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Seizures could appear in a very typical manner. It is tonic-clonic epilepsy. Dr. Anton Titov, MD. But epilepsy could be confused with other symptoms from other diseases. Presentation of some epileptic seizures could be very different from a typical tonic-clonic epileptic seizure. Dr. Tracey Milligan, MD. One UK clinical trial found that “20 to 30% of epileptics may have been misdiagnosed. Many of these patients have cardiovascular syncope. Their abnormal movements are caused by cerebral hypoxia. Several diseases may be difficult to differentiate from epilepsy on clinical grounds.” What medical problems could mask themselves as epilepsy? Dr. Anton Titov, MD. How to ensure that the differential diagnosis in suspected epilepsy is done correctly? Dr. Tracey Milligan, MD. Yes, absolutely! Syncope is one of the most common problems that is misdiagnosed as epilepsy. Patients may lose consciousness due to lack of blood flow to the brain. It can look that patient is having an epileptic seizure. But it is absolutely not an epileptic seizure. It is what we call a “epileptic seizure mimicker”. Because when you look at the patient, it appears as if patient is having an epileptic seizure. We can record the brainwaves at that time. Dr. Tracey Milligan, MD. We will see that it is not an epileptic seizure. It only looks like epileptic epileptic seizure! That is very important to know. There is so many reasons that patients can lose consciousness or faint. Some of those are very benign causes. For example, the sight of blood can cause a person to lose consciousness. Some patients might faint. It could look like they are having an epileptic seizure. They could mimic it. Dr. Anton Titov, MD. But there are other more serious causes. They would cause a patient to lose consciousness or faint. Dr. Tracey Milligan, MD. For example, a cardiac arrhythmia could lead to death. We wouldn’t want to miss that. It is treated very differently. But cardiac arrhythmia can really mimic an epileptic seizure. Loss of consciousness due to heart rhythm problem can look exactly like an epileptic seizure. Another really common misdiagnosis for epilepsy is what we call a psychogenic non-epileptic seizure. These happen when patients are having a “conversion disorder”. psychogenic non-epileptic seizure causes a patient to be completely unconscious. But it is a result of some internal stress, a history of stress. Conversion disorder manifests looks like epilepsy. Dr. Tracey Milligan, MD. Patients look like they are having an epileptic seizure. Psychogenic non-epileptic seizure also is treated very differently. It is treated with psychotherapy. Conversion disorder is not treated with powerful anti-epileptic medications that we have. Psychogenic seizure sometimes requires video EEG monitoring to make the correct diagnosis. Because it can look so much like an epileptic seizure. There are some patients who have a diagnosis of epilepsy. But anti-epileptic medications are not working for these patients. It is really important then to consider these mimickers of epileptic seizures. Dr. Tracey Milligan, MD. Differential diagnosis must include syncope and psychogenic events. Dr. Anton Titov, MD. For the psychogenic events, do patients usually have some control when epileptic seizure-like activity is initiated? This assumption has a perhaps some significance. When patients are being monitored, they probably might not have an epileptic seizure-like event. Because they know that they are being monitored. Or there are some psychological triggers that prevent acute seizure-like event from happening. Dr. Anton Titov, MD. How does it work with the “psychogenic epileptic seizures”? Dr. Tracey Milligan, MD. Yes, I think many patients have a very hard time understanding psychogenic epileptic seizures. But psychogenic epileptic seizures are completely subconscious. They are not under patient’s control. Psychogenic epileptic seizures is not something somebody is doing purposefully. So for that reason we do see them in our Epilepsy Monitoring Unit. It is an important diagnosis to make. We really care about making a diagnosis of psychogenic non-epileptic epileptic seizures. We hope to help the patient get better. Dr. Tracey Milligan, MD. It is not something in their control. 50% of the patients that we see in our Epilepsy Monitoring Unit have psychogenic epileptic seizures. Every person has a different method to physically manifest stress. We may not even experience stress. Dr. Anton Titov, MD. We may not even be able to say that we have some stress. But it will come out in a physical problem. Psychogenic epileptic seizures is a very severe manifestation of history of stress or current stress. 40% of patients with “seizure diagnosis” and on epilepsy medications have wrong diagnosis. They often do not have epileptic seizures. It takes expertise to diagnose people with apparent epileptic seizures correctly. Psychogenic epileptic pseudo-seizures and heart conditions could mimic epileptic seizures exactly. It includes arrhythmia, vaso-vagal syncope. Leading complex epilepsy treatment expert.