Pseudo-pseudo epileptic seizures: the challenging borderland.

day, nonspecific warnings, frequent occurrence out of sleep, brief seizures less than one minute, stereotypical attacks for individual patients sudden onset and ending, minimal or no postictal confusion, prominent complex motor automatisms, including sexual automatisms, complex vocalization, bizarre attacks that appear hysterical, and complex partial status epilepticus. The interpretation of the EEG results could also be a pitfall in the diagnosis. Patients with epilepsy can have a normal routine interictal scalp EEG. Normal ictal EEG is also seen in patients with simple partial seizures especially with auras of temporal lobe origin. In seizures originating in the medial or orbital frontal regions ictal and interictal EEG can be normal 12. Sometimes repeating EEGs by up to four times, can increase the yield by 90% in patients with confirmed partial epilepsy 13. Lieb et al 14 reported that seizures originating in the depth of temporal lobes may not have electrographic correlate on scalp EEG or that the changes could be bilateral synchronous. Williamson et al (1985) also reported ten patients with complex partial seizures with no appreciable change on their scalp ictal EEG and frontal lobe foci were only found after depth electrode studies otherwise they would have been mistaken for non-epileptic seizures. 5 Neuroimaging studies, positron emission tomography and single photon emission computerized tomography revealed medial temporal lobe abnormalities in patients with schizophrenia and seizures 15. Ultimately, continuous video/EEG recording allows observation of the clinical behaviour during an attack and correlation with the changes on the EEG. The presence of structural changes on MRI such as mesial temporal sclerosis or congenital abnormalities suggests the diagnosis of epileptic seizures. The diagnosis could yet be challenging in a subgroup of partial epilepsies. Allen Wyler et al 16 described the results of invasive monitoring in 12 patients with the diagnosis of pseudo epileptic seizures whose diagnosis could not be made with certainty on routine assessment. Six of these patients were diagnosed with complex partial epileptic seizures and underwent surgery. Three had frontal, two had temporal and one patient had bifrontal seizure foci. In the study published in this issue of the Journal, the authors reported six patients with epileptic seizures who were misdiagnosed as having psychiatric illness 17. Although it is true that physicians working in the epilepsy centres have advantage over the referring physicians because of the ability to record the attacks and perform electro clinical correlation, many of these errors could be …