I. https://www.youtube.com/watch?

v=O-qLBoWyfvI - Glasgow Coma Scale

https://www.youtube.com/watch?v=ZYUdPUyYV9w - Neurological Assessment

II. Case
Ms. Veger, an 18 years-old young woman with an apparent history of seizure
disorder was taking antiepileptic medication. She presented to the emergency
department with a persistently low GCS of 3/15 after an episode of seizures. Her
mother reported that her daughter suddenly started shaking uncontrollably. The
assigned nurse noticed that Ms. Veger is weak and showing facial grimace and
irritation. Computed axial tomography (CT) of her brain was performed. The CT
was normal. After some time, the vital signs was performed which are T: 37.3, P:
110, R: 20, BP: 120/90 and returned to a low GCS of 3/15. Further review of the
case revealed a dissociative disorder and was suffering from pseudo--seizures.

III. Definition

A pseudoseizure is a type of nonepileptic seizure that results from psychological

conditions rather than brain function. There are many types of seizure, which can
range in severity from mild to a medical emergency. They fall into two general
categories: epileptic and nonepileptic. Doctors will diagnose someone who is
experiencing epileptic seizures as having epilepsy, which is a condition that causes
frequent bouts of seizures.

Typical epileptic seizures occur when a sudden electrical disturbance in the nerve
cells in the brain causes the person to lose control of their body. The muscles in the
body may jerk or seize up uncontrollably, and the person may also lose
consciousness. Nonepileptic seizures are seizures that occur in someone who does
not have epilepsy.

While pseudoseizures are distinct from epileptic seizures, their symptoms are similar.
Symptoms of a pseudoseizure may include:

 involuntary muscle stiffening, convulsing, and jerking

 loss of attention
 loss of consciousness
 confusion
 falling down
  rigidity
 staring blankly
 lack of awareness of surroundings

As pseudoseizures are often the result of other mental health conditions, many

people will also have symptoms relating to the underlying condition.

Pseudoseizures tend to result from mental health conditions and can often occur
because of severe psychological stress. The stress may be due to a single traumatic
event, or to an underlying chronic condition.

Conditions or disorders that could cause pseudoseizures include:

 anxiety or generalized anxiety disorder (GAD)

 panic attacks
 obsessive-compulsive disorder (OCD)
 attention deficit hyperactivity disorder (ADHD)
 substance abuse
 traumatic injuries
 ongoing family conflict
 anger repression or anger management issues
 emotional disturbance
 physical or sexual abuse
 post-traumatic stress disorder (PTSD)
 dissociative disorders
 schizophrenia

Pseudoseizures and their underlying causes can severely affect quality of life, so it is
essential that people receive a proper diagnosis and treatment.

IV. Anatomy and Physiology

Pseudoseizure is an older term for events that appear to be epileptic seizures

but, in fact, do not represent the manifestation of abnormal excessive synchronous
cortical activity, which defines epileptic seizures. They are not a variation of epilepsy
but are of psychiatric origin. Other terms used in the past include hysterical seizures,
psychogenic seizures, and others. The most standard current terminology is
psychogenic nonepileptic seizures (PNES). Some advocate other terms such as
psychogenic functional spells or psychogenic nonepileptic events, spells, or attacks.
These terms reinforce the idea that the events are not epileptic seizures.
Distinguishing PNES from epileptic seizures may be difficult at the bedside even to
experienced observers. In theory, almost any recurrent behavior may represent
epileptic seizures. The evolution of epilepsy monitoring units and the ability to utilize
simultaneous video and EEG recordings may be a key to diagnosis. Diagnostic delay
of years with psychogenic nonepileptic seizures is common.Treatment of PNES may
be difficult, but it is clear that anti-epileptic drugs (AEDs) are of no benefit. In addition
to unnecessary costs and the potential side effects of AEDs for these patients, life-
threatening side effects such as respiratory depression may occur if psychogenic
nonepileptic status epilepticus is treated with large dosages of benzodiazepines.

V. Pathophysiology (affected part/organ)

Some evidence from functional and structural neuroimaging studies suggests

PNES may reflect alterations in sensorimotor, emotional regulation/processing,
cognitive control, and integration of neural circuits.

VI. Medical Management

There is no simple cure for pseudoseizures, but treating any underlying

psychological conditions can help to reduce symptoms. Psychotherapy, medications,
or counseling can help people to address any trauma and stress that could be
causing the pseudoseizures.

There isn’t one treatment for pseudoseizures that will work for every person.
Determining the cause of the disorder is a significant part of treatment.

The most effective treatment methods include:

 individual counseling
 family counseling
 behavioral therapy, such as relaxation therapy
 cognitive behavioral therapy
 eye movement desensitization and reprocessing (EMDR)
Counseling or therapy can occur at an inpatient facility or as outpatient. People who
can administer counseling are psychiatrists, psychologists, and social workers.

Studies show it’s not clear whether epilepsy medication can help this condition or not.
However, medication for mood disorders may be a viable treatment plan.

VII. Labs/ Diagnostics

People with PNES are often misdiagnosed with epilepsy because a doctor isn’t
there to see the event happen. Psychiatrists and neurologists have to work together
to diagnose pseudoseizures. The best test to run is called a video EEG. During this
test, you’ll stay at a hospital or specialty care unit. You’ll be recorded on video and
monitored with an EEG, or electroencephalogram.

This brain scan will show if there’s any abnormality in the brain function during the
seizure. If the EEG comes back normal, you might have pseudoseizures. To confirm
this diagnosis, neurologists will also watch the video of your seizure. Many
neurologists also work with psychiatrists to confirm a diagnosis. A psychiatrist will talk
to you to help determine if there are psychological reasons that could be causing
your seizures.

VIII. Nursing Management

Nursing assessment includes:

 History. The diagnosis of epileptic seizures is made by analyzing the

patient’s detailed clinical history and by performing ancillary tests for
confirmation; someone who has observed the patient’s repeated events is
usually the best person to provide an accurate history; however, the
patient also provides invaluable details about auras, preservation of
consciousness, and postictal states.
 Physical exam. A physical examination helps in the diagnosis of specific
epileptic syndromes that cause abnormal findings, such as dermatologic
abnormalities (e.g., neurocutaneous syndromes such as Sturge-Weber,
tuberous sclerosis, and others); also, patients who for years have had
 intractable generalized tonic-clonic seizures are likely to have suffered
injuries requiring stitches.

IX. NCP
ASSESSMENT DIAGNOSIS OUTCOMES NURSING RATIONALE EVALUATION
INTERVENTIONS
Subjective:  Risk of STG: Independent STG:
trauma
The patient related to After 8 hours  Discuss - Enable After 8 hours of
reported that loss of of nursing seizure patients to nursing
her daughter large interventions, warning signs protect her interventions,
suddenly muscle patient will and usual self from patient was
started shaking coordinat demonstrate seizure injury able to
uncontrollably. ion behaviors, patterns. demonstrate
lifestyle behaviors,
Objective: changes to -Use of lifestyle
reduce risk  Evaluate helmet may changes to
 Weaknes 
factors and need for provide reduce risk
protect self protective added factors and
 Facial
from injury head gear protection for protect herself
grimace
patient during from injury.
 Irritability seizure
activity.
 Vital Signs
are:  Explore - Lack of
with the sleep,
T: 37.3 flashing lights
patient various
P: 110/min and
stimuli that
R: 20/min prolonged
may
BP: 120/90 television
participate
seizure activity viewing may
 For
increase brain
Significant
activity that
Glasgow
may cause or
Coma
trigger
Scale data
potential
showed a
seizure
low score
activity.
of 3/15