CHAPTER 4
Hysterical Coma or Pseudoseizure
Presentation
The patient is unresponsive and brought to the emergency department on a stretcher. There is usually a history of recent emotional upset: an unexpected death in the family, school or employment difficulties, or the breakup of a close relationship. There may be a history of sexual abuse, eating disorders, depression, substance abuse, anxiety disorders, or personality disorders. Hysterical coma and pseudoseizures rarely occur in social isolation. The patient may be lying still on the stretcher or demonstrating bizarre posturing or even asynchronous or dramatic thrashing with prolonged seizure-like movements. Head turning, from side to side, and pelvic thrusting are typical of psychogenic seizures. A patient with true seizures usually has abdominal contractions but lacks corneal reflexes, whereas a patient with pseudoseizures usually has corneal reflexes but lacks abdominal contractions. The patient’s general color and vital signs are normal, without any evidence of airway obstruction. Consciousness is often partially preserved and sometimes regained very quickly after the convulsive period. Commonly, the patient is fluttering his or her eyelids or resists having his or her eyes opened. With eyelids closed, a patient with rapid (saccadic) eye movements is awake. On the other hand, a patient with slow, roving eye movements has a true depressed level of consciousness. Tearfulness during the event argues against true epileptic seizure. With pseudoseizures, there should not be fecal or urinary incontinence, self-induced injury, or lateral tongue biting. Most true seizures are accompanied by a postictal state of disorientation and altered level of arousal and responsiveness. During an epileptic seizure, the plantar response is often extensor, whereas during a psychogenic nonepileptic seizure, it is usually flexor.
A striking finding in hysterical coma is that the patient may hold his or her breath when the examiner breaks an ammonia capsule over the patient’s mouth and nose. (Real coma victims usually move the head or do nothing.) A classic finding in hysterical coma is that when the patient’s apparently flaccid arm is released over his or her face, it does not fall on the face but drops off to the side. The patient may show remarkably little response to painful stimuli, but there should be no true focal neurologic findings, and the remainder of the physical examination should be normal.
What To Do:
Obtain any available medical records.
Perform a complete physical examination, including a full set of vital signs and O2 saturation. Patients under the stress of real illness or injury sometimes react with hysterical or histrionic behavior. This is especially true in patients with a history of psychiatric illness, substance abuse, or sociopathic behavior. Therefore always fully investigate any suspicion of true underlying pathology.
Check glucose with a bedside finger stick.
When organic illness is unlikely, do not allow any visitors, and place the patient in a quiet observation area, minimizing any stimulation until the patient “awakens.” Check vital signs every 30 minutes.
When there is significant emotional stress involved, administer a mild tranquilizing agent, such as hydroxyzine pamoate (Vistaril) 50 to 100 mg IM or lorazepam (Ativan) 1 to 2 mg IV or IM.
Consider obtaining a drug screen and investigating for possible sexual abuse. In women, consider ordering a pregnancy test.
If a generalized seizure is questionable, verify with a lactate level or blood gas analysis, which would show metabolic acidosis with a true tonic-clonic seizure.
When the patient becomes more responsive, reexamine him or her, obtain a more complete history, explain the apparent emotional cause of the symptoms, and offer follow-up care, including psychological support, if appropriate. Keep in mind that pseudoseizures are commonly associated with sexual abuse, eating disorders, depression, substance abuse, anxiety disorders, and personality disorders.
If the patient is not awake, alert, and oriented after about 90 minutes, begin a more comprehensive medical workup. Illnesses to consider include Guillain-Barré syndrome, myasthenia gravis, electrolyte disorders, hypoglycemia, hyperglycemia, renal failure, occult neoplasm, dysrhythmias, systemic infection, toxins, and other neurologic disorders.
What Not To Do:
Do not become angry with the patient and torture him or her with painful stimuli in an attempt to “wake” the patient.
Do not administer anticonvulsants when pseudoseizures are suspected.
Do not perform expensive workups routinely.
Do not ignore or release the patient who has not fully recovered. Instead, the patient must be fully evaluated for an underlying medical problem, which may require hospital admission.
Discussion
Pseudoseizures and hysterical coma are more common in women than men. True hysterical coma is an unconscious manifestation of psychosocial distress that the patient cannot control. Antagonizing the patient often prolongs the condition, whereas ignoring the patient seems to take the spotlight off of the peculiar behavior, allowing the patient to recover. Some psychomotor or complex partial seizures are difficult to diagnose because of dazed confusion or fuguelike activity and might be labeled a pseudoseizure or psychogenic disorder. If the diagnosis is not obviously hysteria, the patient might require an electroencephalogram (EEG), administered during sleep, and deserves a referral to a neurologist. Psychiatric disorders as potential causes of syncope or coma should be suspected in young patients who faint frequently, patients in whom syncope does not cause injury, and patients who have many symptoms (e.g., nausea, lightheadedness, numbness, fear, dread).
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