Self-induction of seizures: the ultimate non-compliance.

The most extreme form of non-cooperation in the treatment of epilepsy is seen in those patients who deliberately induce their own seizures. The overwhelming majority of these patients are photosensitive and make use of visual stimuli to induce either overt seizures or 'sub-clinical' epileptiform EEG discharges. Best documented is the use of flicker produced by waving one hand in front of the eyes, but much more frequent, if less easily recognised, is the use of a manoeuvre involving slow closure and forced upward deviation of the eyes. This is exhibited by a quarter of patients with photosensitive epilepsy, many of whom report that the manoeuvre gives a pleasant sensation or relieves feelings of stress. Other forms of reflex epilepsy are used less often for self-induction and for a variety of motives. Often there is clear social advantage such as avoidance of school or gaining attention. Some patients find that the risk of a spontaneous attack is lessened following a self-induced seizure and can therefore contrive their fits to occur only in situations which are safe and convenient. Self-induced seizures are notoriously resistant to antiepileptic therapy even if the patient is compliant. Preliminary trials suggest, however, that in some patients dopamine antagonists may reduce this behaviour, apparently by making self-induced discharges or seizures non-rewarding.