Misdiagnosis of epilepsy
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7347.1219 (Published 18 May 2002) Cite this as: BMJ 2002;324:1219
Epilepsy care is deficient for both patients and doctors
- Richard Morton, consultant paediatrician
- Children's Hospital, Derby DE22 3NE
- Royal Liverpool Children's NHS Trust, Roald Dahl EEG Unit, Alder Hey, Liverpool L12 2AP
EDITOR—In their editorial on the misdiagnosis of epilepsy Chadwick and Smith seem to have missed the point.1 The diagnosis of epilepsy is often difficult and mistakes are often made (by specialists and non-specialists), so an improvement in epilepsy services is imperative.
As the editorial says, there are only a derisory 62 paediatric neurologists in the United Kingdom; even at the maximal rate of recruitment to this specialty it will be at least 15 years before an appreciable proportion of children with epilepsy have an opportunity of meeting such a specialist, let alone being treated by him or her on a continuing basis.
The most important improvement in epilepsy services will therefore come from better training for general paediatricians and physicians, together with more effective ways in which they can share their difficult cases with specialist neurologists, who are usually based in tertiary centres. In addition, epilepsy support services provided by trusts, including neurophysiology, need to be radically improved.
None of this was available to Dr Andrew Holton in Leicester, whom Chadwick and Smith mention in the editorial. In the review into his work by the British Paediatric Neurology Association he was noted to be a hard working and conscientious doctor.2 It recommended that he should be returned to his post after six months of retraining. He was no doubt upset to be failing in the management of several of his patients but was without sufficient training, was overworked, waited far too long for electroencephalography to be performed, and was isolated without having any specialist support available at regional level.
Like many patients, Dr Holton has become a victim of the deficiencies in epilepsy care in the United Kingdom for children and adults. We certainly need more specialists, but we also need better training for generalists and better support for us all.
References
Misdiagnosis occurs particularly in children
- Richard E Appleton (Richard.Appleton{at}rlch-tr.nwest.nhs.uk), consultant paediatric neurologist
- Children's Hospital, Derby DE22 3NE
- Royal Liverpool Children's NHS Trust, Roald Dahl EEG Unit, Alder Hey, Liverpool L12 2AP
EDITOR—The editorial by Chadwick and Smith on the misdiagnosis of epilepsy, although referring briefly to the misdiagnosis and mismanagement of epilepsy in children, clearly focuses on adults.1 The range of paroxysmal disorders occurring in children, which are often misdiagnosed as epileptic seizures, is far greater than that encountered in adults; they are more difficult to recognise and diagnose, particularly in children aged 10 and under.2 3
As Chadwick and Smith emphasise in the editorial, the diagnosis of epilepsy should be established on clinical grounds and based on a detailed witnessed account with or without the use of video recordings of the child's paroxysmal episodes. If it remains unclear whether the child is experiencing epileptic seizures, then epilepsy should not be diagnosed and the case should be discussed with a specialist who has a wider knowledge and experience of both the many different epilepsy syndromes and the other frequent paroxysmal disorders in childhood.
In the United Kingdom these specialists are paediatric neurologists, of whom there are fewer than one per million population. This number is wholly unacceptable, not just in addressing the needs of children with epilepsy and their families but also in supporting the needs of the paediatricians in district general hospitals, who tend to manage most of these patients and depend on their paediatric neurology colleagues for advice and guidance.
The editorial did not mention the role and specifically the misuse of electroencephalography in the misdiagnosis of epilepsy. Unfortunately, electroencephalography is often considered to be a definitive diagnostic test for epilepsy, but it rarely fulfils this perceived role. Furthermore, in many cases electroencephalography is undertaken and the scan reported by inexperienced and inadequately trained professionals who are unaware of the normal, maturational electroencephalographic patterns occurring in the first decade of life or the significance of specific abnormal patterns in electroencephalograms. Inadequate recording or inaccurate interpretation of the electroencephalogram, or both, contribute much to the misdiagnosis of epilepsy in children.
Children with epilepsy are being failed by the NHS, as are all children who have a neurological disorder and a neurodisability. As this letter is being read, somewhere in an outpatient clinic in the United Kingdom a child is being misdiagnosed as having epilepsy, being inappropriately investigated with electroencephalography, and being prescribed an unnecessary antiepileptic drug (probably in an inappropriate dose). The Leicester case cited by Chadwick and Smith is just one of many.