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Show The Eyes in Hysterical States of Unconsciousness MICHAEL L. ROSENBERC, M.I). Abstract Forced downward .Ievi.ltion of the eyes has been described as a useful sign in patients with hysterical coma and seizures. Two patients Me described emphasizing the value of this test in prolonged feigned seizured states as well as in hysterical syncopal episodes. Differenti.lting hvsteric.ll illness fr,lm true org. 1l11C dise.lse C.ln be e"tremely difficult. A feigned deere.lse in ment.ll st.ltuS in p.Hticul.H poses .1 birly wmn1l1n problem in neuro!llgic pr.1Ctice. This may mimic com.1, seizures, or more rarely, syncope. Henn,l has reported th.lt forced deviation of the eyes towards the ground can be used to help differentiate organic from nonorganic com.1 and seizures The usefulness of this sign, however, seems not to be well appreciated in the m.1ny papers which h.lVl? recently been published detailing the difficulty in distinguishing real from pseudoseizures."-" The purpose of this report is to emphasize the usefulness of this sign in pseudoseizures as well as to describe its use in another less common type of feigned unconsciousness-hysterical syncope. Case 1 A 30-year-old female h.1d a history of left facial and upper extremity focal seizures as wt>1I as grand mal seizures. Initi.llly these were well controlled on dilantin. Several months I.lter, the p.ltient began to have seizures of .l different type. These were more bizarre, and much more frequent. Twitching would begin in the left face and progress to include the left upper extremity, as they had done in the past. She would then becomt> extremely comb'ltive, .1Ild often wander aimlessly .1bout the room. Loss of consciousness would generally follow .1ssoci.lted with generalized tonic clonic movements that lasted between 5 .lnd 15 minutes. Repetitive interict.ll EECs were norm.ll. Attempts at ictal EEes were attempted, but the seizure state would alw.lys end spont.lneously .1fter From Ihe DepMlml'Il1 "f Nl'un.(o);y. Wilford 11.,11 Air rOnT MedicJI Cenll'r, SJIl Alllolli", '1',"'''. December 1982 the electrodes pl.Ked on the skull. Postictally, however, the EECs were normal. Over the next several months, tre.ltment with therapeutic levels of dilantin, phenobdrbitol, valproic acid, and clonazepam were without affect. There was no strong suspicion that these spells were nonorganic in nature. During several prolonged episodes, the patient W.1S incidentally noted to have a forced downward deviation of the eyes towards the floor no matter which way the head was turned. This suggested the diagnosis of hysteric.lI pseudoseizures. Extensive evalu.ltion with videotape and telemetric electroenceph. llographic recording with n.lsoph.lrynge. ll le.lds confirmed this di.lgnosis. Psychi.ltric consult.ltion W.lS begun, with an immediate and sustained decrease in seizure frequency. Case 2 A 19-year-old fem.lle security policewom.m complained of frequent fainting spells. These had been occurring from 2 to 3 times/week for the t> weeks prior to admission, and were becoming more frequent. They usually occurred after standing for a variable period of time. Observers noted that the head would suddenly drop to her chest, and the patient would slump to the floor. She would remain unresponsive for 10-bO seconds and then return promptly to normal. There was no postict.ll st.lte. EKG, EEG, and .lrteri.l1 blood pre~sure were recorded during two spells th.lt were induced with .1 tilt t.lble. All p.H.1J11l'ters reJ11.1ined unch.1l1ged. During sever.ll epi~odl's, the eves were "bserve'd to turn r.lpidly tow.Hds thl' fi<',)r with prl)J11pt s.lCc.ldic eye movement~. Ill' J11.1ttl?r which dirC'cti,ln the he.ld W.lS turned. Thl' p.ltient W.1S «1I1fr,lnted with the suspected di,lgnosi~ llf psvchogenic syncope, .1l1d, althl1ugh ~he denied it. the spells did n,)t rC'turn. Discussion AltlllHlgh feigned f.linting is r.lre, hystericdl «'m.l .lnd 11l1l1l,rg.lnic pseud,'seizures .He C,'l1lmon di.lgnostic pfl,bleJ11s. Rl'cent p.lpers h.1Ve .lddressed the pfllblem "f distinguishing re.ll frOJ11 pseudoseizure~, but none h.1VC' m.lde usC' of this sign.~-'· Over the 1.1St sC'veral ye.Hs, this sign has been h,und t" be helpful in .1 signific.1l1t number of 259 p,ltienh with kiglwd uncon"cjoll~ne~~ imitJting Clll11,1 clr gClwr,llized epilepsy, ,IS well ,IS in thl' ,1bllVe p,ltient with hy"ll'rir,ll ""ynCllpe." This tl'"t i~ pertl1rnwd by llloving till' p,ltirnt'" IW,ld to the "idc', ,lnd w,lkhing the IllOVC'nH'nt of the p,ltient'" C'YC'''. The he,ld is then turned tll till' oppositl' ~ide ,1nd, ,lg,lin, ,my rh,lngt' in the po"ition of the eye" is noted. This Ill,ly require holding thl' p,ltient's eyes open whill' the he,ld is being turned. The typic,ll resptlnsl' tlf .1 trudy nl/ll,lto~l' p,ltient will be either no nwvenwnt tlf the eyes ("lIch ,IS with St)fllt' drug~indllced or br,lin stem le~ion~), or J sllllltlth IlltlVelllent of thl' eye~ oppo~ite to the direction of the he,ld turn (the "doll'~ l'Yl'~" re~ sptlnse). The eyes of ,1 p,ltient feigning .I cOlllato~e sUte will be dl'viJted tonically tow.Hd~ the floor, ,IS it to ,lVoid IOtlking .It the clbserver. On moving the he,ld to the opposite side, the eyes will either S,lcc,lde directly to the side facing the floor, or occ,lssion,llly dart from side to side bdore coming to rest. As no purely organic lesion causing uncon~ sciousness could allow these sJccadic movements to be m,lde, there should be no false~po<;itive results. Although .I true seizure focus may certainly force the eyes to one side, turning the head from side to side would not .lIter the direction of the forced deyi.ltion of the eyes, thus distinguishing the org.lnic from the nonorganic seizure. This sim~ p/e t('st provides .In important adjunct to the ex,1minJtion of a patient with a depressed mental "t,ltu~ suspected of having psychogenic disease. References Henry, IA ..IJld Woodruff, G.HA.: A di.lgnostic sign in "I,lles llf .Ipp.Henl unconsciousness. Lancet 2: 920() 21, 1()78. , Cohen. RI. .Ind Suter, G.: Hysterical seizures: Sug~ gestion .I" .I provocative EEG test, Ann. NeuroJ. 11: 30 1-395, 1082. 3 f)e".II, BT, I'orter, R.J. and Penry, I.K.: Psychogenic '('Izures: A ,tudy of 42 attacks in six patients, with inten'lve monltoflng. Arch. NeuroJ. 39: 202-209, 10 82. 4. Gulick, T. A., Spinks, JP, and King, D.W.: Pseudo~ seizures: Ictal Phenomena. :VeuroJ. 32: 24-30, 1982. 5 King, OW, Gallagher, BB., Murvin, A.I, Smith, DB, M.Jrcus, D.'., Hartlage, l.C, and Ward, L.C: Pseudoseizures: Diagnostic evaluation. Neurol. 32: 18-23, 10 82 ~\'rill' {or repnnb 10: Michael l. Rosenberg, M.D., Department of :"-ieurolugy, Wilford Hall Air Force Med~ iC.J1 Center, San Antunlo, Te'us 78230. Journal of Clinical Neuro-ophthalmology |
