Pseudoseizures

1. Pseudoseizures Prof. Magdy Dahab Azhar University, Cairo April 18th, 2013

2. Seizure vs Epilepsy Seizures Nonepileptic Epilepsy (Recurrent Seizures) • Cardiovascular(syncope) • Metabolic (glucose, Na, Ca, Mg) • Toxic (drugs, poisons) • Infectious • Febrile convulsions • Pseudoseizure • Alcohol/drug withdrawal • Sleep disorders (cataplexy) Idiopathic (primary) Symptomatic (secondary) M Dahab

3. Pseudoseizures M Dahab Occur typically between 10 and 18 yr of age and are more frequent among girls. Occur with patients with a past history of epilepsy. There are several distinguishing features of pseudoseizure, including lack of cyanosis, normal reaction of the pupil to light, no loss of sphincter control, normal plantar responses, and absence of tongue biting.

4. Pseudoseizures M Dahab The most reliable method of differentiation epilepsy from suspected pseudoseizures is to record an attack. The EEG shows an excess of muscle artifact during the pseudoseizure. After a true epileptic seizure, there is a significant increase in serum prolactin whereas pseudoseizure not.

5. Pseudoseizures M Dahab It may be remarkably difficult to differentiate a pseudoseizure from an epileptic seizure Given that pseudoseizures are not due to abnormal electrical discharges in the brain, they do not respond to anticonvulsant medication, and these patients may end up being inappropriately treated for status epilepticus to the point of being intubated and put into a coma

6. M Dahab Compounding the confusion, is the fact that many patients with pseudoseizures may also have true epilepsy Things that may be seen in the field, which should raise the possibility of a pseudoseizure, include resistance to forced eye-opening, reactivity to noxious stimuli (such as inserting a nasopharyngeal airway), preserved consciousness during a bilateral seizure and asynchronous movements of the extremities

7. M Dahab None of these findings is, however, specific to pseudoseizures Cessation of the seizure in response to command or suggestion strongly suggests a pseudoseizure

8. Somatoform Disorders M Dahab The term somatoform derives from the Greek soma for body and the somatoform disorders are a broad group of illnesses that have bodily signs and symptoms as a major component.

9. DSM-IV-TR recognizes five specific somatoform disorders: M Dahab Somatization disorder Conversion disorder Hypochondriasis Body dysmorphic disorder Pain disorder

10. Conversion disorder M Dahab A conversion disorder is a disturbance of bodily functioning that does not conform to current concepts of the anatomy and physiology of the CNS or the PNS. It typically occur in a setting of stress and produces considerable dysfunction.

11. Conversion disorder M Dahab DSM-IV-TR defines conversion as characterized by the presence of one or more neurological symptoms that can not be explained by a known neurological or medical disorder. The diagnosis requires association of psychological factors with the initiation or exacerbation of the symptoms.

12. Conversion disorder M Dahab Conversation disorder can have its onset at any time from childhood to old age but it is most common in adolescents and young adults. Data include that conversion disorder is most among rural populations, person with little education, those in low socioeconomic groups and military personnel who have been exposed to combat situations.

13. Conversion disorder M Dahab Epidemiology: some symptoms of conversion disorder that are not severe enough to warrant the diagnosis, may occur in up to 1/3 of the general population. The ratio of w/m among adult patients is at least 2/1 and as mush as 10/1 among children.

14. Conversion disorder M Dahab Comorbidity Conversion disorder is commonly associated with diagnoses of major depressive disorder, anxiety disorders, and schizophrenia and shows an increased frequency in relatives of probands with conversion disorder.

15. Conversion DisorderEtiology M Dahab • Multidimensional • Psychoanalytic Factors • Learning Theory • Biological Factors

16. Etiology M Dahab • Psychoanalytic factors: • conversation disorder is caused by subconsciousintrapsychic conflict and conversation of anxiety into a physical symptom in form of symbolic relation. • The symptoms allow partial expression of the forbidden, so that patients can avoid consciously confronting their unacceptable impulses.

17. Conversion DisorderEtiology M Dahab • Learning Theory • Conversion disorder considered as piece of classically conditioned learned behavior • Symptoms of illness, learned in childhood, are called forth as a means of coping with an otherwise impossible situation.

18. Conversion DisorderEtiology M Dahab • Biological Factors • Brain imaging • Hypometabolism of dominant hemisphere • Hypermetabolism of nondominanthemisphere • Corticofugal feedback • ? Excessive cortical arousal setting off negative feedback loops between the cortex and reticular formation • Neuropsychological tests • Subtle cerebral impairments in verbal communication, memory, vigilance, affective incongruity, and attention • Increased incidence with head trauma

19. Diagnosis criteria for conversion disorder M Dahab • One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition. • The initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors. • The symptom or deficit is not intentionally produced or feigned.

20. Diagnosis criteria for conversion disorder M Dahab D) The symptom or deficit cannot be fully explained by a general medical condition or by the direct effects of a substance. E) The symptom or deficit cause clinically significant distress or impairment in social, occupational,…. F) The symptoms or deficit is not better accounted for by another mental disorder.

21. Conversion disorder M Dahab Symptoms Motor symptoms: involuntary movements, tics, blepharospasm, torticolli, opisthotones, seizure, abnormal gait, falling , astasia- abasia, paralysis, weakness, aphonia Sensory deficits: anesthesia(exteremities), blindness, tunnel vision, deafness

22. Symptoms M Dahab Visceral symptoms: psychogenic vomiting, pseudocyesis, globushystericus, syncope, urinary retention, diarrhea. Seizure symptoms: 1/3 of the patient’s pseudoseizure also have a coexisting epileptic disorder.

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24. Limitations of routine EEG: M Dahab Yield of a single routine scalp EEG is 50% Certain artifacts and normal variants can be confused with epileptiform discharges Some EEG abnormalities do not have a close correlation with clinical seizures

25. Limitations of routine EEG: M Dahab • Pathophysiologically – epileptic seizures are characterized by an excessive, disorderly, neuronal discharge • An EEG study may disclose epileptiform abnormalities which have a high correlation with occurrence of epileptic seizures • The only way to definitively prove epilepsy is to record a seizure

26. Limitations of routine EEG: M Dahab • Limited sampling • An EEG is a sampling of brain activity occurring at the timeof the recording • Seizures and spells are paroxysmal and may be missed on a short study • No video to correlate patient behavior with suspicious EEG changes

27. Goals of Video-EEG Monitoring • Epilepsy vs. non-epileptic events • Characterize epilepsy type • Pre-surgical evaluation M Dahab

28. Methodology M Dahab Multi-channel long term EEG recording with split screen video recording Digital storage of EEG and video data that can be reviewed later Performed under close monitoring of trained technologists and nurses Study is reviewed by a trained neurologist or epileptologist

29. Follow-up borderline EEG M Dahab Allows for prolonged collection of digital EEG Areas of uncertainty (i.e. artifact vs. abnormality) can be correlated with video material for clarification

30. Aids in diagnosis of spells: M Dahab • Causes other than epileptic seizures: • Syncope • Sleep apnea • Periodic movements of sleep • Non-epileptic seizures • Breath-holding spells • Migraine

31. Classification of seizure types M Dahab • Generalized • Absence • Generalized tonic, clonic, or atonic • Myoclonic • Partial onset • Simple or complex • Secondary generalization • Non epileptic

32. Non-epileptic events M Dahab • Physiologic (other medical conditions) • Referred to other medical specialist • Psychological or pseudoseizures • Referred to psychiatry and neuropsychologist who work with this type of stress-seizure • Psychiatric medication, psychotherapy, education

33. Diagnosis of non-epileptic events: Pseudoseizures M Dahab Studies have shown that 22% of patients with medically intractable seizures studied by video EEG monitoring had nonepileptic events Approximately 1/3 of patients studied at video monitoring centers have nonepileptic events The majority of patients with nonepileptic events have been inappropriately treated with antiepileptic medications for years

34. DIAGNOSIS - EXCLUDING EPILEPSY M Dahab 1. Clinical suspicion 2. Inter-ictal EEG 3. Telemetry 4. Serum prolactin

35. Treatment M Dahab Resolution of the conversion disorder symptom is usually spontaneous, although probably facilitated by therapy. The most important feature of the therapy is a relationship with a caring and confident therapist.

36. Treatment M Dahab Telling such patients that their symptoms are imaginary often makes them worse. Anxiolytics and behavioral relaxation exercises are effective in some cases.

37. Treatment M Dahab Parenteral amobarbital or lorazepam maybe helpful in obtaining additional historic information, especially when a patient has recently experienced a traumatic event. The longer the duration of these patient’s sick role, the more difficult the treatment.

38. Conversion DisorderCourse and Prognosis M Dahab Initial symptoms resolve within a few days to < a month in 90 to 100% (95% remit spontaneously, usually by 2 weeks) 75% have no further episodes, with 20-25% recurring within a year during periods of stress 25 to 50% present later with neurological disorders or nonpsychiatric medical conditions affecting the nervous system

39. Conversion DisorderCourse and Prognosis M Dahab • Predictors of good prognosis • Sudden onset • Easily identifiable stressor • Good premorbid adjustment • No comorbid psychiatric or medical disorders • Short duration • Short interval between onset and treatment • Above average intelligence • Paralysis, aphonia, blindness (tremor and seizures-poor prognosis)

40. Thank You www.magdydahab.com M Dahab