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Identifying and Treating Non-epileptic Seizures

George W. Culler, IV, MD

Sometimes people will experience episodes that present like epileptic seizures, even to emergency medical technicians and emergency room providers. This can lead to patients being misdiagnosed and being incorrectly medicated with anti-seizure drugs. On average, 25 percent of patients diagnosed with epilepsy, and not responding to medication, are found to be misdiagnosed. A 2007 study of 213 patients admitted to an Epilepsy Monitoring Unit discovered that 21 percent were experiencing non-epileptic events. These patients had been diagnosed with epilepsy and treated with anti-seizure medication for an average of nine years.

Medications to treat epilepsy can cause fatigue, dizziness, nausea, imbalance, abnormal liver function tests, low sodium and rarely, life-threatening rashes. It’s critical that people experiencing non-epileptic events do not take these medications. Proper identification, treatment and monitoring are vital to delivering effective care to epileptic and non-epileptic neurology patients.

Differences in causes, symptoms

Epileptic seizures occur because of abnormal electrical activity in the brain, which can be determined with electroencephalogram (EEG) scans. Patients with non-epileptic seizures will not have abnormal electrical activity on EEG. The diagnosis of non-epileptic seizures requires a comprehensive evaluation which includes: a complete medical, neurologic and psychiatric history, witness description of seizures and diagnostic testing (including the gold standard–video EEG monitoring to record the patient’s typical seizure).

Non-epileptic seizures can feature psychogenic or non-psychogenic episodes that mimic epileptic seizures. Psychogenic non-epileptic events (PNEE) can occur in patients with a history of anxiety, mood disorders, post-traumatic stress disorder (PTSD) and abuse (physical, emotional or sexual). These events are often differentiated from epileptic seizures when anti-seizure medications don’t help and episodes follow specific triggers like emotional events, pain, light and certain sounds–which is highly unusual with epileptic seizures.

Fainting is a common example of a non-psychogenic episode. Shaking, jerking and stiffening of the limbs is common after a fainting episode, and is often mistaken for epilepsy. Frequently there is an underlying physiologic cause like cardiac arrhythmia (irregular, slow or fast heartbeat), low blood pressure or an overreaction to a stressful situation (vasovagal response) that causes fainting. In addition, cataplexy (loss of muscle control triggered by strong emotions), complicated migraine headaches and paroxysmal movement disorder like dystonia (muscular spasms and abnormal posture) may all be misdiagnosed as epilepsy.

While they appear similar, trained neurologists can recognize subtle differences between the appearance of epileptic seizures and non-epileptic episodes. Signs of non-epileptic events include: stuttering, discontinuous (stop-and-go) activity, irregular side-to-side rolling, crying, pelvic thrusting and staying awake during the episode while moving limbs on both sides of the body.

Dedicated treatment required

Accurate diagnosis is critical for patients to receive proper care. Dartmouth-Hitchcock Medical Center (DHMC) has the only Level 4 Epilepsy Center in the region, treating an average of 250 patients each year in its Epilepsy Monitoring Unit, and thousands of outpatients from New Hampshire, Vermont, Maine and western Massachusetts. This provides patients the highest level of intensive neurodiagnostic monitoring, and support for underlying causes of non-epileptic episodes with specialized medical providers, psychologists, psychiatrists and social workers.

An Epilepsy Monitoring Unit stay allows neurologists to diagnose normal or abnormal electrical brain activity with EEG and video monitoring during patient seizures (providers can recreate typical episodic triggers for non-epileptic patients). Five to ten percent of patients are diagnosed with both epileptic and non-epileptic seizures.

Patients diagnosed with non-epileptic episodes who have been on anti-seizure medications are weaned off under their neurologist’s care. The underlying causes of the episodes are treated in tandem with the proper providers: such as psychologists, psychiatrists, social workers and primary care physicians who may prescribe appropriate medication (e.g. anti-anxiety or anti-depressants) and/or cognitive behavior therapy depending on the cause of the episodes. Regardless of the diagnosis, all seizure patients should be followed consistently by a neurologist to ensure positive outcomes.

For more information about non-epileptic seizures and how to recognize them, visit