When most people think of seizures, they picture someone falling to the ground with violent shaking, the dramatic scenes we’ve seen in movies and television. While these tonic-clonic seizures (previously known as grand mal seizures) do occur, the reality is that many seizures look nothing like what Hollywood portrays. They are often subtle, easily missed, and can be mistaken for daydreaming or unusual behavior.

More than 3 million Americans have active epilepsy and approximately 150,000 Americans develop epilepsy each year. This can happen to anyone and at any age. They are not something to be embarrassed about and with proper treatment, whether medication or surgical intervention, many people with epilepsy live full, active lives. Recognizing when someone has a seizure is the first step in getting them the help they need.

Seizures are due to abnormal electrical activity in the brain. What a seizure looks like depends on where the electrical activity is starting and spreading. Here are some seizure types that one can look out for.

Absence seizures (staring spells)

These seizures usually start in childhood. The person suddenly stops what they’re doing, stares blankly, and becomes unaware of their surroundings. Repetitive movements such as chewing and lip smacking may be seen. These typically only last seconds, but can sometimes last longer. These seizures are often mistaken for daydreaming or inattentiveness.

Focal aware seizures

The person experiences unusual sensations, emotions, or movements they cannot control. They remain conscious and are aware of their surroundings during these episodes. The stereotyped nature of the episodes and the aura occurring before bigger seizures is often a clue that these are small seizures (not causing loss of awareness because of limited spread of the electrical activity).

Focal impaired awareness seizures

Similar to absence seizures, some people may suddenly stop what they are doing, stare off, and become unresponsive. They may have repetitive movements such as chewing, lip smacking, and fidgeting of the hands. Others can wander, answer questions, and even do certain activities but appear confused and have no recollection of these events (impaired awareness).

Generalized tonic-clonic seizures

These are the seizures portrayed in media; the person loses consciousness, falls, and has full body stiffening and shaking. The person may have symptoms of the other types of seizure beforehand. They may let out a groan or yell (ictal cry) as their body starts to stiffen. The most important thing to do is to make sure the patient is safe and follow the steps outlined below.

Atonic seizures (“drop attacks”)

These seizures usually start in childhood. The person suddenly loses muscle tone and collapses or drops their head. These happen without warning and can result in injuries from falling.

Myoclonic seizures

These seizures cause brief, shock-like jerks of muscles, which can involve any of the extremities. The jerks can cause people to drop objects and sometimes even cause buckling of the legs.

If you suspect someone is experiencing a seizure, here are simple steps you can take:

• Stay calm & time it: Note when the seizure happens, which generally lasts between 30 seconds and 2 minutes. A seizure lasting 5 minutes or longer is considered a medical emergency (status epilepticus) so if the convulsion is going beyond 2-3 minutes you should consider calling 911.
• Keep them safe: Move furniture or sharp objects away from the person. Gently guide someone to a seated or lying position if they are standing.
• Protect their head: Place something soft under their head.
• Turn them on their side: This will keep the airway clear from any saliva or blood that is coming from the person’s mouth.
• Stay with them: Someone experiencing a seizure may be confused afterward and even try to get up and walk away. Speak calmly to them, reassure them, and keep them safe.
• Never put anything in their mouth.

James Park, DO is a neurologist, epileptologist, and clinical neurophysiologist.

Hoag is a nonprofit, regional health care delivery network in Orange County, California, that treats more than 30,000 inpatients and 480,000 outpatients annually. Hoag consists of two acute-care hospitals – Hoag Hospital Newport Beach, which opened in 1952, and Hoag Hospital Irvine, which opened in 2010 – in addition to nine health centers and 13 urgent care centers.