Pseudoseizures


Article Author:
J. Stephen Huff


Article Editor:
Najib Murr


Editors In Chief:
Mohamed Hegazy
Arayamparambil Anilkumar
Najib Murr


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
2/28/2019 10:08:59 PM

Introduction

Pseudoseizure is an older term for events that appear to be epileptic seizures but in fact do not represent the manifestation of excessive synchronous cortical activity which defines epileptic seizures. They are not a variation of epilepsy but are of psychiatric origin. Terms used in the past included hysterical seizures, pseudoseizures, psychogenic seizures, and others. Perhaps the most standard current terminology is psychogenic nonepileptic spells (PNES) or psychogenic nonepileptic episodes (PNEE). These terms reinforce the idea that the events are not seizures of any type, and PNES is used as a synonym for pseudoseizures.[1][2]

Distinguishing PNES from epileptic seizures may be difficult at the bedside even to experienced observers. In theory, almost any recurrent behavior may represent epileptic seizures. The evolution of epilepsy monitoring units or the ability to utilize simultaneous video and EEG recordings may be a key to diagnosis.[3][4] 

Treatment of PNES may be difficult, but it is clear that anti-epileptic drugs (AEDs) are of no benefit. In addition to unnecessary costs and the potential side effects of AEDs for these patients, in some cases, life-threatening side effects such as respiratory depression may occur.

Etiology

Conversion disorder is thought to be the most common psychiatric mechanism, and the individuals with PNES are thought not to be consciously unaware of their behaviors. Risk factors include a history of physical or sexual abuse and female gender. A disproportionate number of patients with PNES have training in health care careers. Malingering or factitious disorder is thought to be less common as a cause of PNES but might be suspected when there is clear, immediate secondary gain resulting from alterations in behavior. 

Epidemiology

The incidence is unknown. However, of patients admitted to epilepsy monitoring units for unusual or intractable seizures, estimates are that 20% to 40% of admitted patients with extended monitoring have PNES rather than epileptic seizures.

Pathophysiology

Depression, posttraumatic stress disorder, and personality disorders all are common in patients with PNES. History of sexual or physical abuse is a risk factor for the development of events. The majority of patients are adult women. How these risk factors summate to produce spells is unclear, but a conversion disorder may evolve. A conversion disorder by definition implies that the patient is not aware and is not consciously feigning the events. Again, conversion disorder or similar mechanisms are thought to be involved in most patients with PNES. On occasion conscious feigning, or malingering, may be present. There is little literature on this, but anecdotally this seems to occur with law enforcement or judicial events.

History and Physical

Psychogenic nonepileptic seizures may be difficult to distinguish from epileptic seizures. Observation of waxing and waning consciousness, out of phase shaking movements, pelvic thrusting, side to side head shaking, and eye closure during the event are suggestive of PNES. However, at times brief episodes of sudden unresponsiveness may represent the PNES event. Sometimes, friends or family may volunteer a history of non-epileptic seizures or spells, but this frequently is lacking, and the patient has been labeled as having a seizure disorder and administered antiepileptic drugs. 

Even in a busy emergency department, there is always a brief moment of observation before starting treatment. Therapy should not be blindly protocol driven without some inspection and examination. Most patients with convulsive seizures will have open eyes. Closed eyes, especially tightly closed eyes with increased resistance to eye-opening, during an event, is inconsistent with epileptic seizures. Wild thrashing, side-to-side head movements, and yelling verbal phrases likewise are not consistent with epileptic seizures. Four extremity motor movements with seizures would represent diffuse cortical involvement with an epileptic seizure, and the patient should not be able to communicate during such a convulsion. 

A brief loud noise or similar startle stimulus may be used to help determine treatment, since a patient with a generalized epileptic convulsion should not startle or respond to a stimulus during an event.

Evaluation

Again, observation may be key, and clinicians should avoid any rush to unhelpful interventions or treatments.

Correct diagnosis is necessary for successful treatment. Frequently, patients with psychogenic nonepileptic spells have been misdiagnosed as having epilepsy and have been prescribed multiple medications. Consultation with neurology may be helpful. Admission to a monitoring unit may be in order if the diagnosis is uncertain. Approximately 20% to 40% of patients referred to epilepsy monitoring units for difficult-to-control seizures are ultimately found to have PNES. Long-term video EEG monitoring is the most important diagnostic test.[5]

Treatment / Management

In challenging cases, admission to an epilepsy monitoring unit or similar facility with combined video-EEG monitoring may be needed to secure the diagnosis. The best psychiatric treatment is not known but may consist of a combination of medical treatment, when depression, anxiety, or other conditions exist, and cognitive behavioral therapy. An honest and clear discussion of the patient's diagnosis is of utmost importance. In cases of conversion disorder, it is important to acknowledge that the spells are real and cause distress to the patient, family, and friends. It should be articulated that the episodes are not seizures. A respectful approach and the reassurance that supportive therapy will most likely decrease or even eliminate the frequency of spells should be outlined. If the diagnosis of PNES is secure, anti-epileptic drugs should be withdrawn.[6][7] 

Serum prolactin levels have long been noted to increase shortly after a generalized epileptic seizure but not after PNES. This peaks quickly. Though discussed extensively in the literature, this test seems to be of limited pragmatic use. A lactic acidosis commonly follows a generalized convulsion but might also follow prolonged PNES with large muscle group movements.

Pearls and Other Issues

Though the pattern of a generalized convulsive seizure typically is one of abrupt onset, brief tonic posturing followed by synchronized clonic extremity movements, alteration of consciousness, and a post-ictal confusion phase, exceptions do occur, particularly in patients with partial onset seizures starting in frontal or temporal areas. At times there are unusual motor patterns with partial onset seizures or persistent confusional states with minor motor automatisms. If permissible by hospital policies, capturing events with video or smartphones may be useful for later analysis. Sometimes family members will bring in recordings of patient incidents.

Enhancing Healthcare Team Outcomes

Though sometimes used to "wake up" a patient thought to be having feigned unresponsiveness or non-epileptic spells, noxious stimuli such as ammonia capsules are to be avoided. Communciation between health care professionals of observations is essential. 


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Pseudoseizures - Questions

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Which is the most definitive method to differentiate psychogenic nonepileptic seizures from epileptic seizures?



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Which of the following is correct about pseudoseizures (psychogenic nonepileptic spells)?



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Which of the following management method is indicated for pseudoseizures?



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A patient developed generalized tonic-clonic seizures after a brain trauma from a motor vehicle accident at age 16. The patient's seizures have been well controlled with valproic acid for four years. Her seizures have dramatically changed in frequency, though her drug level remains therapeutic. She recently experienced a divorce and has other life stressors. In order to find out if these changes are due to her seizure disorder or a new onset of nonepileptic seizures, which test may be helpful?



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A 17-year-old male is admitted with suspected convulsive status epilepticus despite a therapeutic level of phenytoin. 24-hour video EEG shows multiple episodes of generalized shaking movements. The EEG shows movement artifact but no epileptiform discharges and no post-event EEG abnormalities. Select appropriate management.



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What is the preferred terminology of events that appear to be seizures but are determined not to be seizures?



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Pseudoseizures - References

References

Medical management of epileptic seizures: challenges and solutions., Sarma AK,Khandker N,Kurczewski L,Brophy GM,, Neuropsychiatric disease and treatment, 2016     [PubMed]
Communicating the diagnosis of psychogenic nonepileptic seizures: The patient perspective., Arain A,Tammaa M,Chaudhary F,Gill S,Yousuf S,Bangalore-Vittal N,Singh P,Jabeen S,Ali S,Song Y,Azar NJ,, Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia, 2016 Feb 6     [PubMed]
Psychogenic non-epileptic seizures--definition, etiology, treatment and prognostic issues: a critical review., Bodde NM,Brooks JL,Baker GA,Boon PA,Hendriksen JG,Mulder OG,Aldenkamp AP,, Seizure, 2009 Oct     [PubMed]
What's in a name? 'Psychogenic' non-epileptic events in children and adolescents., Reilly C,McWilliams A,Heyman I,, Developmental medicine and child neurology, 2015 Jan     [PubMed]
Recognition of psychogenic non-epileptic seizures: a curable neurophobia?, O'Sullivan SS,Redwood RI,Hunt D,McMahon EM,O'Sullivan S,, Journal of neurology, neurosurgery, and psychiatry, 2013 Feb     [PubMed]
Diagnosis and Treatment of Nonepileptic Seizures., Chen DK,LaFrance WC Jr,, Continuum (Minneapolis, Minn.), 2016 Feb     [PubMed]
Multicenter pilot treatment trial for psychogenic nonepileptic seizures: a randomized clinical trial., LaFrance WC Jr,Baird GL,Barry JJ,Blum AS,Frank Webb A,Keitner GI,Machan JT,Miller I,Szaflarski JP,, JAMA psychiatry, 2014 Sep     [PubMed]

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