Understanding Focal Cognitive Seizures: Thabo’s story

Meet Thabo

Thabo was 24 when he first noticed something was wrong, though “wrong” didn’t feel like the right word. There was no collapse, no shaking, no dramatic moment that drew attention. Instead, it arrived quietly, slipping into his everyday life.

He was sitting in a café one afternoon, laptop open, preparing for a presentation. The barista called out his name. Thabo looked up, fully aware, but when he tried to respond, nothing came out. He knew exactly what he wanted to say, Yes, that’s me, but his mouth would not cooperate. The words felt trapped somewhere between his thoughts and his lips.

A few seconds passed. Maybe ten. The barista called his name again, louder this time. Thabo finally managed a nod and walked over, heart pounding, embarrassed but confused. He told himself it was stress.

Over the next few months, similar moments kept happening. Sometimes he couldn’t find the names of ordinary objects. Once, while talking to a friend, he pointed awkwardly at a pen and said, “You know… that writing thing.” Another time, he heard his phone ringing but couldn’t make sense of the sound. He recognized it as noise, yet it did not register as a phone, or as something that required action.

The most unsettling episodes were the familiar ones. Occasionally, while walking down a street he had taken a hundred times before, he would be overwhelmed by a powerful sense that he had lived that exact moment already: every sound, every step, every breath. Other times, the opposite happened: his surroundings felt strangely foreign, as if he had been dropped into a replica of his own life.

Throughout all of this, Thabo remained aware. He could think. He could see. He could hear. But something very specific would go offline, briefly and unpredictably.

It wasn’t until a neurologist listened carefully to these details that Thabo heard the words that finally connected the dots: focal cognitive seizures.

Understanding Focal Cognitive Seizures

A focal cognitive seizure is a type of focal seizure that primarily affects a specific cognitive function at its onset. Unlike seizures that cause loss of consciousness or dramatic physical movements, focal cognitive seizures involve targeted disruptions in thinking, language, memory, perception, or awareness of meaning while many other mental functions remain intact.

The key feature is specificity. To classify a seizure as a focal cognitive seizure, the cognitive change must be out of proportion to other cognitive abilities. This is what distinguishes it from seizures where overall awareness is impaired. For example, a person may suddenly be unable to speak, yet remain fully aware of their surroundings and thoughts.

These seizures are considered a type of epileptic aura. An aura reflects the initial electrical disturbance in the brain and may occur on its own or progress into another seizure type, such as a focal impaired awareness seizure or a focal to bilateral tonic-clonic seizure. For some people, the aura is the entire seizure.

How Focal Cognitive Seizures Present

Focal cognitive seizures can take many forms, depending on which brain networks are involved. Because higher cognitive functions are distributed across specific brain regions, the symptoms often point toward the seizure’s origin.

Language-Related Cognitive Seizures

Some focal cognitive seizures affect language production or comprehension:

· Expressive dysphasia or aphasia: The person knows what they want to say but cannot get the words out, as Thabo experienced in the café.

· Receptive dysphasia or aphasia: The person hears speech but cannot understand it, despite being otherwise alert.

· Anomia: A specific inability to name objects, even familiar ones.

· Conduction aphasia: Difficulty repeating spoken language despite understanding it and being able to speak fluently.

· Dyslexia or alexia: A sudden inability to read or understand written words.

· Dysgraphia or agraphia: Difficulty writing, even though motor function is intact.

These seizures commonly involve the dominant hemisphere, particularly the parieto-temporal regions of the brain.

Memory and Familiarity Disturbances

Memory-related focal cognitive seizures can be subtle but deeply unsettling:

· Memory impairment: The person may be unable to retain memories formed during the seizure, even though awareness is preserved.

· Déjà vu: An intense feeling of familiarity, as if the present moment has already been lived.

· Jamais vu: Familiar surroundings suddenly feel unfamiliar or unreal.

These phenomena are often associated with temporal lobe involvement and are among the most reported cognitive auras.

Perceptual and Interpretive Changes

Some focal cognitive seizures alter how the brain interprets sensory information:

· Auditory agnosia: Sounds are heard but not recognized or linked to meaning, such as hearing a ringing without realizing it is a phone.

· Hallucinations: The brain generates perceptions without external stimuli, which may be visual, auditory, or involve other senses. These experiences can carry emotional weight, such as fear or suspicion.

· Illusions: Real stimuli are present, but their perception is altered, for example, sounds seeming distorted or objects appearing unfamiliar.

Importantly, these experiences occur without a generalized loss of awareness.

Higher-Order Cognitive Disturbances

Other focal cognitive seizures affect more complex thought processes:

· Forced thinking: Intrusive, repetitive, or crowded thoughts that appear suddenly at seizure onset.

· Dyscalculia or acalculia: Difficulty performing or understanding mathematical calculations.

· Left-right confusion: An inability to distinguish left from right.

· Neglect: Failure to attend to stimuli on one side of the body or space.

· Dissociation: A feeling of being disconnected from oneself or the environment while remaining aware.

Because these symptoms are not widely recognized as seizures, individuals may initially fear they are experiencing mental health problems or cognitive decline.

Why Focal Cognitive Seizures Are Often Missed

Focal cognitive seizures are frequently underdiagnosed because they do not match the public image of a seizure. There may be no convulsions, no collapse, and no obvious loss of consciousness. Episodes may last only seconds and resolve spontaneously.

People like Thabo may struggle to describe their experiences, especially when language itself is affected during the seizure. Others may normalize the symptoms, attributing them to stress, fatigue, or anxiety. In some cases, these seizures are misinterpreted as panic attacks, dissociative episodes, or attention problems.

Accurate diagnosis requires careful history-taking, sometimes with detailed questioning or cognitive testing early during a seizure. Descriptions from the person experiencing the seizure are often the most valuable diagnostic tool.

Diagnosis

The diagnosis of focal cognitive seizures is made by a medical specialist, typically a neurologist, using a combination of:

· A detailed clinical history

· First-person descriptions of seizure onset and symptoms

· Witness accounts, if available

· Electroencephalography (EEG)

· Brain imaging, when appropriate

Because these seizures involve specific cognitive changes at onset, identifying the first symptom is critical. If the cognitive feature appears later in the seizure, it is described as a symptom rather than used to classify the seizure type.

Treatment and Management

The primary treatment for focal cognitive seizures involves anti-seizure medications (also known as anti-epilepsy drugs). These aim to reduce seizure frequency and severity by stabilizing abnormal electrical activity in the brain.

When seizures do not respond adequately to medication, other treatment options may be considered, including:

· Dietary therapies, such as specialized ketogenic approaches

· Neuromodulation techniques, which use implanted devices to alter brain activity

· Surgical evaluation, in carefully selected cases where the seizure focus can be precisely identified and safely treated

Beyond medical treatment, education plays a crucial role. Understanding that these experiences are seizures, not personal failures or psychological weaknesses can significantly reduce anxiety and stigma.

Living With Focal Cognitive Seizures

For Thabo, the diagnosis was both frightening and relieving. It gave his experiences a name and a framework. He learned to recognize his seizures, explain them to people he trusted, and advocate for himself in professional settings.

Living with focal cognitive seizures often requires patience from the individual and from those around them. Because these seizures affect communication and thought, support and understanding are essential. Simple accommodations, such as allowing extra time to speak or clarifying instructions, can make a meaningful difference.

Most importantly, recognizing focal cognitive seizures validates the lived experience of people whose epilepsy does not look the way others expect it to.

Final Thoughts

Focal cognitive seizures remind us that epilepsy is not a single condition but a spectrum of neurological experiences. They challenge the idea that seizures must be visible to be real and highlight the complexity of the human brain.

By increasing awareness and understanding of focal cognitive seizures, we move closer to earlier diagnosis, better treatment, and reduced stigma for people like Thabo, and for many others whose seizures unfold quietly, within thought itself.

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