Non-epileptic attacks – A common diagnostic challenge

Abstract

Misdiagnosis of children and adolescents with epilepsy is common and it is estimated to be 20–35% of patients diagnosed with epilepsy who are seen at epilepsy centers. The differential diagnosis of seizures is broader in children than in adults, with many nonepileptic but nonpsychogenic conditions to be considered. Physiological and organic events (syncope, hypoglycemia, panic attacks, paroxysmal movement disorders) predominate in infants and young children. Psychiatric disorders (psychogenic non-epileptic attacks) become more common in later childhood and adolescence. Other diagnoses, including parasomnias, self-stimulating behaviors (infantile masturbation), stereotyped mannerisms, hypnic jerks, parasomnias, tics, gastroesophageal reflux with posturing or laryngospasm, arousals, shuddering attacks, breath-holding spells (cyanotic infantile syncope) can be erroneously interpreted as seizures. Diagnosis of seizures should be clinical. Most errors in diagnosis are made because the EEG is overread as abnormal and is interpreted outside of the clinical context. Ambulatory EEGs can contribute to the diagnosis by recording the habitual episode and documenting the absence of EEG changes. The use of prolactin has little value. The gold standard for diagnosis of non-epileptic events is video/EEG monitoring. It is indicated in all patients who continue to have frequent seizures despite antiepileptics.