Talk:Epilepsy

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This article needs more context around or a better explanation of technical details to make it more accessible to general readers and technical readers outside the specialty, without removing technical details. See below for more information.


 Epilepsy is a former good article candidate. There are suggestions below for which areas need improvement to satisfy the good article criteria. Once the objections are addressed, the article can be renominated as a good article. If you disagree with the objections, you can seek a review.

Date of review: 14 October 2006

Previous discussions have been archived here: Archive 1.

Contents

[edit] Spliting into Wikipedia:Summary style

This article is too long. It is a big subject and I believe the length of the article is having an effect not only on readability but is also discouraging expansion of the text. The following articles have already been spawned off:

and they have grown in size and quality since doing so. Of course, the Seizure article is very much related too.

The next in line would be

  • Epilepsy treatment
  • Epilepsies and epileptic syndromes (organised around PMID 2502382)

I hope we can have the following sections, but the current body-text is too short at present:

  • History of epilepsy
  • Social implications of epilepsy - Discussing stigma, legal implications, disablitiy and employment issues.

I would be interested in your comments. Colin Harkness°Talk 17:24, 4 August 2006 (UTC)

[edit] Outdated terms

As per Seizure types, terms like petit mal and grand mal have fallen into disuse following a standardization effort in 1970. FractureTalk   05:41, 4 September 2006 (UTC)

— I disagree. In my experience those terms are still widely in used both in epilepsy clinics and information brochures, and the general public. Dudeglove 22:17, 20 September 2006 (UTC)

Whilst the word "disuse" is too strong here, these terms should not enjoy a prominent place in the vocabulary of a modern healthcare professional. They were superseded over thirty years ago by terms that better describe the seizures. It is perhaps unfortunate that "generalized tonic-clonic seizure" is a bit of a mouthful and its meaning is opaque to a lay person. Not that "petit mal" or "grand mal" are all that informative – their meaning shows a rather embarrasing ignorance by the medical professoin of old. My own examination of the literature offline and online shows that the old terms often only appear in parenthesis and are usually clearly indicated as "old fashioned". Wikipedia should not use these terms by default in the same way that we do not say "Hoover" for vacuum cleaner or "the wireless" for radio. That fact that people still use archaic terms doesn't mean that a modern encyclopaedia should give equal prominence to them.
I think each these terms deserve mentioning at most once only in any relevant article on the subject. It should be in parenthesis or otherwise in a way to clearly indicated that the term is archaic. Colin Harkness°Talk 13:46, 21 September 2006 (UTC)


Yes that seems fair. To leave out the older terms i feel would be to the detriment of the article.Dudeglove 11:34, 22 September 2006 (UTC)

[edit] Flying Airplanes?

Not since aircraft flight was regulated have persons with epilepsy been allowed at the controls of airplanes. In the US, all pilots must obtain a medical certificate from a FAA Medical Examiner which demonstrates, amongst other things, that the holder has no abnormal neurological conditions. There are no exceptions. Epilepsy is specifically mentioned in the FAA medical certificate application. Similar restrictions exist in other countries.

The reference to airplane accidents being caused by epilepsy should be removed as it is patently false. LymanSchool 13:22, 5 October 2006 (UTC)

Done. I was never happy with that unsourced statement and a quick search showed no news articles concerning seizures causing plane crashes. There may well be some cases in history where someone has a seizure whilst flying a plane, but they certainly aren't common as the sentence implied. I've removed the car crash portion too. According to this source it isn't as big a problem as feared. I may rework this section to incorporate the research findings from that study. Colin Harkness°Talk 13:43, 5 October 2006 (UTC)

[edit] Patophysiology

I was thinking of renaming the "Patophysiology" section as "Neurobiology of epilepsy" and adding a bit more about the basic mechanisms underlying epilepsy. I also noticed that this section says excitotoxicity is a cause of epilepsy rather than a consequence of an epileptic seizure. Any concerns about me making some of these changes? Nrets 03:19, 11 October 2006 (UTC)

Thanks for your offer to contribute – it is most welcome. I'm not sure that replacing one medical term with another would help. The "of epilepsy" is redundant in this article. Pathophysiology is the term used in WP:MEDMOS. The alternative, "Mechanism", doesn't in my view cover the whole story.
Please rewrite this section, with good references. The current text suffers from two problems:
  1. It mentions a very specific genetic problem and scientific paper, which may or may not be common enough to warrant inclusion in a general article on epilepsy. Have a look at the excellent work being done by User:Dpryan at Idiopathic generalized epilepsy and related articles, for where such specific details may be better placed. This article would benefit more from referring to textbooks or review papers rather than individual studies.
  2. The kindling/excitotoxicity paragraph has already attracted criticims from one expert. If this is not a commonly accepted mechanism in human epilpesy then it should be dropped or downplayed.
The concept of a "seizure threshold" should be covered. You might briefly cover how understanding the neurobiology helps us design or explain anticonvulsant drugs (though if you can help over at anticonvulsant that would be great too). The pathophysiology of a focal-onset seizure is surely different to a generalised-onset seizure – explain. Why does the neuronal activity become synchronized and why should that be bad? What mechanism (generally) puts an end to a seizure? Why does that fail in status?
Remember that experts in neurobiology are unlikely to consult Wikipedia (see WP:MEDMOS and Wikipedia:Make technical articles accessible). This section may justifiably be the most technical in the article, but try your best. Colin Harkness°Talk 10:31, 11 October 2006 (UTC)
Since I am not a clinician I cannot readily contribute to some of the more directly medically-related issues, but what I'll try to do is to explain some of the basic neurobiological mechanisms in layman's terms and try to link these with some of the clinical symptoms, which is what I had in mind. I'll try and get to that soon (I'll be away for a few days). Nrets 14:02, 11 October 2006 (UTC)

[edit] Failed GA nomination

This article failed good article nomination. This is how the article, as of Oct 13th 2006, compares against the six good article criteria:

1. Well written?: At present the article is a useful reference article for a reader with a medical or scientific background. To improve, I would suggest expanding the lead section to include a definition of what a seizure is, using less technical language throughout, moving the "history" bit up to the introduction, and having an overhaul of the prose to make it flow better. At present it is quite disjointed. This is a difficult subject to tackle comprehensively whilst also being inclusive about all the different subtypes. See something like cancer perhaps.
2. Factually accurate?: Although there are some references in the article, there are probably more uncited statements than cited. For instance, in the diagnosis section it is just stated that neuroimaging is not helpful in diagnosis, but long-term video monitoring EEG is. Whilst this is likely to be true, info must be easily verifiable.
3. Broad in coverage?: This article could do with some more factual information about the underlying pathophysiology of epilepsy. Treatments could perhaps be forked off to another article and explored in more depth. Some more cited information about incidence, prevalence, prognosis, cognitive dysfunction, risk factors, etc would be welcome. It seems odd that in the list of seizures the most common forms are at the bottom.
4. Neutral point of view?: OK
5. Article stability? OK
6. Images?: So far there is only an image of an EEG, which to the untrained eye is not particularly informative. Perhaps an image showing different types of epilepsy surgeries[1], someone undergoing video monitoring EEG[2], someone having a seizure...[3]

When these issues are addressed, the article can be resubmitted for consideration. Thanks for your work so far.

[edit] Canine companion?

Hi, I just want to say I'm not that happy with the section on alternative and canine treatments. It seems very vague, not very helpful, and with no real evidence. In short, a waste of space. Are we sure this isn't just some rubbish someone's added; I've never heard that, and it sounds stupid. Overall, as a medical student, I was less than happy with this article, and will be using GP Notebook UK instead for my research. I found the whole thing too rambling and incorehant, and I'm not sure of its accuracy. - Tim (1st year medical student, Birmingham University) —The preceding unsigned comment was added by 213.48.73.94 (talk) 15:39, 7 November 2006

Thanks for your feedback. I've trimmed the canine bit a little and wikified it so you can follow the link to the full article on that subject. It does not appear to be rubbish. Overall, this article is not one of our best (deemed Featured Articles) and needs more work, particularly adding references so that people can be assured of its accuracy. It would be nice if you could join Wikipedia:WikiProject Medicine to help improve our medical articles. If there are other specific aspects of this article that you think are wrong, or badly worded, let us know.

GP Notebook is a fine resource, aimed at UK doctors. It would be disappointing for those involved in that site if you didn't find it useful in your medical studies. Colin Harkness°Talk 17:23, 7 November 2006 (UTC)

[edit] Definition of Epilepsy

The lead of this article must define epilepsy in a succinct and accurate fashion, in keeping with current consensus medical opinion. Fuller discussion of the precise boundaries of the definition could occur later in the article, since the lead must be necessarily brief. There is also a requirement to be understandable to the general reader, but not at the expense of accuracy.

Recent changes to the definition had the text:

"Epilepsy ... is a common chronic neurological condition that is characterized by chronic recurrent unprovoked behavioral and/or cognitive spells associated with abnormal brain activity. These spells are termed seizures. Epileptic seizures affect approximately 50 million people worldwide."

IMO, there are several problems with this:

1. The term "chronic" is repeated in the first sentence. This is not just untidy English but implies that "chronic" is a necessary requirement for diagnosis. I don't believe this to (always) be the case, and that the basic and well established "recurrent unprovoked seizures" definition is satisfactory. In certain circumstances, it may be necessary to wait in order to confirm that a recent injury (for example) can no longer be considered the provocant, but rather that the patient has actually suffered more permanent detrimental effects. In other circumstances, for example infantile spasms in a child diagnosed with tuberous sclerosis, one does not hang around to see if they go away by themselves. In both cases, the patient will have a "chronic neurological condition" but in the latter, the diagnosis was made without any requirement to wait. For epidemiological purposes, there is no guidance that researchers must only include patients who have had seizures over (say) at least 3 months - see below. Perhaps this is all splitting hairs. Regardless, I think the first use of the word "chronic" is adequate in order to leave the reader in no doubt that we are not talking about some temporary illness.

2. The term "epileptic seizures" as part of the definition has been replaced by "behavioral and/or cognitive spells associated with abnormal brain activity. These spells are termed seizures". Whilst it maybe useful to explain what seizures are in lay terms, such lay terms should not be used in order to define epilepsy. It's just back-to-front. The resulting definition is not of encyclopaedic quality.

3. The phrase "It [epilepsy] affects approximately 50 million people worldwide" has been replaced with "Epileptic seizures affect approximately 50 million people worldwide." which is very much not the same thing. Epilepsy is defined in terms of epileptic seizures, not the other way round and they are not interchangeable. The adjective "epileptic" is used in the term "epileptic seizure" to refer to the "excessive and/or hypersynchronous" neuronal activity and in order to distinguish these seizures from the (usually lay) use of the word when referring to any paroxysmal event.[4] The term "epileptic seizures" does not mean "seizures only in someone who has epilepsy". Far more people will have an epileptic seizure at some point their life than the number that develop epilepsy.

See below for the various definitions of epilepsy proposed over the years. The text

"common chronic neurological condition that is characterized by recurrent unprovoked epileptic seizures."

is I believe a satisfactory mix of the definitions from 1993 and 2001. If a more recent defintion gains acceptance, then of course it can be updated. Colin Harkness°Talk 18:40, 6 November 2006 (UTC)

Definitions are important in an encyclopaedia, which is why I've written a ridiculous number of words to defend one sentence. Consider, however, the authors of the 2005 proposal (below). They spent three whole years and went through three levels of anonymous review before publishing their precious words. Then their colleagues wrote back saying they hated it and "It does not appear that proposed definitions advance the field in any way." That, surely, would have been a bummer of a day. Colin Harkness°Talk 19:49, 6 November 2006 (UTC)

[edit] Definitions over the years

  • 1876 - John Hughlings Jackson, gave the first definition that modern neurologists would agree with.
Epilepsy: A chronic disorder in which there are recurring, sudden, excessive, and rapid discharges of grey matter of some parts of the brain, the clinical manifestations of which are determined by the anatomical site in the brain of the discharge. (Walter J. Friedlander (2001). The history of modern epilepsy: the beginning, 1865-1914. Westport, Conn: Greenwood Press, 2. ISBN 0-313-31589-2.)
  • 1973 - Gastaut, Henri (1973). Dictionary of Epilepsy. Geneva: World Health Organization.
Epilepsy: A chronic brain disorder of various aetiologies characterised by recurrent seizures due to excessive discharge of cerebral neurones (epileptic seizures), associated with a variety of clinical and laboratory manifestations). Single or occasional epileptic seizures (such as febrile convulsions and the seizures of puerperal eclampsia) as well as those occurring during an acute illness should not be classified as epilepsy
  • 1991 - Hauser W, Annegers J, Kurland L (1991). "Prevalence of epilepsy in Rochester, Minnesota: 1940-1980.". Epilepsia 32 (4): 429-45. PMID 1868801. - An oft-cited epidemiologic review.
Epilepsy: Recurrent unprovoked seizures.
Epileptic seizure: A clinical manifestation presumed to result from an abnormal and excessive discharge of a set of neurons in the brain. The clinical manifestation consists of sudden and transitory abnormal phenomena which may include alterations of consciousness, motor, sensory, autonomic, or psychic events, perceived by the patient or an observer.
Epilepsy: A condition characterized by recurrent (two or more) epileptic seizures, unprovoked by any immediate identified cause. Multiple seizures occurring in a 24-h period are considered a single event. An episode of status epilepticus is considered a single event. Individuals who have only febrile seizures or only neonatal seizures ... are excluded from this category.
Epileptic seizure: Manifestation(s) of epileptic (excessive and/or hypersynchronous), usually self-limited activity of neurons in the brain.
Epileptic disorder: A chronic neurologic condition characterized by recurrent epileptic seizures.
Epileptic seizure: a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain.
Epilepsy: a disorder of the brain characterised by an enduring predisposition to generate epileptic seizures and by the neurobiologic, cognitive, psychological, and social consequences of this condition. The definition of epilepsy requires the occurrence of at least one epileptic seizure.
The above definition by Fisher et al has proved highly controversial since it was a "deviation from the previous, almost universally accepted definition of epilepsy as a condition characterized by recurrent unprovoked seizures"[5] and resulted in a number of responses[6] [7] [8] to which the original authors replied.[9]. Although the proposal was the result of consensus discussions, it has not apparently met consensus approval amongst all neurologists.

[edit] Epilepsy and Cultural Ecology

A brief review of available Literature will surely yield far more instances where localized epileptics have high status (and in many cases highly functional[i.e. having integrated structure] social roles)vs. cultures in which they are percieved as a bane and ill. It should be noted that only in industrialized, primarily, Western but also in some contemporary Eastern societies do epileptics seem to be stigmatized (especially in the U.S.). This should not be assumed to be due to modern medical practices but rather to lack of a wholistic component in Western medicine. —The preceding unsigned comment was added by 70.231.127.84 (talk) 11:09, 6 December 2006 (UTC).

[edit] A few brief initial ideas

When talking to audiences about epilepsy, I'll usually start with a series of definitions to create a common language: what is a seizure? what is epilepsy? what is an epileptic syndrome? This both defines the terms and separates each from the others, given that simply having seizures does not mean you have epilepsy, depending on the circumstances.

I'd change the title of the section from seizure syndromes to epilepsy syndromes.

I agree that there is a problem of the level of detail to be included in a single article. I'd be happy to contribute to this, but I'm not sure if one should put, for example, the treatment of epilepsy in the article itself, or in a link.

Seizuredoc 13:47, 11 December 2006 (UTC)

I agree. The lead needs at least another paragraph to help introduce the topic. It dives straight into Classification minutia too quickly. The title change makes sense.
See the top of this talk page for how I think the article could be split up as it expands. The answer to your question is "both" but to different levels of detail. The Treatment section is big and could be bigger. When expanded it needs its own article and what remains still needs to be a compact but comprehensive discussion. Feel free to start an Epilepsy treatment article, copying what is useful from this one. Once that's got off the ground, we can try to compact the remaining section in this article. See Wikipedia:Summary style.
Colin Harkness°Talk 12:34, 14 December 2006 (UTC)
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