Psychogenic non-epileptic seizure
|Psychogenic non-epileptic seizures|
|Classification and external resources|
Psychogenic non-epileptic seizures (PNES) are events resembling an epileptic seizure, but without the characteristic electrical discharges associated with epilepsy. They are of psychological origin, and are one type of non-epileptic seizure mimics. PNES are also known less specifically as non-epileptic attack disorder (NEAD) and functional neurological symptom disorder.
Signs and symptoms
People present with episodes that resemble seizures, and most have received a diagnosis of epilepsy and treatment for it. Most commonly the episodes in question are convulsive (whole body shaking) and resemble generalized tonic-clonic (“grand mal”) seizures, but they can be less dramatic and mimic milder types of seizures (partial seizures, absence seizures, myoclonic seizures).
Most people with PNES (75%) are women, with onset in the late teens to early twenties being typical.
A number of studies have also reported a high incidence of abnormal personality traits or personality disorders in people with PNES such as borderline personality. However, again, when an appropriate control group is used, the incidence of such characteristics is not always higher in PNES than in similar illnesses arising due to organic disease (e.g., epilepsy).
Other risk factors for PNES include having a diagnosis of epilepsy, having recently had a head injury or recently undergone neurosurgery.
The cause is by definition psychological, and can be categorized into several different psychiatric diagnoses. In the vast majority of people, the production of seizure-like symptoms is not under voluntary control, (i.e., the person is not faking). There are several diagnoses defined by the unconscious production of physical symptoms, including seizure-like events. A history of abuse or other psychological trauma is often present as a causative factor.
The differential diagnosis of PNES firstly involves ruling out epilepsy as the cause of the seizure episodes, along with other organic causes of non-epileptic seizures, including syncope, migraine, vertigo, anoxia, hypoglycemia, and stroke. However, between 5-20% of people with PNES also have epilepsy. Frontal lobe seizures can be mistaken for PNES, though these tend to have shorter duration, stereotyped patterns of movements and occurrence during sleep. Next, an exclusion of factitious disorder (a subconscious somatic symptom disorder, where seizures are caused by psychological reasons) and malingering (simulating seizures intentionally for conscious personal gain – such as monetary compensation or avoidance of criminal punishment) is conducted. Finally other psychiatric conditions that may superficially resemble seizures are eliminated, including panic disorder, schizophrenia, and depersonalisation disorder.
The most definitive test to distinguish epilepsy from PNES is long term video-EEG monitoring, with the aim of capturing one or two episodes on both video recording and EEG simultaneously (some clinicians may use suggestion to attempt to trigger an episode). Additional clinical criteria are usually considered in addition to video-EEG monitoring when diagnosing PNES.
EEG-video monitoring will usually answer the following questions:
- Is it epilepsy?
- If not, is it psychogenic?
- If not psychogenic, what other seizure mimic is it?
- If epilepsy, what type?
- If focal epilepsy, where is the focus?
By recording the event in question on video and EEG simultaneously, a clear diagnosis can usually be obtained.
Following most tonic-clonic or complex partial epileptic seizures, blood levels of serum prolactin rise, which can be detected by laboratory testing if a sample is taken in the right time window. However, due to false positives and variability in results this test is relied upon less frequently.
Terminology varies somewhat, although PNES has become the most widely accepted term. The use of older terms including pseudoseizures and hysterical seizures are discouraged. In the English language, the word “seizure” usually refers to epileptic events, so some prefer to use more general terms like "events," "attacks," or "episodes," as the term “seizures” often causes confusion with those affected and families.
PNES may also be referred to as "non-epileptic attack disorder" or "functional seizures," though those terms do not clearly indicate a psychological origin and therefore include other (non psychological) causes of epilepsy mimics. Within DSM IV the attacks are classified as a somatoform disorder, whilst in ICD 10 the term dissociative convulsions is used, classified as a conversion disorder. In DSM-5 PNES is also known as functional neurological symptom disorder and is classified as a conversion disorder, which falls under the diagnostic category of somatic symptom disorders.
Some features are more or less likely to suggest PNES but they are not conclusive and should be considered within the broader clinical picture. Features that are common in PNES but rarer in epilepsy include: biting the tip of the tongue, seizures lasting more than 2 minutes (easiest factor to distinguish), seizures having a gradual onset, a fluctuating course of disease severity, the eyes being closed during a seizure, and side to side head movements. Features that are uncommon in PNES include automatisms (automatic complex movements during the seizure), severe tongue biting, biting the inside of the mouth, and incontinence.
If a person with suspected PNES has an episode during a clinical examination, there are a number of signs that can be elicited to help support or refute the diagnosis of PNES. Compared to people with epilepsy, people with PNES will tend to resist having their eyes forced open (if they are closed during the seizure), will stop their hands from hitting their own face if the hand is dropped over the head, and will fixate their eyes in a way suggesting an absence of neurological interference. Mellers et al. warn that such tests are neither conclusive nor impossible for a determined person with factitious disorder to "pass" through faking convincingly.
People with PNES have typically carried a diagnosis of epilepsy for roughly 7 years, so an understanding of the new diagnosis is crucial for their treatment, which requires their active participation. There are a number of recommended steps to explain to people their diagnosis in a sensitive and open manner. A negative diagnosis experience may cause frustration and could cause a person to reject any further attempts at treatment. Ten points recommended to explain the diagnosis to the person and their caregivers are:
- Reasons for concluding they do not have epilepsy
- What they do have (describe dissociation)
- Emphasise they are not suspected of "putting on" the attacks
- They are not 'mad'
- Triggering "stresses" may not be immediately apparent.
- Relevance of aetiological factors in their case
- Maintaining factors
- May improve after correct diagnosis
- Caution that anticonvulsant drug withdrawal should be gradual
- Describe psychological treatment
Psychotherapy is the most frequently used treatment, which might include cognitive behavioral therapy, insight-orientated therapy, and/or group work. There is also some evidence supporting selective serotonin reuptake inhibitor antidepressants. Mental health professionals typically show little interest in this category of psychiatric diseases and people frequently find themselves stuck between psychiatry and neurology with no one to turn to for treatment.
Though there is limited evidence, outcomes appear to be relatively poor with a review of outcome studies finding that two thirds of people with PNES continue to experience episodes and more than half are dependent on social security at three-year followup. This outcome data was obtained in a referral-based academic epilepsy center and loss to follow-up was considerable; the authors point out ways in which this may have biased their outcome data. Outcome was shown to be better in people with higher IQ, social status, greater educational attainments, younger age of onset and diagnosis, attacks with less dramatic features, and fewer additional somatoform complaints.
The incidence and prevalence of PNES in the general population are difficult to determine, but PNES are consistently found in 20-40% of inpatients at epilepsy centers. Like other somatic symptom disorders, PNES are most common in young adults and women.
PNES are seen in children after the age of 8, and occur equally among boys and girls before puberty. Diagnostic and treatment principles are similar to those for adults, except that in children there is a broader differential diagnosis of seizures so that other possible diagnoses specific to children may be considered.
Hystero-epilepsy is a historical term that refers to a condition described by 19th-century French neurologist Jean-Martin Charcot where people with neuroses "acquired" symptoms resembling seizures as a result of being treated on the same ward as people who genuinely had epilepsy.
Society and culture
PNES rates and presenting symptoms are somewhat dependent on the culture and society. In some cultures they, like epilepsy, can be considered a curse or a demonic possession. In western culture, they are a subtype of a larger category of psychiatric disease.
- Devinsky, Orrin; Gazzola, Deana; LaFrance, W. Curt (2011-04-01). "Differentiating between nonepileptic and epileptic seizures". Nature Reviews. Neurology. 7 (4): 210–220. doi:10.1038/nrneurol.2011.24. ISSN 1759-4766. PMID 21386814.
- Joseph H. Ricker; Reilly R. Martinez, eds. (October 2003). Differential Diagnosis in Adult Neuropsychological Assessment. Springer Publishing Company. p. 109. ISBN 0-8261-1665-5.
- Benbadis, Selim R (6 December 2017). "Psychogenic Nonepileptic Seizures: Background, Pathophysiology, Etiology". Medscape. Retrieved 14 April 2018.
- Bajestan, Sepideh N; LaFrance, W. Curt (October 2016). "Clinical Approaches to Psychogenic Nonepileptic Seizures". FOCUS. 14 (4): 422–431. doi:10.1176/appi.focus.20160020.
- Benbadis, SR (February 2005). "The problem of psychogenic symptoms: is the psychiatric community in denial?". Epilepsy & behavior : E&B. 6 (1): 9–14. doi:10.1016/j.yebeh.2004.10.009. PMID 15652726.
- Benbadis, SR (June 2013). "Nonepileptic behavioral disorders: diagnosis and treatment". Continuum (Minneapolis, Minn.). 19 (3 Epilepsy): 715–29. doi:10.1212/01.CON.0000431399.69594.de. PMID 23739106.
- LaFrance, W. Curt; Baker, Gus A.; Duncan, Rod; Goldstein, Laura H.; Reuber, Markus (November 2013). "Minimum requirements for the diagnosis of psychogenic nonepileptic seizures: A staged approach". Epilepsia. 54 (11): 2005–2018. doi:10.1111/epi.12356.
- Mellers, JD (August 2005). "The approach to patients with "non-epileptic seizures"". Postgraduate medical journal. 81 (958): 498–504. doi:10.1136/pgmj.2004.029785. PMC . PMID 16085740.
- Galimberti, Carlo Andrea; Ratti, Maria Teresa; Murelli, Rosanna; Marchioni, Enrico; Manni, Raffaele; Tartara, Amelia (1 March 2003). "Patients with psychogenic nonepileptic seizures, alone or epilepsy-associated, share a psychological profile distinct from that of epilepsy patients". Journal of Neurology. 250 (3): 338–346. doi:10.1007/s00415-003-1009-0.
- Salmon, Peter; Al-Marzooqi, Suad M.; Baker, Gus; Reilly, James (July 2003). "Childhood Family Dysfunction and Associated Abuse in Patients With Nonepileptic Seizures". Psychosomatic Medicine. 65 (4): 695–700. doi:10.1097/01.PSY.0000075976.20244.D8.
- Brown, Richard J.; Bouska, Julia F.; Frow, Anna; Kirkby, Antonia; Baker, Gus A.; Kemp, Steven; Burness, Christine; Reuber, Markus (October 2013). "Emotional dysregulation, alexithymia, and attachment in psychogenic nonepileptic seizures". Epilepsy & Behavior. 29 (1): 178–183. doi:10.1016/j.yebeh.2013.07.019.
- Dimaro, Lian V.; Dawson, David L.; Roberts, Nicole A.; Brown, Ian; Moghaddam, Nima G.; Reuber, Markus (April 2014). "Anxiety and avoidance in psychogenic nonepileptic seizures: The role of implicit and explicit anxiety". Epilepsy & Behavior. 33: 77–86. doi:10.1016/j.yebeh.2014.02.016.
- Strutt, Adriana M.; Hill, Stacy W.; Scott, Bonnie M.; Uber-Zak, Lori; Fogel, Travis G. (October 2011). "Motivation, psychopathology, locus of control, and quality of life in women with epileptic and nonepileptic seizures". Epilepsy & Behavior. 22 (2): 279–284. doi:10.1016/j.yebeh.2011.06.020.
- Thompson, Alexander W.; Hantke, Nathan; Phatak, Vaishali; Chaytor, Naomi (January 2010). "The Personality Assessment Inventory as a tool for diagnosing psychogenic nonepileptic seizures". Epilepsia. 51 (1): 161–164. doi:10.1111/j.1528-1167.2009.02151.x. PMC . PMID 19490032.
- Wilshire, C. E.; Ward, T. (29 September 2016). "Psychogenic Explanations of Physical Illness: Time to Examine the Evidence". Perspectives on Psychological Science. 11 (5): 606–631. doi:10.1177/1745691616645540.
- Brown, RJ; Reuber, M (April 2016). "Psychological and psychiatric aspects of psychogenic non-epileptic seizures (PNES): A systematic review". Clinical psychology review. 45: 157–82. doi:10.1016/j.cpr.2016.01.003. PMID 27084446.
- Bass, C; Halligan, P (2016). "Factitious disorders and malingering in relation to functional neurologic disorders". Handbook of clinical neurology. 139: 509–520. doi:10.1016/B978-0-12-801772-2.00042-4. PMID 27719868.
- Martin R, Burneo JG, Prasad A, Powell T, Faught E, Knowlton R, Mendez M, Kuzniecky R (2003). "Frequency of epilepsy in patients with psychogenic seizures monitored by video-EEG". Neurology. 61 (12): 1791–2. doi:10.1212/01.wnl.0000098890.13946.f5. PMID 14694050.
- Asano, E; Pawlak, C; Shah, A; Shah, J; Luat, AF; Ahn-Ewing, J; Chugani, HT (2005). "The diagnostic value of initial video-EEG monitoring in children--review of 1000 cases". Epilepsy Res. 66: 129–35. PMID 16157474.
- Bowman, E. S.; Coons, P. M. (2000). "The differential diagnosis of epilepsy, pseudoseizures, dissociative identity disorder, and dissociative disorder not otherwise specified". Bulletin of the Menninger Clinic. 64 (2): 164–180. PMID 10842446.
- Benbadis, Selim R. "EEG Video Monitoring". Medscape. Retrieved 1 April 2018.
- Benbadis SR; LaFrance Jr WC (2010). "Chapter 4. Clinical Features and the Role of Video-EEG Monitoring". In Schachter, SC; LaFrance Jr, WC. Gates and Rowan's Nonepileptic Seizures (3rd ed.). Cambridge; New York: Cambridge University Press. pp. 38–50.
- Diagnosis and management of dissociative seizures, John DC Mellers, The National Society for Epilepsy, September 2005.
- Benbadis, SR (6 July 2010). "Psychogenic nonepileptic "seizures" or "attacks"? It's not just semantics: attacks". Neurology. 75 (1): 84–6. doi:10.1212/WNL.0b013e3181e6216f. PMID 20603487.
- LaFrance WC, Jr (6 July 2010). "Psychogenic nonepileptic "seizures" or "attacks"? It's not just semantics: seizures". Neurology. 75 (1): 87–8. doi:10.1212/WNL.0b013e3181e62181. PMC . PMID 20603488.
- Reuber, Markus; Elger, Christian E. (June 2003). "Psychogenic nonepileptic seizures: review and update". Epilepsy & Behavior. 4 (3): 205–216. doi:10.1016/S1525-5050(03)00104-5.
- LaFrance WC, Jr; Reuber, M; Goldstein, LH (March 2013). "Management of psychogenic nonepileptic seizures". Epilepsia. 54 Suppl 1: 53–67. doi:10.1111/epi.12106. PMID 23458467.
- Benbadis, Selim R (February 2013). "Mental health organizations and the ostrich policy". Neuropsychiatry. 3 (1): 5–7. doi:10.2217/NPY.12.74.
- Reuber M, Elger CE (2003). "Psychogenic nonepileptic seizures: review and update". Epilepsy & Behavior. 4 (3): 205–216. doi:10.1016/S1525-5050(03)00104-5. PMID 12791321.
- McDade (1992). "Non-epileptic seizures: management and predictive factors of outcome". Seizure. 1: 7–10. doi:10.1016/1059-1311(92)90047-5. PMID 1344323.
- Kanner (1999). "Psychiatric and neurologic predictors of psychogenic pseudoseizure outcome". Neurology. 53: 933–938. doi:10.1212/wnl.53.5.933. PMID 10496249.
- Reuber, Markus (March 2003). "Outcome in psychogenic nonepileptic seizures: 1 to 10-year follow-up in 164 patients". Annals of Neurology. 53 (3): 305–311. doi:10.1002/ana.3000. PMID 12601698.
- Asadi-Pooya, Ali A.; Sperling, Michael R. (May 2015). "Epidemiology of psychogenic nonepileptic seizures". Epilepsy & Behavior. 46: 60–65. doi:10.1016/j.yebeh.2015.03.015.
- Benbadis, Selim R. (August 2007). "DIFFERENTIAL DIAGNOSIS OF EPILEPSY". CONTINUUM: Lifelong Learning in Neurology. 13: 48–70. doi:10.1212/01.CON.0000284534.43272.1c.
- Gamgee, A (Oct 12, 1878). "An Account of a Demonstration on the Phenomena of Hystero-Epilepsy Given by Professor Charcot: And on the Modification which they Undergo under the Influence of Magnets and Solenoids". British Medical Journal. 2 (928): 545–8. doi:10.1136/bmj.2.928.545. PMC . PMID 20748992.
- Asadi-Pooya, AA; Valente, K; Alessi, R; Tinker, J (October 2017). "Semiology of psychogenic nonepileptic seizures: An international cross-cultural study". Epilepsy & behavior : E&B. 75: 210–212. doi:10.1016/j.yebeh.2017.08.016. PMID 28865883.
- Epilepsy Foundation article about non-epileptic seizures
- Epilepsy.com article about non-epileptic seizures
- National Society for Epilepsy (UK) article on Non-epileptic attack disorder – a technical article aimed at health professionals