Psychogenic Nonepileptic Seizures

A prior history of head trauma, often of a relatively mild degree, has been described as a potential inciting factor for some cases of PNES [6,13]. In the literature, studies report that as many as 20% of PNES patients attributed their seizures to head trauma, often rather mild head trauma [6,14].

Historcial Context

Historically, what today are called PNES originate with the concept of hysteria, a medical diagnosis in women that can be traced to antiquity [15,16]. By the late 1800s, one of the founders of neurology, Jean Charcot, established hysterical seizures as an important clinical entity with his detailed, elegant descriptions of patients. Charcot formulated clinical methods for distinguishing hysteria and particularly hysterical seizures from epilepsy. He presumed that hysteria and epilepsy were closely related, and he termed seizures due to hysteria as “hysteroepilepsy” or “epileptiform” hysteria. Charcot proposed that hysterical seizures were organic disorders of the brain, like other forms of seizures and epilepsy, and emphasized their relation to disturbance of the female reproductive system [17,18]. Charcot utilized techniques such as manipulation of “hysterogenic zones” and ovarian compression as well as suggestion to both treat and provoke hysteria and hysterical seizures, which he described and documented [17,18]. One of Charcot’s most celebrated students, Sigmund Freud, observed Charcot’s demonstrations but drew different conclusions. He theorized that hysteria and hysterical seizures were not organic disorders of the brain as Charcot proposed, but were rather emotional disorders of the unconscious mind due to repressed energies or drives. Based largely the theories of Freud and Charcot, individuals with hysteria were distinguished from those with epilepsy, with hysterical seizures related to psychological dysfunction while epileptic seizures were associated with physical or organic brain disorders [15,16].

With the introduction of EEG recording in the 1930s, it became possible to characterize epilepsy as an electrical disorder of the brain with associated EEG changes and more effectively distinguish it from hysterical seizures, which did not have such abnormalities. In addition, in the first half of the 20th century, the nature of hysteria as seen and diagnosed by physicians seemed to change. The dramatic, theatrical convulsions described by Charcot and his contemporaries appeared less commonly, while disorders such as chronic pain seemed to increase [1,19].

However, by the 1960s, several reports confirmed that hysterical seizures were actually still prevalent. Newer terms like “pseudoseizures” were used to describe these disorders because the term “hysteria” was thought to be somewhat derogatory, anti-feminist, and antiquated [20,21]. In the 1970s and thereafter, with the increasing availability of video EEG monitoring and growth of inpatient epilepsy monitoring units, it was discovered that these hysterical, pseudo-, or what were also by then termed psychogenic seizures, were actually still common [1,22].

More recently, it has been recognized that the pendulum in some cases may have swung too far in regard to the diagnosis of this disorder. Some rare patients with seizures initially diagnosed as PNES may actually have forms of epileptic seizures such as frontal lobe epilepsy or related physiological disorders rather than psychogenic causes for their episodes [1,23]. These types of epileptic seizures can be very difficult to diagnose properly unless one appreciates how they present and manifest and remains vigilant for them during evaluation [1,23].