eMedicine Specialties > Neurology > Seizures and Epilepsy

Psychogenic Nonepileptic Seizures: Follow-up

Author: Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Contributor Information and Disclosures

Updated: Nov 24, 2009

Follow-up

Further Inpatient Care

  • After diagnosis of psychogenic nonepileptic seizures (PNES), spend adequate time explaining the diagnosis and its implications to the patient and his or her family.
  • Consultation with a psychiatrist need not occur on an inpatient basis.

Further Outpatient Care

The neurologist should continue to monitor the patient with the psychiatrist or psychologist.

Complications

  • Most patients with PNES take anticonvulsants before a correct diagnosis is made.
  • A small number also received intravenous medication for status epilepticus that may have resulted in intubation and ICU admissions.

Prognosis

  • In general, outcomes in adults are tenuous.
    • After having symptoms for 10 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 (ie, inhibition, emotional dysregulation, compulsivity).
    • Patients with the limp or catatonic type may have a better prognosis than those with the convulsive or thrashing type.
    • PNES severely affects the quality of life of affected patients.
  • 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.
    • Obtaining a definite diagnosis of PNES early in the course of disease is critical.
    • The average delay in the diagnosis of PNES is long, indicating that the index of suspicion for psychogenic symptoms may not be high enough.
    • 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.
    • A refusal to go to school and family discord may be significant factors.
    • Serious mood disorders and ongoing sexual or physical abuse are common in children with PNES and should be investigated in every case.

Patient Education

  • Patient education is critical.
    • Thorough patient education 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.

Miscellaneous

Special Concerns

  • Psychogenic nonepileptic seizures (PNES) in perspective
    • The neurology and epilepsy literature on PNES often implies that PNES is a unique disorder. In reality, PNES is but 1 type of somatoform disorder. How the psychopathology is expressed (PNES, paralysis, diarrhea, or pain) is different only in the diagnostic aspects. Fundamentally, the underlying psychopathology, its prognosis, and its management are no different in PNES than they are in other psychogenic symptoms. Whatever the manifestations, psychogenic symptoms are a challenge in both diagnosis and management.
    • Psychogenic (ie, nonorganic, functional) symptoms are common in medicine. By conservative estimates, at least 10% of all medical services are provided for psychogenic symptoms. These symptoms are also common in neurology, representing approximately 9% of all inpatient neurology admissions and probably an even higher percentage of outpatient visits. Common neurologic symptoms that are found to be psychogenic include paralysis, mutism, visual symptoms, sensory symptoms, movement disorders, gait or balance problems, and pain.
    • For several neurologic symptoms, signs or maneuvers have been described to help differentiate organic from nonorganic symptoms. For example, limb weakness is often evaluated by means of the Hoover test, for which a quantitative version has been proposed. Other examples are looking for give-way weakness and alleged blindness with preserved optokinetic nystagmus. More generally, the neurologic examination is often aimed to elicit symptoms or signs that do not make neuroanatomic sense, eg, facial numbness affecting the angle of the jaw, gait with astasia-abasia or tight-roping.
    • Every medical specialty has its share of symptoms that can be psychogenic. In gastroenterology, these include vomiting, dysphagia, abdominal pain, and diarrhea. In cardiology, chest pain that is noncardiac is traditionally referred to as musculoskeletal chest pain, but it is probably psychogenic. Symptoms that can be psychogenic in other specialties include shortness of breath and cough in pulmonary medicine, psychogenic globus or dysphonia in otolaryngology, excoriations in dermatology, erectile dysfunction in urology, and blindness or convergence spasms in ophthalmology.
    • Pain syndromes for which a psychogenic component is likely include tension headaches, chronic back pain, limb pain, rectal pain, and sexual organ pain. Pain is, by definition, entirely subjective; therefore, to confidently say that pain is psychogenic is essentially impossible, and the term psychogenic is all but discredited in the pain literature. One could even argue that all pains are psychogenic; therefore, psychogenic pain is one of the most uncomfortable diagnoses to make. In addition to isolated symptoms, some consider certain syndromes to be at least partly and possibly entirely psychogenic (ie, without any organic basis). These controversial but fashionable diagnoses include fibromyalgia, fibrositis, myofascial pain, chronic fatigue, irritable bowel syndrome, and multiple chemical sensitivity.
    • For a review of this topic, see the Bibliography.7,8,4
  • Uniqueness of PNES among psychogenic symptoms
    • Among psychogenic symptoms, PNES are unique in 1 principal characteristic. With EEG video monitoring, they can be diagnosed with near certainty. This is in sharp contrast to other psychogenic symptoms, which are almost always a diagnosis of exclusion.
    • This unique feature allows a clarity and confidence of diagnosis that may assist in the critical step of convincing the patient and family of the nonorganic nature of the PNES.
 


More on Psychogenic Nonepileptic Seizures

Overview: Psychogenic Nonepileptic Seizures
Differential Diagnoses & Workup: Psychogenic Nonepileptic Seizures
Treatment & Medication: Psychogenic Nonepileptic Seizures
Follow-up: Psychogenic Nonepileptic Seizures
References
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Further Reading

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Keywords

psychogenic seizures, PNES, non-epileptic seizures, psychogenic seizure, nonepileptic seizures, NES, pseudoseizures, nonepileptic episode, nonepileptic events, psychogenic nonepileptic events

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Contributor Information and Disclosures

Author

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
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: Nothing to disclose.

Medical Editor

Raj D Sheth, MD, Professor of Neurology, 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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Jose E Cavazos, MD, PhD, FAAN, Associate Professor with Tenure, Departments of Neurology, Pharmacology, and Physiology, University of Texas Health Science Center at San Antonio; Co-Director, South Texas Comprehensive Epilepsy Center; Director of the Epilepsy Center, 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, American Neurological Association, and Society for Neuroscience
Disclosure: Nothing to disclose.

CME Editor

Paul E Barkhaus, MD, Professor, Department of Neurology, Medical College of Wisconsin; Director of Neuromuscular Diseases, Milwaukee Veterans Administration 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 & Science University; 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; Talecris Consulting fee Review panel membership; AGA Medical Consulting fee Review panel membership; Boehringer Ingelheim Honoraria Speaking and teaching; Concentric Medical Consulting fee Review panel membership; Abbott Consulting fee Consulting; Sanofi  Consulting

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