Pseudoseizures

Seizures are a fairly common 911 call. Fever and epilepsy are the most common causes, but I've also seen patients seize due to head injury, overdose, or withdrawal from drugs or alcohol. 

Recently, I've encountered more patients with a previous diagnosis of "pseudoseizures" or
"behavioral seizures." That was new to me, and based on how these patients were often treated in the ER, I assumed these terms were non-confrontational euphemisms for "faking it." Consider one patient, whom I delivered to the hospital twice in one shift. The patient had been prescribed a number of medications, none of which had been effective in stopping their frequent seizures.  They were going to the ER by ambulance several times a week, where they usually spent a few idle hours before being sent home again. Their seizures weren't associated with any of the signs we usually associate with epileptic events, and the ER staff mostly rolled their eyes and wrote it off as a waste of precious resources. It seemed like a pointless exercise. 

Pseudoseizures, I learned, are not so easily dismissed as fakery. The current term for them is Psychogenic Non-Epileptic Seizures (PNES). They are not associated with the electroencephalographic patterns of epileptic seizures, nor the typical physiological signs we often see in epileptic seizure patients. They are caused, researchers believe, by the mind itself. 

Yet we now differentiate them from malingering, or consciously displaying symptoms for personal gain. That difference is critical: from the patient's perspective, they may be experiencing a distressing event not unlike a seizure. We'll never know for certain, because like the experience of pain, their truth will forever remain their own property, a place we may speculate about but will never visit for ourselves. The entire diagnosis of PNES rests upon a fundamental trust that patients are telling us the truth. 

What is perhaps most interesting (and sad) about the syndrome is that the prognosis for PNES patients is relatively poor. If the seizure events were merely the response to transitory stresses in their lives (or if the people were merely faking), you would assume the symptoms would resolve after a while on their own. Changes in their situation and stressors would eliminate the need for such a disruptive event. But it appears that's not the case. Something about the seizure-like event becomes written into the person's story, and grows difficult to erase. 

When someone's heart stutters and stops, I can reach within them and apply electricity; I can open an access point their vascular system and deliver medications to their core. How do we fix a system we cannot see, or know, and for which the tools we possess may never fit their faltering machinery?