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Psychogenic Nonepileptic Seizures

A Common Mimic of Epilepsy

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Updated September 28, 2013

Written or reviewed by a board-certified physician. See About.com's Medical Review Board.

Let me give you a fictional scenario. Tina Gerald is a 35-year-old woman who has had seizures since she was 20 years old. Her first seizures were classic grand-mal seizures, with her entire body shaking rhythmically. She does not remember what happened during those episodes, and she has not had that type of seizure for many years.

Like many people with epilepsy, Tina also has other kinds of seizures. Lately, she has had episodes where she shakes all over. Whereas her grand-mal seizures caused loss of consciousness and were rhythmic and symmetric, these attacks look more like she is flailing all over with no rhythm or pattern. Unlike the first type of seizure, Tina remembers everything that happens around her.

Tina's life has not been easy. She cannot work because of her seizures, and she has a history of being abused by her ex-boyfriend. She has tried 11 different anti-seizure medications and is now taking four of them. Recently she had a violent confrontation with the police; since then, she has complained of difficulty walking, flashes of light, weakness and trembling in her arms.

During the neurologist's exam, she had irregular jerking of her torso but was able to hold a conversation. Despite her jerking movements, she was able to drink coffee without spilling. Her gait appeared very unsteady, though she never actually fell.

Introducing Psychogenic Nonepileptic Seizures

While Tina has a compelling history of epileptic seizures, the timing of her worsening symptoms directly after a traumatic incident with police, combined with her psychiatric history and other signs, suggest she has psychogenic nonepileptic seizures.

Neurologists have debated whether to call these events actual seizures, since some prefer to reserve the term "seizure" for epileptic attacks only, meaning that there is an electrical abnormality in the brain. Others prefer to focus more on the experience itself, using the term "psychogenic non-epileptic seizures" (PNES). Another term, "pseudoseizure," separates the activity from a true seizure, but some experts find that word demeaning to people. Regardless of terminology, PNES or pseudoseizure describes sudden episodes that resemble true epileptic seizures but have a psychological, rather than a physical, cause.

PNES may be thought of as a type of conversion disorder. While the electrical activity in the brain is not the same as an epileptic seizure, the person is not faking his or her symptoms. The seizure feels as real as epileptic one.

Who Gets PNES?

Psychogenic seizures may occur in any age group but most commonly affects young adults. Also, 70 percent of sufferers are women. Coexisting conditions that commonly have some psychological component, such as fibromyalgia, chronic pain and chronic fatigue, increase the probability of PNES. There is frequently a psychiatric history and often a history of abuse or sexual trauma. Tina, for example, has a history of depression, anxiety and abuse. Like other conversion disorders, the neurological complaint (in this case seizure-like activity) comes on after a traumatic event (a fight with police).

How the Diagnosis Is Made

Distinguishing between epilepsy and PNES is a common problem for the neurologist. About 20 to 30 percent of patients referred to epilepsy centers for seizures are diagnosed with PNES. It is one of the most common conditions to be misdiagnosed as epilepsy, contributing to 90 percent of misdiagnoses. Complicating matters, 15 percent of people with psychogenic seizure have epileptic seizures as well. This makes the true cause of particular seizure-like activity harder to sort out.

Several things may clue a physician into a diagnosis of psychogenic rather than epileptic seizure. Resistance to antiepileptic drugs is often the first clue - 80 percent of patients with PNES have been treated with anticonvulsants first, usually without success. On the other hand, about 25 percent of epileptics are also not helped by anticonvulsive medication.

Tina suffered from irregular movements of both sides of her body. Usually when both sides of the body are involved in an epileptic seizure, the person loses consciousness, but this didn't happen to Tina. Furthermore, her shaking improved when she was distracted (which is why she didn't spill her coffee). Unlike patients with epilepsy, those with PNES rarely hurt themselves during their seizures.

PNES matches someone's concept of a seizure more than an actual epileptic seizure. For example, seizures on television often involve a person thrashing around with no particular pattern, but true epileptic seizures are usually rhythmic and repetitive. Weeping or talking during a generalized epileptic seizure is also very uncommon, but more common in PNES.

While there are many other ways to help distinguish between a psychogenic and an epileptic seizure, none of them is completely foolproof. When diagnosing PNES in a person with a convincing history of epilepsy, a doctor must be very careful of other health problems masquerading as PNES. Real seizures that come from the fontal lobe, for example, often remind physicians of PNES.

The best way to tell a psychogenic from an epileptic seizure is to use an electroencephalogram that records the seizure activity. Epileptic seizures cause particular abnormalities on an EEG that are not seen during a psychogenic seizure.

How Are Psychogenic Seizures Treated?

Education is critical, as learning about this conversion disorder often affects how people recover. According to some estimates, almost 50 to 70 percent of people with PNES become free of symptoms after the diagnosis is made. In my experience, this percentage is overly-optimistic, but education still remains an important first step to healing.

Many people initially react to a diagnosis of any conversion disorder with disbelief, denial, anger and even hostility, especially if they already have been diagnosed with a disease like epilepsy. A mental-health professional should be consulted to treat anxiety or depression. Even if the patient is being worked up for other causes of epilepsy, around 50 percent of epileptics suffer from depression and would also benefit from a psychological evaluation.

What Improves the Chances of Recovery?

People who are younger when the diagnosis is made, with few other complaints and milder episodes have a higher chance of improving. The most important factor is the duration of the illness. If someone has spent years being treated for epilepsy, even if they have all the signs of a conversion disorder, that person is less likely to recover.

The reason people with conversion disorder are less likely to improve if they have been treated for epilepsy for a long time probably involves the concept of reinforcement. According to this theory, each pill taken for epilepsy, each doctor who makes an incorrect diagnosis, even friends supporting the person reinforce the unconscious belief that the symptoms are caused by epilepsy. Such a deeply rooted belief is more difficult to get rid of, even with a more truthful and accurate diagnosis.

Like other forms of conversion disorder, PNES is a diagnosis of exclusion. This means that a doctor making this diagnosis should keep an open mind and consider the possibility that something besides a psychiatric complaint is causing the seizure activity, and then make every effort to rule out such possibilities. Similarly, it is important that patients keep an open mind about the possibility that their problem is psychological and get the help they need.

Sources:

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Benbadis SR. How many patients with pseudoseizures receive antiepileptic drugs prior to diagnosis? Eur Neurol 1999;41:114-15.

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I.A. Awad and D.L. Barrow, Editors, Cavernous Malformations, American Association of Neurological Surgeons Publications Committee, (1993). p55-56.

P.W. Kaplan and R.S. Fisher, Editors, Imitators of Epilepsy, 2nd edition. Demos Medical Publishing, 2005. Chapter 20.

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