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For a long time it has been known that seizures could be evoked in certain epileptic individuals by a discrete physiologic or psychologic stimulus The term re ex epilepsy is reserved for this small subgroup Forster has classi ed these seizures in accordance with their evocative stimuli into ve types: (1) visual ickering light, visual patterns, and speci c colors (especially red), leading to rapid blinking or eye closure; (2) auditory sudden unexpected noise (startle), speci c sounds, musical themes, and voices; (3) somatosensory either a brisk unexpected tap or sudden movement after sitting or lying still, or a prolonged tactile or thermal stimulus to a certain part of the body; (4) writing or reading of words or numbers; and (5) eating Visually induced seizures are by far the most common type of re ex epilepsy The seizures are generalized and are most often triggered by the photic stimulation of television or an EEG examination or by the photic or pattern stimulation of video games In other types of re ex epilepsy, the evoked seizure may be focal (beginning often in the part of the body that was stimulated) or generalized and may take the form of one or a series of myoclonic jerks or of an absence or tonic-clonic seizure Seizures induced by reading, voices, or eating are most often of the complex partial type; seizures induced by music are usually myoclonic A few such instances of re ex epilepsy have been due to focal cerebral disease, particularly occipital lesions Clonazepam, valproate, carbamazepine, and phenytoin are all effective in controlling individual instances of re ex epilepsy Some patients learn to avert the seizure by undertaking a mental task, eg, thinking about some distracting subject, counting, etc,

The well-known febrile seizure, peculiar to infants and children between 6 months and 5 years of age (peak incidence 9 to 20 months) and with a strong tendency to be inherited, is generally regarded as a benign condition Usually it takes the form of a single, generalized motor seizure occurring as the temperature rises or reaches its peak Seldom does the seizure last longer than a few minutes; by the time an EEG can be obtained, there is usually no abnormality Recovery is complete Except for a presumed genetic relationship with benign epilepsy of childhood (Luders et al), which in itself is transient in nature, these patients risk of developing epilepsy in later life is only slightly greater than that of the general population In some families, such as those studied by Nabbout and colleagues, febrile seizures alone, without generalized epilepsy, have been associated with a particular gene defect by linkage analysis Presumably, when the gene product is identi ed, some insight into the nature of defects that lower the seizure threshold will be forthcoming This benign type of febrile seizure should not be confused with a second and more serious type of illness in which an acute encephalitic or encephalopathic state presents during a febrile illness with focal or prolonged seizures, generalized or focal EEG abnormalities, and repeated episodes of febrile convulsions with

or by initiating some type of physical activity Forster has demonstrated that in certain types of re ex epilepsy, the repeated presentation of the noxious stimulus may eventually render the stimulus innocuous This technique requires a great deal of time and assiduous reinforcement, which limits its therapeutic value

These episodes, referred to as psychogenic seizures, are nonepileptic in nature ie, they are not caused by an abnormal neuronal discharge They are mentioned here because they are quite common and frequently mistaken for epileptic seizures and treated with anticonvulsant drugs, to which they are characteristically unresponsive Such seizures are most often a symptom of hysteria in the female (Briquet disease) or of compensation neurosis and malingering in males and females, in which case the terms sham seizures and pseudoseizures are appropriate Of course, patients with true epileptic seizures sometimes exhibit hysterical seizures as well, and distinguishing the two may be dif cult Usually, however, the motor display in the course of a nonepileptic seizure is suf cient to identify it as such: completely asynchronous thrashing of the limbs and repeated side-to-side movements of the head; striking out at a person who is trying to restrain the patient; hand-biting, kicking, trembling, and quivering; pelvic thrusting and opisthotonic arching postures; and screaming or talking during the ictus In general, pseudoseizures tend to occur in the presence of other people, to be precipitated by emotional factors, and to be prolonged for many minutes or hours; with few exceptions, tongue-biting, incontinence, hurtful falls, or postictal confusion are lacking No single one of these features is determinative, however Prolonged fugue states in our practice usually have proved to be manifestations of hysteria or a psychopathy even in a known epileptic The serum creatine kinase and prolactin levels are normal after hysterical seizures; this may be helpful in distinguishing them from genuine convulsions Where doubt remains, a recording of the ictal or postictal EEG or the combined video and EEG recording of an attack will settle the issue This subject is discussed further in Chap 56

Chart Designer Identify the item that you will work on, identify the parameters that you can affect, and explore how and where they can be adjusted You can also go into the system and see that you can find these settings fairly easily and the remaining settings for this object are straightforward