The chart of a new patient includes a long history of dramatic pseudoseizures in response to a variety of nontoxic environmental stimuli. This determination was made by several trusted neurologists. How do I handle this when the patient has an episode in my office? I know she is not going to harm herself, but my staff does not. Am I obligated to call 911 and send her to the hospital whenever this occurs?

At her last appointment, her family refused an ambulance and insisted on taking her home to recuperate. However, the process involved 90 minutes of nursing time, attending to her and making sure she was safe and not in distress. In some ways, it would be easier to call 911 and send her on, but I know her seizures aren’t neurologic in origin. What should I do? — COLLEEN ROOT, MD, Fishers, Ind.

Pseudoseizures are usually a manifestation of a conversion disorder. As such, the prognosis for resolution is generally good. In your patient with longstanding symptoms, however, there is greater risk for recurrence and chronic disability. Some suggestions for office management include (1) educating the staff about the disease and the fact that the patient is not in any danger of hurting herself, (2) adapting a simple protocol for one person (preferably a family member) to monitor the patient in the office until the pseudoseizure stops (you may want to insist that she is always accompanied by a family member who is willing to be the monitor), (3) assuring that the patient is being managed by a psychiatrist to identify and treat any underlying psychopathology or conflict in interpersonal relationships. As long as you are confident in the diagnosis of pseudoseizure, I do not think you need to call 911. — Walter N. Kernan, MD (150-1)