Case Report: Pseudoseizures or Malingering?

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CASE REPORT

A 53-year-old man comes for an outpatient evaluation for frequent seizures. He has not had any head trauma or history of cerebrovascular disease, and he has never been diagnosed with seizures in the past. He has a past medical history of chronic sinus drainage, for which he has taken over the counter decongestants. He has eczema and has taken prescription creams when it flairs up.

The patient’s 19-year-old son, who is home from college on a break, has accompanied him. He says that his father has been incoherent at times throughout the past year when they speak on the phone. He also explains that he has not lived with his father since the age of 10, when his parents divorced, and that, while he does not spend much time with him, there is a recent change in his father’s behavior.

The patient is a mid-level executive is a small company, where he has worked for the past 17 years. The son explains that his father had been living with his girlfriend for two years until she moved out. The former girlfriend informed both the patient’s son and his mother (the patient’s ex wife) that the patient has been irritable. She advised them to keep an eye on him and expressed concern about possible drug use.

Upon hearing this additional social history provided by his son, the patient explained that he is only irritable after a seizure, that the former girlfriend is the one with the drug problem, and that he has started a challenging new project at work where he has been negotiating a promotion.

Physical examination

On physical examination, the patient appears well nourished, and in no acute distress. He uses medical terminology to describe his history, sometimes inaccurately or in the wrong context.

His cardiac, respiratory, and abdominal examinations are all normal. He has occasional facial and eyelid twitching. Otherwise, his neurological examination, including his cranial nerve examination, is normal. He can walk heel to toe without any difficulty and has a negative Romberg.

The patient explains that his seizures occur almost daily, and he suggests that either diazepam or the recently approved cannabis (CBD) medication would help control them.

Diagnostic tests

He was sent for blood tests, including a complete blood count (CBC), blood chemistry, and thyroid levels. He was also given lab order for a urine toxicology screen. He went for these tests about a week after his outpatient visit. Prior to the blood tests, he was given instructions to provide a urine sample. A few minutes after entering the men’s room, he came out and told the lab technician that he had a seizure.

He was immediately sent from the lab to the emergency department (ED), where he had the requested blood tests. His blood tests did not show any abnormalities and his urine toxicology screen did not show the presence of any substances.

Clinical course

The patient was stable and was discharged from the ED. A few minutes after discharge, he returned to the ED to report that he had another seizure in the parking lot. He was instructed to follow up with his doctor. He called his doctor’s office about three times per week over the next several weeks to report and describe additional seizures.

He was sent for an electroencephalogram (EEG). Again, he explained to the technician that he had just had a seizure in the parking lot. The EEG was normal, without evidence of seizure activity, seizure foci, or post-ictal changes. The patient had a sleep deprived EEG about a week later, and it was also normal. He did not have any seizures during either of his EEGs.

He went back to see his doctor and brought several medical articles with him, which stated that seizures do not always produce EEG changes, particularly during the inter-ictal period. The patient again requested a prescription for either diazepam or CBD.

Initially he received a diagnosis of pseudoseizures and sent to an epileptologist, who ordered a 24-hour video EEG. The patient had an event immediately prior to his EEG lead placement. He had non-rhythmic shaking and jerking of his arms and legs bilaterally, with intermittent screaming. He then blinked his eyes rapidly for about 10 minutes after the shaking movements stopped. After the event, he said that he did not remember what had just happened.

The EEG leads were placed, and in the immediate post-event phase, he did not have any post-ictal slowing or signs of seizure activity. He did not have any more events during the 24-hour monitoring period, and his EEG pattern remained completely normal.

A repeat urine toxicology screen was positive for opiates. The patient had not been prescribed opiates; he suggested that this chemical could have been produced by his body as a by-product of his seizures.

Diagnosis: Malingering

The patient was not treated with an anticonvulsant, and his epileptologist requested a consultation with a drug treatment specialist and also requested a social work consultation. Pseudoseizures, also described as non-epileptic convulsions, are events that appear to be somewhat like seizures, or are described as seizures by the patient, or by observers. Pseudoseizures are more common among children, particularly those who have a diagnosis of epilepsy or who have experienced at least one true seizure.

This patient had been diagnosed with pseudoseizures, but his diagnosis was later changed to malingering. While there are some common features of the two conditions, there are several important differences.

Discussion

Pseudoseizures are usually characterized by some involuntary components, and they often occur in people who also have convulsive seizures. Psychological issues or stress may trigger them, and while they can involve secondary gain, such as satisfying the need for attention, many patients are not able to control or suppress them.

Once the complex issues are identified, patients may improve with behavioral therapy.¹ This patient on the other hand, did not display many of the typical characteristics of pseudoseizures. He was malingering and drug seeking-a deliberate behavior that does not respond well to therapy.²

It is important to note that in this case, the patient was also a drug user. Drug use and withdrawal can trigger seizures, but given his normal EEGs, it was unlikely that he was experiencing drug induced seizures.

Take Home Points

• Pseudoseizures and malingering are two distinct entities. Malingering is completely voluntary and conscious, while there is often an involuntary component to pseudoseizures.

• Urine toxicology screening should be obtained immediately, rather than at a later time, because patients may abstain for a time from using substances if a test is scheduled in advance.

• Patients who ask for medication by name rather than focusing on symptoms may have personal motives, rather than a true illness.

References:

1. Cope SR, Poole N, Agrawal N. Treating functional non-epileptic attacks - Should we consider acceptance and commitment therapy? Epilepsy Behav. 2017;73:197-203.

2. Martin R. Treatment Challenges in Nonepileptic Psychogenic Seizures: Finding the Perfect Fit for the No-One-Size-Fits-All Group. Epilepsy Curr. 2017;7:147-149.