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.