Psychogenic nonepileptic seizure

Background
  • Psychogenic nonepileptic seizure (PNES) characterized disturbances of motor, sensory, autonomic, cognitive, and/or emotional functions that can mimic epileptic seizures.
  • In contrast to epileptic seizures, PNES are not associated with abnormally excessive neuronal activity but are instead derived from psychologic causes.
  • The term pseudoseizures and hysterical seizures are historical terms that are now discouraged.
  • Accurate diagnosis is best achieved via a detailed history, physical examination, selected testing, and neurology and/or psychiatry evaluation.
  • Epidemiology
    • Estimated incidence rate ranges from 1.5 to 5 per 100,000 persons per year.
    • Estimate prevalence 2 to 33 per 100,000 persons.
  • Etiology
    • Dissociative disorders and conversion disorders are felt to be the underlying cause to most episodes of PNES.
  • Some patients may have both psychogenic nonepileptic seizures and true epileptiform seizures

Clinical Features
  • Symptoms specific to PNES:
    • Duration > 2 minutes
    • Pelvic thrusting
    • Side to side head rocking
    • Crying/shrieking
    • Voluntary eye movements away from the examiner/forceful closing of the eyes
    • Stuttering/stammering
    • ABSENT postictal confusion
    • ABSENT physical injury
  • Symptoms similar to an epileptic seizure:

Differential Diagnosis
Differential diagnosis of seizures

Seizure

Evaluation
  • May be a clinical diagnosis
  • Consider standard seizure workup
  • If unsure, an urgent neuro consult with EEG can determine the diagnosis

Management
  • Avoid invasive medical procedures
  • Some patients will improve after they are told the diagnosis in a compassionate, non-jugdemental fashion.
  • If new diagnosis or diagnostic uncertainty consider admission for neurology consult and video EEG.
  • Psychiatric intervention is the main treatment modality (e.g. outpatient cognitive behavioral therapy).
    • The purpose of psychiatric consultation is to identify underlying psychiatric conditions that can help direct treatment.

Disposition
  • If symptoms improve consider discharge with close neurology and psychiatry follow-up to rule out epilepsy and identify and treat the underlying psychiatric origin of symptoms.
  • If symptoms cannot be controlled or patient/family are not accepting of diagnosis. Consider admission for observation and further evaluation.

Prognosis
  • 25-38 percent of patients achieve "seizure" freedom
  • Children have a better prognosis than adults, with 70-80% achieving remission

See Also

References
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