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Original Article

Pseudo hot water epilepsy: A pilot study on behavioral psychotherapeutic

management
V. Venkataramiah, V. A. P. Ghorpade
Department of Psychiatry, M. S. Ramaiah Medical College, Mathikere, Bangalore, Karnataka, India

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.

Key words: Assessment trial bath‑treatment trial bath, hot water epilepsy‑pseudo, hot water epilepsy‑psycho behavioral therapy

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
*Both authors are now retired from M. S. Ramaiah Medical College,
Mathikere, Bangalore, Karnataka, India
Address for correspondence: Dr. V. A. P. Ghorpade,
1103, 24th Main, J. P. Nagar, I Phase,
Bangalore ‑ 560078, Karnataka, India.
E‑mail: anandprakashg@yahoo.com
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
Literature survey revealed that, this disorder is prevalent
worldwide. Many researchers[1‑12] 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.[13‑19] Incidence of
HWE among epileptics has been reported to be 2.8% by
Subramanyam[16] and 8.6% by Mani et al.[14]
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How to cite this article: Venkataramiah V, Ghorpade V. Pseudo DOI:

hot water epilepsy: A pilot study on behavioral psychotherapeutic
10.4103/0019-5545.111453
management. Indian J Psychiatry 2013;55:149-53.

Indian Journal of Psychiatry 55(2), Apr-Jun 2013 149

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Venkataramiah and Ghorpade: Pseudo hot water epilepsy
Available reports have shown that etiology of HWE is not yet
clear. Though, Marimoto et al.[7] and Satishchandra et al.[19]
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.
150
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].
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Figure 1: Types of attack – details
Indian Journal of Psychiatry 55(2), Apr-Jun 2013
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Venkataramiah and Ghorpade: Pseudo hot water epilepsy
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



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Figure 2: Hot water epilepsy symptoms
Figure 3: Follow‑up at the end of 1 year
Indian Journal of Psychiatry 55(2), Apr-Jun 2013
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.[14] and Subramanyam[16,17] 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[16]
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.[20] 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.[7]
Lisovosky et al.[4] Tojima et al.,[8] 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
151
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Venkataramiah and Ghorpade: Pseudo hot water epilepsy
was prescribing anticonvulsants and advising use of water
of lesser temperature. Mani et al.,[14,15] Subramanyam,[16]
Satishchandra et al.[19] and Erdem et al.[9] 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[21] 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
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 Hot‑water epilepsy in an adult: Ictal EEG, MRI and SPECT features.
 

 
 
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Figure 4: Comparison of different studies
152
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.
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Venkataramiah and Ghorpade: Pseudo hot water epilepsy

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