CASC Linked OSCE

STATION TITLE:

ASSESSMENT OF NON-EPILEPTIC SEIZURES

LINKED STATION

INFORMATION TO CARER

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CASC Linked OSCE

STATION TITLE: ASSESSMENT OF NON-EPILEPTIC SEIZURES - LINKED STATION

INFORMATION TO CARER

Instructions to Candidate

After seeing Mrs Richards her husband asks to speak to you.

Task:

 Please discuss this case with Mr Richards and answer his questions.

 You have Mrs Richards consent to talk to him.

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CASC Linked OSCE

STATION TITLE: ASSESSMENT OF NON-EPILEPTIC SEIZURES - LINKED STATION

INFORMATION TO CARER

Instructions to Simulated Carer:

You are Mrs Richards’ husband. You have been unemployed for the last 18 months and have
spent a lot of time at home supporting your wife and helping out with child care. You have
recently got a job working on the oil rigs and will be spending a lot of time away from home.
You have had to put off starting work because of your wife’s current illness. You have not
left your wife alone outside the hospital because you are concerned that she may have
another seizure and really hurt herself.

You are quite angry and irritated with doctors on the medical ward who are saying that your
wife’s seizures are not real and you cannot understand how this can be the case, having
witnessed them yourself. You are aware that she has had psychiatric problems in the past
but you cannot see how psychiatric problems could cause the kinds of issues she is having
currently.

You are quite angry with the doctor you are talking to and demand to know how it is
possible that she could be just “putting it on”. You are initially exasperated and angry but
calm down considerably through the interview if things are explained clearly and sensitively
to you.

You have a number of other questions:

 Why are the Neurologists discharging her?

 The doctor said she has mental health problems. How is it possible that mental
health problems can cause this?
 Does this mean that she is just “putting it on”?
 What do you think is the reason all this has started?
 Are there any tablets you can give her to take this away?
 Will she continue to have seizures?
 If I leave her alone and she has these seizures, she may hurt herself or even die. How
can I do that?
 How do you plan to treat this or help this to get better?
 Does she need to be in a psychiatric hospital?

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 CASC Linked OSCE

STATION TITLE: ASSESSMENT OF NON-EPILEPTIC SEIZURES - LINKED STATION

INFORMATION TO CARER

Examiner please mark one lozenge for each objective

Key: A=excellent, B=good, C=average, D=fail, E=severe fail

CONSTRUCT: The candidate should be able to communicate effectively in difficult

circumstances and explain the relationship between stress, mental disorder and physical
symptomatology. They may also introduce concepts of dissociation to the husband.

A B C D E
Communication

Ability to calm husband and develop rapport

Explanation of effect of mental disorder on physical symptoms

Explanation of possible aetiology and maintenance

Description of a clear management plan

GLOBAL RATING

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CASC Linked OSCE

STATION TITLE: ASSESSMENT OF NON-EPILEPTIC SEIZURES - LINKED STATION

INFORMATION TO CARER

Notes on non-epileptic seizures:

Non-epileptic seizures are paroxysmal episodes which resemble and are often misdiagnosed
as epileptic in origin. They are, in fact, physical manifestations of psychological disturbance
and are most often considered to be dissociative in origin i.e. they are not under voluntary
control and are associated with unconscious secondary gain. This is an example of abnormal
illness behaviour with unconscious, maladaptive entry into the sick role leading to
secondary gain.
They are particularly common in epileptic populations but much less so in general
population (up to 30 cases per 100,000). There is often an association with significant past
trauma and/or childhood abuse, a history of previous contact with mental health services
and evidence of past maladaptive coping under stress.
The main psychiatric differential diagnoses are factitious disorder and malingering.
There are a number of points in the history that make non-epileptic seizures more likely.
These include:
 A sudden onset of epilepsy in an adult with a close temporal relationship to a
significant emotional stressor.
 Seizures brought on consistently by stress factors.
 Seizures that occur only when other people are around.
 Significant variation in the pattern of motor disorder during seizures.
 No history of injuries sustained, tongue biting or incontinence.
 Absence of “post-ictal” confusion.
 Apparent indifference to the current circumstances or clear evidence of other
“hysterical” behaviours during interview.
 Evidence of secondary gain for being in the sick role.
The candidate should seek to demonstrate some of these features when interviewing the
patient to help to establish the diagnosis and inform treatment planning.
Perhaps the most important factor in treating non-epileptic seizures is sensitive, non-
judgemental provision of the diagnosis to both the patient and family. 50-70% of patients
will become seizure free after this.
The patient needs to be in no doubt that we see their attacks as very real and involuntary and
we do not think that they are “put on” in any way.
There should be a clear description of the reciprocal relationship between mental health and
physical health and the potential for psychological stress to lead to the production of
physical symptoms.
Psycho-education in this way for the patient and family should allow a more candid
discussion about possible aetiological and maintaining factors.

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CASC Linked OSCE

In these cases there is often a clear emotional precipitant which gives an indication of the
issues/conflicts which may be being avoided as a result of entry into the sick role. Dealing
with these issues and manipulating other aspects of secondary gain are likely to stop or
reduce the frequency/intensity of seizures.
In this case the seizures appear to be a way of avoiding being “abandoned” by her husband
and avoiding having sole responsibility for caring for two children in difficult circumstances.
These may well be added to by the distress associated with the patient’s own difficult
experiences of being parented.
From this perspective provision of practical child care support for the patient (e.g. Sure Start,
social services) and individual supportive psychotherapy at a women’s centre or from a
community nurse may well bolster resilience and reduce potential for relapse or
development of other dissociative type behaviours.
In the longer term, depending on further assessment, referral for dynamic psychotherapy or
to a local specialist personality disorder service may well be indicated.
Adjunctive use of medication to target comorbid anxiety or depressive symptoms would also
be appropriate.