Pseudoseizures vs. Seizures
The title says it all: Ictal eye closure is a reliable indicator for psychogenic nonepileptic seizures.
First, the bottom line:
50/52 patients with pseudoseizures closed their eyes during their "seizure," while 152/156 of actual epileptics opened their eyes during their seizures. That's a sensitivity of 96% and a specificity of 98%. That's gold.
Now, the details:
The authors took 234 consecutive "seizure" patients, hooked them up to video EEGs and stopped their medications. There were 938 total ictal events in 221 patients. 52 (23%) had pseudoseizures, and 156 (70%) had eplieptic seizures. There was a 3:1 female predominance in the pseudoseizures, no difference in epileptics.
In the epileptics, there was rhythmic eye blinking during tonic-clonic activity, and the eyes closed after theseizure was finished.
An interesting corollary to this is when pseudoseizures occur in an actual epileptic: quoting the authors, "the simple question of eye opening or closure can help differentiate between the two types of events. One previous study found that patients with both types of events tended to have their eyes closed during PNES and open during ES.(6)"
Outstanding.
Of course, this is isn't going to mean much to psychiatrists, apparently.
A questionnaire was put to neurologists (N=39) and psychiatrists (N=75) about the utility of video EEG in diagnosing pseudoseizures. 70% of the neurologists, but only 18% of the psychiatrists, thought that video-EEG was accurate "most of the time" in diagnosing pseudoseizures. 12% of the psychiatrists (no neurologists) said it is accurate "almost never." (3% of the psychiatrists gave no clear response. Why doesn't that surprise me?)
So here are some other differentiating symptoms:
In seizure patients, there is a crescendo-decrescendo quality to the spike-wave frequencies on EEG. In pseudoseizure patients, however, the frequency is the same from beginning to end, and it comes on suddenly as if a switch was flicked. The spike-wave on EEG is actually motion artifact, and typically runs around 4 Hz, while epileptics have frequencies that vary between 4-25 Hz.
In a study of 40 pseudoseizure vs. 40 matched normal controls, the pseudoseizure group had more left handers, reduced strength and speed in both dominant and non-dominant hands, and reduction in the dominant hand advantage in strength and speed (i.e. both hands performed equally badly-- the dominant hand wasn't a little better.) Interestingly and importantly, the authors did not think this was due to faking or psychological factors, but felt that it was due to actual neurologic impariment in bilateral pathways: 65% had had a closed head injury, 27% had had physical abuse, and 17% had had a history of substance abuse. 40% had an IQ less than 90!
A study in epileptics vs. pseudoseizure patients trying to determine how long after admission to a video EEG unit it takes for patients to have events (answer: 88% had it on day 1) also found that urinary incontinence, focal neurologic exams, and tongue biting were about the same in both groups. But more epileptics had events less than one minute, and more pseudoseizures lasted > 5 minutes (and very few (13%) lasted less than one minute.)
Slightly different results were found in another study: 11/28 pseudoseizure patients had them on day 1, but 9/28 needed an average of 5 days. 19/28 had an induced pseudoseizure to IV saline challenge within 3-7 minutes. But still-- 3 days should be enough for most patients.
And alexithymia is of no value. It is found more often in epileptics and pseudoseizure patients equally, though still more than expected in the community. A larger, controlled trial had found a similar inability for alexithymia to differentiate: alexithymia was very common in epileptics (76%) and pseudoseizures (90%). Thus, it is likely that alexithymia is a coping strategy, and not an independent trait.
Addendum 11/5/06: I did find an interesting (Greek) study finding an excess of seizures on full moons (34% vs. about 21% for the other phases.) Importantly (and in contrast to suggestions by other studies) these were not pseudoseizures, because all patients were monitored. The authors speculate either electromagnetic/gravitational effects (hey, it could happen) or an interaction between the intrinsic seizure threshold and the environment (i.e. you can change you rown threshold.)
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October 6, 2006 9:47 PM | Posted by : | Reply
Are psuedoseizures real? And if so , do they require seizure medications? Can they be brought on by Post Traumatic Stress Disorder?
October 7, 2006 4:27 PM | Posted by : | Reply
Real? well, they really do shake or stare off into space. A "true" pseudoseizure is a conversion disorder: that means that there is no physical pathology (in this case, no actual electrical problems in the brain) but the patient is creating the symptoms unconsciously. In other words, they're not faking it, they think it's real. If the patient were actually faking, it wouldn't be a "pseudoseizure," it would be faking (malingering.) If the patient is conscious during the event, and realizes that it is anxiety, then that's not a pseudiseizure either-- that's anxiety.
In the "old" days, conversion disorders were spontaneously paralyzed limbs with no pathology.
In actual practice, however, most people with conversion disorder do have an inkling that the disorder isn't physical, but not enough insight to make it go away.
Some clinicians relate this to alexithymia: in inability to voice your emotions. The patient is angry, doesn't "understand" it as anger, so instead of manifesting the emotion as yelling, redness in the face, etc, they manifest it as a "seizure." Isn't the psyche great?
The treatment is to make the causes of the pseudoseizure conscious. (e.g. showing them that they really are angry, etc.) Meds don't help the pseudoseizure, they help the surrounding emotions.
October 7, 2006 5:39 PM | Posted by : | Reply
have been diagnosed with pseudoseizures cannot find a doctor who will help or listen to me even tho it occurs in front of them i need real medical help i can smell fluid and feel fluid in head: ears ringing : 3 hole lumbar punture in 99 :brief vision loss:and ridicule by doctors when i tell them of symptoms i have my medical records showing eeg,lp,ect i am low income and need help please thank you please respond soon
July 14, 2007 5:34 PM | Posted by : | Reply
I'm very interested in these results, but a bit baffled as to what they're likely to mean for my husband, who's been suffering from seizure-like events for the last year. He was placed on 60mg prednisone last August for a flareup of ulcerative colitis, which he's been dealing with for ~10 years now. Five days into the prednisone, he had a seizure-like event with eyes open (they were rolled back into his head for part of the time, but his eyes were open and blinking throughout); I'm not a medical professional, but I observed it, and it sure looked like a generalized tonic-clonic seizure to me. These events continued while he was on the prednisone, though they decreased in frequency and severity as the prednisone dosage dropped. All of them occurred with eyes open, except the ones which occurred while he was asleep. A neurologist ordered an EEG, which showed no evidence of epilepsy; the neurologist suggested he might have a conversion disorder (and had a rather dismissive attitude throughout; he seemed to think my husband was making this up).
The seizure-like events continued, though less frequently, after prednisone was discontinued. However, the flareup didn't go into remission, and he was hospitalized in February. IV salumedrol (methylprednisone) was administered while he was in the hospital; unfortunately I forget the dosage. Less than 36 hours into methylprednisone therapy, he had another seizure-like event, this one the most severe so far. It was witnessed by several nurses, and the neurologist ordered another EEG, but there was still no evidence of epileptic activity.
He hasn't yet had a video EEG (if that means a 24-hour inpatient EEG observation). During and after the February hospitalization they switched from methylprednisone to hydrocortisone, and he's off the hydrocortisone now, but these events still occur, about one a week. Very few of them are longer than a minute, and I don't think any of them have lasted longer than three minutes (the one in the hospital was the longest, IIRC). They're all eyes-open, as well.
We're rather at a loss as to what to do next, so if you can offer any suggestions, I'd be most appreciative; I've left my email address, which you're welcome to redact if you wish.
September 30, 2007 7:05 PM | Posted by : | Reply
I have had these psuedo seizures for 7 years now and at first i dismissed the idea that I was stressed. Now this is really affecting my life, somedays I can't leave my house or go out alone. Still trying to get where this is coming from and why
Alone's response: pseudoseizures don't "come" from anywhere, and especailly not stress. They are a type of reaction to things. In other words, they are less like "real" seizures and more like anger, or fear, or nervous stomach, etc. It's a way of reacting to stimuli that one can't process in another way. For example, if something bad happens to me that makes me feel helpless, my reaction might be to shoot it or someone. But another person might not have the emotional "range" to come up with anger, or despair-- so they (for example) shut down, or have a pseudoseizure. Pseudoseizure is a "conversion disorder." You don't cure it; you unlearn it. Also look up alexithymia.
December 2, 2007 1:10 PM | Posted by : | Reply
kimberly,you r so wong.Pseudoseizures is a big factor of stress.I know because i live wth these.i have seen 6 different doctors confirm that and agree that stress is a huge factor
December 2, 2007 1:11 PM | Posted by : | Reply
kimberly,you r so wong.Pseudoseizures is a big factor of stress.I know because i live wth these.i have seen 6 different doctors confirm that and agree that stress is a huge factor
April 4, 2008 12:26 PM | Posted by : | Reply
i was told i was having pseudoseizures.
they were wrong
i have POTS.
postural orthostatic tachycardia syndrome
we just had to be determined. last hospital visit solved it :)
they did autonomic testing.
POTS causes tremors ( what we were calling seizures )
it causes sooo much.
read about it.
most pts with this are first diagnosed w/ some psycological problem.
Good luck to all of you
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