PSEUDOSEIZURE

GILBERT NERI MD
REASON UNDERSTANDING
• PRESENT TO YOU A • RESIDENT POINT OF VIEW

CLINICAL CASE

• PGI1 POINT OF VIEW

• THE NEUROLOGICAL
FINDINGS

• PGI2 POINT OF VIEW

• THE CHILD PSYCHIATRIC

FINDINGS
• SKEPTICISM

• SKEPTICISM
• INITIAL ORDERS

• FOCUSED PHYSICAL EXAM
 • COURSE IN THE WARD

 CLINICAL PRESENTATION

• PATIENT E.R.M. IS A 14 YEAR OLD FEMALE

• BIRTHDATE: APRIL 22, 2004

• FROM: SAN JOSE, INABANGA, BOHOL

• INFORMANTS: MOTHER'S SISTER, AND HERSELF

• RELIABILITY OF: 80%, 90%

• CHEIF COMPLAINT IS: SEIZURES

 CLINICAL PRESENTATION
• ONE DAY PRIOR OR ADMISSION THE AUNT CLAIMS THE
PATIENT HAD HER FIRST SEIZURE AND WAS
SUBSEQUENTLY ADMITTED TO THE LOCAL HOSPITAL.

• 4 HOURS PRIOR TO ADMISSION THE PATIENT WAS

REFERRED TO OUR INSTITUTION FOR NEGATIVE
NEUROLOGICAL FINDINGS, AND REQUEST FOR A
MENTAL HEALTH CONSULTATION.

• UPON ARRIVAL AT OUR INSTITUTION, THE PATIENT HAD

HER SECOND SEIZURE, AND HER THIRD SEIZURE
DURING THE INITIAL FOCUSED ASSESSMENT.

• NO OTHER HISTORY OF SEIZURE WAS NOTED WITH

THE CHILD. BUT THERE IS EVIDENCE THAT HER FATHER
SUFFERED FROM SEIZURES (NEURO HISTORY).
 NEURO PRESENTATION
• EACH SEIZURE LASTS FOR 1-2 MINUTES.

• EACH IS SIMILAR IN THAT THE PATIENTS ARMS ARE AT

HER SIDES BECOME RIGID. DEEP LABORED
BREATHING THEN BEGINS. HER EYES ROLL TO THE
BACK OF THE HEAD, HER FEET LOCK AND PELVIC
THRUSTS BEGIN. THRUSTS ARE SYMMETRIC AND
THRUST FROM 2-3 CYLES PER SECOND. THIS IS
FOLLOWED BY SCREAMING. AFTER 1-2 MINUTES THE
SEIZURES SUBSIDE.

• THERE IS NO PRE ICTAL AURA, NO HYPER-

SALIVATION, NO TONGUE BITING, NO URINATION, NO
DEIFICATION, NO BRUISING AND NO POST ICTAL LOSS
OF CONSCIOUSNESS.
 NEURO PRESENTATION

• ATTEMPTS WERE MADE TO QUELL THE SEIZURES

PRIOR TO A FOCUSED PHYSICAL EXAM:

• PULSE OX WAS TAKEN AT 98% AND THE PATIENT

WAS ENCOURAGED TO USE PAPER BAG
REBREATHER UNTIL THE PULSE OX DECREASED

TO 95%. THIS DID NOT AFFECT THE PATIENTS
SEIZURES BETWEEN THE SECOND AND THIRD
OCCURRENCE. THUS WAS DISCONTINUED.

• CAPILLARY BLOOD GLUCOSE WAS TAKEN AT:


97 mg/deciliter.
 NEURO PRESENTATION
• ATTEMPTS WERE MADE TO DETERMINE THE
GLASGOW COMA SCALE

• 2 FOR PATIENT OPENING EYES 


TO STERNAL PAIN

• 2 FOR PATIENT MAKES VERBAL SOUNDS 


TO STERNAL PAIN

• 4 PATIENT MAKES BODY MOVEMENTS


TO STERNAL PAIN,

NO DECORTICATE / DECEREBRATE POSTURE

• GCS 8
 NEURO PRESENTATION

• 5 MINUTES FOLLOWING THE PHENOBARBITAL

INFUSION, THE PATIENT HER 4TH SEIZURE
OCCURRENCE. THE PATIENT DISPLAYED POST ICTAL
HYPER LACRIMATION. DISCHARGE IS CLEAR, NO
COLOR, NO CLOUDINESS.

• 5 MINUTES FOLLOWING THE 4TH SEIZURE THE

PATIENT IS CONVERSANT AND SUBMITS TO 

A PSYCH EVALUATION AND A FOCUSED
NEUROLOGICAL EXAMINATION.
 PSYCH PRESENTATION

• DURING THE GCS EXAMINATION A VISUAL THREAT

TEST WAS PERFORMED SHOWING EYE BLINKING.

• EFFORTS ARE MADE TO FORM RAPPORT WITH THE

CHILD.

• HYPER LACRIMATION IS ENCOURAGED TO BLOT

• 4 MINUTES FOLLOWING THE 4TH SEIZURE THE

PATIENT'S FAMILY IS ENCOURAGED TO ALLOW
EXPRESSION OF LOSS.

• HYPER LACRIMATION INCREASES.

 PSYCH PRESENTATION
• 4 YEARS PTA MOTHER AND FATHER SEPARATED.
FATHER FINDS ANOTHER SIGNIFICANT OTHER IN
MANILA, THE FOUR CHILDREN REFER TO HER AS
THEIR STEP MOTHER. RELATIONS WITH THE CHILDREN
VS THE STEP MOTHER WERE CONTENTIOUS. THE
FATHER DEALS WITH HIS PROBLEMS BY DRINKING GIN
AND COBRA. PHYSIOLOGICAL DEPENDENCE IS
EVIDENT WITH HIS HISTORY OF DELIRIUM TREMENS.

• 3 YEARS PTA THE CHILDREN WERE ASKED TO PICK

THEIR FATHER UP AT A LOCAL BAR IN MANILA. UPON
ARRIVAL, THEY FOUND HIS LIFELESS BODY. SIX DAYS
AFTER THE BURIAL, THE PATIENT ATTEMPTED SUICIDE
BY DRINKING GIN AND COBRA, BUT WAS ABLE TO
STOP HAVING SEEN A VISION OF HER FATHER ASKING
HER NOT TO. THE PATIENT WAS 12 YEAR OLD.
 PSYCH PRESENTATION

• 2 YEARS PTA THE 4 CHILDREN WERE ADOPTED BY A

FAMILY FRIENDS IN NORTHERN LUZON. PATIENT
CONTINUES TO SEE VISIONS OF HER FATHER. PATIENT
IS A VICTEM OF A MOTOR VEHICLE ACCIDENT. THE
MOTORCYCLE HIT HER, FALLING TO HER RIGHT
TEMPLE. SHE IS ADMITTED TO A LOCAL HOSPITAL
FOR ONE DAY. HAVING NEGATIVE FINDINGS SHE WAS
RELEASED FROM OBSERVATION.

• 3 MONTHS PRIOR TO ADMISSION PATIENT AND

YOUNGEST BROTHER RELOCATE TO SAN JOSE,
INABANGA, BOHOL. PATIENT PLANS TO RETURN TO
BATAAN AFTER SHE TURNS 18.
 PSYCH PRESENTATION
• SUMMER IN INABANGA PATIENT MEETS AND MAKES FRIENDS.
DESPITE HAVING THE LETTERS SPELLING LOVE ON HER
FINGERNAILS, SHE CLAIMS SHE DOES NOT HAVE CLOSE
RELATIONS.

• DEPRESSION SYMPTOMS: NO DIFFICULTY WAKING UP, NO GUILT,

PATIENTS HAS INTERESTS, THE PATIENT HAS A SUICIDAL IDEATION,
HAS MADE ONE SUICIDE ATTEMPT AND ADMITS THAT IT WAS HER
IMITATING HER FATHER TO JOIN HIM, BUT CURRENTLY HAS NO
SUICIDE PLAN.

• THE PATIENT CONTINUES TO HAVE VIVID VISIONS OF HER FATHER.

WORST BEFORE THE SEIZURE BEGINS. SHE EXPRESSES HER
CLOSENESS TO HIM IN TERMS OF FONDNESS TO ACTIVITIES SUCH
AS PIZZA BURGER TIME.

• TRANSFERENCE: WHEN ASKED PHYSICAL CHARACTERISTICS OF

HER FATHER, THERE IS A NOTED SIMILARITY BETWEEN THE
INTERVIEWER AND THE FATHER AND A NOTED INAPPROPRIATE
GAZE.
 PSYCH PRESENTATION
• HOME IS: THE FAMILY IS SPLIT BETWEEN SAN JOSE
AND BATAAN. BETWEEN MOTHER'S FAMILY AND FAMILY
FRIENDS RESPECTIVELY.

• EDUCATION IS: THE PATIENT IS IN THE 7TH GRADE. SHE

WILL BE GOING TO SCHOOL IN TAGBILARAN CITY IN
THE COMING SEMESTER. SHE GETS GOOD GRADES.

• ACTIVITIES: PATIENT HAS MADE CLOSE FRIENDS AND

ENJOYS SPENDING TIME WITH BOTH GIRLS AND BOYS
(COUSINS)

• DRUGS: PATIENT DENIES HAVING DONE STREET

DRUNGS, AND ONLY ADMITS TO THAT ONE INCIDENT.

• SPIRITUAL: ROMAN CATHOLIC

 CASE PRESENTATION
• SPIRITUAL: ROMAN CATHOLIC

• FAMILY ILLNESSES:

• FATHER 39 / CONSTRUCTION / HSG / ALCOHOLISM

• MOTHER 57 / HOUSE WIFE / 4TH GADE /


HYPERTENSION & BACK PAIN

• 15 GIRL / 7TH GRADE / WELL

• PATIENT

• 12 BOY / 6TH GRADE / WELL

• 9 GIRL / 3RD GRADE / WELL

 PSEUDO SKEPTICAL?
• AFTER BEING PRESENTED WITH THE COMPLEX
HISTORY OF SEIZURES ARE YOU CONVINCED SHE
HAS PSEUDO SEIZURES?

• REMEMBER THE IMPACT OF OF MISDIAGNOSIS CAN

BE LIFE CHANGING. THE SIDE EFFECT PROFILES OF
ANTI-CONVULSIVE MEDICATIONS ARE EXTENSIVE.
 PHYSICAL EXAM
• RESPIRATORY RATE: 22: O2 SAT 98% ROOM AIR, 95%
REBREATHER

• GENERAL: GCS 8 -> GCS 15

• NO EVIDENCE OF HEAD TRAUMA

• HEENT: NO VISIBLE TRAUMA, ESP RIGHT TEMPLE, NO

ALCOHOL ON BREATH, NO THYROID MASSES OR LESIONS

• NO PHYSICAL ETIOLOGY FOR HEAVY CHEST:

• CRT < 2 SECONDS, NO CYANOSIS

• RESPIRATORY: EQUAL, SYMMETRIC, NO SUBCOSTAL

RETRACTIONS.

• CARDIO: ADYNAMIC PRECORDIUM, NORMAL HEART RATE AND

RHYTHM, NO SEPTAL OR VALVULAR MURMURS.
 PHYSICAL EXAM
• NO PHYSICAL SIGNS OF SEIZURE

• NO LIP OR TONGUE BITING

• NO NIPPLE DISCHARGE (MOTHER ASSISTED)

• GU: NEGATIVE KIDNEY THUMP, NO INTRA ICTAL URINATION,

• GI: NO INTRA ICTAL DEIFICATION

• NO EVIDENCE OF DRUG ABUSE

• SKIN: NO NEEDLE TRACK MARKS, NO SKIN POPPING, TATOOS TO

HIDE MARKS

• ORAL: GOOD DENTAL HYGENE, NO ETHANOL BREATH, 


NO FETOR HEPATICAS

• GI: NO CAPUT MEDUSA, NO SPIDER ANGIOMATA, LIVER LESIONS,

ABDOMINAL TENDERNESS
 PHYSICAL EXAM
• NO EVIDENCE OF PHYSICAL ABUSE OR SELF HARM

• HEENT: NORMOCEPHALIC, ATRAUMATIC

• PASSIVE NEGLECT: NO WASTING, NO STUNTING

• EXTREMITIES: NO CUT MARKS, NO BRUISES, NO

JOINT DEFORMITY

• SPINE: MIDLINE, NO TENDERNESS

• NO AVERSION TO PEOPLE ENTERING OR LEAVING

THE EMERGENCY ROOM

• AVERSION TO FAMILY MEMBERS

 PHYSICAL EXAM
• POSSIBLE TRUE FOCAL DEFICIT / OR PSEUDO FOCAL DEFICIT

• CN I - PATIENT CLAIMS NOT TO SMELL VICKS

• CN II - PATIENT CLAIMS NOT TO BE ABLE TO SEE PERIPHERAL

MOVEMENTS

• CN III, IV, VI - EXTRA OCULAR MUSCLES INTACT

• CN V - INTACT, SYMMETRIC

• CN VII - INTACT, SYMMETRIC

• CN VIII - INTACT

• CN IX, X, XII - INTACT SYMMETRIC

• CN XI - INTACT SYMMETRIC

• NO TWO POINT DISCRIMINATION BELOW THE ANKLES

 RESIDENT'S POINT OF VIEW
• THE DECISION TO INFUSE A LOADING DOSE OF
PHENOBARBITAL AND ADMIT THE PATIENT UNDER
SEZURE DISORDER WERE BASED ON THE FOLLOWING
SALIENT FEATURES:

• THE EYES ROLLING BACKWARDS DURING THE 2ND,

AND 3RD SEIZURES.

• NO RESPONSE TO HYPERVENTILATION THERAPY

• NORMAL CAPILLARY BLOOD GLUCOSE LEVEL

• GCS 8

• THE POSITIVE RESPONSE TO THE LOADING DOSE

OF PHENOBARBITAL
 PGI 1 & CONSULTANTS VIEW
• THE DECISION TO ADMIT FOR SEIZURE DISORDER MAY BE
ADJUSTED TO CONSIDER MALINGERING BASED ON THE
FOLLOWING SALIENT FEATURES.

• POSITIVE VISUAL THREAT TEST

• SEIZURE WITH NO HISTORY LOSS OF CONSCIOUSNESS, AND NO

LOSS OF BODILY FLUIDS, AND DEIFICATION.

• NO PHYSICAL SIGNS OF SEIZURE DISORDER: LIP AND TONGUE

BITE MARKS, LOSS OF SALIVA, LOSS OF URINE, NO DEIFICATION.

• SPONTANEOUS GCS 8 TO GCS 15

• THE FACT THAT THE PATIENT IS MORE CONCERNED ABOUT THE

LOSS OF HER FATHER THAN HER ACUTAL 4 SEIZURES SHE HAD.

• SEIZURES SECONDARY TO MALINGERING SHOULD NOT BE

ADMITTED, FOR THE FACT CREATES REPETITIVE ADMISSIONS.
 PGI 2 POINT OF VIEW
• CONVERSION DISORDER IS A RULE OUT DIAGNOSIS.
ALL OTHER MEDICAL CAUSES SHOULD BE RULED OUT.
ALL NEUROLOGICAL CAUSES SHOULD BE RULED OUT,
BEFORE REFERRAL FOR PSYCHIATRIC EVALUATION

• POSITIVE VISUAL THREAT TEST

• SEIZURE WITH NO HISTORY LOSS OF

CONSCIOUSNESS, AND NO LOSS OF BODILY FLUIDS,
AND DEIFICATION.

• NO PHYSICAL SIGNS OF SEIZURE DISORDER: LIP

AND TONGUE BITE MARKS, LOSS OF SALIVA, LOSS
OF URINE, NO DEIFICATION.

• SPONTANEOUS GCS 8 TO GCS 15.

 TRANSFERENCE

• Sigmund Freud

• "Transference is a theoretical phenomenon characterized

by unconscious redirection of the feelings a person has
about a second person to feelings the first person has
about a third person. It usually concerns feelings from an
important second-person relationship from childhood,
and is sometimes considered inappropriate."
 PGI 2 POINT OF VIEW
• PSYCHIATRIC SALIENT FEATURES

• THE FACT THAT THE PATIENT IS MORE CONCERNED ABOUT THE

LOSS OF HER FATHER THAN HER ACUTAL 4 SEIZURES SHE HAD.

• INAPPROPRIATE GRIEVING. TWO YEARS HAD PASSED SINCE

HER FATHER'S DEATH AND SHE CLINGS TO THE THOUGHT THAT
HE IS STILL ALIVE. GRIEF BYOND 6 MONTHS IS INAPPROPRIATE.

• SUICIDAL IDEATION, ONE SUICIDE ATTEMPT


THROUGH IMITATION.

• POSSIBLE IMITATION OF DELIRIUM TREMENS SEIZURES.

• RAPPORT LEADING INAPPROPRIATE GAZE


AND TRANSFERENCE TO DARK FILIPINO MALES

• 4 YEARS OF MAJOR FAMILIAL PROBLEMS AND POSSIBLE

BLAME ON MOTHER.
 Seizure Malingering Conversion
• EYES ROLLING IN
 • EYES ROLLING IN
 • EYES ROLLING IN

THE BACK OF HEAD
THE BACK OF HEAD
THE BACK OF HEAD

• NO RESPONSE TO
 • NO RESPONSE TO
 • NO RESPONSE TO


HYPERVENTILATION
 HYPERVENTILATION
 HYPERVENTILATION

THERAPY
THERAPY
THERAPY

• NORMAL CBS
• NORMAL CBS
• NORMAL CBS

• GCS 8
•
•

• POSITIVE RESPONSE
 • POSITIVE RESPONSE
 • POSITIVE RESPONSE


TO PHENOBARBITAL
 TO PHENOBARBITAL
TO PHENOBARBITAL




 • NORMAL VISUAL
 • NORMAL VISUAL


 THREAT TEST
THREAT TEST




 • NO CLASSIC
 • NO CLASSIC


 SYMPTOMS
SYMPTOMS







• NO CLASSIC
 • NO CLASSIC

PHYSICAL FINDINGS
PHYSICAL FINDINGS






 • SPONTANEOUS
 • SPONTANEOUS

GCS 8 -> GCS 15
GCS 8 -> GCS 15






 • SEIZURE APATHY
 • SEIZURE APATHY


 






 • EVIDENCE OF GRIEF








 • PREVIOUS SUICIDE


 IDEATION -> ATTEMPT


 


 


 
 • TRANSFERENCE



• FAMILIAL PROBLEMS
CONVERSION DISORDER DSM-5
• 1. One or more symptoms are present that either affect

voluntary motor or sensory function or cause 

transient loss of consciousness.

• 2. The symptom is, after appropriate medical assessment, 


found not to be due to a general medical condition, the direct effects
of a substance, or a culturally sanctioned behavior or experience.

• 3. One or more diagnostic features are present that provide evidence

of internal inconsistency or incongruity with recognized neurological
or medical disorder.

• 4. The symptom causes clinically significant distress or impairment in

social, occupational, or other important areas of functioning or
warrants medical evaluation.
INAPPROPRIATE LOADING DOSE
• PHENOBARBITAL LOADING DOSE FOR SEIZURE(S) IS
20mg/kg

• Patient's Weight 49 kg

• 20 mg x 49 kg = 980 mg Needed

• 1 Amp contains 130 mg of Phenobarbital

• 980 Loading Dose - 130 Actual Dose = 850 mg Needed

• PEDIATRIC NEUROLOGIST: 

"So we were just tickling the patient."
 ADMITTING ORDERS
• PLEASE ADMIT THE PATIENT TO • LABS:

PEDIATRIC ADOLESCENT
WARD
• CBC

• SECURE CONSENT TO CARE

• Na+, K+, Ca++, Mg++

• VITAL SIGNS EVERY 4 HOURS • CBS - Drawn at 97 mg/dl

INCLUDING O2 SAT

• SEIZURE PRECAUTIONS

• MONITOR I/O PER SHIFT

• IVF PNSS 1 LITER @ 22 GTTS/

• BED RAILS UP

MIN

• ELEVATE HEAD OF BED

• NPO (SEIZURE PROTOCOL)

• REFER IF SEIZURE
RECURRENCE, POOR
• ECG

PERFUSION, CYANOSIS, 

AND OTHER UNUSUALITY
 ADMITTING ORDERS
• SUGGESTED WOULD BE • CBC RESULTS

SUICIDE PRECAUTION


 • WBC 9.6

ATTENDED BY FAMILY NUT 64, LYM 29, MON 5, 

MEMER OR WATCHER IF EOS 2, BAS 0

NO FAMILY MEMBER IS
AVAILABLE
 • HB 12.1, HCT 35.89, 

MCV 86.1


• ECG RESULTS-

NORMAL SINUS RHYTHM
 • ELECTROLYTE RESULTS




 • Na: 141, K: 3.47, Ca: 1.22,

Mg: .53 mmol/L





• CBS - Drawn at 97 mg/dl

COURSE IN THE WARD
• THE PATIENT SHARED A ROOM
WITH ANOTHER ADOLESCENT
FEMALE WITH SEIZURES OF
UNKNOWN ETIOLOGY

• BOTH WITH SIMILAR FAMILY

ISSUES

• BOTH WITH A VOCAL RANGE

OF MID TO UPPER TONES

• BOTH FEEDING OF EACH

OTHERS VOCAL ENERGY
DURING SEIZURES. IN
CRESCENDO AND
DECRESCENDO.

• BOTH ON CONSULT WITH


THE PEDIATRIC NEUROLOGIST

 COURSE IN THE WARD
• THE PEDIATRIC • PSYCHIATRY CONSULT WAS
NEUROLOGIST CONFIRMED REQUESTED

THE SUSPICION OF PSEUDO-

SEIZURE
• THE PSYCHIATRIC CONSULTANT
ADJUSTED DIAGNOSIS: MIXED
ANXIETY DEPRESSIVE
• AND IT WAS DECIDED THAT
DISORDER

THE DUO WOULD

EVENTUALLY BE MOVED TO
SEPARATE HOSPITAL AREAS • ORDERED ESCITALOPRAM 10mg
TAB,1/2 TAB BREAKFAST OD.

AS THEIR PSEUDO-SEIZURES
DREW ONLOOKERS

• ORDERED RESPIRADONE 1mg

TAB, 1/2 TAB ONCE HS.

• DIAZEPAM 5gm IVTT or


MIDAZOLAM 5mg IV or IM, • THE PATIENT WAS LATER
FOR AGITATION WAS DISCHARGED IN STABLE
ORDERED
CONDITION TO BE FOLLOWED
UP ON AN OUTPATIENT BASIS,
ON THE TAPERED PSYCHIATRIC
• SAFTEY PRECAUTIONS AT
MEDICATION.
ALL TIMES