Non Epileptiform Seizures

3,176 views

Published on

Published in: Health & Medicine
1 Comment
5 Likes
Statistics
Notes
No Downloads
Views
Total views
3,176
On SlideShare
0
From Embeds
0
Number of Embeds
9
Actions
Shares
0
Downloads
113
Comments
1
Likes
5
Embeds 0
No embeds

No notes for slide
  • Not every thing shakes is seizures
  • Non Epileptiform Seizures

    1. 1. NON EPILEPTIFORM SEIZURES Dr. Anant Kumar Rathi Deptt. Of Neuropsychiatry Govt. Medical College, Kota, (Raj) 26/03/2012
    2. 2. Epileptic seizure “A transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain." International League Against Epilepsy (ILAE) Epileptic seizures can occur in someone who does not have epilepsy – as a consequence of Head injury Drugs Toxins Eclampsia Febrile convulsions
    3. 3. Seizure imitators MOVEMENT IMITATORS LOC IMITATORS NO ONE HAVE Each have EPILEPTIFORM some BRAIN features of DISCHARGE epilepsy CONFUSION IMITATORS PSYCHOLOGICAL IMITATORS
    4. 4. Movement imitators Unusual movements or postures – twisting & twitching Tremors – rhythmic shake like movements of body part Dystonia – continuous maintenance of abnormal posture Chorea – hands looks like actually dancing Athetosis – arms & legs move like swimming Hemiballismus – violent flying movements usually restricted to one side of body Tics - habitual quick abnormal movements, semi voluntary
    5. 5. Loss of consciousness imitators Fainting/ Syncope – blood flow to brain suddenly decrease Panic attack – blood pooled to muscles- brain temporarily shut down – vasovagal attack Loss of body fluid – hypovolemia, dehydration Cardiac disease – infarction, heart failure Hypoglycemia – prolonged fasting, excess insulin, medication S/E, reaction to high carbohydrate load Hypoxia – lung disease, choking, high altitude
    6. 6. Confusion imitators TIA – Blood flow to brain interrupted briefly Symptoms depends on area involved TIA affecting speech, memory or sensory-motor area may produce confusion, tingling, weakness Uncontrollable sleepiness – Missed interrupted sleep Medication side effect Sleep disorders – sleep apnea, narcolepsy, night terror Migraine aura – Dizziness, lightheadedness, colors & lights Transient global amnesia – Loss of ability to form new memory Delirium/ encephalopathy - Prolonged confusion that waxes & wanes
    7. 7. Psychological imitators Breath holding spells Temper tantrums Night terrors – child screams & do not remember the episode Panic attacks – extreme anxiety – rapid ventilation – CO2 wash out – dizziness, numbness, confusion, tremors – looks like seizures Psychological Non Epileptic Seizures (PNES)
    8. 8. History Misdiagnosis of epilepsy is common - Approximately 25% of patients with a previous diagnosis of epilepsy that does not respond to drugs PNES is by far the most commonly misdiagnosed condition, accounting for >90% of misdiagnoses EEGs misinterpreted as providing evidence for epilepsy often contribute to this misdiagnosis
    9. 9.  Reversing a misdiagnosis of epilepsy can be difficult -After the diagnosis of seizures is made, it is easily perpetuated without being questioned -Treating Doctor does not want to stop AED
    10. 10. Pseudoseizures Paroxysmal episodes that resemble and often misdiagnosed as epileptic seizures Paroxysmal nonepileptic episodes can be either organic or psychogenic Syncope, migraine, and transient ischemic attacks (TIAs) are examples of organic nonepileptic paroxysmal symptoms
    11. 11. Psychogenic Non Epileptiform Seizures (PNES)/ DS No abnormal electrical discharge from the brain Physical manifestation of a psychological disturbance Most frequent nonepileptic condition seen in epilepsy centers They are a type of conversion disorder Pt. is not aware & can not control PNES can also result from voluntary faking (feigning), as in malingering and factitious disorder
    12. 12. PNES/DS causes Physical symptoms caused by psychological causes can fall under 3 categories: -Somatoform disorder -Factitious disorder -Malingering
    13. 13. Somatoform disorder Unconscious production of physical symptoms due to psychological factors 2 somatoform disorders relevant to PNES are -conversion disorder -somatization disorder Majority of patients with PNES have conversion disorder DSM-IV added a new subcategory conversion disorder with seizures
    14. 14. Factitious disorder and malingering Patient is purposely deceiving the physician, i.e. faking the symptoms Malingering - the reason for the deception is tangible and rationally understandable Factitious disorder- the motivation is a pathologic need for the sick role
    15. 15. Who has dissociative seizures? Can happen to anyone, at any age Some factors make DS more likely -Women (>70%) -Young adults -History of injury or disease -Severe emotional upset or stressful life events -People with other psychiatric conditions depression anxiety personality disorders self-harm
    16. 16. What causes dissociative seizures?  Often caused by traumatic events such as: -accidents -severe emotional upset -psychological stress (such as a divorce) -difficult relationships -physical or sexual abuse -being bullied
    17. 17. Sudden Dissociative seizuresremembering traumatic experience Too difficult to cope with Person splits off Emotional reaction causes Seizures a physical effect unconscious reaction uncontrolled
    18. 18. Clues which should raise the suspicion Resistance to antiepileptic drugs (AED) is usually the 1st clue Presence of specific triggers that are unusual for epilepsy Emotional triggers - stress, pain, certain movements, sounds, and seeing of lights Circumstances in which attacks occur Presence of audience, sleep
    19. 19. PNES/Dissociative seizures Details of the episodes - often inconsistent with epileptic seizures Common and helpful symptoms include - -side-to-side shaking of the head -bilateral asynchronous movements (e.g. bicycling) -weeping, stuttering, and arching of the back -pelvic thrusting -preserved awareness -eye flutter -episodes affected by bystanders (intensified or alleviated)
    20. 20.  Psychosocial history with evidence of maladaptive behaviors or associated psychiatric diagnoses Patients medical history - Coexisting, poorly defined, and probably psychogenic conditions, such as fibromyalgia, chronic pain, and chronic fatigue Certain symptoms suggest epileptic seizures -tongue biting -ictal cry
    21. 21. Physical and neurologicfindings – Anxiety/ depression Inappropriate affect la belle indifference Multiple and vague somatic complaints
    22. 22. How are NES diagnosed? Try and rule out possible physical causes first, including epilepsy Taking a personal history Neurological history Psychological development and mental health family history What happens during the seizure What situations ? Any warning ? What happens during seizure or a witness ? How long the seizures last ? What you remember ? How you feel afterwards and recovery ?
    23. 23. How are NES diagnosed? Laboratory Studies Blood tests - excluding metabolic or toxic causes of seizures (e.g. hyponatremia, hypoglycemia, drugs/toxins) Level of AED in Pt’s blood, whether AED is being taken? Proper dose? Imaging Studies Should be obtained to exclude physical cause Normal in psychogenic nonepileptic seizures Electroencephalogram Records the electrical activity of the brain Often used to see if seizures are caused by disrupted brain activity
    24. 24. Epilepsy & prolactin level elevation > 2-3 fold prolactin elevation measured within 10 – 20 mins of seizure suggests presence of epileptic seizure The lack of such an elevation makes it unlikely that an ictal event was epileptic if the event was a tonic-clonic seizure Limitations :- -Cannot be used to differentiate simple partial seizures or absence seizures from nonepileptic seizures -Prolactin levels may increase during syncope -Complex partial seizures that do not arise from the temporal lobe do not lead to prolactin elevation -10% to 20% of patients with tonic-clonic seizures may not show a postictal prolactin rise -Level rises predictably only after a single seizure, patients having > 2 seizures in 12 hours have progressively smaller elevations, presumably because stored prolactin from pituitary lactotrophs is exhausted
    25. 25. How are PNES diagnosed? Routine EEG is not helpful in confirming diagnosis of PNES Repeatedly normal EEG findings Frequent attacks May be PNES Resistance to medications EEG video monitoring Standard for diagnosis Indicated in all patients having frequent seizures despite AED
    26. 26. EEG video monitoring Principle is to record an episode and demonstrate that no change in the EEG occurs during the clinical event Inductions - Provocative techniques - intravenous injection of saline - principle is suggestibility
    27. 27. Treatment Medical Care Most important step is delivering the diagnosis to patients and their families Obstacle to effective treatment- Physicians are uncomfortable with the diagnosis of PNES They may write, "no EEG change during the episode, no evidence for epilepsy," or "seizures were nonepileptic.“
    28. 28. Treatment Role of the Neurologists Determine whether organic disease exists Once the symptoms are shown to be psychogenic, the exact psychiatric diagnosis and its treatment are best handled by the psychiatrist
    29. 29. Treatment Role of the Psychiatrist Psychotherapy Treatment coexisting anxiety or depression Patient education Family members education Patient & Family members education Thorough patient education is the first step in treatment Patients and their families must understand about the disease Necessity to comply with the recommendations of the psychiatric caregiver
    30. 30. Prognosis Duration of illness is probably most important prognostic factor in PNES Early & definite diagnosis of PNES is critical Generally better in children and adolescents than in adults -duration of illness is shorter -psychopathology or stressors are different in pediatric patients than in adults Prognosis depends on -Pt’s motivation -Treatment of underlying psychological illness -Good medical help
    31. 31. Activity Patients with PNES usually do not require any limitation of activities Nevertheless, restrictions on potentially hazardous activities may be appropriate in some cases
    32. 32. Take home message Everything which moves is not seizure Rule out other possible physical cause Take proper history Most common cause of non epileptic seizures is PNES Susceptible person Presence of stress Frequent attacks Repeatedly normal EEG Not responding to AED Video EEG showing no abnormal electrical discharges during attack confirms the diagnosis
    33. 33. Take home message Early diagnosis is essential Best to be managed by a psychiatrist Delivering the diagnosis is usually the first step Explain the disease to patient as well family members Treatment of co morbid psychiatric illness is necessary Psychotherapy is given Advised to follow up with Psychiatrist

    ×