Clinical Review

Psychogenic Nonepileptic Seizures

Journal of Clinical Outcomes Management. 2014 June;21(6)

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Terminology

There is an ongoing debate regarding the appropriate terminology for psychogenic events, and there is no uniform standardized definition or classification at this time. The term that is currently preferred within the epilepsy community for seizures of psychological origin that are thought to be associated with conversion, somatization, or dissociative disorders is “psychogenic nonepileptic seizures” (PNES). This terminology is felt to be non-disparaging and more neutral as compared with other terms such as pseudoseizures, which were previously favored. Nonepileptic seizures or nonepileptic events are broader terms meant to incorporate both physiologic and psychological causes for disorders that are mistaken for epilepsy. PNES are widely defined as paroxysmal events that appear similar to epileptic seizures but are not due to abnormal electrical discharges in the brain and as noted, are typically thought to be related or caused by conversion, somatization, or dissociative disorders.

Physiologic nonepileptic events are another category of physical disorders that may be mistaken for epilepsy. The underlying causes differ between age-groups, and can include conditions such as cardiac arrhythmias, migraine variants, syncope, or metabolic abnormalities. Physiologic nonepileptic seizures account for only a small proportion of all patients with nonepileptic seizures or events [1]. In general, any patient with a psychological disorder that causes symptoms that are mistaken for epilepsy can be said to have PNES.

Clinical Characteristics And Presentation

PNES and epileptic seizures are predominantly distinguished through clinical observation along with descriptions from the patient or witnesses, and an understanding of seizure semiology. Although video EEG may be needed to confirm the diagnosis, certain clinical characteristics and historical details can help to distinguish between the 2 disorders (Table 1) [24,25]. Features to consider include movements and/or vocalizations during seizures, duration of seizures, and other factors such as injury, incontinence, and amnesia [1,24,25]. Caution must be taken not to use one sign or feature in isolation, as none have been found to be specifically pathognomonic.

The duration of PNES is often significantly longer than that seen in epileptic seizures, which usually last less than 3 minutes, excluding the postictal period. PNES may also exhibit waxing and waning convulsive activity, although this finding can certainly be seen in epileptic seizures as well. PNES may be shown to have distractibility with external stimuli. Additionally, the movements in PNES may appear asymmetric, asynchronous, or purposeful, although this is not diagnostic for this disorder. This may contrast with the well-defined, synchronous tonic-clonic activity typically seen in epileptic seizures [1,24,25]. Back arching and pelvic thrusting movements can also be seen in PNES. Despite these differences, it may still be challenging to distinguish the semi-purposeful behaviors of PNES from the automatisms of certain focal epileptic seizures. The often bizarre-appearing, hypermotor activity that can be seen in frontal lobe seizures is often especially difficult to differentiate from PNES [1,23].

Another important consideration is that consciousness is preserved in PNES, while consciousness and responsiveness are frequently impaired in epileptic seizures. Patients with PNES are often apparently unresponsive during events, although there is no true impairment of awareness. Other characteristics that are more commonly seen in PNES are crying and eye closure [26]. Self-injury and incontinence may be reported, but they are less often clearly witnessed or documented [27,28]. Additionally, although patients may at times appear to be asleep at seizure onset, EEG recordings document the patient to actually be asleep in less than 1% of cases [29]. While epileptic seizures often respond well to antiepileptic medications, PNES characteristically do not [1,3,6,8].