Causes of Pseudoseizures

By Susan Maphis, eHow Contributor

Psychogenic seizures, also called pseudoseizures, are not thought to be epileptic in nature. Rather, they are
believed by many professionals to be caused by mental and psychological stress. Those who suffer from
such seizures often resent the term "pseudoseizures," as it implies the seizures are "all in the head."
However, this is not true. The real physical symptoms sufferers of pseudoseizures experience are caused by
underlying psychological problems.
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1. Triggers for Pseudoseizures
o Pseudoseizures can be brought on by many and various triggers, depending upon the
patient. These can include academic stress, stress at work, family or relationship stress,
fear of being alone, feeling rejected socially by others, and many more. Emotions can
also be triggers. Once triggers of pseudoseizures are properly identified in a patient,
treatment becomes a bit clearer. Most professionals treat pseudoseizures through a
combination of psychotherapy and anti-convulsant drugs.
Symptoms of Pseudoseizures
o The signs and symptoms of pseudoseizures resemble those of epileptic seizures. A person
suffering from pseudoseizures may experience falls and shaking of the body (similar to
convulsions found in epileptic seizures). They may also experience a temporary loss of
focus or attention and engage in staring behavior, also signs of epileptic seizures.
Memory lapses, body tremors, fainting, and confusion are also harbingers of both
pseudoseizures and epileptic seizures.
Diagnosis of Pseudoseizures
o As with epileptic seizures, pseudoseizures are diagnosed by a combination of factors.
One is an EEG. In epileptic seizures, patterns of brain waves appear to signal epilepsy. In
psychogenic seizures, however, the patient experiences seizure symptoms yet shows no
abnormal EEG activity. Video-EEG testing is also common in diagnosing both types of
seizures. Patients with pseudoseizures will show signs of seizure activity on the video,
yet display an EEG with no abnormal activity.
Causes of Pseudoseizures
o As mentioned earlier, pseudoseizures are not caused by any abnormal brain activity, but
rather by psychological factors. Pseudoseizures are thought by many professionals to be
defense mechanisms that occur when individuals are under severe mental or emotional
stress. If the person tries to suppress the stress or trauma, pseudoseizures can develop as a
reaction to this attempt at suppression. In addition to being caused by stress in the
present, pseudoseizures can also be caused by remembered stress from childhood trauma.
As defense mechanisms, pseudoseizures are also coping mechanisms of people under
severe stress.
Treatment of Pseudoseizures
o Pseudoseizures are not fake. They are real medical manifestations of psychological
problems. Therefore, they must be treated medically. Anti-convulsant medications are
thought to possibly worsen symptoms of pseudoseizures. The preferred treatment is a
combination of psychotherapy/counseling with anti-anxiety medication.
Prognosis for Pseudoseizures
o With proper treatment, people experiencing pseudoseizures can expect to live a seizure-
free life. Once a person learns the triggers of his seizures, it becomes easier to recognize
them before they occur. Learning how to deal with stress or psychological trauma is an
important component in a successful recovery from pseudoseizures. Full recovery can be
achieved, however, with proper treatment of pseudoseizures.

Symptoms of Pseudoseizures
The term "pseudoseizures" describes events that appear on the surface to be seizures from epilepsy, but in
patients who are not epileptic. Instead, these seizures are caused by abnormal psychology and as such are
often thought of as a type of conversion disorder. Conversion disorders are conditions in which the patient
suffers from symptoms of diseases that he does not actually have.
1. General Seizure Description
o To understand what a pseudoseizure is, it is important to understand the general
characteristics of a seizure. Seizures can take many forms, but in general they involve a
sudden change in behavior, body function, sensation or movement. Seizures can range
from a sudden and involuntary jerking of the limbs to a temporary loss of cognition and
"freezing" during activities (known as a partial seizure).
Pseudoseizures vs. Seizures
o The symptoms of a pseudoseizure are very similar to those of an epileptic seizure, except
that their origin is psychological, not neurological. One of the characteristics of an
epileptic seizure is that there is an abnormal discharge of electricity from the brain during
the seizure. There is no such discharge during a pseudoseizure.
Distinguishing Features
o Certain behaviors occur more commonly in pseudoseizures than in epileptic seizures. For
example, a person having a pseudoseizure is more likely to bite the tip of her tongue
(during a true seizure an epileptic's tongue goes limp and its tip is often inaccessible to
her teeth). Other characteristics of a pseudoseizure include the seizure having a gradual
onset, its duration lasting for two or more minutes, and the person shutting his eyes
during the seizure. Pseduoseizures often involve the person's head moving from side to
side, which rarely occurs in epileptic seizures.
Diagnosis
o An electroencephalogram (EEG) can rule out epilepsy in a person experiencing
pseudoseizures. This test involves attaching a series of electrodes to the patient's scalp to
monitor her brain's electrical activity. As noted above, pseudoseizures lack the abnormal
electrical activity characteristic of epileptic seizures. In addition, many epileptic seizures
will result in the release of a hormone known as prolactin, which is present in the blood
after the seizure. Pseudoseizures will not involve any subsequent rise in blood prolactin.
Pseudoseizure Risk Factors
o Three-fourths of all people who suffer from pseudoseizures are women. Onset tends to
occur in early adulthood or late in the teenage years. People who suffer from
pseudoseizures generally also have other psychological disorders, such as major
depression or an anxiety disorder. They also typically have a history of many undefined
or poorly understood medical problems
Pseudoseizure Disorder
By Michelle Kerns, eHow Contributor
Pseudoseizure Disorder
Pseudoseizure disorder--also known as psychogenic nonepileptic seizures, or PNES--is a neurological
disorder in which an individual experiences epileptic-type seizures known as pseudoseizures.
Pseudoseizures differ from typical seizures in a number of ways, though differentiating between the two
can be difficult, and often, individuals with epilepsy can suffer from a combination of both.
1. Definition
o Pseudoseizure disorder is a type of conversion disorder, which is a condition in which a
person displays neurological symptoms while at the same time exhibiting signs of stress
and hysteria. This particular disorder is characterized by periods of seizure-like activity
during which the person experiencing the seizure is still cognitively aware of his
surroundings. Pseudoseizure disorder is also strongly linked in individuals with
psychiatric problems such as multiple personality disorder and dissociative amnesia.
Pseudoseizure activity is not typically diminished with the administration of antiepileptic
drugs.
Differences
o There are a number of characteristic differences between a pseudoseizure and an epileptic
seizure. Individuals experiencing pseudoseizures usually close their eyes and resist
attempts to open them. The intensity of a pseudoseizure usually remains constant from
the beginning to the end of the episode, with each episode lasting, on average, about two
minutes. Pseudoseizure disorder is much more common in women, particularly young
women, with a history of mental problems.
By contrast, individuals experiencing epileptic seizures generally keep their eyes open
and experience a sharp spike, then decrease, in the intensity of the episode, which rarely
lasts as long as pseudoseizures. A person suffering from an epileptic seizure will have
elevated blood prolactin levels after the seizure. A person suffering from a pseudoseizure
will not.
Cause
o Pseudoseizure disorder is thought to be an unconscious, involuntary physical reaction to
extreme psychological stress. This is supported by research that indicates pseudoseizure
disorder is more likely in individuals suffering from dissociative disorders and other
disruptive mental problems, particularly young women, who suffered from childhood
abuse or trauma.
Diagnosis
o The best way to diagnose pseudoseizure disorder is with the use of video-EEG
monitoring during an actual seizure episode. In this method, both videotape of the
episode and an EEG (electroencephalogram), which monitors and records electrical
activity in the brain, are recorded simultaneously. The EEG is particularly useful: since
pseudoseizures are psychological in origin and are not a result of electrical "storms" in
the brain, the EEG of a person experiencing a pseudoseizure will look very different from
that of an EEG of a person experiencing an epileptic seizure.
Treatment
o The incidence and frequency of pseudoseizures does not decrease with the use of
antiepiletic drugs. However, because many individuals with epilepsy experience both real
seizures and pseudoseizures, the condition, by itself, can be difficult to isolate and treat.
When pseudoseizure disorder has been positively diagnosed, psychotherapy, often in
conjunction with medication, such as antidepressants, is the most common treatment.
About Pseudo Seizures
By Stephanie Puckett, eHow Contributor
Pseudoseizures, more commonly referred to as psychogenic seizures, are a nonepileptic seizure. A
nonepileptic seizure refers to a seizure that is not caused by abnormal electrical activity in the brain.
1. Causes
o A pseudoseizure is caused by subconscious activity in the mind. According to Selim R.
Benbadis, M.D., and Leanne Heriaud, R.N., these seizures are usually emotion or stress
related.
Risk Factors
o Patients who have high amounts of stress or depression are prone to having
pseudoseizures. More often than not, the patient has had traumatic psychological
experiences that he buried within his subconscious mind.
Symptoms
o Symptoms of pseudoseizures are similar to those of grand mal seizures that include
episodes of confusion, stiffening of the limbs, jerking, and other uncontrollable
movements.
Misdiagnosis
o According to Selim R. Benbadis, M.D., and Leanne Heriaud, R.N., many patients who
experience pseudoseizures have been misdiagnosed as having epilepsy. Epilepsy
medication does not help treat pseudoseizures because the cause of the condition is
different from that of epileptic seizures.
Treatment
o As pseudoseizures are a physiological condition, the technique used to treat the seizures
is psychiatric treatment. A mental health professional will assist patients with
pseudoseizures in managing their stress and depression to help prevent the seizures.
Case Report
A 45 year-old woman presented after a recent hospitalization for stress seizures. Before hospitalization, the
patient had been in her usual state of good health when she had a sudden episode of dizziness while
cooking dinner. She felt a loss of balance and was unable to stand. She sat on the edge of a chair and slid
off to the side. She could hear other people talking to her but could not respond. She did not shake. She also
denied any tongue biting or bladder incontinence.
The patient was taken to a nearby hospital and en route had blurred vision. She underwent a computed
tomographic scan of the brain and blood work, which were reportedly normal. She was released from the
emergency room; however, her symptoms persisted. Several days later, she was hospitalized for 2 days and
had magnetic resonance imaging of the brain and electroencephalography, which were reportedly normal.
She was told she had stress seizures and was prescribed lorazepam. The patient had subsequent
development of tremors throughout her body, with frequent jerking of her legs.
Her history was positive for hypertension and peptic ulcer disease. She denied any history of neurologic
disorder, head trauma, or alcohol or drug use. She denied any form of psychosocial stress. Her medications
included 50 mg daily of metoprolol succinate for blood pressure, and 150 mg daily of ranitidine for peptic
symptoms.
On examination, the patient was a mildly obese, middle-aged woman with prematurely gray hair. She was
well-dressed and well-groomed and appeared to be in no distress. She was accompanied by her husband,
who was very anxious concerning his wife's condition. Vital signs were normal.
When the physical examination began, the patient had the onset of facial grimacing followed by a bowing
back of the body into an arch. This was followed by thrashing of the arms and legs. The episode lasted
several minutes, during which time she appeared to be unresponsive. There was no urinary incontinence,
tongue biting, or postictal behavior noted. The neurologic examination after the episode was normal. The
patient maintained that she was totally aware of her surroundings during the episode but was unable to
speak.
The patient was given 1,000 mg of phenytoin and continued on the 1 mg lorazepam three times daily. An
electroencephalogram with audio/video monitoring was obtained, during which the episodes were
observed. No seizure activity was demonstrated, and the patient was diagnosed with pseudoseizures.
Psychiatric consultation was offered; however, the patient declined. She later claimed that she was healed
by God.
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Discussion
Pseudoseizures have also been known as hysterical seizures, hysterical epilepsy, and conversion reactions.
Although they closely resemble epileptic attacks, pseudoseizures are a psychologic illness, lacking the
abnormal paroxysmal electrical discharges from the brain seen in epilepsy. The incidence of
pseudoseizures is twice as frequent in women, and are more often seen in younger age groups.
In 1885, Gowers
1
developed 12 criteria for distinguishing epileptic seizures from pseudoseizures (Table).
Gowers stated that in hysterical seizures rigid fixation of the trunk and limbs alternates with wild
movements in which the limbs are thrown about; the arms strike out, the legs kick, the head is dashed side
to side.
1
Although Gowers's criteria are still applicable today, the use of simultaneous
electroencephalography and audio/video monitoring have made diagnosis simpler.

Table. Criteria for ...
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In the mid to late 19th century, Jean Charcot, while at the Salpetriere, attempted to distinguish between the
convulsions of women who were epileptics and those of hysterics. Charcot observed that hysterical seizures
had the following characteristics: The patient looses consciousness and the paroxysm proper begins. It is
divided into four periods which are quite clear and distinct. In the first, the patient executes certain
epileptiform movements. Then comes the period of great gesticulations of salutation, which are of extreme
violence, interrupted from time to time by an arching of the body which is absolutely characteristic; the
trunk being bent bow fashion sometimes in front (emprosthotonus), sometimes backward (opisthotonus),
the feet and head alone touching the bed, the body constituting the arch (arc de cercle). During this time the
patient utters wild cries. Then comes the third period, called the period of passional attitudes during which
he utters words and cries in relation with the sad delirium and terrifying visions that pursue himFinally,
he regains consciousness, recognizes the persons around him and calls them by name, but the delirium and
hallucinations continue for some timeNever during the course of these cries has he bitten his tongue or
wet his bed.
2

Physicians also observed that pseudoseizures lasted longer than epileptic seizures, and they occurred more
commonly in the presence of a witness. Environmental stimuli could precipitate or affect the
pseudoseizure. Patients could also follow commands and make eye contact during pseudoseizures. True
tonic-clonic seizures also show a transient elevation in the serum prolactin level, which does not occur in
pseudoseizures.
Neuropsychologic testing in patients with pseudoseizure found the highest incidence of pathologic scores in
schizophrenia, hysteria, and depression. The difficulties in diagnosing psychogenic pseudoseizures are
compounded by the fact that a significant proportion of patients with pseudoseizures also have epilepsy.
Thus, it is not uncommon for patients with pseudoseizures to present on anticonvulsant medication.
The cause of pseudoseizures is puzzling. They may be a form of behavior precipitated by an internal
stimulus, such as anxiety or an epileptic aura, and an external stimulus, such as stress. One theory has
correlated conflict with pseudoseizure activity. A change in the level of consciousness can symbolize the
need to remove oneself from the conflict-the dissociative component. The motor movement during the
seizure fulfills the need to reduce tension and anxiety-the conversion component.
3

After anxiety is reduced by the appearance of the pseudoseizure, the patient is indifferent to symptoms. He
or she receives secondary gains during a seizure in the form of increased attention from observers.
Dependence develops, which further reinforces the behavior. A sick role is created, which allows the
patient to regress and reinforces the dependent role.
3

Psychotherapy is the mainstay of treatment for pseudoseizures. Withdrawal from anticonvulsants is usually
possible. The goal of psychotherapy is to relieve emotional stress and assist the patient in coping with
future stressful events. Hypnosis has also been useful, by determining the precipitating cause of
pseudoseizures and then abolishing it by hypnotic suggestion.

Psychogenic Nonepileptic Seizures
Psychogenic nonepileptic seizures (pseudoseizures) are characterized by episodes
of behavior and/or motor activity that are not the result of abnormal cortical
discharges. It is important to note that psychogenic seizures are different from
malingering and are grouped with psychoneurological illness (e.g., conversion
disorders, somatoform disorders).

Psychogenic seizures can be extremely difficult to differentiate from epileptic
seizures and, when inappropriately labeled, can result in mismanagement.
175, 176, 177

One review cites a mean time to diagnosis as 7.2 years.
178
Several historical, clinical,
and laboratory characteristics of convulsive psychogenic seizures can help the
emergency physician make the correct diagnosis.
179


Epidemiology of psychogenic seizures: The prevalence of psychogenic seizures ranges
from 2 to 33 cases in 100,000 persons in the general population.
180
Five to ten
percent of the outpatient epileptic population has PNES, compared to 20 to 40% of
the inpatient epilepsy population.
181, 182, 183
Confounding the diagnosis is the
concurrence of psychogenic seizures with true seizures. Early studies reported that
up to 60% of patients with psychogenic seizures had a coexistent neurogenic
seizure disorder,
184
although more recent studies using a strict definition of epilepsy
report a co-existence rate of approximately 10%.
188, 185
Authors have reported
epileptic seizures evolving into nonepileptic events.
186


Clinical characteristics: Care should be taken when using clinical characteristics to
distinguish neurogenic from psychogenic seizures. In a cohort of patients referred
by experienced epilepsy neurologists for video-EEG monitoring, misdiagnoses
occurred in 24% of cases.
187
Characteristics that are suggestive, but not diagnostic
of psychogenic seizures are listed in Table 6. Head, extremity, and pelvic thrusting
movements are useful in identifying psychogenic seizures, especially if observed in
conjunction with each other.
187
Neurogenic seizures tend to have in-phase,
synchronous tonic-clonic movement of the extremities. Asynchronous and/or
thrashing movements of the extremities are more characteristic of psychogenic
seizures. This is not an absolute observation and care must be used in applying
these features. In particular, complex motor automatisms, such as thrashing and
kicking, without an associated change in mental status or post-ictal period may be
seen in supplementary motor seizures of the frontal lobe.
188
Interestingly, both self-
injury and urinary incontinence occur in psychogenic seizures and are not helpful in
differentiating them
from neurogenic events.
189


Maneuvers: While some cases of psychogenic seizures may be nearly impossible to
diagnose in the ED, other cases may be uncovered with simple maneuvers. The
simplest involves non-noxious sensory stimulation, such as placing a cotton swab in
the nose, passive eye opening, dropping the patients arm over their face, or corneal
stimulation. These simple tests may result in avoidance (the patients hand never
hitting their face) or resistance (forceful eye closing) from a patient having a
psychogenic seizure. In one study, 18 out of 18 patients with confirmed psychogenic
seizures tested positive to avoidance maneuvers.
190
The geotrophic eye test is
performed by turning the patients head from side to side and observing the eyes:
the patient will look away from the examiner, regardless of which way the head is
turned.
191
Noxious stimulation, such as a sternal rub, firm pressure on a digit, or an
anhydrous ammonia capsule under the patients nose, may also terminate
psychogenic seizures.
192
Patients with psychogenic seizures may terminate in
response to verbal suggestion.
193
Many cases do not reveal themselves even with
maneuvers, and ultimately require video-EEG monitoring to confirm the diagnosis.
The treatment of psychogenic seizures is based on behavioral therapy aimed at
identifying stressors, precipitants, and underlying psychiatric disease.
194