Faking It

Neurology grand rounds today discussed a patient who is experiencing pseudoseizures. In other words, he's faking epilepsy. But it was absolutely the most informative and interesting learning I've done yet on this rotation.

This patient has obviously done some reading on epilepsy, as he starts out his pseudoseizures correctly, but as he progresses he makes mistakes. He was being monitored in his room with a video EEG, which, as the name suggests, films the patient while recording his brain's electrical activity. This is later reviewed, either by his physician, or a roomful of them, like this morning.

When I first watched the video, I thought I was seeing a real seizure, but as the discussion continued, and the tape was rewound and watched over and over, the points in question came out. This patient attempted to simulate decorticate posturing, but he probably read a definition like the one I linked to there, which doesn't say how the arms are twisted. He was supinating his forearms, while pronation is more common. Also, he made thrusting motions with his extensor spinae muscles, rather than the usual fixedly rigid posturing. Ten or fifteen other tiny details were discussed and analyzed. He was moving rhythmicaaly when he shouldn't be, and was fixed when he shouldn't be. The EEG didn't match epilepsy either, and displayed only motor activity. There were no rhythmic cycles in it, and some leads showed almost no activity.

So the staff started asking the residents questions about management. The funniest proposition was from a first year who said he would announce in a loud voice "if this doesn't stop, we're going to have to use rectal diazepam." After the laughter died down, he was gently reproved to use more compassionate techniques. Several different ideas were discussed, and I found it thrilling, in a way, to sit down in a room full of super intelligent people and discuss, essentially, ways to trip up someone who is lying to you, without letting them know you know he is lying.

The staff concluded with a remarkable set of points. First, he said, we have to remember that this patient does indeed have a disease, it's just not epilepsy. And second, we can't let on that we think the patient is faking it, because it won't help his behavior. On the contrary, he'll just try harder to convince us. And in the end, our goal is not to flaunt our intelligence over this poor guy, it's to help him get better and go home.

Time to consult psychiatry.