Misdiagnosis of epileptic seizures as manifestations of psychiatric illnesses.

Can J Neurol Sci. 2011 May;38(3):487-93.

Mirsattari SM, Gofton TE, Chong DJ. SourceDepartment of Clinical Neurological Sciences, The University of Western Ontario, London, Ontario, Canada Department of Medical Biophysics, The University of Western Ontario, London, Ontario, Canada Department of Medical Imaging, The University of Western Ontario, London, Ontario, Canada Department of Psychology, The University of Western Ontario, London, Ontario, Canada.

Abstract Background: Epileptic seizures may be misdiagnosed if they manifest as psychiatric symptoms or seizures occur in patients with known psychiatric illness. Methods: We present clinical profiles of six patients with epilepsy (three male, mean age 39 ± 12 years) that presented with prominent psychiatric symptoms. Results: Two patients had pre-existing psychiatric illnesses.

Three patients were initially diagnosed with panic attacks, two with psychosis, and one with schizophrenia. Five patients had temporal lobe epilepsy (TLE) while the sixth patient was subsequently found to have absence status epilepticus (SE). Cranial computed tomogram (CT) including contrast study was unremarkable in five patients and showed post-traumatic changes in one patient. Cranial magnetic resonance imaging (MRI) revealed dysembryoplastic neuroepithelial tumour (DNET) in one patient, cavernous hemangioma in one, and post-traumatic changes plus bilateral mesial temporal sclerosis in another patient but it was normal in two TLE patients.

Routine electroencephalography (EEG) revealed absence SE in one patient but it was non-diagnostic in the TLE patients. Video-EEG telemetry in the epilepsy monitoring unit (EMU) was necessary to establish the diagnosis in four TLE patients. None of the patients responded to medications aimed at treating psychiatric symptoms alone. Two patients required surgery while the other four required treatment with anti-epileptic drugs. All the patients had favorable response to the treatment of their epilepsy.

Conclusions: This case series illustrates that epileptic patients may experience non-convulsive seizures that might be mistaken as primary psychiatric illnesses. In this subset of patients, evaluation by an epileptologist, MRI of the brain, and/or video-EEG telemetry in an EMU was necessary to confirm the diagnosis of epilepsy if routine EEGs and cranial CT are normal. PMID: 21515510 [PubMed – in process]

2 Comments

  1. I was very happy to find this blog and intrigued by your article. I am the creator of the Anti NMDA Encephalitis in Canada/Encéphalite Anti NMDA au Canada support group. This illness which was only identified in 2007 by Dr. J. Dalmau and assosiates with Anti NMDA Receptor Antibody and also frequently associates with an underlying Teratoma Tumour. Many of those afflicted are first seen by psychiatrists due to psychotic symptoms. There is a danger that there could be misdiagnosis or underdiagnosis. I fear that there may be some that are languishing, over-medicated, when they could be helped. The aim of my group is to raise awareness as much as possible. My daughter may well have been the first diagnosed case in Canada. Testing for the antibody should be done as quickly as possible, and I believe that psychiatrists, if they have the least suspicion should order this test. This illness is devastating and catastrophic, even mild cases and can be lethal

    To date there have been 20+ cases diagnosed in Canada, but most likely there are more that are misdiagnosed.

    I urge you to read
    Clinical experience and laboratory investigations in patients
    with anti-NMDAR encephalitis in the Jan 2011 issue of The Lancet.
    Josep Dalmau, Eric Lancaster, Eugenia Martinez-Hernandez, Myrna R Rosenfeld, Rita Balice-Gordon

    Please help in spreading the word amongst your colleagues.

    1. Nesrin, Thank you for sharing this information and I will post the abstract/link to the Lancet on this blog. The reason why I put this blog together is the fact I suffered from toxic encephalopathy myself and was misdiagnosed by psychiatrists. Here is a link to a narrative I wrote for the Journal of Participatory Medicine regarding my circumstances:

      http://www.jopm.org/perspective/narratives/2011/03/28/psychosis-possibly-linked-to-an-occupational-disease-an-e-patient%e2%80%99s-participatory-approach-to-consideration-of-etiologic-factors/

      Advocacy is greatly needed to call attention to the many underlying medical conditions/substances that can induce psychosis and be misdiagnosed as bipolar disorder/schizophrenia. Currently there are no organized mental health advocacy groups that focus on improving the diagnositic accuracy of symptoms of psychosis to test for and treat underlying causes. It just seems like common sense.

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