User:SkyM99/Psychogenic non-epileptic seizure

Changes are in bold italics. Anything to be removed is marked with a strikethrough. Changes made that have been published are underlined.

Contents

• 1Psychogenic non-epileptic seizures
  • 1.1Signs and symptoms[edit]
  • 1.2Causes[edit]
  • 1.3Risk factors[edit]
  • 1.4Diagnosis[edit]
    • 1.4.1Distinguishing features[edit]
  • 1.5Treatment[edit]
  • 1.6Prognosis[edit]
  • 1.7Epidemiology[edit]
    • 1.7.1Children[edit]
  • 1.8History[edit]
  • 1.9Society and culture[edit]
  • 1.10Terminology[edit]

Psychogenic non-epileptic seizures[edit]

From Wikipedia, the free encyclopedia

"PNES" redirects here. For the Pakistani international school network abbreviated PNES, see Pakistan National English School.

Psychogenic non-epileptic seizures (PNES) are events resembling an epileptic seizure, but without the characteristic electrical discharges associated with epilepsy. PNES fall under the category of disorders known as Functional Neurological Disorders (FND) also known as conversion disorders. These are typically treated by psychologists or psychiatrists.

Incidence [edit][edit]

The number of people with PNES ranges from 2 to 33 per 100,000. PNES are most common in young adults and women. The prevalence for PNES is estimated to make up between 5-20% of outpatient epilepsy clinics, 75-80% of these diagnoses are given to female patients and 83% are to individuals between 15-35 years old.

Children[edit][edit]

PNES are seen in children after the age of 8, and occur equally among boys and girls before puberty. Check source. 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.

Signs and symptoms[edit][edit]

Individuals with PNES present with episodes that resemble epileptic seizures. PNES episodes are nearly indistinguishable from epileptic seizures. The main differences between a PNES episode and an epileptic seizure is the duration of episodes. Epileptic seizures typically last between 30 to 120 seconds depending on the type, while PNES episodes typically last for 2 to 5 minutes.

Causes and Risk Factors[edit][edit]

The cause of PNES has not yet been established. One hypothesis is that they are a learned physical reaction or habit the body develops, similar to a reflex. The individual does not have control of the learned reaction, but this can be retrained to allow the patient to control the physical movements again. The production of seizure-like symptoms is not under voluntary control, meaning that the person is not faking; symptoms which are feigned or faked voluntarily would fall under the categories of factitious disorder or malingering.

The risk factors for FND can include trauma, illness exposure, symptom monitoring, and abnormal beliefs and expectations about illness. Patients with FND have been shown to monitor their symptoms to the point of causing deficits in selective attention. Additionally, patients with FND have been shown to have abnormal beliefs and expectations about illness which often result in the catastrophic misinterpretation of physical symptoms and increased anxiety responses.

Diagnosis[edit][edit]

According to the Diagnostic and Statistical Manual of Mental Disorders (version 5) the criteria for receiving a diagnosis of PNES are:

1. One or more symptoms of altered voluntary motor or sensory function.
2. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions.
3. The symptom or deficit is not better explained by another medical or mental disorder.
4. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

Additionally, the specific symptom type must be reported "with attacks or seizures."

Some individuals with PNES have carried an erroneous diagnosis of epilepsy. On average it takes approximately seven years to receive a proper diagnosis. 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. By recording the event in question on video and EEG simultaneously, a clear diagnosis can usually be obtained.

Laboratory testing can detect rising blood levels of serum prolactin if samples are taken in the right time window after most tonic-clonic or complex partial epileptic seizures. However, due to false positives and variability in results, this test is relied upon less frequently.

Distinguishing features[edit][edit]

Some features are more or less likely to suggest PNES but they are not conclusive and should be considered in 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.

Treatment[edit][edit]

Patient 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. Eight points recommended to explain the diagnosis to the person and their caregivers are:

1. Reasons for concluding they do not have epilepsy
2. What they do have (describe FND)
3. Emphasize they are not suspected of "putting on" the attacks, and the symptoms are not "all in their head."
4. There may be no triggering "stresses"
5. Maintaining factors
6. May improve after correct diagnosis
7. Caution that anticonvulsant drug withdrawal should be done in conjunction with their physician
8. Describe treatment to help regain control of symptoms

Psychotherapy is the most frequently used treatment, which might include cognitive behavioral therapy or therapy to retrain the physical symptoms and allow the individual to regain control of the attacks. 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.

Cognitive Behavioral Therapy (CBT)

CBT treatments for PNES typically target fear avoidance and work to reattribute patients' symptoms to psychosocial issues. For more information see the linked Wikipedia article on CBT.

Retraining and Control Therapy (ReACT)

ReACT, while new and understudied, has shown extremely promising outcomes for reduction of PNES episodes. This therapy focuses on the idea that PNES are caused by a learned physical reaction or habit the body develops, similar to a reflex. ReACT aims to retrain the learned reaction (PNES episodes) by targeting symptom catastrophizing and restoring sense of control over symptoms.

Prognosis[edit][edit]

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.

For individuals who pursue treatment for PNES, CBT has shown varying rates of success but it has been established as one of the most promising treatments to date. ReACT has shown reduction in symptoms by 100% seven days after treatment and 82% of individuals who completed the therapy remained symptom free for 60 days. A follow-up has not been done to see if the therapy retained its reduction of symptoms beyond the 60 days.

History[edit][edit]

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.

The etiology of FND was historically explained in the context of psychoanalytic theory as a physical manifestation of psychological distress and repressed trauma. There is very little supporting evidence for this theory.

The DSM-IV lists conversion disorders instead of the current FND. Additionally, in revision, the DSM-5 was updated to add emphasis to the positive physical signs inconsistent with recognized diseases. The requirement of a history of psychological stressors and that the symptom is not fake was removed as well.

Society and culture[edit][edit]

PNES rates and presenting symptoms are somewhat dependent on the culture and society. In some cultures, they, like epilepsy, are thought of as a curse or a demonic possession. In cultures with a solid establishment of evidence-based medicine, they are considered a subtype of a larger category of psychiatric disease. (What is this?) Pull from DSM-5

Terminology[edit][edit]

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” may cause confusion with epilepsy.

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. Article with list of terms.