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By Dr. Scott Hamilton
April 30, 2021

This week's guest columnist is Dr. Shalini Choudhary, a Family Practice resident at the University Hospital and Clinics here in Lafayette. Growing up I attended an English-style boarding school in India, like Hogwarts in Harry Potter, but without the magic. Except for a rumor that the eerie, abandoned church on the grounds was haunted. Then one day I came upon our dorm's Head Girl lying on the floor, eyes closed, rolling side-to-side, screaming, "I'm back!" As the school nurse held her tight, my friends and I were petrified: was she possessed? Those episodes became more frequent and longer lasting, and students whispered among themselves that feeding the invasive spirit would keep it happy. We all began dropping our ration of cookies, cakes, and candies in the Head Girl's locker to be safe. Now in 2021, a 14 year-old girl came to the Pediatric Emergency Department with apparent seizures. She had recently been diagnosed with Multiple Sclerosis, a neurological disease with recurrent stroke-like and seizure-like symptoms. Soon after she arrived she began convulsing again, closing her eyes and throwing her head back and forth, much like my Head Girl from years ago. But now to my trained eye these didn't look like seizures, they looked like "pseudo-seizures." Psychogenic Non-Epileptic Seizures (PNES) are seizure-like episodes that aren't actually seizures. In real seizures, the brain's normal electrical activity goes haywire, neurons mis-fire at random and the patient falls unconscious and twitches. After a few minutes the seizures stop, and the patient is sleepy for a half-hour or so while the brain recovers. PNES episodes have shaking that is "manufactured" by conscious brain activity, and the patient acts normally immediately after. Sometimes the child is purposefully acting out for some gain, like extra attention or extra goodies from her terrified dormitory underclass!. Other times the child subconsciously believes they're seizing, and it's a psychiatric issue. Back to the Head Girl from my youth in India, where I attended a Hogwarts-style boarding school. She was a bully, taking out whatever frustrations she had on us underclass girls that she was supposed to care for. When she began having seizure-like episodes, we believed she was possessed by the soul of one of her friends who had died in an accident. While she already occasionally stole our cookies and candies, when she began having apparent seizures, we voluntarily put offerings of sweets in her locker to appease her friend's spirit. As the episodes increased, the Head Girl's cake and candy yield increased as well. As we discussed above, PNES, or "pseudo-seizures," describes episodes where a child appears to be seizing, but is actually making seizure-like movements for non-neurological reasons. In other words, they seem to be "faking" seizures. Sometimes it's for obvious secondary gain, like getting attention and sympathy from parents, teachers, and school mates, or getting more sweets!  Sometimes though, PNES is a sign of psychiatric trouble. These kids often have depression, anxiety, and Post-Traumatic Stress Disorder. They don't need anti-seizure medication, they need therapy and sometimes anti-depressants. The 14 year-old girl with newly diagnosed Multiple Sclerosis certainly had reason to be depressed. MS is a life-long, debilitating disease with stroke-like symptoms that come and go. She was having pseudo-seizures apparently as a stress-reaction to this new terrible diagnosis. After her pseudo-seizure we witnessed, she opened up to me about how miserable she was. We discontinued her anti-seizure medication that had been started, and she was discharged with advice to start counseling and see a psychiatrist. Many PNES cases have happy endings. The Head Girl from my youth got over the trauma of losing her friend, stopped her convulsions, and after a social media search I discovered is now a psychiatrist herself!

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