II. Definitions
- Psychogenic Nonepileptic Seizure (PNES, Pseudoseizure)
- Seizure-Like Symptoms without abnormal electrical activity
III. Epidemiology
- Incidence: 1-3 per 100,000
- Prevalence: Up to 33 per 100,000
- May account for up to 25% of Seizures at Epilepsy centers (ambulatory and inpatient)
- Epilepsy patients may also have Psychogenic Seizures in up to 30% of cases
- Females account for at two thirds of Psychogenic Seizure patients
IV. Causes
- Anxiety Disorder
- Hypochondriasis
- Somatization
- Conversion Disorder
- Acute stress response
V. Precautions
- Pseudoseizures (or Psychogenic Seizures, PNES) are not Malingering
- Patients having Psychogenic Seizures typically do not know this is happening
- PNES diagnosis does not exclude neurologic Seizures
- PNES can coexist with Epilepsy and neurologic Seizures
- Martin (2003) Neurology 61(12): 1791-2 [PubMed]
VI. Signs
- Atypical Seizure motor activity
- Asymmetric arm and leg movement
- Often non-focal involving opposite arm and leg (e.g. left arm and right leg activity)
- Contrast with Seizures which tend to be focal
- Pelvic thrusting
- Head turning from side to side
- Dystonic Posture
- Eyes closed and resists Eyelid movement
- Tongue biting limited to tip of Tongue
- Avoidance during Seizure
- Asymmetric arm and leg movement
- Atypical Seizure timing
- Gradual onset and last 2-3 minutes (contrast with 1 minute for typical Seizure)
- Waxing and waing course (contrast with rhythmic periodicity of Seizure)
- Recur frequently
- Typically lacks the postictal period of Seizure Disorder
- Other factors
- Resistance to multiple antiepileptic agents
- Emotional or situational triggers
- Postictal crying
- May remember episode (contrast with Seizure where there is no memory of the episode)
VII. Differential Diagnosis
- See Nonepileptic Seizure
- Movement Disorder (e.g. Tic Disorder, Extrapyramidal Side Effect)
- Atypical epileptic Seizures
- Frontal LobeSeizure
- Atypical motor and verbal activity
- Often occur during sleep and brief duration
- Gelastic Seizure (laughs during Seizure)
- Myoclonic Seizure
- Frontal LobeSeizure
VIII. Diagnosis: End-Tidal CO2
- Prolonged Seizure
- Oxygen Saturation falls
- End-Tidal CO2 rises
- Prolonged Psychogenic Seizure
- Oxygen Saturation remains normal
- End-Tidal CO2 remains normal
IX. Diagnosis: Inpatient Video EEG
X. Diagnosis: Clinical findings that do not identify Seizure Disorder
- Postictal Serum Prolactin
- Tongue-biting, self-injury or Incontinence
- Psychological Testing
- Outpatient Electroencephalogram
XI. Management
- Interdisciplinary approach
- Mental Health
- Cognitive Behavioral Therapy may reduce PNES events in the short term
- Goldstein (2010) Neurology 74(24): 1986-94 [PubMed]
XII. References
- Bright, Shoenberger, Stellpflug in Herbert (2013) EM:Rap 13(3):3-4