Epilepsy Misdiagnosis: Identifying Syncope and Psychogenic Non-Epileptic Seizures

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• Common Epilepsy Mimickers
• Syncope vs Epilepsy
• Psychogenic Non-Epileptic Seizures
• Diagnostic Challenges
• Importance of Correct Diagnosis
• Full Transcript

Common Epilepsy Mimickers

Epilepsy diagnosis is often incorrect, with studies showing 20 to 40% of patients are misdiagnosed. Dr. Tracey Milligan, MD, emphasizes that many conditions present with symptoms identical to epileptic seizures. These are known as epileptic seizure mimickers. The most common misdiagnoses involve syncope and psychogenic non-epileptic seizures. Correctly identifying these conditions is essential for proper treatment.

Syncope vs Epilepsy

Syncope, or fainting from lack of blood flow to the brain, is a primary condition confused with epilepsy. Dr. Tracey Milligan, MD, explains that cerebral hypoxia during a syncopal episode can cause abnormal movements. These movements can appear identical to a tonic-clonic epileptic seizure. More seriously, cardiac arrhythmias can also cause sudden loss of consciousness that mimics a seizure. Missing a cardiac diagnosis can be life-threatening, as Dr. Anton Titov, MD, discusses with Dr. Tracey Milligan, MD.

Psychogenic Non-Epileptic Seizures

Psychogenic non-epileptic seizures (PNES) are another major cause of epilepsy misdiagnosis. Dr. Tracey Milligan, MD, describes PNES as a conversion disorder where psychological stress manifests physically. The patient is completely unconscious during these events, which are not under their conscious control. This condition is treated with psychotherapy, not anti-epileptic drugs. Dr. Tracey Milligan, MD, notes that up to 50% of patients in an Epilepsy Monitoring Unit may have PNES.

Diagnostic Challenges

Differentiating true epilepsy from its mimickers requires expert evaluation and advanced technology. Dr. Tracey Milligan, MD, states that video EEG monitoring is often necessary for a definitive diagnosis. This test records brainwaves during an event to confirm whether it is epileptic. The diagnosis of PNES can be particularly challenging because the events look so authentic. Dr. Anton Titov, MD, and Dr. Tracey Milligan, MD, agree that these events occur subconsciously, even under observation.

Importance of Correct Diagnosis

An accurate diagnosis prevents patients from receiving incorrect and potentially harmful treatments. Prescribing powerful anti-epileptic medications for PNES or syncope is ineffective and exposes patients to side effects. Conversely, failing to diagnose a dangerous cardiac arrhythmia can have fatal consequences. Dr. Tracey Milligan, MD, stresses that the goal is to help the patient get the right care for their specific condition.

Full Transcript

Dr. Tracey Milligan, MD: Seizures could appear in a very typical manner. It is tonic-clonic epilepsy. 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.

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.

Dr. Anton Titov, MD: What medical problems could mask themselves as epilepsy? 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 like the patient is having an epileptic seizure, but it is absolutely not an epileptic seizure.

It is what we call an epileptic seizure mimicker. Because when you look at the patient, it appears as if the patient is having an epileptic seizure. We can record the brainwaves at that time. We will see that it is not an epileptic seizure. It only looks like an epileptic seizure!

That is very important to know. There are 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.

Dr. Tracey Milligan, MD: They would cause a patient to lose consciousness or faint. 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 a 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 and looks like epilepsy. Patients look like they are having an epileptic seizure. Psychogenic non-epileptic seizure is also 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. Anton Titov, MD: Differential diagnosis must include syncope and psychogenic events.

For the psychogenic events, do patients usually have some control when epileptic seizure-like activity is initiated? This assumption has 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 an acute seizure-like event from happening.

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 the patient's control. Psychogenic epileptic seizures are 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. 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. 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 are a very severe manifestation of history of stress or current stress. 40% of patients with seizure diagnosis and on epilepsy medications have the 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.