Introduction
This section is dedicated to the many thousands, probably millions, of people who still receive an erroneous diagnosis of epilepsy, even several years after the publication of the first edition of this book. It is a testament to the broad view of the editors that they have again allotted so much space to this topic, but it also reflects the recognition of the serious clinical issues that surround it.
Historical Perspective
The problem of patients with pseudoneurologic symptoms seen by physicians is as old as the history of medicine,2 and it became of special interest to neurologists around the end of the nineteenth century, notably with the works of Charcot. Patients with seizures have always been of special interest, so much so that the Salpêtrière school reserved a specific category for such attacks, denoted by the term hysteria major. For the first three fourths of the twentieth century, however, interest seems to have dwindled. Even those with a great interest in hysteria, such as Freud and succeeding psychoanalysts, wrote little about seizures, and the borderlands between epilepsy and psychiatry for a long time attracted little in the way of clinical or research interest. Things changed in the last quarter of the twentieth century (see Chapter 199), and with this renewed interest, the question of the misdiagnosis of epilepsy for symptomatically related syndromes, especially psychiatry disorders, was reborn.
Current Problems of Differential Diagnosis
The introduction of new techniques of investigating seizure disorder patients, but especially videotelemetry, led to the realization that many patients who at first sight appeared to have epilepsy and who were given that diagnosis along with prescriptions for anticonvulsant drugs with pronounced sedative effects in fact did not have epilepsy at all.
How frequently this problem occurs is hard to say. It has been estimated, however, that the attacks of up to 20% of patients attending clinics for chronic seizure disorders are nonepileptic in nature, but the epidemiologic studies on this vary, as reviewed by Kanner and colleagues in Chapter 282. The important point is that the figures are not going down with time, in spite of the growing clinical awareness of the problem. These patients often attend for many years, consume large amounts of antiepileptic drugs, and have huge social burdens that in part derive from having been given the label of “epileptic.” Why should these errors of diagnosis be so frequent? It is difficult to conceive of a medical diagnosis other than epilepsy that has such important consequences for the patient and that is so frequently incorrectly given.
The problems may be said to begin with terminology. If the words used by physicians are unclear, ambiguous, or misleading, then the concepts that relate to those words will likewise be obscured. The term pseudoseizures is popular, but it is problematic. The Oxford English Dictionary defines pseudo as “that which is false, counterfeit, pretended or spurious.” However, the seizures that are being discussed for the most part have none of these characteristics; they are real. They are experienced by patients, observed by bystanders, and thought about by physicians.
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