This document discusses psychogenic nonepileptic seizures (PNES). PNES are characterized by sudden disturbances in motor, sensory, cognitive or emotional functioning that mimic epileptic seizures but are caused by psychological factors rather than abnormal brain activity. The diagnosis of PNES is challenging and often delayed due to the diversity of presentations. Video EEG monitoring is the gold standard for diagnosis and should be performed when PNES is suspected to rule out epilepsy. Treatment involves delivering the diagnosis to patients and managing any underlying psychiatric conditions, usually through psychotherapy. Prognosis depends on factors like duration of illness, motivation for treatment and management of comorbid psychological issues.

2.  DEFINITION
 EPIDEMIOLOGY
 ETIOLOGY
 CLINICAL FEATURES
 DIFFERENTIAL DIAGNOSIS
 DIAGNOSIS
 TREATMENT
 PROGNOSIS

3.  PNES are characterized by sudden and
time-limited disturbances of motor, sensory,
autonomic, cognitive, and/or emotional
functions that can mimic epileptic seizures.
 Historical terms for PNES, including
pseudoseizures and hysterical seizures, are
now discouraged
Psychogenic nonepileptic seizures - UpToDate

4.  Incidence rates of PNES in the general
population are not well established.
 estimated incidence rate ranges from 1.5 to
5 per 100,000 persons per year
 The prevalence of PNES has been
estimated to be between 2 to 33 per 100,000
persons
Sigurdardottir KR, Olafsson E. Incidence of psychogenic seizures in adults: a
population-based study in Iceland. Epilepsia

5.  most commonly - third decade of life
 female predominance
 young children and older adults can be
affected
 Race, marital status, and years of education
does not influence the prevalence of PNES

7.  Physical symptoms caused by psychological
causes can fall under 3 categories:
-Somatoform disorder
-Factitious disorder
-Malingering

8.  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

9.  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

10.  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
personality disorders
anxiety
self-harm

11.  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

12. Sudden
remembering
traumatic
experience
Too difficult to
cope with
Person splits off
Emotional
reaction causes
a physical effect
Seizures
unconscious
reaction
uncontrolled

13.  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

15.  A history of sexual or physical abuse is
reported in one-third to one-half of patients
 Individuals with a hx of sex abuse may be
more like to have clinical events that are
more severe and more likely to resemble
epileptic seizures
 They are more likely to exhibit self-harming
behaviors and other medically unexplained
symptoms
Paras ML, Murad MH, Chen LP, et al. Sexual abuse and lifetime
diagnosis of somatic disorders: a systematic review and meta-
analysis. JAMA 2009;

16.  Recognizing PNES can be challenging even
for experienced observers, in part because
of the broad diversity of presentations.
 Nonetheless, clues that raise suspicion for
this diagnosis are often apparent from the
clinical history

17.  Witnesses present- Most episodes of PNES
occur in front of witnesses
 the occurrence of an episode in the doctor's
waiting or examination room was estimated to
have a 75 percent predictive value for PNES
 in a study of patients undergoing
electroencephalography (EEG) monitoring,
episodes that occurred at the time of electrode
placement were found to be PNES, not epileptic
seizures
Woollacott IO, Scott C, Fish DR, et al. When do psychogenic nonepileptic seizures occur on a video/EEG telemetry unit?
Epilepsy Behav 2010;

18.  Relationship to sleep-
 PNES tend not to occur during sleep by
contrast, epileptic seizures can occur during
sleep
 Patients with PNES may appear to be asleep
just before seizure onset, but the EEG in
these cases demonstrates wakefulness

19.  Stress- PNES would be more likely to be
associated with stressful situations, stress is
also commonly cited as a seizure precipitant
in patients with epilepsy
 Menstrual cycle- Increased seizure
frequency during the perimenstrual time
period suggests epileptic seizures. In one
series, perimenstrual exacerbation was
associated with 13 of 27 patients with
epileptic seizures versus 1 of 38 patients
with PNES
Ettinger AB, Weisbrot DM, Devinsky O. Patient reporting of seizure exacerbation near the time of menses
helps distinguish epileptic from nonepileptic seizures. J Epilepsy 1998;

21.  Motor activity- movements in PNES are
more often asynchronous, variable, and may
wax and wane over the course of the ictus
 Specific movements such as writhing,
thrashing, pelvic thrusts, opisthotonus
(arched back), and jactitation (rolling from
side to side) suggest PNES, but these are
not always present, particularly in children

22.  Tongue-biting and self-injury- Classic
symptoms of epileptic seizures such as
tongue-biting, incontinence, and self-injury
are more common in epileptic seizures, but
they can occur in a third or more of patients
with PNES
 A tongue bitten on the side (versus the tip)
and severe tongue-biting (with laceration)
are more specific for epileptic seizure .
 Seizure related burn injuries are also highly
specific for epileptic seizures

23.  Level of awareness- Incomplete loss of
consciousness during the episode,
suggested either by responsiveness to
stimuli or by later recall of events during
segments of ictal unresponsiveness,
supports PNES .
 The presence of an alpha rhythm on the
EEG (ie, neurophysiologic evidence of
wakefulness) during an episode in which the
patient is clinically altered or amnestic also
supports a nonepileptic process.
Bell WL, Park YD, Thompson EA, Radtke RA. Ictal cognitive assessment of partial
seizures and pseudoseizures. Arch Neurol 1998; 55:1456.

24.  Vocalizations- Ictal features of emotional
overlay, such as weeping, stuttering, and
vocalizations with affective content, are
relatively uncommon in epileptic seizures
and suggest PNES
 Auras – A seizure aura is frequently reported
in PNES (25 to 60 percent) and may be a
more common symptom than in epilepsy
 Autonomic signs – Autonomic
manifestations during an ictus (eg,
tachycardia, cyanosis) suggest epileptic
seizure, and their absence, particularly
during a major convulsion, suggests PNES
Opherk C, Hirsch LJ. Ictal heart rate differentiates epileptic from non-
epileptic seizures. Neurology 2002; 58:636.

25.  Eye closure – Eyes are usually open during
the ictus of a convulsive epileptic seizure
.Forced eye closure in particular suggests
PNES
 Atonia – Ictal atonia is not a common PNES
manifestation. However, when prolonged
events of atonia occur, they almost always
represent PNES rather than epileptic seizure
 Duration – While the ictus of an epileptic
seizure is typically very brief, often less than
one minute, PNES are rarely less than one
minute and are usually much longer
 Frequency – Patients with PNES generally
report a higher seizure frequency than
patients with epilepsy

27.  Return to baseline- Rapid alerting and
reorientation are common after PNES but
uncommon with epileptic seizures, except for
certain seizure types, such as absence or
frontal lobe seizures
 Respiratory changes -The postictal period
after GTCS -deep and prolonged inspiratory
and expiratory phases (stertorous breathing
pattern), compared with shallow, rapid
respirations in patients after a PNES .
Epileptic seizures arising from the frontal lobe,
however, were associated with a postictal
breathing pattern similar to PNES

28.  Response to treatment — Most patients
with PNES have seizures for many years
prior to diagnosis,and most are treated
unsuccessfully with antiseizure drugs .
 A failure to make even small improvements
in seizure frequency despite vigorous
antiseizure drug trials suggests the diagnosis
of PNES.
 Similarly, patients who present with
prolonged PNES are often treated with drug
protocols for status epilepticus and fail to
respond

38.  Clinical features of events are often not
sufficiently sensitive or specific to definitively
distinguish seizures from PNES, and
confirmatory video-EEG testing is usually
required to supplement the history
 Levels of diagnostic certainty — Video-
EEG is the gold-standard test for the
diagnosis of PNES and should be performed
in all patients in whom this diagnosis is
suspected

39.  Try and rule out possible physical causes first, including epilepsy
 Taking a personal history
 Neurological history
 Psychological development and mental health familyhistory
 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 ?

40.  Laboratory Studies
 Blood tests - excluding metabolic or toxic causes of seizures (e.g.
hyponatremia, hypoglycemia, drugs/toxins)
 Level ofAED 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

41.  > 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

43.  The diagnosis of PNES can be challenging, with
delays as long as 10 to 15 years in some case
series .
 This is due in part to the broad diversity of
PNES presentations and the lack of one single
unifying presenting symptom.
 Other sources of misdiagnosis include an
› inadequate history,
› Co-occurrence of PNES and epilepsy in the same
patient,
› poor clinician-patient rapport,
› reliance upon clinical observation of the event
› discomfort in making a psychiatric diagnosis, and
› reluctance to obtain a psychiatric evaluation before
the clinician feels confident about the diagnosis-

44.  Routine EEG is not helpful in confirming diagnosis of PNES
 Repeatedly normal EEG findings
 Frequent attacks
 Resistance to medications
 EEG video monitoring
Standard for diagnosis
Indicated in all patients having frequent seizures despiteAED
Maybe
PNES

45.  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

46. MedicalCare
 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.“

47. 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

48. 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

49.  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

50. Activity
 Patients with PNES usually do not require any
limitation of activities
 Nevertheless, restrictions on potentially
hazardous activities may be appropriate in
some cases

51.  Everything which moves is not seizure
 Rule out other possible physical cause
 Takeproper history
 Most common cause of non epileptic seizures is PNES
Susceptible person
Presence of stress
Frequent attacks
Repeatedly normal EEG
Not responding toAED
Video EEG showing no abnormal electrical discharges
during attack confirms the diagnosis

52.  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