Seizures

Hysterical seizures occur only in the presence of an audience or when one is close at hand. They may be precipitated by stress, but more often seem to occur in response to the social setting. The fall to the ground is not usually abrupt or quick, but rather more gradual. Movements may follow the fall with clutching, and sometimes there may be opisthotonos, but the characteristic regular tonic-clonic sequence of epilepsy is not found. Tongue biting and incontinence of urine are rare in hysterical fits, the corneal reflexes are preserved, and the plantar responses are flexor, unless previously abnormal. Firm handling and pressure on the supraorbital nerves to the point of pain may arouse the patient.

The classic features of grand mal are well known, but some epileptic patients, particularly those under treatment, may have only a brief aura or cry, or a modified fit, without more than a few movements, and without tongue biting or incontinence. In temporal lobe epilepsy, ictal behaviour may be limited to a few smacking movements of the lips or face. Patients who have brief or very limited partial tonic- clonic seizures may show poorly organized behaviour afterwards, appearing to be partly in touch with the environment and acting purposively.

Hysterical fits occur most often among epileptic patients or among others who have seen epileptic fits. A few epileptic patients learn how to induce ictal discharges and can produce extra fits. Although rarely available during a fit, the electrencephalogram ( EEG) is abnormal in epilepsy and normal during hysterical fits. Trimble (1,8) showed that serum prolactin was elevated after an epileptic seizure and could be a useful discriminating measure. Syncope, often induced by postural hypotension as a result of drug side-effects, has to be distinguished from fits and may also be provoked by anxiety. Patients can hurt themselves in a fainting episode, but they usually regain consciousness quite rapidly and the initial pallor quickly returns to normal. Cardiac causes of falls and fits also have to be considered.

Hysterical seizures also need to be distinguished from automatisms occurring with lowered blood sugar levels or other metabolic disorders which may mimic an epileptic automatism.

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