Seizures: a question and an answer

One of the readers of my blog wrote to me recently. His question and my reply to it follows. I think some of you may find it helpful.

 

Hello Dr. Sethi,
 
I came to your site/blog while doing a Google search regarding delirium tremens, which I found extremely helpful!  So I thought I would ask for your opinion about a diagnosis my neurologist gave to me about half a year or so ago.  Please feel free to remove my email and name and post on your blog!
 
So my history is that I’m 20 years of age and have had two seizures in the past…36 months or so.  I have had no family history of seizures or epilepsy, one case each of diabetes (treated with metformin), stroke (no known treatment), and breast cancer (treated by partial mastectomy).  Both sides of my family are on high blood pressure medications.  I myself have a history of reactive airway disease.  I have also been prescribed lots of co-actifed and have developed a bit of an addiction to using drugs that cause sedation; among the things I can list are: codeine, diphenhydramine, Actifed, lorazepam, and tramadol (I would say this is probably significant), and I often self dose; with high amounts of codeine, and often double or triple the recommended doses for benadryl and Actifed (as on the box); these three are the most common drugs I take to sleep, I realize I am developing a tolerance to them.  I am trying to stop using these as a way of falling asleep. 
 
Anyway, so the first incidence of my seizure happened when I was working on my computer, writing up a laboratory report that I was working on for a while.  I had been sitting there for several hours already.  I had been taking tramadol on and off for the couple of months or so.  I fell into a seizure and my mother found me.  Nobody saw what happened as I slipped into a seizure, I just fell backwards. 
Key things I remembered/observed:
-I did not have an aura
-I did not have incontinence
-I instinctively bit down, but I do not know if I bit my tongue because my mom had put her finger in my mouth
-I had nausea when I woke up
-The whole sequence of events I believe lasted around 5 or so minutes. 
 
The ER doc and the paramedics had concluded the seizure was due to tramadol. 
 
The second incidence of seizure happened when I was sleep deprived, though arguably I was sleep deprived in the first incidence too.  I had only slept several hours the night before and I did not nap (which I usually do for several hours during the day).  I spent the whole day awake, and I went to a friend’s house afterwards.  I was playing a poker game, which often makes me feel really stressed (I get sweaty palms, feeling of coldness, a bit of light-headedness, and sometimes I get slight dizziness).  I remember that I had not eaten much at dinnertime and I was hungry, so I ate a bunch of chips as a snack, with an iced tea to drink.  I remember I had slipped into a seizure, again with the same symptoms as the first time, lasting about 5 minutes.  The key issue is that I did NOT bite my tongue. 
 
Again, I was taken to the ER and the ER doc was not sure what could have caused it.  I do not recall taking any drugs throughout the course of the day but I might have taken some diphenhydramine to sleep the night before.  I realize that these act on the nervous system.  The ER doc immediately prescribed me phenytoin and referred me to a neurologist, and an EEG ordered. My neurologist subsequently ordered an MRI.
 
 
When I went to see my neurologist, she examined me as usual and asked for the same details I have given above.  Her conclusion given her initial diagnosis was an epileptic seizure of cause unknown.  Her suspected trigger was sleep deprivation.  A second neurologist I visited repeated the diagnosis. 
 
Following the EEG and MRI, I went back to see my neurologist (this was after several visits).  The EEG had come back normal.  I did not lose consciousness (aside from the sleeping phase of the test) nor was ever informed that I had a seizure during the course of the test.  The MRI had also come back as negative in anything in my brain.  I was not informed of any other explanation other than a “possible” epilepsy condition.  Neurologist placed me on phenytoin, which I took for three weeks before having an allergic reaction and had to be switched over to levetiracetam.  Following that I saw the neurologist again due to severe depression and mood disorder.  We decided mutually not to take the medication, of which she warned me that there was a 75% chance of a third seizure in the following year. 
 
To this date, I have not had another seizure, and about 7 months has passed since the incident.  Again I have not taken any antiepileptics aside from occasional (several days to several weeks in between doses) lorazepam 1mg. 
 
I should note also that while having taken lorazepam 1mg-2mg (and being off of it for a week), I have subsequently drank more alcohol than I usually do and taken a ranitidine 150mg before going to drink (supposedly to prevent hangovers and being able to drink more).  The amount I drank was about 2 shots and a beer, before I started to experience delirium tremens.  The odd thing is, however, that exactly one week after that incident, I drank the same amount of alcohol but did not have delirium tremens (without having taken the ranitidine).  I understand how alcohol works in the brain by depressing the nervous system. 
 
I understand that the medication is preventative, but I am worried that I might have another seizure.  It puzzles me since my lack of taking medication should therefore result in seizures if I really have epilepsy.  I understand that drugs can cause seizures, especially in overdosing amounts, however, I would really like a second opinion about whether or not I really do have epilepsy.  Of course I understand that your opinion is only an opinion since I have not been examined by yourself, but I have provided as much relevant information as I can.  I also understand that there are many triggers of epilepsy, and often the cause isn’t really clear.  I would like to be seizure free of course and not have to take medication, but my neurologists are telling me otherwise, which concerns me. 
 
Please reply to me with your opinion as your time allows.  Oh please feel free to also use medical jargon if you wish in your replies, I am actually studying as a pre-med student myself, which might be where the stress is coming from. 
 
With Regards and thanks,
 
xx
Dear XX,
                               thank you for writing in to me. You gave me a very detailed and thorough history. While as a rule I do not and should not diagnose someone over the Internet since I have neither taken the history myself nor examined them, I do have a few words of advice. It is likely you have an underlying tendency to have a seizure. It is also well known that sleep deprivation, excessive use of over the counter antihistamincs and other prescribed medications such as lorazepam, codeine and Tramadol can lower the seizure threshold especially when you are mixing these medications with alcohol.
 
Let me explain in another way. Two of your doctors (ER physician and neurologist) feel that you have epilepsy and prescribed anti-convulsant therapy. A normal EEG and a normal MRI brain do not rule out epilepsy. Infact many epileptics may have a normal routine (40 minutes) EEG study. Hence to increase the yield sometimes a more prolonged EEG study is ordered (such as a 24 hour ambulatory EEG study or an inpatient video-EEG study). If the EEG study clearly shows interictal epileptiform discharges, it strengthens the argument that you suffer from epilepsy and that it shall be prudent to continue taking an anti-convulsant since the chance of a third seizure is high. On the other hand if the EEG study comes back normal, we are back to square one. It does NOT rule out epilepsy. Levetiracetam has been reported to cause psychogenic side-effects such as anxiety. It can also make patients frankly depressed. So a mutual decision between you and your physician was made to stop levetiracetam.
 
If I understand your email right, at present you are NOT on any anti-convulsant therapy. Your physician rightly informed you of the risks of taking this approach. You should remain in close follow up with your neurologist. Also since you have already suffered two convulsions (and have decided not to continue anti-convulsant therapy), it shall indeed be prudent if you make significant lifestyle changes. Namely avoiding alcohol completely or if that is not possible drinking in extreme moderation. I would also advice cutting down your use of over the counter sedatives, antihistaminics and other sleeping aids. You should maintain seizure and fall precautions at all times. Remember seizures are associated with falls and sometimes fatal injuries have occured. I always tell my patients  “you do not want to have a seizure at the wrong place and at the wrong time”. You should not drive as per the law of the state you reside in. Maintain good sleep hygiene and again remain in follow up with your physician. He/she shall be the best person to guide your care going forward.
 
Personal Regards,

Nitin Sethi, MD

Alcohol and seizures: a question and an answer

T

HI
My Father is an aolcoholic and last Sept he was admitted to hospital after a fall when drunk – whilst in hospital he had a fit – understandable he was cold turkey whilst there. He was treated and sent home. Since Dec he has reduced his drinking and now generally consistantly drinks 1 bottle red wine a day – yes this is still too much but about 50% what he used to drink – he reduced gradually and has maintained this intake for a few months now.
What I find strange is that all i can find about these alcohol withdrawl fits relates to 2-3 days without alcohol – Dad had a fit a few mornings ago after a normal day and normal alcohol consumption levels. The hospital saw alcohol in his notes and packed him off home again with some Vitamin B tablets.
How many alcoholics normally get fits whilst they are still drinking? How normal is this? He is eating better these days than he was but still could do with eating more. He borderline underweight and 74 years old – he has been dependant for more years than I can imagine but probably the last 12 years have been the worst. He does not drink in the morning but the first drink in the day is normally 3/4pm and last drink 6/7pm before bed. This one bottle of wine is often enough for him to fall when on his way to bed or even a few hours later I have had to carry him back to bed if he falls in the bathroom. His body just doesnt seem to be able to cope with alcohol any more – less alcohol to get drunk – is this why he is having the fits?
My apologies for long winded questions but the question needed some context to make sense I think. Any I am not delusional about his alcohol intake – I monitor it and he has no other way or place to stash any.

Thank you so much in advance

P.S. the fit was 6.30 am Thursday and now Sat pm he is still very unsteady and his memory is worse than before. What is the normal recovery from these fits?

 

Braindiseases

Dear T,
thank you for writing in to me about your father. There is no one set limit above which alcohol can induce a seizure. The limit varies from person to person. Rum fits (seizures which occur at the height of binging) of course occur when one consumes too much alcohol in too short time. Alcohol withdrawal seizures classically occur 24-48 hours after the last drink (they occur in people who are chronic alcoholics/ people who consume heavy alcohol on a daily basis and who then suddenly stop drinking). Again not every chronic heavy drinker gets alcohol withdrawal seizure if he/she stops drinking suddenly. Usually it is the person who is chronically malnourished and dehydrated who is more predisposed to an alcohol withdrawal seizure in the setting of sudden cessation of drinking. These people as you can well imagine are deficient in multiple vitamins and minerals (commonly the B group of vitamins such as Vitamin B1, B2, B6, folic acid and B12). Their electrolytes are also more likely to be off (meaning they serum sodium, potassium, magnesium is low). They may also have alcoholic liver disease (alcoholic steatosis or fatty liver, alcoholic hepatitis and finally cirrhosis). During their prolonged drinking years they may also fallen down and struck their head. So it is a combination of factors (meaning the overall health status) and not just the sudden cessation of drinking which predisposes some alcoholics to alcohol withdrawal seizures.
Finally over the course of years of heavy drinking, some alcoholics develop epilepsy. The reason for this may be any of the above I have listed. My personal feeling is that these patients likely have underlying epilepsy and alcohol (in excess or sudden cessation after years of drinking) just helps to unmask it.
Now let me answer your last question about time frame of recovery. Again if his pre-existing neurological status is compromised (his memory is already bad after years of drinking, his general medical condition is poor or if he has coexisting medical problems such as chronic lung or liver disease, diabetes or congestive heart failure) his recovery from a convulsion shall be slow as compared to a young person with no pre-existing medical problems.
I hope I have addressed some of your concerns. I wish you both my very best.

Personal Regards,

Nitin Sethi, MD

Seizures associated with excessive alcohol intake-why me?

One of the readers of my blog asked a question about alcohol induced seizures. His question and my reply to it follows. I have removed the name to maintain confidentality as always.

QUESTION

Hi; I wanted to read up about alcohol induced seizures because I have a question(s) for you, but I guess I should give you a little background first. I have had 7 of them, never had a problem before. The first one I do remember…I was drinking heavily ( Vodka ) and had done some recreational drugs too. I was in the kitchen and my bottom jaw “stuck” out and my hands clinched tight! My brain said “lay down” so I did and that’s as much as I remember. My soon to be wife and my son told me that my lips turned blue, eyes rolled up and I “wet” myself.Needless to say they called 9-11 but I refused to go.The other 6 six I do not remember…although the last one happened in the street and I got 3 staples in the head as a result.My Dad was an alcoholic so I never really drank growing up.However,when my son’s mother and I split when he was 2 ( he is 16 now ) I started to drink more, I had socially here and there but not like this.The seizures started about 3+ years ago I would “guesstimate”.I tried rehab 3 times – no good.At my “peak” I was drinking a gallon of Vodka a day.( I am not making any of this up! ).I have had massive panic attacks,spent hours ( every 20 min.) over the toilet,my blood pressure was through the roof and on and on.The “nail in the coffin” for me was one day I had my “other half” leave work to bring me my fix because I couldn’t handle the with-drawls any longer that morning. I drank about a pint and had pain in my chest,irregular breathing and I honestly felt like I was going to die!!My neighbor took me to emergency.When my “other half” got wind of it and showed up I was in horrible shape. The Doctor told her my blood-alcohol was .335 and he wanted to know how come I was even still functioning.( I know nothing of the point scale but I assume that was pretty bad ).I spent 3 days there, 2 on a heart monitor.They gave me Valume ( I don’t think I spelled that right ) and I don’t know what else.I had been given Librium in the past but they did not give me any, nor did I have any seizures while I was there.I was however really scared.When I came home I swore to my family that that was it……..it will 2 years in April !!! I drink a lot of coffee ( w/milk and sugar of course )and I like my ice cream!I build and paint models to “occupy” myself around the house but I do still think about it ( drinking ) here and there.I’m really not to worried about starting again…all I have to do is think about what I put the people I love through and that pretty much ” kills ” any craving,but I am fully aware that I will always be an Alcoholic. I do have an excessive personality, I really can’t do anything in moderation and I have insomnia ( in other words I am VERY high strung to begin with ).I will say that life is sooooo much better now but I do have a couple of questions……Why all of a sudden?  20+ years of “partying” and then one night “boom”( or did I answer my own question? ).It did take awhile to get to a gallon a day ( a few years in fact ). On a bigger scale….what I really would like to know is am I done having them? I think about them once and awhile and it kind of scares me to think I could be out doing something and have another one.I abstain from alcohol and everything else, but I do miss being able to “socialize” like everyone else.I don’t mind when people drink around me, it doesn’t tempt me or anything ( plus I know what they are going to feel like later! ) but I guess I put myself in that “boat”. Am I done having them??? I haven’t had one since I stopped drinking although one night at work shortly after I stopped I did have some kind of “panic attack”( light head,scared,sweating,dizzy-I just went home ) been O.K since but that is what got me wondering if I am truly done w/them.( I cannot associate any pain or anything w/having them – just waking up disoriented in an ambulance or wherever else, but again….I am clean and sober and will stay that way so can I assume that there won’t be anymore?
And to anyone reading this….I am no expert on this and believe me, I don’t tell ANYONE how to live their life but –  if your to the point of having seizures from drinking like I did – time to quit the game and walk away! I was playing a game that almost cost me my life – wasn’t worth it!
Thank you for your time reading this and I look forward to your response.

ANSWER

Thank you for writing in to me. As the name of my post suggests the seizure/ convulsion in the above case is usually temporally associated with excessive alcohol use. I shall use your question to discuss alcohol induced seizures at length namely under the following points:

“I can drink but know exactly when to stop”: people frequently have this misconception (these are people who usually suffer from a drinking problem aka alcoholics but still feel they have their drinking under control). Now what is “excessive” for one may be the “norm” for another. So there is no hard and fixed limit about exactly how much alcohol can be “safely consumed” without provoking a seizure.  Some people can drink like a fish and still not suffer a convulsion and there are others who have suffered an alcohol induced convulsion after just a “few” drinks. In my experience some people are particulary good in knowing when to stop. They shall drink right up to the limit but then stop and “be okay”. That said I feel this is playing with fire and if you are drinking right up the edge, you are playing Russian roulette.  

Another misconception that I have encountered is that people frequently feel that if they drink top shelf vodka or scotch or more commonly wine they are immune from suffering the ill-effects of excessive alcohol intake aka a seizure. Again it is not the type of alcohol which is consumed that makes you prone to have a convulsion, it is the absolute amount consumed. So if you drink bottle after bottle of wine, you are just as likely to suffer a convulsion as when you consume excessive amounts of some bottle shelf vodka. Obviously it goes without saying that one can ‘safely” cosume more bottle of light beer than an alcoholic beverage with a higher quantity of absolute alcohol.

When a person has suffered a convulsion in the field is brought to the emergency room, doctors as a rule usually check the blood alcohol level. This gives a fair indication about exactly how much alcohol was consumed and helps us in determing if excessive alcohol ingestion played a role in the seizure. The absolute blood alcohol level though is just a number and other things have to be considered before a seizure is attributed to excessive alcohol inake:

how long ago was the last drink consumed?  (alcohol is rather quickly metabolized and hence one may obtain a falsely low reading if the blood level is checked after some time has lapsed since the last drink).

over what time frame was the alcohol consumed ?(you are more likely to suffer a convulsion if you consume excessive amounts over a very short interval of time–aka if you are binge drinking). The caveat to that is alcohol withdrawal seizure if which a person who is a chronic alcoholic abruptly ceases drinking and suffers a withdrawal seizure. This usually occurs 24-48 hours after the last drink was consumed.

whether the drinks were mixed? one is more likely to suffer a convulsion in the setting of consuming many different types of drink (vodka, rum, whisky, beer) in one sitting. Again my personal impression is that this is not because one consumed different kinds of drinks, it is because when drinks are mixed you are more likely to consume more alcohol and not get a warning about when to stop.

whether there was use of illicit drugs along with the alcohol? combining alcohol and illicit drugs like cocaine, heroin and even prescription drugs like Xanax (a common drug of abuse), valium, Adderall, anti-depressants such as Wellbutrin, and even some over the counter so called safe herbal medications to lose weight can build the perfect storm to provoke a convulsion.

whether there were other precipitating factors? factors like been sleep deprived, dehydrated, drinking on an empty stomach all help in adding their two cents to build the perfect storm leading to an alcohol induced convulsion.

is there an underlying tendency/predisposition to have a convulsion? this concept is a little difficult to explain but let me attempt to explain with an example. Let us assume you have underlying epilepsy. You are then more likely to suffer a convulsion in the setting of excessive alcohol use that say a person who does not have underlying predisposition to have a seizure. You may both consume the same drinks and the same amount of alcohol, still you remain at higher risk of suffering a convulsion than the other person.

I thank you for your question and wish you good health in the New Year 2011. It takes immense strength of character and determination to walk away a winner from an alcohol addiction.

Personal Regards,

Nitin Sethi, MD

Seizures due to hypoglycemia–a couple of questions and answers.

I got a few insightful questions from my readers which I am sharing here. My reply to them follows.

K

Is it possible to have hypoglycemia and suffer with seizures without diabetes?

My Blood sugar level after a seizure is high though quickly drops down (Shock?)

Can Hypoglycemia be a random problem caused by diet at the time and stress etc?

 
  braindiseases  

Dear K,
thank you for writing in. You ask a good question. There can be many causes of hypoglycemia, diabetes mellitus is one of the more common causes. In diabetes mellitus hypoglycemia commonly occurs in the setting of a missed meal (by that I mean, a diabetic patient takes his anti-diabetic medication/ insulin but forgets to take his meal). Another setting may be if one has what is called brittle diabetes. This is a condition in which the blood sugar varies quite a lot. Such patients need fine control of their blood sugar level to prevent episodes of hypoglycemia or hyperglycemia.
Seizures occur due to hypoglycemia per se (low blood sugar), not because of hypoglycemia due to diabetes. What I mean to say is that hypoglycemia due to any cause can cause a seizure provided the blood sugar falls below a critical level (usually less than 50 mg/dl).
Personal Regards,
Nitin Sethi, MD

  S  

hi
im not here to ask a question sorry, just to ponder your mind a little,
ive had type 1 diabetes since the age of 4 (16 years) and i am now 20. when i was 7 i had my 1st seizure. time went on and since ive been 15 ive had around 20 + full on seizures ive had 2 in the street both ive recovered from, but the rest was in my sleep, with no warning atall. i go ridged and ALWAYS bite my tounge and injure myself, suck as banged my head off the cooker, the floor, raidiator etc. after this happens i get sugar rubbed in my gums by my family or friends till i come round, (no paramedic or hospital service involed) but the confusing thing was when i had them in the street and i came around WITHOUT sugar or anything. witch was also confusing for the hospital and my gp. witch also brings me to my next thing.
ive been to my local gp and also im back attending the hospital on a weekly basis.
as ive now been to see my gp today, and gave him details etc. of each seizure. hes now under the idea of sending me to a neurologist as he dosent beleive that my seizures are in anyway linked to my diabetes.
also ive just had my insulin changed from human mixtard 30 (twice daily) to lantus(morning) & novo rapid(breakfast, lunch, dinner).

what i was wondering was, what your thoughts would be on this ?

 
  braindiseases  

Dear S,
thank you for writing in. This is what I feel. I think it shall be worth your time to see a neurologist and get a thorough evaluation for your seizure disorder. Some of your seizures likely can be accounted for by hypoglycemia (the ones in which you make a rapid recovery when sugar is rubbed onto your gums). It is also possible that you have underlying epilepsy/ seizure disorder. This may result in convulsions which are unrelated to hypoglycemic episodes. Also why should you be having hypoglycemia induced seizures if your diabetes is well controlled? As you can understand there are bits in your history which do not “gel”.
So I feel you need a good work-up. A neuroimaging study of the brain (ideally a MRI scan of the brain) and an electroencephalogram (EEG study) may be warranted. Your doctor may then decide to treat you with an anti-convulsant medication.

Personal Regards,
Nitin Sethi, MD

 

Post traumatic epilepsy: a question and an answer

One of the readers of my blog asked me a question regarding her son. I am reproducing her question here. My answer to it follows.

V

my son was involved in a car crash 3 years ago aged 17 years and required brain surgery to remove a bloodclot. He recovered well with no ill effects. He had his first fit in November 2009. He had another 2 that same month. CT and MRI scans clear but eeg showed slight abnomal waves over area of surgery. Neuroligist said our choice if wanted to be on medication. Last fit was 27th November 2009 but he has just had another on 8th February whilst flying to holiday Do you thnk meds should be started to prevent further fits.

Dear V,

                    thank you for writing in to me. Your son’s condition is consistent with what is called post traumatic epilepsy. Let me attempt to explain this a little further. Your son obviously was not born with a seizure disorder (epilepsy). He was apparently well till he was involved in a motor vehicle accident (MVA). As a result of the MVA, he suffered head injury and from what you decribe an intracranial hematoma (blood clot) which required evacuation (removal of the blood clot surgically). He had an uneventful recovery but soon there-after had his first convulsion (you do not mention the time interval between the head trauma and the first convulsion).

As the name suggests post traumatic epilepsy refers to epilepsy/ seizure disorder which occurs after head trauma. Usually for post traumatic epilepsy to occur, the head trauma has to be significant such as a motor vehicle accident with significant intracranial hemorrhage or head injuries sustained in the battle field. Many of our soldiers returning from the battlefields of Afghanistan and Iraq suffer bullet shot injuries to the head (these as you can imagine are penetrating head injuries and cause significant brain damage as the high velocity bullet traverses through the skull). IED (improvised explosive devices) related blast injuries cause closed but still significant head trauma and are the signature injury of these two wars. Many of these brave men and women later develop post traumatic seizure disorder/ epilepsy. In other words minor bumps to the head (example you walk into a door) do not cause post-traumatic epilepsy.

There are three types of post traumatic epilepsy. Immediate, early and delayed. Let me explain this at length. Let us assume you are involved in an accident. Your head strikes the ground or steering wheel hard. You have a seizure soon after the impact. This is called immediate or impact seizure. This type of seizure does not lead to seizures later in life and hence such a patient does not warrant to be on long term anti-convulsant therapy.

Early post traumatic seizures are those which occur within 6 months of injury while late post traumatic seizures are those which occur after 6 months. Remember you can have your first post traumatic seizure as long as 5 years after the head injury. In other words if 18 months go by and the person has not had a seizure then likely he shall not have seizures as a result of head trauma. Patients who have early and late post traumatic epilepsy may warrant treatment with anti-convulsants. This is because the brain has suffered a scar (as a result of the head injury) and it is this scar tissue (consisting of damaged brain tissue) which then misfires and acts as a seizure focus (point in the brain where the seizure originates from).

In the case of your son, since he has suffered multiple convulsions since his head injury, he likely needs to be on an anti-convulsant. This decision though shall be made by his neurologist after consideration of factors which I mentioned earlier in my post. EEG may or may not be helpful in this regard (a normal EEG does not rule out seizure disorder and vice versa not every patient with a seizure disorder has an abnormal EEG).

I hope this is helpful to you. I wish him my very best.

Personal Regards,

Nitin Sethi, MD

Non epileptic seizures or pseudoseizures

Non epileptic seizures or pseudoseizures-what are they and what is to be done about them?

Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY

I thought in this post of mine, I shall discuss pseudoseizures. As the name suggests pseudoseizures means “not true seizures”. We nowdays prefer to refer to them as non-epileptic events (NEE).

So what do we mean when we say someone has pseudoseizures? Let me illustrate with the aid of an example. A patient lets say Ms.XYZ comes to me for initial consultation for her seizure disorder. History is as follows. She has had 2 episodes where-in she was witnessed to have violent jerking movements of her arms and legs. First episode occurred in school after she got into a heated verbal argument with her best friend while the second occurred after a similar confrontation at home with her mother. None of these events were preceded by any aura. As per history she did not bite her tongue or have loss of bladder control though she says she felt tired after the events.

Hmm sounds suspicious for seizures you might rightly say. I tell her I would like to bring her into the hospital to do a video-EEG study to better characterize her seizure type (see my posts on seizure types at http://braindiseases.info). She agrees to the study.

EEG recording is initiated and is read as normal after 24 hours. The next day in the hospital, I tell her and her mother about the results of the normal EEG. A few hours after my discussion with the family, she is noted by the nursing staff to have a violent “seizure”. I review her EEG. On the camera I notice her to suddenly stiffen and then have violent out of phase (uncoordinated) flinging movements of the arms and legs. Her head moves from side to side and I overhear her  yelling “too much, too much, let me go!!! let me go!!!). The event occurs while her mother and her best friend are by her bedside.

I look at the time locked EEG (EEG synchronized with the video in real time). While she is clinically having a “seizure”, her brain waves are normal (the brain is not having a seizure). A correct diagnosis of pseudoseizures (non-epileptic event) is made and she is discharged home with advise to follow up with a psychiatrist.

So what is a pseudoseizure?

1. It is not a true seizure but rather an episode or episodes which clinically look like seizures but are not accompanied by any EEG changes.

2. It usually has a psychological basis. In my experience I commonly see them in people who are passing through tremendous stress be it interpersonal relationships or at the job.

3. A person may have pseudoseizures to achieve a secondary gain (in the case of our patient, attention and love from her mother and best friend).

4. Pseudoseizures are not treated like seizures. These patients do not need anti-seizure medications. They rather at times need a psychiatrist to explore the underlying reasons for the NEE (conflicts in family etc).

5. Some patients who have true seizures (epilepsy) may also have pseudoseizures.