Abstract
Article abstract The authors report five patients with recurrent psychogenic seizures (PS) during pregnancy, with multiple emergency room visits and continued intake of antiepileptic drugs obtained from various sources, despite awareness of the psychogenic nature of their attacks and the risks of antiepileptic drug use in pregnancy. These patients demonstrate that preexisting PS may persist during pregnancy, and there will be patients who continue to take antiepileptic drugs despite awareness of the risks inherent to these treatments. New-onset or persisting PS with pregnancy can be indicative of serious emotional conflicts, and the child should be considered at risk.
The term “psychogenic seizures” encompasses a number of conditions characterized by episodes or experiences that resemble epileptic seizures but have a purely emotional cause.1-4 The diagnosis can be very difficult and many patients are treated with antiepileptic drugs (AED) for a long time before they are diagnosed correctly. Unfortunately, establishing the correct diagnosis and referring the patient to psychiatric care does not always ameliorate the problem because many patients continue to have “attacks,” ending up in emergency rooms where AED treatment is often reinstituted. Although refractory psychogenic seizures are seen more commonly in women, its occurrence during pregnancy is discussed only rarely. Brockington5 does not mention this problem in his monumental review of more than 700 years of world literature on the subject of motherhood and mental health, and a MEDLINE review of the literature yielded only two articles on this subject published during the past 40 years.5,6
Patients.
We report five patients who had recurrent psychogenic seizures during pregnancy. Three patients had a history of psychogenic seizures before becoming pregnant; two developed psychogenic seizures after pregnancy (table). The diagnosis of psychogenic seizures was confirmed with video-EEG telemetry. Telemetry demonstrated that none of the patients had epilepsy. All five patients had one of their typical “seizures” after a seizure induction with IV administration of a saline placebo.
Clinical and social features of five patients with persisting psychogenic seizures during pregnancy
Patients with preexisting psychogenic seizures.
The frequency and severity of the psychogenic seizures attacks increased in two of the patients early during pregnancy and remained unchanged in the third patient. Events persisted despite psychological counseling and neurologic advice regarding the psychogenic nature of the events and the fact that AED were not needed and could be potentially harmful to the developing child. Attempts to discontinue medications resulted in increased number of attacks, with visits to the emergency room in two patients and reinstatement of AED by the primary care physician in another. These three patients appeared to want the pregnancy; none of them requested termination. These patients had in common very protective and anxious spouses or families who were reluctant to believe these were nonepileptic seizures. The family voiced support for the patient’s requests for seizure medication. The phrase that epitomizes the situation was “she is now having more seizures since you stopped the medication” by an anxious and sometimes angry husband or family member after the patient had yet another event. During follow-up, all three patients delivered healthy term babies.
Patients with psychogenic seizures onset after pregnancy.
Two patients developed psychogenic seizures after learning they were pregnant. Psychogenic seizure symptoms began shortly after pregnancy was confirmed, at 10 and 14 weeks of pregnancy respectively. These patients reported no problems with nausea. Neither patient was married, and both came from strongly religious families that disapproved abortion. One patient had been in “denial of pregnancy” before having psychogenic seizures. Both patients had frequent convulsive psychogenic seizures and were taking suboptimal doses of AED. They had been taken to emergency rooms because of “seizures” and treated with IV AED on several occasions. One patient came to the initial neurologic visit at our institution accompanied by the stepfather; the other patient was accompanied by the mother. The two patients expressed concern about the effects of “all the chemicals” to the child and both wanted to terminate the pregnancy because of fear of having a malformed child. Incest was likely in one patient.
Discussion.
The paucity of information on the subject of psychogenic seizures during pregnancy is striking, in view of the extensive literature on psychogenic seizures in general. This lack of information seems to arise from several misconceptions. Hippocrates stated that the cure for hysteria is “marriage and active sexual life” and that these symptoms were not common during pregnancy.7 Another reason seems to be the unfounded notion that other than the emotional impact of the fits to the patient and family, psychogenic seizures during pregnancy are of no great medical consequence.4 Nothing, of course, could be further from the truth. Patients with psychogenic seizures may exhibit self-injurious behaviors and sustain tongue biting, abrasions, and will occasionally have continuous fits, despite treatments, to the point of requiring intubation.1,2,8 Aggression directed against others during psychogenic seizures, however, is considered rare.1,8 This was clearly not the case in these five pregnant patients. These patients not only put themselves at risk but also “forced” the administration of drugs that were unnecessary and potentially harmful to the child. The two patients who developed their psychogenic seizures during pregnancy had repeated attacks and multiple visits to emergency departments. These patients seemed deliberate in their wish to terminate the pregnancy. After the nonepileptic nature of the attacks was established, they voiced the fear that the fact they were given multiple drugs could have had an adverse effect on the fetus and that they would rather have the pregnancy terminated. Although this type of behavior is perhaps more understandable in the two cases of undesired pregnancy, this was not the case with the other three patients who welcomed their pregnancy. Despite their wish to continue the pregnancy, these three patients continued to have attacks and to take AED, one way or another, throughout their pregnancies.
Because of the small number of patients, our findings have to be viewed with all the reservations that apply to this type of report. Nevertheless, these patients demonstrated that preexisting psychogenic seizures may persist during pregnancy and there will be patients who will continue to have “seizures” and to take AED that they obtain from various sources, despite the awareness of the psychogenic nature of their attacks, that they do not have epilepsy, and that AED pose risks to the developing fetus. The fact that two of our patients came from a background of strict religious observance is interesting but should not be construed as evidence of a causal relationship. The demographics of our patient population could have accounted for that. Lastly, pregnancy resulting from sexual molestation should be considered in these cases and the child should be considered at risk.
- Received December 20, 1999.
- Accepted in final form February 16, 2000.
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