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Though the prevalence of epilepsies is substantially higher in people with intellectual disability (ID) compared with the general population, little is known of the psychosocial burden of epilepsy and adjustment and their respective determinants in this important population. In most modern societies, adult life with an ID is characterized by diminished self-determination, autonomous function, and life choices. These factors alone are known to be critically linked to the individual's overall quality of life. The task is to identify additional burdens attributable to coexisting epilepsy. This article addresses the significance, for people with ID who have epilepsy, of the many different factors, including seizure or epilepsy-related parameters, antiepileptic medication, coexisting motor and sensory impairments, and psychopathological and behavioral disorders, that can impact their quality of life. Discussion also covers the methodological difficulties in published studies, and, finally, proposals are outlined for future research in this field.

We report our experience of training dogs to assist people with epilepsy by providing a useful warning of seizures. An unexpected finding has been that human subjects report an improvement in seizure rate. This may be related to increased confidence and activity levels. We have observed some hazards associated with untrained dogs, which raises questions about future experimental design. We plan further research to test our method and assess outcomes more formally. Recent changes in UK quarantine law provide an opportunity for further international collaboration., (Copyright 2001 BEA Trading Ltd.)

We report 36 cases of pet dogs, who suffered significant adverse health effects as a result of spontaneously reacting to, or anticipating, epileptic seizures in their human owners. These included three cases in which the dog died, and 12 cases in which the dog exhibited aggressive behaviour towards humans. However, where dogs have been specially trained as Seizure Alert Dogs, these adverse effects have not been seen. As interest grows in the use of dogs to anticipate human seizures and support people with epilepsy, it is important to emphasize the need for specially chosen dogs to be used, and for them to be specially trained. This also raises concerns about potential use of untrained dogs as controls in future research using Seizure Alert Dogs., (Copyright 2000 BEA Trading Ltd.)

The parents of 41 young people with epilepsy who were living in the same household as the patients were interviewed using the Camberwell Family Interview, and ratings of expressed emotion (EE) carried out according to standard criteria. The presence of any seizures in the 6 months prior to interview was found to be a predictor of EE (p= 0. 0017). Absolute seizure frequency, as well as presence or absence of seizures was also found to vary with the EE score. Fathers may exhibit high EE by critical comments, mothers by emotional over involvement. Although it is unclear whether high EE is the result of seizures, or whether high EE makes seizures more likely to occur, an intervention study aimed at assessing the effect of lowering parental EE levels on young people's seizure frequency might be worth pursuing., (Copyright 2000 BEA Trading Ltd.)

Approximately 30-40% of people with epilepsy continue to have seizures despite drug treatment. Factors related to cognitive abilities, physical handicap, psychiatric illness and social circumstances are of great importance in the overall management.

The epilepsies are the commonest of serious disorders of brain function. Medical, psychological, social and financial implications can adversely affect quality of life in both patient and family. Accurate categorization of seizure type and epilepsy syndrome, with appropriate choice of drug and other management, can minimize the burden of a seizure disorder.

It is now acknowledged that an excess mortality is associated with epilepsy, over and above that of the underlying disease. This risk is even greater in uncontrolled epilepsy. Because sudden unexplained death in epilepsy (SUDEP) appears to be seizure-related, it is likely that this excess mortality would be reduced if seizures were better controlled or, ideally, stopped. Patients and physicians are in the fortunate position of being able to choose from more effective treatments for epilepsy than at any time in the past. Reductions in mortality, however, must go hand in hand with improved epilepsy care in general. In the past, this area has been overlooked and underfunded. There is some evidence that specialist epilepsy clinics are better at managing cases of epilepsy than general neurology clinics or general medical services. Investing in dedicated epilepsy services could arguably lead to a reduction in mortality. Such investment would also lead to improved provision of counseling and information services for people with epilepsy. It is not yet possible to determine the effects of these interventions or to set targets for a reduction in mortality in people with epilepsy, because there is a lack of accurate data on the prevalence of epilepsy and the rate of SUDEP. Obtaining these figures should perhaps be our first aim. The relevance of these issues to the management of SUDEP are discussed with regard to the United Kingdom Health Service.

The new antiepileptic drugs represent a major part of the wider range of opportunities now available to treat epilepsy. Because of the way in which drugs are developed and the way in which product licences are granted, data sheet information does not necessarily reflect the optimum range of indications, dose escalation, maximum dose or degree of adverse events. Experience suggests that in most cases better results are obtained with slower dose escalations, and that often higher doses may be usefully achieved than those recommended in data sheets. All the new drugs are probably effective in monotherapy.

Evidence now suggests that some people can exert some degree of control over seizure initiation and inhibition. In order to explore this further, 79 young people with epilepsy, attending specialist residential schools, were interviewed regarding awareness of seizure precipitants; recognition of seizure warnings; attempts at seizure inhibition, and ways of self-inducing seizures. Questionnaires with the same content were completed by residential care staff. Results show that many subjects claimed to identify seizure precipitants (63.3%), experienced warnings (70.9%), and had developed means of trying to inhibit seizure occurrence (50.6%). However, in each instance, staff reports were much lower (56.9%, 47.2%, and 22.2%, respectively), and one-to-one concordance was poor. A larger than expected percentage of self-induction was reported for both subjects (8.9%) and staff (9.7%). The implication of these results for both the investigation and treatment of epilepsy are discussed further.

EEG with co-registered electrocardiography was recorded during at least two interictal epileptiform EEG discharges in each of 11 patients who later suffered from sudden unexpected death in epilepsy (SUDEP), and from another 11 age and sex matched patients, also with uncontrolled tonic-clonic seizures, drawn from the same centre who were still alive at the time of investigation (non-SUDEPs). A corrected QT interval for rate (QTc) was obtained and a mean value calculated for the period immediately prior to discharge, during discharge and immediately post discharge. Mean QTc was also obtained interictally without discharge. There was a significant (P = 0.01) increase in the mean QTc during discharge compared to that measured interictally without discharge for the whole population of SUDEPs and non-SUDEPs, and this was maintained for the SUDEPs alone (P = 0.02) but did not hold for the non-SUDEP group alone. Although reaching statistical significance, increases in mean QTc in SUDEP patients only exceeded currently accepted upper limits in one case, and then only marginally. The clinical significance of these findings merits further investigation.

Epilepsy is a condition which spans several disciplines within medicine, as well as having an impact on many non-medical areas such as employment and education. Services for epilepsy in the UK have not been developed according to any coherent strategy and remain fragmented and unevenly distributed. Successive attempts to address these shortcomings by publishing recommendations, even with government assistance, have not led to major improvements. Recent changes in the organization of health care services might at least present an opportunity to effect change by educational initiatives directed towards purchasers and providers. However, the absence of epilepsy from The Health of the Nation objectives represents a failure to get the message through to those with the ability to direct policy. The plethora of new, effective and expensive pharmaceutical treatments should lead to a raising of epilepsy awareness among the medical profession as a consequence of marketing activity, but this is already causing conflict with Family Health Service Associations (FHSAs) and others with equivalent lack of vision. I would suggest that only by politicizing the consumer can the change we seek be brought about.

Eight patients rechallenged with lamotrigine after initial exposure which resulted in a skin rash are reported. On reintroduction of the lamotrigine, six of the patients had no recurrence of the rash. Of the other two patients, one had the occurrence of a mild fluctuating and qualitatively different skin rash on rechallenge. The other patient had developed a dose-related rash on initial challenge resulting in a dose reduction. The first attempt to re-increase the dose resulted in reappearance of the rash which again disappeared on dose reduction. However a further attempt to re-increase the dose did not result in reappearance of a rash. It is suggested that patients who experience a rash but good therapeutic response to lamotrigine might be considered for re-dosing.

Sudden Unexplained Death due to Epilepsy (SUDEP) is not uncommon. The incidence may be difficult to ascertain due to variations in reporting the cause of death investigated by coroners. To study this, we used a cuttings service to identify all cases of SUDEP reported in the UK press during 1992. These cases had been investigated by a number of different pathologists and coroners. Post-mortem reports, witness statements and other relevant information were examined in 40 cases. Inconsistencies were observed both in investigations performed and observations made at time of death. Varying degrees of detail concerning 'type' and history of epilepsy were found. In 70% of cases, type of epilepsy was either not known or not referred to. Similar inconsistencies were found with details of medication, position of body, toxicology reporting and detailed examination of organs, particularly the brain. Attributed cause of death varied considerably, with epilepsy stated as primary cause of death in less than half of the sample. Disparity was noted also in coroner's verdicts, with no distinct pattern emerging in relation to attributed cause of death. The wide variation in practice of individual coroners and pathologists in the investigation and registering of sudden deaths raises issues of quality assurance. As the majority of these deaths are unwitnessed, we rely on these investigations and the statements of officials in the process of registering deaths. If we are to build a profile of people who are at risk of SUDEP, epilepsy must be stated on the death certificate. Until this happens, many more of these deaths will go unrecorded.

The aims of treating epilepsy are to stop seizures, and to neutralize any associated cognitive or psychosocial penalty associated with epilepsy or its treatment. Inappropriate medication and/or continuance of seizures have deleterious effects on quality of life. The Epilepsy Task Force devised a 30-item questionnaire which was sent to children with epilepsy whose families are members of the British Epilepsy Association. The 896 replies which were received within the first two weeks have been analysed. Forty-two per cent of respondents had tonic-clonic seizures. Thirty-five per cent had had no seizures within the previous six months, but 29% reported seizures which occurred at least once a week. Although 42% didn't mind their seizures, the remaining respondents described their seizures as making them feel helpless, scared, panicky, frustrated and different from others. The most common medications were carbamazepine and sodium valproate. Side effects attributed to the medication included tiredness, difficulty in concentrating, dizziness, headache, irritability and weight gain. Thirty-six per cent said that their doctor had never explained about their epilepsy. The questionnaire included space for free-text comments and these were made by more than 400 respondents.

Individuals with learning difficulties commonly suffer from concomitant conditions; epilepsies constitute up to 35%. The prevalence of epileptic syndromes in learning disabled people is less well documented. Non-convulsive status epilepticus (NCSE) occurs with many epileptic syndromes. It can present with insidious or paroxysmal change of neurovegetative, behavioural, cognitive or affective symptoms which can mistakenly be attributed to other causes. NCSE of generalized epilepsy syndromes can show localizing features and NCSE of localization-related epilepsy can show generalized epileptiform discharge patterns. We reviewed 14 residents' (< 20 years, all learning disabled) EEG recordings in inter-ictal stages and in NCSE and conclude that the current nosological grouping of NCSE does not ensure appropriate categorization in a significant number of cases. We developed a revised NCSE classification: (I) Generalized epileptic syndromes: (a) with no evidence of lateralization inter-ictally or in NCSE; (b) with evidence of lateralization in NCSE only. (II) Localization-related epileptic syndromes: (a) with evidence of lateralization/focal activity in NCSE; (b) with evidence of generalized EEG patterns when in NCSE only; (c) with transient forms: same individual shows generalized and lateralized/focal NCSE activity in different EEGs. We suggest our system be tested in larger studies for its sensitivity, reliability and validity.

We present three cases of fatal hepatic necrosis in patients with epilepsy taking anticonvulsants, in which the terminal illness presented as an unusually severe generalized tonic-clonic seizure with failure to regain consciousness. In two cases acute renal failure also occurred. It is not certain to what extent drug therapy, physiological and metabolic changes consequent on prolonged seizures, hitherto undiscovered infective agents, or a combination of any of these may play in such a process. We suggest, however, that the case against the drugs alone has yet to be proved.

Epilepsy is a common condition in people with learning difficulties. The assessment of seizure disorders in this group requires special consideration of psychological and social, as well as medical, aspects. We consider an integrated approach assessing epilepsy and learning difficulties in parallel. Such meticulous assessment can lead to improved quality of life with treatment changes, and will avoid unnecessary medical and social costs.

The inhibition of seizure activity by behavioural methods is becoming more popular. Lockhart's monkey model of focal epilepsy suggests a theoretical approach to behavioural seizure inhibition. Behaviour, by changing the pattern of excitation and inhibition surrounding a focus, is thus able to inhibit seizure activity. This article describes single case studies in which the behavioural methods of cued arousal, covert desensitization and relaxation have brought about a decrease in seizure frequency.

The feasibility and utility of a neuropsychiatric assessment in a cohort of severely impaired children with long-standing epilepsy (n = 96) is tested. This assessment is described, and some results reported in this highly selected group. Substantial difficulties in coordination were present in nearly three-quarters of the sample, and dysarthria identified in two-thirds. Psychiatric interviewing identified cases of mood disturbance that altered overall treatment of that child, and a more systematic behavioural assessment permitted clearer management of behavioural problems already known to staff. This research supports previous findings that a full neuropsychiatric evaluation is both practical and has an important place in the early assessment and ongoing management of complex childhood epilepsy.

The influence of type of seizure and medication on psychological disability was assessed using the Standard Psychiatric Interview in matched epileptic patients. In comparison to patients with idiopathic tonic-clonic seizures, those with temporal lobe epilepsy complained of more irritability and impaired concentration, and were rated as more depressed and slowed up. Compared to patients on phenytoin, those on carbamazepine complained of more sleep disturbance and were more likely to be taking an hypnotic.

Theophylline and antipyrine disposition has been compared in smoking epileptic patients, non-smoking epileptic patients and non-smoking healthy volunteers. Although clear differences in drug clearance and half-life were evident as a result of anticonvulsant drug therapy, no effect of smoking was discernible. Thus, additive effects from induction of the hepatic microsomal monooxygenase system in man by anticonvulsant drugs and polycyclic aromatic hydrocarbons (in cigarette smoke) were not evident.