Diagnosis of Neurologic Spells:
Seizure, Pseudoseizure,
Demonic Possession
or Witchcraft
Jeffrey J. Tramonte, M.D.
Baylor Scott & White Healthcare Round Rock
Director of Neurology
Director of Emory Bellard ALS Clinic
July 15, 2014
Goals
• Differentiate between seizures and
pseudoseizures
• Cast out the demons
• Understand the limitations of EEG
Audience Response System
A) Seizure
B) Pseudoseizure
Case – Recurrent “seizures”
• 30 y/o woman referred for seizures
– 2 month h/o new onset, frequent generalized
convulsions
– PHM, ROS, Exam all normal/negative
– Work-up is normal
• brain MRI, 2 interictal EEGs
– Treatment with 3 combined AEDs (CBZ, PHT,
VPA) ineffective
Case – Recurrent “seizures”
• ER presentation with frequent seizures
– 1) Treated with Valium and Ativan
– 2) Paralyzed, intubated, & sedated due to
“agitation”
– 3) Central line placed for better venous
access
• Developed pneumothorax
• Chest tube
• ICU stay
– 4) Repeat workup normal (LP, EEG, MRI)
Audience Response System
A) Seizure
B) Pseudoseizure
Case – Recurrent “seizures”
• Misdiagnosis and mistreatment of
pseudoseizures is dangerous
Howell S.J. QJM 1989
Demonic Possession
& Witchcraft
• Biblical References
– Epilepsy viewed as possession by evil spirits
• Mark 9:18
Whenever it seizes him, it throws him to the ground. He
foams at the mouth, gnashes his teeth and becomes
rigid. I asked your disciples to drive out the spirit, but
they could not.
Movie Clip – The Exorcist
Audience Response System
A) Seizure
B) Pseudoseizure
Pseudoseizures vs Seizures
• Ictal stuttering is a sign of pseudoseizures
– Sensitivity: 8.5%
– Specificity: 100%
– Pos Pred Value: 100%
Vossler D.G. Neurology 2004
Demonic Possession
& Witchcraft
• Literary References
– Othello by Shakespeare (1604)
• Othello has a seizure preceded by extreme emotional
agitation
• Othello acted with “savage madness”
• Othello must have been seizing when he killed his wife
because he was in a rage
– Silas Marner by George Eliot (1861)
• Marner’s seizures are viewed as “visits from the Devil”
causing him to be accused, found guilty, and cast out by
church members
Audience Response System
A) Seizure
B) Pseudoseizure
Demonic Possession &
Witchcraft
• Salem Witch Trials 1691
– 20 Salem villagers were executed for
bewitching and collusion with the devil
– Signs of bewitching:
•
•
•
•
Fainting and disordered speech
Visual delusions and hallucinations
Odd contortions
Sensations of prickling, pinching, or skin burning
Woolf A. Clin Tox 2000
Demonic Possession &
Witchcraft
• Salem Witch Trials 1691
– Ergot poisoning theory
• 1691-1692 weather conditions favored ergot-producing
fungal growth on rye
• Crop failure forced villagers to eat freshly harvested,
infested rye
• The afflicted were nonrandom and lived along rye supply
routes
• Animals were affected and died (ergotism occurs in grazing
animals)
• Symptoms consistent with ergotism: seizures,
hallucinations, delerium, muscle spasms, and parethesias
Woolf A. Clin Tox 2000
Movie Clip – The Exorcist
Audience Response System
A) Seizure
B) Pseudoseizure
Pseudoseizures vs Seizures
Reuber M. Anaesthesia 2000
Audience Response System
A) Seizure
B) Pseudoseizure
Pseudoseizures vs Seizures
• Asynchronous limb jerking is common to
pseudoseizures
Reuber M. Anaesthesia 2000
Audience Response System
A) Seizure
B) Cough syncope (convulsive syncope)
Movie Clip – The Exorcist
Audience Response System
A) Seizure
B) Pseudoseizure
Pseudoseizures vs Seizures
• Ictal eye closure is a reliable sign of pseudoseizures
– Eyes Closed: (pseudo)
• Sensitivity: 96.2%
• Specificity: 98.1%
• Pos Pred Value: 94.3%
– Eyes Open: (real sz’s)
• Sensitivity: 98.1%
• Specificity: 96.2%
• Pos Pred Value: 98.7%
Chung S.S. Neurology 2006
Audience Response System
A) Seizure
B) Pseudoseizure
Audience Response System
A) Seizure
B) Pseudoseizure
Pseudoseizures vs Seizures
Krumholz A. Neurology 1999
Movie Clip – The Exorcist
Audience Response System
A) Seizure
B) Pseudoseizure
Audience Response System
A) Seizure
B) Pseudoseizure
Audience Response System
A) Seizure
B) Pseudoseizure
American Idol 2008
How are seizures diagnosed?
• Clinical seizure type (direct observation)
• EEG seizure type
• EEG interictal expression
Commission Report. Epilepsia 1981
Audience Response System
18 year old unaware of daydreaming spells
A) Seizure
B) Pseudoseizure
Childhood Absence Epilepsy
The Routine EEG is normal until . . .
Childhood Absence Epilepsy
Hyperventilation triggers absence seizure
How are seizures diagnosed?
• Sensitivity of awake EEG
–
–
–
–
1st 30 min with photic & HV = 50%
2nd “
“ = 62%
3rd “
“ = 74%
4th “
“ = 85%
• Sensitivity of awake & asleep EEG
– Repeated 4 times
= 92%
• Ambulatory EEG monitoring
• Video EEG monitoring
Binnie C.D. Clin Neurophys 1999
Seizures & Epilepsy:
The Bottom Line
• Partial seizures (localization-related
epilepsies)
– Brain MRI for structural etiologies
(neoplasm, sclerosis, stroke, vascular
malformation, hereditary malformation)
• Refer to neurology
– Decision making on AEDs, side effects,
driving privileges, epilepsy monitoring unit
Top Five Take-Home Points
1. Pseudoseizures are commonly
misdiagnosed as seizures
2. Ictal eye closure predicts pseudoseizures
3. Ictal stuttering predicts pseudoseizures
4. A single interictal EEG is only 50%
sensitive
5. Don’t just sit there bust a move (if you see
a patient having a spell, test them)
The End