Non Epileptiform Seizures


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  • 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
    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