Background
Psychogenic nonepileptic seizures (PNES), or pseudoseizures are paroxysmal episodes that resemble and are often misdiagnosed as epileptic seizures; however, PNES are psychological (i.e., emotional, stress-related) in origin.
Paroxysmal nonepileptic episodes can be either organic or psychogenic. Syncope, migraine, and transient ischemic attacks (TIAs) are examples of organic nonepileptic paroxysmal symptoms. This article covers only PNES.
The terminology on the topic has been variable and, at times, confusing. Various terms are used, including pseudoseizures, nonepileptic seizures, nonepileptic events, and psychogenic seizures. PNES has been the preferred term in the literature, but in practice, the term "seizures" is confusing to patients and families, so that it is probably best to replace it with more general terms that so not imply epilepsy, such as "attacks" or "events." [1]
PNES are common at epilepsy centers, where they are seen in 20-30% of patients referred for refractory seizures. PNES are probably also common in the general population, with an estimated prevalence of 2-33 cases per 100,000 population, which makes PNES nearly as prevalent as multiple sclerosis or trigeminal neuralgia.
Diagnostic Criteria (DSM-5)
By definition, PNES is a psychiatric disorder; more specifically it is a conversion disorder, which falls under the diagnostic category of somatic symptom disorders in the
Pathophysiology
Unlike epileptic seizures, PNES do not result from an abnormal electrical discharge from the brain; they are a physical manifestation of a psychological disturbance.
Etiology
Familial pattern
Limited data suggest that conversion disorder frequently occurs in relatives of individuals with conversion disorder. Symptoms are often modeled from affected family members. Therefore, a thorough family history of medical conditions is essential. Case series show an increased risk in monozygotic but not dizygotic twins.
Nongenetic familial factors, such as incestuous sexual abuse in childhood, may be associated with an increased risk for conversion disorder. The conversion disorder may be the only mechanism for communication that remains available to the child or adolescent.
Epidemiology
PNES are commonly misdiagnosed as epilepsy. It is by far the most frequent nonepileptic condition seen in epilepsy centers, where they represent 20-30% of referrals. [19] About 50-70% of patients become seizure-free after diagnosis, and about 15% also have epilepsy.
Similar to conversion disorders, PNES typically begin in young adulthood and occur more frequently in women (approximately 70% of cases) than in men. PNES can also occur in the elderly.
One should be particularly cautious in diagnosing PNES (and psychogenic symptoms in general) when the onset is in early childhood or old age. In these age groups, nonepileptic physiologic events may be more common than other conditions. For example, children may have parasomnias (e.g., night terrors), breath-holding spells, and shuddering attacks.
Prognosis
In general, outcomes in adults are tenuous. PNES severely affects the quality of life of affected patients. After having symptoms for ten years, more than half of all patients continue to have seizures and remain dependent on social security benefits.
Outcomes are improved with education, with an onset and diagnosis at a young age, with episodes characterized by nondramatic features, with few additional somatoform complaints, with low dissociation scores, and with low scores on the high-order personality dimensions (i.e., inhibition, emotional dysregulation, compulsivity).
Patients with the limp or catatonic type may have a better prognosis than those with the convulsive or thrashing type.
The duration of illness is probably the most important prognostic factor in PNES; the longer the patient has been treated for epilepsy, the worse the prognosis.
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Obtaining a definite diagnosis of PNES early in the course of disease is critical.
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The average delay in the diagnosis of PNES is long, indicating that the index of suspicion for psychogenic symptoms may not be high enough.
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In addition, an accurate diagnosis of PNES significantly reduces subsequent healthcare costs.
With PNES, outcomes are generally better in children and adolescents than in adults, probably because the duration of illness is shorter and the psychopathology or stressors are different in pediatric patients than in adults.
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A refusal to go to school and family discord may be significant factors.
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Serious mood disorders and ongoing sexual or physical abuse are common in children with PNES and should be investigated in every case.
Patient Education
Thorough patient education is critical and is the first step in treatment. Patients and their families must understand the diagnosis to comply with the recommendations of the psychiatric caregiver.
Written patient information about PNES is scarce but available. For additional information, visit the Comprehensive Epilepsy Program Web site of the University of South Florida.
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Psychogenic nonepileptic attacks. The event is provoked by an induction (or provocative) technique. Note the typical irregular nonclonic nontonic and asynchronous movements (including bicycling) with stop-and-go phenomenon.
Tables
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