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Pseudoseizure “status”
Journal of Psychosomatic Research, Vol. 42, No. 5, pp. 495-498, 1997 Copyright © 1997 Elsevier Science Inc. All rights reserved. 0022-3999/97 $17.(}0 + .CO
ELSEVIER
S0022-3999(97)00029-9
SHORT REPORT P S E U D O S E I Z U R E "STATUS" THOMAS
RECHLIN,* THOMAS
H. L O E W a n d P E T E R J O R A S C H K Y
(Received 6 February 1996; accepted 5 December 1996) Abstract--Psychogenic pain, disturbances of gait and stance, sensory symptoms, dizziness, and psychogenic seizures have been found to be the most common conversion symptoms in neurology clinics. A retrospective analysis of 18 patients suffering from pseudoseizure "status" is presented in this study. All of the patients fulfilled the DSM-III-R criteria of conversion disorder. However, 5 of them had concomitant major depression, 6 suffered from bulimia nervosa, and 7 met the criteria for substance abuse. On Axis II, 10 cases of borderline personality disorder, 2 cases of antisocial personality disorder, and 3 cases of histrionic personality disorder were diagnosed. The majority of the patients had attempted suicide and other forms of self-destructive behavior. The findings suggest that patients with pseudoseizure "status" suffer from severe affective imbalances and disturbed impulse control. © 1997 Elsevier Science Inc. Keywords:
Pseudoseizure "status;" Pseudoseizures; Factitious disease; Suicide attempts. INTRODUCTION
L e m b e r t et al. f o u n d t h e f r e q u e n c y o f p s y c h o g e n i c d i s o r d e r s to be a b o u t 9 % a m o n g n e u r o l o g i c a l i n - p a t i e n t s [1]. R e t r o s p e c t i v e analysis r e v e a l e d t h a t p a i n was t h e m o s t c o m m o n p s y c h o g e n i c s y m p t o m o f t h e s e p a t i e n t s , f o l l o w e d b y m o t o r s y m p t o m s , in p a r t i c u l a r s t a n c e a n d gait d i s t u r b a n c e s , dizziness, p s y c h o g e n i c seizures, s e n s o r y s y m p t o m s , a n d visual d y s f u n c t i o n [1]. I n a n o t h e r study, l o o k i n g at the 10-year p r o g nosis o f c o n v e r s i o n s y m p t o m s , a b o u t 4 0 % of t h e p s e u d o n e u r o l o g i c a l s y m p t o m s h a d p e r s i s t e d , a n d a s u b g r o u p o f p a t i e n t s m e t the criteria for s o m a t i z a t i o n d i s o r d e r at f o l l o w - u p [2]. Thus, t h e r e is a g r o w i n g i n t e r e s t in t h e clinical f e a t u r e s a n d p r o g n o s i s of c o n v e r s i o n d i s o r d e r s in n e u r o l o g y . This article d e s c r i b e s a p s y c h o g e n i c s y n d r o m e a b o u t which r e l a t i v e l y little is k n o w n . P s e u d o s e i z u r e " s t a t u s " is a p o t e n t i a l l y h a z a r d o u s n e u r o p s y c h i a t r i c s i t u a t i o n u s u a l l y m i s t a k e n l y d i a g n o s e d as a status e p i l e p t i c u s [3]. T h e p r e s e n t s t u d y was des i g n e d to d e s c r i b e t h e f r e q u e n c y of p s e u d o s e i z u r e "status," t h e c o i n c i d e n c e with epi l e p t i c d i s o r d e r s , a n d the o c c u r r e n c e o f p s y c h i a t r i c d i s o r d e r s .
METHODS All patients who were treated in our neurological or psychiatric department for pseudoseizure "status" between 1988 and 1992 were included in the study. Pseudoseizure "status" was diagnosed when disturbances of psychogenic responsiveness, motor behavior and/or respiration occurred simultaneously for Department of Psychosomatics and Psychiatry, University of Erlangen-Ntirnberg, Erlangen, Germany. Address correspondence to: Dr. Thomas Rechlin, Psychiatrische Universit~itsklinik, Schwabachanlage 6, 91054 Erlangen, Germany. Tel: +499131/854395; Fax: +499131/854436. 495
496
Short Report
more than 30 minutes, even though EEG recordings and other diagnosticmeasures did not provide any evidence for epilepsyor another organic disease [4].The patients underwent a full neurologicaldiagnostic evaluation. The evaluation included a medical history;observation of the attacks; ictal, postictal, and interictal EEG recordings; and simultaneous video and EEG recordings; in addition, EEG recordings after sleep deprivation and during photo provocation were conducted. CT scans were performed and postictal serum prolactin concentration was determined. The patients also underwent psychiatricdiagnosticevaluation.This was conducted by qualifiedpsychiatrists who applied a standardizedclinical interviewto the patients at the time when they were acutely ill. RESULTS Within the 5-year period, 18 patients were definitely diagnosed as having pseudoseizure "status." This amounted to 0.13% of all patients treated in our neurological or psychiatric department from 1988 to 1992. The majority of the patients were female (n = 13; 72%). The mean age of the patients was 22 years (range 17-29 years). All patients were initially considered to have a status epilepticus and were admitted to intensive care units. In the initial stages, 15 patients (83%) received thiopental or diazepam intravenously and 10 patients (56%) were intubated.
Pseudoseizure "status" and epilepsy Interictal epileptic activity, accompanied by a typical history of epileptic seizures, was found in three patients (17%). Simultaneous video and E E G recordings revealed the concomitant presence of pseudoseizures in these patients. Epileptic seizures of the three patients probably resulted from brain alteration acquired in early childhood, which was indicated by abnormal CT scans. In four other cases (22%), only the results of interictal E E G recordings suggested the possible occurrence of epilepsy, whereas simultaneous video and E E G recordings definitely proved the presence of pseudoseizures. In the remaining 11 cases, no signs of any epileptic disorder were found.
Psychiatric disorders Psychiatric examination confirmed the presence of a conversion disorder according to the criteria of DSM-III-R [5] in all cases. Additionally, five patients fulfilled the criteria for a major depression (28%), seven were diagnosed with eating disorders (39%), and seven suffered from substance abuse (39%). Fifteen patients suffered from Axis II disorders. Ten patients were diagnosed with borderline personality disorder, two patients with antisocial personality disorder, three patients with histrionic personality disorder. The remaining three patients met the criteria for mild mental retardation.
Suicide attempts, self-destructive behavior, sexual abuse Investigation revealed that 12 patients (67 %) had attempted suicide at least once. The majority of suicide attempts were drug overdoses (82%), whereas six patients had attempted self-strangulation. Seven patients attempted suicide within 1 week after termination of the pseudoseizures. Six of them had injured themselves sufficiently to require treatment at intensive care units. Concealed self-injuries were observed in nine patients (50%), whereas incisions on the arms were noted in five patients. Sexual abuse was reported by five female patients.
Short Report
497
DISCUSSION
Pseudoseizures are defined as psychogenic attacks of sudden unresponsiveness, frequently associated with motor manifestations which more or less resemble epileptic seizures [6]. Such attacks have been designated by a number of different terms, for instance, hysteroepilepsy, simulated epilepsy, and psychogenic seizures [7]. In the past, the close relationship between epileptic seizures and the occurrence of pseudoseizures has been emphasized [7, 8]. For diagnostic purposes, simultaneous video and EEG recordings, as well as plasma prolactin concentrations, have been established as the methods of choice for differentiating between epileptic attacks and pseudoseizures [9, 10]. In the present study, the psychiatric and psychodynamic findings of 18 patients having a history of pseudoseizure "status" showed a preponderance of female and adolescent patients. Interestingly, neurological diagnostics revealed that only a small minority had concomitant epileptic seizures, although peudoseizure "status" is always more or less similar in phenomenology to grand mal status. Accordingly, anticonvulsive status medication had been administered to the majority of these patients and treatment frequently resulted in intubation, artificial respiration, and admission to intensive care unit. The results indicate that the majority of the patients developed their illness in the context of long-standing personality disorders and affective imbalances [11]. In addition, patients with pseudoseizure "status" frequently had a history of suicide attempts, severe self-destructive behavior, eating disorders mainly in the form of bulimia nervosa, and various substance dependencies. In corroboration with these results, Schultz hypothesized that patients with this syndrome constitute a subgroup of the factitious disorders [4]. However, this hypothesis requires further research. From a therapeutic point of view, patients suffering from pseudoseizure "status" require psychological support for the underlying personality disorders. However, different diagnostic data protecting them from unnecessary and potentially dangerous medical intervention is not yet available [12, 13]. Encouraging case reports have been published by Schultz, who has treated a few patients using long-term psychoanalytic therapy. In these single case reports, the development of dissociative states leading to self-destructive behavior and the role of sexual and physical abuse has been illustrated [4, 12]. REFERENCES 1. Lembert T, Dieterich M, Huppert D, Brandt T. Psychogenic disorders in neurology: frequency and clinical spectrum. Acta Neurol Scand 1990;82:335-340. 2. Mace CJ, Trimble MR. Ten-year prognosis of conversion disorder. Br J Psychiat 1996;169:282-288. 3. Wilner AN, Bream PR. Status epilepticus and pseudostatus epilepticus. Seizure 1993;2:257-260. 4. Schultz U. Status pseudoepilepticus. In: Buchheim P, Ermann M, Seifert T, eds. Psychotherapie und Psychosomatik. Heidelberg: Springer; 1986:109-119. 5. Diagnostic and statistical manual of mental disorders, 3rd revised edition. Washington, DC: American Psychiatric Association; 1987. 6. Roy A. Pseudoseizures: a psychiatric perspective. J Neuropsychiat Clin Neurosci 1989;1:69-71. 7. Bauer J, Hilz MJ, Sappke U, Stefan H. Clinical symptomatology and treatment of status epilepticus. Fortschr Neurol Psychiat 1992;60:181-205. 8. Kristensen O, Alving J. Pseudoseizures: risk factors and prognosis. Acta Neurol Scand 1992;85: 177-180. 9. Boon PA, Williamson PD. The diagnosis of pseudoseizures. Clin Neurol Neurosurg 1993;95:1-8.
498
Short Report
10. Anzola GP. Predictivity of plasma prolactin levels in differentiating epilepsia from pseudoseizures: a prospective study. Epilepsia 1993;34:1044-1048. 11. Bowman ES. Etiology and clinical course of pseudoseizures. Relationship to trauma, depression, and dissociation. Psychosomatics 1993;34:333-342. 12. Ramchandani D, Schindler B. Evaluation of pseudoseizures. A psychiatric perspective. Psychosomatics 1993;34:70-79. 13. Moore PM, Baker GA, McDade G~ Chadwick D, Brown S. Epilepsy, pseudoseizures and perceived family characteristics: a controlled study. Epilep Res 1994;18:75-83.
ELSEVIER
S0022-3999(97)00029-9
SHORT REPORT P S E U D O S E I Z U R E "STATUS" THOMAS
RECHLIN,* THOMAS
H. L O E W a n d P E T E R J O R A S C H K Y
(Received 6 February 1996; accepted 5 December 1996) Abstract--Psychogenic pain, disturbances of gait and stance, sensory symptoms, dizziness, and psychogenic seizures have been found to be the most common conversion symptoms in neurology clinics. A retrospective analysis of 18 patients suffering from pseudoseizure "status" is presented in this study. All of the patients fulfilled the DSM-III-R criteria of conversion disorder. However, 5 of them had concomitant major depression, 6 suffered from bulimia nervosa, and 7 met the criteria for substance abuse. On Axis II, 10 cases of borderline personality disorder, 2 cases of antisocial personality disorder, and 3 cases of histrionic personality disorder were diagnosed. The majority of the patients had attempted suicide and other forms of self-destructive behavior. The findings suggest that patients with pseudoseizure "status" suffer from severe affective imbalances and disturbed impulse control. © 1997 Elsevier Science Inc. Keywords:
Pseudoseizure "status;" Pseudoseizures; Factitious disease; Suicide attempts. INTRODUCTION
L e m b e r t et al. f o u n d t h e f r e q u e n c y o f p s y c h o g e n i c d i s o r d e r s to be a b o u t 9 % a m o n g n e u r o l o g i c a l i n - p a t i e n t s [1]. R e t r o s p e c t i v e analysis r e v e a l e d t h a t p a i n was t h e m o s t c o m m o n p s y c h o g e n i c s y m p t o m o f t h e s e p a t i e n t s , f o l l o w e d b y m o t o r s y m p t o m s , in p a r t i c u l a r s t a n c e a n d gait d i s t u r b a n c e s , dizziness, p s y c h o g e n i c seizures, s e n s o r y s y m p t o m s , a n d visual d y s f u n c t i o n [1]. I n a n o t h e r study, l o o k i n g at the 10-year p r o g nosis o f c o n v e r s i o n s y m p t o m s , a b o u t 4 0 % of t h e p s e u d o n e u r o l o g i c a l s y m p t o m s h a d p e r s i s t e d , a n d a s u b g r o u p o f p a t i e n t s m e t the criteria for s o m a t i z a t i o n d i s o r d e r at f o l l o w - u p [2]. Thus, t h e r e is a g r o w i n g i n t e r e s t in t h e clinical f e a t u r e s a n d p r o g n o s i s of c o n v e r s i o n d i s o r d e r s in n e u r o l o g y . This article d e s c r i b e s a p s y c h o g e n i c s y n d r o m e a b o u t which r e l a t i v e l y little is k n o w n . P s e u d o s e i z u r e " s t a t u s " is a p o t e n t i a l l y h a z a r d o u s n e u r o p s y c h i a t r i c s i t u a t i o n u s u a l l y m i s t a k e n l y d i a g n o s e d as a status e p i l e p t i c u s [3]. T h e p r e s e n t s t u d y was des i g n e d to d e s c r i b e t h e f r e q u e n c y of p s e u d o s e i z u r e "status," t h e c o i n c i d e n c e with epi l e p t i c d i s o r d e r s , a n d the o c c u r r e n c e o f p s y c h i a t r i c d i s o r d e r s .
METHODS All patients who were treated in our neurological or psychiatric department for pseudoseizure "status" between 1988 and 1992 were included in the study. Pseudoseizure "status" was diagnosed when disturbances of psychogenic responsiveness, motor behavior and/or respiration occurred simultaneously for Department of Psychosomatics and Psychiatry, University of Erlangen-Ntirnberg, Erlangen, Germany. Address correspondence to: Dr. Thomas Rechlin, Psychiatrische Universit~itsklinik, Schwabachanlage 6, 91054 Erlangen, Germany. Tel: +499131/854395; Fax: +499131/854436. 495
496
Short Report
more than 30 minutes, even though EEG recordings and other diagnosticmeasures did not provide any evidence for epilepsyor another organic disease [4].The patients underwent a full neurologicaldiagnostic evaluation. The evaluation included a medical history;observation of the attacks; ictal, postictal, and interictal EEG recordings; and simultaneous video and EEG recordings; in addition, EEG recordings after sleep deprivation and during photo provocation were conducted. CT scans were performed and postictal serum prolactin concentration was determined. The patients also underwent psychiatricdiagnosticevaluation.This was conducted by qualifiedpsychiatrists who applied a standardizedclinical interviewto the patients at the time when they were acutely ill. RESULTS Within the 5-year period, 18 patients were definitely diagnosed as having pseudoseizure "status." This amounted to 0.13% of all patients treated in our neurological or psychiatric department from 1988 to 1992. The majority of the patients were female (n = 13; 72%). The mean age of the patients was 22 years (range 17-29 years). All patients were initially considered to have a status epilepticus and were admitted to intensive care units. In the initial stages, 15 patients (83%) received thiopental or diazepam intravenously and 10 patients (56%) were intubated.
Pseudoseizure "status" and epilepsy Interictal epileptic activity, accompanied by a typical history of epileptic seizures, was found in three patients (17%). Simultaneous video and E E G recordings revealed the concomitant presence of pseudoseizures in these patients. Epileptic seizures of the three patients probably resulted from brain alteration acquired in early childhood, which was indicated by abnormal CT scans. In four other cases (22%), only the results of interictal E E G recordings suggested the possible occurrence of epilepsy, whereas simultaneous video and E E G recordings definitely proved the presence of pseudoseizures. In the remaining 11 cases, no signs of any epileptic disorder were found.
Psychiatric disorders Psychiatric examination confirmed the presence of a conversion disorder according to the criteria of DSM-III-R [5] in all cases. Additionally, five patients fulfilled the criteria for a major depression (28%), seven were diagnosed with eating disorders (39%), and seven suffered from substance abuse (39%). Fifteen patients suffered from Axis II disorders. Ten patients were diagnosed with borderline personality disorder, two patients with antisocial personality disorder, three patients with histrionic personality disorder. The remaining three patients met the criteria for mild mental retardation.
Suicide attempts, self-destructive behavior, sexual abuse Investigation revealed that 12 patients (67 %) had attempted suicide at least once. The majority of suicide attempts were drug overdoses (82%), whereas six patients had attempted self-strangulation. Seven patients attempted suicide within 1 week after termination of the pseudoseizures. Six of them had injured themselves sufficiently to require treatment at intensive care units. Concealed self-injuries were observed in nine patients (50%), whereas incisions on the arms were noted in five patients. Sexual abuse was reported by five female patients.
Short Report
497
DISCUSSION
Pseudoseizures are defined as psychogenic attacks of sudden unresponsiveness, frequently associated with motor manifestations which more or less resemble epileptic seizures [6]. Such attacks have been designated by a number of different terms, for instance, hysteroepilepsy, simulated epilepsy, and psychogenic seizures [7]. In the past, the close relationship between epileptic seizures and the occurrence of pseudoseizures has been emphasized [7, 8]. For diagnostic purposes, simultaneous video and EEG recordings, as well as plasma prolactin concentrations, have been established as the methods of choice for differentiating between epileptic attacks and pseudoseizures [9, 10]. In the present study, the psychiatric and psychodynamic findings of 18 patients having a history of pseudoseizure "status" showed a preponderance of female and adolescent patients. Interestingly, neurological diagnostics revealed that only a small minority had concomitant epileptic seizures, although peudoseizure "status" is always more or less similar in phenomenology to grand mal status. Accordingly, anticonvulsive status medication had been administered to the majority of these patients and treatment frequently resulted in intubation, artificial respiration, and admission to intensive care unit. The results indicate that the majority of the patients developed their illness in the context of long-standing personality disorders and affective imbalances [11]. In addition, patients with pseudoseizure "status" frequently had a history of suicide attempts, severe self-destructive behavior, eating disorders mainly in the form of bulimia nervosa, and various substance dependencies. In corroboration with these results, Schultz hypothesized that patients with this syndrome constitute a subgroup of the factitious disorders [4]. However, this hypothesis requires further research. From a therapeutic point of view, patients suffering from pseudoseizure "status" require psychological support for the underlying personality disorders. However, different diagnostic data protecting them from unnecessary and potentially dangerous medical intervention is not yet available [12, 13]. Encouraging case reports have been published by Schultz, who has treated a few patients using long-term psychoanalytic therapy. In these single case reports, the development of dissociative states leading to self-destructive behavior and the role of sexual and physical abuse has been illustrated [4, 12]. REFERENCES 1. Lembert T, Dieterich M, Huppert D, Brandt T. Psychogenic disorders in neurology: frequency and clinical spectrum. Acta Neurol Scand 1990;82:335-340. 2. Mace CJ, Trimble MR. Ten-year prognosis of conversion disorder. Br J Psychiat 1996;169:282-288. 3. Wilner AN, Bream PR. Status epilepticus and pseudostatus epilepticus. Seizure 1993;2:257-260. 4. Schultz U. Status pseudoepilepticus. In: Buchheim P, Ermann M, Seifert T, eds. Psychotherapie und Psychosomatik. Heidelberg: Springer; 1986:109-119. 5. Diagnostic and statistical manual of mental disorders, 3rd revised edition. Washington, DC: American Psychiatric Association; 1987. 6. Roy A. Pseudoseizures: a psychiatric perspective. J Neuropsychiat Clin Neurosci 1989;1:69-71. 7. Bauer J, Hilz MJ, Sappke U, Stefan H. Clinical symptomatology and treatment of status epilepticus. Fortschr Neurol Psychiat 1992;60:181-205. 8. Kristensen O, Alving J. Pseudoseizures: risk factors and prognosis. Acta Neurol Scand 1992;85: 177-180. 9. Boon PA, Williamson PD. The diagnosis of pseudoseizures. Clin Neurol Neurosurg 1993;95:1-8.
498
Short Report
10. Anzola GP. Predictivity of plasma prolactin levels in differentiating epilepsia from pseudoseizures: a prospective study. Epilepsia 1993;34:1044-1048. 11. Bowman ES. Etiology and clinical course of pseudoseizures. Relationship to trauma, depression, and dissociation. Psychosomatics 1993;34:333-342. 12. Ramchandani D, Schindler B. Evaluation of pseudoseizures. A psychiatric perspective. Psychosomatics 1993;34:70-79. 13. Moore PM, Baker GA, McDade G~ Chadwick D, Brown S. Epilepsy, pseudoseizures and perceived family characteristics: a controlled study. Epilep Res 1994;18:75-83.