Question

1. What piece of information would have to be withheld from Ms. Lamonica in order to perform the provocative test, and why is this deception necessary?

2. If Dr. Patel performs the provocative test on Ms. Lamonica, what important information will the test provide regarding Ms. Lamonica’s seizures? Be specific.

Ms. Lamonica was admitted for a neurological evaluation after experiencing 2 severe seizures. At 38, Ms. Lamonica was overweight, but otherwise in good health. All studies including electroencephalograms (EEG) were normal. Because her description of her seizures seemed to exclude epilepsy—she remained fully conscious during the events, for example, and experienced no confusion afterward—her team of neurologists led by Dr. Patel began to suspect that her episodes were nonepileptic seizures (NES). The physicians contemplated using a provocative test to confirm the diagnosis. The test was controversial because it entailed deceiving the patient. Ms. Lamonica would have EEG electrodes attached to her scalp and an intravenous catheter inserted. Dr. Patel would then tell her he was administering a solution designed to provoke a seizure. In reality, the solution would be simple saline. If Ms. Lamonica had a seizure, Dr. Patel would stop the infusion, tell her the drug was leaving her system, and watch for a concomitant end to the seizure. If no abnormal electrical activity was seen during the seizure, the diagnosis of NES would be confirmed. An estimated 10 to 20 percent of patients who are hospitalized for seizures or treated at epilepsy clinics are suspected to have NES; some have epilepsy and NES. Nonepileptic seizures are treated with psychiatric rather than neurological interventions. While epilepsy can often be managed with medications, pharmacologic treatment for NES tends to be ineffective. Anticonvulsant medication would be inappropriate. Psychotherapy is useful for some NES patients, though many remain unimproved long after diagnosis. The key to distinguishing NES from epilepsy is whether EEG evidence of a true seizure is recorded by EEG during a typical spell. To avoid keeping the patient attached to the EEG machine for hours or days in hopes of witnessing an episode, some physicians choose to employ the so-called provocative saline infusion—the sham test described above—to expedite the diagnosis. Provocative saline infusion is thus a nocebo, a drug the patient perceives as harmful, which in Ms. Lamonica’s case would mean seizure-inducing. To see if she would even be willing to undergo testing, Dr. Patel offers the possibility of the provocative test to Ms. Lamonica, as well as the alternative of no test. He explains how the test will be performed and truthfully tells her the benefit of the test is that it will help him determine the type of seizure she’s experiencing. However, given the necessary deception associated with the test, he deceives Ms. Lamonica by telling her that the solution will be seizure-inducing and explaining the risks associated with inducing a seizure. In reality, the physical risks associated with a saline infusion are much more minimal than the risks told to Ms. Lamonica. Ms. Lamonica indicates that she would be willing to consent to the test. Dr. Patel is conflicted. He regrets the necessity of deceiving her and feels that she deserves to know the truth, especially for an invasive procedure, but he also knows that the test won’t work if she’s told the truth in advance. By performing the test, he would be able to determine whether anticonvulsive medication would be appropriate for her, and he would have a better idea of how to care for her going forward. Dr. Patel must now decide whether to administer the provocative saline infusion to Ms. Lamonica.

Answer 1

1)*Dr patel withhold from ms lamonica about the name of the solution.He only mentioned it as a solution instead of saying that is simple saline solution.

*It was simple saline solution. And in  In reality, the physical risks associated with a saline infusion are much more minimal than the risks told to Ms. Lamonica.

*Nonepileptic seizures, a psychiatric condition in which emotional or psychological conflicts manifest themselves unconsciously through bodily symptoms, are currently diagnosed by a procedure called “provocative saline infusion.” The test is fundamentally deceptive, requiring the physician to intentionally and directly lie to the patient, causing the patient to believe that the administered solution caused his seizures. Without such deception, the test might be useless.

*This group of patients suffer from psychologically mediated paroxysmal behavioural disturbances that are often dramatic, alarming for bystanders, and all too easily mistaken for epilepsy. Diagnostic errors are the rule rather than an exception. Most patients are treated for epilepsy for several years. And by the time the correct diagnosis is made they will commonly have taken more antiepileptic drugs (AEDs) at higher doses and experience more side effects than an equivalent cohort of patients with epilepsy.

*Here dr patel intentionally withold the name of the solution and said the possibilities,benifits ,of the test and also there is no alternative test..He also made deception that the solution will produse seizures and  it will create more physical risks than normal.He made the deception as NES is a psychiatric condition which is based upon her emotional and psychological thinking.

2)*Here Dr patel performs the provocative test,by saying intenional lies to lamonica.And from the seizure how can he confirm the result is Non Epileptic Seizure?

*Actually the administered solution was saline.and so the seizures are produced due to her psychological thinking.

*Here an emotional or situational trigger is happened by the provocative technique.

* The diagnosis of NES can be challenging and requires careful evaluation to exclude true epileptic seizures or other medical conditions that cause seizures. Epileptic nonepileptic can also be  coexist.

A)*The Clues to differentiate NES with othert seizures:

* High seizure frequency with multiple emergency room visits could be the first clue.

*It can also distinguish by observing the:

1)Pre ictal (State immediately before seizures)

2)Ictal(midphase of seizures)

3)Post ictal phase(after seizure stage.

Pre-ictal features.Pre-ictal pseudo sleep may be present,which is a state that resembles normal sleep . (body motionless, eyes closed), while EEG shows evidence of wakefulness, and rapid eye movement).

Ictal features.*The ictal features of PNES are the easiest to recognize, as they can often be observed by the clinician.

* The contractions are usually asynchronous, There is absence of the rapid contractions and slow relaxation pattern of true epileptic clonic seizures.

*Patients having an episode of NES may exhibit side-to-side head movements. They may also close their eyes forcefully during seizure and resist attempts by the clinician to open their eyelids.

*Another common feature is avoidance behavior during the seizures. For example, a patient having an episode of NES usually will not lose balance and fall on the ground if an episode starts while sitting on a chair.

*Tongue biting, if it occurs, is usually at the tip of the tongue (not the sides as it usually is in epileptic seizures). *Patients during a pseudoseizure episode usually maintain control over their bladder and bowel functions.

*Autonomic changes can occur. described laryngospasm, large pupils, and decreased sensitivity of the conjunctivae due to increased stress-related sympathetic discharge associated with psychogenic seizures.

*Corneal reflex:Touching the cornea with a cotton swab during seizure episode could help differentiate NES from epilepsy, as the patient with NES will likely not allow such a test to be administered due to fear of injury or pain.

*Finally, NES usually has a more prolonged course than an epileptic episode (epileptic seizures usually last 2–3 minutes, while NES can last several minutes to hours).

Post-ictal features. The post-ictal features are easy to recognize. A shallow, irregular, and quiet post-ictal breathing pattern that lasts for short duration (about 1 minute) is very suggestive of NES.

*The ability of the patient to recall the details of a generalized seizure episode, suggesting a loss of consciousness did not occur, leads to a diagnosis of NES.

*Absence of post-ictal symptoms, such as confusion, headache, and fatigue, are negative features.