THE FIRST SEIZURE AND THE DIAGNOSIS OF EPILEPSY: IS REFERRAL TO A SPECIALIST NECESSARY?

Most referrals occur not because family doctors are uncertain as to whether a patient has had a seizure or not, nor because they are seriously concerned in every case about the possibility of serious underlying disease, but for the following reasons:

• People do not like being told they have had an epileptic seizure. One survey showed that this difficult task is left to the hospital doctor in about half the cases.

• People with epilepsy themselves very often feel that some sort of special test is necessary to ‘prove’ the diagnosis. It must be very difficult to accept the diagnosis, with all its social implications, when it is made on the basis of a 30-second description given to a doctor by a relative or bystander. Somehow it does not seem ’scientific’ enough, and yet paediatricians and neurologists place enormous weight on the recounted stories.

• People with epilepsy are very concerned to discover the ’cause’ of their epilepsy. A cause is often not found, but most people think in terms of a single cause, which they believe, if eradicated, will result in the problem being solved once and for all. Occasionally, of course, an important treatable cause is found, and usually special tests are indeed necessary to show this. The difficulty lies in deciding which patients should be so investigated.

• Traditional medical textbooks accentuate the unusual and ‘interesting’ causes of epilepsy, at the expense of the more usual patients. Family doctors, educated partly by these books, tend to play safe and refer if referral centres are available.

• The necessary decisions are quite complex. There are three possible preliminary

diagnoses—seizure, not seizure, and may be seizure; two policies about investigation—to be arranged or not; and four possible outcomes—treatment, no treatment, adoption of a

wait-and-see policy, and referral to another specialist. We do have some sympathy with our colleagues in primary care, when all these combinations are considered, and can readily understand why so many patients are referred.

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