■ Psychogenic Seizures
Nonorganic, nonepileptic seizures arising from psychological factors do not involve loss of consciousness. They are involuntary and unintentional, and thus must be differentiated from simulated seizures, which are voluntarily, consciously, and intentionally produced events. Psychogenic seizures may resemble frontal lobe seizures (p. 194) and are more common in women than men. About 40% of patients with psychogenic seizures also suffer from true epileptic seizures. The case history often reveals characteristic risk factors, which may be biographical (family difficulties, abuse, divorce, sexual assault in childhood), somatic (genetic predisposition), psychiatric (conflicts, stress, psychosocial gain from illness behavior, mental illness), or social (poor living and working conditions). Patients often meet the psychiatric diagnostic criteria for a conversion disorder (F44.5 according to the 1CD-10). Epileptic seizures in family members, or in the patients themselves, may serve as the prototype for psychogenic seizures.
Premonitory signs. Psychogenic seizures can be induced or terminated by suggestion. They may be preceded by a restless, anxious, or fearful state. They usually occur in the presence of others (an "audience") and do not occur when the patient is asleep.
Seizure semiology. Psychogenic seizures usually take a dramatic course, with a variable ending. Their semiology is usually of a type more likely to incite sympathy and pity in onlookers than fear or revulsion. Typical features include an abrupt fall or slow collapse, jerking of the limbs, tonic contraction of the body, writhing (arc de cercle), calling out, shouting, rapid twisting of the head and body, and forward pelvic thrusting; the sequence of movements is usually variable. The eyes are usually closed, but sometimes wide open and staring; the patient squeezes the eyes shut when passive opening is attempted. Urinary incontinence or injury (self-mutilation) may also occur. Tongue-bite injuries, if present, are usually at the tip of the tongue (those in true epileptic fits are usually lateral). The patient is less responsive than normal to external stimuli, including painful stimuli, but not unconscious (squeezes eyelids shut when the eyes are touched, drops arm to the side when it is held over the patient's face and released). The patient's skin is not pale or cyanotic during the ictus. Patients who hyperventilate during psy-chogenic seizures may have carpopedal spasms. Psychogenic seizures often last longer than epileptic seizures.
Postictal phase. No focal neurological deficits can be detected, though there may be a psycho-genic postictal stupor. The serum prolactin level is not elevated (which, however, does not rule out a true epileptic seizure). The seizure may be terminated abruptly by suggestion, or by departure of the "audience." Some patients recall the seizure to some extent, while others emphatically deny memory of it.
Panic disorder is characterized by sudden, unexpected and apparently unprovoked attacks of intense anxiety, which may range in severity from a general feeling of restlessness to a mortal dread. The attacks usually last 5-30 minutes and may awaken the patient from sleep. Accompanying symptoms include feelings of detachment from the environment, i.e., depersonaliza-tion (detachment from one's own body, floating state) and derealization (sensation of being in a dream or nightmare, feeling of unreality); au-tonomic and other physical symptoms of variable severity, including cardiovascular (tachycardia, palpitations, pallor, chest pain or pressure), gastrointestinal (nausea, dry mouth, dysphagia, diarrhea), respiratory (hyperventilation, dyspnea, smothering sensation), and other manifestations (tremor, twitching of the limbs, dizziness, paresthesia, mydriasis, urinary urgency, sweating). The differential diagnosis includes epilepsy (aura, simple partial seizures), hyper-thyroidism, hyperventilation syndrome, pheochromocytoma, heart disease, and hy-poglycemia.
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