gatesandrowan’s nonepilepticseizuresassets.cambridge.org/97805215/17638/frontmatter/... · 2009....

Gates and Rowan’s

Nonepileptic SeizuresThird Edition

www.cambridge.org© in this web service Cambridge University Press

Cambridge University Press978-0-521-51763-8 - Gates and Rowan’s Nonepileptic Seizures, Third EditionEdited by Steven C. Schachter and W. Curt LaFranceFrontmatterMore information

http://www.cambridge.org/9780521517638http://www.cambridge.orghttp://www.cambridge.org

Gates and Rowan’s

Nonepileptic SeizuresThird EditionEdited bySteven C. Schachter

W. Curt LaFrance, Jr.




cambridge university pressCambridge, New York, Melbourne, Madrid, Cape Town,Singapore, São Paulo, Delhi

Cambridge University PressThe Edinburgh Building, Cambridge CB2 8RU, UK

Published in the United States of America byCambridge University Press, New York

www.cambridge.orgInformation on this title: www.cambridge.org/9780521517638

First edition (1993) and second edition (2000) Published by ButterworthHeinemann, c© A. James Rowan and John GatesThird edition Published by Cambridge University Press, c© S. C. Schachterand W. C. LaFrance, Jr. 2010

This publication is in copyright. Subject to statutory exceptionand to the provisions of relevant collective licensing agreements,no reproduction of any part may take place without the writtenpermission of Cambridge University Press.

This edition published 2010

Printed in the United Kingdom at the University Press, Cambridge

A catalog record for this publication is available from theBritish Library

Library of Congress Cataloging in Publication dataGates and Rowan’s nonepileptic seizures. – 3rd ed. / edited by Steven C.Schachter, W. Curt LaFrance Jr.p. ; cm.

Rev. ed. of: Non-epileptic seizures / edited by John R. Gates, A. James Rowan.2nd ed. c2000.Includes bibliographical references and index.ISBN 978-0-521-51763-8 (hardback)1. Convulsions. 2. Convulsions – Psychological aspects.I. Gates, John R. II. Schachter, Steven C. III. LaFrance, W. Curt.IV. Non-epileptic seizures. V. Title: Nonepileptic seizures.[DNLM: 1. Seizures – diagnosis. 2. Diagnosis, Differential.3. Neurobehavioral Manifestations. 4. Seizures – physiopathology.5. Seizures – therapy. WL 340 G259 2010]RC394.C77N66 2010616.8′45 – dc22 2009032957

ISBN 978-0-521-51763-8 Hardback

Cambridge University Press has no responsibility for thepersistence or accuracy of URLs for external or third-partyinternet websites referred to in this publication, and doesnot guarantee that any content on such websites is, or willremain, accurate or appropriate.

All material contained within the DVD is protected by copyright and otherintellectual property laws. The customer acquires only the right to use theDVD and does not acquire any other rights, express or implied, unless theseare stated explicitly in a separate licence.

To the extent permitted by applicable law, Cambridge University Press is notliable for direct damages or loss of any kind resulting from the use of thisproduct or from errors or faults contained in it, and in every case CambridgeUniversity Press’s liability shall be limited to the amount actually paid by thecustomer for the product.

Every effort has been made in preparing this publication toprovide accurate and up-to-date information which is in accord withaccepted standards and practice at the time of publication. Although casehistories are drawn from actual cases, every effort has been made to disguisethe identities of the individuals involved. Nevertheless, the authors, editors,and publishers can make no warranties that the information containedherein is totally free from error, not least because clinical standards areconstantly changing through research and regulation. The authors, editors,and publishers therefore disclaim all liability for direct or consequentialdamages resulting from the use of material contained in this publication.Readers are strongly advised to pay careful attention to information providedby the manufacturer of any drugs or equipment that they plan to use.




Contents

List of contributors page viiPreface xiDedications xiiiRemembrances xvii

Section 1: Recognition, diagnosis,and impact of nonepileptic seizures

1 Epidemiology and classification ofpsychogenic nonepileptic seizures 3Nathan M. Griffith and Jerzy P. Szaflarski

2 Psychogenic nonepileptic seizures:historical overview 17Michael Trimble

3 The burden of psychogenicnonepileptic seizures (PNES) incontext: PNES andmedicallyunexplained symptoms 27James C. Hamilton, Roy C. Martin,Jon Stone, and Courtney B. Worley

4 Clinical features and the role ofvideo-EEGmonitoring 38Selim R. Benbadis and W. Curt LaFrance, Jr.

5 Comorbidity of epileptic andpsychogenic nonepileptic seizures:diagnostic considerations 51Peter Widdess-Walsh, SiddharthaNadkarni, and Orrin Devinsky

6 Nonepileptic paroxysmal neurologicaland cardiac events 62Fergus J. Rugg-Gunn andJosemir W. Sander

7 Parasomnias: epileptic/nonepilepticparasomnia interface 77Roderick Duncan and Aline Russell

8 The use of hypnosis and linguisticanalysis to discriminate betweenpatients with psychogenic

nonepileptic seizures and patients withepilepsy 82John J. Barry and Markus Reuber

9 Diagnostic issues in children 91Tobias Loddenkemper and Elaine Wyllie

10 Diagnostic issues in the elderly 110Christoph Kellinghaus and Gabriel Möddel

Section 2: Nonepileptic seizures:culture, cognition, and personalityclusters

11 Cultural aspects of psychogenicnonepileptic seizures 121Alfonso Mart́ınez-Taboas, RobertoLewis-Fernández, Vedat Sar, and ArunLata Agarwal

12 Psychogenic nonepileptic seizures:why women? 131Bettina Schmitz

13 Use of neuropsychological andpersonality testing to identify adultswith psychogenic nonepileptic seizures 136Carl B. Dodrill

14 Cognitive complaints and theirrelationship to neuropsychologicalfunction in adults with psychogenicnonepileptic seizures 142George P. Prigatano and Kristin A. Kirlin

15 Health Related Quality of Life: utilityand limitation in patients withpsychogenic nonepileptic seizures 149Gemma Mercer, Roy C. Martin, andMarkus Reuber

v




Contents

16 Legal medicine considerations relatedto nonepileptic seizures 157Roy G. Beran, John A. Devereux, andW. Curt LaFrance, Jr.

Section 3: Psychiatric andneuropsychological considerationsin children and adolescents withpsychogenic nonepileptic seizures

17 Psychiatric features andmanagementof children with psychogenicnonepileptic seizures 163Rochelle Caplan and Sigita Plioplys

18 Neuropsychological and psychologicalaspects of children presenting withpsychogenic nonepileptic seizures 179Ann Hempel, Julia Doss, and Elizabeth Adams

19 Adolescents’ and parents’ perceptionsof psychogenic nonepileptic seizures 187Manjeet S. Bhatia and Ravi Gupta

20 Munchausen syndrome 190Ghislaine Savard, Frederick Andermann,and Renée Fugère

Section 4: Psychiatricconsiderations in adults withpsychogenic nonepileptic seizures

21 Classification of nonepileptic seizures 199W. Curt LaFrance, Jr. and Mark Zimmerman

22 Posttraumatic stress disorder, abuse,and trauma: relationships topsychogenic nonepileptic seizures 213Elizabeth S. Bowman

23 Comorbidities in psychogenicnonepileptic seizures: depressive,anxiety, and personality disorders 225Adriana Fiszman and Andres M. Kanner

Section 5: Treatmentconsiderations for psychogenicnonepileptic seizures

24 Historical approaches to treatments forpsychogenic nonepileptic seizures 237W. Curt LaFrance, Jr. and Steven C. Schachter

25 Managing psychogenic nonepilepticseizures in patients with epilepsy 247Roderick Duncan and Meritxell Oto

26 Models of care: the roles of nurses andsocial workers in the diagnosis andmanagement of patients withpsychogenic nonepileptic seizures 253Noreen C. Thompson and Patricia A. Gibson

27 Who should treat psychogenicnonepileptic seizures? 260Andres M. Kanner

28 Designing treatment plans based onetiology of psychogenic nonepilepticseizures 266W. Curt LaFrance, Jr. and Helge Bjørnæs

29 Cognitive behavioral treatments 281Laura H. Goldstein, W. Curt LaFrance, Jr.,Craig Chigwedere, John D. C. Mellers,and Trudie Chalder

30 Group psychotherapy treatment forpsychogenic nonepileptic seizures 289Kim D. Bullock

31 Hypnosis in the treatment ofpsychogenic nonepileptic seizures 297Franny C. Moene and Jarl Kuyk

32 Pharmacological treatments forpsychogenic nonepileptic seizures 307W. Curt LaFrance, Jr. and Dietrich Blumer

33 Family therapy for patients diagnosedwith psychogenic nonepileptic seizures 317Richard C. Archambault and Christine E. Ryan

Appendix 327Index 336vi




Contributors

Elizabeth Adams, PhDMinnesota Epilepsy Group, P.A., St. Paul, MN, USA

Arun Lata Agarwal, MDAssistant Professor, Department of Psychiatry,Maulana Azad Medical College and G.B. PantHospital, New Delhi, India

Frederick Andermann, OC, MD, FRCP(C)Professor of Neurology and Pediatrics,Montreal Neurological Hospital and Institute,McGill University, Montreal, Canada

Richard C. Archambault, EdDClinical Assistant Professor, Department ofPsychiatry and Human Behavior, Brown SchoolMedical, Providence, RI, USA

Miya Asato, MDChildren’s Hospital Pittsburgh, Pittsburgh, PA, USA

John J. Barry, MDProfessor of Psychiatry and Behavioral Sciences,Stanford University Medical Center, Stanford, CA,USA

Selim R. Benbadis, MDProfessor, Department of Neurology, Director,Comprehensive Epilepsy Program, University ofSouth Florida & Tampa General Hospital,Tampa, FL, USA

Roy G. Beran, MB BS, FRACGP, FRACP, Grand Dip(Further Ed), Grad Dip (Text Ed), MD, FAKPHM,BLegS, FACLM, FRCP, FACBS, MHL, AccreditedSleep Physician, PFFLM(Hons)Liverpool Hospital, Sydney, New South Wales,Australia

Manjeet S. Bhatia, MDProfessor and Head, Department of Psychiatry,University College of Medical Sciences and

Guru Teg Bahadur Hospital, Dilshad Garden,Delhi, India

Helge Bjørnæs, PhDThe National Centre for Epilepsy Sandvika andDepartment of Neuropsychiatry and PsychosomaticMedicine, Division of Neuroscience, Oslo UniversityHospital, Oslo, Norway

Dietrich Blumer, MDProfessor of Psychiatry and Head of Neuropsychiatry,University of Tennessee, Memphis School ofMedicine, Memphis, TN, USA

Elizabeth S. Bowman, MDConsulting Psychiatrist, Indiana University AdultEpilepsy Clinic and Adjunct Professor of Neurology,Indiana University School of Medicine, Indianapolis,IN, USA

Kim D. Bullock, MDClinical Assistant Professor, Department ofPsychiatry and Behavioral Sciences, StanfordUniversity, Stanford, CA, USA

Rochelle Caplan, MDProfessor, Semel Institute for Neuroscience andHuman Behavior, University of California,Los Angeles, CA, USA

Trudie Chalder, PhD, MScProfessor of Cognitive Behavioural Psychotherapy,Institute of Psychiatry, King’s College London,London, UK

Craig Chigwedere, BSc, MA, MScCognitive Behavioural Psychotherapist/ClinicalLecturer in CBT, St Patrick’s Hospital and TrinityCollege, Dublin, Republic of Ireland

John A. Devereux, BA, LLB, DPhilProfessor of Common Law, T.C. Beirne School of Law,University of Queensland, St. Lucia, Qld, Australia vii




List of contributors

Orrin Devinsky, MDProfessor of Neurology, Neurosurgery, andPsychiatry, Director, NYU Comprehensive EpilepsyCenter and Director, Institute of Neurology andNeurosurgery at Saint Barnabas, NYU School ofMedicine, New York, NY, USA

Carl B. Dodrill, PhDRegional Epilepsy Center, Departments of Neurologyand Neurological Surgery, University of WashingtonSchool of Medicine, Seattle, WA, USA

Julia Doss, PsyDMinnesota Epilepsy Group, P.A., St. Paul, MN, USA

Roderick Duncan, MD, PhD, FRCPConsultant Neurologist, Institute of NeurologicalSciences, Southern General Hospital,Glasgow, UK

Adriana Fiszman, MDInvestigator and Attending Psychiatrist, Laboratory ofStress-Related Disorders, Institute of Psychiatry of theFederal University of Rio de Janeiro, Rio de Janeiro,Brazil

Renée Fugère, MD, FRCPCMedical Director, National Mental Health Unit forWomen (federal jurisdiction) and Assistant Professor,Department of Psychiatry, University of Montreal,Montreal, Canada

Patricia A. Gibson, MSSWAssociate Professor, Department of Neurology, WakeForest University School of Medicine,Winston-Salem, NC, USA

Laura H. Goldstein, BSc, MPhil, PhDProfessor of Clinical Neuropsychology, Institute ofPsychiatry, King’s College London,London, UK

Nathan M. Griffith, PhDResearch Postdoctoral Fellow in Neuropsychology,UCLA Semel Institute for Neuroscience and HumanBehavior, Los Angeles, CA, USA

Ravi GuptaAssistant Professor, Department of Psychiatry,National Institute of Medical Sciences, Shoba Nagar,Delhi Road, Jaipur, Rajasthan, India

James C. Hamilton, PhDAssociate Professor of Psychology, Clinical AffiliateAssociate Professor of Internal Medicine,University of Alabama, Tuscaloosa, AL, USA

Ann Hempel, PhDMinnesota Epilepsy Group, P.A., and AdjunctAssistant Professor, Department of Neurology,University of Minnesota Medical School,Minneapolis, MN, USA

Andres M. Kanner, MDProfessor of Neurological Sciences and Psychiatry,Rush Medical College, Director, Laboratory of EEGand Video-EEG-Telemetry, and Associate Director,Section of Epilepsy and Rush Epilepsy Center,Rush University Medical Center, Chicago, IL, USA

Christoph Kellinghaus, MDStaff Physician, Department of Neurology, KlinikumOsnabrück, Osnabrück, Germany

Kristin A. Kirlin, PhDSection of Clinical Neuropsychology, BarrowNeurological Institute, St. Joseph’s Hospital andMedical Center, Phoenix, AZ, USA

Jarl Kuyk, PhDDepartment of Psychology, Epilepsy Institute of theNetherlands Foundation (SEIN), Heemstede,The Netherlands.

W. Curt LaFrance, Jr., MD, MPHDirector of Neuropsychiatry and BehavioralNeurology, Rhode Island Hospital, and AssistantProfessor of Psychiatry and Neurology (Research),Brown Medical School, Providence, RI, USA

Roberto Lewis-Fernández, MDAssociate Professor, Department of Psychiatry,Columbia College of Physicians and Surgeons, andDirector, NYS Center of Excellence for CulturalCompetence and Hispanic Treatment Program,New York State Psychiatric Institute, New York, NY,USA

Tobias Loddenkemper, MDAssistant Professor of Neurology, Harvard MedicalSchool, Division of Epilepsy and ClinicalNeurophysiology, Children’s Hospital, Boston, MA,USAviii





Roy C. Martin, PhDAssociate Professor of Neurology, University ofAlabama at Birmingham, AL, USA

Alfonso Martı́nez-Taboas, PhDAssociate Professor, Carlos Albizu University,Puerto Rico

GemmaMercer, ClinPsyD, CPsycholClinical Neuropsychologist, Department of ClinicalNeuropsychology, Salford Royal Hospital, Salford,Manchester, UK

John D. C. Mellers, MBBS, MRCPsychConsultant Psychiatrist, Maudsley Hospital, London,UK

Gabriel Möddel, MDDepartment of Neurology, University Clinics ofMünster, Münster, Germany

Franny C. Moene, PhDClinical Psychologist/Psychotherapist, De GroteRivieren, Organization for Mental Health, Dordrecht,The Netherlands

Siddhartha Nadkarni, MDAssistant Professor of Neurology andPsychiatry, NYU School of Medicine, New York,NY, USA

Meritxell Oto, MRCPsychResearch Fellow, Regional Epilepsy Service,Institute of Neurology, Southern General Hospital,Glasgow, UK

Sigita Plioplys, MDChildren’s Memorial Hospital, Chicago, IL, USA

George P. Prigatano, PhDNewsome Chair of Clinical Neuropsychology, BarrowNeurological Institute, St. Joseph’s Hospital andMedical Center, Phoenix, AZ, USA

Markus Reuber, MD, PhD, FRCPSenior Clinical Lecturer in Neurology,University of Sheffield, Sheffield, UK

Anastasia Sullwold Ristau, PhDLicensed Psychologist of Pediatric PsychologyServices with the Integrative Medicine and PainPrograms of the Children’s Hospitals and Clinics ofMinnesota, Minneapolis, MN, USA

Fergus J. Rugg-Gunn, MBBS, MRCP, PhDConsultant Neurologist, The National Hospital forNeurology and Neurosurgery, London, UK

Aline Russell, FRCPConsultant Clinical Neurophysiologist, Departmentof Neurology Institute of Neurological Sciences,Southern General Hospital, Glasgow, UK

Christine E. Ryan, PhDDirector, Family Research Program, AssistantDirector, Mood Disorders Program, Rhode IslandHospital, and Assistant Professor, Department ofPsychiatry & Human Behavior, Brown MedicalSchool, Providence, RI, USA

Jay Salpekar, MDChildren’s National Medical Center, Washington, DC,USA

Josemir W. Sander MD, PhD, FRCPProfessor of Neurology, Honorary ConsultantNeurologist, University College London, Institute ofNeurology, London, UK

Vedat Sar, MDProfessor of Psychiatry, Director, ClinicalPsychotherapy Unit and Dissociative DisordersProgram, Department of Psychiatry, IstanbulUniversity, Istanbul Faculty of Medicine, Istanbul,Turkey

Ghislaine Savard, MD, FRCPNeuropsychiatrist, Associate Professor, Departmentof Neurology, Montreal Neurological Hospital andMcGill University, Montreal, Canada

Steven C. Schachter, MD, FAANProfessor of Neurology, Harvard Medical School,Chief Academic Officer and Director ofNeuroTechnology, CIMIT and Department ofNeurology, Beth Israel Deaconess Medical Center,Boston, MA, USA

Bettina SchmitzDepartment of Neurology, Vivantes HumboldtKlinikum Berlin, Charité, Humboldt University,Berlin, Germany

Jon Stone, MB, ChB, FRCP, PhDConsultant Neurologist and Honorary SeniorLecturer, Department of Clinical Neurosciences,Western General Hospital, Edinburgh, UK ix





Jerzy P. Szaflarski, MD, PhD, FAANAssociate Professor, Departments of Neurology,Neuroscience and Psychiatry, Cincinnati EpilepsyCenter, University of Cincinnati Academic HealthCenter, Cincinnati, OH, USA

Noreen C. Thompson, RN, MSN, PMHCNS-BCPsychiatric Consultation Liaison Nurse, University ofKansas Hospital and Assistant Clinical Professor,University of Kansas School of Nursing, Kansas City,KS, USA

Michael Trimble, MD, FRCP, FRCPsychProfessor of Behavioural Neurology, Institute ofNeurology, London, UK

Robert T. Wechsler, MD, PhDMedical Director, Idaho Comprehensive EpilepsyCenter, Boise, ID, USA

Peter Widdess-Walsh, MA, MB, MRCPIAssistant Professor of Neurology (Research),NYU School of Medicine, Institute ofNeurology and Neurosurgery at Saint Barnabas,Livingston, NJ, USA

Courtney B. Worley, MPHClinical Health Psychology, The University ofAlabama, Tuscaloosa, AL, USA

Elaine Wyllie, MDProfessor of Pediatrics and Director, Center forPediatric Neurology, Cleveland Clinic, Cleveland,OH, USA

Mark Zimmerman, MDDirector of Outpatient Psychiatry, Rhode IslandHospital and Associate Professor of Psychiatry,Brown Medical School, Providence, RI, USA

x




Preface

The first edition of Non-Epileptic Seizures was pub-lished in 1993 and edited by Drs. A. James Rowanand John R. Gates. Based on a 1990 symposiumcalled “TheDilemma of Non-Epileptic (Pseudoepilep-tic) Seizures,” this instant classic synthesized the avail-able knowledge and hypotheses regarding all facets ofnonepileptic seizures into four sections: neurological,psychiatric and neuropsychological aspects, and fun-damentals of treatment. The second edition was pub-lished in 2000 and reflected the continued outgrowthof the 1993 symposiumaswell as a second conference –“Non-Epileptic Seizures: A Consensus Conference onDiagnosis and Treatment” – held in Bethesda in 1996.

A third conference, the 2005 PsychogenicNonepileptic Seizures (PNES) Treatment Workshop,sponsored by the National Institute of NeurologicalDisorders and Stroke (NINDS), the National Instituteof Mental Health (NIMH), and the American EpilepsySociety and chaired by W. Curt LaFrance, Jr., broughttogether experts from around the world, representingmany disciplines. The enthusiasm emanating fromthat landmark meeting reverberated widely amongstprofessionals interested in the evaluation and treat-ment of persons with PNES. Sadly, the field soonafterwards lost its pioneers: John Gates on September28, 2005 and Jim Rowan on August 27, 2006.

Recognizing the increasingly rapid developmentssince the second edition, the importance of Non-Epileptic Seizures as the embodiment of the field, andthe singular contributions of Drs. Gates and Rowan,we endeavored to organize a new edition and to for-ever link the names of Gates and Rowan with thistopic by their inclusion in the book title. It is there-fore most fitting that this edition includes dedicationsfrom Rita Meyer Gates and Rita Rowan, with our grat-itude, as well as personal remembrances of Drs. Gatesand Rowan.

Historically, neurology and psychiatry were prac-ticed as a unitary model, addressing patients withneurological and psychogenic disorders with equalattention. Unfortunately, as neurologic and psychiatricpractices became dichotomized in the twentieth cen-tury, the topic of PNES fell between the borderlands ofneurology and psychiatry.

Bridging neurology and psychiatry again, the pri-mary aim of this edition is to educate physicians,psychologists, clinicians, allied health providers andresearchers about the diagnosis and treatment of chil-dren and adults with nonepileptic seizures. Buildingon the groundwork laid in the first two editions, theeditors and authors of this third edition provide amul-tidisciplinary approach to the neuropsychiatric disor-der of psychogenic nonepileptic seizures. The authorsare the foremost experts in their respective fieldsand provide an update on the current knowledge ofnonepileptic seizures from the neurologic, neuropsy-chological, psychological, psychiatric, and social per-spectives. The structure of the book sections allowsan in depth appraisal of diagnostic semiology, clini-cal characteristics, issues in children, comorbidities,and, finally, a significant expansion of treatment forPNES. The addition of the DVD provides video sam-ples of different seizure types and vignettes to aid clin-icians with the differential diagnosis and treatment ofnonepileptic seizures.

It is our hope that Gates and Rowan’s Nonepilep-tic Seizures, 3rd edn. will honor the memories andlegacies of its founding editors, and serve to reflectas well as influence the continued development of thefield, informing clinicians and inspiring researchers toimprove the care of persons with nonepileptic seizurestoday and in the future.

Steven C. Schachter and W. Curt LaFrance, Jr.

xi




Participants, 2005 Psychogenic Nonepileptic Seizures Treatment Workshop, sponsored by National Institute of Neurological Disorders andStroke, National Institute of Mental Health, and American Epilepsy Society.

Sitting: (left to right) Sigita Plioplys, Rochelle Caplan, Brenda Burch, Andy Kanner (floor), Joan Austin, Curt LaFrance, Margaret Jacobs,Debra BabcockRow 2: Roy Martin, Claudia Moy, Roberto Lewis-Fernández, Daphne Simeon, Valerie Voon, Selim Benbadis, Elaine Wyllie, Donna Andrews,Patty Shafer, Linda Street, Phyllis Gilbert, Michael FirstRow 3: Ken Alper, Mark Hallett, Mark Rusch, Lynn Rundhaugen, Michael Trimble, David Spiegel, John Gates, Laura Goldstein, Gabor Keitner,Cynthia Harden, Charles Zaroff, Helena Kraemer, Chris SackellaresRow 4: Gregory Mahr, Peter Gilbert, Randall Stewart, Greer Murphy, Richard Brown, Jonathan Halford, Paul Desan, Steve Schachter, John Barry

Not pictured: John Campo, Orrin Devinsky, Frank Gilliam, Dalma Kalogjera-Sackellares, John Mellers, and Markus Reuber contributedsignificantly prior to the workshop but were unable to attend.




Dedication for Dr. A. James Rowan

On the Friday afternoon before his last admission tothe hospital, Jim Rowan presided over his weekly pedi-atric epilepsy conference. He insisted on it. He dressedhimself carefully though every small movement costmore energy than he had to spare – but this was hisfavorite conference of the week.

More effort and energy was expended getting himinto a taxicab and then up to the EEG laboratory wherethe conference was held. It was well attended. Jim wasclearly fatigued, yet, the moment he was given thefirst case the “old” Dr. Rowan was again in charge –no fatigue, no effort, just joy in his competence andknowledge, and yes, his love of it. He sat before thecomputer screen reading EEGs, and without any evi-

dent struggle, expounded as usual on case after case. Itwas a dazzling performance.

Epilepsy, understanding it, treating it, and teach-ing about it was the work to which Jim gave his life.That afternoon he gave his last share of energy to it. Hewould not have had it any otherway.Thepediatric con-ference, concerning epilepsy at the beginning of life,his geriatric research, concerning epilepsy at the end oflife, and thiswork onnonepileptic seizures suggests therange of his interests and the depth of his dedication.It is fitting that the new edition continues to advancethis very important work.

Rita Rowan

xiii




Dedication for Dr. John R. Gates

John was an intentional man who woke each morn-ing with an explicit commitment to proffer his bestin every circumstance, to everyone; who went to sleepeach night weighing the day’s successes and challenges,probing the “what and how” for an inspiration thatmight give rise to the next opportunity. What he tookas a matter of course – expertise, indefatigable energy,imagination, and hustle – others found remarkable,and he devoted himself to patient care, research,writing, teaching, and organizational, volunteer, andcommittee work.

John was fascinated by the workings of the brain,and he believed that neurology, rather than psychia-try, held more potential for effective intervention. Forthis reason, as a young intern he chose to specialize inepilepsy so that he could make a difference. His wishand ambition to make that decisive difference in indi-vidual lives and in the field of epilepsy came to per-meate his work, which in turn became his life. John’sinterests and efforts included advancing surgical tech-niques to improve surgical outcomes, pharmaceuticaland device research, mentoring a broad range of stu-dents, physicians, and adjunct individuals, and mem-bership in local, regional, and national organizationsadvancing quality assurance, professional practice, fis-cal strength, and community resources.

His 25 years of work in the field of psychogenicnonepileptic seizures (PNES) were of a special order;he was determined to mitigate the primary and sec-ondary causes of distress within this special popula-tion. The origin of his passion, the impetus that fueledhis concern and commitment, was his mother’s PNES.And it was his resolve to make a difference, coupledwith his compassion and enthusiastic optimism,whichcompelled him in his work with PNES.

Based on John’s vision of model collaboration, heorganized and convened the initial interdisciplinaryPNES consensus conferences in 1990 and 1993. Theseconferences were the milestones that set the stage foryears of joint effort among epileptologists, psychia-

trists, and neuropsychologists to ensure the best diag-nostic and treatment parameters for PNES. This earlywork defined and continues to influence the multifac-torial, multicultural, and multidisciplinary emphasesin the treatments for these patients. He would havebeen particularly pleased that this new volume wasedited by an epileptologist and a neuropsychiatrist.

John was unabashed in his esteem and admira-tion for his colleagues, his respect and regard for hispatients, and his love for his family and friends. Hewas often generous, exuberant, and forgiving to a fault.His conviction of the inherent value and goodness ofpeople gave meaning to his life and heartened thosearound him.

He set great store by his Jersey street-fighter roots,which he credited for his “backbone.” He had the abil-ity to stand his ground, often alone, under terrific pres-sures. Never one to uphold the status quo, he made‘thinking outside the box’ his mantra long before itwas part of popular culture. John was always keen towork out an impossible situation. But then a braintumor appeared at the age of 53. This was a terrificblow. Though his commitment to his treatment was100+%, there would be no recovery. He would notlive long enough to appreciate the testimonials, hon-ors, and awards that were bestowed to pay tribute tohim; he would not be cognizant of the expressionsof respect, appreciation, and love he had engenderedduring his life.

John would applaud publication of this third edi-tion and then press for continuation of the work. WithJohn, whether flying his plane, guiding boy scouts,fishing in the cold of a Minnesota winter, advocatingfor his special needs son, writing poetry, or absorbedin his work, it was always upwards and onwards.

May his life and dedication to patients with PNEScontinue to be an inspiration.

Rita Meyer Gates xv




In remembrance of Dr. A. James RowanSteven C. Schachter

Dear Jim,You were one of my closest friends, and I miss you

terribly. Your advice and genuine kindness and con-cern brought me through difficult times. Your fatherlypride in anything I accomplished made me try evenharder to please you. You shouldered many burdenswith grace, and shared a few of your own along theway,but you always kept your focus on the task at hand andon the well-being of others.

Everything important to you about the field ofepilepsy became important to us, whether throughyour impassioned lectures, your impromptu conver-sations, or your writings. Your wisdom and perspec-tives will be passed on from us to those who follow.You had that penetrating way of looking at people inthe audience, your glasses half down your nose. Youwouldn’t release your gaze until you were sure theyunderstood the importance of what you were saying.Who can forget the essence of successful aging afterseeing your that picture of Kin and Gin Narita, theJapanese twin sisters, joyously celebrating their 100thbirthday?

The Veterans Affairs Cooperative Study was yourbaby. I served on the Data Safety Monitoring Board,

which conducted periodic checkups during the study’sgestation. I can still picture you pacing back andforth outside the door while the committee met, likean expectant parent. And I can also see you glow-ing when presenting the results of this landmarkstudy.

You never knew it, but you were the inspirationbehind the Epilepsy Foundation’s Seniors and SeizuresInitiative, and the Board of Directors wanted you toknow the Foundation authorized half a million dollarsfor research in the area of epilepsy in the elderly, whichshould make you very proud.

We shared many wonderful times together, per-sonal and professional. Sue and I will never forgetwhen you and Rita flew our family toNewYork to haveChristmas dinner with you.

Whenever I recommend one of your books to oneof our fellows, I say “That book was written by a goodfriend of mine, Jim Rowan.” And now, with a few ofyour favorite words and phrases, I add “He was a ter-rific physician, and a wonderful human being, as amatter of fact.”

Farewell, Jim. Your memory will always remainwith us. God rest your soul.

xvii




Dr. A. James Rowan




In remembrance of Dr. John R. GatesSteven C. Schachter

John R. Gates, MD died September 28, 2005, at age54 from a brain tumor. A moving memorial servicewas attended by over one thousand people, and cen-tered around readings, poetry, and music – all artis-tic favorites of John’s. He was survived by his belovedsweetheart and wife of 15 years, Rita; children, Jason,Rachel, and Stuart; and an extended family. Friends,family, patients, and colleagues around the worldremember a wonderful man who made numerous andsubstantial contributions to the field of epilepsy andthe practice of neurology. With contributions frommany of those who were closest to John, I offer thisappreciation.

A champion fighter from an early ageBorn in the inner city of Trenton, New Jersey,John emerged from humble surroundings to gradu-ate Magna Cum Laude from Harvard University. Hewas brought up by his grandparents. After both hisgrandparents passed away when he was 15 years old,a teacher who recognized his brilliance helped himget a scholarship for disadvantaged youth. He went onto attend elite schools in Massachusetts and England,where he excelled academically. I believe it was becauseof this unique background that hewas able to challengethe establishment with confidence. Indeed, from hischildhood until his untimely death, John “never gaveup the fight.” He was “an enthusiastic paladin for thewars against epilepsies, and more.”

Standout traineeAt the University of Minnesota Medical School, Johnperfected his ability to question, challenge, and shakeup the status quo. John was a 4th year medical stu-dent, rotating through neurology. At that time, Dr.A. B. Bakerwas the chairmanof theNeurologyDepart-

ment, and a very demanding teacher and world classscholar with tremendous clinical experiences in neu-rology. It is very unusual to hear a neurology residentarguingwithDr. Baker, not tomention a 4th yearmed-ical student. But John did. He once said to Dr. Bakerduring a teaching round, “Dr. A. B. Baker, I don’t thinkso. . . . ”We all held our breath, and didn’t knowwhat toexpect. I believe even Dr. Baker was caught by surpriseas well. I can’t recall the detail of the conversation then,but I remember he was able to present his view in acalm and logical manner, though I don’t think he wasable to win the case. His unique way of dealing withauthority left me with an indelible impression.

His fellow residents and teachers witnessed thegrowth and development of a stellar and compas-sionate clinician who sought the truth, sometimes inunconventional ways. I happened to be the very firstchief resident he had to work with. In the beginning, itwas truly a disaster; he almost constantly argued withme in the diagnosis and clinical management of cases.Sometimes in front of the whole crew in the sign-outrounds in the evening, he would challenge me for say-ing something not well founded. The results of thesenumerous arguments were that we both went to thelibrary to look for references to back up what we said,and then Xeroxed articles for each other to prove ourpoints. By the end of his three-month rotation at theMinneapolis VA Hospital, we both had piles of ref-erences from each other, and that is how we learned“evidence-based medicine” in the 1970s.

One of my most poignant memories is when Johnwas chief resident. I was the attending. The case wasthat of a young woman with subarachnoid hemor-rhage. John’s team had been pared to a minimum overthe holidays by scheduled vacations, and John was fill-ing many roles – including single-handedly manag-ing all aspects of critically ill patients, including the

xix




In remembrance of Dr. John R. Gates

young woman. He invested everything of himself in aneffort to stave off what was inevitable. He also becameexhausted. Late on Christmas Eve we took a break inmy office to discuss plans for the night. John told methat the young woman had just deteriorated, and hedid not know what he was going to tell her family.He put his head down and cried. I think I did too.Although he projected unflappable bravado, his com-plete personal investment in his patients and their fam-ilies was also his gift and his emotional Achilles’ heel.

There is the apocryphal tale of the burr hole drilledby John in an emergency room for suspected extrac-erebral hemorrhage. It was dry, but a legend was bornof the most swash-buckling of all neurology residents,ever. He always knew more than his fellow residentsand usually more than his attendings. Even when hedid not, he thought he did. He was at once the mostinspiring of trainees and the most challenging, andalways a force to be reckoned with.

Passion for patients and their doctorsJohn co-founded the Minnesota Epilepsy Group inSt. Paul, a practice that grew into a world-renowned,comprehensive epilepsy center noted for clinical andresearch excellence, and widely emulated. A clinicalprofessor of neurology at the University of Minnesota,John was “passionate in his commitment to patientcare,” tried “his hardest to be the best doctor” forhis patients, and believed “the treatment of epilepsyhad no boundaries” and that “people with epilepsydeserved first rate care.”

Over the years, John recruited and attracted “tech-nically superior and enormously caring staff – all ofwhom were a reflection of John’s core values, and whowill carry on his legacy through their work.” John’scoworkerswere “dedicated to himandheld him in suchhigh esteem. Nurses, psychologists, neurologists, sup-port staff – at every place he worked – would sponta-neously talk about John and his dedication to patients.They truly held him in a special spot in their hearts foryears and that is something one rarely sees.”

His “strong advocacy for compassionate treatmentof people with nonepileptic seizures” was widely rec-ognized and appreciated. “Far too often, these patientsare dismissed and treated as second class citizens byepileptologists. John hated that attitude.”

His influence on patient care and the epilepsymovement spread out from St. Paul to around theworld. “Johnwas one of those special people, and there

are very few, who made a critical difference at all lev-els in the epilepsy movement – patient care, research,public policy, and volunteerism.” He was a “powerfuland effective voice in the world of epilepsy, one whospoke for the needs of clinicians who are truly devotedto the care of their patients.”

Prodigious scholarship, impactfulteaching, and a zest for workJohn authored hundreds of publications and perhapsis best known for his writings and edited books onpsychogenic nonepileptic seizures, efficacious use ofantiepileptic drugs (AEDs), and the surgical manage-ment of epilepsy.

Everyone who knew John was impressed by hisenergy and commitment to “whatever the task, old ornew.” He “always had a smile on his face, and a zestand enthusiasm for his work,” which was “marked bybreadth, honest service, and courage.”

Severalmonths before he died, John participated inaNational Institutes ofHealth (NIH)-sponsoredwork-shoponnonepileptic seizures (NES).While he thoughtof himself as “one of the ‘old dogs’ in the pack,” hewas regarded as the brightest luminary in this fieldby the many accomplished international, interdisci-plinary workshop participants. “In typical John fash-ion, he broke the ice very early on,with a fewbold com-ments about the differences between neurology andpsychiatry. Once the smoke settled, it proved to be aperfect entrée, loosening up everyone for an intenseand invaluable discussion onNES treatment research.”

He excelled at lecturing and was a “masterfulteacher” who “never stood on formalities and sharedhis knowledge and experiencewith young neurologistsand foreign doctors”. His enthusiasm for teaching con-tinued even after his constitutional energy was nearlydepleted. “John couldn’t “turn it off” even when criti-cally ill. To the end, John was lecturing and educatingeven when he needed help walking up to the podium.”

Leadership and dedication to AmericanEpilepsy Society (AES) andInternational League AgainstEpilepsy (ILAE)Johnwas president of numerous organizations, includ-ing the Minnesota Epilepsy Group, the AmericanAcademy of Neurology Congress of Neurosocieties,

xx





the Association of Neurologists of Minnesota,and the Ramsey CountyMedical Society. He served onthe ILAE Commission for Neurosurgery and partici-pated in projects of the Subcommission for PediatricEpilepsy Surgery. He chaired the Practice Committeeof the American Epilepsy Society and served on anumber of other AES committees and task forces, aswell as the AES Board of Directors while courageouslybattling his cancer. “John’s voice on the AES boardalways reflected his passion and commitment to theneeds and best interests of individuals with epilepsy.”

As his wife Rita remarked in accepting the AES J.Kiffin Penry Award for Excellence in Epilepsy Care onJohn’s behalf,

John loved this society. If John were here, he would turn the tables,and, looking out at you, would make it about you. He would thankyou for being such great colleagues. He would talk about how mucheach of you contributed; how he so appreciated your hard work; howkey peopleworking togethermake something come alive; how grate-ful he was that you shared his passion for this work, work that makessuch a difference for somany; and howmuch fun it was to “play withyou in this sandbox.”

Awarm and friendly guy whooccasionally tilted at windmillsEach of us who knew John remembers something spe-cial about him, whether serious or humorous, pro-found or simple. He was the kind of guy who wouldwake up one morning with an idea and then a fewhours, days, weeks, or months later, it would becomea reality. He was a grass roots organizer who gaveuntold time and energy to innumerable epilepsy-related projects, including summer camp for kids,assisted living for young adults, funding for the lesswell-off for affordable medications, and “inventing”local, regional, and national training and mentoringprograms. Above all else, “he was a warm and friendlyguy who made many people, especially his patients,feel special.”

When I think of John, his email address always pops into my mind:[email protected]. It was so appropriate. He seemed to swoop into aroom as if he was a plane landing or, under some circumstances, asa dive bomber when he wanted to destroy opposition to some pointhe held dearly. [email protected] also conveys to me the sense ofsoaring, which also captures his personality to me. He was always apresence in any meeting, no matter how large the group. He neverjust went through the motions of showing up. He was always in themix of any discussion speaking out about the issues near and dear to

him; his patients, the profession of epileptology, and the economicsof running a practice.

I remember his ability to cut through or circumvent nonsense andget to the heart of any matter quickly, and directly, without causingantagonism, which is a great skill. Even when he was very sick, weappreciated his ability to do this.

The two things Iwillmost remember about John are his jokes,mostlyaimed at hospital and HMO administrators; and his unfailing will-ingness to serve as counselor, friend, or mentor. His passion forcompleting projects (the ultimate goal of which was always to helppatients) was matched only by his kindness and collegiality.

A trademark of John that I appreciatedwas his ability to connectwithwhomever he was speaking to. His deep voice conveyed a deport-ment of seriousness, which however was countered by his wide smileand straight look into your eyes that made you feel welcomed to hisattention.

John was an interesting combination of great brilliance, professionaldedication, impeccable ethics and still a lovable nature.

He was deep, funny, irreverent, lovable and infuriating, all in oneday. He was the brightest bulb in every group and knew it. He hadvast energy, and his personal and professional agendas were alwaysway more ambitious than most mortals would or should take on.He had enormous ego strength and self-confidence. If he thought anunproven or unconventional approach made sense for his patient,he forged directly ahead, full speed, against all resistance.

He was intense and very perceptive. He knew what he wanted andwent after it with all his energy, and usually got what he wanted.I admired him for his intelligence, intense energy, drive, and hisunique capacity to think on a grand scale. He was not afraid to beunconventional.

I didn’t always agree with him, but I sure appreciated his passion.I also appreciated that he did not mind if you disagreed with himand I recognized that he sometimes went over the top just to sparksome movement. Just like when he flew his plane, he always wantedto be moving towards some goal and he hated getting bogged downon technicalities.

As you know, he was a pilot. He flew into Seattle for one of the meet-ings. Apparently there are others named Gates in the Seattle area,and with John’s last name, he told me with great amusement that hewas treated very well indeed at the airport.

His kind face, warm smile, and ability to inspire confidence in lessendowed friends were the sparks that spread the epilepsy gospel intoa wheat field in the middle of the country.

I remember his saying that the first thing he told people movingto Minneapolis was to get a new Sears Diehard battery, no matter

xxi





how old their current car battery was. Sort of a “Don’t fool yourself ”approach.

I regarded him as a minor renegade with a sense of humor. John wasa real gentleman who occasionally liked to tilt at windmills.

FarewellJohn will be missed enormously. Many of us can stillhear him say “Hi guy, how are you doing!” As one closecolleague said, “He was special to me. I am not exactlysure why. Maybe it is some form of love.” One of hismany grateful patients said, “You were the best doctor.I had such faith in you and I know God will be withyou always.”

Farewell, John. Your memory and inspiration liveon, and we are all better for having known you.

LegaciesSeveral funds have been established inmemory of JohnGates: the Minnesota Medical Foundation, Dr. John

R. Gates Memorial Award in Neurology, 200 Oak St.SE, Suite 300, Minneapolis, MN 55455-2030; EpilepsyFoundation of Minnesota, John R. Gates MD ProjectFund, 1600 University Ave. W., Suite 205, St. Paul, MN55104; and Minnesota ABC, Dr. John R. Gates Schol-arship Fund, 8761 Preserve Blvd, Eden Prairie, MN55344, attn: Gardner Gay.

Acknowledgments: Remembrances of John weregenerously submitted by the Minnesota EpilepsyGroup,members of theAmerican Epilepsy Society andits Board of Directors, David Anderson, Joan Austin,Greg Barkley, Elinor Ben-Menachem, Martin Brodie,Helen Cross, Richard Gilmartin, Mark Granner, BruceHermann, John Hughes, Barry Johnson, W. CurtLaFrance, Chi-Wan Lai, Ken Laxer, Ron Lesser, GaryMathern, Dick Mattson, Rita Meyer, Georgia Mon-touris, Venkat Ramani, Jim Rowan, Elson So, MikeSperling, Mark Spitz, and Bill Theodore.

Adapted from Schachter S.C. John Gates: AnAppreciation. Epilepsy Behav 2006;9:545–8. With per-mission from Elsevier.

xxii




Dr. John R. Gates



gatesandrowan’s nonepilepticseizuresassets.cambridge.org/97805215/17638/frontmatter/... · 2009....

Documents