Blog #56: Is It PTSD or Is It Non-Convulsive Epilepsy?

      When one is exposed to danger or highly stressful events the body naturally defends itself with a “fight or flight” mechanism to avoid harm. Post-traumatic stress disorder (PTSD) occurs when the fright and stress occur when the danger is no longer present. Combat is not the only precipitating factor. Other physical and emotional traumas can cause this form of mental stress: car and other accidents, child abuse, rape, muggings, etc. 

     PTSD symptoms include re-experiencing the stress-inducing situation in bad dreams, flashbacks and frightening thoughts. Angry outbursts, being easily startled, feeling tense and stressed without any obvious, immediate trigger, feeling guilty, depressed, worried, emotionally numb, avoiding places, events or objects that remind the person of the experience and not recalling the triggering dangerous event are all common symptoms of PTSD. But, there should not be a lapse in thinking; there should not be blanking out. These are not PTSD symptoms. These symptoms suggest non-convulsive epileptic seizures.

     Veterans returning home after various types of head trauma associated with combat and nearby explosions commonly return with symptoms suggesting stress. But, are these symptoms of PTSD or symptoms of epilepsy? Both are common after concussions and severe head traumas? Differentiating non-convulsive seizures from PTSD can be difficult, especially if doctors are not looking for them.

     Sudden brief loss of thinking and train of thought, sudden inappropriate stares and inattention, sudden emotional outbursts, sudden hallucinating metallic tastes and offensive smells―as burning rubber—are all symptoms of non-convulsive epileptic seizures; these can easily be misdiagnosed. This mis-diagnosis by primary-care physicians as symptoms of stress, especially in combat veterans, usually leads to psychiatry referrals. If the psychiatrists and other physicians aren’t looking for post-head trauma epilepsy the patient can be incorrectly labeled with PTSD and inappropriately started on medications that commonly makes epilepsy worse.

     Patients and their families should now be aware of how PTSD can be misdiagnosed because PTSD symptoms seemingly overlap to be confused with non-convulsive epileptic seizures.

 

 

 

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.

 

 

 

 

 

Blog #48: Post-Concussion Epilepsy Can Be Hard to Recognize

(This blog was originally posted on July 24, 2014)

 

Concussions are caused by a non-penetrating trauma to the head such as blows to the head and exposure to nearby explosions as in war. Symptoms of mild concussion include dizziness, blurry vision, vomiting, ear-ringing and tiredness. These may last a few minutes or continue for weeks or longer. More severe concussion results in loss of consciousness that can be followed by headaches, confusion (thinking as if in a fog), memory loss and depression. When neurons (brain cells) are injured during a serious concussion, epilepsy can develop.

          Epilepsy is defined as more than one seizure, even when they are separated by 5-10 years or more. They can be very subtle. These post-concussive seizures may not cause convulsive falling, jerking, tongue biting or incontinence that people commonly associate with epilepsy.

These subtle types of seizures are especially hard to recognize. The person may “blank out” or suddenly lose concentration for a few seconds days, months or even years after the original head trauma. Family and observers often dismiss this behavior or don’t even notice the sudden confusion, blank facial expression and cessation of speech, let alone think it might be a seizure.

Professional medical staff often misdiagnosis post-traumatic stress disorder (PTSD) when it actually is post-traumatic epilepsy. Very brief loss of contact with the person’s environment is the diagnostic clue. Loss of contact with surroundings by “blinking out” or short confusion and cessation of speech may be all that happens.

When psychiatrists evaluate people whose personalities seem changed the above symptoms may be the only clues that non-convulsive epilepsy, and not a psychiatric disorder, is the true problem. Since brain scans and EEGs can be normal in people with epilepsy neurologists are the most expert at sorting out the symptoms and giving the proper treatment.

 

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.

Blog #10: Is It a True Epileptic Seizure or a Faked, Psychogenic Seizure With a Psychological Cause?

(This blog was originally posted on September 23, 2011)

 

          Neurologists have long been aware of fake seizures. These are called pseudoseizures or psychogenic nonepileptic seizures. They can be involuntary due to psychological disturbances. They can also be voluntary-malingered faked seizures. These pseudoseizures occur in up to a third of patients evaluated in epilepsy clinics. One-third of patients who suffer from true epilepsy have additional pseudoseizures.

          Pseudo or false seizures are not originating from a brain abnormality that produces actual epileptic seizures. Diagnosing pseudoseizures can be very challenging. These feigned seizures can include self-injury with lip and tongue-biting and incontinence of urine and/or stool as we observe in true epileptic seizures. However, if an electroencephalogram (EEG) is attached to the person exhibiting gross seizure-type activity, e.g. jerks and vocalizations, the EEG will be normal, in contrast to a true epileptic seizure. The EEG is the most reliable way to make a correct diagnosis.

Patients exhibiting feigned, or pseudoseizures, tend to have significant emotional problems. Schizophrenia, hysteria and hypochondriasis are common diagnoses. Their psychogenic nonepileptic seizures tend to occur when other people are present and during times of heightened emotional stress when secondary gain is available. Whereas true epileptic seizures each tend to appear the same to an observer in any individual patient, i.e. they are stereotypical, psychogenic nonepileptic pseudoseizures manifest differently each time. Additionally, they can last many hours and end abruptly without any typical post-seizure confusion.

Recent studies confirm that psychogenic nonepileptic seizures are prevalent in US veterans. In the September 6, 2011 edition of Neurology, M. Salinsky, et al., reviewed patients who had been admitted to an epilepsy monitoring unit in Portland, Oregon’s Veterans Affairs Medical Center over a ten year interval. Their subjects included 203 veterans and an additional 726 civilians from an affiliated university. Twenty-five percent of the veterans and twenty-six percent of the civilians experienced psychogenic nonepileptic seizures. The correct diagnosis of psychogenic nonepileptic seizures was delayed an average of five years in the veterans versus one year in the civilians. The attending doctors probably did not challenge the epilepsy diagnosis because post-traumatic stress and mild brain injuries—definite conditions associated with epilepsy—are common among battlefield veterans.

  Veterans with psychogenic nonepileptic seizures tend to have higher rates of anxiety, post-traumatic stress disorder and chronic pain, as compared with veterans with true epileptic seizures. Civilians with psychogenic nonepileptic seizures usually attribute their seizures to a past head injury, usually mild ones.

 Psychiatric care can be helpful in treating psychogenic seizures, but success in minimizing or deleting them and stopping the anticonvulsive medications is not always achieved.

 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. DINGS is his first novel.