Epileptic seizures progressing into nonepileptic conversion seizures

Abstract

Sir: Pseudoseizures may often occur in patients with epilepsy. 1 We describe a patient in whom true seizures and pseudo-seizures always occurred together. Case report: Ms. A, a 45-year-old woman, was referred with a 3-to 4-year history of pseudoseizures. The events occurred 6 to 10 times a year, almost always started when Ms. A was in the company of others, and comprised wild, bilateral thrashing of the limbs, convoluted movements of the trunk, crying, resistance of assistance, rolling on the floor, and other bizarre phenomena. Consciousness was fully preserved throughout each event, and recall of experiences during each event was intact. Each event lasted about 5 minutes and was followed by fatigue. All clinicians whom she had previously consulted had unhesi-tatingly diagnosed a conversion disorder and had attempted psychological treatment along conventional lines; their diagnosis was supported by the identification of issues related to stress and failure in coping. Each event started in her left hand and was almost always followed by gradual slumping to the ground and the bizarre behaviors described above; on careful history taking, we found that whereas the phenomena on the right side of her body were random, those on the left side appeared to follow a pattern. Rhythmic, uniplanar jerks began in her left hand and spread to her left forearm and arm and then to her left lower limb; upon recovery, the transient weakness that she experienced was always greater on the left than on the right side. Her residence was close to that of one of the authors (C.A.); accordingly, an arrangement was made that he be informed immediately of an event. The author was notified once the next event began and visited Ms. A's residence. At the time of the visit, the event had concluded; however, examination revealed grade 3 to grade 4 power and absent deep tendon reflexes on the left side; findings were normal on the right. Reexamination an hour later found no abnormalities on either side. A diagnosis was made of left-sided jacksonian seizures with the remaining manifestations identified as pseudoseizure phenomena. She was referred for neurologic evaluation. Further contact was lost because she preferred to be evaluated in her city of birth. The classical progression characteristic of jacksonian seizures , the unilateral absence of deep tendon reflexes immediately after the seizure, and the return of reflexes an hour after the episode all confirm that our patient experienced genuine seizures in the left half of her body. What of the bizarre phenomena on the right side? Bizarre behavior is known to be associated with epileptic foci in limbic structures such as the temporal cortex and the anterior/basal frontal cortex. 2 Nevertheless , for several reasons we believe that these phenomena were nonepileptic. Sensorium was completely preserved; this is not possible in a complex partial seizure or a seizure that has generalized. Jacksonian seizures arise in the primary motor cortex, and the limbic structures in the temporal and anterior/bas...

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