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Comprehensive Epilepsy Program


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Brochure cover This is the "original" version, published in 1994 at The Cleveland Clinic Foundation.

    Authors:
  • Selim R. Benbadis, MD
  • Susan J. Stagno, MD
    Outline:
  • What are non-epileptic seizures?
  • How can I be sure that I have non-epileptic seizures?
  • Why did my other doctor say that I had epilepsy?
  • Do I really need psychiatric treatment?
  • What about children?
  • A final thought
  • Additional information


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WHAT ARE NON-EPILEPTIC SEIZURES?
A seizure is a temporary loss of control that is often accompanied by convulsions, unconsciousness, or both. Most common are epileptic seizures, which are seizures caused by a sudden abnormal electrical discharge in the brain. Non-epileptic seizures, on the other hand, are not accompanied by abnormal electrical discharges and are therefore termed "pseudo" or "false" seizures. The term "pseudoseizures" is misleading, however. The seizures are quite real, and people who have then do not conscious, voluntary control over them. They are "false" only in that they have no physical cause; rather, they are said to be psychogenic, or physical reactions to psychological stresses. Pseudoseizures resemble epileptic seizures, even though their causes are different. Pseudoseizures may be generalized convulsions (similar to "grand-mal" epileptic seizures) that are characterized by falling and shaking. Others are similar to the "petit mal" or "complex partial" epileptic seizures that are limited to temporary loss of attention, "staring into space," or "dozing off." Although you may not have known that seizures can have psychological causes, many people have such seizures. In fact, at the Cleveland Clinic, we see between 50 and 100 patients each year who suffer from pseudoseizures - usually one or two patients each week. About 75% of these patients are women, and most are between the ages of 20 and 40, although pseudoseizures occur in both younger and older patients as well.


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HOW CAN I BE SURE THAT I HAVE NON-EPILEPTIC SEIZURES?
Pseudoseizures can be suspected y your neurologist on the basis of a medical history and physical examination, but other tests are required to rule out other causes and to confirm the diagnosis. It is first necessary to distinguish between psychogenic and epileptic seizures. In fact, the most important consideration in diagnosing pseudoseizures is that epilepsy must be ruled out as a cause. As a result, the diagnosis of pseudoseizures is made only after all tests for epilepsy have been negative. A routine, 20-minute electroencephalogram (EEG) is often helpful in diagnosing epilepsy because it can detect the abnormal electrical discharges in the brain that indicate epilepsy. However, a negative EEG test by itself is not enough to establish a diagnosis of pseudoseizures. The most reliable test I to monitor a patient with a video camera and an EEG until a seizure occurs. (This test requires the patient to spend time in a special facility, often for many hours a day or several days.) by analyzing the video and EEG recordings of a seizure, we can be confident whether abnormal electrical discharges are or are not causing the seizures. Once epilepsy is ruled out, other physical conditions that look like seizures ma also have to be excluded. These conditions include heart disease, stroke, and fainting, as well as some sleep and neuromuscular disorders. If additional tests for these physical causes are negative, then the medical history, physical examination, and a psychological assessment may help confirm the diagnosis of pseudoseizures.


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WHY DID MY OTHER DOCTOR SAY THAT I HAD EPILEPSY?
Most patients with psychogenic seizures have been treated with antiepileptic drugs for some time before the correct diagnosis is made. Such treatment does not mean that doctors who have treated you for epilepsy have been incompetent. Epileptic seizures are potentially more harmful than pseudoseizures, and physicians, when they cannot be certain of the diagnosis usually treat for the more serious illness. If medication stops the seizures, they were probably epileptic. If not, then either the treatment needs to be changed, or the diagnosis is not epilepsy. Few physicians have access to the EEG and video monitoring facilities needed to distinguish pseudoseizures from epileptic ones. At this point, patients are often referred to an epilepsy center for further tests, and this is where the diagnosis is usually made. A diagnosis of pseudoseizures means that most patients can safely be taken off antiepileptic drugs. This fact is important because most antiepileptic drugs (Dilantin, Tegretol, Depakote are the most common) can have harmful or even dangerous side effects. A few patients with epilepsy have pseudoseizures in addition to epileptic seizures. If you have both epileptic and psychogenic seizures, it is important that you and your physician know which are epileptic and which are not so that you can be treated accordingly.


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WHAT CAUSES PSEUDOSEIZURES?
Psychogenic seizures, unlike epileptic seizures, are not the result of a physical disorder of the brain. Rather, they result from traumatic psychological experiences or unusual stresses, sometimes even those in the forgotten past. It has been known since ancient times that emotional or psychological stresses can produce physical reactions in a person with no physical illness. Almost everyone has blushed in embarrassment or been nervous and anxious as part of a "stage fright" reaction. Today, we also know that more extreme emotional stresses can actually cause physical illnesses. Some physical illnesses can be greatly influenced by psychological or emotional factors. These illnesses are called psychosomatic or "mind-body" illnesses. Examples include many forms of acne, allergy, angina (chest pain), asthma, headache, ulcer, obesity, rheumatoid arthritis, and ulcerative colitis. Although psychosomatic illnesses have a strong psychological component, their treatment is primarily medical. Emotional stresses can also cause symptoms that look like physical illnesses in people who are physically healthy. (The medical terms for these symptoms are somatoform "taking form in the body" or conversion disorders). Common examples of such symptoms are paralysis, blindness, and the inability to speak. These disorders differ from psychosomatic illnesses in that both their causes and treatments are primarily psychological and that they have no physical basis. Pseudoseizure is such a disorder. However, it is important to remember that somatoform disorders, including pseudoseizures, are real conditions that arise in response to real stresses; patients are not faking them. Simply because your seizures are believed to be psychological in origin does not mean that you are "imagining" them or that you are only pretending to be ill. Neither does it mean that you must be ashamed for having seizures. The fact that the vast majority of pseudoseizures are not consciously produced is often poorly understood by family members and even by health care professionals who are not familiar with this condition. Many people, including patients themselves, "blame the victim" for having a psychogenic illness or for not "getting better." This "blaming" can be far more destructive that the pseudoseizures themselves. A specific traumatic event, such as physical or sexual abuse, incest, divorce, death of a loved one, or other great loss or sudden change, can be identified in many patients with pseudoseizures. Often the underlying trauma has been blocked from consciousness; many patients can recall the event only with considerable support from a trained therapist. The unconscious processes that give rise to pseudoseizures may also cause or contribute to other conditions, such as depression and anxiety, which also need to be treated. Pseudoseizures differ from other psychogenic disorders in one important aspect: Pseudoseizures can be shown with great certainty to be of psychological origin. With the appropriate tests, the accuracy of the diagnosis is comparable to that of diagnosing a bone fracture with an x-ray. Such certainty is not possible for other psychogenic symptoms, such as pain, blindness, or paralysis. This confidence in the diagnosis of pseudoseizures allows proper treatment to be given and greatly increases the chances of complete recovery.


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DO I REALLY NEED PSYCHIATRIC TREATMENT?
The psychological factors underlying pseudoseizures can best be identified with the help of those with special training in psychological issues: psychiatrists, psychologists, or clinical social workers. As with all other medical conditions, sometimes the exact cause of psychogenic seizures remains unknown; even then, however, we can concentrate on the most important goal: reducing or eliminating your seizures. Some people believe that treatment by a psychiatrist is a sign of being "crazy" or otherwise mentally incompetent. Such is not the case with pseudoseizures, but many patients become upset when told that their seizures are psychological. Remember that psychogenic seizures are not purposely produced -- it is not your "fault" that you have them. It also makes sense to seek treatment from a person most able to help you. Some patients are reluctant to believe the diagnosis. Keep in mind that pseudoseizures represent a well-recognized condition and can be diagnosed with a high degree of certainty. Although there is always the possibility of an error, in most cases, the diagnosis can be made with confidence. The treatment for pseudoseizures may be provided by several medical professionals. At the Cleveland Clinic, your neurologist may continue to see you, but treatment will be provided primarily by a psychiatrist, psychologist, or clinical social worker. Treatment may involve psychotherapy, stress-reduction techniques (such as relaxation and biofeedback training), and personal support to help you cope with the seizures during the course of treatment. The outlook for patients with pseudoseizures is good. With proper treatment, the seizures eventually disappear in 40 to 70% of adults; the percentages are even higher for children and adolescents.


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WHAT ABOUT CHILDREN?
Although pseudoseizures are most common in young adults, they can also occur in adolescents and young children. More common psychogenic symptoms in these age groups include headaches and stomach aches. Most of the points made in this guide apply to children as well as to adults. Young patients generally differ from adult patients only in that the stresses causing pseudoseizures are typically less severe and are often related to the stresses experienced by younger patients, such as school or dating. Children also have a higher rate of recovery.


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A FINAL THOUGHT
Pseudoseizures continue to be the subject of new and promising research. At the 1993 Annual Meeting of the American Epilepsy Society, for example, 18 papers were presented specifically on the diagnosis and treatment of non-epileptic seizures. The references at the end of the booklet also give some idea of the attention being directed to this disorder. Thus, this well recognized diagnosis is being taken seriously by neurologists, psychiatrists, and others in the medical community. We realize this booklet may not have answered all your questions. It is not intended to replace discussions with your physician, but rather to help you understand that you have a known and treatable condition. You are not alone in having pseudoseizures. Treatment is available and is effective for most of the patients who seek it.


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ADDITIONAL INFORMATION

Articles by Cleveland Clinic Physicians:
  • Lesser RP, Lueders H, Dinner DS Evidence for epilepsy is rare in patients with psychogenic seizures. Neurology 1983;33:502-504.
  • Wyllie E, Friedman D, Rothner AD, Luders HO, Dinner DS, Morris HM, Cruse R, Erenberg G, Kotagal P. Psychogenic seizures in children and adolescents: Outcome after diagnosis by ictal video and EEG recording. Pediatrics; Vol 85;No 4; 1990;
Other references:
  • Gates JR. Psychogenic seizures. Merritt-Putnam Scientific advances in epilepsy management. March 1987, Vol 4 No 1.: pages 3-13.
  • Guberman A. Psychogenic seizures in non epileptic patients. Canadian Journal of Psychiatry 1982;Vol 27: pages 401-404.
  • Gumnit RJ, Gates JR. Psychogenic seizures. Epilepsia, 27 (Suppl 2);S124-S129, 1986.
  • King DW, Gallagher BB, Murvin AJ, Smith DB, Marcus DJ, Hartlage LC, Ward IIIC. 1982. Pseudoseizures: Diagnostic evaluation. Neurology 32;18-23.
  • Krumholz A, Niedermeyer E. 1983. Psychogenic seizures: A clinical study with follow up data. Neurology 33;498-502.
  • Lempert I, Schmidt D. Natural history and outcome of psychogenic seizures: A clinical study in 50 patients. Journal of Neurology 1990;237;35-38
  • Lesser RP. Psychogenic seizures. In Recent Advances in Epilepsy. Churchill Livingstone. New York 1985, pages 273-296.
  • Meierkord H, Will B, Fish D, Shorvon S. The clinical features and prognosis of pseudoseizures diagnosed using video-EEG telemetry. Neurology 1991;41:1643-1646.
  • Ramchandani D, Schindler B. Evaluation of pseudoseizures. A psychiatric perspective. Psychosomatics. Vol 34; No 1; 1993: pages 70-79.
  • Rodin EA. Differential diagnosis of epielpstic vs psychogenic seizures. In: Dam M, Gram L, Penry JK (editors). Advances in epielptology: XIIth Epilepsy International Symposium. New York: Raven Press, 1981.
  • Sackellares JC, Giordani B, Berent S, Seidenberg M, Dreifuss FE, Vanderzant CW, Boll TJ. Patients with pseudoseizures: Intellectual and cognitive performance. Neurology 1985;35;116-119.
  • Shen W, Bowman ES, Markland ON. Presenting the diagnosis of pseudoseizure. Neurology 1990; 40; 756-759.
  • Vanderzant CW, Giordani B, Berent S, Dreifuss FE, Sackellares JC. Personality of patients with pseudoseizures. Neurology 1986;36;664-668.
  • Volow MR. Pseudoseizure: an overview. Southeastern Medical Journal 1986;Vol 79: pages 600-607.
  • Williams DT, Siegel H, Mostofsky DI. 1978. Neurogenic and hysterical seizures in children and adolescents: differential diagnosis and therapeutic consideration. American Journal of Psychiatry 135;82-86.