These nonepileptic seizures are caused by stress
DEAR DR. ROACH: I have a loved one who is male, 57 and does not use alcohol or drugs. He has been having seizures for the past eight or nine years. In the early years, they were infrequent and very random. They lasted 30-45 seconds, during which he would stare off into space, and when he came out of it he was confused and very agitated.
He has always worked in the construction industry, as a heavy-equipment operator. Last December he totaled a truck and could have killed or been killed. He has no warning when he’s about to seize. He limits his driving as much as possible. He has been unable to work for the past couple of years, as he has lost four jobs due to seizure-related accidents.
He has been diagnosed as having nonepileptic seizures caused by stress. He had been prescribed 600 mg per day of oxcarbazepine for a couple of years. When they got worse, they doubled it to 1,200 mg, and about a month ago they added paroxetine 20 mg.
He can’t work because he has seizures, he has seizures because he has stress, he has stress because he can’t work. I don’t think he’s seen a neurologist, just a general practitioner. Any suggestions? -- G.G.
ANSWER: It sounds like his doctor has made the diagnosis of psychogenic nonepileptic seizures, which is a challenging and probably unrecognized condition. People with this psychological disorder have events that appear to be seizures, but an EEG done during an event shows no seizure activity. This is a diagnosis that needs to be made by an expert, usually a neurologist with special expertise in epilepsy, and with the evidence of a video EEG. It is associated with other psychological disorders, such as anxiety, depression or post-traumatic stress disorder.
It’s not clear to me that this stringent diagnosis has been made, and I honestly don’t know whether he is having epileptic seizures. Oxcarbazepine is a commonly used seizure medicine, but it does not seem to be working. Paroxetine is an antidepressant that sometimes can increase the likelihood of seizures. I don’t understand why he would be on oxcarbazepine if he is not thought to have epileptic seizures.
I would strongly recommend a complete evaluation by an expert in epilepsy, who may order a video EEG, which is done in the hospital.
DEAR DR. ROACH: I wrote you back in March about an anemia. I had a colonoscopy and an endoscopy done, and I also had a capsule endoscopy done after the first two. Everything was fine, and my doctor didn’t find anything having to do with anemia. However, yesterday I had a physical at my internist’s office and she, once again, said that I’m anemic. Now she wants me to have an echocardiogram, since she said I have a heart murmur. Also, she is referring me to a hematologist with regard to the anemia. Does this sound appropriate? -- C.A.
ANSWER: A heart murmur is a sound made by blood flowing through the heart valves. It can be caused by an abnormal valve or if the blood flow is higher than normal. If you have a significant anemia, the heart has to work extra hard, because your blood can’t carry as much oxygen as it ought to, so a murmur is not uncommon. However, depending on the type and quality of the murmur, your doctor may have reason to send you for an echocardiogram.
If your internist can’t find a reason for your anemia, then yes, I think a visit to a hematologist is a good idea. There are many possible causes.
The booklet on abnormal heart rhythms explains atrial fibrillation and other common heart rhythm disturbances in greater detail. Readers can obtain a copy by writing: Dr. Roach, Book No. 107, 628 Virginia Dr., Orlando, FL 32803.
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