By: Nicholas Parekh
What are Pseudoseizures?
Pseudoseizures are one of the manifestations of conversion disorder, a psychiatric condition where a patient experiences neurological symptoms such as paralysis without an actual cause. Conversion disorder usually occurs after a highly stressful or traumatic event, and a person is at higher risk if they have a dissociative or personality disorder. Patients with conversion disorder do not display symptoms for external benefit (e.g., social credit, skipping work, sympathy). Instead, conversion disorder is often a manifestation of an unconscious inner conflict that the individual is trying to resolve. Pseudoseizures often reflect an individual’s knowledge of seizures, so many tend to mimic the stereotypic generalized tonic-clonic seizure. They are often characterized by violent flailing whereas legitimate generalized-tonic clonic seizures tend to display jerking movements. Patients with pseudoseizures may also yell, cry, or swear during an episode which is not typically seen with actual seizures. The other major type of pseudoseizure is characterized by unresponsiveness or a loss of consciousness. Unlike actual seizures, patients are very much conscious during these episodes, feigning unconsciousness, and keeping their eyes closed (the eyes are usually open during a seizure). If someone tries to open the eyes of someone else experiencing a pseudoseizure, the patient will resist it, and they will also respond to painful stimuli or a hand resting on their face. One study found that 90% of patients with pseudoseizures had closed eyes during episodes while the other 10% likely had coexisting epileptic seizures. Moreover, pseudoseizures tend to last twice as long as seizures with the average pseudoseizure lasting over 2 minutes. Self-injury (e.g., biting the tongue, uncontrolled urination/defecation, breaking bones) is very common during a generalized tonic-clonic seizure but much less likely to occur during a pseudoseizure. Pseudoseizure patients with a history of suicidal behavior are more likely to self-injure during an episode.
How are pseudoseizures diagnosed?
First, a neurologist must have increased suspicion of a patient’s seizure-like activity not being the result of epilepsy. Clues to this include seizure-like activity lasting more than two minutes, consciousness during the seizure, crying, yelling, random movements, lack of postictal (post-seizure) confusion or tiredness, and avoidance of painful stimuli. Frontal lobe complex partial seizures (FLCPS) are similar to pseudoseizures in that patients may have a brief or nonexistent postictal state, display no discernable EEG abnormalities, and speak during them. However, FLCPS typically last less than one minute, occur at night, and look similar to one another.
One method of identifying an epileptogenic seizure is measuring a patient’s prolactin level following a seizure and comparing it to their baseline. Prolactin is a hormone that is elevated during and after a seizure for a brief period. Ninety percent of generalized tonic-clonic seizures coincide with a significant increase in prolactin levels. The accuracy of this measure drops with other types of seizures.
Using an electroencephalogram (EEG) is not necessarily a consistent method either. A single EEG of an epileptic patient may appear normal while that of a patient with pseudoseizures may look abnormal. Therefore, a patient must undergo several EEGs to more definitively conclude whether or not they have pseudoseizures. If a patient has multiple consecutive normal EEGs or a video EEG with a normal brain electrical activity during what appears to be seizure-like activity, then they likely have pseudoseizures. However, certain types of seizures such as simple partial seizures (SPS) and FLCPS may appear normal on an EEG. Because pseudoseizures may occur spontaneously, some physicians attempt to induce them using lights, placebo injections, and sleep deprivation. For obvious reasons, these practices are controversial and lead to some patients not trusting their physicians. Neurologists may also reduce a patient’s anti-epileptic medications before an EEG.
How are they treated?
Pseudoseizures are treated by psychiatrists, not neurologists, using primarily psychotherapy. During psychotherapy sessions, a psychiatrist may guide the patient to describe traumatic experiences in their life, learn how to recognize and communicate their emotions, and understand the basis of their disorder. Psychiatrists may also treat coexisting mental illnesses such as depression and anxiety with antidepressants, anti-anxiety medications, and cognitive behavioral therapy. Patients may also be referred to marriage or family therapy if relationship stress is causing their pseudoseizures. With appropriate treatment, most patients will make a full recovery.
What is the origin of pseudoseizures?
Patients with pseudoseizures often have significant trauma from physical and sexual abuse. They also may have experienced other forms of trauma such as military combat or the loss of a loved one, and approximately 85% of patients with pseudoseizures report past trauma. Research also seems to indicate a strong association between pseudoseizures and dissociative disorders such as dissociative identity disorder (DID) and post-traumatic stress disorder (PTSD). Ninety percent of patients with pseudoseizures in one study were found to meet the criteria for a dissociative disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Psychiatrists believe that pseudoseizures may be a mechanism for patients to dissociate when they encounter a trigger and start to experience unconscious negative emotions and flashbacks of their trauma. This makes more sense when one considers the fact that many pseudoseizure patients have alexithymia which is difficulties with recognizing, describing, and processing emotions. Patients with a history of significant trauma and mental illness (dissociative disorders, depression, and anxiety) who also display seizure-like behavior should be evaluated for pseudoseizures.
Bowman, Elizabeth S., and Omkar N. Markand. “Diagnosis and Treatment of Pseudoseizures.” Psychiatric Annals, vol. 35, no. 4, 2005, pp. 306–16. Crossref, https://doi.org/10.3928/00485713-20050401-05.
Harden, Cynthia L. “Pseudoseizures and Dissociative Disorders: A Common Mechanism Involving Traumatic Experiences.” Seizure, vol. 6, no. 2, 1997, pp. 151–55. Crossref, https://doi.org/10.1016/s1059-1311(97)80070-2.
MedlinePlus. “Conversion Disorder.” MedlinePlus, medlineplus.gov/ency/article/000954.htm#:%7E:text=Conversion%20disorder%20is%20 a%20mental,be%20explained%20by%20medical%20evaluation. Accessed 11 May 2022.