Pseudo Seizures

[Keepstanding]

Friends,

Have you ever had a student present with Pseudo Seizures ? I have a student who has these and no basis for it. Phy. has ruled out Epliepsy. Normal EEG. I am stumped as to why ???

I would love to hear from you to see if you have ever experienced this ??

Thank you.

[sailornurse]

When I was in the Navy back in the 90s Desert Shield Desert Storm era I was assigned to that Neuroscience unit at because the Naval Hospital we would get people trying to get out of the military with pseudo seizures they would be put in the room that had hidden cameras and they did not know it so 24 hours there was a camera going further those that were faking the seizures totally different ballgame now with military.

[Whispera, MSN, RN]

In my experience some are attention seeking. Others are the result of a life that doesn't allow expression of negative emotions. In this situation, the emotions pile up until they are intolerable and the brain forces a reaction that's not an intentional thing on the part of the person. It's subconscious.

In either case, it's a way of coping even though it isn't a good one.

[SnowyJ, RN]

I have little doubt that these pseudo seizures, or whatever you want to call them have an underlying psychiatric/psychological base. However, they are not seizures, and should not be treated as such. Not saying to ignore the issue, something underlying is going on.

In the hospital I once watched a Med Resident do a sternal rub on a pt. having a not so real seizure. She responded with "OW! And slapped his hand away," Interesting.

Thought this was enlightening. Don't throw those ammonia poppers away so fast!

Pseudoseizures–Achieving Accurate Diagnosis | Jail Medicine

[OldDude]

Key word SOME are related to secondary gain. However, when there is the presence of psychopathology, as is with many cases of pseudoseizures it is simply more COMPLICATED than "she's faking it."

I agree. We are saying the same thing...it's pretend or psychogenic. Psychogenic seizures are real to the person experiencing them. As school nurses we seldom get past the umbrella diagnosis of pseudoseizure...end of story. That leaves us in the dark as to how to appropriately treat the child unless we get a very specific seizure action plan from the physician...which we seldom get because there are no specifics regarding the diagnosis. So, usually it defaults to the standard seizure action plan.

[Mandychelle79, ASN, RN]

Not a school nurse, but on our psych unit we see two types of these... True psuedoseizures where we cannot tell if it's a real seizure or no and someone who is faking. Most of the true ones are caused from anxiety.

[OldDude]

Not a school nurse, but on our psych unit we see two types of these... True psuedoseizures where we cannot tell if it's a real seizure or no and someone who is faking. Most of the true ones are caused from anxiety.

As school nurses we face the same dilemma but there isn't a psych unit, physician, any other nurse or any other medical person; just us and whatever seizure action plan we have...if any...and 911

[Mandychelle79, ASN, RN]

As school nurses we face the same dilemma but there isn't a psych unit, physician, any other nurse or any other medical person; just us and whatever seizure action plan we have...if any...and 911

Our procedure for a pseudo is to call a condition which is similar to calling 911. The only time we don't is if it is part of a patients individual care plan. We have one that as long as no oblivious injuries and we do not think there was any potentional for a head injury we don't call a code

[marienm, RN, CCRN]

I've had an adult patient who had 'pseudoseizures' (that's what he was told they were called...he'd had a very extensive workup and was on a couple of anti-seizure drugs). He would start coughing and then become somewhat syncopal (I assume it looked like a petit mal seizure) for a brief time. No memory of the seizure, but no post-ictal state; sometimes incontinence. I don't work neuro much so it sounded more like a vagal syncope to me but 1) I never saw one and 2) according to him they had ruled that out.

[TheMoonisMyLantern, ADN, LPN, RN]

Kind of off topic but in the same vein, I had a memorable patient who would often experience pseudoseizures who would announce melodramatically "I am having a seizure!" then carefully lie down on the floor and thrash around while moaning. As serious business as it was for the patient I couldn't help but stifle "church giggles" within myself at times!

[jadelpn, LPN, EMT-B]

As I have learned it to be, pseudo seizures are a behavioral acting out-- and can be directly related to trauma based mental illness (ie: personality disorders)

To CYA I would always call 911. And I would see about a psych consult.

[SnowyJ, RN]

This...From link I posted above.

It is important to observe and be aware that there are key differences between seizure and pseudo seizure in how they present:

[h=3]"Pseudoseizures look different than true epileptic seizures. Know the key differences.[/h]The two most important differences between pseudoseizures and grand mal epileptic seizures are:

1. During a true epileptic seizure, the patient's eyes are open and deviated (looking off to one side or the other). The eyes of a patient having a pseudoseizure are almost always closed. And if you open the pseudoseizure patient's eyelids with your fingers, the pupils will not be deviated—rather, they will be looking straight ahead.

2. Patients who have had a true epileptic seizure will invariable have a postictal state of confusion after the seizure ends. The postictal state typically lasts much longer than the original seizure. Patients who have had pseudoseizures do not usually exhibit postictal confusion.

Memorize these two key differences! Everything else is less important.

However, other common differences between a true epileptic seizure and a pseudoseizure can also be useful in certain cases:

3. Epileptic seizure patients go through a tonic-clonic movement pattern: flexion of the limbs followed by extension. The arms are held close to the body. Pseudoseizure patients do not follow this pattern. Often, their arms are held akimbo away from the body. They also may also do other movements not seen in a true epileptic seizure, such as rolling side to side, pelvic thrusting, rolling the head back and forth, etc.

4. True epileptic seizures build to a crescendo then abate. Pseudoseizures tend to wax and wane.

5. True epileptic seizure patients commonly bite their tongues and sometimes lose continence. Pseudoseizure patients rarely do either. (Though I once dealt with a particularly skillful patient with factitious disorder who made it a point always to bite his tongue and wet his pants when he staged an event).

6. Grand mal seizure patients usually get hypoxic transiently during a seizure since their chest muscles seize, as well. You can demonstrate this with a pulse oximeter (if you have one handy during the event). Epileptic seizure patients will often show mild hypoxia. Pseudoseizure patients' pulse oximeter readings will remain normal.

7. Blood chemistries following a true epileptic seizure will often show an elevated CPK(due to muscle spasms), an elevated anion gap and depressed serum bicarb (due to lactic acidosis) and, most oddly, elevated prolactin levels.

[h=3]True seizure patients are unconscious![/h]This is the single most important difference between a true Epileptic Seizure and a pseudoseizure: patients having an epileptic seizure are unconscious! Pseudoseizure patients may be unresponsive, but they are not unconscious.

This insight is, of course, useful when a patient is carrying on a conversation during a seizure” event–like the patient who once said to me while she was shaking (with her eyes closed, by the way): I'm having my seizure now! You will need to give me Xanax. It's the only thing my doctor found that helps.”

Most pseudoseizure patients, however, do not give themselves away so easily. They are more typically unresponsive: You can talk to them, shake them—no response.

In my emergency medicine training, I was taught many ways to determine whether a patient was truly unconscious or not. One method was to take the patient's hand and drop it over their face. If the patient is unconscious, the hand will smack them in the face. If the patient is not unconscious, the hand will invariably slide away to the side. I personally don't use this procedure.

A method more commonly taught in training programs is the sternal rub. It is so commonly taught that I bet almost everyone reading this is aware of this test! The sternal rub consists of using your knuckles to rub forcefully up and down the patient's sternum. The idea is that this hurts, and if the patient is not unconscious, he will wake right up and say stop! Unfortunately, the sternal rub has a couple of problems. First, how painful it is depends on how forcefully one rubs, on how much fat padding” the patient has and on the patient's tolerance to pain. I have seen the sternal rub fail on many occasions for one or more of these reasons.

Because of this, I was taught in my residency several other even more painful procedures to inflict on unresponsive patients—nerve roots to poke, pressure points to grab ala Mr. Spock, and—well, you get the point. Similarly, I've seen health care providers use foley catheters and large bore IVs to wake up” a patient they suspected of having a pseudo-event.

However, the more important problem with all of these painful techniques is that they are ethically questionable. Intentionally hurting our patients? I don't know. Such procedures especially tend to be misused when the medical provider feels angry at the patient for faking” a seizure. I've seen caregivers” become quite cruel and even borderline sadistic applying such painful procedures. I personally am uncomfortable with these techniques . . . especially when there is a better alternative."

[Flare, ASN, BSN]

I thought about this last night. I Had a student in my multiple disabled room last year who has since moved to another district - so i can no longer reference the chart, but I believe after work up upon work up he was ultimately diagnosed with pseudo seizure. Now, i may be wrong - i am dealing with my end of year brain to think about a student that my brain decided i can start purging facts on. So that exact detail is hazy - but i can tell you that he was on daily meds - depakote or something, which i thought was odd, because his parents were insistent that he did not have a seizure disorder despite his shiny new seizure action plan and tendency to become unresponsive, staring gaze, etc... these periods could easily go longer than 5 minutes. This child did not have the mental capacity to think up faking a seizure. So if it wasn't a seizure, then the doctors needed to keep digging because something abnormal was happening and there was some sort of abnormal activity occurring.