Psychogenic Nonepileptic Seizure

Aka: Psychogenic Nonepileptic Seizure, Psychogenic Seizure, Hysterical Seizure, Pseudoseizure, PNES, Psychogenic Non-Epileptiform Activity, PNEA

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II. Definitions

  1. Psychogenic Nonepileptic Seizure (PNES, Pseudoseizure)
    1. Seizure-Like Symptoms without abnormal electrical activity

III. Epidemiology

  1. Incidence: 1-3 per 100,000
  2. Prevalence: Up to 33 per 100,000
  3. May account for up to 25% of Seizures at Epilepsy centers (ambulatory and inpatient)
  4. Epilepsy patients may also have Psychogenic Seizures in up to 30% of cases
  5. Females account for at two thirds of Psychogenic Seizure patients

IV. Risk Factors

  1. Traumatic Brain Injury
  2. Sexual Trauma

V. Causes

  1. Anxiety Disorder
    1. Panic Attacks
    2. Post-Traumatic Stress Disorder
  2. Conversion Disorder
  3. Acute stress response

VI. Precautions

  1. Pseudoseizures (or Psychogenic Seizures, PNES) are not Malingering
  2. Patients having Psychogenic Seizures typically do not know this is happening
  3. PNES diagnosis does not exclude neurologic Seizures
    1. PNES can coexist with Epilepsy and neurologic Seizures
    2. Martin (2003) Neurology 61(12): 1791-2 [PubMed]

VII. Signs

  1. Atypical Seizure motor activity
    1. Asymmetric arm and leg movement
      1. Often non-focal involving opposite arm and leg (e.g. left arm and right leg activity)
      2. Contrast with Seizures which tend to be focal
    2. Pelvic thrusting
    3. Head turning from side to side
    4. Dystonic Posture
    5. Eyes closed and resists Eyelid movement
    6. Tongue biting limited to tip of Tongue
    7. Avoidance during Seizure
  2. Atypical Seizure timing
    1. Gradual onset and last 2-3 minutes (contrast with 1 minute for typical Seizure)
    2. Waxing and waing course (contrast with rhythmic periodicity of Seizure)
    3. Recur frequently
    4. Typically lacks the postictal period of Seizure Disorder
  3. Other factors
    1. Resistance to multiple antiepileptic agents
    2. Emotional or situational triggers
    3. Postictal crying
    4. May remember episode (contrast with Seizure where there is no memory of the episode)

VIII. Differential Diagnosis

  1. See Nonepileptic Seizure
  2. Movement Disorder (e.g. Tic Disorder, Extrapyramidal Side Effect)
  3. Atypical epileptic Seizures
    1. Frontal LobeSeizure
      1. Atypical motor and verbal activity
      2. Often occur during sleep and brief duration
    2. Gelastic Seizure (laughs during Seizure)
    3. Myoclonic Seizure
  4. Somatization
    1. Hypochondriasis

IX. Diagnosis: End-Tidal CO2

  1. Prolonged Seizure
    1. Oxygen Saturation falls
    2. End-Tidal CO2 rises
  2. Prolonged Psychogenic Seizure
    1. Oxygen Saturation remains normal
    2. End-Tidal CO2 remains normal

X. Diagnosis: Inpatient Video EEG

  1. Typical Seizure as confirmed by witnesses of Seizure
  2. No corresponding EEG abnormalities
  3. Interrater reliability of EEG monitoring is poor
    1. Benbadis (2009) Neurology 73(11):843-6 [PubMed]

XI. Diagnosis: Clinical findings that do not identify Seizure Disorder

  1. Postictal Serum Prolactin
  2. Tongue-biting, self-injury or Incontinence
  3. Psychological Testing
  4. Outpatient Electroencephalogram

XII. Management

  1. Acute Seizure management
    1. Start with Benzodiazepines (as with Status Epilepticus)
  2. Interdisciplinary approach
    1. Psychogenic Seizure cannot be fully differentiated from epileptic Seizure without EEG
  3. Mental Health
    1. Cognitive Behavioral Therapy may reduce PNES events in the short term
    2. Goldstein (2010) Neurology 74(24): 1986-94 [PubMed]

XIII. Complications: High Mortality

  1. Mortality related to Psychogenic Seizures is 2.5 fold higher than the general population (8 fold higher in age <30 years)
  2. In age <50 years, Suicide is responsible for 20% of deaths in patients with Psychogenic Seizure

XIV. References

  1. Bright, Shoenberger, Stellpflug in Herbert (2013) EM:Rap 13(3):3-4
  2. Marcolini and Swaminathan (2024) EM:Rap, 7/1/2024

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