Pseudoseizures

Psychogenic seizures/ Non-epileptic events

Nitin K. Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

 Non-epileptic events

Non-epileptic events are paroxysmal episodes that resemble and are often misdiagnosed as epileptic seizures. Non-epileptic events can be further of two kinds

Psychogenic non-epileptic seizures (PNES)

Non epileptic but not psychogenic (“physiologic”) event

Non-epileptic but not psychogenic (physiologic) events: examples include

  • Tremors
  • Myoclonus which is not cortical (segmental/ spinal)
  • Dystonia
  • Dyskinesias
  • Parasomnias: sleep walking, nocturnal panic attacks, nightmares, sleep terrors
  • Syncope
  • Complicated migraine
  • Transient ischemic attacks
  • Cataplexy
  • Startle induced phenomena

 Psychogenic non-epileptic events

Multiple terminology: pseudoseizures, nonepileptic seizures, nonepileptic events, and psychogenic non-epileptic seizures.

 By definition PNES are psychogenic (psychological) in origin.

Can be

  • a form of conversion disorder or more broadly somatoform disorder—these are involuntary 
  • a form of malingering or factitious disorder—these are voluntary

 

Frequency/ sex ratio and age of onset

  • Up to one in five patients with apparently medical intractable epilepsy referred to epilepsy centres.
  • Incidence and prevalence varies in different countries: likely on account of differences in social and cultural norms.
  • More frequent in women as compared to men.
  • Typical age of onset is young adulthood

 

 Making the diagnosis

Misdiagnosis is common!!!

Patients present with history of uncontrolled seizures/ typical events inspite of

multiple inpatient admissions

multiple physicians

multiple anti-epileptic drugs (AEDs)

multiple tests

Making the diagnosis

  • Good history forms the backbone
  • History of typical event
  • From patient
  • From family/ caregiver/bystander

Points to consider:

Does the event occur out of sleep or do the events always occur during daytime when people are around

Specific triggers that are unusual for epilepsy: events are clearly precipitated by emotional stress (“I become angry and then shake”)

Circumstances in which attacks occur: around an audience (family, social events)

Details of the typical event: motor movements characteristics that are inconsistent with epileptic seizures: side-to-side shaking of the head, bilateral asynchronous trashing movements which are out of phase, weeping, verbalization and arching of the back (pelvic thrusting), eyes are closed and cannot be pried open.

History of other coexisting psychogenic conditions: fibromyalgia, chronic fatigue syndrome, IBS.

Good psychosocial history: depression, bipolar disorder, personality disorders (hysterical personality), family dynamics.

History of sexual abuse is specially important.

 Making the diagnosis

 

 VIDEO-EEG study is the gold standard

  • Helps to make an electroclinical correlation: capture a typical event on the video and interpret the electrographic correlate.
  • No change in the background EEG during the clinical event.
  • Clinical event is inconsistent with known seizure semiology: event starts-stops-then starts again, awareness is preserved in spite of bilateral motor convulsive activity.

 If Video-EEG facility is unavailable: routine EEG, ambulatory EEG, extended EEG—with suggestibility—lower yield

Imaging studies may or may not be normal: correlate the MRI/ CT with the history

Blood tests: prolactin (increased for about 30 minutes after a generalized convulsion)—impractical, hence not too useful.

 Treatment

Not easy!!!

patients frequently do not accept their diagnosis (” I am not crazy” ” I shall see another doctor”)

hence the way one delivers/explains the diagnosis to patients and their families is an art: some physicians are blunt, others are more vague or mask their words

Patients may or may not be agreeable to seeing a psychiatrist

  • Assure continuity of care
  • Be supportive
  • Be non confrontational

 

Other issues:

can AEDs be tapered off?

Does the patient have co-existing true seizures?

So your doctor may get other professionals involved: social workers, psychiatrists

Outcomes!!!

 

 

  • Not all patients become “seizure”/spell free—many in fact do not
  • Males become spell free more than females
  • If they have a previous psychiatric diagnosis or some motive like disability/ unresolved marital stress—they shall not become spell free
  • Events may become less dramatic—less hospitalizations or visits to the doctor
  • They may be lost to follow up and find another doctor

Non epileptic seizures or pseudoseizures

Non epileptic seizures or pseudoseizures-what are they and what is to be done about them?

Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY

I thought in this post of mine, I shall discuss pseudoseizures. As the name suggests pseudoseizures means “not true seizures”. We nowdays prefer to refer to them as non-epileptic events (NEE).

So what do we mean when we say someone has pseudoseizures? Let me illustrate with the aid of an example. A patient lets say Ms.XYZ comes to me for initial consultation for her seizure disorder. History is as follows. She has had 2 episodes where-in she was witnessed to have violent jerking movements of her arms and legs. First episode occurred in school after she got into a heated verbal argument with her best friend while the second occurred after a similar confrontation at home with her mother. None of these events were preceded by any aura. As per history she did not bite her tongue or have loss of bladder control though she says she felt tired after the events.

Hmm sounds suspicious for seizures you might rightly say. I tell her I would like to bring her into the hospital to do a video-EEG study to better characterize her seizure type (see my posts on seizure types at http://braindiseases.info). She agrees to the study.

EEG recording is initiated and is read as normal after 24 hours. The next day in the hospital, I tell her and her mother about the results of the normal EEG. A few hours after my discussion with the family, she is noted by the nursing staff to have a violent “seizure”. I review her EEG. On the camera I notice her to suddenly stiffen and then have violent out of phase (uncoordinated) flinging movements of the arms and legs. Her head moves from side to side and I overhear her  yelling “too much, too much, let me go!!! let me go!!!). The event occurs while her mother and her best friend are by her bedside.

I look at the time locked EEG (EEG synchronized with the video in real time). While she is clinically having a “seizure”, her brain waves are normal (the brain is not having a seizure). A correct diagnosis of pseudoseizures (non-epileptic event) is made and she is discharged home with advise to follow up with a psychiatrist.

So what is a pseudoseizure?

1. It is not a true seizure but rather an episode or episodes which clinically look like seizures but are not accompanied by any EEG changes.

2. It usually has a psychological basis. In my experience I commonly see them in people who are passing through tremendous stress be it interpersonal relationships or at the job.

3. A person may have pseudoseizures to achieve a secondary gain (in the case of our patient, attention and love from her mother and best friend).

4. Pseudoseizures are not treated like seizures. These patients do not need anti-seizure medications. They rather at times need a psychiatrist to explore the underlying reasons for the NEE (conflicts in family etc).

5. Some patients who have true seizures (epilepsy) may also have pseudoseizures.