| Abstract|| |
Background: Diagnostic accuracy of Hot Water Epilepsy (HWE) on history alone was observed to be less satisfactory by the first author while managing such patients psychologically. To confirm this observation this pilot study was planned.
Materials and Methods: Symptoms as reported by the patient was confirmed by the two authors in the wards by giving them Hot Water Head Bath. Following this they were subjected to behavioral Psychotherapeutic treatment to relieve them from their distressful symptoms.
Results and Conlusion: Confirmed the hypothesis and it was concluded that by witnessing the symptoms of HWE by the treating doctor would improve the outcome of any treatment.
Keywords: Assessment trial bath-treatment trial bath, hot water epilepsy-pseudo, hot water epilepsy-psycho behavioral therapy
|How to cite this article:|
Venkataramiah V, Ghorpade V. Pseudo hot water epilepsy: A pilot study on behavioral psychotherapeutic management. Indian J Psychiatry 2013;55:149-53
| Introduction|| |
Bathing a routine activity in everyone's life is seldom associated with any distressful physical or psychological symptoms, but in a few, physical symptoms including seizures occur, most often after hot water head bath which is considered as hot water epilepsy (HWE) or Immersion epilepsy. These cases are managed with anti-convulsants medicines like any other epilepsy, or with suggestions to use Luke warm water or usually avoid hot water for bathing.
While managing such patients, first, author tried to confirm the diagnosis of HWE by witnessing the experimentally induced symptoms with hot water head bath. Initially, these cases were asked to bathe with hot water of temperature lower than the temperature which used to precipitate a "seizure," later the temperature of water was increased slowly and steadily, every day until patient could tolerate it. Varied symptoms especially, of the non-seizure type were observed, which raised the possibility of these cases, being a form of pseudo-seizure. This procedure gave rise to encouraging results; this enabled the authors to hypothesize that "patients diagnosed clinically as HWE may have organic or psychogenic etiological factors or both." To test this hypothesis, the present study was planned.
Literature survey revealed that, this disorder is prevalent worldwide. Many researchers ,,,,,,,,,,, have reported this disorder, which is recognized as HWE induced by immersion in hot water. These reports are either single case reports or a small series of patients. On the other hand, large series of patients have been reported from southern part of India, particularly Bangalore in Karnataka state. ,,,,,, Incidence of HWE among epileptics has been reported to be 2.8% by Subramanyam  and 8.6% by Mani et al. 
Available reports have shown that etiology of HWE is not yet clear. Though, Marimoto et al.  and Satishchandra et al.  have found organic factors to be associated with patients of HWE, the specific etiology remains unclear. All the studies reviewed have stressed the organic aspect of HWE and there has been no study to suggest that psychological factors could be responsible. This study addresses this issue.
| Materials and Methods|| |
Seventeen cases, clinically diagnosed as HWE by consultant neurologist and psychiatrist, were recruited from the out-patients of neurology and psychiatry in MSRMTH. Only 12 cases consented to take part in this study and informed consent was taken from them after explaining about the investigations, trial, and treatment bath in the wards they would be subjected to. Other 5 cases did not consent to take part in the study due to their personal reasons. Their main presenting complaint was that, following hot water head bath, they would develop physical symptoms. All these cases were subjected to physical and psychiatric examination and were investigated to rule out any underlying physical disease. The investigations were routine hemogram, radiograph of the skull, chest and Electro Encephalo Graphy (EEG).
Following this initial evaluation, all patients were requested to take bath in the presence of the investigator, a female nurse and relatives, to witness the nature of symptoms following hot water head bath and to determine the temperature and amount of hot water, which usually precipitated the symptoms. The temperature of water to be used was determined by the patient himself. This procedure is termed as assessment trial bath. After this assessment trial bath, patients were prepared for the therapeutic intervention. To begin with, the water with which they bathed will be 1°C lesser than the temperature at which they got the symptoms (as determined during the Assessment trial bath). The quantity of hot water that used was also taken into account. During this procedure, the investigator continuously keeps the patient engaged in conversation which boosts up his confidence to take bath and divert his attention away from anticipatory anxiety. This procedure was repeated, over a few days, increasing the temperature of water by 2°C each time till the highest tolerable level.
When the symptoms fail to appear and the confidence of patient to take bath independently improved to satisfactorily level of both the therapist and the patient, this procedure was terminated. This procedure is named as treatment trial bath. Patient was followed up regularly after discharge.
| Results|| |
20.9 years (Range 9-32 years) was the mean age of subjects. 41.2% were in the 30-39 years range. There were 9 male subjects (M:F was 3:1).
One case had an EEG with sharp wave discharges in the fronto-temporal region. No other productive investigations were noted in the whole sample.
Historically, 7 of the 12 subjects had repetitive symptoms every time they had a hot water head bath. The other five cases were having symptoms irregularly, despite regular head bath. The duration of illness ranged from 1 month to 27 years (Mean 7.61 years; SD 8.081).
The important outcome of assessment trial was the revision of the diagnoses. Historically, 10 cases out of 12 were diagnosed as epileptic (two cases of tonic and clonic and eight cases as complex partial seizure). After the assessment trial bath, only one case was found to be of tonic and clonic type and three cases were of complex partial seizures whereas remaining eight cases had features, which were not suggestive of epilepsy [Figure 1].
Results of assessment trial showed the instability of historical diagnosis. Historically, cases were over-diagnosed as HWE (83.43%;10/12) which dropped down to 33.33% [Figure 1]. This could be attributed to the vague symptoms such as giddiness, weakness, headache, drowsiness, depression and intense itching, which historically was in 2 (16.67%) cases changed to 8 (66.66%) which could mislead the clinician while making a diagnosis in favor of organic or psychogenic etiology. By correlating the clinical symptoms precipitated by hot water head bath with EEG evidence of seizure discharge would completely eliminate these diagnostic errors. This ideal situation is rarely witnessed by the clinician.
During the treatment trial, four cases developed symptoms in the beginning of the trial, and all the 12 cases were free of symptoms at the end of the trial, with which they presented initially. All of them enjoyed the hot water bath with full confidence and with no anticipatory anxiety or worry [Figure 2].
There are a few more differences between assessment and treatment trial findings. Many tolerated higher temperature and larger volume of water as the treatment trial progressed. Ten cases had the attack during the assessment trial, while only four cases had attacks during the beginning of treatment trial. The duration of the attacks was observed to decrease from Mean of 3.3 minutes during the assessment trial to 30 seconds during the treatment trial. All the patients were able to take hot water head bath leisurely and with pleasure which they could not during the assessment trial and also historically. None of them were put on anti-convulsant medicines for HWE.
Out of 12 cases, authors could follow-up 8 cases (66.66%) for 1 year after the treatment trial. Out of eight cases, six cases were free of initial symptoms completely (75%), two cases did not show any improvement (25%). One case underwent Psycho Behavioral therapy as he had a minor relapse of non-seizure type of symptoms-itching, which was relieved [Figure 3]. During follow-up no investigations were done.
| Discussion|| |
The accuracy of diagnosis determines the management and outcome of any case. The result of this study highlights the usefulness of the assessment trial bath in clarifying symptoms as the saying goes "seeing is believing." Mani et al.  and Subramanyam , failed to confirm the nature of attacks in 50% and 23% respectively while the patients took hot water head bath in the presence of the investigator. In the present study the success of inducing an attack and confirming the diagnosis by witnessing hot water head bath by the patient was successful to the extent of 100% which could be due to small sample size.
The benefit of this procedure is to delineate the presenting symptoms as true or pseudo, which in turn guides to plan the line of management of these patients. Subramanyam  reported that 7.69% of his cases did not require any anti-convulsant drugs and were symptom free during the follow-up period. Could this be due to the placebo effect of the non-drug treatment they received?
The diagnosis of HWE (both in true and pseudo form) results in psycho-social complications such as phobia of head bath. Non-seizure symptoms that were present in the patients of this study could be understood as arising out of the anxiety and avoidance or dependence on others. This is well-demonstrated in the case report by Ghorpade.  The other co-morbid psychiatric conditions that were seen in this study were dysthymia and dhat Syndrome. These comorbid psychiatric states can be tackled either with Psychological ways or psychotropic medicines. None of the studies mentioned earlier have raised the possibility of a pseudo HWE seizure in their patients series.
This study suggests existence of pseudo HWE, similar to other forms of pseudo seizures. The results of the present study point out that some of the un-confirmed cases of HWE could be one of pseudo HWE. Probably, this study is the first to propose that, HWE could be of psychogenic origin. In order to confirm the diagnosis, almost all the studies have relied upon basic blood investigations and EEG. The percentage of abnormalities findings varied up to 56% whereas in the present study only one case had an abnormal interictal EEG recording suggestive of Epilepsy. This could be due to the sample size which is small and may not reflect on the center where it was carried out. One can expect more reliable results by subjecting these patients to one hour EEG study rather than 30 minutes which is the routine practice in many of the centers. Marimoto et al.  Lisovosky et al.  Tojima et al.,  showed intracranial lesions with intensive investigations in three cases of HWE. To establish the fact whether these organic factors are the direct or indirect cause of HWE or as associated findings, comparing pre- and post-operative status of these cases when subjected to intracranial lesion surgery, will clear the question.
Hitherto the approach towards the treatment of such cases was prescribing anticonvulsants and advising use of water of lesser temperature. Mani et al., , Subramanyam,  Satishchandra et al.  and Erdem et al.  have strongly recommended anti-convulsants. Treating all the cases with anti-convulsant drugs, is likely to give rise to various psycho-social complications such as adjustment reaction in working area as well as in the house especially marital relationship, which can be minimized by this Psycho Behavioral approach, by which patients are educated about the true nature of the disease and the right approach. Antebi and Bird  recommended psychological approaches in the management of reflex epilepsy in general but no mention about HWE has been made. No literature is available in this connection. Advising these patients to avoid the bath with Hot water over a period of time, could be the cause of a HWE phobia. Psycho Behavioral therapeutic management of such cases could potentially yield good and sustained results.
Another reason for this disorder to develop could be the result of conditioning process over a period of time. In the present study, after studying their cultural practices and environment of the bathing place, which could have been traumatic, authors hypothesized that right from the early age, due to behavioral conditioning, chances of developing the phobic symptoms are high. This could not be clarified due to some practical difficulties. This Psycho Behavioral therapeutic approach has incorporated de-sensitization procedure to overcome the phobia. As the sample size in this study is small, no comments could be made whether this procedure benefits those cases where the symptoms are undoubtedly epileptic type. In the present study, follow-up data of one patient who had tonic and clonic type of convulsions along with HWE did not help us to answer the question, whether Psycho Behavioral therapeutic approach is more efficacious than drugs or not, in the management of these cases. Controlled study with large samples is needed to answer this question.
Development of non-reflex epilepsy in different studies [Figure 4] ranges from 16% to 100% whereas in the present study none of them developed non-reflex epilepsy during the follow-up period. Diagnosis of HWE may require to be changed during follow-up as what started as a reflex phenomenon could become a non-reflex type as this could be due to kindling phenomenon. Diagnostic criteria is based upon only two factors viz. occurrence of an tonic and clonic or simple or complex partial seizure corroborated with investigation findings. Only Mani et al. and Subramanyam were the two authors who incorporated this supervised bathing to witness symptoms in addition to the other methods, which have been described above.
Is there any requirement for modifying diagnostic criteria of HWE with these findings is a question to ponder over.
One can say that Psycho Behavioral therapy is beneficial for pseudo HWE and may not be for non-reflex epilepsy. Keeping the kindling phenomena in mind, one can raise a doubt whether, by giving repeated trial bath with hot water, one is leading many cases of HWE to get converted into non-reflex epilepsy? From this angle one can say anti-convulsant medication to all these patients could prevent the conversion of HWE into non-reflex epilepsy, not to complete extent. Further well-planned studies would answer these questions.
| Conclusion|| |
The diagnostic entity HWE probably has organic/idiopathic as well psychogenic causes. Hence, the possibility of pseudo HWE diagnosis should be kept in mind as in general epilepsy, which can help in the management of such patients. All patients need not be treated with anticonvulsants only. Psycho Behavioral therapeutic approach may be beneficial. To confirm the efficacy of this approach conclusively, more studies are needed with a bigger sample size.
| References|| |
|1.||Mofenson HC, Weymuller CA, Greensher J. Epilepsy due to water immersion: An unusual case of reflex sensory epilepsy. JAMA 1965;191:600-1. |
|2.||Keipert JA. Epilepsy precipitated by bathing; water immersion epilepsy. Aust Paediatr J 1969;5;244-7. |
|3.||Szymonowicz W, Meloff KL. Hot water epilepsy. Can J Neurol Sci 1978;5:247-51. |
|4.||Lisovoski F, Prier S, Koskas P, Dubard T, Stievenart JL, Dehen H, et al. Hot-water epilepsy in an adult: Ictal EEG, MRI and SPECT features. Seizure 1992;1:203-6. |
|5.||Itoch M, Kurtial I. A case of hot water epilepsy in Monozygotic co-twin. Polio Psychiatry Neurol (Japan) 1979;33:329-30. |
|6.||Kurata S. Epilepsy precipitated by bathing a follow up study. Brain Dev 1979;11;400-5. |
|7.||Morimoto T, Hayakawa T, Sugie H, Awaya Y, Fukuyama Y. Epileptic seizures precipitated by constant light, movement in daily life, and hot water immersion. Epilepsia 1985;26:237-42. |
|8.||Tajima Y, Minami N, Sudo K, Moriwaka F, Tashiro K. Hot water epilepsy with pineal cyst and cavumseptipellucidi. Jpn J Psychiatry Neurol 1993;47:111-14. |
|9.||Erdem E, Topcu M, Renda Y, Ciger A, Varli K, Zileli T. Hot water epilepsy. Clin Electroencephalogr 1992;23:152-8. |
|10.||Roos RA, van Dijk JG. Reflex-epilepsy induced by immersion in hot water. Case report and review of the literature. Eur Neurol 1988;28:6-10. |
|11.||Allen IM. Observations on cases of Reflex Epilepsy. NZ Med J 1945;44:135-42. |
|12.||Mani KS, Gopalakrishnan PN, Vyas JN, Pillai MS. "Hot-water epilepsy" - A peculiar type of reflex epilepsy. A preliminary report. Neurol (India) 1968;16:107-10. |
|13.||Mani KS, Mani AJ, Ramesh CK. Hot water epilepsy, clinical electroencephalographic features- study of 60 cases. Neurology (India) 1972:237-40. |
|14.||Mani KS, Mani AJ, Ramesh CK. Hot-water epilepsy - A peculiar type of reflex epilepsy: Clinical and EEG features in 108 cases. Trans Amer Neurol Assoc 1975;99:224-6. |
|15.||Subramanyam HS. Hot water epilepsy. Prog Clin Neurosci 1989;33-43. |
|16.||Subramanyam HS. Hot water epilepsy. Neurol India 1972;20 (suppl 2):241-3. |
|17.||Satishchandra P, Shivaramakrishna A, Kaliperumal VG. Hot water epilepsy - A variant reflex epilepsy in parts of South India. J Neurol 1985;232:212. |
|18.||Satishchandra P, Shivaramakrishana A, Kaliaperumal VG, Schoenberg BS. Hot-water epilepsy: A variant of reflex epilepsy in southern India. Epilepsia; 1985;29:52-6. |
|19.||Gururaj G, Parthasarathy, Satishchandra P. Correlates of hot water epilepsy in rural south India: A descriptive study. Neuroepidemiology 1992;11:173-9. |
|20.||Ghorpade VA. Reflex Neurosis (NEAD). Indian J Psychiatry 2008;50:71-2. |
|21.||Antebi D, Bird J. The facilitation and evocation of seizures. Br J Psychiatry 1992;160:154-64. |
V. A. P. Ghorpade
1103, 24th Main, J. P. Nagar, I Phase, Bangalore - 560078, Karnataka
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4]