IMPACT OF DIFFERENT CHRONIC CONDITIONS:Psychosocial Factors in Epilepsy

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Health Psychology PSY408

Lesson 29

IMPACT OF DIFFERENT CHRONICCONDITIONS

1. Epilepsy

Epilepsy is a condition marked by recurrent,sudden seizures that resultfrom electrical disturbances of the

cerebral cortex. Although the seizures epilepticsexperience can vary greatly, the twomost common types

arethe:

1. Grand mal (or"tonic-clonic") attack, which is the mostsevere form and entailstwo phases. It begins

with a very brief tonic" phase, in which the person losesconsciousness and body is rigid. It thenprogresses

to a longer "clonic" phase thatlasts 2 or 3 minutes andincludes muscle spasms andtwitching. The body

maythen relax until the personawakens soon. Sometimes before a grand mal attack epilepticsexperience an

aurawhich consists of unexplained sounds,smells, or othersensations.

2. Petit mal (or "absence")attack, which involved diminished consciousness, and in which the person stares

blanklyfor a short while, perhaps only a few seconds, and may show slight facial twitching. When the

episodeends, the person simply resumeswhatever he or she wasdoing, sometimes not even being aware

that the event happened. Petit malattacks occur mainly in childhoodand usually disappear by adulthood.

Estimates of the prevalence of epilepsy vary somewhat, but it afflicts about l % of people worldwide. There

areprobably over 2 millioncases of epilepsy in the UnitedStates, perhaps half of which are undiagnosed

anduntreated. Over 100,000 newcases are diagnosed eachyear. Although the conditioncan develop at any

age, the great majority of epilepticsexperience their firstseizures by 20 years of age.

WhatCauses Epilepsy?

Sometimesphysicians find a specific neurological defect that is the cause of an epileptic's disorder, but

usually the reasons are unknown.Risk factors for developingepilepsy include a strong family history of the

condition,severe head injury, infections of the central nervous system, andstroke.

MedicalRegimens for Epilepsy

Anticonvulsantdrugs provide the mainmedical treatment for epilepsy.These medications must be taken

regularly to maintain the most effective serumconcentrations throughout the dayand can haveundesirable

sideeffects, such as facial hair in women, and blurred visionand nausea if the dose is too high. A promising

new treatment involves using an implanted device that deliversstimulation to the Vagalnerve.

Epileptics whose seizures result fromclear neurological defects mayhave the option of surgical treatment if

they have frequent, severe attacksand other treatments do notwork or cause problematic sideeffects.

Neuro-psychologists conduct tests to pinpoint the affectedarea of the brain and minimize cognitive and

motorimpairments the surgery mightproduce. After surgery, as many as 80% of patients becomeseizure-

free in the next few years. But undergoing surgery without becomingseizure-free may lead to subsequent

psychosocialdifficulties, such as heightened anxiety and depression.

PsychosocialFactors in Epilepsy

Becauseindividuals who are having epileptic episodes lose control of their behavior and "actstrange", their

conditionstigmatizes them among people who do not understand it. Longago, many people believed that

individualswith this condition werepossessed by the devil. Although few people in advanced societies

today shun victims of epilepsy, witnessing an attack may still arousefeelings of fear andaversion.

Aside from the reactions theirattacks produce in people, what otherproblems do epileptics face as a result

of their illness? Having strongseizures, especially with a loss of consciousness, is sometimesassociated with

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importantcognitive and motorimpairments that can limiteligibility for certainactivities and jobs: such as

thosethat involve high workloads or danger from heights or machinery.

Epilepsy seems to be related to psychosocialprocesses in two ways. First, some evidence suggeststhat

emotionalarousal, such as of anxiety, mayincrease the likelihood or severity of epileptic episodes. Second,

epilepticsand their families sometimesadjust poorly to the disorder, especially if episodes are frequentand

severe.Emotional difficulties, such as with anxiety or depression, oftenlead clients to drop out of

rehabilitationprograms. Many of the adjustmentproblems that epilepticsface can be reducedthrough

counselingwhen the diagnosis is madeand through the work of support groups.

What to Do for a Seizure

Peoplereact negatively to seeing a grandmal attack for manyreasons, one of which may be that they don't

know what to do to help. Actually, there is little one can do otherthan to remain calm andtry to protect the

epileptic from injury as he or shefalls or flails about during the tonic or clonic phases. If you witness a

seizure, the following six actionsare recommended:

1. Prevent injury from falls or flailing. Break the fall if possible and provide a cushion, such as a coat,

between the person's head and the ground.

2. Do not put anything in the person's mouth. Many people believe they must put a spoon or other object

in the mouth to prevent the epileptic from swallowing his or her tongue, whichactually can nothappen.

3. Loosen tight clothing around the neck.Turn the person on his or her side so that salivadoes not obstruct

breathing.

4. Do not restrain the person. If you believe the epileptic could be injured while flailing near a hard object,

try to move the object.

5. If the person does not comeout of the attack in about 5 minutes, call an ambulance.

6. After the person wakes up, describe what happened and see if he or she needs help whenready to leave.

Epileptics are often disoriented after an attack.For the most part, the role of the bystander requirescalm

andcomposed caring and common sense.

2. Nervous SystemInjuries

Manythousands of people in the United Statesand many more all around the world suffer injuries to the

brain or spinal cord each year, leaving them debilitated for life. Neuro-psychologists and health

psychologists play important roles in assessingthese patients' impairments andhelping them adapt to their

conditions. In this section, we will focus on the impact of having a spinal cord injury.

Prior to the 1940s, medical practitioners knew almost nothing about treating people who suffered a severe

injury to the spinal cord. In World War I, 80% of the soldiers who receivedsuch injuries died within 2

weeks.People who survived severespinal cord injuries had a poorprognosis for their future health, which

wascharacterized by major health complications and a short life span. As a result,patients and practitioners

had a defeatist attitude, and little attempt was made towardrehabilitation.

But in World War II, Englandestablished special medical units to develop and provide comprehensivecare

andrehabilitation for people withspinal cord injuries. These medical units served as a model for others to

be developed in countries around the world.

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The Prevalence, Causes and Physical Effects of Spinal CordInjuries

The term spinal cord injury refers to neurological damage in the spine thatresults in the loss of motor

control,sensation, and reflexes in associated body areas. Thedamage may be caused by disease or by an

injurythat compresses, tears, or severs the cord. When the cord is badly torn or severed, the damage is

permanentbecause little or no nervetissue will regenerate; but if the cord is compressed or has an abrasion,

somefunction may be recoveredwhen the pressure is removed or healingoccurs.

Thedegree to which the person'sfunction is impaired depends on the amount of damage and itslocation.

If the cord is completely severed in the neck region, quadriplegia results. Actor, Christopher Reeve's

(Superman) horse-riding accident left him quadriplegic. If a lower portion is severe, paraplegia results. If the

cord is not completely severed, partialfunction remains.

Millions of people around the world are livingwith spinal cord injuries; in the UnitedStates, there aremore

than250,000 people with this affliction,and about 8,000 new casesoccur each year. Abouthalf of these

people suffer neck injuries and arequadriplegics. The greatmajority of Americans whoreceive spinal cord

injuries are males, and most of them are between 10 and 30 years of age at the time. The most common

cause is automobile and motorcycle accidents, and the remainder result mainly fromfalls, sporting

activities,and wounds, such as from a gunshot or stabbing.

Thephysical effects patientsexperience after spinal cord injuries change over time andprogress through

twostages:

1. Short-term effects

Theimmediate physiological reaction is called"spinal shock", which usuallylasts between a few daysand 3

months. In spinal shock, neuralfunction is devastated either by the cord being severed or by inflammation

at the site of lesser damage.The result is that the body cannot regulate blood pressure,temperature,

respiration, and bladder and bowelfunction. Medical personnelmust intervene to control these functions.

Usually, the shorter the period of spinal shock, the better the prognosis of recovery.

2. Long-term effects

Thefull extent of spinal cord damagemay not be clear forsome time, and long term predictions are

difficult to make during the first 6 months or so. If the cord is not severed,considerable functionalrecovery

mayoccur over a long period of time. If the cord is severed, some autonomic functions will recover, but

otherfunctions will not. Peoplewho survive severe damage to the higher regions of the cord aretypically

fullyparalyzed and unable to breathe without a respirator.

Theinitial care these patientsreceive typically focuses on their medical needs, withlittle or no attention to

theirpsychological reactions. They receive very little information abouttheir prognosis because it is so hard

to predict, and medical staff want to avoid the depression their speculationsmight produce. Oncethe

condition of these individuals hasstabilized, the process of rehabilitationbegins. Almost all spinal cord

injurypatients enter rehabilitationexpecting to regain totalfunction and are notprepared to cope with the

reality of permanent functional losses. A major goal for psychologists at this time is to help these people

adjust to the demands and limitations of the rehabilitation process.

Physical Rehabilitation

Theprocess of physical rehabilitationfor people with spinal cord injuries is geared toward helping them (1)

regain as much physical function as the neurological damage will allowand (2) become as independent in

theirfunctioning as possible. This processfocuses initially on training the patients to develop bladder and

bowelcontrol and on assisting them in moving paralyzed limbs to maintain theirrange of motion.

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Hygienic bladder care is extremely importantbecause a common cause of death in these patients after the

spinalshock period is kidneyfailure from repeated infections.

Thenext phase of rehabilitationextends the focus of physical therapy toward maintaining andimproving

the function of muscles overwhich the person has somecontrol. For example,quadriplegics receivespecial

attentiontoward improving respiration; paraplegics do exercises to strengthen the upper body. When some

neural connection to affected parts of the bodyremains, therapy with biofeedback to `re-educate' the

muscles in those areas appears to help some, but not all, patients.

Thelast phase of physicalrehabilitation extends the therapy as much as possible to include activities of daily

living.Those patients who haveregained sufficient functionlearn how to performself-care activities

independently and to use devices to compensate for permanentphysical losses. Somedevices today are

highlysophisticated and usecomputers, allowing paralyzedindividuals to turn on lights, answer the

telephone, and operate computer keyboardswith voice commands.

PsychosocialAspects of Spinal CordInjury

The victims' main challenges after spinal cord injury are to make the most of their remaining abilities and

lead as full a life as possible.What can health careworkers, family, and friends do to help? Psych-

physiologists John Adams and ErichLindemann described andcontrasted case studies of two young men,

17 and 18 years of age, whohad suffered spinal cord injuries that rendered them quadriplegic. One adapted

successfully,and the other didnot.

Thepatient who adapted wellwas able to accept the injury and abandon the part of his self-conceptthat

wasassociated with his being a fine athlete. He then turnedhis energies toward academicpursuits and

eventually became a history teacher. He also coached a localbasketball team from hiswheelchair.

Theother patient provides a strikingcontrast. He was never able to accept the injury or the permanence of

hiscondition. He became extremelywithdrawn and depressed--at onepoint he was spending much time in

bedwith the curtains drawn andfrequently with the sheetover his head. A Fewyears later, he wasre-

admitted to the hospital after taking an overdose of medication. At last contact, he wasliving at home, still

clinging to the hope that he would walk again.

Why did these young men adapt so differently to their similarphysical conditions? Adams andLindemann

noted the strikingly different waysthese patients' families and friends responded to their condition. In the

case of the patient who adaptedwell to his condition, hisparents and friends alsoaccepted his paralysisand

provided an environment in which he could redefine his self-concept. Forinstance, his parents installed

ramps in their home and widened doorways to accommodate a wheelchair.The other patient's familyand

friends were not able to accepthis condition or provide the support he needed to help himadapt.

Family and friends can also help by providing social supportwithout being overprotective and`taking over'

when the patient has difficultyperforming self-help tasks. Having a disabled individual in the household

increases the stress of all familymembers. They need to makemany adjustments in daily livingand, while

doingso, try not to make the person feel like a burden. If the patient is a husband or wife, his or her spouse

faces very difficult adjustments. Rolechanges occur immediately--atleast for a while, andperhaps

permanently.

The healthy spouse, with or without the help of other familymembers, must suddenly take on full

responsibility for providing the family's income, maintaining the household, caring for the children, and

caringfor the disabled person.Sexual-problems brought on by the patient's injury may become a major

source of stress in the marital relationship.

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Disabled people also experience manyunpleasant thoughts about themselves,their future, their relations

withother people in general, andphysical barriers in society. They find that many places they once liked to

go to are inaccessible by wheelchair,for example. Further more, people in general act strangelytoward

them--staring, or quickly averting their eyes, or behaving awkwardly or uncomfortably in theirpresence.

Theseexperiences tend to reduce the self-esteem of disabled people many of whom have heightened levels

of depression and drug and alcohol use. Adapting to becomingdisabled takes time, and a couple of years

maypass before many individualswith spinal cord injuries report improvements in their adjustmentand

quality of life.

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