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A Pox On This Place

Fake Seizures

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I don't think that we have much of an ability to distinguish "fake" seizures from "real" seizures. The spectrum of possible seizure disorders includes randomly staring off into space in the middle of a conversation for a few seconds ("petit mal"), suddenly collapsing to the floor ("atonic seizures" / "drop attacks"), or random crazy psych-like behaviour ("complex partial seizures" / "temporal lobe seizures"/ "psychomotor seizures"). Not everything that is a seizure is a tonic-clonic seizure.

I guarantee that many of us, myself include, would be willing to write off many people exhibiting real seizure activity as having behavioural issues or being syncope of some other etiology, e.g. potentially cardiac -- especially if we haven't witnessed the event ourselves but are responding to it minutes or hours later. I'm sure plenty of emergency physicians make mistakes, and I know from talking to neurologists, that even with multiple EEGs and a lot of investigation, it's not easy to differentiate seizure activity from other syncope, unless you witness the actual event occurring.

I'd say it's more important to be able to determine which patients should be receiving benzodiazepines, i.e. primarily those with generalised tonic-clonic activity, than it is to label patients as "fakers" or "not-fakers". Applying a label like this is something that may follow the patient through their stay in the emergency department and negatively affect the care they receive when they have a legitimate medical concern. It might be better to simply make a judgment as to whether benzodiazepines are necessary, collect the best history available, and let the ER / neurology sort it out.

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That is something that so many people take for granted. While you are having a fake seizure, someone out there is actually having a real one. It is difficult knowing which is which, but in the end, their conscience will ride them. In this field, there is no time in deciding if it is fake or not, it is litteraly a matter of acting on what you see. When you are trying to save someone's life, just to find out that they took you for a fool, makes you almost whish that that person could have a real one, just so they can see that it is no joke.

Welcome to EMS and to the city. Since you listed your occupation as a student you will be cut some slack but you will need to lose the hero syndrome if you expect to survive in this field. With proper education and experience you will learn who is faking, who has PNES and who is real. If you don't properly assess your patient, you will pump up a junkie with so much ativan that they will need you because of the iatrogenic apnea.

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It can be difficult to differentiate at times but we have a lot of pseudoseziures here. Risk factors- Female, teenaged, mental health hx :P

There are signs to look for, Obviously if they are appearing to have a tonic/clonic seizure you can look at things like their breathing and eye activity, response to painful stimuli. No post-ictal phase, with the pt telling you they suffer from seizures but unable to elaborate on the hx of their condition, who their neurologist is, and not being on any epilepsy type medication. If in serious doubt always treat it as it presents. If that means giving Midaz/Loraz/Diaz to someone faking it, then so be it. Better than withholding from someone actually having genuine convulsions.

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I think we need to make sure we all understand that there is a difference between faking and pseudoseizures/PNES (PNES is just the newer name for pseudoseizures). PNES won't have a postictal period and will also lack the tongue biting, incontinence. Often times, people with true epilepsy won't be on antiepileptics, so don't be misguided.

So, how can you tell? Let me share some anecdotal evidence. If you are working in the ER and take a call that goes something like this, you can be pretty sure the pt is faking it.

EMS: We have a XX year old female whose having seizures. We've given her 6mg of IV ativan and need orders for more for a pt in status epilepticus.

ER: Are you sure she is still seizing or had a seizure?

EMS: Yes, she is still shaking and she is telling us she needs more ativan because she is still seizing.

ER: Uh, OK. Hold off on the ativan and we will assess when she gets here.

EMS gets to the ER, stops in the hall, pt gets up off the stretcher and walks out.

Edited by ERDoc
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Doc, thank you breaking my balls and moving me beyond my comfy been-there response to problematic seizures. While PNES is a disagnosis beyond my pay grade as a lowly Basic in a bupkus volly service in Wisconsin, it's a very real diff diagnosis thing.

Thank you.

Edited by A Pox On This Place
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EMS: We have a XX year old female whose having seizures. We've given her 6mg of IV ativan and need orders for more for a pt in status epilepticus.

ER: Are you sure she is still seizing or had a seizure?

EMS: Yes, she is still shaking and she is telling us she needs more ativan because she is still seizing.

ER: Uh, OK. Hold off on the ativan and we will assess when she gets here.

EMS gets to the ER, stops in the hall, pt gets up off the stretcher and walks out.

Awesome, and a little frightening.

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I gave you a negative for that. Why would you take the albeit slight risk of injecting a substance into a patient with no therapeutic benefit for the patient?

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I imagine that would also involve lying to a patient by way of telling them you're giving them pain medication.

Poor form.

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ever tried normasaline for pain control.... works wonders :)

I have never heard of Normasaline.

If you mean Normal Saline, I can direct you to literature that disproves your analgesic claim.

Back to the thread.....

I have dealt with a few pseudoseizure patients multiple times. This was complicated by the fact that hey also had epileptic seizures as well.

I am with Doc on this one, in that, if you think pseudoseizure means "faking", you need to do some research to start providing better care for your patients. That said, I am not real quick to give benzo's to pseudoseizures, as I am so charming - I can usually stop them with some coaching.

I do not however, say an absolute "no" to treating them with drugs. It just goes from treating a siezure, to treating a psyc event (Which uses the same drug).

These are my anecdotal tips.

Pseudo:

Typical patient - Female, teen to early 20's. Hx of depression. Perhaps drug us history, current or recovering

Eyes cannot be pryed open

Eyes making purposful movements (Looking at you)

No tongue biting, peeing, (as was said by Dwayne)

Will be in a safe place (Bed, couch, floor away from furniture)

Will be ventilating adequatly (As detected by EtC02 and Sp02)

Cannot tolerate NPA

Rythmic up and down movement of head, but not hitting head on the floor when it comes down

Withdraws from pain at toes

Withdraws from pen scratch on foot (as if testing for Babinski)

Cooperates with I.V. start

I dunno.... that's what I look for.

Bottom line for me is, wheather it is psycogenic,or neurologic, it needs treatment.

A all out faker is prety easy to disern by taking a proper history IMO

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