Pseudo-seizures

[Lucyinthesky]

I am a new nurse still orienting to the ICU, so yes, I am very green. I had my first experience with what was originally thought to be grand mal seizures but was soon suspected to be pseudo-seizures. The whole experience was mind boggling to me. The seizures were whole body spasmodic lasting for less than 30 seconds, no loss of bowel functions, no post-ictal (sp?), completely coherent within minutes, some expiratory wheezing afterwards, eyes responded to stimulus, and always occurred soon after the patient was emotionally upset. She had a seizure while she sitting in an upright chair and amazingly did not even end up on the floor or get hurt. I might also add that the seizures NEVER occurred as long as someone was in the room with her and giving them her full attention.

The pt. was completely noncompliant with the nursing staff, refusing to stay in bed (even though we explained REPEATEDLY the danger of being up with the frequency of the seizures), tearing leads off, even attempting to walk off the floor half naked to drive herself home. She went ballistic when she overhead the possibility of restraints. She swung from being completely happy, to being anxious, to crying, to apologizing, to screaming, etc.

As the shift went on more and more information came out - she was a frequent flyer and many of the staff remembered her from years prior at different hospitals. It was very difficult to decipher what of her history was true or not as she has changed doctors quite often.

She was currently on Dilantin, and surprisingly enough, NO psych meds. We ended up having someone come from another floor to act as a sitter and she seemed as happy as a pig in mud then. I was not her primary nurse and an still wondering why a psych consult was not ordered for her.

I have no psych experience and am completely naive in that way but I just couldn't believe someone would put themselves through the physical and emotional hell she was going through just for attention. I guess my question is has any had any experience with this? What would you have done in this situation?

[Daytonite, BSN, RN]

Yes. I worked on a neuro unit. We carried ammonia capsules (used to be referred to as smelling salts) in our pockets. You break one of these open and wave it under the persons nose. If they are truly having a seizure it will not faze them. If they are faking--the smell makes them and you, as well, try to pull away from it because it smells so pungent.

We had an interesting patient with pseudo-seizures who would tell us she felt a seizure coming on, put the tongue blade in her mouth and proceed to have her seizure where she just moved her head violently from side to side like she was saying "no". We could ask her questions and she would stop this activity long enough to answer and then resume the seizure.

[GOMER42]

It is not up to you to decide if she was faking or not.

This can only be determined by an EEG.

Not all persons experiencing a tonic-clonic (grand mal) seizure lose bowel/ bladder control nor do all lose consciousness or have disorientation afterward (what would be considered postical).

Don't be so quick to judge. You treat the symptoms that are presented to you, not the ones you choose to see.

[RN1982]

I've had patients in that type of situation. I just document it and call the doctor. Usually patients have this because of some psych disorder.

I had a 28yo female who had a hx of pseudoseizures and allergic reaction. This girl got herself intubated by faking respiratory distress. I remember admitting her from ER. She came up with a breathing treatment on and it was one of the 1 hour breathing treatments. She had gotten two of them. Her heart rate was in the 130s. We got abgs and they were perfectly normal. I took the treatment off and threw it in the garbage. She told me that I would have to get her out of bed to the commode as she could not get up by herself. I knew from her history that she had a psych disorder called conversion disoder where the patient presents with neurological symptoms but there is no neurological explanation. So I didn't believe her when she said she couldn't walk to the commode and I told her that she was perfectly able to get up by herself and without my help. She did and had no problems all night.

I left the room while assessing her and within the two minutes I was gone from the room her mom said she was having a seizure, so you know, everyone is flying into the room and there she is, completely awake and asking for pain meds. So I call her doc who says, I don't know why the neurologist keeps saying she has seizures when they are pseudo seizures and I don't want her to get any Ativan. I went to the room and told the patient and her mother exactly what the doctor said and for the rest of the night the patient did not try to manipulate me..From this girl's history, she had gotten herself intubated three times because of respiratory distress which she was faking and later on in my shift she tried to pull the same thing with me and the respiratory therpist. The RT was giving her a breathing treatment and the patient was "having" stridor. I told her very firmly to breath normally which she did and the RT said she was clear. And she didn't have any more stridor for the rest of the morning.

These patients have psych disorders and you have to decide what you are willing to put up with and what you won't put up with. Patients like this are manipulative and are doing what they are doing to get attention whether or not its good attention. Sorry for the long post. I know exactly what you went through.

[RN1982]

I would just like to add that for the patient that I was describing in my post, she had multiple EEGs and CT scans of her head and were all normal. Her chest xray when I admitted her for her respiratory distress was also normal. I would just like to reiterate that she was diagnosed with a psych disorder called conversion disorder so I'm not trying to be judgemental but with certain psych patients you have to be straight forward and matter of fact when you are dealing with them.

[WolfpackRed]

In the ICU that I work, one MICU attending does not accept the dx of "pseudo-seizures", unless a neuro or psych consult on that admission identifies it as such.

Second, when I was working in another ED one day, a pt came in with "pseudo-seizures" was having one, when the MD was in the room, and the MD said "How can I get your hx if you are seizing?(the pt was having/imitating full-body convulsions)" I swear, the pt stopped, maybe coincidental?, sat up and gave the doc his hx. Doc said thats when he knew the pt was faking.

[nrsang97, BSN, RN]

I have had many pseudo seizures, but no one as bad as this one 18 y/o girl. This girl deffinately had psych issues. She was so good at faking she would be able to avoid the ammonia salts (most are able to ignore after a while.) She once started having a siezure and the phone rang, she stopped her seizure, carried on a phone conversation, and hung up the phone and continued with her seizure. That was on day shift. I had her on nights. She was pulling the same crap and I called the house officer. He was tired of her crap and came up to the floor. Before he went into the room, he asked for a 60ml syringe and the biggest needle I could find. I gave them to him. We went into her room and she was faking a seizure, the doc told her "I have to drain some of the fluid off from behind your eyeballs so you will stop seizing". She stopped instatnly and was stunned. She didn't do that for me for the rest of the night. All her seizures were a ploy for attentnion, she had cystic fibrosis as well. I remember she would call up her family and make all kinds of threats to them. This girl also tortured her family along with hospital staff. I called report to transfer her to a children's hospital, and they remembered her and said she was so good that she ended up intubated many times.

[cardiacRN2006, ADN, RN]

Oh, I've had lots of psuedo seizures as well. With the last dude, I told him his girlfriend could not visit if he continued to behave this way. Miraculously he stopped! Like magic!

To the OP, Your girl needs a psych evaul badly. She's in some real need of help.

And, yes, it's possible to determine if the seizures are fake without the need for an expensive EEG. And for those who are faking, I don't placate them. They won't get any extra attention for that kind of behavior.

[vashtee, RN]

We went into her room and she was faking a seizure, the doc told her "I have to drain some of the fluid off from behind your eyeballs so you will stop seizing". She stopped instatnly and was stunned.

:D:D

[RN1982]

That was a good story, Ang.

[locolorenzo22, BSN, RN]

see this is a very interesting question...I work on a neuro/detox unit, and we had a detox patient who continually was trying to walk off the floor, get pain meds...etc. I was standing with the tech at our back station, trying to ask her about a few patients of mine, and the housekeeper goes flying in there..."nurse, hey NURSE!" (on a side note, it took me a minute to figure out that they were yelling at me)

The patient had a hx of faking seizures, but she was shaky, wouldn't talk, eyes shut, spasming muscles....the housekeeper and I got her in bed, and she kept going (after 2-3 minutes) she was ready to get up(which made me suspucious)...but I just am there to keep her safe, and tell the doc. It's not up to me to dx her with a fake seizure, or yours.

[cardiacRN2006, ADN, RN]

It's not up to me to dx her with a fake seizure, or yours.

Yeah, it is our responsibility to deal with them. And, we aren't diagnosing them. We are treating them. Big difference.

I know you are a new nurse loco, but let me tell you, it get's old, old, old to deal with pts who are faking and sapping you of your energy.

If you play into it, they keep doing it.

For your pt, I would tell her she was no longer allowed out of bed without a sitter, and was no longer allowed out in the halls at all.

Otherwise, you're going to be filling out lot more incident reports as these people take advantage of you.