Indian Pediatrics 2004; 41:673-679
Term Hysteria has been derived from Greek word Hystera (uterus). In simple non- Freudian terms, hysteria is an unconscious expression of emotional conflicts in the form of physical symptoms(1). It is this unconscious expression that differentiates hysteria from malingering or hypochondriasis. An alternative hypothesis suggested by some workers(2) observe that the children with hysteria are at least partly conscious of their actions and learn through experience to use their physical symptoms as a maladaptive defense against anxiety. Contrary to hysterical disorders, childhood hysteria has not been accorded due recognition as pointed out by some workers. Some of the presentations of hysteria have not been studied in detail. They include pseudoseizures or hysterical fits.
Because of few studies on childhood pseudo seizures, a certain amount of extrapolation from observations of adults is inevitable, but it does not undermine the general principles suggested, especially when applied to older children and adolescents(3).
Pseudoseizures are paroxysmal alterations in behavior that resemble epileptic seizures but are without any organic cause. Out of various terms used for pseudoseizures (Table I), the term "Non-Epileptic Seizures" (NES) is considered as most favored because it is non-judgmental, often used, acceptable to patients and best describes problem without implying causation.
Table I Synonyms of Pseudoseizures.
Nonepileptic seizures (NES)
Nonepileptic psychogenic seizures
Nonepileptic attack disorder (NEAD)
Nonepileptic events (NEE)
Nonepileptic conversion seizures (NECS)
P sycho seizures
The incidence has been reported to be 6.5 to 10.6% in various studies probably because of variations in the diagnostic criteria used by different workers(4-7). Pseudoseizures constitute about 25% of total patients of hysteria(3,5-8) and 20% of patients referred to epilepsy centers. In a community survey of rural India(8), the prevalence of pseudoseizures has been found to be 2.9 per 1,000 population. Furthermore, among patients with epilepsy (1% of general population) up to 10% may develop pseudoseizures.
Pseudoseizures can present in various forms e.g., (a) convulsive type of pseudo-seizures; (b) hysteroepilepsy (including classical arc de cercle opisthotonic posture); (c) loss of tone; (d) loss of awareness; (e) unresponsiveness accompanied by complicated behavior where the risk of confusion with complex partial seizures is greatest and; ( f ) myoclonus(9,10).
Table II may help to differentiate a pseudo- seizure from a true seizure. The common precipitants of pseudoseizures are often related to family (parental discord, separation, death, chronic illness in a parent, over-protection or neglect, financial problems, alcoholism in father etc.) or school (pressure of performance, forthcoming exams, peer- pressure, abuse or any recent change in school, class or friends). The psychiatric comorbidity of pseudoseizures must also be considered as underlying predisposing or precipitating factors.
TABLE II Differences between Pseudoseizure and True Seizure.
Various important causes of misdiagnosis (9-15) are summarized in Table III. Pseudoseizures have to be differentiated from epilepsy. Nonepileptic attacks are not always pseudoseizures. They may reflect the symptoms of malingering, somatization disorder (Briquets syndrome), dissociative trances, factitious disorder, hyperventilation syndrome, panic attacks, post-traumatic stress disorder, startle disease, migraine, syncope, narcolepsy, Tourettes syndrome or cardiac arrythmias(16,17). Organic lesions such as mesial temporal sclerosis, low grade gliomas, cavernous angiomas, dysplasia, arachnoid cysts and midline brain tumors may present with symptoms of pseudoseizures. Keeping in view the differential diagnosis in mind, relevant investigations are done(18).
Causes of Misdiagnosis of Pseudoseizures
The acceptance of diagnosis of pseudo-seizures both by clinician and patient is must. Pseudoseizures must be correctly recognized because a misdiagnosis can be harmful and patients who have psychogenic status epilepticus may develop respiratory arrests caused by treatment, and intubation(19). Unnecessary investigations and anti-con-vulsants may add to wastage of resources and side effects. The recognition of pseudo- seizures is important even in epileptic patients otherwise one will go for unneeded investigations or increase in dose of anticonvulsant medication. Relatives are taken into confidence by telling about underlying psychopathology, diagnosis and treatment so that doctor-patient relationship is not harmed.
The patient is educated about the illness, its causation (i.e., role of unconscious) and outcome. Supportive psychotherapy and confrontation has been found useful in over 75% patients(20). In psychodynamic model, a repressed, unconscious intrapsychic conflict is expressed symbolically through the symptom such as pseudoseizure. From the symptom, patient gets primary gain (relief from stress or conflict) or avoidance of unpleasant situations and secondary gain (attention from relatives or doctors). Psychodynamic psychotherapy is useful in selected cases. Patients with lack of motivation or introspection capabilities, borderline intelligence, important secondary gains or a tendency for behavioral acting-out are poor candidates for insight-oriented psychotherapy. If there is an acute loss or adolescent sexual conflict or physical assault, short- term crisis intervention is needed.
Behavior therapists believe that pseudo- seizures or other hysterical features are a behavioral response to a variety of emotional stresses or as a chronic maladaptive behavior symptomatic of a variety of psychiatric disorders, reinforced by environment (advise on time-out from reinforcement of such behavior is very useful). The secondary gain (attention received from surroundings) should be immediately stopped. Behavior therapy is useful for those who are not good candidates for psychodynamic therapy (as neither motivation or normal intelligence or insight are necessary)(18). Relaxation methods and biofeedback as adjunctive techniques may be beneficial in some(18). In those patients in which pseudoseizure act as a coping mechanism, new coping skills are taught. A combination of psychodynamic and behavior therapy are useful in some patients.
Family therapy is useful in some cases because pseudoseizures may largely result from problems related to the dysfunctional family(21). Physical and sexual abuse are important family related etiological factors. Overprotection and rigidity are important attitudes which tend to perpetuate conflict.
Anxiolytic or antidepressants and hypnosis(22) play adjunctive role to psycho-therapy. Aversion methods are also sometimes helpful but care should be taken so as not to physically or psychologically harm the patient. Problem arises when physicians working in casualty believe pseudoseizures as malingering and give unwarranted physical aversion (abusive talk, beating, giving ammonia inhalation to patient) which may further create physical or psychological or legal problems.
The psychiatric comorbid disorders (21,23,24) such as depression, factitious disorders, somatization, generalized anxiety disorder, personality disorders or schizo-phrenia and associated organic disorders (epilepsy, space occupying lesion or any medical problem) also need specific treatment.
Provocative testing with suggestion is an important diagnostic and therapeutic tool. Suggestion that a specific maneuver is likely to stop a seizure is useful. The use of placebo for diagnosis and therapy is debatable as it may at times become confrontational and make the patient more resistant to further treatment.
Acute onset, short duration of symptoms, healthy premorbid functioning, absence of coexisting organic psychopathology, presence of an identifiable and removable stressor and good family support and cooperation are related to better prognosis(24,25).
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