Classification and etiology of convulsive states
According to A.I. Boldyrev's classification (1984), typical epileptiform seizures do not always indicate epilepsy as an independent nosology. Broadly speaking, convulsive states are divided into three main forms:
- Epilepsy proper (true epilepsy).
- Epileptic syndrome.
- Epileptic reactions.
The etiology of seizures is extremely diverse. The main causes include organic lesions of the central nervous system (vascular events, atrophy processes such as Alzheimer's disease), severe infections (syphilis, AIDS), as well as non-paroxysmal psychoses (schizophrenia, acute alcoholic psychoses). A distinct group is formed by hysterical paroxysms, which require a specific approach to diagnosis.
Epileptic syndrome
Epileptic syndrome is characterized by persistent and recurring seizures, yet it remains merely a symptom rather than an independent disease. It is typical of many organic brain lesions.
Crucial clinical marker (red flag): if paroxysms (convulsive seizures, twilight states of consciousness, psychosensory disorders) first appear in a patient older than 30 years, it highly likely indicates intracranial tumors or other space-occupying processes (metastases, cysts, hematomas, cysticercosis).
Additionally, the syndrome may develop:
- In extracerebral pathologies, for example, hormonally active tumors (insulinoma).
- At late stages of severe diseases (cerebral syphilis, general paresis of the insane, cerebral atherosclerosis, Alzheimer's disease).
The prognosis and treatment of epileptic syndrome differ fundamentally from the management of true epilepsy and require targeting the primary disease.
Epileptic reactions
Unlike the syndrome, epileptic reactions occur strictly episodically and have a rigid link to an external pathogenic factor. The golden rule: once the provoking factor is removed, the seizures do not recur, so prescribing specialized antiepileptic therapy is unnecessary.
Typical causes and examples of epileptic reactions include:
- Age-related reactions: febrile seizures in children.
- Withdrawal syndrome: single seizures during withdrawal in alcohol, barbiturate, or benzodiazepine dependence.
- Acute conditions: eclampsia, electric injury.
- Industrial intoxications: poisoning by lead, organic solvents, or organophosphates.
- Iatrogenesis (medication intake): seizures can be triggered by camphor, bromocamphor, corazole, bemegride, ketamine, as well as cholinesterase inhibitors such as neostigmine methylsulfate.
Differential diagnosis of seizures
Every convulsive episode requires careful differential diagnosis, as completely different underlying conditions may be masked behind it.
- Life-threatening conditions (cardiac arrest, asphyxia). Sudden loss of consciousness accompanied by convulsions, involuntary urination, and cyanosis may be a sign of acute hypoxia during cardiac arrest. Furthermore, epilepsy itself carries a colossal risk of asphyxia due to aspiration of vomit or dental prostheses (dentures). Without immediate assistance, there is no chance of saving the patient.
- Hysterical seizures. Unlike epilepsy, hysterical attacks are characterized by extreme behavioral demonstrativeness, polymorphism of manifestations, and a lack of strict staging and stereotypy. Important nuance: patients with confirmed true epilepsy can experience both typical epileptic and hysterical seizures simultaneously under strong emotional stress.
- Non-paroxysmal psychoses (schizophrenia). Epileptic manifestations such as hallucinations and psychic automatism phenomena occurring at the time of a seizure can masterfully mimic the clinical picture of schizophrenia. The difference lies in the fact that in schizophrenia, productive symptoms persist for a long time, do not disappear suddenly, and are always accompanied by specific personality changes.
Briefly: answers to topical questions
Which infectious diseases can act as a cause of convulsive states?
Convulsive states can be caused by infectious diseases such as:
- Syphilis.
- AIDS.
What types of aura can precede a generalized epileptic seizure?
A generalized epileptic seizure may be preceded by several types of aura indicating focal cerebral cortex dysfunction. The following types are distinguished:
- Olfactory — indicates the localization of the pathological focus in the uncus.
- Visual — indicates involvement of the occipital lobes.
- Auditory — one of the variants of sensory aura.
- Somatomotor — associated with the postcentral gyrus.
- Paroxysmal mental state alterations — brief psychological phenomena preceding the seizure.
What specific personality changes develop in patients with long-standing epilepsy?
With long-standing epilepsy, patients develop specific personality changes and intellectual disorders. These include:
- Egocentrism — increasing preoccupation with one's own interests.
- Torpidity — general sluggishness, stiffness, and slowing of mental processes.
- Pedantry — heightened attention to detail and strict adherence to rules.
- Explosiveness — irascibility, despotism, and vindictiveness.
- Tendency to flattery — fawning behavior toward others.
- Speech peculiarities — excessive use of diminutive suffixes.
As an outcome of the disease, some patients develop a specific defect — concentric dementia.
What forms of twilight states of consciousness are distinguished in psychiatry?
Psychiatry distinguishes several forms of twilight states of consciousness occurring as un conscious automated actions. These include:
- Ambulatory automatism — organized twilight confusion without delusional or hallucinatory experiences.
- Fugues — brief episodes lasting 1–2 minutes during which patients suddenly bolt and run.
- Transes — prolonged episodes of aimless wandering where patients may travel far from home.
- Somnambulism — sleepwalking occurring during nocturnal sleep, in which patients perform actions and overcome obstacles.
To easily remember the three forms of convulsive states according to Boldyrev, use the acronym "BSR": B — Disease (true epilepsy), S — Syndrome (symptom of another organic pathology), R — Reaction (response to a temporary external stimulus).
Class and exam questions
Does the presence of seizures always require prescribing antiepileptic drugs?
No. If seizures are an epileptic reaction (e.g., febrile seizures in children or a seizure during alcohol withdrawal), special antiepileptic therapy is not required. Seizures stop once the cause is eliminated.
What does a first seizure in a patient over 30 years of age indicate?
The appearance of paroxysms at this age is considered a red flag. It is often the first symptom of developing intracranial tumors or other space-occupying processes (cysts, hematomas, metastases).
How to distinguish epileptic psychosis from schizophrenia?
Epilepsy manifestations (hallucinations, automatisms) occur only at the time of the seizure and tend to disappear suddenly. In schizophrenia, productive symptoms persist for a long time and are accompanied by progressive specific personality changes.
Can hysterical seizures occur in a patient with true epilepsy?
Yes. In patients with true epilepsy, severe emotional stress can trigger not only typical epileptic seizures but also hysterical (psychogenic non-epileptic) seizures.
What else to study on this topic
- Mechanisms of development and clinical presentation of epileptic syndrome in space-occupying brain lesions.
- Emergency management of a seizure: prevention of asphyxia and cardiac arrest.
- Pathogenesis of seizures in withdrawal syndromes (alcohol, barbiturates, benzodiazepines).
- Differential diagnosis of hysterical and true epileptic seizures.
- Toxic epileptic reactions: mechanism of action of cholinesterase inhibitors and industrial poisons.
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