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Psychogenic nonepileptic seizures
AuthorAlan B Ettinger, MD Section EditorTimothy A Pedley, MD Deputy EditorJanet L Wilterdink, MDLast literature review version 17.1: January 2009 | This topic last updated: February 5,2009 (More)
INTRODUCTION
 
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Clinicians are regularly challenged to identify the nature of episodicneurologic symptoms. Events associated with prominent motor activity or alteredconsciousness are often presumed to be epileptic seizures. However, the event may actuallyrepresent one of a wide array of nonepileptic paroxysmal events, such as syncope,parasomnias, and movement disorders.Another notable type of episodic behavior is a psychogenic nonepileptic seizure (PNES).Characterized by sudden and time-limited disturbances of motor, sensory, autonomic,cognitive, and/or emotional functions, PNES can mimic epileptic seizures. However, in contrastto epileptic seizures, PNES are not associated with physiological central nervous systemdysfunction but are instead psychogenically determined [1-4] .Other terms, such as pseudoseizures or hysterical seizures, have been used to describe theseepisodes. The term "hysterical" seizures or "hysteroepilepsy" is now discouraged as bothpejorative and oversimplified, failing to capture the broad range of underlyingpsychopathology. The term "pseudoseizures" is also discouraged, since the root "pseudo," orfalse, invalidates the genuine, even if psychogenic, disorder that a patient experiences.It is important that clinicians consider PNES when evaluating patients with episodic symptoms.Missing this diagnosis may result in inappropriate treatment with antiepileptic drugs that areassociated with potential morbidity, especially if drug toxicity is incurred in the attempt tosuppress episodes [5-7] . Prolonged episodes, "psychogenic status epilepticus" in particular,are often treated with toxic antiepileptic drug doses, intubation, and iatrogenically inducedcoma [6-14] . When PNES occur during pregnancy, these treatments pose additional risks tothe fetus [2] . Recurrent visits to the emergency room and hospitalizations for uncontrolled,unrecognized PNES place a cost burden on the healthcare system [15] . Finally, failure torecognize psychiatric issues may promote the persistence of conversion symptoms and denythe patient needed psychiatric interventions.The diagnosis of PNES can be challenging. In some case series, delay to PNES diagnosis hasbeen as long as 9 to 16 years [16,17] . This is due in part to the broad diversity of PNESpresentations and the lack of one single unifying presenting symptom. Other sources of 
 
misdiagnosis include an inadequate history, co-occurrence of PNES and epilepsy in the samepatient, poor physician-patient rapport, reliance upon clinical observation of the event,discomfort in making a psychiatric diagnosis, and reluctance to obtain a psychiatric evaluationbefore the clinician feels confident about the diagnosis [18] . While advances in technology,especially the advent of video-electroencephalography, have greatly advanced our ability torecognize PNES, an accurate diagnosis is best achieved by assimilating a wide variety of cluesincluding a detailed history from the patient and observers, the physical examination, selectedtesting, and a psychiatric evaluation.The epidemiology, clinical features, diagnosis, and treatment of PNES are discussed here.Other nonepileptic paroxysmal disorders are discussed separately. (See "Nonepilepticparoxysmal disorders in adolescents and adults").
EPIDEMIOLOGY
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Incidence rates of PNES in the general population are not well established.One epidemiologic study in Iceland reported an incidence rate of 1.4 per 100,000 individualsover age 15 years; a study in Ohio documented a mean incidence of 3 per 100,000 between1995 and 1998 [3,5,19] . The prevalence of PNES has been estimated to be between 2 to 33per 100,000 [20] .Among patients referred to outpatient epilepsy centers, 5 to 25 percent of patients are felt tohave PNES, while 25 to 40 percent of patients evaluated in inpatient epilepsy monitoring unitsfor intractable seizures are diagnosed with PNES [3,21] .PNES most commonly presents in the third decade of life [17,22-25] . However, most agegroups can be affected, including young children and the elderly [26-28] . One study suggeststhat the age of onset may be influenced by pre-existing features; patients with learningdisabilities had a relatively younger age of onset compared to those with a history of physicalor psychosocial trauma [29] . (See "Nonepileptic paroxysmal disorders in children" and see"Seizures and epilepsy in the elderly: Diagnosis and treatment").PNES has a female predominance ranging from 66 to 99 percent in different series[5,22,23,25,28,30-34] . This is consistent with gender ratios described in conversion disorder,one of the salient psychiatric conditions underlying PNES [35,36] . (See "Psychosocial history"below). Race, marital status, and years of education do not appear to influence the prevalenceof PNES [24] .
CLINICAL FEATURES OF EVENTS
 
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Recognizing PNES can be challenging even for experiencedobservers, in part because of the broad diversity of PNES presentations. Nonetheless, cluesthat arouse suspicion for this diagnosis are often apparent from the clinical history. It isimportant to remember that no single feature is either sensitive or specific for PNES.A history from patients with suspected PNES should elicit information relevant to anyparoxysmal disorder including seizures: Detailed description of the event as perceived by thepatient and as witnessed by others, including prodromal and postictal features Precipitants,circumstances in which episodes occur Episode frequency, duration Factors that reduce seizurefrequency or attenuate an episode
 
Precipitants and setting
 
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The setting in which an episode occurs can be helpful indistinguishing PNES and epilepsy. Most episodes of PNES occur in front of witnesses [37,38] . Inone study, the occurrence of an episode in the doctor's waiting or examination room wasestimated to have a 75 percent predictive value for PNES [37] . PNES tend not to occur duringsleep. In contrast, epileptic seizures can occur during sleep, and in some forms of epilepsy,nocturnal episodes are most frequent. However, nocturnal seizures are frequentlyunwitnessed, and patients with PNES may report (erroneously) that seizures occur during sleep[39-41] . Patients with PNES may appear to be asleep just before seizure-onset, but the EEG inthese cases demonstrates wakefulness [40] . (See "Video-EEG monitoring" below). While it isintuitive that PNES would be more likely to be associated with stressful situations, stress iscommonly cited as a seizure precipitant in patients with epilepsy [42,43] . Increased seizurefrequency during the perimenstrual time period suggests epileptic seizures. In one series,perimenstrual exacerbation was associated with 13 of 27 patients with epileptic seizuresversus 1 of 38 patients with PNES [44] . PNES are often frequent. At the time of evaluation,most report at least daily episodes; less than one event a week is uncommon[5,17,23,25,34,38,45] . This observation may reflect a sampling bias.
Ictal features
 
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Unresponsive behavior with motor manifestations mimicking a generalizedconvulsion or a complex partial seizure is the most common manifestation of a PNES[22,23,28,32,38,45-47] . Less common are events that mimic atonic, absence, or simple partialseizures. A variety of clinical behaviors may occur during PNES, some of which are useful indistinguishing them from epileptic seizures (show table 1). However, no single semiologicfeature is either sensitive or specific for PNES [5] . A variety of convulsive-like motor activitycan occur in PNES. While motor manifestations of an epileptic seizure usually take the form of brief tonic posturing or a synchronized convulsion with a defined progression of motor activity;movements in PNES are more often asynchronous, variable, and wax and wane over thecourse of the ictus [21,22,48] . Specific movements such as writhing, thrashing, pelvic thrusts,opisthotonus (arched back), and jactitation (rolling from side to side) suggest a PNES, but theseare not always present [22,38,46,48] . Moreover, some epileptic seizures, such as those of frontal lobe origin, can produce unusual-appearing motor activities similar to PNES [21,39,49-54] . Stereotyped and consistent lateralization of motor features usually, but not always,suggests epilepsy [39,47] . (See "Localization-related epilepsy: Causes and clinical features",section on Frontal lobe epilepsy). Classic symptoms of epileptic seizures such as tongue biting,incontinence, and self-injury, are more common in epileptic seizures, but they can occur in athird or more of patients with PNES [16,17,22,23,34,45,55] . A tongue bitten on the side ismore specific for epileptic seizure, than when bitten on the tip [56] . Incomplete loss of consciousness during the episode, suggested either by responsiveness to stimuli or by laterrecall of events during the ictus, suggests PNES [22,57] . Weeping, ictal stuttering, andvocalizations are relatively uncommon in epileptic seizures and suggest PNES [58-61] . Whenvocalization occurs in an epileptic seizure, it usually occurs at seizure onset, not during theconvulsion. A seizure aura is frequently reported in PNES (25 to 60 percent) and may be amore common symptom than in epilepsy [32,34,38] . Autonomic manifestations during anictus (eg, tachycardia, cyanosis) suggest epileptic seizure, and their absence, particularly duringa major convulsion, suggests PNES [48,61,62] . Eyes are usually open during the ictus of ageneralized convulsive seizure [56,63] . Forced eye closure in particular suggests PNES.
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