Complex partial and pseudoseizure disorders

Behavioural mechanisms involved in pseudo-epileptic seizures: a comparison between patients with epileptic seizures and patients with pseudo-epileptic seizures

The diagnosis of pseudo-epileptic seizures (PES) is confirmed in 7-10% of the patients that are considered to suffer from 'refractory epilepsies'. As yet no consistent model is available to explain the development of PES in individual patients. This open non-randomized clinical study aimed at assessing behavioural mechanisms that trigger PES, independent of the underlying personality characteristics. Twenty-four patients with PES were compared with pairwise matched patients that suffered exclusively from genuine epileptic seizures (ES). The patients were assessed with two personality inventories that measured potential important behavioural mechanisms: the 19 PF-form B of the Cattell IPAT Anxiety Scale and the Dutch ABV-scale, largely based on Eysenck's Maudsley Personality Inventory. This assessment was complemented with individual history taking and psychiatric examination. The results are presented in a model in which three factors are involved that have a combined effect on the development of PES in individual patients: personality disorders (of heterogeneous origin), the behavioural mechanism of somatization and a familiarity with epilepsy as a modifying factor.

Gender-related differences in non-epileptic attacks: a study of patients' cases in the literature

Gender-related differences for disorders of consciousness other than true epilepsy usually point to a larger number of women suffering especially from non-epileptic attacks or pseudoseizures. Recently, sexual abuse has been suggested as a possible cause for this increased prevalence in women. It has, however, not been very clear if women have a different phenomenology of these type of seizures from men. In the present study, patients' cases as published in the literature are analysed in a detailed way, using a working classification by Betts et al to look for gender-specificity. Of the 62 cases, 76% concern women and 24% men; a percentage comparable to those published elsewhere. Ages range from 14 to 77 years-of-age, but 89% of patients are younger than 40. Sexual abuse was proven in 18 cases, all women. The phenomenology of the attacks was divided into tonic-clonic type and complex partial type of attack, or a combination of the two. Also, special types of attacks (swoons, tantrums, abreactive attacks and forthright simulation) were looked for. Males tended to suffer especially from tonic-clonic type seizures (80% of cases), while in women as many tonic-clonic type as complex partial type attacks were observed. Special types of attacks were observed at the same frequency in both sexes. The group of sexual abuse victims did not differ from the total group of women in this respect. The clinically more impressive nature of a tonic-clonic-type attack, that is more easily suspected to be 'real', might make this type of seizure a more male form of acting out. A prospective study on the incidence and phenomenology of pseudo-epileptic seizures in the general population is suggested to answer the new questions raised in this survey.

Pseudoseizures after epilepsy surgery

Seizure surgery for medically intractable partial epilepsy in selected patients usually results in dramatically improved seizure control. However, the authors present six patients who, after surgery for refractory complex partial seizures, postoperatively experienced pseudoseizures (also known as nonepileptic seizures), confirmed with EEG monitoring. Three of these patients also had nonepileptic seizures preoperatively that coexisted with their partial epilepsy. Psychiatric assessment revealed that this patient group had several characteristics in common, which suggests that preoperative psychiatric consultation may help identify those patients at risk for developing nonepileptic seizures. Treatment strategies with anticonvulsant medications and behavioral therapy are reviewed.

Provocation of pseudoseizures by psychiatric interview during EEG and video monitoring

OBJECTIVE

This paper discusses a new technique for diagnosing pseudoseizures. The technique consists of an intensive psychiatric interview designed to provoke a pseudoseizure during EEG and video monitoring. We wished to determine the overall efficacy of the technique and learn how our patients felt about having undergone the procedure. We were also interested in whether their seizures persisted approximately three years later.

METHOD

We reviewed medical records and conducted telephone interviews with thirty of thirty-two patients who had previously undergone the procedure as part of an evaluation for unusual or intractable seizures. All evaluations had been performed on a university hospital neurology service. The patients were consecutive referrals to the consultative psychiatry service for suspicion of pseudoseizures.

RESULTS

Nineteen of the thirty-two patients interviewed had a pseudoseizure under EEG and video monitoring. Of the thirty reached by telephone for follow-up, twenty-two recalled the procedure as helpful or benign. None regarded the overall psychiatric consultation negatively. Among the patients who had exhibited pseudoseizures there was a variety of psychiatric diagnoses with a preponderance of personality disorders. Two thirds of those patients without coexisting epilepsy stopped having seizures or rarely had seizures following their evaluations.

CONCLUSIONS

The diagnostic technique described here is useful in patients with possible pseudoseizures. It does not appear to be harmful when employed as part of a comprehensive psychiatric consultation. How it may compare with other methods of pseudoseizure diagnosis will have to be determined by further study.

Hysterical seizures as a manifestation of "depression" in old age

A case of hysterical seizures is presented which is ultimately diagnosed as depression and treated successfully with tricyclic antidepressants. The need to re-examine our understanding of illness and the effect of classification on treatment decisions is emphasized.

Neuropsychiatric and electroencephalographic aspects in the diagnosis of complex partial seizures

The authors review from a psychiatric perspective some of the electroencephalographic techniques that may assist the clinician in diagnosing complex partial seizures (temporal lobe epilepsy). Routine scalp electroencephalograms may not detect temporal lobe EEG abnormalities, leading to the false impression of pseudo or hysterical seizures. Knowledge of the advantages of a sleep recording, specialized EEG electrodes (nasopharyngeal, sphenoidal), and natural or pharmacological activation techniques will increase one's diagnostic acumen. The authors discuss the appropriate use of these methods and their relevance to psychiatry.