Seizures Real vs Fake

Specialties Correctional Nursing Q/A


There was a patient/IM that had a possible seizure and the staff that responded were claiming that it was fake because she was alert and oriented.

How do you handle this situation, and how do you know the difference between real vs fake seizures?

I know there are different kinds of seizures. I am new to the jail population of patients and am trying to be safe with the real seizures vs the manipulators.

43 Answers

Rob72, ASN, RN

685 Posts

Specializes in Infectious Disease, Neuro, Research.

Probably the easiest "tell" for seizure activity, whether absence or GTC, is the pain response. Use a Bic pen (tail or cap), and press it forcefully into the cuticle area of a fingernail. If they withdraw, they're faking. If they are playing GTC (generalized tonic clonic) with flopping, shaking and foaming at the mouth, they may continue with this, but the limb receiving pain will be rigid, attempting to minimize manipulation which would cause more pain.

For an absence seizure (staring spell) you can flick at their eyes, and they won't blink. Again, risky in that they may alleged that you hurt them, they may injure you, using sx activity as an excuse, etc..

I say this with the obvious caveat that you may have someone take a swing at you, and say they were, "out of it". Either get a CO to do it for you, do it only under very controlled circumstances, or just let them flop(probably safest).

For your experience level, and being female, I would probably simply say that if they display a post-ictal state, they had the real thing(confusion, discoordination, lethargy). Anything else is faker-faker.

Specializes in Acute Care Psych, DNP Student.


Tend to pinch their eyes shut

Lack excessive secretions

Maintain normal or almost normal blood oxygenation

Do not have bite marks on their tongues

Do not have post-ictal confusion

Tend to sometimes "wake up" afterwards like waking up from sleep

Will allow you to drop their hand into their face - they've all seen or heard of that episode of ER

Strong sternal rub can bring them out


Excessive secretions

Lose bladder/bowel control

Pale, diaphoretic

High HR & high BP

Low blood oxygenation at times

Post-ictal confusion

Specializes in Correctional, QA, Geriatrics.

One of my favored methods for sorting out the real from the fake was an ammonia inhalant. Broken and waved under the nose of someone faking a seizure (usually with their tightly clamped eyes and mouths ensuring all the fumes went right up the nares) it never failed to elicit a marked response from the fakers.

Specializes in Acute Care Psych, DNP Student.


I know the ammonia inhalant is supposed to work, but I've had two fakers recently who managed to not respond to it. One even admitted later that he was faking and trying to get a fix of diazepam - he showed no response.


8 Posts

In correctional nursing you rely on more of the objective data than subjective data. To differentiate real from fake always assess efficiently. General apperance, vital signs, incontinence, pupils, foaming, sounds, movement, sensation, orientation, etc. At first it'll be hard but it get's easier to spot the real and fake ones. Never get in the mentality that everyone is faking or don't let custody or even other health care influence your assessment if they say he/she is just faking.

ImThatGuy, BSN, RN

2,139 Posts

I walked back into the jail once to see an inmate that was having a "seizure" after "falling" off his bunk onto the floor. I radioed to the deputy room and had one of the guys come back with his K9. As soon as Stinger entered the pod on lead the "seizing" inmate jumped to his feet and quickly scrambled back to the top bunk. It was a miracle.


2 Posts

The first thing I check is pupillary response.....pupils will generally be dilated and/or sluggish to respond to light. There is almost always nystagmus with the dilated pupils. As soon as they stop jerking, I generally start asking questions as if they are awake when I suspect faux do you take seizure meds, what med, when was the last dose, how long have you had seizures, when was your last drug level, was it low, etc. The fakers generally end up answering all the questions accurately, albeit with some drama. After 32 years of ER nursing I can say I've never seen anyone wake up from a seizure and be able to answer those type of questions.

Two Sheds

47 Posts

We have SO many fake seizures it's ridiculous! There are 2 inmates who always manage to have "seizures" within 10 minutes of one another, even though they are in different units. We still have not figured that one out.

I laughed at y'all's comments about the smelling salts because I have started to use those and they truly are "miracle workers" lol. Personally, I wish we could inform the inmates that "new research" indicates that large-volume enemas are the cure for seizures. But then again, some of them may like that.

What's crazy is that we have a couple of inmates who are so predictable that the COs will call us in medical saying, "I/M ____ is going to have a seizure in 5 minutes...just a heads-up." Sure, enough, it happens. And they are such BAD actors! They come out of the "seizure" and they'll be like, "Wh- wh- where am I?" Nauseating, but funny as heck!

This is how we outed this one malingerer: the Dr. came to the unit when the emergency was called, and he observed as we stated things like, "I don't know...if it was a real seizure, his jaw would be jutting out more," and the I/M jutted his jaw out. Then we said, "Yeah, his right leg would be at more of an angle" and other ridiculous, fake "symptoms." Every symptom we mentioned, the I/M would start doing. The Dr. finally ordered that next time he has a "seizure," he is to be put into the turtle suit (the green suicide getup) and put into the observation room for 4 hours. That room is FREEZING so it took only 1 time in there for him to be "cured."

Specializes in ER.

WHOOP- I LOVE these- Being an ED nurse, we sure see a lot of them- We use the amonia ampule as well- Another good trick I learned from a Neurologist- If someone is having a "Seizure" or a "Coma"- taking a needle cover and putting it up inside their nose and wiggeling it will always casue them to react. Easy to tell the fakers from the real thing- much more accurate than the "Hand drop on the face"- Too many frequent fliers know that is coming-


50 Posts

A trick that was passed on to me was "Protecting their airway" with a nasal airway (NPA). That generally seems to weed out the fakers!


22 Posts

I have become a real fan of the ammonia inhalants. However, I am a bit intrigued by using an NPA to "protect the airway". Could that be considered battery?!? Inquiring minds wanna know!!

OrganizedChaos, LVN

1 Article; 6,883 Posts

Specializes in M/S, LTC, Corrections, PDN & drug rehab.

I loved using ammonia inhalants! Then when I started working at a chemical treatment facility for adolescents there was one client who they claimed to have "seizures". They kept sending her out to the ER, repeatedly! I was tired of this & pulled on my corrections knowledge, grabbed some ammonia inhalants, cracked them & put them to her nose. It cracked me up to see her try to hold her breath then turn red, sit up & "come out of it".

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