Pseudoseizures with urinary incontinence in a child with Neuromyelitis optica: a rare association

Background: Paroxysmal non epileptic events or pseudoseizures are common seizure mimics in children. But occasionally PNES events can present or coexist along with organic neurological disorders complicating the clinical scenario posing great challenges for diagnostic and therapeutic implications. Unusual symptomatology in PNES like frothing, tongue bite or urinary incontinence can be seen in PNES. Here, we present a rare case of pseudoseizures with urinary incontinence in a child with Neuromyelitis optica which posed a challenge for diagnosis and proper management with a favourable clinical outcome. A 14 years old girl who was known diagnosed case of Neuromyelitis optica on treatment with oral steroids presented with a history of repeated attacks of involuntary movements affecting all four limbs preceded by a feeling of fear and pain and these events were associated with urinary incontinence. Electroencephalogram and magnetic resonance imaging were performed on the patient. Ictal video EEG confirmed the diagnosis of pseudoseizures. Neuropsychological evaluation was performed which revealed multiple psychological stressors. Repeated counseling sessions and psychotherapy provided significant improvement in the form of remission of pseudoseizures.

Los idiomas del cuerpo: un estudio de caso sobre una paciente con epilepsia bifocal fármacorresistente

El autor del presente trabajo realiza un estudio de caso teórico-clínico acerca de un paciente que presenta un cuadro epiléptico bifocal fármacorresistente, detectable en el encefalograma, alternado con pseudocrisis epilépticas (histeroepilepsia), lo que lo lleva a cuestionarse, por un lado, sobre el alto porcentaje (30%) de pacientes epilépticos fármacorresistentes y su relación con los trastornos psicosomáticos; así como sobre la combinación en un mismo paciente de dos niveles de funcionamiento psíquico: uno narcisista no neurótico (las epilepsias como un trastorno psicosomático) y un funcionamiento neurótico histérico conversivo (las pseudocrisis). La importancia de dicho trabajo reside en el aumento en la consulta de pacientes con trastornos narcisistas no neuróticos, en los que se encuentran los trastornos psicosomáticos, así como en el difícil manejo (y alto porcentaje) de los pacientes epilépticos refractarios, que desde la neurología y la psiquiatría han representado un reto no resuelto y donde la clínica psicoanalítica tiene un saber por aportar.

The author of this paper builds a theoretical and clinical case study, based on a patient presenting with drug resistant bifocal epilepsy, detectable by EEG, that alternates with epileptic pseudoseizures (hystero-epilepsy) that rises the question on one side, about the high percentage (30%) of drug-resistant epileptic patients and its relationship with psychosomatic disorders; and, on the other, the combination of two levels of psychic functioning with the same patient: a non-neurotic narcissist (epilepsy as a psychosomatic disorder) and a functioning neurotic hysterical conversive operation (the pseudoseizures). The importance of this work lies in the increased consultation of patients with non-neurotic narcissistic disorders, among which are psychosomatic disorders, as well as the hard-to-handle (and high percentage of) refractory epilepsy patients, that have presented an unresolved challenge to Neurology and Psychiatry and where the psychoanalytic clinic has the knowledge to contribute.

Psychogenic non-epileptic seizures in the post-anesthesia recovery unit / Convulsões não epilépticas psicogênicas em sala de recuperação pós-anestésica

Abstract Introduction: Psychogenic non-epileptic seizures (PNES or “pseudoseizures”) remain an obscure topic in the peri-operative setting. They are sudden and time-limited motor and cognitive disturbances, which mimic epileptic seizures, but are psychogenically mediated. Pseudoseizures occur more frequently than epilepsy in the peri-operative setting. Early diagnosis and management may prevent iatrogenic injury. Case: 48 year-old female with a history of depression and “seizures” presented for gynecologic surgery. She described her seizure history as “controlled” without anticonvulsant therapy. The patient underwent uneventful general anesthesia and recovered neurologically intact. During the first two postoperative hours, the patient experienced 3 episodes of seizure-like activity with generalized shaking of extremities and pelvic thrusting; her eyes were firmly closed. No tongue biting or incontinence was noted. The episodes lasted approximately 3 min each, one of which resolved spontaneously and the other two following intravenous lorazepam. During these episodes, the patient had stable hemodynamics and adequate ventilation such that endotracheal intubation was deemed unwarranted. Post-ictally, the patient was neurologically intact. Computed axial tomography of the head, metabolic assay, and electroencephalogram showed no abnormalities. A presumptive diagnosis of PNES was made. Discussion: Psychogenic non-epileptic seizures mimic shivering, and should be considered early in the differential diagnosis of postoperative shaking, as they may be more likely than epilepsy in this setting. Pseudoseizure patterns include asynchronous convulsive episodes lasting more than 90 s, forced eye closure with resistance to opening, and retained pupillary responses. Autonomic manifestations such as tachycardia, cyanosis and incontinence are usually absent. A psychiatric background is common. Knowledge and correct diagnosis of pseudoseizures is of great importance for anesthesiologists to prevent morbidity and iatrogenic injury such as respiratory arrest caused by anticonvulsant therapy, in addition to the risks associated with endotracheal intubation and prolonged hospital stays. The diagnosis of pseudoseizures must be thoroughly documented and relayed in transfer of care to avoid misdiagnosis and iatrogenic complications. Treatment recommendations are anecdotal; psychiatric interventions are the hallmark of treatment. Anesthetic recommendations include techniques involving the minimum required short-acting agents, along with high levels of peri-operative psychological support and reassurance.

Resumo Introdução: As convulsões não epilépticas psicogênicas (CNEP ou “pseudoconvulsões”) permanecem como tema obscuro no cenário perioperatório. Trata-se de distúrbios motores e cognitivos súbitos, mas por tempo limitado, que imitam as convulsões epilépticas, mas que são psicogenicamente mediados. Pseudoconvulsões ocorrem com mais frequência do que epilepsia em cenário perioperatório. O diagnóstico e o tratamento precoces podem evitar lesões iatrogênicas. Caso: Paciente do sexo feminino, 48 anos, com história de depressão e “convulsões”, apresentou-se para cirurgia ginecológica. A paciente descreveu sua história de convulsões “controladas” sem o uso de terapia anticonvulsivante. Foi submetida à anestesia geral sem intercorrências e recuperou-se neurologicamente intacta. Durante as duas primeiras horas de pós-operatório, apresentou três episódios semelhantes à convulsão, com tremores generalizados das extremidades e impulso pélvico; seus olhos estavam bem fechados. Não observamos mordedura da língua ou incontinência. Os episódios duraram cerca de três minutos cada; um dos episódios resolveu espontaneamente e os outros dois após a administração de lorazepam por via intravenosa. Durante os episódios, a condição hemodinâmica da paciente era estável e a ventilação adequada, de modo que a intubação traqueal foi considerada injustificável. Após a convulsão, a paciente estava neurologicamente intacta. Tomografia axial da cabeça, teste metabólico e eletroencefalograma não mostraram alterações. O diagnóstico de provável CNEP foi feito. Discussão: As convulsão não epilépticas psicogênicas imitam o tremor e devem ser inicialmente consideradas no diagnóstico diferencial de tremor pós-operatório, pois podem ser mais prováveis do que a epilepsia nesse cenário. Os padrões da pseudoconvulsão incluem episódios convulsivos assíncronos que duram mais de 90 segundos, olhos forçadamente fechados com resistência à abertura e respostas pupilares mantidas. Manifestações autonômicas, como taquicardia, cianose e incontinência, normalmente estão ausentes. Uma história psiquiátrica é comum. O conhecimento e o diagnóstico correto de pseudoconvulsões são muito importantes para os anestesiologistas para a prevenção de morbidade e lesões iatrogênicas, como a parada respiratória causada por terapia anticonvulsivante, além dos riscos associados à intubação orotraqueal e internação prolongada. O diagnóstico de pseudoconvulsões deve ser cuidadosamente documentado e retransmitido nas trocas de equipes médicas para evitar erros de diagnóstico e complicações iatrogênicas. As recomendações de tratamento são anedóticas; intervenções psiquiátricas são o pilar do tratamento. As recomendações anestésicas incluem técnicas que envolvem o uso de agentes de ação curta, juntamente com altos níveis de apoio e amparo psicológico no período perioperatório.

Syncope in patients with drug-resistant epilepsy without apparent cardiovascular disease / Sincope em pacientes com epilepsia farmaco resistente sem doenca cardiovascular aparente

Epilepsy and syncope are clinical conditions with high prevalence rates in the general population, and the differential diagnosis between them is difficult. Objective To assess the frequency of syncope in patients diagnosed with drug-resistant epilepsy (DRE) without appa­rent heart disease, to investigate the relationship between clinical and electroencephalographic (EEG) changes, and to verify the role of the inclination test (IT). Method An open, prospective study from 2004 to 2006, including 35 consecutive patients from the Epilepsy Program of Hospital Universitário Clementino Fraga Filho who were diagnosed with DRE without apparent heart disease. Results The frequency of syncope was 25.7% (n=9), with a significant prevalence in women. Vasovagal syncope (VVS) was the most frequent diagnosis. Conclusion We found a significant association between syncope and the presence of autonomic symptoms (p=0.005). The IT plays an important role in the differential diagnosis of patients with DRE presenting with autonomic symptoms, regardless of EEG results and brain magnetic resonance imaging (MRI) abnormalities. .

Epilepsia e síncope são condições clínicas com alta prevalência na população geral e, às vezes, o diagnóstico diferencial entre elas é difícil. Objetivo Investigar a frequência de síncope em pacientes diagnosticados com epilepsia fármaco resistente (EFR), sem doença cardíaca aparente; investigar a relação entre alterações clínicas e eletrencefalográficas; verificar o papel do teste de inclinação (TI). Método Estudo aberto prospectivo, realizado de 2004 a 2006, incluindo 35 pacientes consecutivos do Programa de Epilepsias do Hospital Universitário Clementino Fraga Filho, diagnosticados com EFR, sem doença cardíaca aparente. Resultados A frequência de síncope foi de 25,7% (n=9), com prevalência significativa em mulheres. Síncope vasovagal (SVV) foi o diagnóstico mais frequente. Conclusão Encontramos uma significativa associação entre síncope e a presença de sintomas autonômicos (p=0,005). O TI tem importante papel no diagnóstico diferencial de pacientes com diagnóstico de EFR que apresentam sintomas autonômicos, a despeito de alterações eletrencefalográficas e de ressonância magnética do crânio. .

A patient experiencing pseudoseizures: a case report / Paciente con pseudo-ataques epilépticos: reporte de caso

Pseudoseizures are a relatively complex problem of unknown aetiology and prognosis. They can at times resemble genuine seizure attacks but they have no abnormal electroencephalograpic (EEG) activity. Understanding the patient's unique psychological background appears to be fundamental in managing seizure frequency. Pseudoseizures can be disruptive to a person's lifestyle, limiting their ability to function and progress in society, particularly when it comes to employment or social interaction. The case discussed involves a 59-year old man who presents with what is believed to be seizure-related activity but through the course of clinical evaluation, this turned out to be pseudoseizures.

Los pseudo-ataques de epilepsia son un problema relativamente complejo de etiologia y prognosis desconocidas. En ciertos momentos pueden parecer genuinos ataques epilépticos, pero no muestran actividad electroencefalográfica (EEG) anormal alguna. Entender el especial trasfondo psicológico del paciente parece ser fundamental a la hora de manejar la frecuencia de los ataques. Los pseudoataques pueden tener un efecto disociador en el estilo de vida de una persona, limitando su habilidad para funcionar y progresar socialmente, en particular cuando se trata de empleos o interacción social. El caso que se analiza corresponde a un hombre de 59 anos de edad que acude con lo que se cree que es una actividad relacionada con un ataque epiléptico, pero en el curso de la evaluación clinica, resultó ser una pseudoepilepsis.

Characteristics of Psychogenic Non-Epileptic Seizure Patients using MMPI Profiles

PURPOSE: The purpose of this study was to know psychological characteristics of psychogenic non-epileptic seizure (PNES) patients by analyzing profiles of Minnesota Multiphasic Personality Inventory (MMPI). In addition, we tried to investigate whether there are differences of MMPI profiles, depending on the gender and age.METHODS: We included 65 patients with non-epileptic psychogenic seizures. Their diagnosis was based on clinical features, provocative test and confirmed by video-EEG monitoring.RESULTS: The results of MMPI analysis did not show any statistically significant differences of quantitative scoring on the main clinical scales. However, additional analysis indicated that patients with PNES had some characteristics of more somatic complaints and depressive mood. According to sex difference, the MMPI profiles of female group showed an increase in the depression scale (D-Pt), whereas those of male group revealed an increased in the somatisation (Hs-Hy). According to age difference, MMPI profiles of adolescent group had the characteristics of personality pattern with a tendency toward somatisation. MMPI profiles of adult group had more depressive tendency. This study suggests that profiles of MMPI, according to the gender and age, can have different characteristics.CONCLUSIONS: Clinical consideration of those factors may be helpful for improving the care of PNES patients.

Characteristics of Psychogenic Non-Epileptic Seizure Patients using MMPI Profiles / 대한간질학회지

PURPOSE: The purpose of this study was to know psychological characteristics of psychogenic non-epileptic seizure (PNES) patients by analyzing profiles of Minnesota Multiphasic Personality Inventory (MMPI). In addition, we tried to investigate whether there are differences of MMPI profiles, depending on the gender and age. METHODS: We included 65 patients with non-epileptic psychogenic seizures. Their diagnosis was based on clinical features, provocative test and confirmed by video-EEG monitoring. RESULTS: The results of MMPI analysis did not show any statistically significant differences of quantitative scoring on the main clinical scales. However, additional analysis indicated that patients with PNES had some characteristics of more somatic complaints and depressive mood. According to sex difference, the MMPI profiles of female group showed an increase in the depression scale (D-Pt), whereas those of male group revealed an increased in the somatisation (Hs-Hy). According to age difference, MMPI profiles of adolescent group had the characteristics of personality pattern with a tendency toward somatisation. MMPI profiles of adult group had more depressive tendency. This study suggests that profiles of MMPI, according to the gender and age, can have different characteristics. CONCLUSIONS: Clinical consideration of those factors may be helpful for improving the care of PNES patients.

Epilepsy in patients with psychogenic non-epileptic seizures / Epilepsia em pacientes com crises não epilépticas psicogênicas

The aim of this study was to evaluate the frequency of epilepsy in patients who presented psychogenic non-epileptic seizures (PNES). The evaluation was carried out during intensive VEEG monitoring in a diagnostic center for epilepsy in a university hospital. The difficulties involved in reaching this diagnosis are discussed. Ninety-eight patients underwent intensive and prolonged video-electroencephalographic (VEEG) monitoring; out of these, a total of 28 patients presented PNES during monitoring. Epilepsy was defined as present when the patient presented epileptic seizures during VEEG monitoring or when, although not presenting epileptic seizures during monitoring, the patient presented unequivocal interictal epileptiform discharges. The frequency of epilepsy in patients with PNES was 50 percent (14 patients). Our findings suggest that the frequency of epilepsy in patients with PNES is much higher than that of previous studies, and point out the need, at least in some cases, for prolonging the evaluation of patients with PNES who have clinical histories indicating epilepsy.

O objetivo deste estudo foi avaliar a frequência de epilepsia em pacientes que apresentaram crises não epilépticas psicogênicas (CNEP). Isto foi realizado durante monitoração intensiva por video-EEG num centro diagnóstico de epilepsia em um hospital universitário. As dificuldades envolvidas para se chegar a este diagnóstico são discutidas. Noventa e oito pacientes foram submetidos a monitoração intensiva por video-EEG; 28 destes pacientes apresentaram CNEP durante a monitoração. Epilepsia foi considerada presente quando o paciente apresentou crises epilépticas durante a avaliação pelo video-EEG ou quando, apesar da não ocorrência de crises epilépticas durante a avaliação, descargas epilépticas interictais inequívocas estavam presentes. A frequência de epilepsia em pacientes com CNEP foi 50 por cento (14 pacientes). Nossos achados sugerem que a frequência de epilepsia em pacientes com CNEP é maior do que a apresentada em estudos anteriores e apontam para a necessidade de, ao menos em alguns casos, prolongar a avaliação de pacientes com CNEP, mas com história clínica sugestiva de epilepsia.

Pseudoseizures: Any Psychosocial Determinants.

A sample of 80 subjects; 15 male and 65 female in age group of 5 to 45 years well educated; were diagnosed for pseudo-seizures in Neurology OPD and were included in the study. Subjects were excluded who were with any psychiatric or major physical illness. The patients, as the diagnosed case of pseudo seizures, were referred for psychosocial evaluation and were included in the study. Several sessions were held with such patients, their family members and friends to explore the psychosocial stressors as well as secondary gain if any. We observed no significant difference in relation to marital, socioeconomic and educational status among the males and females. But there were significant differences in the findings of the study in relation to the sociodemographic profile of the patients in relation to age, marital status, education and occupation of the patients. Other variables like gender, socio economic status, habitat, religion and family did not reveal any significant difference. These results are in conformity to other reported studies on patients with pseudoseizures, who have a number of stressors i.e. financial burden, family conflicts, marital disharmony, love affairs, disruption in career related issues and academic failure etc.

Epilepsy surgery in patients with coexisting psychogenic nonepileptic seizures: diagnosis and treatment / Crises não-epilépticas e cirurgia na epilepsia: uma revisão

The prevalence of epileptic seizures among patients with psychogenic nonepileptic seizures may range from five to fifty percent. Diagnosis of both conditions occurring in association may be difficult and requires both clinical skills and prolonged video-EEG monitoring. Occurrence of seemingly psychogenic events during video-EEG monitoring should be interpreted with caution, and the relative role of both psychogenic and epileptic seizures in day-to-day living should be carefully evaluated for each individual patient. Surgery is not contraindicated in this setting, however patients and family members should be educated about both conditions before surgical decision. Psychogenic seizures and other psychiatric co-morbidities should be properly assessed and treated before surgery. Diagnosis and management of postoperative events (epileptic or psychogenic) is challenging. This difficulty can be minimized by appropriate presurgical management, that includes diagnostic testing, neurologic and psychiatric treatment and patient and family counseling.

A prevalência de crises epilépticas entre pacientes com crises não-epilépticas psicogênicas varia entre cinco e 50 por cento. A diagnóstico desta comorbidade pode ser difícil, e requer experiência clínica, além de monitorização prolongada por vídeo-EEG. A ocorrência de eventos sugestivos de crises não-epilépticas durante a monitorização por vídeo-EEG deve ser interpretada com cautela. O papel relativo de cada uma das co-morbidades na vida diária do paciente deve ser avaliada caso a caso. Não há contra-indicação formal para a cirurgia, contudo pacientes e familiares devem ser esclarecidos acerca de ambos os diagnósticos e as crises psicogênicas e outras comorbidades psiquiátricas devem ser diagnosticadas e tratadas adequadamente antes da cirurgia. O diagnóstico e tratamento de eventos epilépticos ou psicogênicos que ocorram após a cirurgia é ainda mais difícil, porém esta dificuldade pode ser minimizada com uma avaliação pré-operatória cuidadosa, que inclui diagnóstico e tratamento neurológico e psiquiátrico precisos, além de aconselhamento a pacientes e familiares.