A Case of Pseudoseizures

J. D. Haines, MD

Disclosures

South Med J. 2005;98(1):122-123. 

In This Article

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 (arc 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.

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