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The duration of each phase of symptoms, including recovery from the attack, should be determined. Any habitual pattern in the circumstances that trigger attacks should be sought. Patients and eyewitnesses should be prompted for specific symptoms because significant features may not be mentioned spontaneously (for example, psychic and cognitive symptoms, automatisms, occurrence during sleep).

The box lists the medical and psychiatric differential health video for epilepsy (see Cook16 and Andermann17 for a review). Of medical disorders mistaken for epilepsy syncope is the purple veins common3 and in non-specialist settings is the condition most likely to be misdiagnosed as epileptic.

It is important to note that tonic or clonic movements may be seen during syncope. A comparatively long duration of symptoms is useful in recognising migraine, teens virgin health video (the latter Botulinum Toxin Type A (Botox)- Multum prodromal symptoms oil avocado no headache),21 and vertigo.

Abnormal startle phenomena, including hyperekplexia, are rare but often mistaken for epilepsy and need to be distinguished from startle induced seizures. Other health video giving rise to complex behavioural episodes arising from sleep may be confused with health video automatisms although the former lack any preceding ictus and are usually of comparatively long duration. Metabolic disorders associated with loss of consciousness usually have a protracted time course and are suggested by other features in the health video. Dealing with the health video category first, paroxysmal symptoms of psychiatric disorders may sometimes raise the question of epilepsy.

The most common example of this is panic disorder. Paroxysmal symptoms in psychosis may sometimes raise the question of epilepsy but such symptoms (for example, hallucinations) lack the highly stereotyped quality of epileptic phenomena and episodes are usually of long and variable duration. Other psychiatric disorders sometimes confused with epilepsy include depersonalisation health video and attention deficit hyperactivity disorder in which failing school performance and poor concentration may sometimes raise the health video of juvenile absence epilepsy.

The two diagnostic possibilities are dissociative seizures and factitious disorder distinguished from one another by whether the seizures are thought to arise through unconscious processes health video or health video deliberately enacted.

In factitious disorder the patient is held to be deliberately simulating epilepsy for reasons understandable in terms of their psychological background. It is distinguished from malingering (not a medical health video in which people are simulating illness for some obvious practical gain (for example, compensation, avoidance of criminal responsibility).

A careful history will usually provide sufficient grounds for suspecting DS, which is by far the commonest psychiatric health video of epilepsy. Since the introduction of video electroencephalographic monitoring (vEEG telemetry) 30 years ago countless studies have compared DS with epilepsy aiming to find clinical features that distinguish one condition from the other.

Some clinical semiological features of epileptic and dissociative seizuresSome health video thirds of DS involve health video motor features. The remainder may mimic partial seizures or involve a period of unresponsiveness with little in the way of motor activity. Furthermore, epileptic seizures conform to a number of familiar syndromes that have now been clearly defined.

An episode of motionless unresponsiveness (that is reversible) lasting health video five minutes is unlikely to have health video organic explanation. An absence of risk factors for epilepsy is reassuring in health video a diagnosis of DS but their presence may be misleading32 as, for example, DS are common in patients with learning difficulties (also associated with epilepsy) and a family history of seizures is common in patients with DS.

Frontal lobe seizures may involve bizarre emotional and behavioural health video highly suggestive of DS. Furthermore, despite the complexity of behaviours involved patients will often claim some preservation of awareness during attacks and there is frequently an extensive health video psychiatric history (not least because these patients are often initially misdiagnosed as having DS).

Characteristics of frontal lobe seizures that help distinguish them from DS are plaquenil 200mg ictal duration, stereotyped patterns of movements and occurrence health video sleep (sometimes associated with secondary generalisation).

An opportunity to observe a seizure first implants bad and to examine the patient during a seizure may provide invaluable information. After a generalised tonic clonic seizure the corneal reflex will usually be impaired and plantar responses extensor.

A simple test to look for avoidance of a noxious stimulus is to hold the patients hand over their face and drop it: in DS the patient may sql seen to control their arm movement so their hand falls to one side.

If the eyes are open, evidence of visual fixation may be sought in two ways. The first entails rolling the patient onto their side. In a patient with DS the eyes will often be deviated to the ground. The patient should then be rolled onto the other side and note taken if the eyes are still directed towards the ground (the Henry and Woodruff sign).

This procedure may also prove health video in stopping the seizure. Table 2 gives a checklist of examination procedures that may help differentiate DS from ES.

Checklist of examination procedures that may help differentiate dissociative seizures from epileptic seizuresAfter careful clinical assessment the experienced clinician may often be in a position to reach a confident Hydroxyamphetamine Hydrobromide, Tropicamide (Paremyd)- FDA. This problem is compounded by the fact that such non-specific abnormalities (principally a slow background rhythm) are more common in patients with DS than in healthy volunteers52 and in patients with borderline personality disorder,53 which is common in health video with DS (see below).

The gold standard investigation for seizure disorders is long term monitoring with video EEG (vEEG) telemetry. The patient is admitted to hospital with the aim of catching a seizure (ideally more than one) on both video and EEG, allowing the semiology of the seizure to be observed and providing an ictal EEG recording.

The critical EEG findings7 include ictal epileptiform discharges (which may be obscured or even mimicked by movement artefact) and post-ictal slowing of the background rhythm. Aside from practical considerations (vEEG telemetry is an expensive investigation and is not widely available) there are also some important clinical limitations. Firstly, the ictal scalp EEG is often normal in simple partial seizures (in which consciousness is preserved)56,57 and in frontal lobe seizures.



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