Confirm Epilepsy Diagnosis

Most patients with seizures are treated with antiepileptic drugs at some point before a diagnosis can confirm whether seizures are caused by epilepsy. Epileptic seizures are potentially more harmful than non-epileptic seizures and physicians, when uncertain of the diagnosis, usually treat for the more serious illness. If medication stops the seizures, they probably were epileptic. If not, then either the treatment needs to be changed or the diagnosis is not epilepsy.

Few physicians have access to the EEG and video monitoring facilities needed to distinguish non-epileptic seizures from epileptic ones. At this point, patients are often referred to an epilepsy center for further testing, such as the one we have at Cleveland Clinic. This is where the diagnosis usually is made.

For patients with medication-resistant seizures, patients may be subject to prolonged recordings in our Epilepsy Monitoring Units. At Cleveland Clinic one is dedicated to adults and another is located in our Children’s Hospital. These recordings may last several days and, thus, require hospitalization. Digital video recordings are done during these prolonged EEGs so that the data may be matched with symptoms and signs during a seizure.

Non-epileptic seizures are not accompanied by abnormal electrical discharges. They have been previously called pseudoseizures, but that term is misleading. These seizures are quite real, and people who experience them do not have conscious, voluntary control over them.

Non-epileptic seizures have no identifiable physical cause, but they are believed to be physical reactions to psychological stresses.

Non-epileptic seizures resemble epileptic seizures in outward appearance, even though their cause is very different. Nonepileptic seizures may appear to be generalized convulsions, similar to grand mal epileptic seizures, characterized by falling and shaking.

They also may resemble petit mal epileptic seizures, or complex partial seizures, characterized by temporary loss of attention, staring into space or dozing off. Many people experience non-epileptic seizures.

At Cleveland Clinic, we see between 100 and 200 patients each year with this condition. Most of our patients are between ages 20 and 40, but non-epileptic seizures can occur in both younger and older people as well.

Your neurologist may suspect non-epileptic seizures based on your medical history and the results of a physical examination, but additional tests will help to rule out other causes and confirm your diagnosis.

The most important factor in diagnosing non-epileptic seizures is to rule out the possibility of epilepsy. A final diagnosis of non-epileptic seizures typically is not made until all tests for epilepsy are found to be negative.

A routine 20-minute electroencephalogram (EEG) often is helpful in diagnosing epilepsy because it can detect the abnormal electrical discharges in the brain that indicate epilepsy. However, a negative EEG test by itself is not enough to establish a diagnosis of non-epileptic seizures.

The most reliable diagnostic test is to monitor a patient with a video camera and an EEG until a seizure occurs. This test requires the patient to spend time in a specialized Epilepsy Monitoring Unit (EMU). By analyzing the video and EEG recordings of a seizure, your neurologist can determine whether abnormal electrical discharges are present. If epilepsy is ruled out, other physical conditions that resemble seizures also may have to be excluded as possibilities.

These conditions include heart disease, stroke and fainting, as well as some sleep and neuromuscular disorders. If additional tests for these issues are negative, then a psychological assessment can help to finalize your diagnosis of non-epileptic seizures.

A diagnosis of non-epileptic seizures means that most patients can safely be taken off antiepileptic drugs. This is important because antiepileptic drugs can have harmful or even dangerous side-effects. Few patients with epilepsy have both non-epileptic and epileptic seizures. If you are diagnosed with both types, it is important that you and your physician know which are epileptic and which are not so that you can be treated accordingly.

Unlike epileptic seizures, non-epileptic seizures are not caused by physical disorders of the brain. Rather, nonepileptic seizures may result from traumatic psychological experiences or unusual stresses, sometimes even those in the forgotten past.

It has been known since ancient times that emotional or psychological stresses can produce physical symptoms in a person with no apparent physical illness. Almost everyone has blushed in embarrassment or been nervous and anxious as part of a “stage-fright” reaction.

Today, we know that more extreme emotional stresses can actually cause physical illnesses. In addition, some physical illnesses can be greatly influenced by psychological or emotional factors. Such illnesses are called psychosomatic, or mind-body, illnesses. Examples include forms of acne, allergy, angina (chest pain), asthma, headache, ulcer, obesity, rheumatoid arthritis and ulcerative colitis. Although psychosomatic illnesses have strong psychological components, their treatment is primarily medical.

Emotional stresses also can cause symptoms that resemble physical illnesses, but have no underlying physical cause. The medical term for these symptoms are somatoform, meaning they take form in the body. Examples include forms of paralysis, blindness and even the inability to speak. These disorders differ from psychosomatic illnesses in that both their causes and treatments are primarily psychological.

Non-epileptic seizures represent such a disorder. No underlying physical cause is known to be responsible. It is important to remember, however, that somatoform disorders, including non-epileptic seizures, are real conditions that arise in response to real stresses. Patients are not imagining or inventing these symptoms.

If your seizures are determined to be psychological in origin, you should not be ashamed or self-conscious of that fact. But, unfortunately you should recognize that your situation is poorly understood by many people, including some healthcare professionals.

As a result, some people, including loved ones, may try to blame you for having a psychogenic illness or for not getting better. You may even want to blame yourself. Such blame can be far more destructive than the non-epileptic seizures themselves.

A specific traumatic event — such as physical or sexual abuse, incest, divorce, death of a loved one or other great loss or sudden change — can be identified in many patients with non-epileptic seizures. Often the underlying trauma has been blocked from consciousness. Many patients can recall the event only with considerable support from a trained therapist. The unconscious processes that give rise to nonepileptic seizures also may cause or contribute to other conditions, such as depression and anxiety, which need to be identified and treated.

Non-epileptic seizures differ from other psychogenic disorders in one important aspect: Non-epileptic seizures can be shown with great certainty to be of psychological origin. With the appropriate tests, the accuracy of the diagnosis is comparable to that of diagnosing a broken bone with an X-ray. Such certainty is not possible for other psychogenic symptoms, such as pain, blindness or paralysis. This confidence in the diagnosis allows proper treatment to be given and greatly increases the chances of complete recovery.