NONCONCLUSIVE STATUS EPILEPTICUS AND ITS TREATMENT: JOANE’S CASE HISTORYJoanne was a bright, sparkly second grader when we first met her. She was referred because of a “weird” episode the previous week. One day in school, she quite suddenly did not seem herself. She was quiet, wandered about the class, and responded inappropriately to the teacher. Her mother took her home, and after another hour or two, when she still wasn’t herself, she had been taken to another hospital. No cause for the sudden change was found, but the next morning an EEG showed slowing, as if she might have previously had a seizure.When we saw her the following week, she was fine and back to her usual self. Since she had never had seizures, and was otherwise normal, we asked her mother to bring her back during another episode, should one occur.It was almost a year later when we received a call from Joanne’s mother in the middle of the day. “She is doing it again.” We didn’t remember Joanne, but told her mother to bring her in immediately. A very attractive, dull ten-year-old came into the office. She could answer questions and count, but seemed to be mildly retarded. If her mother had not insisted that this was not Joanne’s usual state, and if our records had not confirmed a previously sparkling young lady, we might have been fooled.An immediate EEG confirmed “spike-wave stupor,” a continuous electrical status on the EEG, and after a small dose of diazepam (Valium), she immediately returned to her usual state. When she was admitted from the EEG lab to the ward, the resident wanted to know why we were admitting this perfectly normal, charming young lady. With anticonvulsant medication, she has never had another episode.There is no evidence that spike-wave stupor causes permanent damage to the brain, even when it goes on for hours or days. However, it clearly disrupts the child’s level of function. Spike-wave stupor can easily be treated, but it is far better to prevent these seizures with continued use of an appropriate anticonvulsant medication.Although many myths and fears still persist about status epilepticus, with early recognition and appropriate treatment, children who have an episode of status should return to their previous function and have no residual effects.*134\208\8*

life—which may well be reduced if seizures are frequent. Throughout all of life with epilepsy, they have to act as their own public relations officer, deciding how much to tell and how much to conceal. Their circle of friends and choice of sexual partner may well be narrowed. Their inability to hold a driving licence and limitations in employment reduce their earning power, social status, and long-term financial security. By avoidance of factors which they believe may precipitate seizures, social activities may be greatly reduced. It is not surprising, therefore, that people with epilepsy become anxious, or depressed, or resentful and irritable.

The age of onset of epilepsy influences the psychological effects suffered. A robust man of 45 in previous good health who develops epilepsy following a head injury has established his personality, social life, family, and employment before the injury. Although he may encounter problems with future employment, there is no change in how his friends and family perceive him and react to him. The late age of onset and the clear-cut cause of seizures allows this man and his family to take up the position that although he may have a few blackouts he is not really ‘an epileptic’.

It is quite different for a girl whose epilepsy begins at the age of 12, with frequent seizures throughout her school career. Whatever her abilities, her friends and teachers perceive her as ‘an epileptic’. Epilepsy dominates social intercourse, the development of personality, and possibilities of future employment and establishment of married life. Such a person will have more profound psychological difficulties than the 45-year-old man described above. Anxiety, depression, and resentment are entirely comprehensible reactions to the fact of epilepsy. One might say: ‘I would feel like that if I had her problems’. To that extent, therefore, it would be wrong to categorize these psychological effects as an illness, though that does not mean that advice and support from friends, or the family doctor, or a psychiatrist may not aid the person with epilepsy to come to terms with their disability. However skilled the counsellor, we are convinced that the ability to cope depends primarily upon the strength of personality of the person with epilepsy.

Occasionally depression in association with epilepsy may become so severe that treatment with an antidepressant drug is indicated. This drug should be chosen with care.

Depression and inability to cope with the life situation caused by epilepsy may be so severe as to cause the unfortunate sufferer to take his own life. Suicide is approximately five times more common in those with epilepsy than in the general population.

A psychotic illness with symptoms similar to those of paranoid schizophrenia may occasionally be seen in those with epilepsy arising from a temporal lobe lesion. The occurrence of the psychosis is not necessarily related to the frequency of seizures. Indeed, there is a curious group of patients in whom the psychosis becomes prominent as seizures settle, only to remit as seizures return.

One cause of epilepsy is impaired fetal development of the brain or brain damage occurring at or around the time of birth. Children with such brain damage may be less intelligent than their siblings, be more easily distracted from work and play, and be prone to emotional extremes. Because of constant restlessness, this behaviour is sometimes known as the ‘hyperkinetic (or hyperactive) syndrome,. It should be understood that both the behaviour and the epilepsy share a common cause; the epilepsy in itself does not cause this behaviour.

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