On the surface, epilepsy seems like an easy diagnosis to make—how could anyone miss a major event like a seizure? However, epilepsy can be deceiving. There are many types of seizures that are more subtle than the obvious tonic-clonic seizure, and many seizure types that look bizarre are misdiagnosed as nonepileptic. As a result, a large number of people with epilepsy experience lengthy delays before appropriate diagnosis and therapy provide relief. Conversely, there are many nonepileptic events that are easily mistaken for seizures, which lead to numerous misdiagnoses of epilepsy in nonepileptic patients. These patients are subjected to unnecessary treatment with toxic medications. In this article, I examine the range of diagnostic tests that can be used to establish a diagnosis of epilepsy, to help select the most appropriate form of therapy, to monitor and adjust therapy, to select appropriate surgical candidates, and to decide when therapy can be discontinued.

Epilepsy is common, but conditions that imitate epilepsy are even more common. In order to make a correct diagnosis of epilepsy, the clinician must carefully elicit a detailed history of the seizure episode. Realizing the overlap that exists between seizures that define epilepsy and those of other psychiatric conditions can also help in differentiating between epilepsy and an imitator of epilepsy. Deciphering the features of a seizure episode is also key to correct diagnosis.

In this article, the physiological and psychological imitators of epilepsy are described, as well as the features of a seizure episode that should be considered in making a diagnosis. Seizure presentations are also explained followed by a description of common diagnostic pitfalls to avoid.

People with epilepsy live and struggle every day with social issues that are relatively minor for people without epilepsy. Apprehension about securing and maintaining one's job or getting a driver's license is significantly greater for the person with epilepsy. Misconceptions held by the general public about epilepsy contribute to and often compound the difficulties and fears experienced by people with epilepsy. Because different people in society react to seizures in different ways, it is important to foster a supportive environment for people with epilepsy. This can be achieved by health care providers and families of people with epilepsy, who can help minimize the negative and inaccurate perceptions that are prevalent regarding people with epilepsy, and maximize their opportunities to integrate successfully into society.

Epilepsy in children and adolescents is associated with a higher rate of comorbid psychiatric disorders than other chronic childhood illnesses. This article describes various psychiatric disorders that occur in children and their effects on brain development, neurologic and intellectual function, and psychological adaptation for children and their families.

The risk of psychopathology is greater in persons with epilepsy than it is in the general population. This increased risk is related to a variety of factors including neurobiologic differences associated with epilepsy, medication-related effects, and disease-related psychosocial factors. Choice of appropriate psychoactive therapy must take into consideration effects on seizure threshold and potential interactions with antiepileptic drugs. Identification of psychopathology and effective treatment can reduce unnecessary morbidity in patients already suffering from a chronic disorder.