer from epilepsy are, in fact, encouraged to participate in all normal social activities and in general keep their lifestyle as normal as possible. Some seizures may be triggered by emotions such as stress, boredom and/or excitement. Environmental factors such as bright , flashing lights or objects moving quickly can also bring on a seizure. Something as simple as the light and movement of the television can trigger an episode. Staring at the television with a blank look does not always indicate complete absorption of the program being watched, but could be a sign of seizure.
Effective treatment of epilepsy first involves accurate diagnosis. Once epilepsy is diagnosed, it is important to begin treatment as soon as possible. Studies have shown that medication is most effective if used before seizures and the results of these seizures are well established in the patient. Research also shows that for most epileptic's treatment with the newest drugs may need to be tapered off over a long span of time in order to wean them from the drug. In one recent study, patients (mostly adults), who had been seizure free for at least 4 years, were asked to participate in a study of withdrawal of medication. Of the 62 who elected to enter the withdrawal phase 15 (24%) had a recurrent seizure. Of the 157 who declined to withdraw from medication, 10 (6%) had a seizure." (Leppik, 1997 ).
The first antiepileptic drugs were bromides, introduced by an English physician named Sir Charles Locock in 1857. He left behind records that indicated that the bromides had a sedative effect and seemed to reduce seizures in some patients. During the first half of this century the main drugs for the treatment of epilepsy were phenobarbitone (1912) and phenytoin (1938). Since the 1960s there have been more and more drugs discovered for the treatment of epilepsy. These discoveries have occurred simultaneously with the greater understanding of the electrochemical activities of the brain.
More than 20 different antiepileptic drugs are now on the market, all with different benefits and side effects. Prescribing the correct medication and dosage depends on many different factors. These factors may include the type of seizure the person has, the person's lifestyle and age and how frequently the seizures occur. Besides these factors, for women the likelihood of pregnancy is also considered.
Carbamazapine, valproate, or phenytoin are the usual drugs of choice unless the epilepsy is a type that may require a different kind of treatment. For an absence of seizures, ethosuximide is usually the initial treatment. Other pharmaceuticals that are prescribed include clonazepam, phenobarbital, and primidone. The names of the newest drugs on the market are tiagabine, lamotrigine, gabapentin, topiramate, levetiracetam and felbamate. The drug diazepam is used for people with stereotypical recurrent severe seizures that are recognized by the person's family. (Penry 1986)
The side effects from most antiepileptic drugs are usually not too overwhelming. They usually are effects such as fatigue, dizziness, or weight gain. Common effects that are also associated too any other drugs. There are times when allergic reactions can occur and can be life threatening. Some patients may develop depression or psychoses. Medical attention and consult is important not only for those living with epilepsy but also as treatment begins. Epilepsy medication can interact with many other drugs and it is important that the physician is aware of any medications being taken by the patient.
When medication is not enough to control seizures the patient can be recommended for surgery. A team of doctors in a medical center usually performs this type of surgery. The type or types of seizures the patient experiences determine the beneficial effects of surgery. The brain region involved and how important that area is for everyday behavior is considered before surgery is done. Areas of the brain that are necessary for speech, language and hearing or other abilities are usually avoided by surgeons. Electrodes implanted on the surface of the brain can indicate where the seizure is taking place.
There are three different types of surgery performed on the epileptic depending on the site of the seizure. The temporal lobe surgery is performed to remove brain tissue where the epileptic seizure starts. This type of surgery often removes part of the cortex of the temporal lobe, hippocampus and amygdala. A second type of surgery is called the corpus callosotomy or "split brain" operation. In this type of surgery, surgeons cut the corpus callosum, to separate the right and left cerebral hemispheres. This procedure prevents the spread of seizure from one side of the brain to the other. The third type of surgery is the hemispherectomy where one cerebral hemisphere is removed. This procedure is not performed very often. Children who have this surgery can function quite well although they often have trouble using their arm on the side of the body opposite to the surgery. In some of these surgeries, there is removal of only specific lobes of the brain.
In the 1990 National Institutes of Health consensus conference on surgery for epilepsy concluded that there were three broad categories of epilepsy that could be treated successfully with surgery. They were: partial seizures, seizures that begin as partial seizures before spreading to the rest of the brain and unilateral multifocal epilepsy with infantile hemiplagia.
New types of therapy are being experimented by doctors today. One preliminary clinical trial has involved transplanting fetal pig neurons that produce Gamma-amonobutyric acid (GABA) into the brains of patients to learn whether the cell implants can control seizures. Investigations are underway for a prototype device. This device has been developed out of the fact that research shows that the brain goes through subtle changes before the seizure. If it is successful, it could greatly reduce the risk of injury from seizure by allowing people to move to a safe area before their seizures start.
The newest areas of the brain that are being mapped, are and will be instrumental in helping those that have epilepsy. As the different areas of the brain and the function they serve are identified, researchers will become more accurate in identifying and treating the immediate area where the seizure starts. This research will help to open new doors to understanding epilepsy and releasing its sufferers from the decades of misunderstandings that has surrounded this disorder and help epileptics become more functional in society.
References
Batshaw, Mark L., (Ed). (1997). Children with Disabilitie., Baltimore, Maryland: Brooks Publishing Co.
Chipps, Esther M., Clanin, Norma J., and Campbell, Victor G. (1992). Seizure Disorder, Neurologic Disorder. St. Louis: Mosby-Yearbook, Inc.
Good News Bible (Catholic Study Ed.). (1979). New York: Thomas Nelson Publisher.
Leppik, Ilo E., (1998). Contemporary Diagnosis and Management of the Patient with Epilepsy. Pennsylvania: Handbooks in Healthcare.
Long, Barbara C. Phipps, Wilma J., (1985). Essentials of Medical Surgical Nursing: A Nursing Approach. St. Louis: The C.V. Mosby Co.
Penry, J. Kiffin. (1986). Epilepsy Diagnosis Management Quality of Life. New York: Raven Press.
Pueschel, Siegried M. Scola, Patricia S. Wiedeman, Leslie. Bernier, James C. (1995). The Special Child. Baltimore, Maryland: Paul H. Brooks Pub. Co.
Reisner, Helen (Ed). (1998). Children with Epilepsy: A Parent's Guide. Rockville, Maryland: Woodbine House.
Temkin, Owsei. (1994) The Falling Sickness: A History of Epilepsy from the Greeks to the Beginning of Modern Neurology. Maryland: John Hopkins Press.
Thoene, Jess G. (1995). Physician's Guide to Rare Diseases. Montvale New Jersey: Dowden Pub.
Whaley, Lucille F. and Wong, Donna L. (1983). A Nursing Care of Infants and Children. St. Louis: The C.V. Mosby Co.
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