Page 191 - ILAE_Lectures_2015

Table 1. The differential diagnosis of epilepsy.
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A. Medical causes of paroxysmal neurological dysfunction

1. Syncope
- vasovagal
- cardiogenic

2. Neurological
- cerebrovascular
- migraine
- vertigo
- cataplexy
- parasomnias
- movement disorders
- startle-induced phenomena

3. Endocrine and metabolic
- hypoglycaemia
- hypocalcaemia
- hereditary fructose intolerance
- pheochromocytoma
- drugs and alcohol

B. Psychiatric disorders

1. Dissociative seizures
2. Psychiatric disorders that may be mistaken for epilepsy

- panic disorder
- psychosis
- attention deficit hyperactivity disorder
- depersonalisation disorder
3. Factitious disorder
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partial seizures that feature anxiety as part of the aura11,12. The cognitive symptoms of panic
disorder (specific feared consequences of the attack, such as a fear of choking, having a heart
attack, dying, losing control, etc), the presence of environmental precipitants (crowded
places, queues in supermarkets, etc) and the avoidance of such situations (agoraphobia) help
identify panic. The often unique subjective quality of ‘ictal fear’, abrupt onset without
environmental triggers and the presence of other epileptic semiology are useful in recognising
the epileptic origin of such symptoms in partial seizures. Very rarely, paroxysmal symptoms
in psychosis (hallucinations, thought block) may raise the possibility of epilepsy, and
attentional problems in a child may raise the differential diagnosis of attention deficit
hyperactivity disorder and petit mal seizures. An uncomfortable sense of unreality concerning
one’s self (depersonalisation) or the environment (derealisation) is not uncommon in
temporal lobe seizures. These symptoms may be the primary complaint in depersonalisation
disorder and are a non-specific feature of affective disorder and psychosis13. In psychiatric
disorder these phenomena are usually of relatively gradual onset, prolonged duration and
accompanied by other psychiatric symptoms. Overall, the abrupt onset, brief duration and
highly stereotyped nature of epileptic symptoms help distinguish them from functional
psychiatric disorder.