Ammonia Capsules Are a Great Tool for Assessing Pseudoseizures

The question of whether a seizure-like event is a true epileptic seizure or some type of pseudoseizure is often very hard to sort out. Oftentimes (in fact, most of the time) these events do not happen in front of us. We just hear reports from the deputies of “something happening–looked like a seizure.” Or perhaps the patient himself will tell us that he had an seizure, like the patient I saw recently who told me “I’ve had four seizures this week.” Of course all of them were un-witnessed by anyone else.

Even though you might suspect that these un-witnessed seizure-like events are pseudoseizures, you should be very cautious about labeling such events “fake.” The absolute worst mistake that you as a medical provider can make in these cases is to declare an event “fake”—and be wrong. Until you are very sure, it is better to assume that un-witnessed events are real–or at least keep that possibility in the forefront of your mind. Until you have more evidence, you just don’t know for sure.

That is why it is so valuable when a patient has one of these seizure-like events right in front of you. This is the one opportunity to use objective findings to distinguish a true epileptic seizure from a pseudoseizure. I discussed in my last post the various differences in presentation between epileptic seizures and pseudoseizures, such as the nature of the shaking, eye deviation and a post-ictal period. Unfortunately, however, none of these findings are perfect.040 Continue reading

Pseudoseizures–Achieving Accurate Diagnosis

You are called by jail deputies to see a patient who had a short seizure and now is having another. The patient has only been in jail for a couple of days. He did not mention a seizure disorder at booking. He was arrested on a meth charge.

When you arrive, the patient is on the floor of the dorm, unresponsive and twitching. What do you do?

The diagnostic problem here is whether this is a true epileptic seizure or whether this is one of the various kinds of pseudoseizure. Accurate diagnosis is important because the treatment for the two conditions is so different.

Two epileptic seizures in short succession should make you think about status epilepticus and calling an ambulance. Even if the seizure stopped and you didn’t send this patient to the hospital, you would want a detailed examination in clinic to determine why these seizures happened. Is this a manifestation of some type of withdrawal, such as alcohol withdrawal? Does he have a seizure disorder that he did not tell you about before? You might consider a benzodiazepine like Ativan acutely and an anti-seizure drug like phenytoin. Down the road, you might want to do a work up, such as blood work, an EEG and maybe even a specialist referral.

On the other hand, if this is a seizure look-alike such as a Psychogenic Non-Epileptic Seizure (PNES), your treatment algorhythm would look much different. Then, your goal is just to stop the event and hopefully, be able to intervene in some way (counseling?) to prevent these from happening in the future. No ER visit. No seizure drugs. No EEG etc.

To get the diagnosis wrong—either way—would be to treat the patient inappropriately and perhaps even to harm the patient. So, accurate diagnosis is paramount.

It turns out that there are several observations, “field tests” and tools that can be useful in differentiating true epileptic seizures from pseudoseizures. There are even lab tests that can be useful! Some of these are much more reliable and accurate than others and I will point these out. Continue reading

Pseudoseizures—the Right Approach

I recently had to mediate a complaint from a jail deputy about a jail nurse. The jail deputy had called the nurse in to evaluate an inmate who was having seizures. The nurse said that they were pseudoseizures. The deputy was upset because “You’re accusing this inmate of faking. These weren’t faked. I was there and saw them.” He also was upset that “nothing was done” meaning that the patient was not sent to the ER and was not given any anti-seizure medications (the patient had requested Xanax to help control her seizures).

This little vignette has all of the elements of a good seizure/pseudoseizure case: a diagnostic dilemma (are these real seizures or not?), the potential for medical mismanagement if you get the diagnosis wrong, the possibility that the inmate is manipulating the situation, and, above all, a LOT of emotion. Everybody was upset here: The deputy was upset with the nurse for doing nothing about the patient’s medical problem. The nurse was disgusted and irritated with the patient for “faking.” The patient was upset—and filed a grievance– that she had not been given her “seizure medication” (Xanax).

The issue of seizures/pseudoseizures is a common occurrence in correctional institutions. Little has been written about this phenomenon. So today I’m going to begin to tackle the topic of pseudoseizures. It is a big enough subject that I am going to break it up into discrete segments, each of which (I hope) will have at least one pearl of wisdom to help guide the correctional care provider through this potential mine field.  We need to start by defining what I mean by a “real” epileptic seizure and what I mean when I say “pseudoseizure.”

Today’s Take Home Message: The word “pseudoseizure” does NOT equal “fake seizure.” Assuming this is a medical mistake and will get you into trouble. Continue reading