Psychogenic Nonepileptic Seizures Clinical Presentation

  • Author: Selim R Benbadis, MD; Chief Editor: Helmi L Lutsep, MD   more...
 
Updated: Oct 6, 2011
 

History

Misdiagnosis of epilepsy is common. Misdiagnosis occurs in approximately 25% of patients with a previous diagnosis of epilepsy that does not respond to drugs. Most cases of misdiagnosed epilepsy are eventually shown to be psychogenic nonepileptic seizures (PNES) or, more rarely, syncope. Other paroxysmal conditions are occasionally misdiagnosed as epilepsy, but PNES is by far the most commonly misdiagnosed condition, accounting for >90% of misdiagnoses at epilepsy centers. EEGs misinterpreted as providing evidence for epilepsy often contribute to this misdiagnosis.[1, 2, 3]

Reversing a misdiagnosis of epilepsy can be difficult, as it is with other chronic conditions. Unfortunately, after the diagnosis of seizures is made, it is easily perpetuated without being questioned, which explains the usual diagnostic delay and cost associated with PNES. Despite the ability to diagnose PNES with near certainty by using EEG-video monitoring, the time to diagnosis is long, about 7-10 years. This delay indicates that neurologists may have an insufficiently high enough index of suspicion for PNES.

  • The patient's history may suggest the diagnosis. Several clues are useful in clinical practice and should raise the suspicion that seizures may be psychogenic rather than epileptic.
    • Resistance to antiepileptic drugs (AEDs) is usually the first clue and the reason for referral to the epilepsy center, though intractable epilepsy is a common cause of resistance to AEDs.
    • Approximately 80% of patients with PNES have been treated with AEDs before the correct diagnosis is made. A psychogenic etiology should be considered when AEDs have no effect on the patient's condition.
    • The presence of specific triggers that are unusual for epilepsy may suggest PNES, and these triggers should be specifically sought during history taking. For example, emotional triggers such as stress or becoming upset are common in PNES. Other triggers that suggest PNES include pain, certain movements, sounds, and seeing of lights, especially if they are reported to consistently trigger an apparent seizure.
    • The circumstances in which attacks occur can be helpful. Like other psychogenic symptoms, those of PNES usually occur in the presence of an audience, and an occurrence in the physician's office or waiting room is highly suggestive of PNES. Similarly, PNES usually do not occur during sleep, though they may seem to and though they may be reported as such.
    • Details of the episodes often include characteristics that are inconsistent with epileptic seizures. In particular, some characteristics of the motor (ie, convulsive) phenomena are associated with PNES (see EEG video monitoring in Other Tests). Common and helpful symptoms include side-to-side shaking of the head, bilateral asynchronous movements (eg, bicycling), weeping, stuttering, and arching of the back. (See video below.) In a study of 120 seizures (36 PNES and 84 epileptic seizures) from 35 patients, only a few signs were reliable in predicting the diagnosis. PNES were predicted by preserved awareness, eye flutter, and episodes affected by bystanders (intensified or alleviated). Epileptic seizures were predicted by abrupt onset, eye-opening/widening, and postictal confusion/sleep. In addition, as compared with signs viewed on video recording, eyewitness reports of these signs were not reliable.[4]
      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.
    • The patient's medical history can be useful. Coexisting, poorly defined, and probably psychogenic conditions, such as fibromyalgia, chronic pain, and chronic fatigue, are associated with psychogenic symptoms.[5] Similarly, a florid review of systems suggests somatization.
    • A psychosocial history with evidence of maladaptive behaviors or associated psychiatric diagnoses should raise the suspicion of PNES. Pay particular attention during mental status evaluation, especially to the patient's general demeanor, the appropriateness of this or her level of concern, overdramatization, and hysterical features.
  • Certain symptoms suggest epileptic seizures. These include significant injury. In particular, tongue biting and an ictal cry[6] are highly specific to generalized tonic-clonic seizures and are helpful signs when present.
  • Antecedent sexual trauma or abuse is thought to be important in the psychopathology of psychogenic seizures and psychogenic symptoms in general. A history of abuse may be more frequent in convulsive rather than limp type of PNES.
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Physical

  • Physical and neurologic findings are usually normal.
  • Psychological features suggestive of psychogenic episodes include anxiety, depression, inappropriate affect or lack of concern (la belle indifference), multiple and vague somatic complaints suggestive of somatization disorder, and abnormal interaction with family members.
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Causes

By definition, PNES is a psychiatric disorder. According to the Diagnostic and Statistical Manual for Mental Disorders (DSM) classification, physical symptoms caused by psychological causes can fall under 3 categories: somatoform disorder, factitious disorder, and malingering.

  • A somatoform disorder is the unconscious production of physical symptoms due to psychological factors.
    • The symptoms are not under voluntary control, ie, the patient is not faking and not intentionally trying to deceive.
    • Somatoform disorders are subdivided into several disorders depending on the characteristics of the physical symptoms and their time course.
    • The 2 somatoform disorders relevant to PNES are conversion disorder and somatization disorder.
    • The vast majority of patients with PNES have conversion disorder.
    • The Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) added a new subcategory of conversion disorder (from the Diagnostic and Statistical Manual for Mental Disorders, Revised Third Edition [DSM-III-R]) specifically termed conversion disorder with seizures.
  • Factitious disorder and malingering imply that the patient is purposely deceiving the physician, ie, faking the symptoms.
    • The difference between factitious disorder and malingering is that, in malingering, the reason for the deception is tangible and rationally understandable (albeit possibly reprehensible). In factitious disorder, the motivation is a pathologic need for the sick role.
    • An important corollary is that malingering is not considered a mental illness, whereas factitious disorder is.
  • A generally accepted view is that most patients with PNES have somatoform disorder rather than malingering or factitious disorder.
    • Although the DSM classification is simple in theory, knowing whether a given patient is faking it is nearly impossible. In some circumstances, intentional faking can be diagnosed only by catching a person in the act of faking (eg, self-inflicting injuries, ingesting medications or eye drops to cause signs, putting blood in the urine to simulate hematuria).
    • Malingering may be underdiagnosed, partly because the diagnosis of is essentially an accusation.
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Contributor Information and Disclosures
Author

Selim R Benbadis, MD  Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, Tampa General Hospital, University of South Florida College of Medicine

Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association

Disclosure: UCB Pharma Honoraria Speaking, consulting; Lundbeck Honoraria Speaking, consulting; Cyberonics Honoraria Speaking, consulting; Glaxo Smith Kline Honoraria Speaking, consulting; Pfizer Honoraria Speaking, consulting; Sleepmed/DigiTrace Honoraria Speaking, consulting

Specialty Editor Board

Raj D Sheth, MD  Professor, Mayo College of Medicine; Chief, Division of Pediatric Neurology, Nemours Children's Clinic

Raj D Sheth, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Pediatrics, American Epilepsy Society, American Neurological Association, and Child Neurology Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Jose E Cavazos, MD, PhD, FAAN  Associate Professor with Tenure, Departments of Neurology, Pharmacology, and Physiology, Program Director of the Clinical Neurophysiology Fellowship, University of Texas School of Medicine at San Antonio; Co-Director, South Texas Comprehensive Epilepsy Center, University Hospital System; Director of the San Antonio Veterans Affairs Epilepsy Center of Excellence and Neurodiagnostic Centers, Audie L Murphy Veterans Affairs Medical Center

Jose E Cavazos, MD, PhD, FAAN is a member of the following medical societies: American Academy of Neurology, American Clinical Neurophysiology Society, American Epilepsy Society, and American Neurological Association

Disclosure: GXC Global, Inc. Intellectual property rights Medical Director - company is to develop a seizure detecting device. No conflict with any of the eMedicine articles that I wrote or edited.

Paul E Barkhaus, MD  Professor, Department of Neurology, Medical College of Wisconsin; Director of Neuromuscular Diseases, Milwaukee Veterans Affairs Medical Center

Paul E Barkhaus, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and American Neurological Association

Disclosure: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD  Professor, Department of Neurology, Oregon Health and Science University School of Medicine; Associate Director, Oregon Stroke Center

Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology and American Stroke Association

Disclosure: Co-Axia Consulting fee Review panel membership; AGA Medical Consulting fee Review panel membership; Concentric Medical Consulting fee Review panel membership

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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.
 
 
 
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