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  • http://www.dana.org/uploadedImages/Images/Content_Images/art_v6n2gumnit_2.jpg
  • Differentiating between nonepileptic and epileptic seizuresOrrin Devinsky, Deana Gazzola and W. Curt LaFrance JrDevinsky, O. et al. Nat. Rev. Neurol. 7, 210–220 (2011); published online 8 March 2011; doi:10.1038/nrneurol.2011.24
  • What causes my attacks?Non-epileptic attacks (NEAs) are not caused by changes in the brain which can be picked up with a brain scan or by a neurological disease or disorder. It is better to think about them as a mechanism which the brain uses to "shut down" when it is overloaded. During NEAs parts of the brain stop working together properly. NEAs happen for different reasons in different people.NEAs can be linked to emotions or stress, but the causes are not always obvious. Most NEAs are an unconscious mechanism, which the brain uses to protect itself against overwhelming distress. NEAs can be triggered by a wide range of situations, emotions, physical sensation, thoughts or memories. People are not always aware of these triggers. Often it feels like their attacks are happening “out of the blue”.Usually, several things have to come together for non-epileptic attack disorder (NEAD) to develop. There are a number of reasons why a person may be particularly vulnerable to developing NEAs . These can include inherited factors and childhood experiences. Often NEAs start when people face difficulties in adulthood. These difficulties could be unexpected life events (such as someone’s death or an accident), health problems or personal dilemmas (like situations in which there does not seem to be a good way forward). Other factors may then cause the attacks to continue.Below is a diagram, which shows you how these factors could act together. You can click on the blue words in the diagram to read more information about these.http://nonepilepticattacks.com/3_causes.html
  • Can frequently be precipitated by suggestion & certain clinical tests (hyperventilation, photic stimulation, intravenous saline infusion or tactile (vibration) stimulation, or pinching the nose to induce apnea) hyperventilation and photic stimulation may also induce true epileptic seizures, but their clinical features are usually distinctive.Some physicians avoid the use of placebo procedures  possibility that the patient may feel tricked and this could have an adverse effect on the doctor-patient relationship (Parra et al. 1998)

Transcript

  • 1. Pseudoseizure Ersifa Fatimah, dr. PPDS Neurologi RSUD Dr Soetomo - Universitas Airlangga Surabaya, 2012
  • 2. An epileptic seizure is defined as a transientneurological dysfunction resulting from anexcessive abnormal electrical discharge ofcerebral neuronsThe clinical manifestations are numerous,including disturbances of consciousness,changes in emotions, changes in sensation,abnormal movements, and changes in visceralfunctions or behavior (Bradley, 2004) Ersifas 2
  • 3. Systemic Disturbances Neurologic Disturbances • Migraine• Metabolic, Endocrine • Cerebrovascular disorder• Syncope • Sleep disorder • Myoclonus • Movement disorder Disorders That Can Be Confused with Epilepsy Engel & Pedley,Psychiatric Disturbance Epilepsy: A Comprehensive Textbook,• PNES 2nd Ed, 2008• Episodic dyscontrol• Discociative disorder• Panic disorder• OCD• Psychoses Ersifas 3
  • 4. • Can be the expression of organic or psychogenic processes. • Can mimic convulsive and nonconvulsive epileptic seizures • A clear distinction cannot always be made between PNES somatization disorder, conversion disorder, factitious disorder, and malingering as the conditions blur into each other (it can be difficult to decide sometimes whether someones motivation is truly unconscious). Apparent motivation is also based to some extent on a clinicians subjective interpretation • Rare but severe form of human aggressive behavior Episodic • Paroxysmal • Often is accompanied by other neurologic or psychiatric disordersDyscontrol • The question of whether IED is pathogenetically related to epilepsy is unresolvedEngel & Pedley, Epilepsy: A Comprehensive Textbook, 2nd Ed, 2008 Ersifas 4
  • 5. • Disruption in the usually integrated functions of consciousness,Dissociative memory, identity, or perception of the environment (DSM-IV), the loss of control over bodily movements (ICD-10) • Temporary disruption in consciousness or volition Disorder • Amnesia, fugue, déjà vu, etc • Certain aspects of epilepsy are dissociative, but they do not involve (esp. Conversion) the same type of dissociation as that underlying nonepileptic attacks Panic • “Discrete period of intense fear or discomfort”  many of the symptoms of panic attacks are reminiscent of symptoms that may appear during some types of epileptic seizuresDisorder (Fear is a commonly encountered component of partial seizures and is the most common ictal psychiatric symptom)Engel & Pedley, Epilepsy: A Comprehensive Textbook, 2nd Ed, 2008 Ersifas 5
  • 6. • The symptoms of senseless repetitive actions Obsessive- (compulsions) or recurrent intrusive thoughts (obsessions) on some occasions might resemble compulsive the automatisms that occur with complex partial Behavior seizures arising from the temporal or frontal lobes. Nonaffective • The symptoms of psychosis (hallucinations, delusions), suggest deviant neurologic processing, and underlying Psychoses, this will be disturbances of neurologic function, often secondary to structural disease. Schizophrenia • There are biologic underpinnings to the psychotic & disorders of epilepsy …. the discussions revolve around similar anatomic deviations as in schizophrenia Schizophrenia- in the absence of epilepsy and involve medial temporal structures, the amygdala and hippocampus in like Psychoses particular, and their efferent projections.Engel & Pedley, Epilepsy: A Comprehensive Textbook, 2nd Ed, 2008 Ersifas 6
  • 7. Pseudoepileptic Pseudoseizure seizure PsychogenicNon-Epileptic Seizure Non-Epileptic Seizure Non-Epileptic Attack Nonepileptic events Disorder Ersifas 7
  • 8. Nonepileptic seizures (NESs) Paroxysmal events that mimic (or are confused with) epileptic seizures, but which do not result from epileptic activity. NESs can be the expression of organic or psychogenic processes.Engel & Pedley, Epilepsy: A Comprehensive Textbook, 2nd Ed, 2008 Ersifas 8
  • 9. http://www.dana.orgErsifas 9
  • 10. Johnson: Current Therapy in Neurologic Disease (7/E) Ersifas 10
  • 11. Pseudoepileptic seizuresParoxysmal episodes of altered behavior thatsuperficially resemble epileptic seizures but lackthe expected EEG epileptic changes(Ettinger et al. 1999) Bradley, 2004 Ersifas 11
  • 12. The ChallengeThe decision whether a patients seizures belong in thedomain of epilepsy or nonepileptic events  may have to bebased on various sets of criteria + EEG data.The distinction between epilepsy and nonepilepsy cannotalways be made with complete confidence, and the physicianworking in this field must be able to tolerate some degree ofuncertainty.Epileptic and nonepileptic seizures also may coexist. Engel & Pedley, Epilepsy: A Comprehensive Textbook, 2nd Ed, 2008 Ersifas 12
  • 13. EpidemiologyApproximately 40% of patients with pseudoepileptic / nonepileptic seizures alsoexperience true epileptic seizures. [Bradley, 2004](PNES) It is by far the most frequent nonepileptic condition seen in epilepsycenters, where they represent 20-30% of referrals. About 50-70% of patientsbecome seizure-free after diagnosis, and about 15% also have epilepsy. [Medscape,2011]Occur in children and adults, more common in females [Bradley, 2004] (70%) .[Medscape, 2011] Ersifas 13
  • 14. Risk FactorAge• Epilepsy: Bimodal age curve• PNES: Inverse unimodal age curve  70% at decade 2-4thObeseChronic pain, anxiety, PTSD• Male veterans with PNES Ersifas 14
  • 15. Risk factorsAge Epilepsy PNESInfant / Genetic-metabolic Difficulties in school - 46%Children disorder Family discord – 42 % Infection Interpersonal conflict – 25 % Physical abuse – 12% Sexual abuse – 5%Elderly Stroke Traumatic experience Neurodegenerative (female < 55 ys  prior sexual abuse) disorder (elder adult: severe physical-health Tumor problem, health-related traumatic experience) Developmental factors Adolescent: depression Prepubescent: cognitive dysfunction, epilepsy (comorbid) Devinsky, O. et al. Nat. Rev. Neurol. 7, 210–220 (2011); published online 8 March 2011; doi:10.1038/nrneurol.2011.24 Ersifas 15
  • 16. PathogenesisDevelopmental insult/trauma psychological stress > coping capacity• Janet: Psychosocial automatism• Freud: unconscious conflict symbolically converted into somatic symptoms  reduce anxiety, shield conscious self from painful emotion  Primary & secondary gainMay have abnormality in brain structure, but seizurenot associated with specific area/type of lesion Ersifas 16
  • 17. What causes my attacks? - www.nonepilepticattacks.com Ersifas 17
  • 18. Bradley: Neurology in Clinical Practice, 5th edATTACK FEATURE PSYCHOGENIC SEIZURE EPILEPTIC SEIZUREStereotypy of attack May be variable Usually stereotypicalDuration May be prolonged BriefDiurnal variation Daytime Nocturnal or daytimeInjury Rare Can occur with tonic- clonic seizuresTongue biting Rare Can occur with tonic- clonic seizuresIctal eye closure Common Rare (eyes generally open)Urinary incontinence Rare FrequentMotor activity Prolonged, uncoordinated; pelvic Automatisms or coordinated tonic- thrusting clonic activityProlonged loss of muscle tone Common RarePostictal confusion Rare CommonPostictal crying Common RareRelation to medication changes Unrelated Usually relatedTriggers Emotional disturbances NoInterictal EEG findings Normal Frequently abnormalReproduction of attack by Sometimes NosuggestionIctal EEG findings Normal AbnormalPresence of secondary gain Common UncommonPsychiatric disturbances Common Uncommon Ersifas 18
  • 19. Ersifas 19
  • 20. Ersifas 20
  • 21. Ersifas 21
  • 22. Differentiating between nonepileptic and epileptic seizures Orrin Devinsky, Deana Gazzola and W. Curt LaFrance Jr Devinsky, O. et al. Nat. Rev. Neurol. 7, 210–220 (2011); published online 8 March 2011; doi:10.1038/nrneurol.2011.24 Ersifas 22
  • 23. Differentiating between nonepileptic and epileptic seizures Orrin Devinsky, Deana Gazzola and W. Curt LaFrance Jr Devinsky, O. et al. Nat. Rev. Neurol. 7, 210–220 (2011); published online 8 March 2011; doi:10.1038/nrneurol.2011.24 Ersifas 23
  • 24. Differentiating between nonepileptic and epileptic seizures Orrin Devinsky, Deana Gazzola and W. Curt LaFrance Jr Devinsky, O. et al. Nat. Rev. Neurol. 7, 210–220 (2011); published online 8 March 2011; doi:10.1038/nrneurol.2011.24 Ersifas 24
  • 25. Differentiating between nonepileptic and epileptic seizures Orrin Devinsky, Deana Gazzola and W. Curt LaFrance Jr Devinsky, O. et al. Nat. Rev. Neurol. 7, 210–220 (2011); published online 8 March 2011; doi:10.1038/nrneurol.2011.24 Ersifas 25
  • 26. Differentiating between nonepileptic and epileptic seizures Orrin Devinsky, Deana Gazzola and W. Curt LaFrance Jr Devinsky, O. et al. Nat. Rev. Neurol. 7, 210–220 (2011); published online 8 March 2011; doi:10.1038/nrneurol.2011.24 Ersifas 26
  • 27. Pseudoseizure Factitious disorder (a Somatoform Disorder) a condition where patients MalingeringConversion, Somatization intentionally fake disease, or the intentional faking ora psychiatric condition that intentionally cause disease in creating of illness in order to results in order to play the ‘patient obtain secondary gain (e.g.a neurological complaint or role’. workers compensation, symptom, without any characterized by patients disability payments, avoiding underlying neurological frequently feigning illness to work or jail time, pain cause. obtain attention, sympathy, medication, etc.) or other emotional feedback [1] Simon, Greenberg, Aminoff, Clinical Neurology 7th ed, 2008 [2] http://shortwhitecoats.com/2011/conversion-vs-factitious-disorder-vs-malingering Ersifas 27
  • 28. PseudoseizureConversion, Somatization Malingering Px unaware of Factitious disorder Conscious awareness of psychogenic nature of Px recognize te spells are production of symptomssymptoms & motivation self-induced, but not the & underlying motivation of their production [1] reason for doing so Intentional, secondary Unintentional, due to Intentional, primary or and often monetary gain emotional stressors, no ‘emotional’ gain ‘gain’ to the patient [2] [1] Simon, Greenberg, Aminoff, Clinical Neurology 7th ed, 2008 [2] http://shortwhitecoats.com/2011/conversion-vs-factitious-disorder-vs-malingering Ersifas 28
  • 29. Ersifas 29
  • 30. What epileptic seizures are most likely to be mistaken for NESs?Frontal lobe seizures• Unsual midline movement (pelvic thrusting, bicycling)• Very brief post-ictal states• Ictal EEG abnormality may escape detection Simon, Greenberg, Aminoff, Clinical Neurology 7th ed, 2008 http://shortwhitecoats.com/2011/conversion-vs-factitious-disorder-vs-malingering Ersifas 30
  • 31. Diagnosis• In px with epilepsy NES should be considered when previously controlled seizures become medically refractory.• Other psychiatric disturbances  high frequency of hysteria, depression, and personality disturbances Px should have a psychological assessment• A secondary gain can be identified.• Can frequently be precipitated by suggestion & certain clinical tests Bradley, 2004 Ersifas 31
  • 32. Benbadis, Medscape, 2011Laboratory Studies• Useful only in excluding metabolic or toxic causes of seizures (eg, hyponatremia, hypoglycemia, drugs).• Prolactin & creatine kinase (CK) levels rise after generalized tonic-clonic seizures and not after other types of episodes. However, sensitivity is too low to be of any practical value (ie, lack of elevation does not exclude epileptic seizures).Imaging Studies• Normal in psychogenic nonepileptic seizures (PNES), images should be obtained to exclude organic pathology. Ersifas 32
  • 33. Benbadis, Medscape, 2011EEG and ambulatory EEG• Because of its low sensitivity, routine EEG is not helpful in confirming a diagnosis of PNES. However, repeatedly normal EEG findings, especially in light of frequent attacks and resistance to medications, can be viewed as a red flag.• Ambulatory EEG is increasingly used, it is cost effective, and it can contribute to the diagnosis by recording the habitual episode and documenting the absence of EEG changes.EEG video monitoring• the criterion standard for diagnosis and indicated in all patients who have frequent seizures despite taking medications.• combined electroclinical analysis of both the clinical semiology of the ictus and the ictal EEG findings allows for a definitive diagnosis in nearly all cases.• The principle is to record an episode and demonstrate that no change in the EEG occurs during the clinical event and that the clinical episode is not consistent with seizures unaccompanied by EEG changes. Ersifas 33
  • 34. MRI• up to 30% of patients with PNES were identified as having MRI abnormalities (most often non-specified gliosis), other studies have indicated that imaging abnormalities—the most common being postoperative defects—are present in 10% of these patients• Patients with PNES and patients with epileptic seizures can both have normal brain MRI findings• MRI findings support, but cannot confirm, a diagnosis of epilepsy• MRI may not differentiate between these two types of seizures Ersifas 34
  • 35. SPECT• The capability of SPECT to differentiate between PNES and epileptic seizures remains unknown.• Patients with epileptic seizures or PNES can have normal ictal and interictal SPECT findings. Ersifas 35
  • 36. Subtraction of interictal from ictal SPECT coregistered to MRI (SISCOM)• No changes in SPECT abnormalities occur during episodes in 85% of patients with PNES  negative finding on SISCOM are considered to support a diagnosis of PNES• Px with epileptic seizures may also have non- localizing findings on SISCOM  SISCOM of little value in diagnosing PNES. Ersifas 36
  • 37. Psychiatric Evaluation• Comorbid psychiatric disorders (most often): depression, anxiety, PTSD & personality disorders  significantly impact quality of life• Identify conflicts or traumatic experiences  aid diagnosis of PNES• Psychiatric consultations facilitate the appropriate inpatient or outpatient follow-up after discharge• Might be a first step to helping patients with seizures cope with their condition but, at present, psychiatric assessments in seizure evaluations are underutilized Ersifas 37
  • 38. Therapy• Education• Some px with pseudoseizure also have genuine epileptic seizure that require anticonvulsant• Psychiatric referral may be helpfulSimon, Greenberg, Aminoff, Clinical Neurology 7th ed, 2008 Ersifas 38
  • 39. The End