Am

PSEUDOEPILEPSY

with

some

comments

Psychoanal Assoc 8. Holland NW: The 9. 10.

Oxford Myerson

University PG: How

56:556-585, Munsterberg

the

origin

of esthetic

Press, 1968 the psychiatrist

Seminars in Psychiatry Swan J: Giving new

28, 1975 11. Withim P: 12.

about

Response.

might

5:245-260, depth to the

feelings.

J Am

New

relate

to the

York,

19.

writer. 20.

1975 surface.

Psychoanal

Rev

21.

Psychodynamics 1969-1970 H:

The

of

literature.

Psychoanal

Rev 22.

Film:

195, 1964 Herman D: Federico Hamilton JW: Some

A Psychological

Study.

New

York,

Silence” and its sociocultural Psychiatry 8:367-373, 1969 16. Dervin D: The primal scene

Am

implications.

17. Goldstein M: Antonioni’s Imago 32:240-263, 1975

and the technology

Child

of perception

from

crib to camera.

A Study

GROSS,

Acad

in

26.

Am

27.

may

lemma

of how

Presented

at the

be confronted

to differentiate

accepted Dr. Gross Cleveland

210

I 3 1st annual

Atlanta, April

18,

JW: Some film. Bulletin

choanalysis Greenberg

JW:

“Straw

Dogs”

Press,

and vio-

: aggression

Am Imago 30:221-49, 1973 dynamic and genetic aspects of the of the

Philadelphia

21:230-246, 1971 H: The Movies on Your

Schneider

“new” of Psy-

Association

Mind.

New

York,

Saturday

1975

I: Images

of the

mind:

psychiatry

in the

commercial

film. Am J Psychiatry 134:613-620, 1977 Beck LF: A review ofsixteen millimeter films in psychology and allied sciences. Psychol Bull 35: 129-133, 1938 Nichtenhauser A, Coleman M, Ruhe H: Films in Psychiatry, Psychology and Health Education

Mental Council,

Health. 1953

Humphreys

Nesmith

LW,

Court Educ Adlen trate

MH,

New Pohl

York SL,

for audiovisual

JH: New teaching 42:708-709, 1967 MW: Measuring problems of intra-

40:742-752, film on blood and

and

et al:

Minneapolis,

Development

materials 1965 medical

pressure: inter-observer

of

by students

of

psychology.

J Med

a training film variation.

to illusBritish

Journal of Medical Education 9:195-1%, 1975 Smith JM: The movie as medium for the message. chiatr Care 12:157-164, 1974

Perspect

Psy-

Hysteria

the one with

between

who the

works

with

diagnostic

real

di-

epileptic

seizures

and

Ga., 1978.

is Head, Section Clinic, 9500 Euclid

meeting

May

8-12,

of the American 1978. Received

on Child and Adolescent Ave., Cleveland, Ohio

0002-953X/79/02/02

Psychiatric Feb. 6, 1978;

Psychiatry,

shows

lO/04/$00.45

© 1979

that

are

psychogenic

or function-

only

a nonspecific

abnormality.

The

EEG

might

show a nonspecific abnormality in a nonepileptic mal individual or hysterical patient. Should such tient be convulsive

for many tions

diagnosed as medications?

years

is a very

epileptic and A decision

or for life with difficult

one,

treated to treat

with antia patient

anticonvulsant

considering

the

nora pa-

medicaside

effects

of such medications, the restrictions on driving and everyday activities, the social stigma, unavailability of jobs, etc. It is very important to rule out the possibility of epilepsy in psychogenic seizures, or so-called pseudoepilepsy. The correct diagnosis enables the adolescent who suffers from psychogenic seizures to get the right treatment for the disorder and also inpsychotherapy

to

help

him

or

her

cope

with

personal conflicts in a better and healthier way. Psychogenic seizures are hysterical in nature. They have components of dissociative reaction, conversion reaction,

44106.

seizures

al in origin. The adolescent patient may complain of convulsions associated with complete blackout and amnesia to the time of the spell, while the EEG does not show clear-cut evidence of epileptic activity or

tensive Association,

film.

/979

M.D.

especially

NEUROLOGIST,

adolescents,

Hamilton American

in Adolescent

0f19 adolescents with diagnosed psychogenic seizures, 13 had hysterical convulsions and4 had amnesiacfugues. Sixteen ofthe patients were given a diagnosis ofhysterical neurosis; 2, process schizophrenia; and I, borderlinepsychosis. Thirteen ofthe patients were initially diagnosed incorrectly as having epilepsy and were ireatedfor an average of 15 months with anticonvulsant medication. The therapist should always consider the possibility of psychogenic f actors in children and adolescents who suffer from seizures.

THE

25.

with a look at “Potem62:269-304, 1975

“Blow-Up”

Pseudoepilepsy: MEIR

J Am

F, Hamilton

in modern

a reviewing procedure medicine. J Med Educ

Imago 26:251-268, 1969 about Ingmar Bergman’s “The

theatre and film: a historical perspective kin” and “Psycho.” Psychoanal Rev

BY

23.

24. Fellini. comments

Hagenauer

Review

62:5-

Dover Publications, 1970 13. Montani A. Pietranera G: First contribution to the psychoanalysis and aesthetics of motion picture. Psychoanal Rev 33:17714. 15.

18.

lence

19: 193-240, 1971 Dynamics of Literary

J Psychiatry 136:2, February

American

or

both.

Psychiatric

Difficulties

Association

in

diagnosing

dis-

Am

J Psychiatry

sociative

136:2,

reaction

February

1979

or conversion

MEIR

reaction

DISCUSSION

as hysterical

neurosis stem from the fact that the physician is not able to see the disease as part of the patient and does not recognize the patient as a whole person. If the diagnostician concentrates only on the symptoms,

trying

he or she patient

to classify

is liable

should

them

in an entity

to misdiagnose

be

viewed

and

of a disease,

the

problem.

evaluated

as

The

a person.

The symptoms should be weighed as to their value to the patient and how the patient views the symptoms. Does he or she have indifferent feelings toward the seizures (Ia belle indifference)? Is there any secondary gain from the symptoms? Does the patient have an underlying conflict that is being temporarily dealt with by developing the symptoms? What is the symbolic meaning of the symptoms to the patient? What type of personality

defense patient or her

does

the

patient

have,

clinician

will

consider

these

questions

the patient, it is most likely rectly diagnose the existence

THE

what

kind

when

tients there 5 cases one

and

stepfather,

evaluating

of 2 years, 19 adolescents suffering seizures were diagnosed at the The 14 girls and 5 boys ranged in age (mean= 15.79). In all but 2 of the pa-

strict. and

mother’s

Sixteen

of an underlying conflict. In were overprotective, over-

One

girl had

another

had

been

been

molested

raped

by her

health

patients

deteriorate

were

due

given

by nat-

to cancer.

a diagnosis of hysterical and I borderline psycho-

neurosis; 2, schizophrenia; sis. Thirteen patients had histories ofpassing either convulsions or tremors. Four suffered nesiac episodes, and 2 of these patients also tiple personalities (1 had 2 personalities and ,

had

3). One

patient

had

spells

stuttering, Thirteen convulsive

and hallucinating; of the patients medications

age= 15.54 medications

months). Six were since the proper

epilepsy

was

not met,

then

ruled

out.

of feeling

out, with from amhad multhe other

“frozen,”

1 had fainting spells. were treated with antifor 3-48 months (aver-

Twelve

not given diagnosis patients

by conventional psychotherapy, either or supportive; 5 of them also received antidepressant medication. Seven treated primarily by hypnotherapy.

anticonvulsive was made and were

the disorder

should

symptoms or part of another as schizophrenic reaction.

The

female

14:5, toms, times

to male

almost Engel females

ratio

3:1. In (3) cited have

be called

syndrome

in the

conversion

or entity,

present

such

study

was

his report on conversion sympa ratio of 2-3: 1 . Since ancient been more prone to hysterical

neurosis.

that he will be able to corof hysterical seizures.

ural father while he was drunk. Two girls had recently separated from their boyfriends. In 4 cases the parents had recently divorced. Two boys with low IQs were failing at school and felt hopeless about being able to cope with their academic difficulties. One girl had not worked through her grief over the recent death of her mother from breast cancer, and one boy had watched his

tients, not all of them would be categorized as having hysterical personalities. As Chodoff (1) noted, hysterical features appear in patients with other than hysterical personality types. Moreover, hysterical symptoms can be one of the signs of a developing borderline psychosis or schizophrenia, as seen in 3 of the patients. Rock (2) suggested that if the criteria for conversion reaction (as part of the hysterical neurosis) are

Most ofthe patients in the present adolescence. Bernstein (4) has noted vulnerable to hysterical convulsions; the adolescent’s turmoil is then

struggle

was evidence or both parents

demanding,

From the description of these patients, it is clear that not all of them had hysterical neuroses; and if one would classify the personality patterns of these pa-

of

Is the as his If the

SUBJECTS

Within a period from psychogenic Cleveland Clinic. from 14-18 years

her

and

mechanisms does he or she tend to use? using denial, repression, and suppression main repertoire of defense mechanisms?

GROSS

treated

insight oriented neuroleptic or patients were

for

self-identity

and

study were in late that this period is it appears that at its peak. The

role

differentiation

is

quite stressful for the adolescent. The adolescent is striving toward independence, while being afraid to give up the previous dependencies. The period of adolescence is one of changing behavior, lability of mood, and fragile, changing defenses (5).

The

conflict

area

during

adolescence

can

include

separation from a boyfriend or girlfriend, grief, and divorcing parents. Passing out or change in level of consciousness during the seizure symbolizes the adolescent’s need to get away from the conflictual situation.

Change ponent

in level of awareness of the seizure. The

is the dissociative motor convulsion

comis the

conversion reaction component, and it serves to release tension or anxiety. The mechanism is functional in origin and is created by the adolescent’s need to use denial, repression, and suppression as the main defenses. The conflict is thus passed to the unconscious. Not one of the patients in the present study was maIm-

gering, was

since

the

completely

Once anxiety iety,

the (the

the

process

of producing

the

symptoms

unconscious.

symptoms primary

patient

shows

occur, there is a reduction gain). Instead of expressing indifference

to the

in anx-

symptoms.

If the patient benefits from the sick role (e.g., gets more attention, is able to control the environment or manipulate family members), he or she may continue to take

helps

advantage

the

patient

of it (the

to regress

secondary

and

gain).

become

Being

sick

dependent,

which satisfies his or her dependency needs. Thirteen of the patients were first diagnosed as epileptics. There was no evidence of epilepsy on any of

the EEGs, but the treating physicians still considered the condition as organic and tried to treat it as such. Only after there was no response to treatment did they

211

Am

PSEUDOEPILEPSY

refer the patients to the Cleveland rologist, who requested psychiatric first treating physicians showed bility

of

tended

functional

to make

considering flict. Rock physicians.

problems

in

diagnoses

the patient (2) also noted

Clinic’s child neuconsultation. The denial of the possi-

by

the

patients.

exclusion

as having an such attitudes

and emotional by the

They

not

by

contreating

Diagnosis can be made using positive signs and symptoms, even without the elimination of organicity first. There is always the possibility of superimposed functional pathology in addition to physiological disorder (6). Hysterical convulsions should be suspected whenever there is no biting of the tongue and no fecal or urinary incontinence. Such seizures are less sudden in onset, and there is usually no bodily injury associated with them. Postconvulsive stupor or sleep is absent, and occasionally subjects may recall the event. In 7 of the patients in the present study, hypnosis was also used in making the differential diagnosis. Schwartz and associates (7) noted that both epilepsy and hysterical convulsions can be activated by hypnosis and

that

the

EEG

ofepileptic

terical patients, will show Schneck (8) suggested differential diagnosis of noted that convulsions can trance; the epileptic patient gestion, but the hysterical sociates

(9)

noted

that

patients,

but

not

hys-

paroxysmal activity. the use of hypnosis for the psychomotor epilepsy. He be induced during hypnotic cannot stop them by sugpatient can. Sumner and as-

hysterical

patients

could

(12),

in a review

ofthe

literature

up to 1957,

noted that ‘there is no good bibliography available pertinent to childhood hysteria.” Stevens (13) also mentioned the paucity of literature on conversion hysteria from about 1957-1967. Is childhood hysteria as rare as one might assume from a review ofthe literature? It is my opinion that if more attention were paid to the possibility of childhood hysteria, it might be diagnosed more frequently. In our study 13 patients received anticonvulsant mcdications for an average of 15.5 months before the correct diagnosis was made, and it was made primarily because there was no response to the drugs. Treatment of psychogenic seizures is needed to prevent fixation of symptoms. The untreated patient may hold on to his or her secondary gain, but also will be limited for life. The patient may prefer to see himself or herselfas a real epileptic, will limit his or her activi‘

212

and

regress

in social

contacts

to the

point

1979

of social

isolation. It is important to reassure the child and the parents. Usually the child will not accept the existence of any emotional factor in his or her condition. He or she often refuses to see a psychiatrist, and for this reason the first stage of therapy should focus on fostering rapport with the patient and building a good alliance that will be the cornerstone for further therapy. After the patient’s resistance is reduced, he or she will be more ready to give up the pathological defenses. It is important to reassure the parents about the very good prognosis

when

the

child

becomes

involved

in therapy.

If

the parents support the therapist it will be easier for the adolescent to give up the secondary gain, especially if he or she cannot manipulate them any more. Treatment usually takes 3-6 months. The removal of the seizures is not enough; follow-up is necessary in order to help the patient solve the main conflict that caused the appearance of symptoms. Once the patient gives up the secondary gain he or she is more ready to consider changing his or her defenses. The defenses of children and adolescents are more labile than those of adults and more rapid change is possible. Brief therapy is usually

sufficient;

however,

the

more

severe

cases

may require 6 months or more of therapy. In the present study 6 months of therapy were enough to eliminate symptoms and enable the patients to develop healthier defenses and coping mechanisms.

recall

what happened during their spells while in hypnotic trance but that the epileptic patients could not. They also noted that the hysterical patients tended to be more hypnotizable. The 7 patients with hysterical convulsions who were diagnosed by hypnosis were very hypnotizable, and all ofthem could recall the previous spells, including what had happened during them while the patients were under hypnosis (10). Psychogenic convulsions are much more common than they are thought to be. Hysterical symptoms in children are considered rare and have been on the decrease since the rigid Victorian age (11). Proctor

ties,

J Psychiatry 136:2, February

CONCLUSIONS

Emphasis should be put on early diagnosis of psychogenic seizures; it is common to diagnose them correctly only after treatment with anticonvulsant mcdications has failed. With early diagnosis the prognosis is fairly good, in the child’s

dealt

with

since the personality.

in the

first

symptoms If the

stages

less need for the patient ondary gain. It is important

to

are not emotional

of the hold that

yet fixated conflict is

disorder,

there

on to his or the practitioner

her

is

5ccmove

from an organic point of view to an evaluation of the child’s whole personality and social and environmental background. This will help the therapist in making the right diagnosis early and in starting therapy when it can still change ego defenses and improve the prognosis. REFERENCES

I. Chodoff

P: Hysteria,

34:536-539,

the

mimicry

of disease.

Med

Ann

DC

1965

2. Rock NL: Conversion reactions in childhood: a clinical study on childhood neurosis. J Am Acad Child Psychiatry 10:65-93, 1971 3. Engel GL: Conversion symptoms, in Signs and Symptoms, 5th ed.

Edited

Lippincott 4. Bernstein Neuropsychiatry 5.

by

MacBryde

CM.

Co, 1970 NR: Psychogenic

RS.

Philadelphia,

JB

seizures in adolescent girls. Behav 1969 Problems of Adolescence. New York, InPress, 1967

1:31-34,

Deutsch H: Selected ternational Universities

Blacklow

Am

J Psychiatry

6. Pasquarelli

February

B, Bellak

epilepsy 139,

136:2,

and

L: A case

psychogenic

JOHN

of co-existence

convulsions.

of idiopathic

Psychosom

Med

9:137-

1947

7. Schwartz ena,

BE,

Bickford

including

RG,

Schneck

JM:

Rasmusen

hypnotically

activated

electroencephalogram. 8.

1979

J Nerv

Hypnosis

in

Modern

Charles C Thomas, 1963 9. Sumner JW, Cameron RR, ferentiation of epileptic from ogy 2:395-402, 1952

Child

Ment

Dis

Hypnotic

Medicine.

with

the

1955

Springfield,

Hypnosis seizures.

Education

F. GREDEN,

phenom-

studied

122:564-574,

Peterson DB: convulsive-like

Psychiatry

BY JOHN

WC: seizures,

Ill,

in difNeurol-

for

F.

10. Gross M: Treatment ofdissociative reaction with hypnosis. Presented at the 29th annual meeting of the American Association of Psychiatric Services for Children, Washington, DC, Nov 1620, 1977 11. Freedman AM, Kaplan HI, Sadock BJ: Comprehensive Textbook of Psychiatry. Baltimore, Williams & Wilkins, 1975, pp 2 15 1-2 155 12. Proctor JT: Hysteria in childhood. Am J Orthopsychiatry 23:394-407, 1958 13.

Stevens H: Conversion Clin Proc 43:54-64,

General

hysteria:

a neurologic

emergency.

Residents

made

WHAT CONSTITUTES an ideal child psychiatry experience for general residents? This question has perplexed generations of educators. Although child psychiatrists began their fight for recognition as a distinct professional discipline more than 50 years ago (I 2), and great strides have been ,

in some

areas,

in many

educational

impact of child psychiatry in training has been minimal. There are marked subjectively and objectively, in child

riences

among

general

give verbal support in only a few is this didactic and clinical

residencies

programs

(3). Most

for learning child actually translated emphasis.

ment,

and only

tients with by continued

then

neuroses debate,

that phase

Kubie conresidents and children

all

residents work with adolesof learning child develop-

would and

at the 130th annual meeting of the American Psychiatric Toronto, Ont. , Canada, May 2-6, 1977. Received Sept. revised April 14, 1978; accepted May 18, 1978.

Dr. Greden is with the Department of Psychiatry, University of Michigan Medical Center, Ann Arbor, Mich. 48109. At the time this work was done he was Director of Residency Education; he is now

Associate Studies

Professor Inpatient

The author participated uation, and

of Psychiatry Unit

acknowledges as a member of Deborah

and

Day

and Hospital

Medical

Director,

Clinical

Program.

the assistance of Larry Brain, of the subcommittee conducting Bland, who compiled the survey

0002-953X/79/02/02

M.D. this data.

13/04/$00.45

,

who eval-

© 1979

programs

psychiatry, but into substantial

More than a decade ago Lawrence fronted this issue by advocating that launch their training by studying infants (4). He also suggested cents after the initial

the

general residents differences, both psychiatry expe-

they

evaluate

and

psychoses. As Kubie’s proposals

treat

pa-

demonstrated did not

re-

solve the problem. Had his suggestions been widely accepted, child psychiatry experiences for general residents would certainly be longer, more intense, and more influential than they currently are. Instead, it is still child

an exceptional residency psychiatry experiences.

A program

that

has

emphasized

that

offers

extensive

child

psychiatry

training for general residents is the one at the ty of Michigan. Consequently, consideration igan’s program might provide some insights 14, 1977;

Mayo

1968

M.D.

There is continuing debate about what child psychiatry experiences should be included in a general residency. The author describes the program at the University ofMichigan in an effort to provide some insights into the interface between child psychiatry and general residency training. This program is unique in several respects: a 12-month rotation in childpsychiatry is offered, and thefaculty size and budget ofthe youth services are comparable to those ofthe adult services. A survey ofall residents and f aculty pointed up numerous disagreements as to the length ofthe rotation andpriorities in curriculum. The author discusses the influence ofthe various competitive processes on the educational program.

Presented Association,

GREDEN

Universiof Michinto the

still-nebulous interface between child psychiatry and general residency training. Several training factors seem unique to Michigan. Perhaps most important, from 1972 to 1977, almost all of the general psychiatry residents spent their entire seeond year on what is known as the youth service. The youth service at Michigan consists of child and adolescent programs. During the 12-month youth rotation, there is an emphasis on developmental theory, psyAmerican

Psychiatric

Association

213