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.

Blog #26: Children's Stories About Epilepsy

(This blog was originally posted on August 20, 2012)

                                   

 

          I recently found three colorfully illustrated books that will help children relate to their epilepsy and to better understand their unique circumstances. These books coach children who live with epilepsy on how to share and describe their symptoms with their families, teachers, schoolmates and friends. Some of these authors actually have epilepsy themselves or have the condition in their families which validates their insights.

          Karen’s Epilepsy, by Elizabeth Baltaro, is about a girl in grade school who has several seizures each week. Her usual seizure consists of walking around and making noises for several minutes while totally unaware of what she is doing. These complex partial seizures are poorly controlled despite anti-seizure medications. She fears telling new friends about her epilepsy. She is devastated when one of these seizures occurs in front of her classmates at school. They mock her and ostracize her. Karen’s knowledge about epilepsy and how to treat someone during a seizure leads to a surprise ending. Karen is accepted by her classmates and she becomes a hero at her school. The author wrote this book about her own unrecognized seizures that began at age nine. It was not diagnosed until more obvious tonic-clonic convulsive seizures occurred at age twelve. Elizabeth Baltaro is now a physician

          Growing up, Danielle M. Rocheford could find no books about epilepsy that were written for children, so she wrote Mommy, I Feel Funny! The book is about Nel, a young girl who experiences complex partial seizures and how her epilepsy is diagnosed. The seizures are confusing and frightening for her. This book features a sympathetic description of Nel’s symptoms and the MRI and EEG testing that she undergoes. Seizure warnings—the auras—are discussed including imagining smelling bad odors ( olfactory hallucinations) which are common when seizures originate in abnormal neuron cells in the brain’s temporal lobes. Her follow-up history notes that Nel continues to lead a full life, including having her own family. At age 27 her epilepsy was cured by brain surgery; she is seizure-free without antiseizure medications.

          The third book, Taking Seizure Disorders to School, is written by Kim Gosselin. Ms. Gosselin shows how a child can imagine a seizure as “sparks” in the brain. Illustrations accompany a school-age child’s descriptions of complex partial and grand mal seizures. The author also mentions antiseizure medications and their blood-test monitoring regimen. The importance of wearing Safety-Alert bracelets in order to aid their care by first-responders if they have a seizure is discussed. Epilepsy doesn’t stop the protagonist, Jaime, from doing anything other kids can do. She hopes doctors will one day find why she has epilepsy and discover a cure. Illustrations show her having fun roller skating wearing a helmet with knee and elbow pads.

          I found these books available for purchase at on-line bookstores.

 

 

 

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

 

           

Blog #24: You Witness a Convulsion. What SHould You Do?

(This blog was originally posted on June 29, 2012)

   

 

            You see it happen, or you hear a commotion. Someone has fallen. He is on the ground thrashing, and jerking, uttering strange animal-like moaning and groaning sounds. The eyes may be open and rolled back or squeezed shut. There is blood on the lips and teeth; long, expiring breaths blow out pink, blood-tinged bubbles. Breathing stops as rigidity is followed by jerking of the arms, legs and torso. The lips and skin assume a blue-gray hue as the person holds his breath.

            Is the person dying? Certainly something terrible seems to be happening. It is awful to watch, but not as serious as you think. Almost always, the jerking stops after one or two minutes. Then you hear a prolonged sigh as the muscles in the person’s jaw, limb and torso relax and breathing resumes. You see wetness as it’s common for involuntary urination and even bowel movements to occur from loss of bodily function control. Several minutes to an hour or more later the person awakens but is confused. His speech may be gibberish and nonsensical as his mind recalibrates and returns to normalcy. He is embarrassed to have caused this commotion. He is exhausted and groggy; he arises, collects himself mentally, and goes on his way. He’s done this before, probably many times before.

            What should you do happening upon the scene of an ongoing convulsion?

•           If there’s an opportunity to prevent injury at the beginning of the convulsion, protect the head and lower the person to the floor.

•           Turn him on his side so that any excess saliva or vomit will fall out of the mouth and not be breathed into the lungs, resulting in choking.

•           Loosen tight neck buttons, scarves and ties, etc.

•           Do not attempt to stick an object or your finger into the person’s mouth trying to prevent tongue-biting. If at the start the tongue is positioned in the mouth so as to be bitten there’s nothing you can do to prevent it. If the tongue is not bitten at the start, it won’t be as the jaws have already clamped shut. If you see blood on the lips, that is the explanation. No one swallows or bites off the tongue during a convulsion! It looks frightening but it’s not serious. The person will have a painful mouth; the laceration will heal in days.

•           The cessation of breathing and the blue-gray coloring is part of the convulsion. Breathing automatically restarts at the end of the jerking. There is no need to try mouth-to-mouth resuscitation.

•           The loss of bladder or bowel control is embarrassing, not serious.

•           Stay with the person until his senses and comprehension returns, usually after minutes to over an hour.

            If you know the person and you are aware of his epilepsy follow the above steps and wait out the jerking until the seizure “runs its course.” Calling for an ambulance is usually unnecessary. Help him home where he can sleep and rest. Family members of these patients are very familiar with this routine. Medical alert bracelets are often worn to alert by-standers that the person has been diagnosed and is under treatment for epilepsy. Treatment with medications completely controls seizures in only one-half of the epilepsy population. The rest will still have an occasional seizure despite the anti-seizure medications.

            If the convulsing person is unknown, has no companion and wears no medical alert bracelet then call an ambulance.

            If the convulsive jerking lasts more than three or four minutes without stopping, definitely call an ambulance. This represents a potentially serious and even lethal epilepsy complication known as status epilepticus. It results in lack of oxygen which leads to dangerous brain or heart damage or pneumonia.

 

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

 

 

 

Blog #19: Are My Symptoms Seizures or Migraines--or Both?

(This blog was originally posted on February 8, 2012)

 

Epilepsy and migraine are episodic conditions. Both manifest their specific symptoms in stereotypical fashion, i.e., each attack is usually just like the previous one.

• Epilepsy occurs in almost one percent of the American population, and in one percent of the world’s population.

• Migraine is seen in approximately fifteen percent of people; seventy percent of migraineurs are women. Five-eight percent of young children suffer with migraine; higher percentages of older children and teenagers are affected.

• Of patients with migraine, six percent also have epilepsy.

• Up to twenty-six percent of people with epilepsy also have migraine (1, 2, 3).

The two conditions share genetic changes that occur in specific chromosomes. This fact strengthens the theory that there are common genetic factors in epilepsy and migraine headaches. More research is needed, though, to document this relationship (4). The specific cause of migraine is not known.

 

People with epilepsy frequently experience warnings before their seizures. These warnings often consist of numbness, weakness or jerking in various body parts, vertigo and confusion. Visual changes can also be experienced, such as seeing flashing spots and lines, or objects that appear distorted and altered in size. These can be auras—the warnings of seizures—or the actual seizure itself. They typically last several seconds to minutes and are often followed by the post-ictal confused state and headache.

Some or all of these same symptoms are also experienced during a migraine. Confusion is not typical although transient speech impairment can occur. Furthermore, pain does not always occur in migraine. If just these other symptoms are experienced without headache, they are diagnosed as migrainous phenomena. A positive family history of headache is typical in migraine. In contrast, epilepsy is far less associated with a family history of seizures.

A colorful example of migraine-induced altered vision can be found in the nineteenth century novel, Alice’s Adventures in Wonderland. Its author, Lewis Carroll, reportedly suffered from migraine. In the novel, Alice became a tiny person who encounters a strange wonderland—probably a product of migrainous illusions.

Epilepsy and migraine don’t usually cause diagnostic changes on brain scans. However, specific abnormalities may occur in the electroencephalogram (EEG) in epilepsy that are not found in migraine. Differentiating the subtle symptoms of epilepsy from migraine can be very challenging for the clinical neurology specialist.

Of interest is the fact that certain anti-seizure medications are very useful in controlling both migraine and epilepsy.

 

1.      Bigel ME, Lipton RB. The epidemiology, burden, and comorbidities of migraine. Neurol Clin 2009; 27: 321-334.

2.      Marks DA, Ehrenberg BL. Migraine-related seizures in adults with epilepsy…Neurology 1993; 43: 2476-2483.

3.      Ottman R, Lipton RB. Comorbidity of migraine and epilepsy. Neurology 1994; 44:2105-2110.

4.      Polvi A, Siren A, et al. Shared loci for migraine and epilepsy on chromosomes… Neurology 2012; 78: 202-209

 

 

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