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Commentary: Contra pseudoseizure
Commentary: Contra Pseudoseizure The Problem of Intention in Nonepileptic Events Stephen L. Snyder, M.D.
In “In Defense of Pseudoseizure” [l], Dr. Phillip Slavney calls attention to the issue of intentionality in nonepileptic events mimicking epileptic seizures. This is an interesting but difficult topic. Dr. Slavney proposes a classification scheme wherein seizures are to be distinguished from pseudoseizures by what amounts to a single test: whether or not the event in question is “intended.” A seizure, whether epileptic or not, is to be defined by the absence of intention: “A seizure is something that happens to somebody. Its form is not chosen and its initial occurrence is never intended.” The term pseudoseizure, by contrast, is to be used to denote “a more or less conscious behavior whose form is chosen and whose every occurrence is (at some level of awareness) intended [l].” The notion that seizures, which “happen to” the patient, might be conceptually distinguished from which are intended, sounds pseudoseizures, straightforward. Clinical and research evidence, however, suggests that the world of seizures and seizure-like events may be more complicated than Dr. Slavney’s model would indicate. It is doubtful that the single test of intentionality will suffice to organize it. Clinically speaking, a test of intentionality may be difficult to apply in many of the more complex cases referred for psychiatric evaluation. Theoretically speaking, the test implies a separation of mind and body which is contrary to prevailing trends in neuropsychiatry; its either/or format may not capture the richness and complexity
Mount Sinai Medical Center, New York, New York Address reprint requests to: Stephen L. Snyder, Behavioral Medicine and Consultation Psychiatry, Mount Sinai MedicaI Center, Box 1228, One G.L. Levy Place, New York, NY 10029
248 ISSN 0163X343/94/$7.00
of the psychophysiological phenomena in question. Increasingly sophisticated monitoring techniques have cast doubt on the ability of even experienced clinicians to discriminate epileptic from nonepileptic behaviors by clinical examination. With the introduction of simultaneous video-EEG monitoring in the early 198Os, many patients previously considered to have only epilepsy were found to have nonepileptic seizures, either exclusively or in addition to their epileptic seizures [24]. Conversely, careful study using intracranial electrodes (so-called electrocortico-graphic/video monitoring [5]) in patients with seizure events traditionally considered to be hysterical has demonstrated that, remarkably, some are indeed epileptic [5-81. Certain patients whose events are marked by odd features such as kicking, thrashing, genital manipulation, and shouted obscenities, but whose surface EEG is entirely normal, may, with intracranial recording, be shown to have frontal complexpartial seizures [6]. Although such types of seizures are now familiar to epilepsy specialists, they represent phenomena which several decades ago might have been classified with confidence as pseudoseizures and therefore intentional. There is no reason to believe that the current state of our knowledge of epilepsy vs mimicking conditions is authoritative for all time. In a recent series of 12 patients who had been classified with conventional video-EEG monitoring as pseudoepilepfic, further study with intracranial electrodes found evidence for complex-partial seizures in six (50%) [5]. It is to be expected that each new technical advance in neurophysiologic assessment will reconfigure some familiar clinical notion along unfamiliar lines. As the borderland between the General Hospital Psychiatry 16, 24KL50, 1994 0 1994 Elsevier Science Inc. 655 Avenue of the Ameticas, New York, NY 10010
Contra Pseudoseizure neurological and the mental is mapped out more precisely, it is also likely that this borderland will increasingly be seen to contain mixed or ambiguous forms [9]. Dr. Slavney’s paper highlights the fact that a concept of intention is implicit in the psychiatric categories, such as conversion disorder, which we may currently apply. It is a strength of the Diagnostic and Statistical Manual ofMental Disorders in its successive editions that it struggles to address phenomena where intentional@ may be a factor. In actual practice, however, categories such as conversion disorder may convey a false sense of precision. The conclusion that the patient has conversion disorder, and is therefore “unconsciously producing” seizure-like behavior, may serve to cut short a diagnostic process which might otherwise reveal latent neurological [lO,ll], psychiatric [1216], and neuropsychological [17,18] features of the illness. In fact, as has been discussed elsewhere [ 191, conversion is more a “special symptom” than a disorder. An interesting twist on the question of intentionality is suggested by recent work concerning the high prevalence of panic disorder [15,16] and dissociative disorders [14] in certain groups of patients with nonepileptic or psychogenic seizures. In both panic disorder and dissociative disorders, the patient may suffer experiences (such as severe anxiety, or depersonalization in its various forms) that involve a feeling of total loss of control [20], or that to the patient himself are completely baffling and difficult to verbally communicate to others. It is possible that such patients may enact a seizurelike behavior in response to these mental experiences. Such an enactment might be seen by us as intended behavior, except that what is intended would occur in response to internal experiences that are not at all intended, but that happen to the patient. The observed prevalence of dissociative disorders and panic disorder, neither of which are strictly volitional, in these patients suggests that the issue of intentional@ is far from straightforward. It might be argued that even though the presence or absence of intention may be difficult to assess clinically, still the issue is conceptually important and therefore worth preserving in our vocabulary. This may be so. Intentionality is an important dimension to be noted in describing and eventually classifying the disorders resembling or mimicking epilepsy. However, the information available at this time does not seem to argue for a
simple dichotomy between intended and unintended nonepileptic events. Intentionality in nonepileptic seizures certainly represents an important piece of the puzzle. However, it is a very complicated puzzle, and there is much more work to be done before any comprehensive theory can be formulated. An important test of the adequacy of such a theory would be that it link the mental and the neurological, not split them apart.
References 1. Slavney PR: In defense of pseudoseizure. Gen Hosp Psychiatry 16:243-245, 1994 2. Desai BT, Porter RJ, Penry JK: Psychogenic seizures: a study of 42 attacks in six patients, with intensive monitoring. Arch Neurol 39:202-209, 1982 3. King DW, Gallagher BB, Murvin AJ, et al: Pseudoseizures: diagnostic evaluation. Neurology 32:1823, 1982 4. Gates JR, Ramani SV, Whalen S, et al: Ictal characteristics of pseudoseizures. Arch Neurol 42:118% 1187, 1985 5. Wyler AR, Hermann BP, Blumer D, et al: Pseudopseudoepileptic seizures. In Rowan AJ, Gates JR (eds), Non-Epileptic Seizures. Boston, ButterworthHeinemann, 1993, pp 73-84 6. Williamson I’D, Spencer DD, Spencer SS, et al: Complex partial seizures of frontal lobe origin. Ann Neurol 18:497-504, 1985 7. Morris HH, Dinner DS, Luders, et al: Supplementary motor seizures: clinical and electroencephalographic findings. Neurology 38:107>1082, 1988 8. Kanner AM, Morris HH, Luder H, et al: Supplementary motor seizures mimicking pseudoseizures: some clinical differences. Neurology 40:140~1407, 1990 9. McNamara ME, Fogel BS: Anticonvulsant-responsive panic attacks with temporal lobe EEG abnormalities. Neuropsychiatry 2:193-196, 1990 10. Gatfield PD, Guze SB: Prognosis and differential diagnosis of conversion reactions: a follow-up study. Dis Nerv Syst 23:623-631, 1962 11. Slater ETO, Glithero E: A follow-up of patients diagnosed as suffering from “hysteria.” J Psychosom Res 9:9-13, 1965 12. Roy A: Hysterical seizures. Arch Neurol36447, 1979 13. Stewart RS, Lovitt R, Stewart RM: Are hysterical seizures more than hysteria? A Research Diagnostic Criteria, DSM-III, and psychometric analysis. Am J Psychiatry 139:92&929, 1982 14. Bowman ES: Etiology and clinical course of pseudoseizures: relationship to trauma, depression, and dissociation. Psychosomatics 34:33%342, 1993 15. Rosenbaum DH, Snyder S, Rowan AJ, et al: Outpatient multidisciplinary management of non-epileptic seizures. In Rowan AJ, Gates JR (eds), Non-Epileptic Seizures. Boston, Butterworth-Heinemann, 1993, pp 275-283 16. Snyder SL, Rosenbaum DH, Rowan AJ, et al: SCID
249
S. L. Snyder diagnosis of panic disorder in psychogenic seizure patients. J Neuropsychiatry Clin Neurosci (in press) 17. Blumer D: The paroxysmal somatoform disorder: a series of patients with non-epileptic seizures. In Rowan AJ, Gates JR (eds), Non-Epileptic Seizures. Boston, Butterworth-Heinemann, 1993, pp 165-172 18. Bookheimer SY, Fedio I’: Ictal psychological changes in non-epileptic seizures and suspected frontotemporal dysfunction. In Rowan AJ, Gates JR (eds),
Non-Epileptic Seizures. Boston, mann, 1993, pp 243-255
Butterworth-Heine
19. Ford CV, Folks DG: Conversion disorders: view. Psychosomatics 5:371-383, 1985
an over-
20. Sheehan DV, Sheehan KH: The classification of anxiety hysterical states: Part II. Toward a more heuristic classification. J Clin Psychopharmacol2:386-393, 1982
In “In Defense of Pseudoseizure” [l], Dr. Phillip Slavney calls attention to the issue of intentionality in nonepileptic events mimicking epileptic seizures. This is an interesting but difficult topic. Dr. Slavney proposes a classification scheme wherein seizures are to be distinguished from pseudoseizures by what amounts to a single test: whether or not the event in question is “intended.” A seizure, whether epileptic or not, is to be defined by the absence of intention: “A seizure is something that happens to somebody. Its form is not chosen and its initial occurrence is never intended.” The term pseudoseizure, by contrast, is to be used to denote “a more or less conscious behavior whose form is chosen and whose every occurrence is (at some level of awareness) intended [l].” The notion that seizures, which “happen to” the patient, might be conceptually distinguished from which are intended, sounds pseudoseizures, straightforward. Clinical and research evidence, however, suggests that the world of seizures and seizure-like events may be more complicated than Dr. Slavney’s model would indicate. It is doubtful that the single test of intentionality will suffice to organize it. Clinically speaking, a test of intentionality may be difficult to apply in many of the more complex cases referred for psychiatric evaluation. Theoretically speaking, the test implies a separation of mind and body which is contrary to prevailing trends in neuropsychiatry; its either/or format may not capture the richness and complexity
Mount Sinai Medical Center, New York, New York Address reprint requests to: Stephen L. Snyder, Behavioral Medicine and Consultation Psychiatry, Mount Sinai MedicaI Center, Box 1228, One G.L. Levy Place, New York, NY 10029
248 ISSN 0163X343/94/$7.00
of the psychophysiological phenomena in question. Increasingly sophisticated monitoring techniques have cast doubt on the ability of even experienced clinicians to discriminate epileptic from nonepileptic behaviors by clinical examination. With the introduction of simultaneous video-EEG monitoring in the early 198Os, many patients previously considered to have only epilepsy were found to have nonepileptic seizures, either exclusively or in addition to their epileptic seizures [24]. Conversely, careful study using intracranial electrodes (so-called electrocortico-graphic/video monitoring [5]) in patients with seizure events traditionally considered to be hysterical has demonstrated that, remarkably, some are indeed epileptic [5-81. Certain patients whose events are marked by odd features such as kicking, thrashing, genital manipulation, and shouted obscenities, but whose surface EEG is entirely normal, may, with intracranial recording, be shown to have frontal complexpartial seizures [6]. Although such types of seizures are now familiar to epilepsy specialists, they represent phenomena which several decades ago might have been classified with confidence as pseudoseizures and therefore intentional. There is no reason to believe that the current state of our knowledge of epilepsy vs mimicking conditions is authoritative for all time. In a recent series of 12 patients who had been classified with conventional video-EEG monitoring as pseudoepilepfic, further study with intracranial electrodes found evidence for complex-partial seizures in six (50%) [5]. It is to be expected that each new technical advance in neurophysiologic assessment will reconfigure some familiar clinical notion along unfamiliar lines. As the borderland between the General Hospital Psychiatry 16, 24KL50, 1994 0 1994 Elsevier Science Inc. 655 Avenue of the Ameticas, New York, NY 10010
Contra Pseudoseizure neurological and the mental is mapped out more precisely, it is also likely that this borderland will increasingly be seen to contain mixed or ambiguous forms [9]. Dr. Slavney’s paper highlights the fact that a concept of intention is implicit in the psychiatric categories, such as conversion disorder, which we may currently apply. It is a strength of the Diagnostic and Statistical Manual ofMental Disorders in its successive editions that it struggles to address phenomena where intentional@ may be a factor. In actual practice, however, categories such as conversion disorder may convey a false sense of precision. The conclusion that the patient has conversion disorder, and is therefore “unconsciously producing” seizure-like behavior, may serve to cut short a diagnostic process which might otherwise reveal latent neurological [lO,ll], psychiatric [1216], and neuropsychological [17,18] features of the illness. In fact, as has been discussed elsewhere [ 191, conversion is more a “special symptom” than a disorder. An interesting twist on the question of intentionality is suggested by recent work concerning the high prevalence of panic disorder [15,16] and dissociative disorders [14] in certain groups of patients with nonepileptic or psychogenic seizures. In both panic disorder and dissociative disorders, the patient may suffer experiences (such as severe anxiety, or depersonalization in its various forms) that involve a feeling of total loss of control [20], or that to the patient himself are completely baffling and difficult to verbally communicate to others. It is possible that such patients may enact a seizurelike behavior in response to these mental experiences. Such an enactment might be seen by us as intended behavior, except that what is intended would occur in response to internal experiences that are not at all intended, but that happen to the patient. The observed prevalence of dissociative disorders and panic disorder, neither of which are strictly volitional, in these patients suggests that the issue of intentional@ is far from straightforward. It might be argued that even though the presence or absence of intention may be difficult to assess clinically, still the issue is conceptually important and therefore worth preserving in our vocabulary. This may be so. Intentionality is an important dimension to be noted in describing and eventually classifying the disorders resembling or mimicking epilepsy. However, the information available at this time does not seem to argue for a
simple dichotomy between intended and unintended nonepileptic events. Intentionality in nonepileptic seizures certainly represents an important piece of the puzzle. However, it is a very complicated puzzle, and there is much more work to be done before any comprehensive theory can be formulated. An important test of the adequacy of such a theory would be that it link the mental and the neurological, not split them apart.
References 1. Slavney PR: In defense of pseudoseizure. Gen Hosp Psychiatry 16:243-245, 1994 2. Desai BT, Porter RJ, Penry JK: Psychogenic seizures: a study of 42 attacks in six patients, with intensive monitoring. Arch Neurol 39:202-209, 1982 3. King DW, Gallagher BB, Murvin AJ, et al: Pseudoseizures: diagnostic evaluation. Neurology 32:1823, 1982 4. Gates JR, Ramani SV, Whalen S, et al: Ictal characteristics of pseudoseizures. Arch Neurol 42:118% 1187, 1985 5. Wyler AR, Hermann BP, Blumer D, et al: Pseudopseudoepileptic seizures. In Rowan AJ, Gates JR (eds), Non-Epileptic Seizures. Boston, ButterworthHeinemann, 1993, pp 73-84 6. Williamson I’D, Spencer DD, Spencer SS, et al: Complex partial seizures of frontal lobe origin. Ann Neurol 18:497-504, 1985 7. Morris HH, Dinner DS, Luders, et al: Supplementary motor seizures: clinical and electroencephalographic findings. Neurology 38:107>1082, 1988 8. Kanner AM, Morris HH, Luder H, et al: Supplementary motor seizures mimicking pseudoseizures: some clinical differences. Neurology 40:140~1407, 1990 9. McNamara ME, Fogel BS: Anticonvulsant-responsive panic attacks with temporal lobe EEG abnormalities. Neuropsychiatry 2:193-196, 1990 10. Gatfield PD, Guze SB: Prognosis and differential diagnosis of conversion reactions: a follow-up study. Dis Nerv Syst 23:623-631, 1962 11. Slater ETO, Glithero E: A follow-up of patients diagnosed as suffering from “hysteria.” J Psychosom Res 9:9-13, 1965 12. Roy A: Hysterical seizures. Arch Neurol36447, 1979 13. Stewart RS, Lovitt R, Stewart RM: Are hysterical seizures more than hysteria? A Research Diagnostic Criteria, DSM-III, and psychometric analysis. Am J Psychiatry 139:92&929, 1982 14. Bowman ES: Etiology and clinical course of pseudoseizures: relationship to trauma, depression, and dissociation. Psychosomatics 34:33%342, 1993 15. Rosenbaum DH, Snyder S, Rowan AJ, et al: Outpatient multidisciplinary management of non-epileptic seizures. In Rowan AJ, Gates JR (eds), Non-Epileptic Seizures. Boston, Butterworth-Heinemann, 1993, pp 275-283 16. Snyder SL, Rosenbaum DH, Rowan AJ, et al: SCID
249
S. L. Snyder diagnosis of panic disorder in psychogenic seizure patients. J Neuropsychiatry Clin Neurosci (in press) 17. Blumer D: The paroxysmal somatoform disorder: a series of patients with non-epileptic seizures. In Rowan AJ, Gates JR (eds), Non-Epileptic Seizures. Boston, Butterworth-Heinemann, 1993, pp 165-172 18. Bookheimer SY, Fedio I’: Ictal psychological changes in non-epileptic seizures and suspected frontotemporal dysfunction. In Rowan AJ, Gates JR (eds),
Non-Epileptic Seizures. Boston, mann, 1993, pp 243-255
Butterworth-Heine
19. Ford CV, Folks DG: Conversion disorders: view. Psychosomatics 5:371-383, 1985
an over-
20. Sheehan DV, Sheehan KH: The classification of anxiety hysterical states: Part II. Toward a more heuristic classification. J Clin Psychopharmacol2:386-393, 1982