Pseudoseizures?

[NurseJacqui]

I work in the ER and a few nights ago, a fellow nurse and friend began to have repeated seizures while at work. She had a seizure history. They admitted her to critical care for status epilepticus. When I went home that night something was bothering me and I couldn't put my finger on it. Well, I found out yesterday that during the EEG, she had another " seizure" . The neurologist took her parents aside and told them..." She's not having seizures. She's faking it. She doesn't need a neurologist...she needs a pyschiatrist," They downgraded her to a regular floor and transferred her out. Now I know what was bothering me but I guess I didn't want to admit it to myself. Now I question everything she has ever said or done. Why would an ER nurse, of all people fake seizures WHERE SHE WORKS, especially during an EEG. She let me put a foley in her for pete's sake. Could this be an involuntary stress reaction or is she pulling the wool over our eyes? Come to think of it, she also said she had a chest tube a few months back but when we undressed her, there was no scar. I feel so disgusted with her. Like I have been deceived. :o Has anyone else had any experience with this?

[teeituptom, BSN, RN]

Also used as a drug seeking behaviour, granted thats psych also.

Ive seen quite a fair number of pseudoseizure patients in the ER over all these years.

My fav was the one who's S.O, told me only Dilaudid would stop the seizure. Right.

Do they all have psych issues, yes, but dont get sucked into it. Besides once they get their meds you see most of them either sign out AMA or Bolt out the doors.

When you look at it, there really isnt a lot you can do in the ER for them. But it is fun watching new nurses and MDs who dont know these patients get all excited.

Then there are the ones who have been through every neurologist in town, and has fired them all after they were told they were pseudoseizures.

[Tweety, BSN, RN]

Yeah and how about the kid who suddenly has an asthma attack when mom and dad are fighting or scolding him for being bad. What a faker.

[bellehill, RN]

My very first pseudoseizure patient was a learning experience. The patient appeared to have actual seizures, as many as 14 a shift...I was the only one who believed her. While no one told her she was faking psych was called in and she was given the negative EEG results. This patient was attention seeking for some reason we couldn't figure out.

My point is, no they aren't faking but they do not have a neurological disease. Get psych consulted as quickly as possible and get these patients the help they need. Be supportive of their treatment plan but don't get sucked in again!

[VickyRN, MSN, DNP, RN]

On one pediatric clinical floor in which I was conducting clinicals a patient (girl of about 10 years of age) was having frequent "seizures." The resident opened a smelling salt and put it under her nose during one of these episodes while I watched. Lo and behold, her seizure was "cured" that very instant.

[Blackcat99]

When I was a new LPN many many years ago there was a lady who had many grand mal seizures. I was horrified. In the old days, they would have nurses give fake placebo water shots. The doctor told me to give a water shot and tell the patient it was a shot of Demerol. I gave her the water shot and she immediately stopped having the seizure. :uhoh21:

[louloubell1]

This is personal information and a violation if HIPPA btw for you to know, unless she told you herself. I hope the staff taking care of her aren't gossiping about her. :)

I'm thinking the same thing. How is it that you are aware of what the neurologist had to say about her EEG? Nobody's business but hers, and a huge, huge HIPAA violation....

[MryRose]

This nurse may have a Somatoform disorder which might explain why she is frequently feeling ill. People who have this disorder are not aware that this is psychological. I've included some imformation that you may find interesting.

I can understand how anxious this would make you feel as a co-worker and a friend. Even if it turns out that this is a conscious drug or attention seeking behavior, this person still needs some professional help right now. Perhaps you can arrange to meet with her privately and express your concerned for her well being and your friendship. For whatever reason, this person is calling out for help and she may feel safest asking for it from the people she sees caring for others everyday. I wish you the best, it's a tough position to be in.

Hugs to you Both,

MaryRose

Conversion disorder is included as a somatoform disorder under the general classification of hysterias in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, Fourth Edition (DSM-IV). Although defined as a condition that presents as an alteration or loss of a physical function suggestive of a physical disorder, conversion disorder is more precisely understood as the expression of an underlying psychological conflict or need.

The presence of the psychological factor usually is not apparent at onset but becomes evident in the history when a cause-effect relationship between an environmental event or stressor and the onset of the symptom is discovered. The symptoms are not intentionally produced but are the result of unintentional motives. This condition is not considered under voluntary control and, after appropriate medical evaluation, cannot be explained by any physical disorder or known pathological mechanism.

Clinical descriptions of conversion disorder date to almost 4000 years ago; the Egyptians attributed symptoms to a "wandering uterus." In the 19th century, Paul Briquet described the disorder as a dysfunction of the CNS. Freud first used the term conversion to refer to the substitution of a somatic symptom for a repressed idea.

Pathophysiology: The nature and character of presenting symptoms can range the entire field of clinical neurology. A conversion reaction can be entertained in the differential diagnosis of any neurological syndrome. Reactions usually are characterized by symptoms that suggest lesions in the motor or sensory pathways of the voluntary nervous system. Most commonly reported symptoms are weakness, paralysis, sensory disturbances, pseudoseizures, and involuntary movements such as tremors. Symptoms more often affect the left side of the body. This loss or distortion of neurologic function cannot adequately be accounted for by organic disease. Involvement of the corticofugal inhibitory system has been suggested. Symptoms specifically excluded are those limited to pain or sexual functioning or those due to somatization disorder or schizophrenia.

Diagnostic criteria for conversion disorder as defined in the DSM-IV are as follows:

One or more symptoms or deficits are present that affect voluntary motor or sensory function that suggest a neurologic or other general medical condition.

Psychologic factors are judged to be associated with the symptom or deficit because conflicts or other stressors precede the initiation or exacerbation of the symptom or deficit.

The symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering).

The symptom or deficit, after appropriate investigation, cannot be explained fully by a general medical condition, the direct effects of a substance, or as a culturally sanctioned behavior or experience.

The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of somatization disorder, and is not better accounted for by another mental disorder.

According to psychodynamic theory, conversion symptoms seem to be maintained by operant conditioning. The person derives "primary gain" by keeping an internal conflict or need out of awareness. The symptom has a symbolic value that is a representation and partial solution of a deep-seated psychological conflict.

According to learning theory, conversion disorder symptoms are a learned "maladaptive response to stress." Patients achieve "secondary gain" by avoiding activities that are particularly offensive to them, thereby gaining support from family and friends, which otherwise may not be offered.

Frequency:

In the US: True conversion reaction is rare. Predisposing factors, according to the DSM-IV, include prior physical disorders, close contact to people with real physical symptoms, and extreme psychosocial stress.

Incidence has been reported to be 15-22 cases per 100,000 people. In patients with chronic pain, incidence was 0.22%. Conversion reaction may occur more often in rural settings, where patients may be naive about medical and psychological issues. In one study, high rates were seen in Appalachian males. The disorder is observed more commonly in lower socioeconomic groups and may be more common in military personnel exposed to combat situations.

Cultural factors may play a significant role. Symptoms that might be considered a conversion disorder in the US may be a normal expression of anxiety in other cultures.

One study reports that conversion disorder accounts for 1.2-11.5% of psychiatric consultations for hospitalized medical and surgical patients.

Internationally: At the National Hospital in London, the diagnosis was made in 1% of inpatients. Iceland's incidence of conversion disorder is reported to be 15 cases per 100,000 persons.

Mortality/Morbidity:

Studies report that 64% of patients with conversion disorder show evidence of an organic brain disorder, compared with 5% of control subjects.

An earlier study revealed that a medical explanation eventually emerged from presenting chief complaints in only 7% of patients. Incidence of true neurological disease discovered at a latter date is extremely rare, largely due to advances in diagnostic testing.

Sex: Sex ratio is not known although it has been estimated that women patients outnumber men by 6:1. Many authors have related the development of conversion disorder in women with sexual maladjustment. Other authors disagree, stating that men are as likely to experience conversion symptoms as women. Men seem to be especially prone if they have suffered an industrial accident or have served in the military. In a study at the University of Iowa conducted from 1984-1986, patients diagnosed with conversion disorder were in large part men, especially those with a history of military combat.

Age:

Conversion disorder may present at any age but is rare in children younger than 10 years or in persons older than 35 years. Some studies have reported another peak for patients aged 50-60 years.

In a University of Iowa study of 32 patients with conversion disorder, however, the mean age was 41 years with a range of 23-58 years.

In pediatric patients, incidence of conversion is increased after physical or sexual abuse. Incidence also increases in those children whose parents are either seriously ill or have chronic pain.

The above information was obtained from:

http://www.emedicine.com/emerg/topic112.htm

[bmullins34]

I just wanted to say thank you. My daughter has pseudo-seizures. She was a perfectly healthy child unit April 2008. Then she started having about 26 of these a day. It has been a terrible road. One doctor suggested that she was "faking" so after she went to sleep, I snuck into her room and watched her. She had several right there in front of me without even knowing that I was in the room. I have also video taped the episodes with a hidden camera. I have seen her fall and cut her feet, carpet burns on her knees, her glasses have fallen of and broken, she's fell out of bed and bruised her back. My daughter sits and cries because she can't do things that other kids her age are doing. She won't even go shopping (which she loved to do before). This has affected her whole life. We are at the point now where we are taking her to a psychiatrist to see if that helps. I was appalled at some of the posts I read about what some nurses will do to see if a patient is "faking". Maybe some of them are but that doesn't mean you should disregard them or treat them as less than human. It has been almost a year now and she doesn't like it when people make a fuss over her, she has an episode and moves on. During an episode I just keep her from hitting her head and then I leave her alone. Hopefully the psychiatrist can help. I will let you know. Again, thank you for letting people know that some people actually have a problem and are not faking it.

[pinkestar]

bmullins-

Thank you for sharing your story. I'm so sorry that your family has had to go through this, and that you've met some less than compassionate doctors along the way. Hopefully by reading your story, some nurses may be a little less quick to judge anyone as "faking" their illness. Best of luck to you and your daughter.

Nicole

[diane227, LPN, RN]

A pseudoseizure is a seizure usually due to stress or anxiety. It is a known disorder in psychiatry. It is usually a reaction to a stressful event and the seizure comes on as a reaction to that stress. You may have a patient that is talking to you and demonstrating seizure activity at the same time or the action may be the same as with a "regular" seizure. These patients do not usually have a post ictal state. They are easily treated with anti anxiety medications. Please avoid referring to them as a "fake seizure" because they are not. They are a valid illness and should be treated as such. There are many locations on the internet where you can find information regarding pseudoseizures. Precautions that you take with any type of seizure should be the same.