begins in childhood, potentially impeding education, em-
ployment, social relationships and development of a sense of
self-worth. Prompt, accurate diagnosis with appropriate so-
cial and medical management will optimize the situation. A
family physician, in conjunction with a neurologist, can as-
certain (a) if the episodes represent epileptic seizures and
(b) if so, which epileptic syndrome they represent.
A harmonized partnership between family physician and
neurologist will facilitate the recognition and care of
epileptic disorders. As the role of the family physician in
the care of patients with epilepsy increases, the principles
delineated in this article will be ever more utilized.
pilepsy and stroke are the 2 most common neurologi-
cal disorders: at any one time 7 in 1000 people in the
general population have epilepsy. Epilepsy usually
Before determining whether paroxysmal events repre-
sent an epileptic disorder, one must consider 2 alternatives:
(a) nonepileptic events mimicking epileptic seizures (Table
1) and (b) true epileptic seizures caused by a nonneurologi-
cal condition (Box 1). Three conditions are common imita-
tors of epilepsy: syncope, excessive daytime sleep and pseu-
Table 2 lists several distinguishing manifestations of
syncope, which resembles a generalized tonic-clonic
(GTC) seizure in the middle of the attack but not at its on-
set or termination. Almost always while in an erect sitting
or standing position, the patient feels faint, vision may blur,
the face becomes pale, sweating may occur, and the patient
falls atonically with occasional bilaterally synchronous tonic
or myoclonic phenomena followed by rapid recovery, albeit
with fatigue. The principal differential diagnosis is a treat-
able cardiac arrhythmia, and this should be strongly sus-
pected if syncope-like attacks occur in other circumstances,
particularly upon exercise.
Excessive daytime sleep, as episodes of microsleep, oc-
curs in children at school and in adults; it superficially re-
sembles temporal lobe seizures or absence attacks. The pa-
tient stares without specific warning or appears inattentive;
automatisms may occur. Unlike seizures, episodes of mi-
crosleep can be reliably and instantly aborted with an affer-
ent stimulus. Evidence of sleep deprivation includes less
than 7 hours of sleep, hypnic jerks in drowsiness, frequent
dreaming, prominent snoring, morning arousal only with
stimuli, morning irritability, excessive caffeine intake and
prolonged sleeping on weekends.
Psychogenic nonepileptic events may be defined as “a
paroxysmal behavioural pattern mimicing epileptic seizures
and initiated by psychological mechanisms”.1Diagnosis de-
pends principally on symptomatology (Table 2). A physician
should suspect such events in any patient with an apparently
intractable cryptogenic “seizure disorder,” except in infants
or elderly people. Psychogenic events may mimic any type of
epileptic seizure and may occur as a pseudostatus epilepticus.
Distinguishing between psychogenic and frontal lobe epilep-
tic seizures may be difficult although the latter are shorter
and occur principally at night. Psychogenic events may su-
pervene in some truly epileptic patients. Electroencephalo-
gram (EEG) monitoring may be required. However, epilep-
tic seizures that arise from mesial or inferior cortical surfaces
may demonstrate no interictal or ictal EEG abnormality. At
the Epilepsy Programme in London, Ont., we have devel-
oped a system for identifying suspected psychogenic attacks
that consists of taking a detailed description of the attack, 24-
hour telemetered EEG recordings over 2–3 days and a clini-
cal psychological consultation including the Minnesota Mul-
tiphasic Personality Inventory-2 (MMPI-2). The MMPI-2
contains profiles of significant sensitivity and specificity for
anxiety, somatization and hysteria, components that predis-
pose a person to pseudoseizures. The evaluation concludes
with an interview with the patient, one or more close rela-
tives, the clinical psychologist and the neurologist.
An erroneous diagnosis of epilepsy carries serious conse-
quences. Missing a cardiac arrhythmia could be fatal. The pa-
tient could be unnecessarily exposed to side effects of
antiepileptic medications; this occurs principally in emergent
situations with pseudostatus epilepticus. Potentially treatable
psychiatric conditions could be overlooked. The patient could
unnecessarily lose his or her driver’s licence and occupation.
Diagnosis and management of epilepsy
Warren T. Blume
THIS ARTICLE CONCISELY DESCRIBES the more common epilepsy con-
ditions and will enable physicians to efficiently evaluate and
manage these disorders. Salient aspects of the history and exami-
nation, together with electroencephalography, will usually deter-
mine the epilepsy syndrome (category), forming the basis for any
further investigation and possible antiepileptic therapy. Imaging
may be required in some circumstances.
CMAJ • FEB. 18, 2003; 168 (4)
© 2003 Canadian Medical Association or its licensors
only equal or one-third greater among drivers with epilepsy
as compared with the general population,31this near equality
may have been achieved by the implementation of the
CMA’s guidelines. Risk assessment should include seizure
frequency and loss of awareness or other faculty during the
events. Legal responsibility for failing to report possibly in-
capable drivers is being placed ever more upon physicians.
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JAMC • 18 FÉVR. 2003; 168 (4)
This article has been peer reviewed.
Competing interests: None declared.
Dr. Blume is Professor, Department of Clinical Neurological Sciences, Epilepsy
and Clinical Neurophysiology, London Health Sciences Centre — University
Campus, London, Ont.
Correspondence to: Dr. Warren T. Blume, London Health Sciences
Centre — University Campus, 339 Windermere Rd., London ON
N6A 5A5; fax 519 663-3753; email@example.com