This 22-year-old woman presented for evaluation of syncope. Several weeks previously, she was watching the end of the movie Hannibal when Dr. Lecter was slicing pieces of the exposed brain of a conscious victim and cooking them. She became hot, sweaty, and nauseated. These symptoms increased as she watched the next scene where Dr. Lecter is about to cut off a hand. Approximately 10 minutes later, as she was leaving the theater, she began to think about these gory scenes and felt hot and sweaty with progressive loss of vision and dizziness. She grabbed onto a pole and squatted down and then rolled over on the ground. Her companion observed generalized seizure activity for approximately 15 seconds. She had urinary incontinence but no tongue biting. She was not confused afterwards. There was a history of a similar episode 2 years ago precipitated by waiting in a long line on a warm day. From about the ages of 10 years to 17 years, she had episodes of transient dizziness with rapid standing but no syncope. Past medical history was otherwise negative.

General, cardiac, and neurologic examination were normal. A complete blood count, serum chemistry, magnetic resonance imaging scan of the brain, electroencephalogram, electrocardiogram, and echocardiogram were normal. A head-up tilt-table evaluation was abnormal. In the upright tilt position at 65 degrees, supine blood pressure was 106/80 mm Hg and was maintained at or above 100 mm Hg for 17 minutes. At 18 minutes of upright tilt, she complained of dizziness. She passed out and had mild generalized shaking without incontinence. Blood pressure was not palpable. She had 10 seconds of sinus arrest interrupted by a singular ventricular escape beat. The patient was rapidly placed in the Trendelenburg position and given a bolus of intravenous fluids. She had a rapid return of consciousness and sinus rhythm. After a thorough discussion with the patient, she was advised to regularly ingest salt and fluids and to avoid prolonged standing and emotionally disturbing gory movies.

This patient has neurocardiogenic syncope with an episode provoked by watching a frightening movie. This may be a rare precipitant but we are not aware of any prevalence data. Convulsive syncope is a rather common event. For example, in a study of patients with vasovagal syncope provoked by a blood donation, 12% of episodes were associated with some convulsive features.^[1] The motor accompaniment is not an electrocortical seizure, as the electroencephalogram during an episode shows no seizure activity.^[2]

In summary, frightening movies may provoke convulsive syncope in susceptible individuals who can literally be scared almost to death. Perhaps the movie rating board should consider a new hyphenated rating such as "R-S" for "restricted- syncopal risk."

References

1. Lin JTY, Ziegler DK, Lai CW, Bayer W. Convulsive syncope in blood donors. Ann Neurol. 1982;11:525-528.
2. Aminoff MJ, Scheinman MM, Griffin JC, Herre JM. Electrocerebral accompaniments of syncope associated with malignant ventricular arrhythmias. Ann Intern Med. 1988;108:791-796.

Randolph W. Evans, MD, Department of Neurology, University of Texas at Houston Medical School and Clinical Associate Professor, Baylor College of Medicine, Houston, Texas. Email: rwevans@rwevansmd.com

Nadim Nasir, Jr, MD, Texas Arrhythmia Institute and Clinical Assistant Professor, Baylor College of Medicine, Houston, Texas.