Pseudoseizures in the ED

[bear14]

What is your ED's philosophy in treat pseudoseizures? We had a pt come in that was in her 40's with a pseudoseizure, vitals were stable. So, that being said we still treated it as we would with any other seizures but she received a ridiculous amount of medication for it. She managed to mumble some stuff during it too. She calmed down and then later went into another one for which she was again treated for it. When I was on the floors I had a pt that had them and was not treated. What does your ED do for them?? Thanks in advance.

[grizun]

We laugh in their face and tell them to quit faking it.

[sukinsin]

I once had an attending show me to hold the patient's hand over their face and let it go. If they are truly having a seizure, the hand will hit their own face. If they are faking it, they will pull their hand so that it doesn't hit their face. That same attending one time farted in a patient's face who he suspected of having a pseudoseizure. He said only fakers would turn their head to avoid the odor.

[bear14]

We did the hand thing and she pulled it away so she didn't hit herself.

[sukinsin]

We did the hand thing and she pulled it away so she didn't hit herself.

Personally, I prefer the farting technique because, if they are really having a seizure, they don't even know. If they are faking it they act all offended that you just ripped one in their face. Then you point out,"Yeah, but you faked a seizure." They then get all embarrassed at the realization that they are the ones in the wrong.

[heinz57]

Please don't do the hand drop. EMS does this a lot and we end up also treating the patient for nose and eye injuries along with trying to explain why some resort to unnecessary bodily harm for an assessment. Some old habits need to just go away.

There are many types of seizures and different assessment techniques work better on some than others. If a person is going through the trouble of faking a seizures for attention or drugs, they have other issues which may require a psych evaluation rather than just being dismissed. We see this behavior in kids also. The sooner we get them an appropriate intervention, the less likely they will be a frequent flier later.

[sukinsin]

Please don't do the hand drop. EMS does this a lot and we end up also treating the patient for nose and eye injuries along with trying to explain why some resort to unnecessary bodily harm for an assessment. Some old habits need to just go away.

There are many types of seizures and different assessment techniques work better on some than others. If a person is going through the trouble of faking a seizures for attention or drugs, they have other issues which may require a psych evaluation rather than just being dismissed. We see this behavior in kids also. The sooner we get them an appropriate intervention, the less likely they will be a frequent flier later.

I have never in my life seen an eye or nose injury from dropping a patient's hand on his face from 12 inches away. But hey, if you're that concerned, just use the farting technique.

[Lev, MSN, RN, NP]

we do the hand face test or if really mean a whiff of ammonia

[sukinsin]

we do the hand face test or if really mean a whiff of ammonia

Ammonia, methane. It's all the same.

[OrganizedChaos, LVN]

I'm kinda offended by the responses. I have worked in a facility with teens, one of the girls was obviously attention seeking & would fake seizures. I would get the ammonia & put it under her nose. It would wake her right up.

Having both epilepsy & bipolar disorder I get treated like garbage from ER staff. I remember when I was having a bunch of stress induced seizures when I was pregnant with my first child. My husband took me to the ER in town & he said the staff treated me horribly. It turned my stomach.

Another time I went to an ER in a city over an hour from me. I was taking Lithium at the time & for some reason I was not able to speak. I would get the thoughts in my head but it wouldn't connect from my head to my mouth. Since I took the Lithium BID & only took my morning dose (it was night time by the time I was seen) it was starting to wear off. The ER doctor just brushed me off as a crazy person/attention seeking. By some miracle of God the pharmacist knew what I was going through & told me not to take the Lithium any more because she has seen negative side effects from it. She will always be in my heart. If that ER doctor would've done an inch of research he would've seen that it is more common than he knows.

After those experiences I am not only hesitant to reveal my mental health hx but I also don't judge people. You don't know them & dont know them or their situation. If they are faking a seizure it is an obvious cry out for help that we should be assisting with, not farting in their faces.

[la_chica_suerte85, BSN, RN]

Wait, are we talking people faking seizures or the PNES (psychogenic non-epileptic seizure) type of seizures?

We had a patient come to us that was having some form of a seizure but they were definitely non-epileptic. There was a lot of psychosocial weirdness with this patient but the fear was that maybe there was some kind of CNS malignancy. Ultimately, it was PNES. The patient wasn't faking it and would desat and be super-tachy so the O2 was on and the Ativan would be drawn up just in case they continued holding their breath for too long (and this wasn't purposeful breath-holding, their lips would turn blue). Afterward, they would fall asleep for a good long while. I can see it being a thin line between straight up faking it and having some sort of pyschogenic condition, though. This patient thought they had been given Ativan a few times (it was never given) and was kinda miffed when they found out they hadn't. It wasn't quite drug-seeking but nothing psychologically normal was happening there either. Very strange.

[Julius Seizure]

Okay, pet peeve of mine. "Pseudoseizure" is a real diagnosis. The real name is "psychogenic nonepileptic seizure". It is not the same as faking a seizure. Yes, I acknowledge that some patients may also actually pretend to have a seizure intentionally. It's not appropriate to fart in their face either. That person needs a different type of care, but they don't need/deserve to be mocked or disrespected.

Here is a good article that supports the idea that pseudoseizures are not "fake":

https://jamanetwork.com/journals/jamaneurology/article-abstract/1377563

I'd also like to share some info with you from UpToDate, but of course, a link won't work because its a pay site, so bear with me as I quote a few things. If you have access to UpToDate and would like to confirm this info or know more, its from the page titled "psychogenic nonepileptic seizure", and you can find it by doing a search for "pseudoseizure" as well. Here we go:

"The term "pseudoseizures" is also discouraged, since the root "pseudo," or false, invalidates the genuine, even if psychogenic, disorder that a patient experiences."