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  • Gates and Rowan’s

    Nonepileptic SeizuresThird Edition© in this web service Cambridge UniversityPress

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

  • Gates and Rowan’s

    Nonepileptic SeizuresThird EditionEdited bySteven C.Schachter

    W. Curt LaFrance, Jr.© in this web service Cambridge UniversityPress

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

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

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

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    Library of Congress Cataloging in Publication dataGates andRowan’s nonepileptic seizures. – 3rd ed. / edited by StevenC.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 referencesand 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-epilepticseizures. V. Title: Nonepileptic seizures.[DNLM: 1. Seizures –diagnosis. 2. Diagnosis, Differential.3. NeurobehavioralManifestations. 4. Seizures – physiopathology.5. Seizures –therapy. WL 340 G259 2010]RC394.C77N66 2010616.8′45 – dc222009032957

    ISBN 978-0-521-51763-8 Hardback

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    Every effort has been made in preparing this publicationtoprovide accurate and up-to-date information which is in accordwithaccepted standards and practice at the time of publication.Although casehistories are drawn from actual cases, every efforthas been made to disguisethe identities of the individualsinvolved. Nevertheless, the authors, editors,and publishers canmake no warranties that the information containedherein is totallyfree from error, not least because clinical standards areconstantlychanging through research and regulation. The authors, editors,andpublishers therefore disclaim all liability for direct orconsequentialdamages resulting from the use of material containedin this publication.Readers are strongly advised to pay carefulattention to information providedby the manufacturer of any drugsor equipment that they plan to use.© in this web service Cambridge UniversityPress

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  • Contents

    List of contributors page viiPreface xiDedicationsxiiiRemembrances xvii

    Section 1: Recognition, diagnosis,and impact of nonepilepticseizures

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

    2 Psychogenic nonepileptic seizures:historical overview17Michael 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 38SelimR. Benbadis and W. Curt LaFrance, Jr.

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

    6 Nonepileptic paroxysmal neurologicaland cardiac events62Fergus J. Rugg-Gunn andJosemir W. Sander

    7 Parasomnias: epileptic/nonepilepticparasomnia interface77Roderick Duncan and Aline Russell

    8 The use of hypnosis and linguisticanalysis to discriminatebetweenpatients with psychogenic

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

    9 Diagnostic issues in children 91Tobias Loddenkemper and ElaineWyllie

    10 Diagnostic issues in the elderly 110Christoph Kellinghaus andGabriel Möddel

    Section 2: Nonepileptic seizures:culture, cognition, andpersonalityclusters

    11 Cultural aspects of psychogenicnonepileptic seizures121Alfonso Mart́ınez-Taboas, RobertoLewis-Fernández, Vedat Sar,and ArunLata Agarwal

    12 Psychogenic nonepileptic seizures:why women? 131BettinaSchmitz

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

    14 Cognitive complaints and theirrelationship toneuropsychologicalfunction in adults with psychogenicnonepilepticseizures 142George P. Prigatano and Kristin A. Kirlin

    15 Health Related Quality of Life: utilityand limitation inpatients withpsychogenic nonepileptic seizures 149Gemma Mercer, RoyC. Martin, andMarkus Reuber

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  • Contents

    16 Legal medicine considerations relatedto nonepileptic seizures157Roy G. Beran, John A. Devereux, andW. Curt LaFrance, Jr.

    Section 3: Psychiatric andneuropsychological considerationsinchildren and adolescents withpsychogenic nonepileptic seizures

    17 Psychiatric features andmanagementof children withpsychogenicnonepileptic seizures 163Rochelle Caplan and SigitaPlioplys

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

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

    20 Munchausen syndrome 190Ghislaine Savard, FrederickAndermann,and Renée Fugère

    Section 4: Psychiatricconsiderations in adults withpsychogenicnonepileptic 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 Fiszmanand Andres M. Kanner

    Section 5: Treatmentconsiderations for psychogenicnonepilepticseizures

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

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

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

    27 Who should treat psychogenicnonepileptic seizures? 260AndresM. Kanner

    28 Designing treatment plans based onetiology of psychogenicnonepilepticseizures 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 TrudieChalder

    30 Group psychotherapy treatment forpsychogenic nonepilepticseizures 289Kim D. Bullock

    31 Hypnosis in the treatment ofpsychogenic nonepileptic seizures297Franny C. Moene and Jarl Kuyk

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

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

    Appendix 327Index 336vi© in this web service Cambridge UniversityPress

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  • Contributors

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

    Arun Lata Agarwal, MDAssistant Professor, Department ofPsychiatry,Maulana Azad Medical College and G.B. PantHospital, NewDelhi, India

    Frederick Andermann, OC, MD, FRCP(C)Professor of Neurology andPediatrics,Montreal Neurological Hospital and Institute,McGillUniversity, 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 BehavioralSciences,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), GradDip (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 ofPsychiatry,University College of Medical Sciences and

    Guru Teg Bahadur Hospital, Dilshad Garden,Delhi, India

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

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

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

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

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

    Trudie Chalder, PhD, MScProfessor of Cognitive BehaviouralPsychotherapy,Institute of Psychiatry, King’s CollegeLondon,London, UK

    Craig Chigwedere, BSc, MA, MScCognitive BehaviouralPsychotherapist/ClinicalLecturer in CBT, St Patrick’s Hospital andTrinityCollege, 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© in this web service Cambridge UniversityPress

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  • List of contributors

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

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

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

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

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

    Renée Fugère, MD, FRCPCMedical Director, National MentalHealth Unit forWomen (federal jurisdiction) and AssistantProfessor,Department of Psychiatry, University ofMontreal,Montreal, Canada

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

    Laura H. Goldstein, BSc, MPhil, PhDProfessor of ClinicalNeuropsychology, Institute ofPsychiatry, King’s CollegeLondon,London, UK

    Nathan M. Griffith, PhDResearch Postdoctoral Fellow inNeuropsychology,UCLA Semel Institute for Neuroscience andHumanBehavior, Los Angeles, CA, USA

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

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

    Ann Hempel, PhDMinnesota Epilepsy Group, P.A., andAdjunctAssistant Professor, Department of Neurology,University ofMinnesota Medical School,Minneapolis, MN, USA

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

    Christoph Kellinghaus, MDStaff Physician, Department ofNeurology, KlinikumOsnabrück, Osnabrück, Germany

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

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

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

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

    Tobias Loddenkemper, MDAssistant Professor of Neurology, HarvardMedicalSchool, Division of Epilepsy and ClinicalNeurophysiology,Children’s Hospital, Boston, MA,USAviii© in this web service Cambridge UniversityPress

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  • List of contributors

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

    Alfonso Martı́nez-Taboas, PhDAssociate Professor, Carlos AlbizuUniversity,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 ClinicsofMünster, Münster, Germany

    Franny C. Moene, PhDClinical Psychologist/Psychotherapist, DeGroteRivieren, Organization for Mental Health, Dordrecht,TheNetherlands

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

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

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

    George P. Prigatano, PhDNewsome Chair of ClinicalNeuropsychology, BarrowNeurological Institute, St. Joseph’sHospital andMedical Center, Phoenix, AZ, USA

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

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

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

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

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

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

    Josemir W. Sander MD, PhD, FRCPProfessor of Neurology, HonoraryConsultantNeurologist, University College London, InstituteofNeurology, London, UK

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

    Ghislaine Savard, MD, FRCPNeuropsychiatrist, AssociateProfessor, Departmentof Neurology, Montreal Neurological HospitalandMcGill University, Montreal, Canada

    Steven C. Schachter, MD, FAANProfessor of Neurology, HarvardMedical School,Chief Academic Officer and DirectorofNeuroTechnology, CIMIT and Department ofNeurology, Beth IsraelDeaconess Medical Center,Boston, MA, USA

    Bettina SchmitzDepartment of Neurology, VivantesHumboldtKlinikum Berlin, Charité, Humboldt University,Berlin,Germany

    Jon Stone, MB, ChB, FRCP, PhDConsultant Neurologist and HonorarySeniorLecturer, Department of Clinical Neurosciences,WesternGeneral Hospital, Edinburgh, UK ix© in this web service Cambridge UniversityPress

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  • List of contributors

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

    Noreen C. Thompson, RN, MSN, PMHCNS-BCPsychiatric ConsultationLiaison Nurse, University ofKansas Hospital and Assistant ClinicalProfessor,University of Kansas School of Nursing, Kansas City,KS,USA

    Michael Trimble, MD, FRCP, FRCPsychProfessor of BehaviouralNeurology, Institute ofNeurology, London, UK

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

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

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

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

    Mark Zimmerman, MDDirector of Outpatient Psychiatry, RhodeIslandHospital and Associate Professor of Psychiatry,Brown MedicalSchool, Providence, RI, USA

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  • Preface

    The first edition of Non-Epileptic Seizures was pub-lished in1993 and edited by Drs. A. James Rowanand John R. Gates. Based on a1990 symposiumcalled “TheDilemma of Non-Epileptic(Pseudoepilep-tic) Seizures,” this instant classic synthesized theavail-able knowledge and hypotheses regarding all facetsofnonepileptic seizures into four sections:neurological,psychiatric and neuropsychological aspects, andfun-damentals of treatment. The second edition was pub-lished in2000 and reflected the continued outgrowthof the 1993symposiumaswell as a second conference –“Non-Epileptic Seizures: AConsensus Conference onDiagnosis and Treatment” – held in Bethesdain 1996.

    A third conference, the 2005 PsychogenicNonepileptic Seizures(PNES) Treatment Workshop,sponsored by the National Institute ofNeurologicalDisorders and Stroke (NINDS), the National InstituteofMental Health (NIMH), and the American EpilepsySociety and chairedby W. Curt LaFrance, Jr., broughttogether experts from around theworld, representingmany disciplines. The enthusiasm emanatingfromthat landmark meeting reverberated widely amongstprofessionalsinterested in the evaluation and treat-ment of persons with PNES.Sadly, the field soonafterwards lost its pioneers: John Gates onSeptember28, 2005 and Jim Rowan on August 27, 2006.

    Recognizing the increasingly rapid developmentssince the secondedition, the importance of Non-Epileptic Seizures as the embodimentof the field, andthe singular contributions of Drs. Gates andRowan,we endeavored to organize a new edition and to for-ever linkthe names of Gates and Rowan with thistopic by their inclusion inthe book title. It is there-fore most fitting that this editionincludes dedicationsfrom Rita Meyer Gates and Rita Rowan, with ourgrat-itude, as well as personal remembrances of Drs. GatesandRowan.

    Historically, neurology and psychiatry were prac-ticed as aunitary model, addressing patients withneurological and psychogenicdisorders with equalattention. Unfortunately, as neurologic andpsychiatricpractices became dichotomized in the twentieth cen-tury,the topic of PNES fell between the borderlands ofneurology andpsychiatry.

    Bridging neurology and psychiatry again, the pri-mary aim ofthis edition is to educate physicians,psychologists, clinicians,allied health providers andresearchers about the diagnosis andtreatment of chil-dren and adults with nonepileptic seizures.Buildingon the groundwork laid in the first two editions,theeditors and authors of this third edition provideamul-tidisciplinary approach to the neuropsychiatric disor-der ofpsychogenic nonepileptic seizures. The authorsare the foremostexperts in their respective fieldsand provide an update on thecurrent knowledge ofnonepileptic seizures from the neurologic,neuropsy-chological, psychological, psychiatric, and socialper-spectives. The structure of the book sections allowsan in depthappraisal of diagnostic semiology, clini-cal characteristics,issues in children, comorbidities,and, finally, a significantexpansion of treatment forPNES. The addition of the DVD providesvideo sam-ples of different seizure types and vignettes to aidclin-icians with the differential diagnosis and treatmentofnonepileptic seizures.

    It is our hope that Gates and Rowan’s Nonepilep-tic Seizures,3rd edn. will honor the memories andlegacies of its foundingeditors, and serve to reflectas well as influence the continueddevelopment of thefield, informing clinicians and inspiringresearchers toimprove the care of persons with nonepilepticseizurestoday and in the future.

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

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  • Participants, 2005 Psychogenic Nonepileptic Seizures TreatmentWorkshop, sponsored by National Institute of Neurological DisordersandStroke, National Institute of Mental Health, and AmericanEpilepsy Society.

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

    Not pictured: John Campo, Orrin Devinsky, Frank Gilliam, DalmaKalogjera-Sackellares, John Mellers, and Markus Reubercontributedsignificantly prior to the workshop but were unable toattend.© in this web service Cambridge UniversityPress

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  • Dedication for Dr. A. James Rowan

    On the Friday afternoon before his last admission tothehospital, Jim Rowan presided over his weekly pedi-atric epilepsyconference. He insisted on it. He dressedhimself carefully thoughevery small movement costmore energy than he had to spare – butthis was hisfavorite conference of the week.

    More effort and energy was expended getting himinto a taxicaband then up to the EEG laboratory wherethe conference was held. Itwas well attended. Jim wasclearly fatigued, yet, the moment he wasgiven thefirst case the “old” Dr. Rowan was again in charge –nofatigue, no effort, just joy in his competence andknowledge, andyes, 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 adazzling performance.

    Epilepsy, understanding it, treating it, and teach-ing about itwas the work to which Jim gave his life.That afternoon he gave hislast share of energy to it. Hewould not have had it anyotherway.Thepediatric con-ference, concerning epilepsy at thebeginning of life,his geriatric research, concerning epilepsy atthe end oflife, and thiswork onnonepileptic seizures suggeststherange of his interests and the depth of his dedication.It isfitting that the new edition continues to advancethis veryimportant work.

    Rita Rowan

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  • Dedication for Dr. John R. Gates

    John was an intentional man who woke each morn-ing with anexplicit commitment to proffer his bestin every circ*mstance, toeveryone; who went to sleepeach night weighing the day’s successesand challenges,probing the “what and how” for an inspirationthatmight give rise to the next opportunity. What he tookas amatter of course – expertise, indefatigable energy,imagination, andhustle – others found remarkable,and he devoted himself to patientcare, research,writing, teaching, and organizational, volunteer,andcommittee work.

    John was fascinated by the workings of the brain,and he believedthat neurology, rather than psychia-try, held more potential foreffective intervention. Forthis reason, as a young intern he choseto specialize inepilepsy so that he could make a difference. Hiswishand ambition to make that decisive difference in indi-viduallives and in the field of epilepsy came to per-meate his work,which in turn became his life. John’sinterests and efforts includedadvancing surgical tech-niques to improve surgical outcomes,pharmaceuticaland device research, mentoring a broad range ofstu-dents, physicians, and adjunct individuals, and mem-bership inlocal, regional, and national organizationsadvancing qualityassurance, professional practice, fis-cal strength, and communityresources.

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

    Based on John’s vision of model collaboration, heorganized andconvened the initial interdisciplinaryPNES consensus conferences in1990 and 1993. Theseconferences were the milestones that set thestage foryears of joint effort among epileptologists, psychia-

    trists, and neuropsychologists to ensure the best diag-nosticand treatment parameters for PNES. This earlywork defined andcontinues to influence the multifac-torial, multicultural, andmultidisciplinary emphasesin the treatments for these patients. Hewould havebeen particularly pleased that this new volume waseditedby an epileptologist and a neuropsychiatrist.

    John was unabashed in his esteem and admira-tion for hiscolleagues, his respect and regard for hispatients, and his lovefor his family and friends. Hewas often generous, exuberant, andforgiving to a fault.His conviction of the inherent value andgoodness ofpeople gave meaning to his life and heartenedthosearound him.

    He set great store by his Jersey street-fighter roots,which hecredited for his “backbone.” He had the abil-ity to stand hisground, often alone, under terrific pres-sures. Never one to upholdthe status quo, he made‘thinking outside the box’ his mantra longbefore itwas part of popular culture. John was always keen toworkout an impossible situation. But then a braintumor appeared at theage of 53. This was a terrificblow. Though his commitment to histreatment was100+%, there would be no recovery. He would notlivelong enough to appreciate the testimonials, hon-ors, and awardsthat were bestowed to pay tribute tohim; he would not be cognizantof the expressionsof respect, appreciation, and love he hadengenderedduring his life.

    John would applaud publication of this third edi-tion and thenpress for continuation of the work. WithJohn, whether flying hisplane, guiding boy scouts,fishing in the cold of a Minnesotawinter, advocatingfor his special needs son, writing poetry, orabsorbedin his work, it was always upwards and onwards.

    May his life and dedication to patients with PNEScontinue to bean inspiration.

    Rita Meyer Gates xv© in this web service Cambridge UniversityPress

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  • 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 broughtme through difficult times. Your fatherlypride in anything Iaccomplished made me try evenharder to please you. You shoulderedmany burdenswith grace, and shared a few of your own alongtheway,but you always kept your focus on the task at hand andon thewell-being of others.

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

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

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

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

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

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

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

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

    John R. Gates, MD died September 28, 2005, at age54 from a braintumor. A moving memorial servicewas attended by over one thousandpeople, and cen-tered around readings, poetry, and music – allartis-tic favorites of John’s. He was survived by hisbelovedsweetheart 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 manwho made numerous andsubstantial contributions to the field ofepilepsy andthe practice of neurology. With contributions frommanyof those who were closest to John, I offer thisappreciation.

    A champion fighter from an early ageBorn in the inner city ofTrenton, New Jersey,John emerged from humble surroundings togradu-ate Magna Cum Laude from Harvard University. Hewas brought upby his grandparents. After both hisgrandparents passed away when hewas 15 years old,a teacher who recognized his brilliance helpedhimget a scholarship for disadvantaged youth. He went onto attendelite schools in Massachusetts and England,where he excelledacademically. I believe it was becauseof this unique backgroundthat hewas able to challengethe establishment with confidence.Indeed, from hischildhood until his untimely death, John “nevergaveup the fight.” He was “an enthusiastic paladin for thewarsagainst epilepsies, and more.”

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

    ment, and a very demanding teacher and world classscholar withtremendous clinical experiences in neu-rology. It is very unusualto hear a neurology residentarguingwithDr. Baker, not tomention a4th 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. Ibelieve even Dr. Baker was caught by surpriseas well. I can’trecall the detail of the conversation then,but I remember he wasable to present his view in acalm and logical manner, though Idon’t think he wasable to win the case. His unique way of dealingwithauthority left me with an indelible impression.

    His fellow residents and teachers witnessed thegrowth anddevelopment of a stellar and compas-sionate clinician who soughtthe truth, sometimes inunconventional ways. I happened to be thevery firstchief resident he had to work with. In the beginning,itwas truly a disaster; he almost constantly argued withme in thediagnosis and clinical management of cases.Sometimes in front ofthe whole crew in the sign-outrounds in the evening, he wouldchallenge me for say-ing something not well founded. The results ofthesenumerous arguments were that we both went to thelibrary tolook for references to back up what we said,and then Xeroxedarticles for each other to prove ourpoints. By the end of histhree-month rotation at theMinneapolis VA Hospital, we both hadpiles of ref-erences from each other, and that is how welearned“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 withsubarachnoid hemor-rhage. John’s team had been pared to a minimumoverthe holidays by scheduled vacations, and John was fill-ing manyroles – including single-handedly manag-ing all aspects ofcritically ill patients, including the

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  • In remembrance of Dr. John R. Gates

    young woman. He invested everything of himself in aneffort tostave off what was inevitable. He also becameexhausted. Late onChristmas Eve we took a break inmy office to discuss plans for thenight. John told methat the young woman had just deteriorated, andhedid not know what he was going to tell her family.He put his headdown and cried. I think I did too.Although he projected unflappablebravado, his com-plete personal investment in his patients andtheir fam-ilies was also his gift and his emotional Achilles’heel.

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

    Passion for patients and their doctorsJohn co-founded theMinnesota Epilepsy Group inSt. Paul, a practice that grew into aworld-renowned,comprehensive epilepsy center noted for clinicalandresearch excellence, and widely emulated. A clinicalprofessor ofneurology at the University of Minnesota,John was “passionate inhis commitment to patientcare,” tried “his hardest to be the bestdoctor” forhis patients, and believed “the treatment of epilepsyhadno boundaries” and that “people with epilepsydeserved first ratecare.”

    Over the years, John recruited and attracted “tech-nicallysuperior and enormously caring staff – all ofwhom were a reflectionof John’s core values, and whowill carry on his legacy throughtheir work.” John’scoworkerswere “dedicated to himandheld him insuchhigh esteem. Nurses, psychologists, neurologists, sup-portstaff – at every place he worked – would sponta-neously talk aboutJohn and his dedication to patients.They truly held him in aspecial spot in their hearts foryears and that is something onerarely sees.”

    His “strong advocacy for compassionate treatmentof people withnonepileptic seizures” was widely rec-ognized and appreciated. “Fartoo often, these patientsare dismissed and treated as second classcitizens byepileptologists. John hated that attitude.”

    His influence on patient care and the epilepsymovement spreadout from St. Paul to around theworld. “Johnwas one of those specialpeople, and there

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

    Prodigious scholarship, impactfulteaching, and a zest forworkJohn authored hundreds of publications and perhapsis best knownfor his writings and edited books onpsychogenic nonepilepticseizures, efficacious use ofantiepileptic drugs (AEDs), and thesurgical manage-ment of epilepsy.

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

    Severalmonths before he died, John participated inaNationalInstitutes ofHealth (NIH)-sponsoredwork-shoponnonepileptic seizures(NES).While he thoughtof himself as “one of the ‘old dogs’ in thepack,” hewas regarded as the brightest luminary in this fieldby themany accomplished international, interdisci-plinary workshopparticipants. “In typical John fash-ion, he broke the ice veryearly on,with a fewbold com-ments about the differences betweenneurology andpsychiatry. Once the smoke settled, it proved to beaperfect entrée, loosening up everyone for an intenseandinvaluable discussion onNES treatment research.”

    He excelled at lecturing and was a “masterfulteacher” who “neverstood on formalities and sharedhis knowledge and experiencewithyoung neurologistsand foreign doctors”. His enthusiasm for teachingcon-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 upto the podium.”

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

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  • In remembrance of Dr. John R. Gates

    the Association of Neurologists of Minnesota,and the RamseyCountyMedical Society. He served onthe ILAE Commission forNeurosurgery and partici-pated in projects of the Subcommission forPediatricEpilepsy Surgery. He chaired the Practice Committeeof theAmerican Epilepsy Society and served on anumber of other AEScommittees and task forces, aswell as the AES Board of Directorswhile courageouslybattling his cancer. “John’s voice on the AESboardalways reflected his passion and commitment to theneeds andbest interests of individuals with epilepsy.”

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

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

    Awarm and friendly guy whooccasionally tilted at windmillsEachof us who knew John remembers something spe-cial about him, whetherserious or humorous, pro-found or simple. He was the kind of guywho wouldwake up one morning with an idea and then a fewhours,days, weeks, or months later, it would becomea reality. He was agrass roots organizer who gaveuntold time and energy to innumerableepilepsy-related projects, including summer camp for kids,assistedliving for young adults, funding for the lesswell-off foraffordable medications, and “inventing”local, regional, andnational training and mentoringprograms. Above all else, “he was awarm and friendlyguy who made many people, especially hispatients,feel special.”

    When I think of John, his email address always pops into mymind:[emailprotected]. It was so appropriate. He seemed to swoopinto aroom as if he was a plane landing or, under somecirc*mstances, asa dive bomber when he wanted to destroy oppositionto some pointhe held dearly. [emailprotected] also conveys to methe sense ofsoaring, which also captures his personality to me. Hewas always apresence in any meeting, no matter how large the group.He neverjust went through the motions of showing up. He was alwaysin themix of any discussion speaking out about the issues near anddear to

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

    I remember his ability to cut through or circumvent nonsenseandget to the heart of any matter quickly, and directly, withoutcausingantagonism, which is a great skill. Even when he was verysick, weappreciated his ability to do this.

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

    A trademark of John that I appreciatedwas his ability toconnectwithwhomever he was speaking to. His deep voice conveyed adeport-ment of seriousness, which however was countered by his widesmileand straight look into your eyes that made you feel welcomedto hisattention.

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

    He was deep, funny, irreverent, lovable and infuriating, all inoneday. He was the brightest bulb in every group and knew it. Hehadvast energy, and his personal and professional agendas werealwaysway more ambitious than most mortals would or should takeon.He had enormous ego strength and self-confidence. If he thoughtanunproven or unconventional approach made sense for his patient,heforged directly ahead, full speed, against all resistance.

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

    I didn’t always agree with him, but I sure appreciated hispassion.I also appreciated that he did not mind if you disagreedwith himand I recognized that he sometimes went over the top justto sparksome movement. Just like when he flew his plane, he alwayswantedto be moving towards some goal and he hated getting boggeddownon technicalities.

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

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

    I remember his saying that the first thing he told peoplemovingto Minneapolis was to get a new Sears Diehard battery, nomatter

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

    I regarded him as a minor renegade with a sense of humor. Johnwasa real gentleman who occasionally liked to tilt atwindmills.

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

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

    LegaciesSeveral funds have been established inmemory ofJohnGates: 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, JohnR. Gates MD ProjectFund, 1600 University Ave. W., Suite 205, St.Paul, MN55104; and Minnesota ABC, Dr. John R. Gates Schol-arshipFund, 8761 Preserve Blvd, Eden Prairie, MN55344, attn: GardnerGay.

    Acknowledgments: Remembrances of John weregenerously submittedby the Minnesota EpilepsyGroup,members of theAmerican EpilepsySociety andits Board of Directors, David Anderson, Joan Austin,GregBarkley, Elinor Ben-Menachem, Martin Brodie,Helen Cross, RichardGilmartin, 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, JimRowan, Elson So, MikeSperling, Mark Spitz, and Bill Theodore.

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

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