Psychosomatics 41:152-153, April 2000
© 2000 The Academy of Psychosomatic Medicine
Reevaluation of Serum Cortisol in Conversion Disorder With Seizure (Pseudoseizure)
Zeliha Tunca, M.D.,
Ülkü Ergene, M.D.,
Hüray Fidaner, M.D.,
Can Cimilli, M.D.,
Ay egül Özerdem, M.D.,
Tunç Alk n, M.D., and
Belgin Ünal Aslan, M.D., Departments of Psychiatry, Emergency Medicine, and Department of Public Health, Dokuz Eylül University, Medical School, Balçova, 35340, Izmir, Turkey
Key Words: Serum Cortisol • Conversion Disorder • Pseudoseizure
TO THE EDITOR: The pathogenesis of psychogenic seizure is not well understood. The findings on serum cortisol levels with psychogenic seizure are contradictory.1–3 We reported previously that depressive symptoms supervening to conversion disorder contributed to disruption of hypothalamic-pituitary-adrenal (HPA) axis function.4 The patients in that study not only had seizures but also other pseudoneurologic findings, such as paralysis and aphonia. The present study investigates cortisol level during psychogenic seizures and its relationship to depression, anxiety, the impairment of consciousness, blood pressure, and pulse rate.
Eighteen patients (16 women, 2 men; mean±SD age=27.2±8.5) admitted to the emergency unit with seizures of complete or partial deficits of consciousness and/or convulsions were studied. Detailed medical and psychiatric histories were taken from family members; physical and neurological examinations were also performed. Routine laboratory tests, ECG, and EEG (and CT scan and CSF examinations if necessary) were normal. None of the patients had a history of brain injury, drug toxicity, or alcohol/substance dependence. None of the patients had body injury, tongue biting, or urinary incontinence during the seizure, and postictal confusion was not observed. Glasgow Coma Scale was scored during the seizures. Patients were interviewed by a psychiatrist when they had recovered clear consciousness and were diagnosed as conversion disorder with seizure and convulsions according to DSM-IV criteria.5 They were scored by Turkish versions of the 17-item Hamilton Rating Scale for Depression (Ham-D) and the Hamilton Rating Scale for Anxiety (Ham-A), which have been found to be reliable and valid. Eight volunteers, age and sex matched (5 women, 3 men), were recruited as control subjects.
The serum cortisol of the 18 seizure patients was measured from blood samples obtained during the seizure. To investigate possible contribution of circadian rhythm on cortisol, the patients were divided into three groups according to their time of seizures (morning, afternoon, and evening). The seizures of 5 patients were between 11:00 A.M. and 12:00 A.M., 5 were between 1:00 P.M. and 2:00 P.M., and 6 were between 4:00 P.M. and 5:00 P.M.; this information was missing for 2 patients. Extra blood samples were obtained from 8 patients the following morning at 8:00 A.M., when they were symptom- and drug-free. Cortisol levels of control subjects were also obtained at 8:00 A.M. Cortisol measurements were done by radioimmunassay standard kit (Gamma BTC Cortisol, Immunodiagnostic System, UK). Intra- and interassay coefficient variations were 5.8% and 9.1%, respectively.
The mean serum cortisol levels during seizure for these 18 patients were higher (22.5±10.2 µg/dl) than levels for the healthy control subjects (11.8±4.0 µg/dl) (Mann-Whitney U test: 118.00, P=0.01). The next morning, for patients with seizures, mean serum cortisol levels were lower (16.4±9.5 µg/dl) than during seizures but were still higher than the levels of the control subjects (P=0.22; NS). The mean time period between seizure and the next morning at 8:00 A.M. was 18.1±2.2 hours. Cortisol levels were higher in the afternoon and evening hours (24.6±10.53 and 24.72±8.06 µg/dl, respectively) than the levels of control subjects (Mann-Whitney U-test=20.5, P=0.016 and U=2.5, P=0.01, respectively), but not in the morning (18.32±12.90 µg/dl) (Mann-Whitney U=20.0, P=0.3; NS) (Figure 1). Twelve patients had impairment of consciousness and 6 had both impaired consciousness and convulsions. Cortisol levels did not differ according to the types of seizures (21.12±10.25 µg/dl and 25.17±11.70 µg/dl, respectively, Mann-Whitney U=41.000, P=0.462; NS). The mean Glasgow Coma score was 11.0±4.0, Ham-D soon after seizure was 20.7±9.6 and Ham-A was 19.6±5.8, and none of the patients fulfilled the criteria for the diagnosis of major depression according to DSM-IV. There was a weak, but not statistically significant, positive correlation between cortisol level and Glasgow Coma score, depression and anxiety scores, systolic/diastolic blood pressures, and heart rates.
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FIGURE 1. Cortisol levels through the day for control subjects ( ) and pseudoseizure patients during (•) and before ( ) seizure episodes
Note: (), n=8; (•), n=16; (), n=8Solid lines indicate the mean in each group. The dotted line indicates +4 standard deviations (SD) in control subjects. Cortisol levels in 1 control (12.5%), 5 patients' interictal (50%), and 11 patients during seizure (75%) exceed 4 SDs from control mean.
P<0.01 (Mann-Whitney U test).
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Increased cortisol and escape from dexamethasone suppression in depression are documented.6 Cortisol secretion follows a circadian rhythm and peaks at 8:00 A.M., and this rhythm is impaired in depression and remains high in the evening.7 We found a tendency of cortisol to increase during the seizure in the evening hours, as observed in depression. Depression frequently accompanies conversion disorder.8 Cortisol increases in epileptic seizures.1,9,10 Rao et al.3 showed increased serum cortisol during epileptic seizures that decreased about 50% within 2 hours, whereas in patients with psychogenic seizures, cortisol levels fluctuated and dropped 90% compared to the interictal level. The apparent half-life of cortisol in epileptic patients is about 120 minutes. In our patients, cortisol dropped about 30% in 18 hours. Increased serum cortisol may be due to a nonspecific and protracted affective arousal. In conclusion, HPA axis is moderately impaired in conversion disorder; therefore, it would be difficult and impractical to suggest serum cortisol level as a good predictor in differential diagnosis of epileptic and conversion disorder seizures.
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