Psychogenic nonepileptic seizures

[NomadicMedic]

I'm curious how other medics treat psychogenic nonepileptic seizures or "pseudoseizures".

As some background, Psychogenic nonepileptic seizures (PNES), or pseudoseizures are paroxysmal episodes that resemble and often misdiagnosed as epileptic seizures; however, PNES are psychological (ie, emotional, stress-related) in origin.

I've found that ED staff is not very tolerant of these patients, as they all seem to think the PT is faking the seizure activity, beacuse there is no postictal period, the patient doen't have a seizure history, isn't on antiseizure meds or admits to pseudoseizures.

Anyone have experience with this?

 

[NomadicMedic]

I ask because I had a patient this weekend, found in seizure on the kitchen floor. Her husband told me she has a history of pseudoseizures and conversion disorder. I'm not a mental health professional, nor am I going to try to differentiate between and epeleptic and non-epileptic seizure in the field. My only option was to get the patient into the back of my medic unit, try and reduce her anxiety and treat her with some benzos. As I mentioned above, there was no postictal period. When the seizure activity ended, she was lucid, and did not want to be transported to the hospital because she was tired of being labeled a "faker and drug seeker".

It was a confusing and, after hearing her history, sad case...

 

[Veneficus]

I ask because I had a patient this weekend, found in seizure on the kitchen floor. Her husband told me she has a history of pseudoseizures and conversion disorder. I'm not a mental health professional, nor am I going to try to differentiate between and epeleptic and non-epileptic seizure in the field. My only option was to get the patient into the back of my medic unit, try and reduce her anxiety and treat her with some benzos. As I mentioned above, there was no postictal period. When the seizure activity ended, she was lucid, and did not want to be transported to the hospital because she was tired of being labeled a "faker and drug seeker".
It was a confusing and, after hearing her history, sad case...

Poor medicine, no other explanation unless she is a drug seeker.

 

[NomadicMedic]

Poor medicine, no other explanation unless she is a drug seeker.

I don't understand... My treating the patient was poor medicine, or the hospital had been treating her poorly?

When I arrived at the ED with the PT, the RN rolled his eyes after I filled him in on the situation and history. But, faking or not, I'm going to treat the patient with compassion, kindness and respect.

 

[Aidey]

In my limited experience I think these patients frustrate the hospitals because there is pretty much nothing they can do but watch them and send them home with xanax (or whatever) and a referral to psych. EDs do not like patients who use them for management of a chronic condition on a regular basis.

Imagine if you had a diabetic, who rather than giving themselves insulin, waited till their blood sugar was high enough and then went to the ED for their insulin. Or a patient with depression that goes to the ED when they want to talk to someone rather than make regular appointments with a counselor.

There is also the fact that there is still a bias in healthcare asa whole about psych patients.

Something I have run into are people with psychogenic seizures who do not understand their disorder at all, which really complicates the situation.

 

[mycrofft]

IF you consider Munchhauisen's an illness, many more are sick.

The perceived necessity to lie or prevaricate to get attention and care can be either emotional insecurity, psychatric or psychological illness, or something of them all. This can include a partner who reports then participates in the whole shebang

This is not including those who pragmatically do it to get drugs of abuse.

ER and all medical staff just get tired of people lying to them and non-postictal seizures look like lying.

Differential: if someone has a full blown funky chicken grand mal, they are going to be postictal, not neccesarily incontinent, and may show signs of trauma from unguarded falling or biting inside of mouth. Postictal means out of it, no resisting eyelid lifting, no holding their breath when they hear the ammonia "pop", no smiling, no cracking open eyelids to peek around. I personally know individuals for whom the sternal rub is a joke.

Absence seizures or petite mal with very limited epileptiform activity can conceiveably not always have a postictal state beyoind having "lost" the period of time their brain was otherwise occupied.

I am convinced that people reporting grand mal without postictal were "had" by a false seizure but working in good faith based on trusting the pt explicitly.

Follow your protocols and treat em fairly and honsetly , you may avoid undertreating someone who needs it, and fakers or Munchausen victims will sue you, in fact, may set traps to get witnesses see you non-treating them

 

[Melbourne MICA]

In control

I think we've all had this kind of patient at least once in our careers and what can you do? Treat all patients with respect, courtesy and kindness, definitely.
As for how you treat if at all - you have to make some form of clinical judgement. If they don't need interventions then they don't need interventions. Transport may well be mandated if for no other reason than to cover your butt. If ED staff want to scoff and roll their eyes then you can ask them what they would do in your shoes with your limitations and imposed directives.

As for picking the seizure faker I agree with mycroft - there are physiological signs that come with generalised seizures as well as general principles you can apply to make the assessment more accurate.

One principle I use is to look for voluntary muscle control. In a generalised seizure - ie one involving the whole brain the motor cortex is disabled. So the patient CANNOT have voluntary muscle movements and both sides are affected at the same time.

So I look for them if the situation looks suspect - eg normal obs, no tachy, no sweating or hot skin, no wrist flexion, no Phx or meds, no head trauma or drugs involved, they hold a limb on one side in one position while the other is doing something different etc.

Doesn't always work but works often enough. The attention seeker wants attention. Walk out of the room, pack up your gear but have one observer handy to sneak a peak around a corner. And if the seizure is legit you still won't compromise the pt if the obs were good to start with by walking out for a few minutes.

MM

 

[Veneficus]

I don't understand... My treating the patient was poor medicine, or the hospital had been treating her poorly?

When I arrived at the ED with the PT, the RN rolled his eyes after I filled him in on the situation and history. But, faking or not, I'm going to treat the patient with compassion, kindness and respect.

I meant the hospital was practicing poor medicine. Sorry for the confusion.

 

[ExpatMedic0]

I had a patient we went on regularly that sounds just like yours. However whenever I got them loaded into the ambulance they always stopped, every time. The hospital would always be irritated when I should up with the patient.

 

[OrlMedic3388]

I have several patients where I work that have pseudoseizures. I was told by a doctor in one of the hospitals that if in fact it is a pseudoseizures, you can verbally control the patients "seizure." Next time you encounter them trying telling them to stop doing what they are doing. The doctor said to use a loud voice (not yelling though) and tell them to stop. Obviously if it is a real seizre this wont work. I have seen this work on two different patients.

 

[medicsb]

Where I worked, I encountered enough people faking seizures and unconsciousness that it was at the top of my differential. But, these weren't people diagnosed with severe psychological disorders such as conversion disorder. For her to have actually been diagnosed with conversion disorder suggests that she got an intense work-up from neurologists and psychiatrist, likely included an EEG that was negative for seizure despite what appeared to be seizure activity. She wasn't faking, per se, though. Part of the premise of conversion disorder is that the patient is not consciously producing the symptoms, thus it could be impossible to tell the difference without a known history of conversion disorder with seizures/convulsions.

Anyhow, where I worked, these patients (fakers) were generally triaged to BLS. Febrile SZ with antipyretic given prior to arrival and any patient not post-ictal with a history of seizures were often triaged to BLS. (Only done after a thorough H&P, etc.)

To be sure I have seen a few seizures that were not followed post-ictal states such as partial and complex partial seizures.

 

[Dada Simba Detuned]

Wow... some of you really need to educate yourselves a bit!

As someone who has been diagnosed and dealing with PNES for over two years, I am shocked that so many of you have the gall to judge these patients when you haven't fully educated yourselves. Try to exercise a little bit of compassion and when you have a few minutes (do your job and) read this: [this chat board will not allow me to include the link because I am a new user]. I can assure you that when I am transported by ambulance to an ED it is NOT what I want to be doing or where I want to be, and "telling me to cut it out" is not going to help me control my behavior. I am a sexual trauma survivor who has a REAL condition that is NOT malingering or drug or attention seeking... I'm actually benzo intolerant and more often than not have a paradoxical reaction to any benzos or sedation. Stop judging and try to exercise a little compassion while doing your job! And don't ever come to my aid during a seizure where I am (involuntarily) slamming my head against a concrete patio... because if you start telling me to "cut it out" I'll probably give you reason to "Section 12" me (in MA)!

 

[STXmedic]

 

[Dada Simba Detuned]

Not sure I understand what your image is intended to convey...

Could you "enlighten" me?

 

[VFlutter]

Could you "enlighten" me?

Your first post was very confrontational. I understand your frustrations but I think you could have eased you way into it as a new member on this forum. The picture is anticipating that your post will "stir the pot" and get some equally aggressive responses.

As someone who has been diagnosed and dealing with PNES for over two years, I am shocked that so many of you have the gall to judge these patients when you haven't fully educated yourselves.

I do not think any of us are trying to discredit true PNES but the fact is that the condition is extremely rare and far out numbered by people who intentionally fake seizures. It is truly unfortunate that we most often assume a person to be faking but it is hard not to when 99 times out of 100 it is the case.

 

[JPINFV]

[righteous indignation]

Here's the problem. Generalizing a bit, there are three different types of "seizures." Real seizures, psychogenic seizures (seizure like activity without EEG change, but not in control of the patient), and malingering seizures ("fakers" looking for some sort of external benefit). Unfortunately, from a "The patient is seizing right now and we have nothing to go off of besides a history and physical," the psychogenic and the malingering seizures are going to look pretty similar.

 

[Dada Simba Detuned]

Thank you Chase

For clarifying the intent of the post with the picture. I am sorry if my posts seem confrontational. I am a health provider, but also a peer advocate for PTSD patients. I have personally experienced and witnessed EMTs (but more often other medical personnel) re-traumatize trauma patients with this notion that we are "faking it" or can just somehow "snap out of it" if a provider yells at us and (further) scares us enough. Many of the EMTs in Boston with whom I have worked professionally in the past are VERY compassionate when transporting me... but in many cases it's because they know me professionally before I became their patient. So... yes... I am a bit frustrated I guess. My intent IS to get attention... so that folks will take a few minutes to think about their assumptions and how they may actually be harming patients with their actions and behavior. If I need to be "confrontational" in order to get someone's attention (as long as I'm not so much so that they shut down and don't listen)... so be it. Thanks for your insight/reply.

 

[Dada Simba Detuned]

For clarifying the intent of the post with the picture. I am sorry if my posts seem confrontational. I am a health provider, but also a peer advocate for PTSD patients. I have personally experienced and witnessed EMTs (but more often other medical personnel) re-traumatize trauma patients with this notion that we are "faking it" or can just somehow "snap out of it" if a provider yells at us and (further) scares us enough. Many of the EMTs in Boston with whom I have worked professionally in the past are VERY compassionate when transporting me... but in many cases it's because they know me professionally before I became their patient. So... yes... I am a bit frustrated I guess. My intent IS to get attention... so that folks will take a few minutes to think about their assumptions and how they may actually be harming patients with their actions and behavior. If I need to be "confrontational" in order to get someone's attention (as long as I'm not so much so that they shut down and don't listen)... so be it. Thanks for your insight/reply.

Could someone explain to me why I have just been "blocked" for not following a rule that was impossible for me to follow?

 

[Dada Simba Detuned]

Could someone explain to me why I have just been "blocked" for not following a rule that was impossible for me to follow?

I tried to post a hyperlink many times, and once the system finally did let me do so, I now find that I have been "blocked" by the moderator from any additional posts. I guess you folks aren't really all that interested in learning about PNES. Be well...

 

[STXmedic]

It's not impossible. She provide the information you were required to put. You didn't put it. She removed the quoted information. Repost it with the appropriate required information and I doubt there would be a problem.