A seizure is a sudden disturbance in brain electrical activity that can cause changes in behavior, movements or feelings. Epilepsy is defined as two or more unprovoked seizures occurring more than 24 hours apart. Psychogenic non-epileptic seizures (PNES) present as paroxysmal alterations in motor, sensory, autonomic or cognitive signs and symptoms but are not caused by epileptiform brain activity. PNES are commonly misdiagnosed as epilepsy, leading patients to take unnecessary anti-epileptic drugs for years and undergo risky medical procedures. A diagnosis of PNES requires detailed clinical history, testing to rule out epilepsy, and may involve cognitive behavioral therapy and addressing any secondary gains from the episodes

2. Seizure VS Epilepsy
(Mayo Clinic, Roland D Thijs et al 2019,Lancet)
A seizure is a sudden, uncontrollable
electrical disturbance in brain,
which can cause change in your
behaviour, moments or feelings, and
in levels of consciousness.
Epilepsy is defined as two
unprovoked seizures
occurring more than 24
hrs apart.

3. Hysterical fit
Dissociative
attacks
Psychogenic
seizures
Non epileptic
conversion
seizures
Pseudo
epileptic attacks
Pseudo-
epilepsy
Psycho seizures
Functional
seizures
Non-epileptic
attack disorder
Pseudo-seizures
Hystero
epilepsy

4. sadi-Pooya AA, Brigo F, Mildon B, Nicholson TR. Terminology for psychogenic non-epileptic seizures: Making the
case for "functional seizures". Epilepsy Behav. 2020;104:106895
However the term adopted by the International League Against Epilepsy (ILAE) is

5. Psychogenic nonepileptic seizures (PNES)
• https://aepi.biomedcentral.com/articles/10.1186/s42494-019-0008-4#ref-CR1
PNES present as paroxysmal time-limited,
alterations in motor, sensory, autonomic, and/or
cognitive signs and symptoms, but are not caused by
Ictal epileptiform activity.

6. Prevalence
The prevalence of PNES was found to be 2.9/1000 population in a study in
rural India,
Currently estimated as 2-50/100,000 in the general population.
The prevalence of coexistent epilepsy and pseudo seizures is estimated
around 5%-40%.
GENDER
WOMEN: 70% OF DIAGNOSED PNES
MEN: 30% OF DIAGNOSED PNES
AGE
TYPICALLY BEGIN IN YOUNG ADULTHOOD
CAN OCCUR IN CHILDREN AND ELDERLY

7. A misdiagnosis can lead to:
• •
Dangerous interventions in the emergency room, (e.g. being "loaded up" with
powerful drugs and being intubated.
PATIENTS WITH PNES USUALLY TAKE ANTIEPILEPTIC DRUGS UNNECESSARILY FOR
MANY YEARS BEFORE THE DIAGNOSIS IS REVISED.
THIS EXPOSES PATIENTS TO UNTOWARD EFFECTS OF MEDICATION WITH NO BENEFIT
TO THEM WHATSOEVER.
SOME PATIENTS MAY RECEIVE IV MEDICATIONS FOR STATUS EPILEPTICUS THAT MAY
HAVE RESULTED IN INTUBATION AND POSSIBLE ADMISSION TO ICU.
EXPOSED THE PATIENT AND FAMILY TO A HIGH LEVEL OF STRESS WITH NO PROSPECT
OF RELIEF FROM THE PROBLEM.
UNNECESSARY MEDICAL COSTS/NEUROLOGISTS SERVICES/INPATIENT HOSPITAL DAYS
IMAGING/ EXTENDED EEG MONITORING AND VIDEO MONITORING

9. Pseudo seizure
(PNES)
True Seizure
HISTORY
(a)
Pattern
absence of any estabilished
pattern
Stereotyped pattern
(b)
Precipitant
Obvious emotional precipitant
and occurrence in presence of
others
May be there but less obvious and presence of
others not associated
(c)
Occurrence in sleep
Not there
May occur

10. OBSERVATIONS
(a)
Onset
Gradual Abrupt
(b)
Duration
Time variable but longer (10-15
min)
Short duration upto 1-2 minutes
(c)
Consciousness
Usually preserved with bilateral
motor activity.
May be fluctuating but some
response to pain
Lost and unresponsive to pain
(d)
Aura
Aura unusual except for symptoms
of hyperventilation
Aura usual
(e)
may have moan, cry, scream or
weep
Monotonous epileptic cry

11. f)
Movements
Nonsynchronous out of phase
movements (may be mild, jerky,
side to side head movements,
pelvic thrusting, limping,
motionless, unresponsive) •
Opisthotonic posturing or rigidity
for extended periods
Generalized tonic clonic movements starting
with fast small amplitude movements to
slower larger movements. Briefer rigidity,
supplementary movements (e.g. arms in
abduction)
h)
Injury
Self protection before fall, seldom
self injury
Frequent self-injury, bite tongue, hit head, hurt
limb
(i)
Reflexes
No pathological reflexes
Babinski reflex and pupillary constriction after
seizure
(j)
Postictal confusion Little and
patient unconcerned
Postictal confusion or transient paralysis

12. (k)
Amnesia
Better memory for event; Non-
organic amnesia
Amnesia
(l)
In front of significant others
usually occur
Unconcerned
(m) Independent witness Absent Present
(n)
Induction by suggestion Readily
induced or stopped
Not
(o)
Induction by sleep, Photic stimuli,
sleep deprivation,
hyperventilation not readily
Often precipitated
(p)
Others Avoidance behavior, arm
drop, eye openings genotropic
movement
Seeking help, tiredness, look blank, pupillary
reflexes

13. TESTING
(a)
pH immediately after attack
Normal
May change
(b) Creatinine kinase after attack NormalRises (significant if positive)
(c) Prolactin after attack Normal Rises (significant if positive)(16)
(d)
EEG
No epileptic form discharge,
maintenance of alpha rhythm with
only discontinuous muscle activity
record during attack and absence of
slowing with immediate
reappearance of previous occurred
alpha rhythm
• EEG may be abnormal in 10-
53%(14) and prompt clinical and EEG
recovery from a generalized
convulsive episode.
• Epileptic changes in majority (VEEG
preferred) Takes time to recovery (VEEG
useful)
(e)
Provocative methods Psychiatric
interview, suggestion, placebo
medication or hypnosis
Hyperventilation, photic stimuli or sleep
deprivation

14. Diagnosis ??
Rule out
possible
physical/organic
causes including
epilepsy.
Detailed clinical
history
Medical/Neurologi
cal/ psychiatric
Ask everything
about
pre/during and
post episode.
Laboratory
Studies
Imaging
EEG

15. Management
•
•
Patient
Education Family Education
MOST IMPORTANT
STEP IS DELIVERING
THE DIAGNOSIS TO
THE PATIENT AND
FAMILY
MAY COMMENT “ARE
YOU ACCUSING ME
OF FAKING?” OR “ARE
YOU SAYING I’M
CRAZY?”
UNLESS PATIENT AND
THEIR FAMILY
UNDERSTAND THE
DIAGNOSIS, THEY
WILL NOT FOLLOW
THROUGH WITH
TREATMENT

16. Mx contd
• Selective Serotonin Inhibitors Has Shown A Reduction In
Pnes.
• Use Of Psychotropic Medications To Treat Comorbid
Anxiety And Depressive Disorders Is Appropriate
• The Secondary Gain (Attention Received From
Surroundings) Should Be Immediately Stopped.
• Cognitive Behavioral Therapy Has Been Helpful In Reducing
Pnes
• Supportive psychotherapy and confrontation has been
found useful in over 75% patients.
• If A Psychiatrist Is Skeptical About The Diagnosis Of Pnes, A
Consultation With The Neurologist To View The Video
Recording May Be More Helpful Than A Written Report