We studied 57 patients with poorly controlled or atypical seizures to identify hysterical attacks with a provocative test consisting of initiation and termination of an attack with suggestion and saline injection during electroencephalographic (EEG) monitoring. Using this method, we diagnosed 48 patients as having hysterical attacks. Three additional patients had spontaneous hysterical attacks during routine recordings. Of the 51 patients with hysterical attacks, 78% were female. Two-thirds of the patients were between the ages of 20 and 35 years. Thirty-two patients had taken anticonvulsants before the study. Each patient's hysterical attack, aura, and postictum was stereotyped, and the 6 patients subject to both hysterical and organic seizures described the two types of attacks as different stereotyped behaviors. Tongue laceration, urinary incontinence, and postictal confusion were common. Twelve patients had evidence of past or present neurological disease. Abnormal EEGs were recorded in 37% but only 12% had spike or spike and wave discharges. The provocative EEG test employing saline and suggestion is a useful tool in the diagnosis of hysterical "seizures."

Hysterical seizures: Suggestion as a provocative EEG test

Induction by suggestion has previously been reported to be effective in the diagnosis of psychogenic seizures (PS). However, the sensitivity and specificity of this procedure has not previously been studied. Results of induction of PS by suggestion were analyzed in 93 patients with purely PS. The diagnosis of PS was based on the recording of a clinical event on video-electroencephalography, the absence of clinical or electroencephalography the absence of clinical or electroencephalographic evidence of epilepsy, and the subsequent followup and withdrawal of anticonvulsants supporting the diagnosis of PS. A control-group was composed of 20 patients with epilepsy in which induction was tried. Both groups were comparable for age, sex, and educational level. Induction was performed following a standardized protocol. The test was carried out placing a colored patch on the neck. The test was considered positive when the induced clinical events were typical, according to a witness familiar with the patient's seizures. Induction was positive in 72 of 93 cases with PS and in none with epilepsy. Sensitivity of this test for the diagnosis of PS was 77.4%, specificity 100%, positive predictive value 100%, and negative predictive value 48.7%.

Predictive value of induction of psychogenic seizures by suggestion.

Forty-three patients exhibiting psychogenic seizures with onset before the age of 16 years were studied. All patients underwent intensive electroencephalography and video-electroencephalography monitoring. Thirty-two were female and 11 male. Mean age of the population at seizure onset was 12.4 years (range, 5 to 16 years). Twenty-one patients (48.8%) were taking anticonvulsants. Neurologic past history was abnormal in nine cases. Family history of epilepsy was found in 15 cases (34.9%). Median seizure frequency was one seizure every 5 days. Clinical characteristics of the seizures varied. However, unresponsiveness with generalized violent and uncoordinated movements involving the whole body (n = 19) or with generalized trembling (n = 11) were the most common features. Neuropsychological testing, carried out in 22 cases, failed to show major abnormalities in most of the cases. Significant personal and family distress was found in most of the cases. An important impact on patient's quality of life was evident when the seizures were present as compared to the seizure-free periods. There were no statistically significant predictors of clinical outcome.

Psychogenic Seizures in Children: Long-Term Analysis of 43 Cases

For a 2-year period, all patients admitted to the inpatient adult EEG videotelemetry unit of the University of Miami School of Medicine underwent attempted event induction with intravenous normal saline placebo. Of 175 patients monitored during that period, 101 underwent attempted placebo saline induction, whereas 58 patients were either in the pediatric age group, were undergoing a repeat hospitalization (i.e., depth electrode monitoring), or refused induction. The final diagnosis in each patient was established after review of the history; physical, interictal, and ictal EEG findings; brain imaging studies; interictal and postictal brain single photon emission computed tomography (SPECT) and serum prolactin levels; psychiatric and psychological evaluations; and detailed neuropsychological testing. Final diagnoses were separated into epilepsy alone, pseudoseizures, epilepsy and pseudoseizures, and other (neither epilepsy nor pseudoseizures). No patient with an eventual diagnosis of epilepsy alone was inducible. Forty-one patients with a diagnosis of epilepsy were not inducible. Of 32 patients with an eventual diagnosis of pseudoseizures, 29 were inducible. One of these 29 was also diagnosed with epilepsy. Three patients with an eventual diagnosis of pseudoseizures were not inducible; 90.6% of patients with an eventual diagnosis of pseudoseizures were inducible, i.e., had events identical to those reported by history, after injection of saline placebo. Placebo saline injection is a safe and effective means of distinguishing epilepsy from pseudoseizures.

Induction of pseudoseizures with intravenous saline placebo.

Gender-related differences for disorders of consciousness other than true epilepsy usually point to a larger number of women suffering especially from non-epileptic attacks or pseudoseizures. Recently, sexual abuse has been suggested as a possible cause for this increased prevalence in women. It has, however, not been very clear if women have a different phenomenology of these type of seizures from men. In the present study, patients' cases as published in the literature are analysed in a detailed way, using a working classification by Betts et al to look for gender-specificity. Of the 62 cases, 76% concern women and 24% men; a percentage comparable to those published elsewhere. Ages range from 14 to 77 years-of-age, but 89% of patients are younger than 40. Sexual abuse was proven in 18 cases, all women. The phenomenology of the attacks was divided into tonic-clonic type and complex partial type of attack, or a combination of the two. Also, special types of attacks (swoons, tantrums, abreactive attacks and forthright simulation) were looked for. Males tended to suffer especially from tonic-clonic type seizures (80% of cases), while in women as many tonic-clonic type as complex partial type attacks were observed. Special types of attacks were observed at the same frequency in both sexes. The group of sexual abuse victims did not differ from the total group of women in this respect. The clinically more impressive nature of a tonic-clonic-type attack, that is more easily suspected to be ‘real', might make this type of seizure a more male form of acting out. A prospective study on the incidence and phenomenology of pseudo-epileptic seizures in the general population is suggested to answer the new questions raised in this survey.

Gender-related differences in non-epileptic attacks: a study of patients' cases in the literature

Failure to recognize pseudoseizures is a common problem, affecting both epileptic patients who additionally have pseudoseizures and nonepileptic patients inappropriately called epileptic. Pseudoseizures most commonly mimic generalized tonic-clonic (GTC, "grand mal") seizures or complex-partial seizures. Several patients whose speudoseizures were not recognized are described. Adhering to logical principles of diagnosis for epilepsy, as for other medical problems, and remaining aware of basic beahvioral dynamics should eliminate the confusion between pseudoseizures and epileptic seizures.

Recognition of pseudoseizures.

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Recognition of pseudoseizures.