Content analysis of subjective experiences in partial epileptic seizures

The promises and pitfalls of seizure phenomenology

The typical adult patient presenting with a first seizure has a normal clinical examination, uninformative investigations, and often has no witness to their episode. The assessing clinician, therefore, has one primary source of information to guide their assessment; the patient's experience. However, seizure phenomenology - the subjective seizure experience - has received relatively less attention by researchers than objective semiology or investigations. This essay reviews the clinical importance of seizure phenomenology, and the challenges clinicians face in eliciting accurate and clinically relevant descriptions of ictal experience. I conclude by discussing tools that clinicians may use to support the clinical application of seizure phenomenology, and exploring the subjectivity of epilepsy more broadly.

Somatosensory Auras in Epilepsy: A Narrative Review of the Literature

An aura is a subjective experience felt in the initial phase of a seizure. Studying auras is relevant as they can be warning signs for people with epilepsy. The incidence of aura tends to be underestimated due to misdiagnosis or underrecognition by patients unless it progresses to motor features. Also, auras are associated with seizure remission after epilepsy surgery and are an important prognostic factor, guiding the resection site and improving surgical outcomes. Somatosensory auras (SSAs) are characterized by abnormal sensations on one or more body parts that may spread to other parts following a somatotopic pattern. The occurrence of SSAs among individuals with epilepsy can range from 1.42% to 80%. The upper extremities are more commonly affected in SSAs, followed by the lower extremities and the face. The most common type of somatosensory aura is paresthetic, followed by painful and thermal auras. In the primary somatosensory auras, sensations occur more commonly contralaterally, while the secondary somatosensory auras can be ipsilateral or bilateral. Despite the high localizing features of somatosensory areas, cortical stimulation studies have shown overlapping sensations originating in the insula and the supplementary sensorimotor area.

Seizure semiology: ILAE glossary of terms and their significance

This educational topical review and Task Force report aims to address learning objectives of the International League Against Epilepsy (ILAE) curriculum. We sought to extract detailed features involving semiology from video recordings and interpret semiological signs and symptoms that reflect the likely localization for focal seizures in patients with epilepsy. This glossary was developed by a working group of the ILAE Commission on Diagnostic Methods incorporating the EEG Task Force. This paper identifies commonly used terms to describe seizure semiology, provides definitions, signs and symptoms, and summarizes their clinical value in localizing and lateralizing focal seizures based on consensus in the published literature. Video-EEG examples are included to illustrate important features of semiology in patients with epilepsy.

Subjective distinguishability of seizure and non-seizure Déjà Vu: A case report, brief literature review, and research prospects

Roughly two-thirds of all people report having experienced déjà vu-the odd feeling that a current experience is both novel and a repeat or replay of a previous, unrecalled experience. Reports of an association between déjà vu and seizure aura symptomatology have accumulated for over a century, and frequent déjà vu is also now known to be associated with focal seizures, particularly those of a medial temporal lobe (MTL) origin. A longstanding question is whether seizure-related déjà vu has the same basis and is the same subjective experience as non-seizure déjà vu. Survey research suggests that people who experience both seizure-related and non-seizure déjà vu can often subjectively distinguish between the two. We present a case of a person with a history of focal MTL seizures who reports having experienced both seizure-related and non-seizure common déjà vu, though the non-seizure type was more frequent during this person's youth than it is currently. The patient was studied with a virtual tour paradigm that has previously been shown to elicit déjà vu among non-clinical, young adult participants. The patient reported experiencing déjà vu of the common non-seizure type during the virtual tour paradigm, without associated abnormalities of the intracranial EEG. We situate this work in the context of broader ongoing projects examining the subjective correlates of seizures. The importance for memory research of virtual scenes, spatial tasks, virtual reality (VR), and this paradigm for isolating familiarity in the context of recall failure are discussed.

Differentiating psychogenic nonepileptic from epileptic seizures: A mixed-methods, content analysis study

BACKGROUND

Identification of clinical features that might distinguish psychogenic nonepileptic seizures (PNES) from epileptic seizures (ES) is of value for diagnosis, management, and understanding of both conditions. Previous studies have shown that patients' descriptions of their seizures reflect differences in content and delivery. We aimed to compare verbal descriptions of PNES and ES using a mixed-methods approach.

METHODS

We analyzed data from semi-structured interviews in which patients with video-electroencephalography (EEG)-confirmed ES (n = 30) or PNES (n = 10) described their seizures. Two masked raters independently coded the transcripts for relevant psychological categories and discrepancies that were noted and resolved. Additional analyses were conducted using the Linguistic Inquiry and Word Count system. The identified phenomena were descriptively compared, and inferential analyses assessed group differences in frequencies. A logistic regression analysis examined the predictive power of the most distinctive phenomena for diagnosis.

RESULTS

As compared with ES, PNES reported longer seizures, more preseizure negative emotions (e.g., fear), anxiety symptoms (e.g., arousal, hyperventilation), altered vision/olfaction, and automatic behaviors. During seizures, PNES reported more fear, altered breathing, and dissociative phenomena (depersonalization, impaired time perception). Epileptic seizures reported more self-injurious behavior. Postseizure, PNES reported more fear and weeping and ES more amnesia and aches. The predictive power when including these variables was 97.5%. None of the single predictor variables was significant. The few but consistent linguistic differences related to the use of some pronouns and references to family.

CONCLUSIONS

Although no single clinical feature definitively distinguishes PNES from ES, several features may be suggestive of a PNES diagnosis, including longer duration, negative emotion (i.e., fear) throughout the events, preseizure anxiety, ictal dissociation, and postseizure weeping. Fewer reports of ictal self-injury and postseizure amnesia and aches may also indicate the possibility of PNES.

Seizure-alerting behavior in dogs owned by people experiencing seizures

INTRODUCTION

The unpredictability of epileptic seizures is considered an important threat to the quality of life of a person with epilepsy. Currently, however, there are no tools for seizure prediction that can be applied to the domestic setting. Although the information about seizure-alert dogs - dogs that display changes in behavior before a seizure that are interpreted by the owner as an alert - is mostly anecdotal; living with an alerting dog (AD) has been reported to improve quality of life of the owner by reducing the stress originating from the unpredictability of epileptic seizures and, sometimes, diminishing the seizure frequency.

AIM OF THE STUDY

The aim of the study was to investigate, at an international level, the behaviors displayed by trained and untrained dogs that are able to anticipate seizures and to identify patient- and dog-related factors associated with the presence or absence of alerting behavior.

METHODOLOGY

An online questionnaire for dog owners with seizures was designed. Information about the participants (demographics, seizure type, presence of preictal symptoms) and their dogs (demographics, behavior around the time of seizures) was collected. In addition, two validated scales were included to measure the human-dog relationship (Monash Dog-Owner Relationship scale (MDORS)) and five different traits of the dogs' personality (Monash Canine Personality Questionnaire refined (MCPQ-R)).

RESULTS

Two hundred and twenty-seven responses of people experiencing seizures were received from six participant countries: 132 from people with dogs that had started alerting spontaneously, 10 from owners of trained AD, and the rest from owners of dogs that did not display any alerting behavior (nonalerting dog (NAD)). Individuals' gender, age, or seizure type did not predict the presence of alerting behavior in their dogs. People who indicated that they experience preictal symptoms were more likely to have a spontaneously AD. The owner-dog bond was significantly higher with ADs compared with NADs, and ADs scored significantly higher than NADs in the personality traits "Amicability", "Motivation", and "Training focus".

CONCLUSION

This study collected a large group of dog owners with seizures reporting behavioral changes in their dogs before their seizures occurred. This was associated with the presence of preictal symptoms. The seizure-alerting behavior of the dog may have a positive influence on the bond between the owner and the dog.

The semiology of febrile seizures: Focal features are frequent

OBJECTIVE

To clarify the semiology of febrile seizures (FS) and to determine the frequency of FS with symptoms suggestive of focal onset.

METHODS

FS symptoms in children were reported within 24h of seizure onset by the parents using a structured questionnaire consisting principally of closed-ended questions. We focused on events at seizure commencement, including changes in behavior and facial expression, and ocular and oral symptoms. We also investigated the autonomic and motor symptoms developing during seizures. The presence or absence of focal and limbic features was determined for each patient. The associations of certain focal and limbic features with patient characteristics were assessed.

RESULTS

Information was obtained on FS in 106 children. Various events were recorded at seizure commencement. Behavioral changes were observed in 35 children, changes in facial expression in 53, ocular symptoms in 78, and oral symptoms in 90. In terms of events during seizures, autonomic symptoms were recognized in 78, and convulsive motor symptoms were recognized in 68 children. Focal features were evident in 81 children; 38 children had two or more such features. Limbic features were observed in 44 children, 9 of whom had two or more such features. There was no significant relationship between any patient characteristic and the numbers of focal or limbic features.

SIGNIFICANCE

The semiology of FS varied widely among children, and symptoms suggestive of focal onset were frequent. FS of focal onset may be more common than is generally thought.

Ecstatic Epileptic Seizures: A Glimpse into the Multiple Roles of the Insula

Ecstatic epileptic seizures are a rare but compelling epileptic entity. During the first seconds of these seizures, ecstatic auras provoke feelings of well-being, intense serenity, bliss, and "enhanced self-awareness." They are associated with the impression of time dilation, and can be described as a mystic experience by some patients. The functional neuroanatomy of ecstatic seizures is still debated. During recent years several patients presenting with ecstatic auras have been reported by others and us (in total n = 52); a few of them in the setting of presurgical evaluation including electrical brain stimulation. According to the recently recognized functions of the insula, and the results of nuclear brain imaging and electrical stimulation, the ecstatic symptoms in these patients seem to localize to a functional network centered around the anterior insular cortex, where we thus propose to locate this rare ictal phenomenon. Here we summarize the role of the multiple sensory, autonomic, affective, and cognitive functions of the insular cortex, which are integrated into the creation of self-awareness, and we suggest how this system may become dysfunctional on several levels during ecstatic aura.

Thoughts, emotions, and dissociative features differentiate patients with epilepsy from patients with psychogenic nonepileptic spells (PNESs)

Psychogenic nonepileptic spells (PNESs) are often very difficult to treat, which may be, in part, related to the limited information known about what a person experiences while having PNESs. For this retrospective study, thoughts, emotions, and dissociative features during a spell were evaluated in 351 patients diagnosed with PNESs (N=223) or epilepsy (N=128). We found that a statistically higher number of thoughts, emotions, and dissociative symptoms were endorsed by patients with PNESs versus patients with epilepsy. Patients with PNESs reported significantly more anxiety and frustration, but not depression, compared with those with epilepsy. Emotions and dissociations, but not thoughts, and a history of any type of abuse were endorsed significantly more often by patients with PNESs. Patients with PNESs are prone to having poor outcomes, and interventions focusing on their actual experiences may be helpful for treatment planning.

Auras in generalized epilepsy

OBJECTIVE

We studied the frequency of auras in generalized epilepsy (GE) using a detailed semistructured diagnostic interview.

METHODS

In this cross-sectional study, participants with GE were drawn from the Epilepsy Phenome/Genome Project (EPGP). Responses to the standardized diagnostic interview regarding tonic-clonic (grand mal) seizures were then examined. This questionnaire initially required participants to provide their own description of any subjective phenomena before their "grand mal seizures." Participants who provided answers to these questions were considered to have an aura. All participants were then systematically queried regarding a list of specific symptoms occurring before grand mal seizures, using structured (closed-ended) questions.

RESULTS

Seven hundred ninety-eight participants with GE were identified, of whom 530 reported grand mal seizures. Of these, 112 (21.3%) reported auras in response to the open-ended question. Analysis of responses to the closed-ended questions suggested that 341 participants (64.3%) experienced at least one form of aura.

CONCLUSIONS

Auras typically associated with focal epilepsy were reported by a substantial proportion of EPGP subjects with GE. This finding may support existing theories of cortical and subcortical generators of GE with variable spread patterns. Differences between responses to the open-ended question and closed-ended questions may also reflect clinically relevant variation in patient responses to history-taking and surveys. Open-ended questions may underestimate the prevalence of specific types of auras and may be in part responsible for the underrecognition of auras in GE. In addition, structured questions may influence participants, possibly leading to a greater representation of symptoms.

What physicians need to know about dreams and dreaming

PURPOSE OF REVIEW

An overview of the current status of dream science is given, designed to provide a basic background of this field for the sleep-interested physician.

RECENT FINDINGS

No cognitive state has been more extensively studied and is yet more misunderstood than dreaming. Much older work is methodologically limited by lack of definitions, small sample size, and constraints of theoretical perspective, with evidence equivocal as to whether any special relationship exists between rapid eye movement (REM) sleep and dreaming. As the relationship between dreams and REM sleep is so poorly defined, evidence-based studies of dreaming require a dream report. The different aspects of dreaming that can be studied include dream and nightmare recall frequency, dream content, dreaming effect on waking behaviors, dream/nightmare associated medications, and pathophysiology affecting dreaming.

SUMMARY

Whether studied from behavioral, neuroanatomical, neurochemical, pathophysiological or electrophysiological perspectives, dreaming reveals itself to be a complex cognitive state affected by a wide variety of medical, psychological, sleep and social variables.

Déjà experiences in temporal lobe epilepsy

Historically, déjà vu has been linked to seizure activity in temporal lobe epilepsy, and clinical reports suggest that many patients experience the phenomenon as a manifestation of simple partial seizures. We review studies on déjà vu in epilepsy with reference to recent advances in the understanding of déjà vu from a cognitive and neuropsychological standpoint. We propose a decoupled familiarity hypothesis, whereby déjà vu is produced by an erroneous feeling of familiarity which is not in keeping with current cognitive processing. Our hypothesis converges on a parahippocampal dysfunction as the locus of déjà vu experiences. However, several other temporal lobe structures feature in reports of déjà vu in epilepsy. We suggest that some of the inconsistency in the literature derives from a poor classification of the various types of déjà experiences. We propose déjà vu/déjà vécu as one way of understanding déjà experiences more fully. This distinction is based on current models of memory function, where déjà vu is caused by erroneous familiarity and déjà vécu by erroneous recollection. Priorities for future research and clinical issues are discussed.

The neurophilosophy of epileptic experiences

Monaco F, Mula M, Cavanna AE. The neurophilosophy of epileptic experiences.

Background:Specific alterations of consciousness have a central role in the phenomenological description of epileptic seizures and in the patient's subjective reports.

Methods:This article discusses the use of philosophical methodology within a neurological framework to understand consciousness.

Results:How the alterations in consciousness are experienced by patients with epilepsy depends largely on the localization of the underlying neurophysiological dysfuntion.

Discussion:Rigorous conceptual analysis of ictal experience reports can help to illuminate the study of consciousness.

Ictal consciousness in epilepsy and nonepileptic attack disorder

Exploration of subjective experiences during seizures may enhance knowledge of the differing natures of epilepsy and nonepileptic attack disorder (NEAD). We performed a quantitative evaluation of both the general level of awareness and the specific contents of consciousness during seizures using the Ictal Consciousness Inventory (ICI). Ninety-five adult outpatients attending general neuropsychiatry and epilepsy clinics with established diagnoses of either epilepsy (n = 66) or NEAD (n = 29) completed one ICI for each witnessed seizure recalled. Patients with a dubious/dual diagnosis were excluded. ICI Level (ICI-L) and ICI Content (ICI-L) scores were calculated for the 167 questionnaires generated by patients with epilepsy (n = 119, of which 58 from patients with temporal lobe epilepsy, 14 frontal lobe epilepsy, and 47 idiopathic 30 generalized epilepsy) and patients with NEAD (n = 48). Mann-Whitney U tests revealed statistically significant higher ICI-L and ICI-C scores for patients with NEAD (both P = 0.01). Subjective reports of consciousness experiences varied between epilepsy and NEAD, with patients with NEAD reporting significantly greater levels of general awareness/responsiveness and more vivid subjective experiences during attacks. The ICI is proposed as a potentially useful self-report instrument to supplement clinical and instrumental tests for the differential diagnosis of epilepsy and NEAD.

The default-mode, ego-functions and free-energy: a neurobiological account of Freudian ideas

This article explores the notion that Freudian constructs may have neurobiological substrates. Specifically, we propose that Freud's descriptions of the primary and secondary processes are consistent with self-organized activity in hierarchical cortical systems and that his descriptions of the ego are consistent with the functions of the default-mode and its reciprocal exchanges with subordinate brain systems. This neurobiological account rests on a view of the brain as a hierarchical inference or Helmholtz machine. In this view, large-scale intrinsic networks occupy supraordinate levels of hierarchical brain systems that try to optimize their representation of the sensorium. This optimization has been formulated as minimizing a free-energy; a process that is formally similar to the treatment of energy in Freudian formulations. We substantiate this synthesis by showing that Freud's descriptions of the primary process are consistent with the phenomenology and neurophysiology of rapid eye movement sleep, the early and acute psychotic state, the aura of temporal lobe epilepsy and hallucinogenic drug states.

Ecstatic epileptic seizures: a potential window on the neural basis for human self-awareness

The anatomical correlate of epileptic seizures with ecstatic auras has not been established. We document precise descriptions of the ecstatic seizures experienced by five patients, all of whom reported intense feelings of well-being and a heightened self-awareness. We propose here that the descriptions by these patients, together with the neurophysiological and neuroradiological evidence, support a theoretical framework for understanding ecstatic states based on hyperactivation of the anterior insula, rather than the temporal lobe. Epileptologists who have access to patients who experience episodic feelings of ecstasy and heightened self-awareness have an opportunity to provide insights that might help clarify the neural basis of consciousness.

Alterations in the contents of consciousness in partial epileptic seizures

Epilepsy research suffers from a deficiency of systematic studies concerning the phenomenology of the contents of consciousness during seizures, partially because of the lack of suitable research methods. The Phenomenology of Consciousness Inventory (PCI), a standardized, valid, and reliable questionnaire, was used here to study which dimensions of the contents of consciousness are distorted during partial epileptic seizures compared with baseline. Further, the similarity of the altered pattern of subjective experiences across recurring seizures was also explored. Our results indicate that patients with epilepsy report alterations on most dimensions of the contents of consciousness in conjunction with seizures, but individual seizure experiences remain similar from one seizure to another. The PCI was found suitable for the assessment of subjective experiences during epileptic seizures and could be a valuable tool in providing new information about phenomenal consciousness in epilepsy in both the research and clinical settings.