Psychogenic Nonepileptic Seizures 

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

Background

Psychogenic nonepileptic seizures (PNES), or pseudoseizures are paroxysmal episodes that resemble and often misdiagnosed as epileptic seizures; however, PNES are psychological (ie, 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 is the preferred term and the one used throughout this article.

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.

Next

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. They are a type of conversion disorder or, more broadly, a type of somatoform disorder, and they are usually involuntary. PNES can also result from voluntary faking (feigning), as in malingering and factitious disorder. This cause is thought to be rare, but it is difficult to prove.

Previous
Next

Epidemiology

Frequency

United States

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. About 50-70% of patients become seizure-free after diagnosis, and about 15% also have epilepsy. Like most manifestations of conversion and other somatoform disorders, PNES occur more frequently in women (approximately 70% of cases) than in men.

International

The international prevalence is similar to that in the United States.

Sex

Like most manifestations of conversion and other somatoform disorders, PNES occur more frequently in women (who account for approximately 70% of all cases) than in men.

Age

PNES, similar to conversion disorders, typically begin in young adulthood.

PNES occur in children and adolescents and also in elderly people.

  • 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 (eg, night terrors), breath-holding spells, and shuddering attacks.
Previous
Proceed to Clinical Presentation
 
 
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

References

  1. Benbadis SR, Tatum WO. Overintepretation of EEGs and misdiagnosis of epilepsy. J Clin Neurophysiol. Feb 2003;20(1):42-4. [Medline].

  2. Benbadis SR, Lin K. Errors in EEG interpretation and misdiagnosis of epilepsy. Which EEG patterns are overread?. Eur Neurol. 2008;59(5):267-71. [Medline].

  3. Benbadis SR. Errors in EEGs and the misdiagnosis of epilepsy: importance, causes, consequences, and proposed remedies. Epilepsy Behav. Nov 2007;11(3):257-62. [Medline].

  4. Syed TU, Lafrance WC Jr, Kahriman ES, et al. Can semiology predict psychogenic nonepileptic seizures? a prospective study. Ann Neurol. Jun 2011;69(6):997-1004. [Medline].

  5. Benbadis SR. A spell in the epilepsy clinic and a history of "chronic pain" or "fibromyalgia" independently predict a diagnosis of psychogenic seizures. Epilepsy Behav. Mar 2005;6(2):264-5. [Medline].

  6. Elzawahry H, Do CS, Lin K, Benbadis SR. The diagnostic utility of the ictal cry. Epilepsy Behav. Jun 1 2010;[Medline].

  7. Benbadis SR, LaFrance WC Jr, Papandonatos GD, Korabathina K, Lin K, Kraemer HC. Interrater reliability of EEG-video monitoring. Neurology. Sep 15 2009;73(11):843-6. [Medline].

  8. Hubsch C, Baumann C, Hingray C, Gospodaru N, Vignal JP, Vespignani H, et al. Clinical classification of psychogenic non-epileptic seizures based on video-EEG analysis and automatic clustering. J Neurol Neurosurg Psychiatry. Sep 2011;82(9):955-60. [Medline].

  9. Benbadis SR, O'Neill E, Tatum WO, Heriaud L. Outcome of prolonged video-EEG monitoring at a typical referral epilepsy center. Epilepsia. Sep 2004;45(9):1150-3. [Medline].

  10. Goldstein LH, Chalder T, Chigwedere C, Khondoker MR, Moriarty J, Toone BK, et al. Cognitive-behavioral therapy for psychogenic nonepileptic seizures: a pilot RCT. Neurology. Jun 15 2010;74(24):1986-94. [Medline]. [Full Text].

  11. Benbadis SR. Psychogenic non-epileptic seizures. In: Wyllie E, Gupta A, Lachhwani DK, eds. The Treatment of Epilepsy: Principles and Practice. 4th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2005:623-30.

  12. Benbadis SR. The problem of psychogenic symptoms: is the psychiatric community in denial?. Epilepsy Behav. Feb 2005;6(1):9-14. [Medline].

  13. Abubakr A, Kablinger A, Caldito G. Psychogenic seizures: clinical features and psychological analysis. Epilepsy Behav. Jun 2003;4(3):241-5. [Medline].

  14. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.

  15. American Psychiatric Association. Web site of the American Psychiatric Association. Available at http://psych.org/public_info/index.cfm. Accessed February 13, 2004.

  16. Bazil CW, Kothari M, Luciano D, et al. Provocation of nonepileptic seizures by suggestion in a general seizure population. Epilepsia. Jul-Aug 1994;35(4):768-70. [Medline].

  17. Behrouz R, Heriaud L, Benbadis SR. Late-onset psychogenic nonepileptic seizures. Epilepsy Behav. May 2006;8(3):649-50. [Medline].

  18. Benbadis SR. How many patients with pseudoseizures receive antiepileptic drugs prior to diagnosis?. Eur Neurol. 1999;41(2):114-5. [Medline].

  19. Benbadis SR. Hypergraphia and the diagnosis of psychogenic attacks. Neurology. Sep 12 2006;67(5):904. [Medline].

  20. Benbadis SR. Provocative techniques should be used for the diagnosis of psychogenic nonepileptic seizures. Arch Neurol. Dec 2001;58(12):2063-5. [Medline].

  21. Benbadis SR. The EEG in nonepileptic seizures. J Clin Neurophysiol. Aug 2006;23(4):340-52. [Medline].

  22. Benbadis SR. What can EEG-video monitoring do for you and your patients?. J Fla Med Assoc. Jun-Jul 1997;84(5):320-2. [Medline].

  23. Benbadis SR, Agrawal V, Tatum WO 4th. How many patients with psychogenic nonepileptic seizures also have epilepsy?. Neurology. Sep 11 2001;57(5):915-7. [Medline].

  24. Benbadis SR, Chichkova R. Psychogenic pseudosyncope: an underestimated and provable diagnosis. Epilepsy Behav. Aug 2006;9(1):106-10. [Medline].

  25. Benbadis SR, Hauser WA. An estimate of the prevalence of psychogenic non-epileptic seizures. Seizure. Jun 2000;9(4):280-1. [Medline].

  26. Benbadis SR, Heriaud L. Psychogenic nonepileptic seizures: a guide for patients and families. Available at http://hsc.usf.edu/COM/epilepsy/PNESbrochure.pdf.

  27. Benbadis SR, Johnson K, Anthony K, et al. Induction of psychogenic nonepileptic seizures without placebo. Neurology. Dec 26 2000;55(12):1904-5. [Medline].

  28. Benbadis SR, Lancman ME, King LM, Swanson SJ. Preictal pseudosleep: a new finding in psychogenic seizures. Neurology. Jul 1996;47(1):63-7. [Medline].

  29. Benbadis SR, Stagno SJ. The Cleveland Clinic Educational Foundation. Psychogenic seizures: a guide for patients and families. Cleveland, Ohio: Department of Scientific Publications; 1993.

  30. Benbadis SR, Tatum WO, Vale FL. When drugs don't work: an algorithmic approach to medically intractable epilepsy. Neurology. Dec 26 2000;55(12):1780-4. [Medline].

  31. Benbadis SR, Wolgamuth BR, Goren H, et al. Value of tongue biting in the diagnosis of seizures. Arch Intern Med. Nov 27 1995;155(21):2346-9. [Medline].

  32. Bergen D, Ristanovic R. Weeping as a common element of pseudoseizures. Arch Neurol. Oct 1993;50(10):1059-60. [Medline].

  33. Bhatia M, Sinha PK, Jain S, et al. Usefulness of short-term video EEG recording with saline induction in pseudoseizures. Acta Neurol Scand. Jun 1997;95(6):363-6. [Medline].

  34. Carton S, Thompson PJ, Duncan JS. Non-epileptic seizures: patients' understanding and reaction to the diagnosis and impact on outcome. Seizure. Jul 2003;12(5):287-94. [Medline].

  35. Cohen LM, Howard GF, Bongar B. Provocation of pseudoseizures by psychiatric interview during EEG and video monitoring. Int J Psychiatry Med. 1992;22(2):131-40. [Medline].

  36. Cohen RJ, Suter C. Hysterical seizures: suggestion as a provocative EEG test. Ann Neurol. Apr 1982;11(4):391-5. [Medline].

  37. Davies KG, Blumer DP, Lobo S, et al. De novo nonepileptic seizures after cranial surgery for epilepsy: incidence and risk factors. Epilepsy Behav. Dec 2000;1(6):436-443. [Medline].

  38. Davis BJ. Predicting nonepileptic seizures utilizing seizure frequency, EEG, and response to medication. Eur Neurol. 2004;51(3):153-6. [Medline].

  39. Desai BT, Porter RJ, Penry JK. Psychogenic seizures. A study of 42 attacks in six patients, with intensive monitoring. Arch Neurol. Apr 1982;39(4):202-9. [Medline].

  40. Eiris-Punal J, Rodriguez-Nunez A, Fernandez-Martinez N, et al. Usefulness of the head-upright tilt test for distinguishing syncope and epilepsy in children. Epilepsia. Jun 2001;42(6):709-13. [Medline].

  41. Fahn S, Williams DT. Psychogenic dystonia. Adv Neurol. 1988;50:431-55. [Medline].

  42. Ford CV. The somatizing disorders. Psychosomatics. May 1986;27(5):327-31, 335-7. [Medline].

  43. Gates JR. Nonepileptic seizures: time for progress. Epilepsy Behav. Feb 2000;1(1):2-6. [Medline].

  44. Gates JR. Provocative testing should not be used for nonepileptic seizures. Arch Neurol. Dec 2001;58(12):2065-6. [Medline].

  45. Gates JR, Ramani V, Whalen S, Loewenson R. Ictal characteristics of pseudoseizures. Arch Neurol. Dec 1985;42(12):1183-7. [Medline].

  46. Glosser G, Roberts D, Glosser DS. Nonepileptic seizures after resective epilepsy surgery. Epilepsia. Dec 1999;40(12):1750-4. [Medline].

  47. Guberman A. Psychogenic pseudoseizures in non-epileptic patients. Can J Psychiatry. Aug 1982;27(5):401-4. [Medline].

  48. Gudmundsson O, Prendergast M, Foreman D, Cowley S. Outcome of pseudoseizures in children and adolescents: a 6-year symptom survival analysis. Dev Med Child Neurol. Aug 2001;43(8):547-51. [Medline].

  49. Harden CL, Burgut FT, Kanner AM. The diagnostic significance of video-EEG monitoring findings on pseudoseizure patients differs between neurologists and psychiatrists. Epilepsia. Mar 2003;44(3):453-6. [Medline].

  50. Hoefnagels WA, Padberg GW, Overweg J, et al. Transient loss of consciousness: the value of the history for distinguishing seizure from syncope. J Neurol. Feb 1991;238(1):39-43. [Medline].

  51. Hudak A, Agostini MA, Van Ness P, et al. Use of video-EEG monitoring in the differential diagnosis of posttraumatic seizure disorders. Epilepsia. 2003;44(suppl 9):5.

  52. Kanner AM, Morris HH, Lüders H, et al. Supplementary motor seizures mimicking pseudoseizures: some clinical differences. Neurology. Sep 1990;40(9):1404-7. [Medline].

  53. Kotagal P, Costa M, Wyllie E, et al. Paroxysmal nonepileptic events in children and adolescents. Pediatrics. Oct 2002;110(4):e46. [Medline].

  54. LaFrance WC, Benbadis SR. Avoiding the costs of unrecognized psychological nonepileptic seizures. Neurology. Jun 13 2006;66(11):1620-1. [Medline].

  55. Lancman ME, Asconape JJ, Craven WJ, et al. Predictive value of induction of psychogenic seizures by suggestion. Ann Neurol. Mar 1994;35(3):359-61. [Medline].

  56. Lancman ME, Brotherton TA, Asconape JJ, Penry JK. Psychogenic seizures in adults: a longitudinal analysis. Seizure. Dec 1993;2(4):281-6. [Medline].

  57. Leis AA, Ross MA, Summers AK. Psychogenic seizures: ictal characteristics and diagnostic pitfalls. Neurology. 1992;42:95-9. [Medline].

  58. Lempert T, Dieterich M, Huppert D, Brandt T. Psychogenic disorders in neurology: frequency and clinical spectrum. Acta Neurol Scand. Nov 1990;82(5):335-40. [Medline].

  59. Lesser RP. Psychogenic seizures. Neurology. 1996;46:1499-2507. [Medline].

  60. Lesser RP, Lueders H, Dinner DS. Evidence for epilepsy is rare in patients with psychogenic seizures. Neurology. Apr 1983;33(4):502-4. [Medline].

  61. Luther JS, McNamara JO, Carwile S, et al. Pseudoepileptic seizures: methods and video analysis to aid diagnosis. Ann Neurol. Nov 1982;12(5):458-62. [Medline].

  62. Martin RC, Gilliam FG, Kilgore M, et al. Improved health care resource utilization following video-EEG-confirmed diagnosis of nonepileptic psychogenic seizures. Seizure. Oct 1998;7(5):385-90. [Medline].

  63. McCahill ME. Somatoform and related disorders: delivery of diagnosis as first step. Am Fam Physician. Jul 1995;52(1):193-204. [Medline].

  64. McGonigal A, Oto M, Russell AJ, et al. Outpatient video EEG recording in the diagnosis of non-epileptic seizures: a randomised controlled trial of simple suggestion techniques. J Neurol Neurosurg Psychiatry. Apr 2002;72(4):549-51. [Medline].

  65. Meierkord H, Will B, Fish D, Shorvon S. The clinical features and prognosis of pseudoseizures diagnosed using video-EEG telemetry. Neurology. Oct 1991;41(10):1643-6. [Medline].

  66. Ney GC, Barr WB, Napolitano C, et al. New-onset psychogenic seizures after surgery for epilepsy. Arch Neurol. May 1998;55(5):726-30. [Medline].

  67. Peguero E, Abou-Khalil B, Fakhoury T, Mathews G. Self-injury and incontinence in psychogenic seizures. Epilepsia. Jun 1995;36(6):586-91. [Medline].

  68. Reuber M, Fernandez G, Bauer J, et al. Diagnostic delay in psychogenic nonepileptic seizures. Neurology. Feb 12 2002;58(3):493-5. [Medline].

  69. Reuber M, Kral T, Kurthen M, Elger CE. New-onset psychogenic seizures after intracranial neurosurgery. Acta Neurochir (Wien). Sep 2002;144(9):901-7; discussion 907. [Medline].

  70. Reuber M, Kurthen M, Fernandez G, et al. Epilepsy surgery in patients with additional psychogenic seizures. Arch Neurol. Jan 2002;59(1):82-6. [Medline].

  71. Reuber M, Pukrop R, Bauer J, et al. Outcome in psychogenic nonepileptic seizures: 1 to 10-year follow-up in 164 patients. Ann Neurol. Mar 2003;53(3):305-11. [Medline].

  72. Riley TL, Berndt T. The role of the EEG technologist in delineating pseudoseizures. Am J EEG Technol. 1980;20:89-96.

  73. Rosenow F, Wyllie E, Kotagal P, et al. Staring spells in children: descriptive features distinguishing epileptic and nonepileptic events. J Pediatr. Nov 1998;133(5):660-3. [Medline].

  74. Schachter SC, Brown F, Rowan AJ. Provocative testing for nonepileptic seizures: attitudes and practices in the United States among American Epilepsy Society members. J Epilepsy. 1996;9:249-52.

  75. Scheepers B, Clough P, Pickles C. The misdiagnosis of epilepsy: findings of a population study. Seizure. Oct 1998;7(5):403-6. [Medline].

  76. Selwa LM, Geyer J, Nikakhtar N, et al. Nonepileptic seizure outcome varies by type of spell and duration of illness. Epilepsia. Oct 2000;41(10):1330-4. [Medline].

  77. Shen W, Bowman ES, Markand ON. Presenting the diagnosis of psychogenic seizure. Neurology. 1990;40:756-9. [Medline].

  78. Slater JD, Brown MC, Jacobs W, Ramsay RE. Induction of pseudoseizures with intravenous saline placebo. Epilepsia. Jun 1995;36(6):580-5. [Medline].

  79. Smith D, Defalla BA, Chadwick DW. The misdiagnosis of epilepsy and the management of refractory epilepsy in a specialist clinic. QJM. Jan 1999;92(1):15-23. [Medline].

  80. Sperling MR, O'Connor MJ. Auras and subclinical seizures: characteristics and prognostic significance. Ann Neurol. Sep 1990;28(3):320-8. [Medline].

  81. Stagno SJ, Smith ML. Use of induction procedures in diagnosing psychogenic seizures. J Epilepsy. 1996;9:153-8.

  82. Szaflarski JP, Hughes C, Szaflarski M, et al. Quality of life in psychogenic nonepileptic seizures. Epilepsia. Feb 2003;44(2):236-42. [Medline].

  83. Thacker K, Devinsky O, Perrine K, et al. Nonepileptic seizures during apparent sleep. Ann Neurol. Apr 1993;33(4):414-8. [Medline].

  84. Vossler DG, Haltiner AM, Schepp SK, et al. Ictal stuttering: a sign suggestive of psychogenic nonepileptic seizures. Neurology. Aug 10 2004;63(3):516-9. [Medline].

  85. Walczak TS, Williams DT, Berten W. Utility and reliability of placebo infusion in the evaluation of patients with seizures. Neurology. Mar 1994;44(3 Pt 1):394-9. [Medline].

  86. Wyllie E, Friedman D, Luders H, et al. Outcome of psychogenic seizures in children and adolescents compared with adults. Neurology. May 1991;41(5):742-4. [Medline].

  87. Wyllie E, Glazer JP, Benbadis S, et al. Psychiatric features of children and adolescents with pseudoseizures. Arch Pediatr Adolesc Med. Mar 1999;153(3):244-8. [Medline].

 
Previous
Next
 
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.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.