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The diagnosis
epilepsy
General conditions
Seizures which are not epilepsy
Single seizures (stress convulsions)
Low blood sugar
Fainting
Heart disease
Reduced blood supply to the brain
Migraine
Kinking of blood vessels
Dizziness
Narcolepsy
Abstinence seizures
Panic attacks
Psychogenic seizures (pseudo-seizures)
General conditions
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In order to reach the diagnosis epilepsy,
the doctor must combine all the information from the patient's
case history with the results of the EEG examination. In most
cases it is possible to decide if the person has epilepsy or is
suffering from something else. There will however still be some
people remaining perhaps with an uncharacteristic seizure description
or an uncertain EEG finding. Then it may be a case of giving it
time to collect further details of the seizures. If these occur
sufficiently often one tries to make an EEG recording of a seizure,
either as a cassette-EEG or as a video-EEG. These investigations
will nearly always make it possible to decide with certainty if
it is a case of epilepsy, or if the seizures have quite another
cause. It is very rarely the case that an epilepsy diagnosis can
neither be confirmed or denied.
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Diagnostic treatment
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In these cases one can chose to initiate
a diagnostic treatment. This means that treatment is started with
an antiepileptic drug on the assumption that the patient suffers
from epilepsy. If the seizures stop, it may be concluded, that
the person has epilepsy.
As previously mentioned, the diagnosis
epilepsy requires two or more seizures. It will therefore seldom
happen that treatment is started after a single seizure. Many
adults, may at some time in their lives experience a single seizure,
without having epilepsy (see below).
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Seizures which are not epilepsy
Single seizures (stress
convulsions).
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Many people will once their
lives experience a generalized convulsion. Typical provocative conditions
are stress, of physical or mental character, the intake of alcohol,
or lack of sleep. If they avoid coming into such a strained situation
again, most of these people will never have another seizure. Only
about one out of ten people will in the long run develop epilepsy,
that is to say, have repeated, unprovoked seizures. |
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Seizure threshold
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This situation shows that all
persons’ brains, if subjected to sufficient provocation, can react
by having a seizure. The threshold for how much provocation is needed
to trigger the seizure is different from person to person. It can
be exceeded in all cases, as long as conditions are extreme enough. |
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Low blood sugar
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A too low blood sugar can give
seizures which may resemble epilepsy. This condition can be caused
by diet or various drugs such as insulin. The symptoms often start
with the patient feeling unwell and tired. Anxiety and panic can
follow, accompanied by hunger and palpitations of the heart. The
face is pale, the pulse galloping and a sweat breaks out over the
whole body. The person's gait becomes unsteady, and his whole way
of behaving can change dramatically, with severe psychological symptoms
appearing. Finally there can be a reduction of consciousness, leading
to total unconsciousness and generalized or partial convulsions.
An acute blood test to determine the blood sugar levels gives the
correct diagnosis. |
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Fainting
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Fainting can sometimes resemble
epilepsy. If the attacks occur when the person is anxious, frightened,
has an unpleasant experience, or sees blood, it is clear that the
faint is of psychological origin. The symptoms consist of indisposition,
with blurred vision, buzzing in the ears, diminished consciousness
developing into a short period of unconsciousness. The pulse is
slow. Treatment consists of rapidly increasing the blood flow to
the brain. This can be done by putting the head between the knees.
Fainting can also occur standing still for a long time, or on standing
up suddenly from a sitting or lying position. When a person faints
he slides down without hurting himself. Jerks of the arms or legs
may be seen, which can cause those around to think that there has
been a convulsion. |
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Heart disease
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Some forms of heart disease
can bring about a sudden loss of consciousness. This is often caused
by a sudden disturbance in the heart's rhythm and a prolonged electrocardiogram
(ECG) will often provide the correct diagnosis. |
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Reduced blood
supply to the brain
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A reduced blood supply to some
parts of the brain can sometimes be caused by small blood clots
lodging in the finest blood vessels. Sudden paralysis of an arm,
sensory disturbance, blindness, confusion and twitching can occur.
The symptoms can disappear in the course of minutes or hours, but
can also prove permanent., in which case one calls it a stroke.
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Migraine
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Migraine causes one-sided sensory
changes with a feeling of numbness or "pins and needles" in the
face, or an arm or leg. There may also be hallucinations. An important
difference is that the symptoms in migraine take minutes to develop,
while in epilepsy they take only seconds. In some migraine attacks,
fainting, or sudden falling, without loss of consciousness, can
occur.
If a person with migraine gets the
typical migraine headache afterwards, it is easy to reach the
diagnosis. It is said that epilepsy is more common in persons
with migraine than one otherwise would expect. It could be because
the contracting of the blood vessels of the brain which is seen
in migraine, can cause a reduced blood supply to such a degree
that nerve cells die, leaving scars, as occurs after thrombosis.
The scar can, in time, cause epilepsy.
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Kinking of blood
vessels
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Cases are seen in the elderly, most
often in elderly women, where the person suddenly falls to the
ground. There is no loss of consciousness, except perhaps for
a fraction of a second. The person is awake again before she hits
the ground. Bruises, scrapes and even broken bones can result.
The attacks can be triggered off
by turning the head when crossing the street, or by looking upwards
at a bird flying, or simply by looking up at the top shelf in
a cupboard. The symptoms are caused by kinking of calcified blood
vessels and are difficult to treat.
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Dizziness
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It may be difficult to tell the difference
between attacks of dizziness and epilepsy. Attacks of dizziness
with a spinning sensation, nausea, vomiting, diarrhea and sweating
are often caused by diseases of the inner ear. The person will
often have suffered from deafness and "noises" in the ear for
months or years previously. In contrast to epileptic attacks,
these attacks can last for half an hour, or even many hours.
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Narcolepsy
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Narcolepsy is an illness sometimes
confused with epilepsy. It starts in late childhood or adolescence.
The main symptom is an irresistible urge to sleep. The person often
falls asleep in the strangest circumstances, even in the middle
of a conversation. He is easily woken, and feels refreshed. Many
of those affected also suffer from cataplexy, in which the head
suddenly falls forward, the mouth falling open, the knees sag and
the person may even fall to the ground, without loss of consciousness.
These symptoms are provoked by laughter, surprise, excitement, sorrow
or anger. Now and again a condition is seen in which the person
may be unable to move for seconds or minutes, just before falling
asleep or on waking. This illness should be treated with quite different
drugs to those used to treat epilepsy. |
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Abstinence seizures
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Alcohol
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If a person has drunk a lot
of alcohol over a long time and suddenly stops drinking for several
days, there will be a high risk of having a seizure. The seizure
will look like a generalized convulsion and cannot superficially
be distinguished from an epileptic seizure. On EEG the abnormal
discharges will disappear more quickly in the case of withdrawal
seizures than with epilepsy. Before the seizure other symptoms of
abstinence are present, such as sweating, tremor of the hands and
increasing restless and anxiety. If these symptoms are treated with
phenobarbital and diazepam, the seizures can often be prevented.
Seizures often occur when a person suddenly stops drinking. A period
of heavy drinking should either be gradually phased out, or the
person should take medicine for a short time when he wants to stop
drinking completely. |
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Medicine abuse
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A lengthy period of medication can
give the same type of abstinence seizures if the drug is stopped.
Sudden withdrawal of diazepam, clonazepam or sleeping pills of
the barbiturate type, can give convulsions.
On admission to hospital it is important
to give exact information about the medicine one usually takes,
The symptoms of medicine withdrawal can be seen for up to three
weeks after the medicine has been stopped. The larger the dose
has been, the more likelihood there is of convulsions occurring.
Seizures can be prevented by taking another drug with a long half-life,
usually phenobarbital.
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Panic attacks
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These start with rapid breathing,
triggered off by mental stress, anxiety or pain. The person has
a prickling or a numb feeling in the face, hands and feet, followed
by stiffness in the hands and feet. This is caused by a greatly
increased excretion of carbon dioxide, caused by the fast breathing.
This changes the body's acidity. The consciousness is slowly affected
and his arms and legs tremble. If he is made to breathe into a plastic
bag for a short while, the symptoms disappear quickly. Signs of
lack of oxygen, blue discoloration of nails and skin, should be
watched out for. The plastic bag should then instantly be removed.
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Psychogenic
seizures (pseudo-seizures)
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Psychogenic seizures are quite common.
They are seen both in persons with epilepsy and in the rest of
the population. The attacks are often triggered by an unconscious
desire for more care and attention. The person is conscious and
alert and flings his arms and legs about, as if he is having an
epileptic seizure. The movements are dramatic and appealing, and
they normally only occur when there are other people present.
The attack lasts longer than an epileptic seizure, and is not
followed by tiredness or urge to sleep. These people will often
have had other psychological problems earlier in their life. The
symptoms often occur quite unconsciously, only rarely are they
used to try to achieve something or other, in that the person
is clear as to what they are doing. Psychogenic seizures can be
seen in both children and adults.
It is rare that a person has these
epilepsy-like attacks without having experienced real epileptic
seizures, either his own or those of someone in his circle. The
attacks should be treated by a psychologist or a psychiatrist.
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