Epilepsy And Pseudo-epilepsy





EPILEPSY





With regard to the major neuroses generally, very much more

therapeutic benefit can be secured than in any other way that we know

by reassuring the patient's mind, by careful regulation of his life

and by such modifications of his occupation as will take him out of a

strenuous existence, so likely to be harmful to a nervous system

laboring under these serious handicaps. In recent years we have come

to realize that epilepsy, for instance, is more favorably influenced

by a simple outdoor life in the country without worries and cares,

with carefully regulated exercise in the open air and special

attention to the digestive tract, than by any formal remedial measures

or drug treatment. The fewer the emotional storms the less likelihood

of repetitions of attacks of epilepsy. No medicine is so effective in

prolonging the intervals between attacks as this placing of the

patient in favorable conditions of mind and body. Our experience with

the colony system has emphasized the fact that drug treatment is quite

a subsidiary factor in this general care for the patient. The most

important element in this treatment is the effect on the

patient's mind and the consequent gain in poise and in resistive

vitality against emotional explosions which are so often the immediate

occasion of attacks. This lessens their number and it is well known

that frequent repetition is likely to be associated with that

deterioration of the physical nature and mental condition which is

most to be dreaded.





Mental Influences.--When living a quiet placid life without worry

about himself or his concerns, the number of the epileptic attacks

goes down in a noteworthy degree and the intervals between them become

longer and longer. After years of quiet country living epileptics who

had two or three attacks a week have scarcely more than one a month,

if, indeed, that often, and their general condition is greatly

improved. We have had many remedies for the affection, only a few of

which have proved to be really therapeutic. The remainder have had

their effect through the mental influence that went with them, the

assurance of relief and the confidence that it aroused.



First attacks of epilepsy are not infrequently the result of an

immediately preceding fright or sudden emotion of some kind or other.

Gowers tells the story of a sentinel posted near a graveyard who was

very much disturbed by his proximity to the dead and who, during the

night, saw a white goat run past him, jump over a low wall and

disappear. He was sure it was a ghost. He had his first attack of

epilepsy shortly after. Children not infrequently have their first

attack after a scare from a dog or a rough-looking stranger who has

come near them. After the affection has established itself attacks of

epilepsy follow vehement mental disturbances of any kind. Sometimes

after a long interval of freedom from attacks a sudden strong emotion

is followed by a fit and then the epileptic habit is reestablished. In

order to be as free as possible from the affection patients must be

protected from emotional storms.





Power of Suggestion.---A strong proof of the favorable influence of

suggestion upon epilepsy was given when operations for epilepsy became

common about twenty years ago. A number of patients were operated on

by trephining, even though almost nothing else was done except to open

the dura and examine the brain, for often no definite pathological

condition to justify surgical intervention was found. But these

patients did not suffer from attacks of epilepsy for months and

sometimes years afterwards. Many surgeons reported these cases as

cured, as they apparently were when discharged from the hospitals, for

no attacks had recurred; but physicians had to treat them later when

their epilepsy redeveloped. The surgical procedure, as indeed might

have been expected from the findings, had given only temporary

betterment. The real therapeutic factor at work had probably been not

any definite change within the skull, but the suggestive influence of

the operation, the period of rest with favorable suggestion constantly

renewed, and the confidence of recovery inspired during convalescence.

Even in cases where adhesions were found between the dura and

calvarium and these were broken up, the relief afforded was usually

but temporary. The succession of events, the relief afforded and

subsequent relapse, probably represented the same influence of

suggestion as in the preceding cases with perhaps a slight physical

betterment in addition.



An important factor in the psychotherapeutics of epilepsy is to

relieve the patient as far as possible from the haunting dread of

insanity, which, especially if he has read much of the disease, is so

likely to hang over him as a pall because of the absolutely bad

prognosis which often occupies so prominent a place in older

text-books and articles on epilepsy. There is no doubt that in a great

many cases epilepsy is a progressive degenerative disease and that a

state of lowered mentality will eventually develop. There are many

cases, however, in which epilepsy is only a series of incidents which

does not seem to affect the intellectual life and which is quite

compatible not only with prolonged existence, but with mental

achievements of a high order and, above all, with a personality that

may be commanding in its power over others. This knowledge, which

unfortunately is not usually given in text-books because they are

studies in the pathology rather than in the psychology of epilepsy, is

extremely important for the epileptic. This view is of special

significance for those sufferers from the disease who are well

educated and in whom mentality means so much.





The Individual in Epilepsy.--In epilepsy, indeed, the individual

counts much more than his ailment, and even in severe cases of

epilepsy there are individuals to whom the recurring convulsions are

only annoying occurrences of life, somewhat dangerous because of the

risks encountered during unconsciousness, but without any ulterior

significance for degeneration of character or intellectual power. As a

matter of fact, there are many men in history who were epileptics and

who yet succeeded in great work of many kinds, even purely

intellectual, unhampered by this condition, and some of them have

proved to be leaders in achievement. In his paper read before the

National Association for the Study of Epilepsy and the Care and

Treatment of Epileptics, at its eighth annual meeting. Dr. Matthew

Woods discussed what certain famous epileptics had accomplished in

spite of epilepsy. He takes three typical examples--Julius Caesar,

Mohammed and Lord Byron--the founders, respectively, of an empire, a

religion and a school of poetry--with regard to whom there is

convincing evidence that they were epileptics. A fourth name, that of

Napoleon, might easily have been added. Greater accomplishments than

these epileptics made in their various departments are not to be found

in the history of the race.



Many other names of epileptics distinguished for achievement might

well have been added to the list. The argument that would be founded

on their lives is not that epileptics are necessarily or even usually

of high intelligence, but that some of them, at least, retain in spite

of the major neurosis, or even serious brain disorder, whichever it

may be, all their intellectual qualities undisturbed. Lombroso,

arguing from the other standpoint, has pointed out that there is a

close relation between genius and insanity, and he sets down epilepsy

as one of the forms of insanity (mental un-health) often associated

with extraordinary mental qualities. A study of this subject is

extremely reassuring to the epileptic who is prone to think from

traditions with regard to the disease that his fate is almost sure to

be a gradual lapse into imbecility. No epileptic is likely to be at

all worried over the suggestion that epilepsy and genius are allied,

for since he has the one he is quite willing that the other shall

follow.





Treatment.--Reassurance is especially important when patients develop

epilepsy in adult life. There is an unfortunate social stigma attached

to the disease which adds to the unfavorable suggestions that are

likely to run with it. This probably cannot be overcome, for it is a

heritage, not alone of many generations, but of many centuries.

Our better knowledge of epilepsy, however, should gradually take the

disease out of the sphere of suspected mystery in which it has been

popularly placed and set it among the diseases to which human nature

is liable, but which is surely as physical in its character as any

other. If a favorable attitude of mind on the patient's part can be

secured there is less necessity for many of the disturbing drugs that

are used and there seems to be no doubt that even in producing the

effect of these, such as it is, suggestion of a favorable character

plays a large role. Over and over again in the history of the

affection we have had remedies introduced which have seemed to be

quite efficient in producing longer intervals between attacks, making

the patient less nervous and putting him in better physical health.

After a time, however, these have proved to be quite useless, or at

most of but very slight value. It was suggestion that gave them their

apparent value, and this suggestion must be used without the drugs

whenever possible.



The bromides have done good in the treatment of epilepsy, but they are

the only drugs that maintain the reputation they first had. All the

others accomplished whatever benefit they conferred on the patient,

and some of them for a time seemed to excellent authorities of large

experience to give marvelous results, through their influence over the

patient's mind. Nothing can produce more confidence in the physician

who is using suggestion for epilepsy than this fact. Even the

bromides, unless used carefully, easily do more harm than good and

they have often worked mischief. Favorable suggestion cannot do harm.

At the present time those of largest experience in the treatment of

epileptics, the directors of farm colonies, as Dr. Shanahan of Craig

Colony, insist that diet, hygiene, especially hydrotherapy, are of

much more importance than drugs, but that the patient's attitude of

mind towards himself and his malady and the future of it is even more

important. He must have occupation of mind so as not to worry about

himself. He must have recreation so as to relieve the gloom so likely

to come in the disease. He must have outdoor air and proper exercise,

which these patients are so prone to neglect.



Those who have studied the subject most in recent years agree that the

great majority of cases of epilepsy are not primarily due to acquired

causes, but to some congenital defect, so that there is an inherent

instability of the nervous system. This makes the patient liable to

explosions of nerve force, figuratively represented as boilings over

of nervous energy, when not properly inhibited. Once such a paroxysm

occurs it is likely to happen again, and very often it brings on

gradual degeneration of the nervous system and of mentality. In many

cases, however, this degeneration can be delayed or even completely

kept off by putting the patient under favorable conditions. These

patients need, above all, to realize that they cannot live the

strenuous life nor even the ordinary busy life of most people. They

are as cripples compelled to limit the sphere of their activities. If

they will but take this to heart, however, and not attempt too busy

occupations, they may live quite happy lives for many years, and if

mentally content and without worrying anxieties they will have so few

attacks as to incur only to a slight degree the dangers inevitably

associated with fits of unconsciousness. To get the epileptic's mind

into a condition of satisfaction with his condition must be the main

portion of the treatment.









PSEUDO-EPILEPSY





There is a large and important field of psychotherapeutics in a class

of cases so closely related to epilepsy that it is often extremely

difficult to make the differential diagnosis between the two varieties

of seizure. Fifteen years ago, while I was at the Salpetriere, there

was much discussion of a variety of attack called hystero-epilepsy, in

which the patients' symptoms were such that it was difficult if not

practically impossible to decide whether the case was true epilepsy or

merely hysteria. Personally I do not think there is any third,

intermediate variety deserving a separate term. The attacks are either

hysterical, or, to use a less objectionable name, neurotic, or they

are genuinely epileptic, that is, due to some as yet not well-defined

change in the brain, and therefore not likely ever to be completely

relieved. To decide whether a given case is neurotic or epileptic,

however, is sometimes quite out of the question until long and careful

study of it has been made. It is true that such signs as full loss of

consciousness, biting of the tongue, the so-called epileptic cry,

involuntary urination, dangerous falls and the like in the midst of an

attack, have often been declared to be signs of true epilepsy, but

there are cases in which one or other of these signs has been present,

yet the subsequent course of the affection has shown them to be

functional and not organic in origin.





Neurotic Simulation of Epilepsy.--Nearly every physician who has

reasonably large experience with neurotic patients has seen cases in

which there were recurrent attacks of loss of consciousness that came

on sometimes at most inopportune moments, that rendered the patient

quite incapable of caring for himself for the moment, yet lacked many

of the signs of true epilepsy. Teachers sometimes complain of a

complete lapse of memory that begins without warning and then recurs

at intervals, making their work very difficult. Preachers sometimes

bring the story of having lost the thread of their discourse and

forgetting absolutely what they were talking about, there being a

complete blank for some seconds at least. Occasionally such lapses are

associated with falls that resemble fainting spells and seem to be

accompanied by complete loss of consciousness. Usually after them

there is a distinct tired feeling and an inclination to sleep, though,

as a rule, there is a more marked tendency to want to get away from

observation. Some of the cases are much more severe than those

described and the conclusion that they are true epilepsy seems

inevitable, yet they recover so completely that this conclusion is

negatived.



Occasionally such attacks occur only when the patient has been

strenuously exerting mind or body for a much longer period than usual.

In teachers it is likely to occur toward the end of the year or in the

midst of the hard work about examination time. In students this same

period is likely to be a favorite starting point for the attacks and

they recur oftener at this time than at others. Very often there is a

story of some digestive disturbance in connection with the attacks. At

times it seems possible to trace them to some interference with the

cerebral circulation through a distended stomach pressing upward

through the diaphragm and interfering with the heart action. In such

cases stomach resonance will sometimes be found as high as the fifth

rib and the apex beat may be pushed out to the nipple line or

beyond it. This may be true though there are no signs of valvular

lesions and no symptoms or physical signs of dilatation or hypertrophy

of the heart.





The Suggestive Element.--Analysis shows the real course of the

trouble in these cases. The sufferer is usually following a sedentary

occupation, not getting much exercise or diversion and prone to

introspection. Many symptoms of themselves of no importance have been

emphasized by concentration of attention on them. Especially is this

true of any heart irregularity. The patient has dreaded for some time

lest the feeling of pressure in the precordia and of discomfort in the

heart might not sometime interfere with him in the midst of his

teaching or preaching duties. Some day when he is feeling much worse

than usual, in the midst of his work, there comes over him the feeling

that now his intellect is going to stop action because there is

something the matter with him. The sudden concentration of his

attention on this with the fear of the consequences and the

uncomfortable feeling that he will not be able to go on with his flow

of ideas, cuts off the thread of what he is thinking about and puts

but one single object before him--this possibility of failure of

mental action. Usually the first attack is only such an interruption

as is thus indicated. The fear of subsequent attacks, the worry over

what has happened, the dread that some serious mental affection or

nervous disease is at work emphasizes introspection and subsequent

attacks are even more likely to be serious, and especially to last

longer than the first.



The more the cases are studied the more the conclusion comes that in

many of these instances it is nothing more than auto-suggestion that

is responsible for the mental lapse. It is true that some physical

condition may be the occasion, though the mental state is the active

immediate cause. Suddenly concentrated attention on the dread of

mental interruption inhibits mental action and what was dreaded

follows almost necessarily. It is a sort of auto-hypnotism in which

the patient's train of thought is interrupted by a momentary or longer

hypnotic state the causes of which can be traced. Even when there is a

real organic lesion of the heart, the lapses of memory and even of

reasoning power that occasionally occur, have often seemed to me to be

due rather to the patient's dread than to any real physical condition.

I cannot think that there is a sufficient interruption of the cerebral

circulation, even though only for a moment, to cause such a lapse. It

is a question of nerve interferences rather than of blood supply. If

the blood were diverted, even though only for a moment, or if there

was a stoppage, the consequences would be more serious and more

lasting than they are.



What evidently happens is some disturbance of neurotic connections

within the brain brought on by sudden dread or emotion. The will has

lost control or has seriously disturbed the conducting apparatus. The

best proof that this is what happens and that it is not the result of

organic change is found in the fact that when the physical occasion,

that is, the digestive disturbance or the heart palpitation which is

the initial factor in these states, is relieved, the attacks do not

take place. Patients in whom they have occurred even for years cease

to have them. This improvement does not begin, however, until their

solicitude over their condition has been lessened by a confident

declaration to them that they are suffering from merely functional and

local reflex conditions apart from the brain itself. Usually it needs

to be made clear to them, too, that their anxiety in the matter

means much more for the continuance of the attacks than any physical

condition.



Almost invariably patients somewhat resent this suggestion. Their

response to this explanation of their ailment usually is that the

attacks come on them when they are not particularly expecting them and

that there is first some physical symptom which might readily be taken

for a sort of aura to a genuine epileptic attack and then the attack

itself comes on. It is this preceding symptom, pain or discomfort, or

whatever else it may be, that provokes the suggestive element and

brings about the state of quasi-hypnosis, which is the main part of

their attack.





Neurotic Syncopal Attacks.--Some of the cases of pseudo-epilepsy are

very mild, though if the word epilepsy has been mentioned there

naturally arises a feeling of dread in patient and friends with

consequent unfavorable suggestion. A type not infrequently seen has

for its main symptom a period, usually of but short duration, in which

there is an intense tired feeling so that even the eyelids droop and

require effort to lift them. During such attacks the respirations may

slow down to fifteen or below, though usually the pulse is inclined to

be rapid. The feeling of fatigue is almost entirely subjective, in the

sense that, if patients are required to do something, they are able to

accomplish it by a little urging, though a moment before they were

sure that they could not. Such attacks are invariably functional, have

no organic basis and do not deserve the name of epilepsy. If called

hysterics this will cause the patient, who is often a woman, to rouse

herself and so gradually overcome them. They are really a loss of

confidence in one's power to do things and a passing astasia-abasia.

The use of the word hysterics may cause the patient to lose the

sympathy of her friends, though she may need it; for often there is an

underlying pathological condition not in the nervous but in the

somatic system. Sometimes the patients are anemic, sometimes they have

an abortive form of Graves' disease, and sometimes they are low in

nutrition.



These conditions give the indication for treatment. What is needed is,

of course, improvement of the general condition, but, above all, a

restoration of the patient's confidence in herself. Once it is made

clear to her that the attacks are largely subjective, that is, are due

to a feeling of prostration because of the fear that she is unable to

do something, then the intervals between the attacks will gradually

grow longer. It is important that long hours of sleep should be

advised with plenty of fresh air, and that whatever disturbances of

the digestive system are present should be carefully treated.





Pseudo-Epilepsy and the Menopause.--A number of these cases of

pseudo-epilepsy occur at the menopause. They seem particularly likely

to occur in women who have not much to occupy themselves with.

Childless women who have no cares and enjoy every luxury sometimes

seem to have these pseudo-epileptic attacks as equivalents for the

flushings of the ordinary menopause. During "a rush of blood to the

head" they lose control of themselves. Occasionally mothers who have

two or three daughters and who get their menopause late in life, that

is, well after fifty, are especially likely to suffer in the same way.

The solicitude of those near them seems to eliminate some of their

power of inhibition and makes them think overmuch of themselves. If

then they keep much at home, as women at this time are prone to do,

have few diversions of mind, little fresh air and exercise,

there is an accumulation of unused nervous energy which dissipates

itself in explosive attacks very like epilepsy. It is with regard to

these that the term hystero-epilepsy almost seems justified. Just as

soon as occupation and diversion of mind and relaxation of the

solicitude of friends for them is secured they begin to get better.



The differential diagnosis of these cases is made from the absence of

certain of the pathognomic signs of true epilepsy. The tongue is not

bitten, involuntary urination does not take place, and when the

patient falls she does not hurt herself as a rule, though occasionally

the fall may result in accidental abrasions or bruises, but these are

quite trivial. If stress is laid upon the fact before these patients

that they do not present any or all of the symptoms of epilepsy, some

of them are likely to occur a little later. Slight abrasions on the

tongue will be noted and the sputum will become a little bloody. Even

very cleanly women will sometimes wet themselves. It is not a

deliberate attempt at deception, but their curious psycho-neurotic

condition causes suggestion to act upon them. Their attacks are really

auto-hypnotic and during these the remarks made by the physician occur

as suggestions and then are accomplished. If the suggestions in this

matter have been carelessly made by previous physicians the attacks

will so closely simulate true epilepsy that it will often be almost

impossible to differentiate them with assurance.



In the preliminary diagnosis of these cases, as well as of all other

cases of pseudo-epilepsy, we must, as far as possible, avoid the use

of the word epilepsy, even of hystero-epilepsy. The unfavorable

suggestion attached to such terms will have the worst possible effect.

There is no need to fear that the patient will be any less taken care

of, if the disease is called by some other name, for instance,

neurotic paroxysms or nervous attacks.





Cure by Suggestion.--Such patients are often cured by remedial

measures of one kind or another that are administered with the

confident declaration that they will get well. A number of cases of

epilepsy which were really of this character have been reported cured

by Eddyism. A number also have been very favorably influenced by

osteopathic treatment. Needless to say, the reports of such cured

cases have not been diminished in significance by the publicity

bureaus of these various cults. Mental healing has relieved a number

more. Usually this relief has been afforded these cases after they had

tried regular physicians who had treated them in the ordinary way with

bromides, without doing anything more than causing them to miss a few

attacks for a temporary period of relief, if even that, giving them

bromism and further increasing their solicitude about themselves by

unconsciously emphasizing their ideas as to how serious epilepsy can

be. The cures of these cases are not due to the various treatments to

which the patients proclaim their debt of gratitude, but to the

confident assurance given them that their condition is not serious,

and will be cured. After analysis of their attacks has shown them to

be neurotic and not genuinely epileptic, the regular medical

practitioner can readily do as much and even more; for psychotherapy

has much more to do in affording relief in these cases than any other

form of treatment. It must be applied with confidence and the results

are often most favorable.





Electrotherapy Exercise facebooktwittergoogle_plusredditpinterestlinkedinmail

Feedback