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Counselling adults who experience a first seizure

Open ArchivePublished:September 29, 2016DOI:https://doi.org/10.1016/j.seizure.2016.09.012

      Highlights

      • First seizure can result in significant uncertainty, fear and apprehension.
      • Accurate, timely counselling can allay fears, remove misconceptions and reduce the risk for injury in seizure recurrence.
      • Key role of the clinician is to provide comprehensive counselling.
      • Counselling is a complex and time consuming task that should incorporate numerous components.
      • Counselling should be completely individualized for every patient.

      Abstract

      Purpose

      A first seizure can result in significant uncertainty, fear and apprehension. One of the key roles of the clinician in the setting of first seizure is to provide accurate, timely information and counselling.

      Method

      We review the numerous components to be considered when counselling an adult patient after a first seizure.

      Results

      We provide a framework and manner to provide that counselling. We focus on an individualized approach and provide recommendations and information on issues of diagnosis, etiology, prognosis, the role and importance of medical testing, lifestyle considerations, driving, medication and other key counselling considerations.

      Conclusion

      Accurate, timely counselling can allay fears and anxieties, remove misconceptions and reduce the risk for injury in seizure recurrence.

      Keywords

      1. Introduction

      The experience of an unprovoked first seizure event brings with it a great deal of fear and apprehension. Although a seizure can present clinically as almost any subtle, stereotypical, recurrent event; it is rarely these subtle events that bring patients forward for medical attention. It is usually a first generalized tonic–clonic seizure that, because of its intense nature and the anxiety that follows, mobilizes a patient to seek medical evaluation. A key role of the clinician in this setting is to not only provide appropriate medical care, but also to provide accurate, timely information and counselling. The education provided through this counselling can allay fears and anxieties, eliminate misconceptions and can reduce the risk for injury if seizure recurrence happens. Having information about one’s medical condition provides insight into that condition as well as providing expectations in regards to prognosis, testing, treatment options and lifestyle implications. Accurate information promotes self-management and assists patients in making informed choices. Such counsel can offer patients a semblance of control in a very uncertain and challenging time and is essential for comprehensive first seizure care [
      • Pohlmann-Eden B.
      • Legg K.T.
      Treatment of first seizure in adults: a comprehensive approach integrating 10 key principles.
      ]. It includes numerous components (Table 1) that must be considered and tailored to the individual and their own particular situation.
      Table 1Components for counselling after first seizure.
      • Acknowledging the event
      • Explanation of what a seizure is (and is not)
      • Possible etiology and prognosis
      • Purpose and limitations of tests
      • Lifestyle considerations (safety, occupation, seizure threshold)
      • Driving
      • Seizure first aid
      • Role of medication
      • Medication action and side effects (if appropriate)
      • Psychological implications
      • Next steps and when to call for help
      Detailed counselling may need to extend over a prolonged visit or a number of visits and will often require repetition once epilepsy is diagnosed. Utilizing the skills and resources of members of the interdisciplinary team to assist with the counselling process may be beneficial; as will the presence of family members or friends during the sessions. In addition to verbal counselling and information, written materials and directions to vetted websites and community resources should also be provided. For those requiring additional support and counselling the opportunity to link with trained counsellors and/or community support groups/associations should be offered. Provision of a “New Diagnosis” package will complement the counselling. Providing detailed counselling will often prevent repeat referrals, unnecessary investigations, inappropriate utilization of additional health care services and resources and personal distress.

      2. Acknowledging the event

      A first seizure can provoke a multitude of reactions including denial, fear, sadness or anger. The individual response to this unexpected, stressful situation depends on coping skills and life experiences, and is also influenced by our response to the person [
      • McClain G.
      • Buchman M.
      After the diagnosis: how patients react and how to help them cope.
      ]. Acknowledging the emotional and physical impact a first seizure has had on the individual provides recognition of the importance of the event and forms the basis for a therapeutic relationship between provider and patient. Often the person who has experienced the seizure is completely amnestic of the event and thus not overly bothered by it. However, acknowledgement and support often needs to extend to the patient’s family member who might have witnessed the seizure and is traumatized by the experience. Providing adequate time for the patient to tell their story and express their concerns can further promote respect and trust. It enables the patient the opportunity to articulate the emotional aspects of this event and then focus on the information being provided.
      Adults presenting with a first seizure are often surprised at how common a first seizure is. Studies indicate that we all possess a life-time risk of between 8 and 10% of experiencing a single seizure, and a 3% risk of developing epilepsy [
      • Hauser W.A.
      • Rich S.S.
      • Annegers J.F.
      • Anderson V.E.
      Seizure recurrence after a 1st unprovoked seizure: an extended follow-up.
      ]. It is further estimated that isolated unprovoked seizures occur at an incidence of approximately 61/100,000 person-years [
      • Hauser W.A.
      • Annegers J.F.
      • Kurland L.T.
      Incidence of epilepsy and unprovoked seizures in Rochester, Minnesota: 1935–1984.
      ]. Based on current population numbers, this would mean that over 4 million individuals world-wide will experience isolated, unprovoked first seizures each year. Closer to home this translates to more that 21,000 Canadians and more than 14,000 Australians presenting with a first seizure each year. In the United States it is estimated that approximately 150,000 adults will present with a first seizure each year [
      • Hauser W.A.
      • Hesdorffer D.C.
      Epilepsy: frequency, causes, and consequences.
      ]. Making patients aware of how frequently first seizure events occur can provide some reassurance and can reduce their apprehension.

      3. What is a seizure?

      Once the diagnosis of a first seizure has been confirmed a clear explanation of what a seizure is will be the first point in counsel. It is important that patients understand that the seizure itself is not a disease but a transient symptom due to abnormal excessive or synchronous neuronal activity in the brain [
      • Fisher R.S.
      • van Emde Boas W.
      • Blume W.
      • Elger C.
      • Genton P.
      • Lee P.
      • et al.
      Epileptic seizures and epilepsy: definitions proposed by the International League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE).
      ]. Although most first seizure presentations are of a generalized tonic–clonic seizure (GTCS) it should be explained that a seizure can present in many different ways, depending on which part of the brain is affected. Elaboration of how a seizure differs from other paroxysmal events (Table 2) is also important as these may be relevant.
      Table 2Differential diagnosis for seizure.
      • Syncope
      • Transient ischemic attack
      • Psychogenic non-epileptic seizures (PNES)
      • Cardiac disorders
      • Migraine
      • Medication, alcohol or drug Intoxication
      • Sleep disorders
      • Panic attacks/hyperventilation
      • Movement disorders
      • Hypoglycemia
      • Transient global amnesia
      • Other
      Discussions should include the common clinical characteristics associated with seizure (Table 3) and specifically those factors of their individual event that are convincing for seizure. This detailed explanation assists the individual (and their family/spouse) who has experienced the seizure in understanding why the clinician believes their experience is indeed a seizure and not a paroxysmal event of some other kind. Belief and acceptance of the diagnosis may depend on this.
      Table 3Common clinical characteristics associated with a generalized tonic–clonic seizure.
      • Sudden onset
      • Eyes open and rolled back
      • Stiffening
      • Tonic–clonic movements
      • Urinary incontinence
      • Tongue bite
      • Post-ictal confusion
      • Post event fatigue and muscle ache
      Additional discussion may include the distinction between a first seizure and a diagnosis of epilepsy. Explaining that the term epilepsy refers to a condition in which individuals have a tendency to have seizures may help alleviate stigma associated with the term. Further explaining that epilepsy is diagnosed when someone has experienced 2 or more unprovoked seizures; when an epilepsy syndrome is identified on EEG; or when someone has had a single seizure in a setting of an enduring predisposition for seizure recurrence [
      • Fisher R.
      • Acevedo C.
      • Arzimanoglou A.
      • Bogacz A.
      • Cross J.
      • Elger C.
      • et al.
      A practical clinical definition of epilepsy.
      ] will set the stage for future discussions around the role of medications after first seizure or in the event of a second. The individual presenting with their first generalized tonic–clonic seizure may have been experiencing more subtle, stereotypic events, consistent with seizure, for some time. Determining this is important as it allows a syndrome diagnosis early on and might help explain symptoms that may have been ignored, trivialized or misdiagnosed.

      4. Possible etiology and prognosis

      Providing information about possible causes for seizure as well as risk for further events is a key component of counselling after a first seizure. Patients need to understand some of the provocations for seizure (Table 4). Acute symptomatic seizures that occur as a result of a clearly identified cause are less likely to reoccur if the identified cause is removed [
      • Beghi E.
      • Carpio A.
      • Forsgren L.
      • Hesdorffer D.C.
      • Malmgren K.
      • Sander J.W.
      Recommendation for a definition of acute symptomatic seizure.
      ].
      Table 4Causes for seizure.
      • Remote brain injury (tumour, vascular, traumatic, post-encephalitic, developmental)
      • Acute brain injury (hemorrhage, encephalitis)
      • Metabolic derangements
      • Medications
      • High fever
      • Significant sleep deprivation
      • Withdrawal from alcohol or drugs
      • Excessive alcohol intake
      • Unknown
      The risk of a second seizure is highest shortly after the initial event and decreases with time. Berg and Shinnar [
      • Berg A.
      • Shinnar S.
      The risk of seizure recurrence following a first unprovoked seizure: a quantitative review.
      ] in their meta-analysis, found that 60–70% of seizure recurrences occur within the first 6 months and decreases exponentially over time. Epilepsy eventually develops in 34% of first seizure cases within 5 years [
      • Hauser W.A.
      • Rich S.S.
      • Annegers J.F.
      • Anderson V.E.
      Seizure recurrence after a 1st unprovoked seizure: an extended follow-up.
      ].

      5. Purpose and limitations of tests

      A clinical suspicion for seizure will stimulate further investigation. Patients must understand that the diagnosis of seizure is usually a clinical one and is based on the description of the event. Testing is ordered to provide additional information and to assist with understanding any possible underlying process. The purpose and limitations of the tests ordered needs to be clearly explained including that no single test, clinical finding, or symptom is reliable in discriminating between an initial seizure and other non-epileptic events [
      • Krumholz A.
      • Wiebe S.
      • Gronseth G.
      • Shinnar S.
      • Levisohn P.
      • Ting T.
      • et al.
      Practice parameter: evaluating an apparent unprovoked first seizure in adults (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society.
      ]. General testing including an electrocardiogram (to rule out a cardiac cause for loss of consciousness) and laboratory testing (to identify any metabolic cause) are often done in the emergency setting where many patients with first seizure initially present. The results of these tests and any others done at the time of presentation for the first seizure event, and how they aid in assessment of first seizure need to be fully explained to the patient.
      More specific neurodiagnostic testing usually includes computed tomography (CT), magnetic resonance imaging (MRI) an electroencephalograph (EEG) and/or a sleep deprived EEG. Patients need to be informed that these tests are done with the goal of identifying a possible etiology, for localization and for assisting with prediction for risk for seizure recurrence. It is also important that patients understand that in most situations more than a single EEG or brain imaging test may be needed for identification of a possible epilepsy syndrome. King et al. [
      • King M.A.
      • Newton M.R.
      • Jackson G.D.
      • Fitt G.J.
      • Mitchell L.A.
      • Silvapulle M.J.
      • et al.
      Epileptology of first-seizure presentation: a clinical, electroencephalographic, and magnetic resonance imaging study of 300 consecutive patients.
      ] looked at the combined value of early EEG, sleep-deprived EEG and MRI as a comprehensive, rapid diagnostic strategy for patients presenting with their first unprovoked seizure. They found that early EEG, done within with 24 h of presenting seizure, provided a higher diagnostic yield than previous studies. They further demonstrated that accurate diagnosis was improved with a sleep-deprived EEG and MRI.
      Many patients believe they are having the EEG done to “prove” that the event they experienced was or was not a seizure. It is important that they understand that the EEG has a role in identifying where in the brain the difficulty may have come from, classification of a specific syndrome if it is evident, and to assist in predicting risk for further seizure. Schreiner and Pohlmann-Eden [
      • Schreiner A.
      • Pohlmann-Eden B.
      Value of the early electroencephalogram after a first unprovoked seizure.
      ] found that standard EEG was more sensitive in detecting abnormalities compared to clinical and neuroradiological data. Evidence shows that a normal EEG does not exclude the presence of a seizure disorder and on average about 50% of individuals with a clinical diagnosis of seizure have a normal EEG [
      • Krumholz A.
      • Wiebe S.
      • Gronseth G.
      • Shinnar S.
      • Levisohn P.
      • Ting T.
      • et al.
      Practice parameter: evaluating an apparent unprovoked first seizure in adults (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society.
      ]. However, when EEG contains epileptiform activity, either focal spikes or generalized spike and wave discharges, there is a higher risk for seizure recurrence. A meta-analysis done by Krumholz et al. [
      • Krumholz A.
      • Wiebe S.
      • Gronseth G.
      • Shinnar S.
      • Levisohn P.
      • Ting T.
      • et al.
      Practice parameter: evaluating an apparent unprovoked first seizure in adults (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society.
      ], demonstrated that the estimated probability of seizure recurrence for patients with epileptiform abnormalities on EEG was 49.5%, compared to a seizure recurrence risk of only 27.4% for those with normal EEG. Pohlmann-Eden and Newton [
      • Pohlmann-Eden B.
      • Newton M.
      First seizure: EEG and neuroimaging following an epileptic seizure.
      ] concluded that an early abnormal EEG, especially when showing focal epileptiform activity, seems to be an excellent predictor for seizure recurrence. The few data available on subsequent sleep-deprived EEG supports the view that it provides valuable additional information with regard to syndrome classification and seizure recurrence rates for those who had normal initial routine EEG [
      • Pohlmann-Eden B.
      • Newton M.
      First seizure: EEG and neuroimaging following an epileptic seizure.
      ]. Clinicians should employ careful consideration for sleep-deprived EEG if there is any clinical suspicion for undiagnosed generalized epilepsy as the risk for provoking seizure increases with sleep deprivation.
      Patients need to clearly understand that neuroimaging is done to assist in identifying any underlying structural etiology for the seizure and to assist in predicting risk for seizure recurrence. The role of CT or MRI in adults presenting with first seizure, is to assist with diagnosis of essential brain lesions. These neuroimaging tests have been shown to identify significant brain lesions in about 10% of cases [
      • Krumholz A.
      • Wiebe S.
      • Gronseth G.
      • Shinnar S.
      • Levisohn P.
      • Ting T.
      • et al.
      Practice parameter: evaluating an apparent unprovoked first seizure in adults (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society.
      ]. CT scan is the most common initial scan and it effectively identifies significant lesions. This is likely related to the fact that preliminary assessment for a first seizure usually occurs in an emergency department where CT is generally more easily accessible. MRI is known to provide more detailed imaging and is more sensitive than CT in identifying subtle lesions; however, its diagnostic yield after a single first seizure event is not yet clearly known [
      • Pohlmann-Eden B.
      • Newton M.
      First seizure: EEG and neuroimaging following an epileptic seizure.
      ]. It is recognized that identification of more subtle lesions may assist in predicting seizure recurrence risk and thus MRI is beneficial as part of the neurodiagnostic work-up after first seizure. It behoves the clinician to remember that CT scans expose patients to ionizing radiation and if available and clinically possible, MRI is the imaging modality of choice after first seizure.

      6. Lifestyle considerations

      A diagnosis of first seizure significantly impacts on daily activities and lifestyle. Paramount in counselling is a discussion about safety since seizure recurrence could put themselves, or others, at risk for injury or death. This includes situations associated with working with heavy machinery, at heights, operating a motor vehicle, swimming and tub bathing. Other specific considerations depend on the individual situation and can include handling infants, cooking, exercising strategies, and specific work-related activities. Depending on occupational activities, a first seizure can compromise employment and this needs to be explored closely with each individual. Occupational safety considerations need to be assessed and if needed information and supporting documentation may be provided to employers. Patients may also need to be linked with community support services if income is impacted. Counselling about SUDEP (sudden unexplained death in epilepsy) would be reserved for a diagnosis of epilepsy.
      Also to be included are lifestyle factors that can lower seizure threshold and predispose to recurrence. These include sleep deprivation, the use of alcohol and social drugs. Although the exact mechanism of why sleep deprivation increases risk for seizure is not known, it is clear that an association exists for some people. Careful counselling outlining the importance of getting enough, good quality sleep to reduce the risk of seizure recurrence is imperative. Having one or two drinks has not been shown to lead to increased seizure activity in most people. Seizures found to be associated with alcohol are primarily related to alcohol withdrawal or binge drinking. The risk is thought to be much higher after 3 or more drinks. Counselling in regards to the impact life stressors have on sleep and coping strategies should be included to ensure that individuals are aware of the influence stress may have on lowering seizure threshold and increasing risk for seizure recurrence.

      7. Driving

      The risk for seizure recurrence after a first seizure is not negligible and as such some restriction in driving is warranted. The objective of these restrictions is to prevent a seizure-related accident. Driving restrictions after a first seizure vary greatly around the world but in most countries there is some form of limitation. Most guidelines include a requirement for a seizure free period during which assessment, evaluation and monitoring occur. The requirements and limitations around driving may differ if the individual’s licence is for personal driving or if it is a licence for commercial driving. Brown et al. [
      • Brown J.W.L.
      • Lawn N.D.
      • Dunne J.W.
      When is it safe to return to driving following a first-ever seizure.
      ] prospectively analysed 1386 patients with first seizure from a quantitative perspective to try to identify probability of seizure recurrence. Their data suggests that patients who experience a first seizure should not be driving for between 5 and 8 months; with the longer restriction for unprovoked events. They further indicate that driving time influences risk and that driving time of more than 1 h/day means a longer restriction time is warranted. This supports the practice of many jurisdictions where the restrictions are often more stringent for commercial driving.
      For many, driving is considered essential for employment, socialization and sense of independence. Any restriction comes with implications in all these areas. This is an area of great concern for most people who experience a first seizure and often is an animated and protracted part of the counselling process. Understanding that seizures cause unpredictable, episodic, impairments that result in sudden incapacitation that cannot be compensated for is paramount. It is also helpful to explain that any driving restriction implemented is usually at the discretion of the licensing body, not the clinician. The clinician is obliged to be aware of the driving regulations in their own state or province and to communicate this to the patient. In some jurisdictions mandatory reporting by the clinician to the licensing authority is required. It is of utmost importance that the patient fully understands that the reason for limitations on driving after a first seizure is to minimize risk to the public as well as to themselves. The importance of compliance and the possible medical and legal implications of failing to comply need to be plainly stated.

      8. First aid

      Patients, their family, friends and co-workers need to know what to do in case of another seizure. The principal advice in seizure first aid is to keep the person safe during and after the seizure. The specific components of seizure first aid (Table 5) should be reviewed. Counselling should include things that should not be done such as not forcibly holding the person down and to never put anything in the person’s mouth.
      Table 5Seizure first aid.
      • Keep the person safe—remove harmful objects
      • Provide comfort—pillow under head, loosen tight clothing, remove eyeglasses
      • Stay with the person until the seizure ends and they are fully awake
      • Remain calm and reassuring
      • Reposition to support breathing—turn the person gently onto their side in the recovery position after the seizure has stopped
      • Time the seizure—use a watch for accuracy
      • Call for emergency assistance—if the seizure lasts more than 5 min, if the seizure re-occurs shortly after the first one, if the person is injured or has trouble breathing after the seizure, if the person cannot be awakened, or if the person is aggressive
      • Do not restrain or hold the person down it can result in injury
      • Do not put anything in the person’s mouth

      9. Role of medication

      Patients are often relieved to hear that in most first seizure circumstances treatment with antiepileptic drugs (AED) will not be recommended. This is supported by the findings of Marson et al. [
      • Marson A.
      • Jacoby A.
      • Johnson A.
      • Kim L.
      • Gamble C.
      • Chadwick D.
      • et al.
      Immediate versus deferred antiepileptic drug treatment for early epilepsy and single seizures: a randomised controlled trial.
      ] indicating that although AEDs have been shown to reduce seizure recurrence when used immediately after a first seizure event, they have not been proven to impact long-term outcomes. Knowing this and considering the balance between individual risk for seizure recurrence and the side effect profiles of AEDs, individual recommendations can be made. Patients who are not initially deemed to be at increased risk for seizure recurrence should be counseled that AED treatment will be recommended if there is a recurrence. This is based on the work of Hauser et al. [
      • Hauser W.A.
      • Rich S.S.
      • Annegers J.F.
      • Anderson V.E.
      Seizure recurrence after a 1st unprovoked seizure: an extended follow-up.
      ] who found that the risk for recurrence after 2 seizures was as high as 70%.
      There are some patients in whom AED treatment may be recommended after a single first seizure event (Table 6). This includes those patients with an enduring predisposition for further seizure, those at significant risk for injury from another seizure, and those for whom a second seizure would result in catastrophic social implications. For these patients, it is important that they understand that the treatment is not curative but is used to suppress seizure activity and that medication can only work if taken regularly.
      Table 6Situations when AED use after first seizure may be recommended.
      • Enduring causative underlying brain lesion
      • Epileptiform discharges on EEG—especially those suggesting genetic generalized epilepsy
      • Remote brain lesion and corresponding focal epileptiform discharges on EEG
      • High risk for injury from another seizure—severe osteoporosis, high bleeding risk, poly-trauma situation
      • Evidence of prior more subtle seizures
      • Social situation in which a second seizure would result in catastrophic results—like job loss

      10. Medication action and side effects (if appropriate)

      For patients who begin an AED, clear and comprehensive counselling on the specific medication is required. This includes discussing reasons for recommending that specific agent, efficacy, side effect profile, cost and any potential interactions with other medications they might be taking. This is particularly important for the interactions some AEDs have with oral contraception. Risk for birth control failure and requirement for alternative methods need to be reviewed. Individualized, detailed counselling must be done for women of childbearing age in regards to the risks and benefits of AED use in pregnancy. The use of folic acid supplementation should be reviewed. Further discussions about AED dosages and monitoring during pregnancy, teratogenicity of individual AEDs and breastfeeding considerations must be included when an AED is prescribed to a woman of childbearing potential. With all patients starting an AED, discussions should include the role of calcium and vitamin D supplementation in their individual situation.
      The importance of medication compliance must be emphasized. Providing information about strategies that can be incorporated to assist with compliance is often helpful. This includes utilizing pill counters, setting phone reminders and having extra medication with them or at their place of work/school.

      11. Psychological implications: cognitive and emotional

      The first seizure can have profound social and emotional consequences. The uncertainty of recurrence and the significant and usually negative effect on lifestyle (independence, mobility/driving, employment and social) can have consequences beyond the initial isolated event. Velissaris et al. [
      • Velissaris S.L.
      • Wilson S.J.
      • Saling M.M.
      • Newton M.R.
      • Berkovic S.F.
      The psychological impact of a newly diagnosed seizure: losing and restoring perceived control.
      ] looked at the psychological impact of a first seizure and found that all individuals experienced some perception of loss of control. They further identified two different psychological adjustment trajectories in response to that loss of control. These were primarily determined by the individuals’ perceived level of loss of control and were defined as either pervasive or limited. Those with a pervasive loss of control had a higher risk for persistent and significant psychological impact. Acknowledging this loss of control and counselling patients on the strategies of coping is crucial. Patients need to be aware that formal psychological or psychiatric intervention may be warranted when significant psychological distress persists beyond the 3 month follow-up [
      • Velissaris S.L.
      • Wilson S.J.
      • Saling M.M.
      • Newton M.R.
      • Berkovic S.F.
      The psychological impact of a newly diagnosed seizure: losing and restoring perceived control.
      ].
      Many people who experience a first seizure report cognitive difficulties. Velissaris et al. [
      • Velissaris S.L.
      • Wilson S.J.
      • Newton M.R.
      • Berkovic S.F.
      • Saling M.M.
      Cognitive complaints after a first seizure in adulthood: influence of psychological adjustment.
      ] found that approximately half of the first seizure patients reported some impact of the first seizure on their cognitive abilities. Included were difficulties with attention, concentration, memory and word finding. However, on formal testing the majority of their patients did not demonstrate objective findings of cognitive impairment; rather they found that the primary correlate of cognitive complaints following a first seizure was related to mood state. This again points to the importance of psychological assessment, counselling and support. Those with extensive cognitive complaints may benefit from formal assessment of mood/adjustment issues [
      • Velissaris S.L.
      • Wilson S.J.
      • Newton M.R.
      • Berkovic S.F.
      • Saling M.M.
      Cognitive complaints after a first seizure in adulthood: influence of psychological adjustment.
      ] and of cognition.
      A later study by Velissaris et al. [
      • Velissaris S.L.
      • Saling M.M.
      • Newton M.R.
      • Berkovic S.F.
      • Wilson S.J.
      Psychological trajectories in the first year after a newly diagnosed seizure.
      ] looked at depression and anxiety trajectories for up to a year after presentation. They found that the strongest predictor of depression and anxiety was the patient’s sense of loss of control at the 1-month post first seizure evaluation. Those reporting pervasive loss of control at the 1 month visit reported the highest levels of depression and anxiety one year later. Patients need to be aware that there is a process of psychological adjustment following the seizure and that this complex adjustment process may require therapeutic intervention [
      • Velissaris S.L.
      • Wilson S.J.
      • Saling M.M.
      • Newton M.R.
      • Berkovic S.F.
      The psychological impact of a newly diagnosed seizure: losing and restoring perceived control.
      ]. Although most patients appear to be psychologically resilient after a first seizure this data suggests we need to screen and monitor for depression and anxiety to distinguish between significant psychological distress and normal adjustment processes [
      • Velissaris S.L.
      • Saling M.M.
      • Newton M.R.
      • Berkovic S.F.
      • Wilson S.J.
      Psychological trajectories in the first year after a newly diagnosed seizure.
      ].

      12. Next steps and when to call for help

      Ongoing communication is a key part of counselling after a first seizure. Patients need to have a clear understanding of what the next steps will be. They need to know when to expect to be seen in follow-up and who they should contact if they have questions or concerns. They also need clear direction as to what the plan will be should they experience another seizure and who to contact if that occurs. If further testing is being arranged, patients need to be prepared and they should be informed of who to contact to get the results of those tests.

      13. Summary

      Counselling after a first seizure is an integral and essential part of holistic care. It is a key component of the diagnostic and prognostic process of evaluation and management of patients experiencing first seizure. Comprehensive counselling is a complex and time consuming task that must incorporate numerous components and be completely individualized for every patient. We need to assess their knowledge and understanding, answer their questions and acknowledge the personal and emotional impact the diagnosis of first seizure has. It is our responsibility as care providers to ensure that we present our patients with the best information available to assist them in understanding the medical situation and in making informed decisions about their management and treatment.

      Conflict of interest statement

      The authors of this publication “Counseling for Adults Who Experience a First Seizure” have no actual or potential conflicts of interest to report in relation to the information provided in this publication.

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