Commentary: Consciousness of Epilepsy

The enormous practical importance of alteration and loss of consciousness in epilepsy is readily apparent. Terminology and academic understanding of these concepts are equally crucial because they inform clinical thinking. Drs. Lüders1 and Blumenfeld2 are to be commended for their vigorous analyses of the issues surrounding this nomenclature in epilepsy. Yet, the difficulty in explaining higher brain functions such as memory, learning, and language pales in comparison to the complexity in explaining consciousness and the conscious brain. The conscious life of a person comprises many types of subjective experiences, including visual, sensory, and internal body sensations, as well as mental imagery and a flow of occurrent thought. Consciousness involves telling you what it is like to be me and how things seem to me. As conscious beings, we not only notice things, but we notice that we notice. It is thus, a personal, private, and ineffable experience.3 Aspirant explanatory theories and constructs about consciousness abound. Building on John Hughlings Jackson's view of brain function as the product of increasing levels of evolutionary complexity,4 some researchers postulate a structural “communication plexus” that constitutes the essentially human dimension of consciousness.5 But the framework addresses more structure than phenomenology and does not attempt to explain how consciousness actually “feels.” Others conceptualize the problem in terms of what is in or what is out of the “stream of consciousness,” but the existence of such a linear stream is challenged by observations of gaps and discontinuity of perception under normal day-to-day circumstances.3 Some cognitive philosophers argue that the intrinsically “first person” experience of consciousness cannot be wholly assessed by “third person” observations.6 Neuroscientists have generally taken the view that the various components of consciousness can be scientifically explored and understood, thereby addressing the more yielding aspects of consciousness such as perception, memory, affect, and voluntary movement, but at the expense of overlooking important epistemologic issues.7 Do we have the correct approach to the nomenclature and understanding of consciousness in epilepsy? Some parallels could be drawn with the now-defunct concept of vitalism, that is, the notion that the functions of all living organisms are explained by a vitalistic, mysterious principle existing in all living creatures. That prominent experimentalists and deep thinkers such as Louis Pasteur, Marie François Xavier Bichat, and François Magendie staunchly defended this principle, illustrates how the study of difficult constructs—in this case the driving force of life—can lead to the protracted use of untenable concepts. Failure to find the vitalistic element eventually gave way to new scientific theories and understanding of the functions of living organisms, but the idea was not entirely abandoned until the first half of the 20th century. Is the modern epileptologist at risk of viewing consciousness as the ancient philosophers and erstwhile scientists viewed vitalism? As professor Pierre Gloor posited in 1986, could we be prisoners of “a linguistically formulated concept which has evolved to meet the needs of human social communication, [whereas] brain mechanisms do not embody linguistic concepts.”7 A further problem relates to how we assess impairment or loss of consciousness during a seizure in the clinical setting. This often relies on a historical account of whether patients recall what happens during an event, therefore inappropriately equating amnesia with unresponsiveness and unconsciousness. Moreover, most evaluations of consciousness in clinical practice entail verbal assessment of responsiveness—not of consciousness—and they should be referred to as such. It would seem that pursuing consciousness as a unitary concept in the nomenclature and classification of epilepsy and seizures does little to advance clinical discourse and understanding. Much could be gained if we eschewed the limitations imposed by linguistic constructs and focused instead on individual descriptive elements of seizure semiology. A descriptive approach would enhance communication and allow for empirical exploration of the function and structure associated with semiologic elements such as alertness, responsiveness, language, memory, subjective experience, and voluntary motor function. I have no conflicts of interest to disclose. I confirm that I have read the Journal's position on issues involved in ethical publication and affirm that this report is consistent with those guidelines. Dr. Samuel Wiebe is Professor of Neurology at the University of Calgary.

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