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New Treatment for Pseudoseizures

Discussion in 'Emergency Medicine' started by southerndoc, Feb 18, 2012.

  1. southerndoc

    southerndoc life is good Physician Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

    Jun 6, 2002
    I'm having great success with using Geodon for patients with pseudoseizures. Used it about ten times over the past few months for those patients. I'm seeing a lot of patients who can only take Dilaudid for their chronic pain have pseudoseizures when they find out they will not be getting their Dilaudid shot.

    Anyone else using mood stabilizers for those that like to fake their convulsions?
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  3. The White Coat Investor

    The White Coat Investor AKA ActiveDutyMD Physician Partner Organization 10+ Year Member

    Nov 18, 2002
    SDN Partner
    I prefer using normasaline.
  4. diphenyl

    diphenyl Dancing doctor 7+ Year Member

    Jul 31, 2008
    I used normasaline on a guy who kept yelling he was having a seizure while he was thrashing himself against the rails lol
    Angry Birds likes this.
  5. WilcoWorld

    WilcoWorld Senior Member 10+ Year Member

    Nov 2, 2004
    I use intranasal ammonia ampules supplemented with a non-rebreather mask. It's absolutely phenomenal at restoring purposeful movement - diagnostic and therapeutic.
  6. Muscletoe

    Muscletoe Do-gooder 2+ Year Member

    Feb 20, 2009
    Nasal trumpet.
  7. gutonc

    gutonc No Meat, No Treat Administrator Physician PhD 10+ Year Member

    Mar 6, 2005
    A fibrotic stroma
    Perhaps this thread should me merged with the rectal exam one.
  8. myhandsarecold

    myhandsarecold 2+ Year Member

    Dec 2, 2009
    SpacemanSpifff likes this.
  9. sacrament

    sacrament somewhere east 15+ Year Member

    Makes sense. Improptu rectal exams are curative maneuevers for pseudoseizures, and are also helpful exercises for developing the physician's hand-eye coordination.
  10. NinerNiner999

    NinerNiner999 Senior Member 10+ Year Member

    Nov 4, 2003
    Where it's at.
    I have found that ordering a foley catheter is very successful.
  11. allendo

    allendo Senior Member 10+ Year Member

    Dec 13, 2004
    I rub lubricant on their forehead and tell them its a new transdermal seizure medicine, works every time.
  12. EctopicFetus

    EctopicFetus Keeping it funky enough 10+ Year Member

    May 3, 2004
    If my pseudoseizure patient is a woman, I give then a sternal rub to no end. My success rate is 100% as they instinctively reach for my arm to remove it.

    If a man I twist their nipples to about 720 degrees.. success is equally high. I do like some of the other suggestions in the room but I will keep with my current techniques.
  13. njac

    njac Senior Member 10+ Year Member

    we have a couple frequent fliers who are quick to tell you about their special seizures - they're called "A-C-T" seizures - upon arrival. They're super rare or something.
  14. pinipig523

    pinipig523 I like my job! 10+ Year Member

    Jan 6, 2004
    Missing Chicago
    Had a patient present yesterday - wife said that he's trying to wean himself off of heroin after 25 years of being on it. She says that he think he's withdrawing from it and having these jerking/myoclonic movements without affecting state of consciousness.

    Looked at the pupils - pinpoint b/l.

    Asked the wife, "So when was the last time he did heroin if he's trying to quit after 25 years?"

    "Right before we came into the ER."

    "Fantastic," I said.
  15. Jarabacoa

    Jarabacoa non carborundum ilegitemi 10+ Year Member

    Mar 24, 2005
    I think a tazer would be the best thing to use on a pseudoseizure. I had a cop tazer a patient a few months back. It was the coolest thing I've ever seen. The 6 foot 7 300 pound martial arts guru went from being aggressive, menacing, and psychotic to crying like a baby, exceedingly compliant and apologetic. Far more quick and effective than any zyprexa I've seen. I'm willing to bet the pseudo-seizure retards would never have another one the rest of their life.

    If only I were the King of the USA.
  16. gutonc

    gutonc No Meat, No Treat Administrator Physician PhD 10+ Year Member

    Mar 6, 2005
    A fibrotic stroma
    "Recent evidence suggests that remote electroconvulsive therapy provides the most effective and durable treatment of 'seizures' Mr. Jones. Please hold still and face away from Officer Smith."
  17. Nervous Ned

    Nervous Ned 5+ Year Member

    Apr 7, 2010
    Worcester, MA
    Sorry if this is a stupid question, but I had thought pseudoseizures were a conversion disorder. In other words, the patient isn't consciously faking them. This thread is making it sound more like it's malingering or factitious.
  18. Sweet Pea

    Sweet Pea 5+ Year Member

    Nov 6, 2007
    Most of the pseudoseizures I've seen I would call malingering or factitious rather than true conversion. . . . And my preference of treatment is sternal rub, works every time.
  19. Apollyon

    Apollyon Screw the GST Physician Lifetime Donor Classifieds Approved 10+ Year Member

    Nov 24, 2002
    If it was conversion, though, people wouldn't protect themselves. If they never knew what was actually a seizure, how could they fake one? Or, how about the shaking people that are saying to you, "I...ammmm.....haavvvinnnnggg....aaaaa.....SEIZURE!!!!!"? For them to fake it, they have had to either have had one before, or seen one (and, as an attending said years ago, "People that fake seizures have seizures, do have seizures").

    There was a woman that used to live in our fire district when I was a volunteer who would have factitious seizures. It was always at an inopportune moment. One time, it was actually when I was working EMS, and she had a "seizure" - when she couldn't pay the $0.50 bridge toll. I was surprised as hell when I saw this woman 20 miles from my volly district.

    Some may be unconscious, although not true seizures, but, at the same time, there always seems to be some secondary gain.
  20. The right Path

    The right Path Goodbye Cherry Ames 2+ Year Member

    Dec 10, 2009
    Just curious...

    Does suggesting a rectal dose of valium ever cure these "seizures"?
  21. TheBlueBlazer

    TheBlueBlazer 7+ Year Member

    Mar 17, 2008
    Charm City
    I just VERY thoroughly evaluate their rectal tone, temperature, and make sure to get a second opinion.

    While doing EMS, on a police standby, I saw a guy come running out of a surrounded house, and funny how the second he realized he was caught, and saw the K9s, his seizures started acting up. He did have a brief interval though where he was lucid enough to realize he was still surrounded and nobody was moving before starting up again.
  22. Daiphon

    Daiphon Semper Ubi Sub Ubi Physician SDN Advisor 10+ Year Member

    Nov 6, 2003
    The Windy City
    Absolutely love this... and it's EBM-based. d=)
  23. Socrates25

    Socrates25 7+ Year Member

    Aug 30, 2009

    The way you cure pseudoseizures is as follows:

    1. Tell the patient that it would be very helpful if they would have a seizure in the next 30 seconds while you are standing there so you can observe it.

    2. When the pt starts having the pseudoseizure, quickly thump them on the forehead unexpectedly and say "STOP"

    3. When the pt stops, tell them that it cant be real seizures because real seizures cant be stopped by such a stimulus. Tell the pt that this proves they are lying. Tell the pt to get the hell out of your ER.

    If that fails, tell them that they will have to get a spinal tap with no anesthesia every single time they have a pseudoseizure to "check for infection."
  24. pinipig523

    pinipig523 I like my job! 10+ Year Member

    Jan 6, 2004
    Missing Chicago
    Awesome.. just awesome. :thumbup::thumbup::thumbup:
  25. zinjanthropus

    zinjanthropus Physician Faculty 10+ Year Member

    May 31, 2003
    I'm also using Geodon a lot in general - our neuro dept uses it for pseudoseizures and I have done so as well in the ED. good drug.
  26. lockjaw

    lockjaw 7+ Year Member

    Sep 12, 2010
    New England
    You're right, there is a separate condition once known as "pseudoseizures," now termed "psychogenic non-epileptic seizures," which are not faked and are similar to conversion disorder. The name was changed in part to avoid confusion over whether someone using the term "pseudoseizure" was referring to factitious/malingering seizure-like activity vs. psychogenic, non-faked movements. I think most people in this thread are using the term to refer to factitious seizures.

  27. Venko

    Venko True to self Physician Lifetime Donor Classifieds Approved 10+ Year Member

    Jan 24, 2006
    Rochester, MN
    You're bringing up a great point.

    Last night I had a patient who was clearly not having an epileptic spell, but she was also not consciously making the movements she was making. I was explaining to my team that even if our most fit individual tried to continue to shake with the same rhythm as she did for that long straight it would not be possible.

    As a former psychiatry resident and now EM attending, I have a special piece of compassion for these individuals. I have found that if you are sure that it it is not a true seizure (as in yesterday, both legs, no arms, purposeful gaze, while face twitches), if you tell the patient you are providing a treatment (whatever it is gel on the forehead, sodium chloride in the IV etc) and give a reasonable expectation of when it will work (i.e. 1 minute), these generally stop.

    Now I look for what could have triggered the event. Sometimes I think of this like DKA, there could be any underlying infection, mechanical issue, etc that could trigger these events and patients with mental illnesses can sometimes not tell you whats going on.

    I hope this helps!

    As for those patients who are knowingly trying to get xanax, or opiates etc for seizures, some of the above maneuvers may be more appropriate...

  28. Redrox

    Redrox 7+ Year Member

    Oct 28, 2008
    Fakers can be annoying as hell, tying up our resources and sucking up time. But yeah I agree, actual conversion disorder, like any number of legit psych disorders, can be some sad situations.

    Had me a lady once who checked her blood sugar every day when stressed (wasn't a diabetic) and had full psuedoseizures every time it levels changed according some bizarre criteria. Educated lady, very kind and pollite, hated going to doctors, miserable, later extremely grateful for our special drug norMALsaline.

    Refused to see anybody from psych, willing to try a tablespoon of salt in glass of water at home but I'm still afraid we created a new frequent flyer. Wish we could have done more, but life's like that.

    More humorous/impressive of a conversion disorder was a young guy who basically did nonstop situp "seizures" his entire ED stay after hearing some bad GF relationship news.
    WildcatS11 likes this.
  29. Septiae


    Aug 24, 2016
    Responses like these from students and doctors is exactly the reason why people talk about how 'cruel and heartless' you are. Seriously, making jokes claiming PNES is fake, you're only hurting yourselves, because no one wants a insensitive jerk who thinks these very real and stressful events for both patients and their family is funny. You should be ashamed of yourself if you're making jokes about this sort of thing. As someone who's mother has PNES and it is VERY real, seeing people who are supposed to become the next doctors pass it off as fake nonsense, saying that something truly distressing and sometimes more than just mentally painful is just 'faking it' makes me really afraid for the future. It's disgusting and perhaps YOU are the ones who need to seek medial help with your lack of empathy. I personally hope that you either never get your license or you learn how to be real adults before you try helping others with their health problems and before you start with the "It's just a joke" nonsense, there are somethings you should NEVER joke about because it's a very sensitive subject, and at that point, you are no better than those that do fake PNES. Think before you speak, you're supposed to be here to HELP people, not mock their problems to feel better about yourself. It's petty and pathetic.
  30. Angry Birds

    Angry Birds Angry Troll 5+ Year Member

    Dec 4, 2011
    When I was a brand new intern, the chief resident--who was very smart but had very crappy bedside manner-- said to me while examining a pseudo seizure patient, "this is pseudoseizures." Then for ten minutes the patient kept asking--while flapping around--"what's pseudoseizures? What's pseudoseizures?"
  31. Angry Birds

    Angry Birds Angry Troll 5+ Year Member

    Dec 4, 2011
    Worse than pseudoseizures are those patients who fake unresponsive. After negative million dollar work up I use ammonia smelling salts. I tape them inside face mask and slap them on patients face.
    njac, turkeyjerky and Gither like this.
  32. emergentmd

    emergentmd 7+ Year Member

    Jul 6, 2008
    I started to put in a chest tube on a guy with pseudoseizures and he stopped after seeing the large tube.
  33. KinesiologyNerd

    KinesiologyNerd 5+ Year Member

    Aug 16, 2012
    Anytown, USA
    Maybe read the thread before you speak?
    winkleweizen and theseeker4 like this.
  34. WilcoWorld

    WilcoWorld Senior Member 10+ Year Member

    Nov 2, 2004
    Unfortunately, allopathic medicine is just as inept at treating a paucity of empathy as it is at treating PNES.
    turkeyjerky and hundreddaysoff like this.
  35. MackandBlues

    MackandBlues 5+ Year Member

    Jan 1, 2012
    I've also seen an ammonia smelling salt broken inside a 60cc syringe then the whole 60 cc of air injected up someone's nose :)

    Sent from my iPhone using SDN mobile
    njac and Daiphon like this.
  36. Angry Birds

    Angry Birds Angry Troll 5+ Year Member

    Dec 4, 2011
    I started doing a lumbar puncture on a lady who was faking decreased responsiveness and severe headache. Right before needle goes in she jumps up and yells, "I'm ok! I'm much better!"

    Diagnostic and Therapeutic LP without even doing it.
    PlutoBoy and njac like this.
  37. Angry Birds

    Angry Birds Angry Troll 5+ Year Member

    Dec 4, 2011
    See, that seems too extreme to me, to the point of being assault. Same with putting in foleys if the only intent is to make them stop "seizing."

    I draw the line at ammonia smelling salts near the face/nose.
  38. littlejuan

    littlejuan 10+ Year Member

    Jul 3, 2007
    I've done the straight cath for urine cure before. Worked amazingly well.

    I just saw Angry Birds post. This guy was not waking up despite ammonia, sternal rub, etc. So I legitimately needed the urine for my work up at the time. He woke right up as soon as the nurse placed the straight cath in. I wouldn't do it for someone who it was obvious they were having pseudo seizures.
    Last edited: Aug 24, 2016
    Angry Birds likes this.
  39. The White Coat Investor

    The White Coat Investor AKA ActiveDutyMD Physician Partner Organization 10+ Year Member

    Nov 18, 2002
    SDN Partner
    In my experience it's usually psychosomatic and not malingering, so I treat accordingly.
    WilcoWorld likes this.
  40. filhodeinferno

    filhodeinferno 7+ Year Member

    Mar 22, 2009
    This is what I've been using as well. Heck, even one time it diagnosed a real seizure.
  41. VisionaryTics

    VisionaryTics SeƱor Member 7+ Year Member

    Jan 13, 2009
  42. engineeredout

    engineeredout 7+ Year Member

    May 11, 2008
    I like playing Tetris on my PNES
  43. Fox800

    Fox800 That drug that starts with "d"... Physician 10+ Year Member

  44. DissocativFugue

    DissocativFugue 7+ Year Member

    Jul 26, 2010
    What's more disturbing is the stigma that goes along with psychiatric conditions. Every discussion I've had with people with pseudoseizures where I've recommended discussion with psychiatry has ended poorly. We are in a busy system with minimal resources trying to differentiate psychiatric/social issues from pathology we can treat in the ED. Many people try to scam us for benzos. Usually there's some sort of secondary gain involved as well. Treating all "seizure like activity" with benzos has its own side effects, not that I expect you to understand that, or our mindset. All this adds up to gallows humor and a need to vent online. So before you berate us online, try to understand, we were all bright eyed, "deer in headlamp" students once. That ended the first month of residency, if not sooner.

    Sent from my iPhone using Tapatalk
    bravotwozero likes this.
  45. hamstergang

    hamstergang may or may not contain hamsters 5+ Year Member

    May 6, 2012
    In case you come back, you should realize that most of the above responses confuse pseudoseizures with malingering, but they are ER docs, not psychiatrists, so they're allowed to confuse our terminology from time to time.

    Also, I bolded 2 important false statements in the above quote. First, everything is fine to joke about, but it depends on context. Which brings us to the second bold statement: we're not on this forum to help patients. This is a place for students and doctors to discuss what we go through. It's for us and meant to help us. This thread is very different seen in that context than in one meant to be shared with patients.
    Ceke2002, Psai, bravotwozero and 3 others like this.
  46. Doctor Bob

    Doctor Bob EM/CC Physician Faculty 7+ Year Member

    Feb 12, 2009

    oh, it's an 11 out of 10?


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