THE FACTS-THE FIRST SEIZURE AND THE DIAGNOSIS OF EPILEPSY: OTHER CAUSES OF IMPAIRED OXYGEN SUPPLY TO THE BRAIN-SIMULATED SEIZURES
It might seem strange that anyone would wish to pretend to have an epileptic seizure, but in consultant practice this is one of the more common differential diagnoses to be considered. The great majority of such patients have some knowledge of epilepsy—either they have seen a relative with seizures, or more commonly they have had some true seizures themselves. Unless the true and suspect attacks are both seen by an expert, it may be impossible to sort out exactly what is happening. A doctor may be trapped into giving more and more anti-epileptic drugs for seizures which he believes to be out of control. Conversely if he sees one fit which he is quite sure is feigned, he may well wrongly believe all are feigned.
The points which distinguish a true and simulated seizure are the character of the convulsions, which are often not imitated very well. A colleague (David Marsden) has rightly remarked that they are ‘intensified by restraint and mollified by inattention’. Incontinence does not distinguish between true and simulated seizures as this can be, and often is, simulated. A normal EEG recorded during a generalized ‘seizure’ is virtually incontrovertible evidence of simulation. However, the records may be so technically marred by the patient’s thrashing around that interpretation is difficult. Combined video and EEG recording is often more helpful.
Psychiatrists, rightly or wrongly, draw a distinction between simulation of disease due to conscious malingering, for example, a man pretending to be sick to avoid conscription to the army, and unconscious hysteria, in which it is alleged that the simulation is the product of the unconscious mind. In each case some potential gain to the patient from the pretence is apparent. The gain in simulating seizures usually is to seek more attention. Rather than lay blame, doctors should regard these events as an indication that patients cannot cope with their life problems, and they should do their best to help and not to blame.
Finally, seizures may occur in a number of other, systemic illnesses or disorders such as hypoglycaemia (low blood sugar) (which may occur in treated diabetes mellitus if too much insulin is given); renal (kidney) failure; hepatic (liver) failure; respiratory (lung) failure; alcohol abuse and its withdrawal; and inborn errors of body metabolism. Finally, the potential effects of prescription or illicit drugs in precipitating seizures must always be considered.
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Tags: General health