Falling Into the Fire: A Psychiatrist's Encounters with the Mind in Crisis (21 page)

Seizures require doctors to act counter to their natures. Generally doctors tend to be action-oriented problem solvers. Don’t just stand there, do something! The medical maxim of initial seizure treatment is antithetical to this impulse:
Don’t just do something, stand there.
Unless a seizure lasts more than five minutes, the course of action in seizure treatment is simply to wait it out. A seizure that lasts more than five minutes may not remit—a dangerous condition called status epilepticus. Without intervention a patient in status epilepticus risks damage to her brain and other organs. Yet prior to that mark, the prescribed course of action is to wait and see. When someone is moaning and convulsing in front of you, five minutes is a long time. Imagine it. Watch the clock.

“Staff was in here with her when she started,” the nurse said, “so we know exactly how long it’s been.”

The mental-health worker who had been watching Phyllis when she began to seize looked down at his watch. “Three minutes and fifteen seconds,” he said.

That sounded right, since they had hit the buzzer immediately and I’d had time to run from one end of the hospital to the other and be briefed by the nurse. I was paging through Phyllis’s chart to look for evidence of a preexisting seizure disorder, or else for medical etiologies or lab abnormalities that might explain why she was seizing. For starters, a huge percentage of our psychiatric medications have the capacity to lower the seizure threshold in a person taking them. This means that patients on certain psych meds are more susceptible to having seizures than they otherwise would be. Phyllis was on several medications that could theoretically be culprits. Other patients are particularly at risk of seizures when withdrawing from alcohol or tranquilizers, but Phyllis had been closely monitored over the five days since her admission and had shown no signs of withdrawal. She’d never had a traumatic brain injury or a stroke that might have predisposed her to seize. Nothing in her medical history stood out. Phyllis continued to groan and convulse. It had been four minutes.

I flipped to the psychiatric section of her chart, and on the third page, buried in a paragraph about prior medication trials, was a sentence that read, “The patient has a known history of pseudoseizures.”

“Pseudoseizures?” I asked the nurse.

“Oh, yeah,” she said. “I’m so sorry. I forgot you didn’t know her. She pulls this kind of stunt every now and again, but of course we never know if one of them is going to turn out to be real.”

There was judgment in the nurse’s characterization of Phyllis as pulling a “stunt,” but there was also wisdom in her assessment of the ambiguity of the situation. Pseudoseizures—more accurately referred to as psychogenic nonepileptic seizures—are, as their name indicates, seizures whose origins are psychological rather than neurological. The idea is a mind-boggling one. The body behaves exactly as it would if the brain were firing electrical impulses, causing convulsions. Yet here there are no such impulses to be found. In epileptic seizures, brain waves form recognizable aberrant patterns on an EEG. In psychogenic seizures, patients’ bodies shake, overtaken by tremors, but their monitored brain waves show no seizure activity. Their EEG patterns are consistent with an entirely alert and awake state.

Despite this measurable distinction on EEG, the diagnosis of psychogenic seizures is a notoriously difficult one to make and to treat. As the neurologist J. Chris Sackellares writes, detection of psychogenic seizures teaches “the neurologist an important lesson in humility: even the best clinician can misdiagnose a pseudoseizure as an epileptic seizure or mistake an epileptic seizure for a psychogenic pseudoseizure.”

While Phyllis’s body continued to shake, beating against the floor, I felt the full force of uncertainty as to whether her seizures were neurological or psychological in origin. I was flooded with a range of feelings, all of them uncomfortable. Tonight, as during each of the medical emergencies I had run to the previous two nights, I felt overcome by adrenaline’s edgy, rattling buzz. During both of those scenarios, I fell back on the mantra of a life-support checklist:
Check the airway of the unresponsive woman. Ask the nurse to get her oxygen. Feel for a pulse—it’s there, and strong. Get a set of vitals. Have the staff call rescue. This man is having a heart attack. Get him oxygen and aspirin. Have the nurse get a sublingual nitroglycerin out of the Pyxis. Get an EKG going. Call rescue. Call rescue. Call rescue.
When I first got to Phyllis, my mind began charting its way through seizure protocol, but a history of pseudoseizures complicated the picture and immediately shifted the course of action from clear to murky.

Ordinarily, with a patient still seizing as the four-minute mark came and went, I would administer a sedative—rectally, so the patient wouldn’t spit it out or, worse, aspirate it or choke on it. I would call an ambulance to transfer her to the medical emergency room for status epilepticus. But Phyllis’s history made it likely that she wasn’t in status epilepticus, that she wasn’t even having an epileptic seizure. In which case emergent transfer was not only unnecessary, it was contratherapeutic. Given the fact that transfer to a medical hospital would likely mean administration of more and more sedating medications in an attempt to stop the seizure, it was also potentially dangerous.

As Phyllis’s seizure continued, so did my unease. Her limbs and trunk thumped brutally against the floor, her head slamming over and over again into the thin hospital pillow. The staff members who stood around me shifted their gazes from Phyllis’s convulsing body to me and back again.

“Five minutes,” the mental-health worker read from his watch. I sat quietly beside Phyllis, trying to will my stillness into her wild and unrelenting movements. “Six now,” he said. My heart was beating with such force that I felt it in my temples. I tried to reassure myself again and again,
Pseudoseizures. She has known pseudoseizures.
But what if this one wasn’t? What if she were having an epileptic seizure? What if I were sitting—inert—beside her while she was going into status epilepticus and I did nothing to intervene?

“Okay,” I said.
Shit,
I thought. Close to seven minutes had passed. “Somebody please call rescue, and let’s give her the rectal diazepam. Who’s holding arms and who’s holding legs? The nurses are going to need some help to get it into her.” Immediately the room broke into motion. A mental-health worker ran out to make the phone call. Gloved hands held Phyllis to the floor by her wrists and ankles. A female nurse slid her hands beneath Phyllis’s nightgown.

“In,” she said.

“Okay, great. You can let her go,” I said. The staff backed away from Phyllis. She continued to seize.

Another minute went by. Then three more. Then five. Phyllis was sweating badly now, her hair stuck in damp ribbons across her reddened face. The lack of effect from the medicine told me nothing; both nonepileptic seizures and status epilepticus can fail to respond to acute treatment. Finally, after several minutes more, I heard the clang of the unit doors opening to rescue’s gurney and the deep voices of the EMTs. I began to stand, to go brief them on Phyllis, her history, the length of this seizure, the steps we had taken. As I did, Phyllis’s shaking suddenly ceased. She opened her eyes and looked straight at me.

Rather than relief that her convulsions had finally stopped, I was surprised to feel mostly overcome by anger. I felt as though this woman had
fooled
me.

The EMTs rounded the corner and arrived at the Quiet Room’s doorway. “We’re actually good,” I said to them. “We’re all set. You can cancel the rescue.”

“Cancel it?” the lead EMT asked.

“Yeah,” I said. “Thanks for making it here so quickly. Sorry for the false alarm.” I stood, turned toward the door, and let out a deep breath, trying to defuse my anger.

The nurse in charge of the unit turned to me. “Well, I guess she got her benzo, huh, Doc?”

I didn’t answer. The implication in the nurse’s comment was clear: Phyllis had pulled one over on us all. On me. I took another breath, then turned back around into the room. Phyllis sat herself up and was pushing her hair back out of her face.

“You all right?” I asked her.

“Yes,” she said quietly. “Yes, I’m fine. After my spells I just need a little water and some rest. Or maybe someone could bring me some ginger ale?”

“Sure,” I said, trying to keep my voice calm so as not to show I was seething inside. “Sure. We can get you some ginger ale.”

•   •   •

T
he diagnostic “gold standard”—the most conclusive evidence—for psychogenic nonepileptic seizures is video EEG. In this test, patients are hospitalized, hooked up to electrodes that continuously monitor their brain activity, and simultaneously videotaped. To establish the diagnosis, the patient must seize while hospitalized and under these dual forms of observation. Then video-recorded seizure activity must be juxtaposed against the EEG reading of the same time period to show there is no epileptic activity on EEG. It’s easy to imagine an aha moment that follows, where the detective/doctor swoops in at the end to reveal to the patient that he’ll be fooled no more, the ruse is up. End of seizures, end of treatment, end of story.

As is true in most of medicine, the real narratives are not nearly so neat. First and foremost, establishing a diagnosis via video EEG is both difficult and costly. The seizure has to happen during the period in which the patient is hospitalized and under observation. Most patients’ seizures are not predictable enough to ensure that the period of time required would be a reasonable one. Days of hospital treatment are staggeringly expensive, as is round-the-clock monitoring. For hundreds of thousands of Americans who suffer from psychogenic seizures (a recent estimate puts the range between 135,000 and 540,000), video EEG is not a realistic option. Even those patients who do receive a definitive diagnosis are not likely to capitulate and thus heal themselves. Patients may have little or no conscious awareness that their thoughts and feelings are driving their dramatic bodily responses. Although making patients aware that their seizures are psychological in origin is an essential component of treatment, it is rarely, in and of itself, curative.

The neuropsychologist Dalma Kalogjera-Sackellares describes the complexity associated with this shift in thinking by underscoring that for most patients with psychogenic nonepileptic seizures, their seizures have long been conceptualized by them, by their family members, even by their doctors as something they
have
rather than something they
do.
Once the diagnosis of psychogenic nonepileptic seizures is made, the role of psychotherapy is to help “the patient realize, in a gradual and reasonable way, that spells are something a patient does in order to deal with something that disturbs him, [that] spells have a purpose in his life.” The goal of this reconceptualization is to shift the nonepileptic seizure from being a symptom of a disease to being a sign of distress, of difficulty coping. The ability to acknowledge and accept that shift, according to Kalogjera-Sackellares, is, “in its own right, a strong positive prognostic factor. On the other hand, patients who continue to view their spells as having nothing to do with them psychologically have a poor prognosis.” If they will not acknowledge their seizures as psychologically based, they can’t begin in earnest to discover what might be causing them.

•   •   •

T
hese intersections of neurology and psychiatry are studied and treated by doctors in the specialized field of neuropsychiatry, a field that inhabits a narrow interspace at the confluence of psychiatry and neurology. Brown University neuropsychiatrist and behavioral neurologist W. Curt LaFrance Jr. is a world-renowned expert in the treatment of neurologic symptoms that arise from psychiatric illness. He specializes in the diagnosis and treatment of conversion disorders, such as nonepileptic seizures and psychogenic movement disorders, in which psychic conflicts are converted into physical symptoms.

LaFrance underscores that the risks associated with misdiagnosis and overtreatment of psychogenic nonepileptic seizures—as when doctors misdiagnose a lengthy nonepileptic seizure as status epilepticus—can be grave. “Complications of pseudostatus are iatrogenic,” he writes.
Iatrogenesis,
from the Greek
iatro-,
“physician,” and
-genesis,
“the origin.” This means that medical problems brought about by pseudo-status, or nonepileptic status, have nothing to do with the seizure itself but rather with the medical response to it. Iatrogenic complications, therefore, are caused by those of us whose Hippocratic edict is to first do no harm. According to LaFrance, these complications found in the medical literature include the effects and potential hazards of every single medical intervention employed. In order to stop a patient from seizing, doctors may insert catheters into major veins, which can bring about blood loss or infection. They may administer high-dose sedatives, requiring patients to be intubated if their breathing slows too significantly. Rarely, through their interventions, doctors can cause respiratory arrest. “Intubation is more common in pseudostatus rather than status epilepticus,” LaFrance writes, because psychogenic nonepileptic seizures last longer and do not respond to antiepileptic drugs.

I met Dr. LaFrance for lunch in a local bakery on an unseasonably warm November day to talk with him about my encounter with Phyllis and the mystifying nature of psychogenic nonepileptic seizures. Over sandwiches and gingerbread cake, Dr. LaFrance explained that the difficulty of distinguishing epileptic seizures from their nonepileptic counterparts is only part of the equation. The larger issue, he believes, has to do with the inherent discomfort doctors have with helplessness. In an emergency situation, how well can they sit with the fact that they cannot stop the patient from seizing? The answer is partially physician-dependent, of course, but it turns out for most of us the answer is . . . not too well.

“The psychiatrists are sometimes better at this than their neurology or emergency-medicine colleagues,” he began. “You know, we neurologists can inject you with medicine to bust a clot and reverse the effects of an oncoming stroke. A person can come into the ER with new-onset weakness or paralysis, and we restore full function with these powerful drugs. Emergency docs are used to performing that same kind of heroic intervention,” he said. I nodded. Of course this was true. My friends who are doctors in the ER often see my patients before I do. They empty a woman’s stomach from her overdose and cleanse her liver from the toxins she ingested. They intubate her if she has taken enough pills or poison to stop breathing; they resuscitate her if her heart has stopped. They suture knife wounds, desperate and deep, that my patients have sliced into their arteries, then give their bodies back the pints of blood that they have lost. They find the lodged bullet from the self-inflicted gunshot that somehow missed its mark.