Tag: psychogenic nonepileptic seizures

When a seizure is not a seizure…let us talk about Pseudoseizures

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Nitin K Sethi, MD, MBBS, FAAN

sethinitinmd@hotmail.com

Epilepsy is a common neurological condition in which patients suffer recurrent seizures (also referred to as convulsions).

A generalized convulsion is a rather dramatic event. If it occurs while the patient is standing, frequently the patient gets no warning and falls down striking the ground hard. This is the time injuries occur. As the patient is falling down, he/she is amnestic for the entire episode. Family/bystanders notice that initially the patient stiffens (arms and legs are extended, eyes are rolled up into the head, clenching of the teeth occurs which at times leads to the tongue getting bitten, the patient may at times suffer loss of bladder control). This “tonic” phase is followed by the “clonic” phase during which convulsive movements occur. The seizure stops in a minute or two but the patient remains unresponsive and slowly regains consciousness.

If the above convulsion occurs WHILE the patient is undergoing an EEG test (electroencephalogram), the abnormal brain activity is picked up by the test (see example below) and the diagnosis confirmed.

Based on the misfiring recorded on the EEG, the neurologist can then opine what kind of epilepsy the patient has and where (which part) in the brain the seizures are originating from.

EEG showing abnormal brain waves (spike wave discharges) and beginning of a seizure (IMAGE SOURCE: Wikipedia-the image is used for purely educational purpose)

WHEN A SEIZURE IS NOT A SEIZURE–LET US TALK ABOUT PSEUDOSEIZURES

Pseudoseizure is the term used for events that appear to be epileptic seizures but, in fact, are not. So while the patient may have a dramatic event where in he/she shakes, may roll up the eyes, arch his back, moan, make noises and vocalize, THERE IS NO ABNORMAL EXCESSIVE SYNCHRONOUS CORTICAL ACTIVITY (meaning that on the EEG, the brain waves appear normal without any misfiring).

Pseudoseizures are referred to by various names such as psychogenic non-epileptic events (PNES), non epileptic events (NEE), non epileptic seizures, hysterical seizures.

When pseudoseizures are suspected, a neurologist or epileptologist (epilepsy specialist) shall take a detailed history, may order a MRI scan of the brain and then attempt to capture one of these events on VIDEO-EEG MONITOR (Video-EEG is a special kind of EEG in which simultaneous EEG and video recording of the patient is carried out). The goal is to capture one of the patient’s reported events on video-EEG. If no misfiring of the brain is observed during the event, a diagnosis of pseudoseizures is made.

The non-epileptic (“YOU DO NOT HAVE EPILEPSY” OR “THESE ARE NOT SEIZURES”) nature of the events is then explained to the patient and the family and an attempt is made to try to determine the underlying cause (Why is the patient having these events?). There are many causes of pseudoseizures such as mental stress, sexual or physical abuse, personality disorders, dissociative disorders, affective disorders (mood disorder, anxiety, depression), substance abuse disorder, family conflict, conflict or stress at work, problems in marriage among others.

The treatment is usually a combination of psychotherapy and use of medications (selective serotonin reuptake inhibitors). With support and understanding most patients start to improve and the events either stop completely or become less frequent.

When a seizure is not a seizure (pseudoseizures)

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When a seizure is not a seizure (pseudoseizures)

Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

The month of Feb finds me in New Delhi, India. I have been invited to present a talk on psychogenic non-epileptic seizures (PNES). You may now be wondering what does that mean. Well that is what I plan to discuss in this post of mine. Let us look at the term again:

P–stands for psychogenic  meaning the event has a psychological basis to its existence.

NES–stands for non-epileptic seizure meaning the event is not a epileptic seizure.

So let me put it all together in simple language.  Let us assume our character for this short story is Michelle. Now Michelle is a 25-year-old young lady who is married to John. All looks great from outside. Michelle has a good job, a fun life in Manhattan and a good circle of friends. But all is not hunky dory. Michelle and John have been having some problems. John is verbally and lately physically abusive to her. Michelle feels trapped in a loveless marriage but sees no way out.

So one day Michelle and John are at a dinner party.  Seated at their table are few close friends as well as some strangers. As the main course is served, Michelle suddenly leans back, she utters a cry. Then her eyes are noticed to roll up.  John and Michelle’s friends quickly ease her to the ground. She is then noted to have vigorous side to side shaking movements of her head, asynchronous out of phase thrashing movements of her arms and legs. All this time her eyes are open and she is muttering help me, help me.

Michelle is rushed to the hospital where a doctor like me is called to consult on her.  What happened to Michelle?  Seizure or not a seizure, is the question. To help determine the etiology, her doctor orders a video-EEG study.  Michelle is admitted to the hospital and electrodes are pasted on the top of her head to record her brain waves (encephalogram). The encephalogram is time locked to the video camera mounted on the ceiling which records Michelle’s movements. Hence the name VIDEO-EEG.

So imagine Michelle. Sitting in bed, wires attached to her head, surrounded by friends, family and most importantly an extremely concerned John by her bedside. And then it happens again. A dramatic event where she yells a bone chilling cry and then shakes all over.  Now everyone wants to know what is plaguing Michelle.

So what did the video-EEG record?  Was it a seizure or not? Surprisingly when the EEG data is analysed, at the time when Michelle is having her “seizure” the EEG shows no change in the brain waves.  Meaning than Michelle is not having a true seizure, the event is non-epileptic.

Events such as the above are called PNES. They are psychogenic since they have a psychological basis to them. In Michelle’s case they likely reflect her struggles in her marriage and may be a sign for help. Some patients have psychogenic seizures/ pseudoseizures voluntary.  Meaning they might malinger a “seizure” for a secondary gain such as to get social security payments, to escape school and so forth.

PNES  are common and difficult to diagnose and treat.  As you may imagine patients are frequently misdiagnosed. Some are misdiagnosed as true seizures/ epilepsy and started on anti-convulsant drugs which have their own side-effects.  When one drug fails to stop the “seizure”, new drugs are tried.  So frequently these patients are on multiple anti-convulsants and their “seizures” still continue.

PNES do not stop till the underlying psychological issues are tackled. In Michelle’s case simply telling her that she does not have true seizures is not the end of the road. She needs to be referred to a psychiatrist and a therapist. Only then she may be cured.