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How to distinguish fits, faints and pseudo-epilepsy seizures

GP Dr Stefan Cembrowicz

asks consultant neuropsychiatrist

Dr Jonathan Bird how GPs can help patients with seizures and when referral is necessary

hat proportion of GP referrals to you for an apparent fit, black-out or other odd episode are true epilepsy?

In our fast-track epilepsy clinic, about 50 per cent of referrals actually have epilepsy. The majority of the rest are faints or vaso-vagal attacks. A small group of people have other physical problems, such as cardiac dysrhythmia. Occasionally people with the prolonged QT syndrome Romano-Ward syndrome have palpitations, feel very panicky and then black out. Small-print referrals such as carcinoid are diminishingly rare.

The other group that turns out

not to be epilepsy are psychogenic

pseudo-seizures of one kind or another, also known as non-epileptic attack

disorder (NEAD).

What's the best way for GPs to sift through these patients, to save unnecessary referral?

Take a careful history, both from the individual and also from any good witness to these episodes. Most witnesses will give a fairly good description of a true-blue tonic-clonic or grand mal-type seizure.

If the patient has had some sort of aura-like experience prior to black-out, with a convulsion, that clearly needs referral straightaway, and is usually fairly obvious as long as there's been a witness.

Flushing, feeling light-headed with sounds drumming in the ears, and a witness description from somebody who says 'he went terribly pale and then sort of crumpled' are usually vaso-vagal attacks.

Sometimes during vaso-vagal attacks, if the person is propped upright by friends, they remain relatively hypoxic and start twitching, which usually means that people drop them and they recover. Twitching and shaking are part of a relatively severe vaso-vagal attack, perhaps occurring in people who have just got up, or are going to the toilet, or are in a hot stuffy environment.

Those can generally be ruled out just by history taking unless there are additional complications or they're very frequent.

Cardiac dysrhythmias generally are easy to spot, unless you get a black-out with them, which is pretty rare. An ECG and basic blood tests are helpful before referral.

What's your order of investigations of such patients at secondary level?

I take the patient's and witnesses' history myself very carefully. The next investigation is an EEG.

An abnormal EEG makes it more likely that they have epilepsy and that it's worth treating because it's likely to recur. A single seizure with a normal EEG has about a 20 per cent likelihood of recurrence, whereas an abnormal EEG implies about an 80 per cent chance of recurrence. If it appears likely that the individual has had a true epileptic seizure, brain imaging, preferably an MRI scan (though in most places a CT scan is more easily available), should be carried out to exclude an intra-cranial lesion. And lastly, a thorough physical and neurological examination should be done.

Of the patients that you investigate, what proportion turn out to have psychogenic pseudo-seizures (NEAD)?

Some 20 per cent turn out to have psychogenic, non-epileptic seizures ­ seizures that are not epilepsy, not faints, are not due to some cardiac dysrhythmia or other identifiable physical cause.

They can present as panic attacks with some complication, or indeed as true psychogenic pseudo-seizures that look like true epilepsy. These are different in subtle ways and are generally regarded as being due to psychological disruption. One problem is that a person with epilepsy can also have pseudo-seizures.

What is the psychopathology behind NEAD?

Our understanding centres around the relatively Freudian view that it is an expression of some underlying trauma. A number of people with these attacks have suffered significant traumas or been sexually abused, but many haven't. The attacks may be understandable in terms of stresses and strains in their life, but it's not often easy to see why it has started at this particular time. Psychogenic pseudo-seizures can get very entrenched, and can become the habitual response of the individual under strain.

How do you recognise pseudo-seizures?

Superficially, they look like epileptic seizures. A surprising number, up to 50 per cent, will complain of some kind of aura ­ whether this is because stress is building up and they're feeling more anxious or some other reason is not known.

They will then appear to black out, although they are often more responsive to people around them than people in true epileptic seizures. Touching people in these circumstances often makes them a lot worse.

One diagnostic feature is that people in true epileptic seizures, even partial ones, generally have widely dilated and unresponsive pupils; people in pseudo-seizures have normal reactive pupils.

Seizures in non-epileptic attacks tend to be non-stereotyped. They tend to flail around with pelvic thrusting and thrashing about, rather than the clearly convulsive, bilateral seizure you see in a true epileptic attack.

What is the best way to manage patients with pseudo-seizures?

The most important thing is to recognise them as early as possible. Unfortunately, many people with pseudo-seizures have been diagnosed as having epilepsy, and are on often large amounts of medication.

Epilepsy surgery programmes regularly find a significant proportion who don't have epilepsy at all on investigation. As with all somatoform disorders, it is important to recognise these early on and to use every approach possible, both to reassure the individual but also to reduce their illness behaviour, to reduce the family's expectations, and to find some way out of the situation.

One approach we use with patients who have had pseudo-seizures for a long time is to video them and then demonstrate carefully, with discussion, what kind of attacks they're having and that their attacks are not actually epileptic.

Many patients' response is that we think they're mad or putting it on. It's very important to stress that we're not saying there's nothing wrong, and that they're doing it on purpose. Malingering in these circumstances is very rare ­ these attacks are expressions of some sort of habit of the mind and of distress.

Then we gradually reduce medication. If you reduce sedative medication people feel more in control of themselves.

At the same time we explore any traumas that may have arisen, using a cognitive behavioural approach.

It's worth trying to train patients' families to tackle these attacks. I call it observant neglect, so that people make sure nothing terrible happens, but do not leap in, holding them down, rolling them into the recovery position, putting things in their mouths and making a big drama out of it all. Reducing the amount of psychological distress among the family is very important too.

Does the older age group also present with psychogenic epilepsy?

A number of patients have their first non-epileptic or pseudo-seizures over the age of 60 or 65. These are often patients who have become depressed and are collapsing as they are simply unable to go on, psychologically speaking. Sometimes they find that, as they've got older, things that happened in their past have come back to haunt them, and they need to switch off from whatever memories are now emerging, so they collapse.

They find that if the collapses are fairly dramatic people are more likely to help them and to look after them than if they had just felt a bit faint for a while, which obviously a lot of older people do.

So the treatment is to determine whether they are depressed or not. Most younger people with pseudo-seizures are not depressed, but elderly sufferers are more likely to be so and that should be treated. Also any worries or distressing memories should be explored as well.

How many patients with pseudo-epilepsy will an average GP have on their list?

Most GPs will have about 10 patients with apparent epilepsy, but it is likely that one or even two of those may not have true epilepsy, or do have epilepsy but non-epileptic attacks as well.

The GP is in an excellent position to take the full and first history, both from the patient and from witnesses. The GP is also in a prime position to understand the patient's environment. A great deal can be done to reduce the amount of illness behaviour by understanding that, feeding that back to the patient and helping them to alter before they even get near a specialist.

How to distinguish fits, faints and pseudo-epilepsy seizures

Many patients with pseudo-seizures have been diagnosed with epilepsy and are often on large amounts of medication~

Neurology waiting lists are very long in some areas

How is the service for patients with possible fits being improved?

Clearly it is a priority that people with new-onset seizures should be seen as soon as possible. National and local guidelines indicate that a person with a first seizure should be seen at a specialist service in the first four weeks after referral, and preferably within two or three weeks.

Indicators for more urgent referral include: if the seizures are becoming very frequent, or if there is an associated neurological deficit which might suggest an intracranial or growing lesion, or that there's been a bleed. These are neurological emergencies, and a number of people with epilepsy also present with status or serial seizures.

People who present with a single seizure and have no others in the three or four weeks until their referral are less likely to have a serious neurological condition. Another problem is the waiting list for scans and EEGs, so even when they've seen a neurologist or neuropsychiatrist, there may still be a long wait for investigations.

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