Hysterical Coma or Seizure

1.05 Hysterical Coma or Seizure

Presentation
The patient is unresponsive and brought to the emergency department on a stretcher. There is usually a history of recent emotional upset--an unexpected death in the family, or breakup of a close relationship. The patient may be lying still on the stretcher or demonstrating bizarre posturing or even seizure-like activity. The patient's general color and vital signs are normal, without any evidence of airway obstruction. Commonly, the patient will be fluttering his eyelids or will resist having his eyes opened. A striking finding is that the patient may hold his breath when the examiner breaks an ammonia capsule over the patient's mouth and nose (real coma victims usually move the head or do nothing). A classic finding is that when the patient's apparently flaccid arm is released over his face, it does not fall on the face, but drops off to the side. The patient may show remarkably little response to painful stimuli, but there should be no true focal neurologic findings and the remainder of the physical exam should be normal.
What to do:



Do a complete physical exam. Patients sometimes react with hysterical coma under stress of illness or injury.



When there is significant emotional stress involved, administer a mild tranquilizing agent such as hydroxyzine pamoate (Vistaril) 50-l00mg im.



Do not allow any visitors and place the patient in a quiet observation area, minimizing any stimulation until he "awakens." Check vital signs every 30 minutes. o If there is a question of a generalized seizure, verify with a lactate level or blood gas that shows metabolic acidosis.



When the patient becomes more responsive, re-examine him, obtain a more complete history, and offer him followup care, including psychological support if appropriate.



If the patient is not awake, alert, and oriented after about 90 minutes, begin a more comprehensive medical workup.
What not to do:



Do not get angry with the patient and torture him with painful stimuli in an attempt to make him "wake up."



Do not perform an expensive workup routinely.



Do not ignore or release the patient who has not fully recovered. Instead, he must be fully evaluated for an underlying medical problem, which may require hospital admission.
Discussion
True hysterical coma is substantially an unconscious act that the patient cannot control. Antagonizing the patient often prolongs the condition, while ignoring him seems to take the spotlight off his peculiar behavior, allowing him to recover. Some psychomotor or complex partial seizures are difficult to diagnose with their dazed confusion or fuge-like activity, and might be labeled hysterical. If the diagnosis is not obviously hysteria, the patient might need an EEG during sleep and deserves a referral to a neurologist.