Psychogenic nonepileptic seizures (PNES) are a common yet not well-known subtype of conversion disorder affecting sensory and motor function. Psychogenic nonepileptic seizures are classified as a functional neurologic symptom disorder and defined as an alteration in behavior, mood, perception, and sensation that resemble epileptic seizures but are not caused by epileptiform activity in the brain.1-3 Psychogenic nonepileptic seizures are linked to frequent, often more disabling episodes than true epileptic seizures.4

The seizure-like response in PNES is a manifestation of the body to a psychological stimulus, such as when a patient cannot directly express distress.5,6 An estimated 53% to 100% of patients with PNES have at least 1 comorbid psychiatric disorder, the most common of which are depression and anxiety.7,8 Therefore, it is important for providers to increase their suspicion of PNES in patients with these comorbidities presenting with seizure symptoms.

The incidence of PNES is estimated to be 1.4 to 4.9 cases per 100,000 people per year and the prevalence is 2 to 33 per 100,000 people.7 Psychogenic nonepileptic seizures are typically diagnosed in epilepsy centers and account for approximately 10% of epileptic emergencies and 30% of epilepsy unit cases.3,6 However, misdiagnosis of PNES as a seizure disorder is common. Patients with PNES are often treated with antiepileptic drugs, further delaying and complicating the diagnosis as well as putting patients at risk for potentially harmful effects of these medications.7,9 Data suggest that 20% to 40% of adult patients and 10% to 23% of children considered to have drug-resistant epilepsy are later accurately diagnosed with PNES.7


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Patients with PNES most commonly present in their 20s and 40s.10 However, these episodes are not uncommon in childhood. This condition occurs in both sexes but is more common in females vs males with a ratio of 3:1.7 Females are at higher risk for other conversion disorders as well.

Factors associated with PNES include childhood physical or sexual abuse, traumatic brain injury (with comorbid depression, behavioral impulsivity, or posttraumatic stress disorder), medical comorbidities, and brain dysfunction.10 Precipitating stressors may include injury, death of or separation from family members or friends, job loss, rape, childbirth, surgical procedures, natural disasters, relationship difficulties, and legal problems.10 In one study on childhood PNES, parental awareness of their child’s other psychiatric symptoms was poor and played a major role in the course of illness and digression of the patient.2

Although these risk factors can occur in adulthood and manifest in adulthood, research suggests that early exposure to abuse or neglect can “deregulate the child’s developing neurobiological system by reducing its resistance to stressful events, leading to later problems of emotional regulation.”11 In a recent study, a cohort of patients with PNES (aged 18 to 84 years) was characterized by socioeconomic deprivation with many of them either unemployed or reliant on state financial benefits. In this cohort, 67% were classified as economically inactive, meaning either unemployed, employed but on sick leave, student taking time off, or retired.12

Following a traumatic event, the onset of developing PNES can be weeks, months, or, more commonly, years. An accurate diagnosis of PNES may take up to 7 years.10 Timely diagnosis is critical for the optimal management of these patients.

History and Physical

The first step in the workup of PNES is to take a detailed history, record witness reports, and perform a physical examination. Witness reports from parents, spouses/partners, and friends are an important aspect of the initial workup because they are often able to describe the specific characteristics of the episodes, such as symptoms and if symptoms are the same or different with every attack, how often attacks occur, common triggers, and the aftermath of each attack. If available, a video of an attack can aid in diagnosis.16 The patient is typically unaware of what is happening and will not be able to describe this information.

Signs and Symptoms of Psychogenic Nonepileptic Seizures

Although many clinical findings are closely related to those of epileptic seizures, a few findings differ. Classic findings in PNES include long seizure duration, waxing and waning consciousness, forceful eye closure, ictal-phase crying, side-to-side head shaking, tremor, asynchronous limb movements, pelvic thrusting, fluctuating ictal course, memory recall issues, and absence of postictal confusion.8,16 Some researchers say that these movements mimic the actions that incited the episodes, such as trying to say no to something, unwanted sexual intercourse, something being forced on them, and crying from pain.13 Differences in signs and symptoms between PNES and epileptic seizures are shown in Table 1.9,10,14

Table 1. Clinical Signs in Psychogenic Nonepileptic Seizures vs Epileptic Seizures9,10,14

SignPsychogenic Nonepileptic SeizuresEpileptic Seizures
Closed eyes with resistance to openingHighly specificInconsistent
Yelling verbal phrasesHighly specificInconsistent
Pelvic thrustingHighly specificInconsistent (except in frontal lobe seizures)
Side-to-side head shakingHighly specificInconsistent (except in frontal lobe seizures)
Wild thrashingHighly specificInconsistent
Preservation of pupillary reflex during eventHighly specificInconsistent; altered in epileptic seizures
Stuttering during an eventMay occurInconsistent
Open mouthInconsistent; mouth may be clenchedHighly specific
Postical period of somnolence or confusionInconsistentHighly specific
Increase in heart rate ≥30%InconsistentConsistent
Altered pupillary reflex during eventInconsistentHighly specific

Patients with suspected PNES are admitted for observation to an epilepsy monitoring unit (EMU), which can be difficult for the patient as the typical stay is 2 to 7 days, depending on how often the episodes occur, and monitoring is conducted 24 hours per day except for a few moments of privacy.4 Video electroencephalography (EEG) is the gold standard for diagnosis.10 In PNES patients, the EEG will show an absence of epileptiform activity. Video EEG can effectively rule out epilepsy, but does not necessarily confirm a diagnosis of PNES. Therefore, PNES is confirmed once there is a correlation between the history, observed physical characteristics of the attack, and lack of abnormal EEG brain activity.

Treatment of Psychogenic Nonepileptic Seizures

Although making an accurate diagnosis is a crucial step in evaluating a patient with PNES, research shows that the treatment phase can be difficult and should be a step-by-step process and involve a multidisciplinary team approach.

The treatment process starts with the delivery of the diagnosis, which can be upsetting for the patient.3,4,13,15,17 Often, the patient will react negatively to hearing that they have a psychological disorder and will typically seek a second opinion or express denial. This information must be given to the patient in a clear, concise, and understandable way for the patient and family to understand. It has been noted that patients who do not accept a diagnosis of PNES have a worse outcome, most likely because they are unwilling to seek help.15 Therefore, the delivery of the diagnosis is an important step because it can help determine the rate of a successful outcome.

The neurologist typically delivers the diagnosis and the maintenance of care is generally the responsibility of the primary care provider. Many patients with a new diagnosis of PNES have been misdiagnosed with epilepsy and treated with antiepileptic drugs (AEDs) for upwards of 5 years or more. For these patients, the next step is to discontinue AED by slowly titrating off these medications to avoid withdrawal.13  

The mainstay of treatment for PNES is cognitive behavioral therapy (CBT) and pharmacological agents such as selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs) for patients with comorbid depression and anxiety.10,18,19 The main goal of CBT is to decrease the symptoms of stress, posttraumatic stress disorder (PTSD), depression, anxiety, and triggering responses to previous trauma.10 The goal is to teach the patient new coping skills for overwhelming circumstances and identify and change the conditioned response to any identified environmental triggers.20

Another alternative or adjunct treatment is psychodynamic therapy, which helps the patient gain a deeper understanding of their own emotions and mental processes.20 It helps to engage their unconscious coping mechanisms and thoughts. Other treatments can include eye movement desensitization, hypnotherapy, mindfulness-based therapy, acceptance commitment therapy, and psychoeducation-based therapy.20,21 These all seek to target the underlying condition, bring awareness to the patient and work with them on appropriately expressing their emotions.

Conclusion

Primary care providers need to recognize the symptoms of this subtype of conversion disorder. Proper diagnosis limits the potential risks of inappropriately prescribing AEDs and allows for timely initiation of appropriate treatment. Recovery begins with acceptance and initiation of CBT and other psychological interventions. Other vital recovery factors include physician education, engagement, and patient access to resources. The clinician-patient relationship is significant in the success of these patients’ recoveries. Patients need to know that they can trust their health care providers, and providers need to be willing to discuss the diagnosis and treatment plans with patients. To build trust, providers need to schedule regular visits with these patients.

Sibley McCallie, PA-S, is a PA student at Augusta University in Georgia; E. Rachel Fink, MPA, PA-C, is an assistant professor at Augusta University Physician Assistant Program in Georgia.

References

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