Journal of Clinical Outcomes Management. 2014 June;21(6)
References
In addition, the patients who tended to have less seizures and do better long term, had less somatoform and dissociative symptoms on psychometric testing [51]. These findings are often explained by the theory that patients who do not do well have poor coping strategies to deal with stress and anxiety and that in a sense, these patients have emotional dysregulation.
Special Issues
Coexisting Epileptic and Psychogenic Nonepileptic Seizures
A complicating factor in diagnosis is that both PNES and epileptic seizures may occur in a single patient. Indeed, approximately 10% to 40% of patients identified to have PNES also have been reported to have epileptic seizures [1,23,33,56]. There are several possible explanations for this. Some patients with epilepsy may learn that seizures result in attention and fill certain psychological needs. Alternatively, they may have concomitant neurologic problems, personality disorders, cognitive deficits, or impaired coping mechanisms that predispose them to psychogenic symptoms [69–71]. Fortunately, in such patients with combined seizure disorders, the epileptic seizures are usually well controlled or of only historical relevance at the time a patient develops PNES [1,22,23,33,72–74].
In other patients, both epileptic and PNES may start simultaneously, making management even more complex. In such patients, we have found it particularly helpful to focus on the semiology of seizure manifestations as recorded by video EEG monitoring to distinguish PNES from the epileptic seizures. We then direct our treatment of the patient according to the semiology manifesting at that time. We also have found it useful to show the videos of seizures to family members or caregivers with patient consent to help them understand how to respond best to a patient’s symptoms when epileptic and PNES co-exist.
Misdiagnosis of Psychogenic Nonepileptic Seizures
Sometimes events that are initially diagnosed as nonepileptic actually prove to be epileptic. Such events can be called “pseudo-pseudo” or “epileptic-nonepileptic” seizures [1]. Frontal lobe seizures in particular may not be associated with significant EEG changes ictally and therefore misdiagnosed as PNES [23,75,76]. Clinical presentation and proper diagnosis of these types of events warrant emphasis.
Notable manifestations of frontal lobe seizures that may easily be confused with hysterical behavior include shouting, laughing, cursing, clapping, snapping, genital manipulation, pelvic thrusting, pedaling, running, kicking, and thrashing [23,75–77]. Not all of these behaviors are specific for frontal lobe seizures. For example, bicycling leg movements have also been reported in seizures originating from the temporal lobe [78].
Summary
PNES represent a common yet challenging problem within neurology. This is due to the difficulty in diagnosis as well as lack of effective and widely available treatment options. Overall outcomes of patients with PNES vary, and may relate to an individual patient’s chronic psychological and social problems. However, an accurate and timely diagnosis remains critical and can help provide direction for implementing appropriate treatment.
Corresponding author: Jennifer Hopp, MD, Department of Neurology, University of Maryland Medical Center, Room S12C09, 22 South Greene Street, Baltimore, MD 21201, jhopp@som.umaryland.edu.
