Thursday, January 22, 2015

Blog #49: Psychogenic "Fake" Non-Epileptic Seizures

(This blog was originally posted on August 27, 2014)
Experience shows that up to one-third of our patients in epilepsy clinics have involuntary, psychogenic, fake pseudoseizures. They resemble the patient’s true epileptic seizures; distinguishing between them can be very challenging.
Some of our “epilepsy” patients are misdiagnosed: they never had epilepsy to begin with. Close follow up may lead to clues that the seizures are not real, such as: poor seizure control in the face of repeatedly normal electroencephalograms (EEGs); varied physicality of the “seizures;” and they occur conveniently during emotional stress.
 Psychogenic “seizures” show no abnormalities on the EEG indicating that they do not originate in abnormal epileptogenic nerve cells in the brain. Highly sensitive EEG telemetry recordings with video pictures of patients in a hospital setting show this when patients exhibit their “seizure” activity. That pseudoseizures occur complicates care of our patients. Twenty to thirty percent of patients have poorly controlled refractory epilepsy; anti-seizure medications can’t prevent them. Neurologists must consider if the patient’s refractory seizure control could be due to involuntary, psychogenic seizures in addition to the patient’s true epileptic seizures or they do not have epilepsy at all.
So then, what is the problem? In most cases the patient is not consciously “faking” their seizures. Rather, underlying psychological problems and stresses seem to induce the “seizure.” These “seizures” could support the patient’s loss of control and augment his dependency in his life patterns without insight or understanding. This, in turn, relieves responsibility for his failings. He becomes a sick and dependent person satisfying his various psychological needs. This is called a “conversion syndrome.”
LaFrance and associates recently published a study on treatment of “refractory” seizure patients who had never showed EEG abnormalities during their “seizures.” They did not actually have epilepsy. A form of psychotherapy which his group calls “cognitive behavioral therapy,” reduced seizures by 51.4%; it also improved their quality of life, social interactions and reduction in depression and anxiety. This Cognitive Behavior Therapy is unique. It will be found in the researchers’ Taking Control of Your Seizures: A Workbook, to be published later in 2014 by Oxford University Press (1). This therapy emphasizes assertive communication. The patients learned to identify auras for their pseudoseizure so they could then act to avoid it. Some kept thought records so they could review their thoughts and moods from a different perspective. The researchers found that many of these patients had suffered abuse and trauma. This version of psychotherapy addressed their patients’ core beliefs. It helped people who felt victimhood to feel empowered and to take control of their “seizures.”
The longer the pseudoseizure condition exists without effective treatment the more difficult it is to control. Neurologists can improve psychogenic non-epileptic seizure-healing by suspecting it earlier. Ordering EEG video monitoring sooner, and which lasts hours to days after initiating care for a new poorly-controlled epilepsy patient, can reveal the true diagnosis. Then patients can discontinue their ineffective antiseizure medications and get into an effective psychiatric treatment program as identified above.
(1) LaFrance WC Jr, Baird GL, et. al. Consortium Multicenter Pilot Treatment Trial for Psychogenic Nonepileptic Seizures: A randomized clinical trial. JAMA Psychiatry, Epub 2014 Jul 2.
Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. DINGS is his first novel. It is a mother’s dramatic story that teaches epilepsy.

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