Strange Tastes, Smells, Sounds, Visions and

Feelings: Nonepileptic Events that Mimic Simple

Partial Seizures
Ross FineSmith, MD, Eric B. Geller, MD, and Orrin Devinsky, MD.
An accurate identification of epileptic seizure and epilepsy types is
necessary to provide optimal treatment. The physician must distinguish
between epileptic and nonepileptic events, and among epileptic events,
between partial (focal) onset versus generalized onset seizure types.
Further diagnostic evaluation helps determine the epilepsy syndrome,
localization (if focal epilepsy), and etiology. Partial-onset seizures may
begin with subjective phenomena or auras before progressing to loss of
consciousness. The earliest symptoms experienced presumably arise in or
near the epileptogenic zone, and provide significant clues in localizing the
epileptic focus (Table 10.1). Thus, great attention must be paid to these
symptoms, and the physician must carefully question the patient about
them. Unfortunately, the experiences created by epileptic seizures can
also be due to numerous other medical, psychiatric, and neurologic
disorders or may be found in people without any pathological process at
all.

Table 10.1Localizing Value of Simple Partial Seizure Symptoms

Location
Limbic

Lateral temporal
lobe

Occipital lobe
Parietal lobe

Symptoms
Olfactory
Gustatory
Epigastric
Mnemonic
Psychic-experiential
Auditory
Vestibular
Aphasic
Complex visual hallucinations
Visual hallucinations (usually unformed) and
illusions
Somatosensory (contralateral)
Visual
Distortions of body or spatial perception

Frontal lobe

Focal motor
Aphasic
Forced thinking
Cognitive disturbances
From: Chapter 10, Strange Tastes, Smells, Sounds, Visions and Feelings:
Nonepileptic Events that Mimic Simple Partial Seizures

Table 10.1
Localizing Value of Simple Partial Seizure
Symptoms.
This chapter reviews conditions that may be confused with simple partial
seizures (SPS). SPS are epileptic seizures, arising from one region of the
brain, which do not affect consciousness (1). "Consciousness" is a
problematic term to define precisely, and is operationally defined as the
"inability to respond normally to exogenous stimuli by virtue of altered
awareness and/or responsiveness" (1). An SPS without motor symptoms
has also traditionally been called an "aura." Aura is derived from the Greek
for "breath" or "breeze." Its original use in English was for "a gentle
breeze." In the seventeenth century, the aura epileptica was considered a
rising breeze that caused the seizure (2). Cullen (1827) first referred to the
aura specifically as a premonitory symptom in epilepsy and broadened its
scope to a sensation of something moving in the body towards the head
(2).
Electrographically, SPS begin in a localized discharge over the
corresponding area of cortical representation. These discharges are not
always recorded on the scalp. Indeed, one study with blinded reviewers
found that only 15% of nonmotor SPS were associated with an ictal
discharge on scalp EEG (3). The symptoms of an SPS may manifest as
any of the countless perceptions, sensations, and emotions our brains can

experience. Although we traditionally think of "positive" phenomena such

as a hallucination or sweating, SPS can also cause negative symptoms
such as a scotoma or diminished auditory acuity. These experiences are
divided into four main categories:

With focal motor symptoms (not further considered here)

With somatosensory or special-sensory symptoms: somatosensory,
visual, auditory, olfactory, gustatory, and vertiginous
With autonomic symptoms or signs (including epigastric sensation,
pallor, sweating, flushing, piloerection, and pupillary dilatation)
With psychic symptoms or disturbances of higher cerebral functions,
affecting language, memory, cognition, affect, complex
hallucinations, or illusions

As the electrophysiological epileptic seizure spreads and evolves over

time, the corresponding symptomatology may change. SPS may progress
into epileptic complex partial seizures (partial seizures associated with loss
of consciousness) and possibly secondarily generalized tonic-clonic
seizures, or they may even progress directly to the tonic-clonic seizure
without a complex partial phase. SPS also typically last seconds or a few
minutes, with the exception of the "aura continua" or simple partial status
epilepticus. The diagnostic key to recognizing SPS is the temporal
relationship to an event more clinically evident as an epileptic seizure. This
relationship is not always present or readily identified in people with
epilepsy. However, isolated auras or symptoms that suggest a SPS, but
are never associated with focal motor features or impaired consciousness,
are a red flag: they may not be caused by seizures. What is the likelihood
that someone with paroxysmal subjective symptoms has epilepsy? Ardila
et al. (4) surveyed 2,500 subjects in a general population sample for the
presence of episodic psychic symptoms. Although some subjects had
epilepsy (as might be expected in such a large group), many risk factors
for such feelings were identified, including head injury, car accident, febrile
illness, or birth injury. Significant correlations existed with other paroxysmal
conditions such as sleep disorders, migraine, and allergies. Holmes and
Dodrill (5) reviewed 379 adults who underwent video-EEG monitoring to
characterize subjective events. They found in this more highly selected
group that 52% had epileptic seizures, 7% had psychogenic nonepileptic
seizures (NES), 1% had both, and 40% had only subjective events. Thus,
nonepileptic causes of subjective events are very common and must

always be considered in the differential diagnosis.

Two case examples illustrate the diagnostic difficulties in clinical practice.

Case Study #1
A 25-year-old woman presented with a history of seizures since her teen
years. Seizures began with several minutes of confusion or cognitive
difficulty (but preserved responsiveness) before secondarily generalizing
into a tonic-clonic seizure. On careful questioning, she noted that she had
frequent, strong sensations of dj vu. On the basis of this history, the
diagnosis of partial epilepsy (probably temporal lobe) was made, but trials
of carbamazepine and other drugs were ineffective. Video-EEG monitoring
captured typical episodes: her periods of cognitive difficulty were actually
frequent, brief absence seizures with a 3-Hz generalized spikewave
pattern on EEG, which evolved to a primary generalized tonic-clonic
seizure. The dj vu spells had no EEG correlate. She became seizurefree after changing medication to divalproex sodium.

Case Study #2
A man in his 30s had a history of rare generalized tonic-clonic seizures,
usually occurring when he was off medication. He also complained of daily
episodes of difficulty thinking on awakening each day, diagnosed as
complex partial seizures. Trials of multiple antiepileptic medications
increased to toxic levels and did not alleviate these latter symptoms.
Video-EEG monitoring captured several typical spells: all occurred in the
early morning hours, on arousal from sleep, and none showed EEG
seizure patterns. The diagnosis of confusional arousal was made, allowing
significant medication reduction and elimination of both toxicity and
anxiety.
We approach the differential diagnosis of nonepileptic causes of SPS-like
phenomena by first broadly considering some common alternative
paroxysmal disorders, and then more specifically addressing the
symptomatology described in the ILAE seizure classification.

Contents
Nonepileptic Paroxysmal Disorders
Simple Partial Epileptic Seizures and Their Nonepileptic Imitators
Conclusion
References