A case of pseudoseizures.

Abstract: Pseudoseizures, historically described as hysterical seizures, closely resemble epileptic attacks. However, they lack the abnormal paroxysmal electrical discharges from the brain seen in epilepsy. Pseudoseizures may represent a dissociative coping mechanism in which anxiety is reduced by the appearance of the pseudoseizure. Psychotherapy is the mainstay of treatment for pseudoseizures.

Key Words: anxiety, epilepsy, pseudoseizures

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Case Report

A 45 year-old woman presented after a recent hospitalization for "stress seizures." Before hospitalization, the patient had been in her usual state of good health when she had a sudden episode of dizziness while cooking dinner. She felt a loss of balance and was unable to stand. She sat on the edge of a chair and slid off to the side. She could hear other people talking to her but could not respond. She did not shake. She also denied any tongue biting or bladder incontinence.

The patient was taken to a nearby hospital and en route had blurred vision. She underwent a computed tomographic scan of the brain and blood work, which were reportedly normal. She was released from the emergency room; however, her symptoms persisted. Several days later, she was hospitalized for 2 days and had magnetic resonance imaging of the brain and electroencephalography, which were reportedly normal. She was told she had "stress seizures" and was prescribed lorazepam. The patient had subsequent development of tremors throughout her body, with frequent jerking of her legs.

Her history was positive for hypertension and peptic ulcer disease. She denied any history of neurologic disorder, head trauma, or alcohol or drug use. She denied any form of psychosocial stress. Her medications included 50 mg daily of metoprolol succinate for blood pressure, and 150 mg daily of ranitidine for peptic symptoms.

On examination, the patient was a mildly obese, middle-aged woman with prematurely gray hair. She was well-dressed and well-groomed and appeared to be in no distress. She was accompanied by her husband, who was very anxious concerning his wife's condition. Vital signs were normal.

When the physical examination began, the patient had the onset of facial grimacing followed by a bowing back of the body into an arch. This was followed by thrashing of the arms and legs. The episode lasted several minutes, during which time she appeared to be unresponsive. There was no urinary incontinence, tongue biting, or postictal behavior noted. The neurologic examination after the episode was normal. The patient maintained that she was totally aware of her surroundings during the episode but was unable to speak.

The patient was given 1,000 mg of phenytoin and continued on the 1 mg lorazepam three times daily. An electroencephalogram with audio/video monitoring was obtained, during which the episodes were observed. No seizure activity was demonstrated, and the patient was diagnosed with pseudoseizures. Psychiatric consultation was offered; however, the patient declined. She later claimed that she was healed by God.

Discussion

Pseudoseizures have also been known as hysterical seizures, hysterical epilepsy, and conversion reactions. Although they closely resemble epileptic attacks, pseudoseizures are a psychologic illness, lacking the abnormal paroxysmal electrical discharges from the brain seen in epilepsy. The incidence of pseudoseizures is twice as frequent in women, and are more often seen in younger age groups.

In 1885, Gowers (1) developed 12 criteria for distinguishing epileptic seizures from pseudoseizures (Table). Gowers stated that in "hysterical" seizures "rigid fixation of the trunk and limbs alternates with wild movements in which the limbs are thrown about; the arms strike out, the legs kick, the head is dashed side to side." (1) Although Gowers's criteria are still applicable today, the use of simultaneous electroencephalography and audio/video monitoring have made diagnosis simpler.

In the mid to late 19th century, Jean Charcot, while at the Salpetriere, attempted to distinguish between the convulsions of women who were epileptics and those of "hysterics." Charcot observed that "hysterical" seizures had the following characteristics: "The patient looses consciousness and the paroxysm proper begins. It is divided into four periods which are quite clear and distinct. In the first, the patient executes certain epileptiform movements. Then comes the period of great gesticulations of salutation, which are of extreme violence, interrupted from time to time by an arching of the body which is absolutely characteristic; the trunk being bent bow fashion sometimes in front (emprosthotonus), sometimes backward (opisthotonus), the feet and head alone touching the bed, the body constituting the arch (are de cercle). During this time the patient utters wild cries. Then comes the third period, called the period of passional attitudes during which he utters words and cries in relation with the sad delirium and terrifying visions that pursue him ... Finally, he regains consciousness, recognizes the persons around him and calls them by name, but the delirium and hallucinations continue for some time ... Never during the course of these cries has he bitten his tongue or wet his bed." (2)

Physicians also observed that pseudoseizures lasted longer than epileptic seizures, and they occurred more commonly in the presence of a witness. Environmental stimuli could precipitate or affect the pseudoseizure. Patients could also follow commands and make eye contact during pseudoseizures. True tonic-clonic seizures also show a transient elevation in the serum prolactin level, which does not occur in pseudoseizures.

Neuropsychologic testing in patients with pseudoseizure found the highest incidence of pathologic scores in schizophrenia, hysteria, and depression. The difficulties in diagnosing psychogenic pseudoseizures are compounded by the fact that a significant proportion of patients with pseudoseizures also have epilepsy. Thus, it is not uncommon for patients with pseudoseizures to present on anticonvulsant medication.

The cause of pseudoseizures is puzzling. They may be a form of behavior precipitated by an internal stimulus, such as anxiety or an epileptic aura, and an external stimulus, such as stress. One theory has correlated conflict with pseudoseizure activity. A change in the level of consciousness can symbolize the need to remove oneself from the conflict--the dissociative component. The motor movement during the seizure fulfills the need to reduce tension and anxiety--the conversion component. (3)

After anxiety is reduced by the appearance of the pseudoseizure, the patient is indifferent to symptoms. He or she receives secondary gains during a seizure in the form of increased attention from observers. Dependence develops, which further reinforces the behavior. A sick role is created, which allows the patient to regress and reinforces the dependent role. (3)

Psychotherapy is the mainstay of treatment for pseudoseizures. Withdrawal from anticonvulsants is usually possible. The goal of psychotherapy is to relieve emotional stress and assist the patient in coping with future stressful events. Hypnosis has also been useful, by determining the precipitating cause of pseudoseizures and then abolishing it by hypnotic suggestion.

Table. Criteria for distinguishing epileptic seizures from
pseudoseizures

Description       Epileptic               Pseudoseizure

Apparent cause    Absent                  Emotional disturbance
Warning           Varies, but more        Palpitation, malaise,
                    commonly                choking, bilateral foot aura
                    unilateral or
                    epigastric aura
Onset             Commonly sudden         Often gradual
Scream            At onset                During course
Convulsion        Rigidity followed by    Rigidity or "struggling,"
                    "jerking," rarely       throwing limbs and head
                    rigidity alone          about
Biting            Tongue                  Lips, hands, or more often
                                            other people and things
Micturation       Frequent                Never
Defecation        Occasional              Never
Duration          A few minutes           Often half an hour or several
                                            hours
Restraint needed  To prevent self-injury  To control violence
Termination       Spontaneous             Spontaneous or artificially
                                            induced (water, etc)

Accepted June 5, 2004.

References

1. Gowers WR. Epilepsy and Other Chronic Diseases. New York, William Wood and Company, 1885, p 189.

2. Havens LL. Charcot and hysteria. J Nerv Ment Dis 1966;141:505-516.

3. Konikow NS. Hysterical seizures or pseudoseizures. J Neurosurg Nurs 1983;15:22-26.

RELATED ARTICLE: Key Points

* Pseudoseizures closely resemble epileptic attacks; however, they are a psychological illness, and lack the abnormal paroxysmal electrical discharges from the brain seen in epilepsy.

* Pseudoseizures occur twice as frequently in women.

* After anxiety is reduced by the appearance of the pseudoseizure, the patient becomes indifferent to symptoms.

* Psychotherapy is the mainstay of treatment for pseudoseizures.

J. D. Haines, MD

Private practice.

Reprint requests to Dr. J. D. Haines, 2310 West 7th Street, Stillwater, OK 74074. E-mail: [e-mail]