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Glenn Yank, MD is a Psychiatrist located in Tennessee.


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Question:
I am requesting additional information on pseudoseizures. My son was diagnosed with epilepsy after becoming ill with viral encephalitis. He takes medications and has had a right temporal lobectomy. Before the surgery, we were constantly in ER, after a call from school, never from home. Some of the attending physicians explained to me that what had occurred was not a real seizure. I have been struggling with this situation for three years. He has been dismissed from one school and it looks like it is about to happen again. He is 16 years old. My husband and I are divorced and his father doesn’t spend much time with him. I have taken him to five different counselors in four years. Do you have any suggestions? It is ruining his life and mine. Thank you. Paula1295

Answer:

The subject of Nonepileptic Seizures or Psychogenic Pseudoseizures, which are two of several names for the same phenomenon, is a complex one. Let me start with definitions. Nonepileptic seizures have been defined as “paroxysmal events that alter or appear to alter neurologic function to produce motor signs or sensory, autonomic, or psychic symptoms that at least superficially resemble those occurring during epileptic seizures” (Vossler, 1995). Paroxysm means a sudden, uncontrollable attack. The emphasis in this definition, therefore, is that the event occurs all of a sudden and dramatically, is outside of the person’s control, and shows symptoms that resemble those of a true seizure. However, the cause of the event is not an electrical abnormality in the brain, as in true epilepsy.

The phrase “psychogenic pseudoseizure” emphasizes more that this is a psychiatric conversion disorder, and has factors in common with other conversion disorders. These common factors include occurring or worsening when the person is under stress, and that the symptoms are not produced consciously or intentionally.

An interesting discussion of what to name this disorder can be found at: http://www.pni.org/neuropsychiatry/seizures/epilepsy/pseudo_seizure.html.

Making this subject even more complicated is that Nonepileptic Seizures can occur in patients who have or have had real epilepsy, as is the case with your son. Studies of this comorbidity show quite variable results, ranging from 4-58%, but rates of 22-24% have been found in patients with medically refractory epilepsy undergoing video-EEG monitoring. In other words, almost a quarter of people with documented epilepsy also had seizures during which their EEG was normal. On the other hand, one standard EEG will be normal in about 50% of people with real epilepsy, which is why 24 hour monitoring studies are sometimes needed to make a diagnosis.

Also, there is great overlap in the clinical features of epileptic and nonepileptic seizures, making them very difficult to tell apart for observers. Unusual phenomena during a seizure or “spell” are not in themselves diagnostic of nonepileptic seizures, since patients with frontal and temporal lobe seizures can have rather bizarre symptoms. The features of nonepileptic seizures may vary more from one episode to another, compared to epileptic seizures, which are usually quite stereotyped for each individual. There are some characteristic, subtle differences that are seen in noneptileptic seizures compared to epileptic seizures, that may point the diagnosis in this direction, although they do not establish the diagnosis with certainty. Some more common features of nonepileptic seizures are that:

  • An audience is usually present – they seldom happen when the patient is alone.
  • Nonepileptic are seldom sleep related.
  • Nonepileptic seizures are often triggered by stress, but this can occur in epilepsy, too.
  • The patient usually retains ability to avoid painful stimuli or harm, nonepileptic seizures seldom occur while a person is cooking or driving.
  • Non epileptic seizures seldom result in injury.
  • Incontinence is rare.
  • Nonepileptic seizures often start and end gradually, rather than abruptly.
  • Jerking movements of the extremities are not coordinated, as they are in epilepsy.
  • The autonomic system not involved (changes in blood pressure, pupil size, skin color).
  • Cyanosis (skin turning blue from lack of oxygen) and pallor are rare.
  • Postictal (after the seizure) features of clouded consciousness and disorientation are minimal, compared to epilepsy.
  • There is little or no amnesia for the event.
  • Jerking movements tend to increase if the person is restrained.
  • Reflexes are not changed after a nonepileptic seizure, whereas they are increased after an epileptic seizure.

People who have nonepileptic seizures usually have some kind of “model” on which the nonepileptic seizure is based, either a past epileptic seizure that the patient has had, or a seizure that they have witnessed. They then unconsciously “learn” to show this model of behavior when very stressed or otherwise “triggered.” I emphasize “unconsciously” because nonepileptic seizures are not produced consciously or deliberately. The are not faked or feigned.

Previous childhood sexual and/or physical abuse, or other trauma has been associated with conversion disorder, including nonepileptic seizures. Theories linking nonepileptic seizures to trauma include that such seizures can be a reaction to flashbacks, or that seizures can be symbolic re-enactments of trauma, as can other conversion symptoms.

Treatment of nonepileptic seizures, like the treatment of other conversion disorders, requires first and foremost development of a caring therapeutic alliance. Of note, according to Kaplan & Sadock’s Comprehensive Textbook of Psychiatry, “what seems to be least likely to be effective is trying to get the newly afflicted patient to accept the therapist’s opinion that the somatic symptom is a direct manifestation of a psychosocial problem (e.g. that the physical disability is the representation of a psychiatric problem).

It is not helpful to argue with the patient about the cause of the conversion disorder” (Seventh Edition, pp. 1513-1514). Such arguments are stressful for the patient, and therefore likely to cause an increase in symptoms! More useful is to educate the patient to the concept that some of their seizures may be nonepileptic, which the comorbidity data supports, and that in either case (nonepileptic seizures or epileptic seizures) the seizures are more likely when the patient feels very stressed. Thus, it will help decrease the frequency of seizures to exam the stresses in the person’s life, and help them learn better coping skills to address these stresses.



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