Psychogenic Seizures by mikesanye

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									Non-epileptic Seizures

      Dr Nitin Patel
An epileptic seizure is defined as a
    sudden, involuntary, time-limited
    alteration in behavior, motor
    activity, autonomic function,
    consciousness or sensation
    accompanied by an epileptiform
    electrographic ictal pattern.
A Pseudoseizure is a paroxysmal non-
    epileptic event that derives its
    name from its clinical similarity to
    epileptic seizures, in the absence
    of concurrent electrographic ictal
NES (non-epileptic seizure) are
    involuntary episodes of
    movements, sensations or
    behavior similar to epileptic seizure
    that do not result from abnormal
    cortical discharges.
Nearly, all patients who present
 with seizures will turn out to
 be epilepsy cases.
But what about those cases that have
    seizure episode yet their EEG
    shows normal activity?
17-30% of patients referred to tertiary
    epilepsy center with diagnosis of
    intractable epilepsy ultimately are
    found to be non-epileptic.
Because the management of
    Pseudoseizures is completely
    different from that of epileptic
    seizure, establishing the correct
    diagnosis is of paramount
Non-epileptic seizures can mimic any
    kind of epileptic seizure, being
    mistaken for GTC, absence,
    simple and complex partial
     They have been recognized
         since ancient times as a form
         of hysteria.
Jean Charcot first described non-
    epileptic seizure in the late 1800’s
    calling it “hysteroepilepsy” or
    “epileptiform hysteria”.
“Non-epileptic seizure” is preferable to
    the older term hysterical seizure or
    “pseudoseizure” because those
    terms are pejorative and seems to
    indicate that patients are having
    episodes intentionally.
Try to avoid using the term
     psychogenic seizure, which many
     patients have difficulty in
     differentiating from epileptic
Non-epileptic Seizure Classification
Physiologic                     Psychogenic
-- Panic attacks                -- Psychopathological processes:
-- Syncopal episodes                - Conversion disorder
-- Complicated migraines            - Somatization disorders
-- Transient ischemic attacks       - Dissociative disorders
  (TIAs)                            - Anxiety disorders
-- Cardiac arrhythmias               (including PTSD)
-- Hypoglycemia                     - Hypochondriasis
-- Drug/Toxic effects               - Psychoses
-- Dysautonomia                 -- Misinterpretation of physical
-- Sleep disorders                symptoms
-- Movement disorders           -- Response to acute stress
-- Vestibular symptoms            without evidence of
                                -- Reinforced behavior patterns
                                  in cognitively impaired patients
                                -- Malingering
                                -- Factitious disorder
Differential Diagnosis of Non-epileptic Seizures
       Term                                          Definition
Seizures                 A general term referring to convulsions; somatomotor, somatosensory
                          and other phenomena that may or may not be related to epilepsy
non-epileptic seizures   Episodic changes in behavior; somatosensory or other seizure-like
                          events; however, not caused by abnormal electrical activity in the
                          brain (epilepsy)
Physiological events     Episodic changes in behavior attributable to physiological factors such
                          as a cardiac arrhythmia or TIA
Psychogenic seizures     A subset of NES attributable to psychologic causes
Malingering              A willful production of symptoms for specific external incentives
Factitious disorder      Consciously determined symptoms driven by a powerful unconsciously
                         determined need to assume the sick role (typically without external
                         A subjective phenomenon caused by focal seizure activity and
Aura                     heralding
                         the onset of an event
Prodome                  A premonitory symptom not directly related to seizure activity
NES = non-epileptic seizures; TIA = transient ischemic attack
Non-epileptic seizure are far more
 often psychogenic

  They are physical manifestation of
   psychological distress
Psychogenic non-epileptic (PNES) are
    grouped in the category of psycho-
    neurological illnesses like other
    conversion and somatization
    disorder, in which symptoms are
    psychiatric in origin but neurologic
    in manifestation.
This is reverse of neuropsychiatric
     disorder which is neurological in
     origin but psychiatric
     manifestations, as in Parkinson’s
     disease and Huntington’s disease.
Definitive Diagnosis for Unclear
Several factors considered (Gold
 standard is VEEG monitoring)
 Presence or absence of self injury
    incontinence
    post ictal prolactin level
    psychologic test MMPI
    historical factors
  Ambulatory EEG monitoring
Techniques are used by practitioners to
 induce PNES
     Hypnotic seizure induction and
     Patient can do to self
Definitive diagnosis achieved with VEEG
 monitoring in which he patient is
 observed having typical seizure, but
 there is no accompanying abnormality
 on EEG
  Family member or witness must
    agree with episode recorded on
Study by Alsaadi et al.
     121 patients that experienced
    having epilepsy were referred to
     Out of these, 29 (24%) were
               22 patients diagnosed
              with epilepsy were found
              to have NES
               4 patients diagnosed with NES
              were found to have epileptic
As one can see, even experience in the
 diagnosis and treatment of epilepsy
 cannot prevent misdiagnosis in such
Historical and Clinical Details Suggesting
Psychogenic Seizures
Historical Features
-- History of sexual and physical abuse
-- High seizure frequency
-- No response or paradoxical increase in seizures with AEDs
-- Seizures occur only in presence of others or only alone
-- Lack of concern ("la belle indifference") or excessive/exaggerated emotional
-- Personal, family or profession experience with epilepsy
-- Flurries of seizures or recurrent pseudostatus epilepticus leading to multiple
 emergency visits or hospitalizations
-- No history of injury from seizures
-- Associated (often multiple) psychiatric disorders
-- Multiple unexplained physical symptoms
Clinical signs
-- Prolonged seizure (>2-3 minutes)
-- Gradual onset and cessation
-- Emotional/situational trigger
-- Change in semiology/nonstereotypic seizure patterns
-- Nonphysiologic progression
-- Asynchronous limb movements
-- Intermittent or waxing & waning motor activity
-- Dystonic posturing (including opisthotonus)
-- Pelvic movements (especially forward thrusting)
-- If tongue biting present, usually tip, not side of tongue
-- Side-to-side head movements
-- Ictal crying, weeping
-- Closed eyes, during seizure
-- Resisted eyelid opening
-- Ability of observer to modify motor activity
-- Avoidance behavior during seizure
-- Seizures provoked by suggestion
Early diagnosis of PNES is critical
  Accurate diagnosis is often
  Mean latency is 7.2 years between
     manifestation and diagnosis of
PNES patients experience iatrogenic
 morbidity from inappropriate AEDs
         Frequent ER visit for
         Harmful interventions like
A larger study on PNES found that at the
  time of diagnosis:
     79% patients with PNES were on AEDs
     22% experienced drug toxicity
     70% experienced loss of consciousness
     60% reported seizure related injury
     51% had at least one episode
     More than ½ of them were intubated
     28% were admitted to ICU
     Early diagnosis may be therapeutic for
         some and stop PNES
A study by Martin et al concluded that
  early diagnosis can also help
      84% reduction in total seizure-
     related medical charges in 6 months
     after diagnosis
      Average diagnostic test charges
     down by 76%
      Medication charges down by 69%
      Outpatient visit down by 80%
      ER visits down by 97%
Non-epileptic Epidemiology
2 to 33 per 100,000 people in general
  population have NES
  Making it as common as MS and
    Trigeminal Neuralgia
  5-10% outpatient epileptic population have
  10-40% inpatient in epilepsy centers
  20-30% patients in tertiary centers
    diagnosed with NES
  75-85% are female patients with NES
  Age is wide range  5-75 years
Prevalence of PNES is increased in
  patients with:
      Head injury
      Learning disabilities
      Isolated neuropsychological
Patient with PNES has a higher than
 average rate of abnormal MRIs/EEGs,
 suggesting abnormal brain plays a
 role in PNES
PNES also seen in patients with CNS
 lesions that are expected to produce
 epilepsy ie stroke, trauma, infection
 and malformation
     Such lesions could delay
    diagnosis of PNES
Coexistence of epilepsy & PNES
 estimates vary widely from 5-60%
     VEEG finds only 5-10% of
    patients with NES have concurrent
    epileptic seizure
     While 10% patients diagnosed
    with NES actually have epileptic
Etiology and Psychology
All PNES function as a coping
      NES patients perceive their
     lives as stressful and they use
     maladaptive coping strategies to
     handle stress
In PNES, psychological conflicts are
  translated into physical symptoms

          SEIZURE
In this way, intolerable internal distress
  is separated (dissociated) from
  painful conscious experience of
  trauma or forbidden emotions causing
  the distress
Thus genuine PNES (as opposed to
 factitious disorder or malingering) are
 necessarily not intentional:
     They are psychological defense
    mechanism to keep internal stress out of
    conscious awareness
     They do not have single cause
     They may be response to acute stress in
    patient without psychopathology
     Reinforced behavior pattern in cognitively
    impaired individual
     Rarely malingering or factious disorder
43-100% of NES
patients have current
psychiatric illness
Comorbid Psychiatric Disorders in
Non-epileptic Seizure Patients
Diagnosis                     Current   Lifetime
Major depressive disorder      47%        80%

Any affective disorder         64%        98%

PTSD                           49%        58%

Anxiety d/o other than PTSD    47%        51%

Personality disorder           62%        62%

Conversion sx-not seizures      4%        82%

Any dissociative disorder      91%        93%

Any Somatoform disorder        89%        98%
There is often past medical history of:
  Physical or sexual abuse
  Psychological stress for which patient
 perceives no resolution called “unspeakable
  84% of patients have experienced trauma
      Sexual – 67%
      Physical Abuse – 69%
      Other trauma – 74%
More recently found significantly higher
 rates of:
     PTSD
     Childhood sexual abuse
     Dissociative symptoms
     History of assaultive trauma
To determine why particular patient is
 having PNES:
     Clinician must understand what the
    psychological function of seizure is
     A detailed systematic psychiatric
    evaluation and an assessment of family,
    social, financial and employment problems
    should provide insight
     Many schemes have been proposed to
    classify PNES based on underlying etiologies
Classification of PNES By Underlying
Etiology                 Description                                              Suggested Treatments
1. Anxiety/panic/        Atypical symptoms of anxiety or panic are                Treatment of panic attacks;

  physical symptoms      misdiagnosed as PNES, or the patient misinterprets       reassurance that physical

                         physical sensations or symptoms.                         symptoms are not seizures.

2. Reinforced behavior   Often seen in cognitively impaired people; they have     Behavior modification therapy

  pattern                developed because of the functional advantages that

                         are reinforced by the PNES, e.g. attention or avoiding


3. Psychosis             PNES can be manifested of psychosis; this is rarely      Treatment of underlying psychosis

                         the case and the diagnosis is clear.

4. Poor interpretation   Patients often diagnosed with borderline personality     Intensive psychodynamic psychotherapy

 skills and affect       disorder, which have history of abuse. Patient may       to help identify and express threatening

 regulating disturbed    come from a family with poor emotional expression        emotions (conflict, anger and rejection)

 family systems          and be unable to identify and effectively express        and set realistic goals for relationships;

                         strong emotions. PNES function to resolve inter-         family therapy when family systems

                         personal crisis or threatening emotions or situations.   support maintenance of PNES.
Classification of PNES By Underlying Etiologies (cont)
5. Somatization/    The PNES represent emotional distress converted               Cognitive behavioral therapy (CBT) to
  somatoform/       into physical symptoms; there is often a long history         identify links between stress and NES
  conversion        of medical attention for unexplained physical symptoms.       and develop more adaptive coping; for
  disorders         The patient can often identify precipitating stressful        severe somatization, regular visits not
                    events; the PNES are therefore a conversion symptom.          contingent on symptoms, focus on living
                                                                                  with symptoms rather than investigating
                                                                                  and treating them.
6. Depression/      In this case, the PNES are not precipitated by a specific     Antidepressants for depression, CBT to
  dissatisfaction   stressor; rather, the patient is generally unhappy, and the   challenge depressive thoughts and basic
                    PNES function as distraction or an acceptable to get          assumptions about self/illness,
                    support and attention.                                        encourage active involvement to lifestyle
                                                                                  changes and problem solving.
7. PTSD/            Patients have active, chronic PTSD and dissociative           Exposure-based therapies and SSRIs for
  dissociation      symptoms. PNES triggered by flashbacks, recollections         PTSD.
                    or sensory triggers. Often there is a history of severe
                    childhood abuse, and/or current abuse.
8. Acute/           PNES develop after multiple and/or acute stressors over-      Supportive psychotherapy, lifestyle
  situational       whelm the patient's coping ability. There may not be an       changes, group or family therapy as
  stresses          underlying psychopathology.                                   indicated.
Disease Course and Prognosis
Course is variable for NES
  Depends on underlying etiology
Bowman study in 1999 on PNES
  40% became seizure free
  1/3 seizure reduction
  1/3 chronic, unimproved PNES
Reubar analyzed 942 patients in study
 groups (mean FU of 39 months)
  76% patients were female
  37% were PNES seizure free
  36% were living independently
  30% still on AEDs
Reubar and colleagues own study:
   1-10 years outcome of 164 patients with PNES
   40% had poor outcome (not seizure free/dependent)
   40% intermediate (seizure-free but dependent)
   16% had good outcome (seizure free/living
   11 years after onset and four years after diagnosis
             71% still having PNES
             56% still dependent

Worse than outcome for newly diagnosed epilepsy
Prognostic Factors in PNES
FAVORABLE                                   UNFAVORABLE
--Female                                    --Male
-- Independent lifestyle                    -- Longer duration of PNES
-- Younger age at diagnosis                 -- Longer history of psychiatric disorders
-- Shorter duration of PNES                 -- Unemployment/Disability
-- Higher intelligence & education          --Persistently somatizing patient
-- Less dramatic PNES:                      -- Disbelief of diagnosis
    -- No positive motor features           -- Co-existing epilepsy
    -- No ictal incontinence or biting      -- Ongoing psychosocial stressors
    -- No admissions to ICU                 -- Family structure that supports
    -- No pseudostatus with intubation        dependency and illness
-- Family structure that supports           -- Pending litigation
 autonomy                                   -- Ongoing physical and/or sexual abuse
-- Having friends currently                 -- Reluctant self-disclosure
-- Having good relationships with friends   -- Restricted expression of anger and
 as a child                                   positive feelings
-- Acceptance of nonepileptic nature of
-- Higher ability to express emotions
-- Less tendency to dissociate
-- Less extreme scores on traits defining
 emotional dysregulation
Studying Brain not Mind
PNES treatment recommended on
 logical but unproven theory
     NES are psychogenic in origin,
    will respond to psychiatric
     Psychotherapy is more effective
    than no intervention
Neuropsychiatric treatment model by
 LeFrance and Devinsky:
      1st step proper diagnosis with history
 exam and VEEG
      2nd step Diagnosis should be     presented
 to the patient and family with 4 E’s:
            Explanation
            Exploration
            Exportation
            Exiling
  Continue to follow the patient after referring
 to mental health
 3rd Psychiatric treatment by identifying
predisposing and perpetuating factors

 Finally, addressing pharmacology:
         Tapering of AEDs
         Titration of appropriate
Future Direction
Most appropriate treatment
 is psychiatric evaluation
SCID module for diagnosis and

Double blind controlled study with
 Zoloft for comorbid conditions with
Much more investigation needed
to determine effective treatment

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