Psychogenic non-epileptic seizure

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Psychogenic non-epileptic seizures
Other namesPseudoseizure, non-epileptic seizure, dissociative non-epileptic seizure, FNEA (functional non-epileptic attacks), NEAD (non-epileptic attack disorder) [1]
Specialty Neurology, psychiatry

Psychogenic non-epileptic seizures (PNES), also referred to as pseudoseizures, non-epileptic attack disorder (NEAD), functional seizures, or dissociative seizures, [2] [3] are episodes resembling an epileptic seizure but without the characteristic electrical discharges associated with epilepsy. [4] [3] PNES fall under the category of disorders known as functional neurological disorders (FND) [5] and are typically treated by psychologists or psychiatrists.

Contents

Incidence

The number of people with PNES ranges from 2 to 33 per 100,000. [6] PNES are most common in young adults, particularly women. [6] The prevalence for PNES is estimated to make up 5–20% of outpatient epilepsy clinics; 75–80% of these diagnoses are given to female patients and 83% are to individuals between 15 and 35 years old. [7]

Children

PNES are seen in children after the age of eight, and occur equally among boys and girls before puberty. Diagnostic and treatment principles are similar to those for adults, except that in children there is a broader differential diagnosis of seizures so that other possible diagnoses specific to children may be considered. [8]

Signs and symptoms

PNES episodes can be difficult to distinguish from epileptic seizures without the use of long-term video EEG monitoring. Some characteristics which may distinguish PNES from epileptic seizures include gradual onset, out-of-phase limb movement (in which left and right extremities jerk asynchronously or in opposite directions, as opposed to rhythmically and simultaneously as in epileptic seizures), closed eyes, high memory recall, and lack of post-ictal confusion. [9] [10] [11] Although these symptoms are possible in epileptic seizures, they are much more commonly found in PNES.

PNES episodes are often less injurious than epileptic seizures. Unlike epilepsy, many PNES patients presenting with total unresponsiveness still retain some form of conscious response, including the natural behavior to protect oneself from harm. This is often reflected by a lack of tongue-biting, urinary and/or fecal incontinence, fall-related trauma, or accidental burns, all of which are significantly less common in PNES than in epileptic seizures. [9] [10] Other means of determining consciousness include dropping a patient's hand above the nasopharyngeal lead; the natural response is to prevent it from falling. Visual tracking and resistance to passive eye movements can also be used to determine PNES when the eyes are open. [9] However, total unresponsiveness is possible in PNES, and lack of conscious response on its own is not enough to indicate an epileptic seizure.

While most epileptic seizures last no more than two minutes, PNES episodes may last five minutes or longer. An epileptic seizure lasting longer than five minutes is considered a life-threatening medical emergency, which is not a risk in PNES.

Causes and risk factors

The cause of PNES has not yet been established. One hypothesis is that they are a learned physical reaction or habit the body develops, similar to a reflex. The individual does not have control of the learned reaction, but this can be retrained to allow the patient to control the physical movements again. [12] The production of seizure-like symptoms is not under voluntary control; [13] [14] symptoms which are feigned or faked voluntarily would fall under the categories of factitious disorder or malingering. [15]

Risk factors for PNES include having a history of head injury, and having a diagnosis of epilepsy. [16] Approximately 10–30% of people diagnosed with PNES also have an epilepsy diagnosis. People diagnosed with PNES commonly report physical, sexual, or emotional trauma, but the reported incidence of these events may not differ between PNES and epilepsy. [17]

Diagnosis

According to the DSM-5, the criteria for receiving a diagnosis of PNES are: [18]

  1. One or more symptoms of altered voluntary motor or sensory function.
  2. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions.
  3. The symptom or deficit is not better explained by another medical or mental disorder.
  4. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

Additionally, the specific symptom type must be reported "with attacks or seizures". [18]

Some individuals with PNES have carried an erroneous diagnosis of epilepsy. On average, it takes seven years to receive a proper diagnosis. The differential diagnosis of PNES firstly involves ruling out epilepsy as the cause of the seizure episodes, along with other organic causes of non-epileptic seizures, including syncope, migraine, vertigo, anoxia, hypoglycemia, and stroke. However, 5–20% of people with PNES also have epilepsy. [19] Frontal lobe seizures can be mistaken for PNES, though these tend to have shorter duration, stereotyped patterns of movements, and occurrence during sleep. [20] Next, an exclusion of factitious disorder (a subconscious somatic symptom disorder, where seizures are caused by psychological reasons) and malingering (simulating seizures intentionally for conscious personal gain – such as monetary compensation or avoidance of criminal punishment) is conducted. Finally, other psychiatric conditions that may superficially resemble seizures are eliminated, including panic disorder, schizophrenia, and depersonalization-derealization disorder. [20]

The most definitive test to distinguish epilepsy from PNES is long term video-EEG monitoring, with the aim of capturing one or two episodes on both video recording and electroencephalography (EEG) simultaneously (some clinicians may use suggestion to attempt to trigger an episode). [21] Additional clinical criteria are usually considered in addition to video-EEG monitoring when diagnosing PNES. [22] By recording the event in question on video and EEG simultaneously, a clear diagnosis can usually be obtained. [23]

Laboratory testing can detect rising blood levels of serum prolactin if samples are taken in the right time window after most tonic-clonic or complex partial epileptic seizures. However, due to false positives and variability in results, this test is relied upon less frequently. [20]

Treatment

Patient understanding of the new diagnosis is crucial for their treatment, which requires their active participation. [24] A negative diagnosis experience may cause frustration and could cause a person to reject any further attempts at treatment. Psychotherapy, particularly cognitive behavioral therapy (CBT), is most frequently used to treat PNES. There is also some evidence supporting selective serotonin reuptake inhibitor (SSRIs). [25]

Retraining and Control Therapy (ReACT)

ReACT, while new and understudied, has shown extremely promising outcomes for reduction of PNES episodes in pediatric patients. [26] This therapy focuses on the idea that PNES are caused by a learned physical reaction or habit the body develops, similar to a reflex. ReACT aims to retrain the learned reaction (PNES episodes) by targeting symptom catastrophizing and restoring sense of control over symptoms.

Prognosis

For individuals who pursue treatment for PNES, CBT has shown varying rates of success but it has been established as one of the most promising treatments to date. [27] ReACT has shown reduction in symptoms by 100% seven days after treatment and 82% of individuals who completed the therapy remained symptom free for 60 days. A follow-up has not been done to see if the therapy retained its reduction of symptoms beyond the 60 days. [26] In the cognitive behavioral therapy for adults with dissociative seizures (CODES) trial, the largest regarding CBT treatment for PNES though found no significant reduction in monthly episodes compared to the control arm at 12 months, however there were significant improvements on a number of secondary outcomes, such as psychosocial functioning, and self-rated and clinician-rated global change. [28] A secondary analysis of the CODES trial demonstrated improved frequency of PNES episodes at 6 months with CBT.

History

Hystero-epilepsy is a historical term that refers to a condition described by 19th-century French neurologist Jean-Martin Charcot [29] where people with neuroses "acquired" symptoms resembling seizures as a result of being treated on the same ward as people who genuinely had epilepsy.

The etiology of FND was historically explained in the context of psychoanalytic theory as a physical manifestation of psychological distress and repressed trauma. There is very little supporting evidence for this theory, as there is little research. [30]

The DSM-IV lists conversion disorders instead of the current FND. Additionally, in revision, the DSM-5 was updated to add emphasis to the positive physical signs inconsistent with recognized diseases. The requirement of a history of psychological stressors and that the symptom is not fake was removed as well. [31]

Society and culture

PNES rates and presenting symptoms are somewhat dependent on the culture and society. In some cultures, they, like epilepsy, are thought of as a curse or a demonic possession. [32] In cultures with a solid establishment of evidence-based medicine, they are considered a subtype of a larger category of psychiatric disease.

Terminology

The term PNES is sometimes considered a misnomer, because the word "seizure" refers to a surge of electrical discharges in the brain, which does not occur in PNES episodes. Many prefer to use more general terms like "spells," "events," "attacks," or "episodes." [33] "Non-epileptic attack disorder," or NEAD, is typically used in the UK for this reason. [34] Although "pseudoseizures" remains a common term for PNES episodes in the medical field, many patients dislike it due to associated stigma and implications of malingering. [35]

Within DSM-5, patients presenting with PNES may meet the criteria for functional neurological disorder and in some cases, somatic symptom disorder, whilst in ICD-10 it may meet the criteria for a conversion disorder. [20]

Related Research Articles

<span class="mw-page-title-main">Catatonia</span> Psychiatric behavioural syndrome

Catatonia is a complex syndrome, most commonly seen in people with underlying mood or psychotic disorders. The onset of catatonia can be acute or subtle and symptoms can wax, wane, or change during episodes. It has historically been related to schizophrenia, but catatonia is most often seen in mood disorders. It is now known that catatonic symptoms are nonspecific and may be observed in other mental, neurological, and medical conditions. Catatonia is now a stand-alone diagnosis, and the term is used to describe a feature of the underlying disorder.

<span class="mw-page-title-main">Epilepsy</span> Group of neurological disorders causing seizures

Epilepsy is a group of non-communicable neurological disorders characterized by recurrent epileptic seizures. An epileptic seizure is the clinical manifestation of an abnormal, excessive, and synchronized electrical discharge in the neurons. The occurrence of two or more unprovoked seizures defines epilepsy. The occurrence of just one seizure may warrant the definition in a more clinical usage where recurrence may be able to be prejudged. Epileptic seizures can vary from brief and nearly undetectable periods to long periods of vigorous shaking due to abnormal electrical activity in the brain. These episodes can result in physical injuries, either directly, such as broken bones, or through causing accidents. In epilepsy, seizures tend to recur and may have no detectable underlying cause. Isolated seizures that are provoked by a specific cause such as poisoning are not deemed to represent epilepsy. People with epilepsy may be treated differently in various areas of the world and experience varying degrees of social stigma due to the alarming nature of their symptoms.

<span class="mw-page-title-main">Seizure</span> Period of symptoms due to excessive or synchronous neuronal brain activity

A seizure is a sudden change in behavior, movement, and/or consciousness due to abnormal electrical activity in the brain. Seizures can look different in different people. It can be uncontrolled shaking of the whole body or a person spacing out for a few seconds. Most seizures last less than two minutes. They are then followed by confusion/drowsiness before the person returns to normal. If a seizure lasts longer than 5 minutes, it is a medical emergency and needs immediate treatment.

A convulsion is a medical condition where the body muscles contract and relax rapidly and repeatedly, resulting in uncontrolled shaking. Because epileptic seizures typically include convulsions, the term convulsion is often used as a synonym for seizure. However, not all epileptic seizures result in convulsions, and not all convulsions are caused by epileptic seizures. Non-epileptic convulsions have no relation with epilepsy, and are caused by non-epileptic seizures.

A headache is often present in patients with epilepsy. If the headache occurs in the vicinity of a seizure, it is defined as peri-ictal headache, which can occur either before (pre-ictal) or after (post-ictal) the seizure, to which the term ictal refers. An ictal headache itself may or may not be an epileptic manifestation. In the first case, it is defined as ictal epileptic headache or simply epileptic headache. It is a type of pain seizure that can remain isolated or be followed by other manifestations of the seizure. On the other hand, a ictal non-epileptic headache is a headache that occurs during a seizure but it is not due to an epileptic mechanism. When the headache does not occur in the vicinity of a seizure, it is defined as inter-ictal headache. In the case it's a disorder separate from epilepsy, it's a comorbidity.

Conversion disorder (CD), or functional neurologic symptom disorder (FNsD), is a functional disorder that causes abnormal sensory experiences and movement problems during periods of high psychological stress. Individuals with CD present with highly distressing neurological symptoms such as numbness, blindness, paralysis, or convulsions, which are not consistent with a well-established organic cause and can be traced back to a psychological trigger.

Landau–Kleffner syndrome (LKS)—also called infantile acquired aphasia, acquired epileptic aphasia or aphasia with convulsive disorder—is a rare childhood neurological syndrome.

Dissociative disorders (DDs) are a range of conditions characterized by significant disruptions or fragmentation "in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior." Dissociative disorders involve involuntary dissociation as an unconscious defense mechanism, wherein the individual with a dissociative disorder experiences separation in these areas as a means to protect against traumatic stress. Some dissociative disorders are caused by major psychological trauma, though the onset of depersonalization-derealization disorder may be preceded by less severe stress, by the influence of psychoactive substances, or occur without any discernible trigger.

<span class="mw-page-title-main">Aura (symptom)</span> Symptom of epilepsy and migraine

An aura is a perceptual disturbance experienced by some with epilepsy or migraine. An epileptic aura is actually a minor seizure.

Non-epileptic seizures (NES), also known as pseudoseizures, non-epileptic attack disorder (NEAD), functional seizures, or dissociative seizures, are paroxysmal events that appear similar to an epileptic seizure, but do not involve abnormal, rhythmic discharges of neurons in the brain. Symptoms may include shaking, loss of consciousness, and loss of bladder control.

Long-term or "continuous" video-electroencephalography (EEG) monitoring is a diagnostic technique commonly used in patients with epilepsy. It involves the long-term hospitalization of the patient, typically for days or weeks, during which brain waves are recorded via EEG and physical actions are continuously monitored by video. In epileptic patients, this technique is typically used to capture brain activity during seizures. The information gathered can be used for initial prognosis or long-term care management.

Frontal lobe epilepsy (FLE) is a neurological disorder that is characterized by brief, recurring seizures arising in the frontal lobes of the brain, that often occur during sleep. It is the second most common type of epilepsy after temporal lobe epilepsy (TLE), and is related to the temporal form in that both forms are characterized by partial (focal) seizures.

In the field of neurology, seizure types are categories of seizures defined by seizure behavior, symptoms, and diagnostic tests. The International League Against Epilepsy (ILAE) 2017 classification of seizures is the internationally recognized standard for identifying seizure types. The ILAE 2017 classification of seizures is a revision of the prior ILAE 1981 classification of seizures. Distinguishing between seizure types is important since different types of seizures may have different causes, outcomes, and treatments.

Abdominal epilepsy is a rare condition most frequently found in children, consisting of gastrointestinal disturbances caused by epileptiform seizure activity. Though a few cases of it have been reported in adults too. It has been described as a type of temporal lobe epilepsy. Responsiveness to anticonvulsants can aid in the diagnosis. Distinguishing features of abdominal epilepsy include (1) Abnormal laboratory, radiographic, and endoscopic findings revealing paroxysmal GI manifestations of unknown origin (2) CNS symptoms (3) Abnormal EEG. Most published medical literature dealing with abdominal epilepsy is in the form of individual case reports. A 2005 review article found a total of 36 cases described in the medical literature.

Geschwind syndrome, also known as Gastaut–Geschwind syndrome, is a group of behavioral phenomena evident in some people with temporal lobe epilepsy. It is named for one of the first individuals to categorize the symptoms, Norman Geschwind, who published prolifically on the topic from 1973 to 1984. There is controversy surrounding whether it is a true neuropsychiatric disorder. Temporal lobe epilepsy causes chronic, mild, interictal changes in personality, which slowly intensify over time. Geschwind syndrome includes five primary changes: hypergraphia, hyperreligiosity, atypical sexuality, circumstantiality, and intensified mental life. Not all symptoms must be present for a diagnosis. Only some people with epilepsy or temporal lobe epilepsy show features of Geschwind syndrome.

Classified as a "conversion disorder" by the DSM-IV, a psychogenic disease is a condition in which mental stressors cause physical symptoms matching other disorders. The manifestation of physical symptoms without biologically identifiable cause results from disruptions in normal brain function due to psychological stress. During a psychogenic episode, neuroimaging has shown that neural circuits affecting functions such as emotion, executive functioning, perception, movement, and volition are inhibited. These disruptions become strong enough to prevent the brain from voluntarily allowing certain actions. When the brain is unable to signal to the body to perform an action voluntarily, physical symptoms of a disorder arise. Examples of diseases that are deemed to be psychogenic in origin include psychogenic seizures, psychogenic polydipsia, psychogenic tremor, and psychogenic pain.

Migralepsy is a rare condition in which a migraine is followed, within an hour period, by an epileptic seizure. Because of the similarities in signs, symptoms, and treatments of both conditions, such as the neurological basis, the psychological issues, and the autonomic distress that is created from them, they individually increase the likelihood of causing the other. However, also because of the sameness, they are often misdiagnosed for each other, as migralepsy rarely occurs.

<span class="mw-page-title-main">Epilepsy in children</span>

Epilepsy is a neurological condition of recurrent episodes of unprovoked epileptic seizures. A seizure is an abnormal neuronal brain activity that can cause intellectual, emotional, and social consequences. Epilepsy affects children and adults of all ages and races, and is one of the most common neurological disorders of the nervous system. Epilepsy is more common among children than adults, affecting about 6 out of 1000 US children that are between the age of 0 to 5 years old. The epileptic seizures can be of different types depending on the part of the brain that was affected, seizures are classified in 2 main types partial seizure or generalized seizure.

Forced Normalization (FN) is a psychiatric phenomenon in which a long term episodic epilepsy or migraine disorder is treated, and, although the electroencephalogram (EEG) appears to have stabilized, acute behavioral, mood, and psychological disturbances begin to manifest. If, or when, treatment for the disorder is halted, the disturbances go away, but the episodic spikes on the EEG reappear. H. Landolt coined the term 'Forced Normalization' in 1953 in response to a change he witnessed in epileptic EEGs, which monitor electrical activity in the brain. These changes were followed by abrupt behavioral changes in the patient. Landolt concluded that forced normalization is "the phenomenon characterized by the fact that, with the occurrence of psychotic states, the electroencephalography becomes more normal or entirely normal, as compared with previous and subsequent EEG findings." Forced normalization, as described by Landolt, was therefore an electrophysiological phenomenon with the electroencephalograph at its helm.

Functional neurologic disorder or functional neurological disorder (FND) is a condition in which patients experience neurological symptoms such as weakness, movement problems, sensory symptoms, and convulsions. As a functional disorder, there is, by definition, no known disease process affecting the structure of the body, yet the person experiences symptoms relating to their body function. Symptoms of functional neurological disorders are clinically recognisable, but are not categorically associated with a definable organic disease.

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