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Review Article

Diagnosis and Treatment


Address correspondence
to Dr W. Curt LaFrance Jr,
Rhode Island Hospital, Brown
University, 593 Eddy Street,
Providence, RI 02903,
william_lafrance_jr@brown.
edu.
of Nonepileptic Seizures
Relationship Disclosure: David K. Chen, MD; W. Curt LaFrance Jr, MD, MPH, FAAN, FANPA, DFAPA
Dr Chen reports no disclosure.
Dr LaFrance serves on the
Epilepsy Foundation
Professional Advisory Board; ABSTRACT
has served as a clinic
development consultant for Purpose of Review: This article details the evaluation process involved in the diagnosis
the Cleveland Clinic, Emory of psychogenic nonepileptic seizures (PNES). The psychological underpinnings, prog-
University, Spectrum Health, nostic factors, and recent treatment advances of PNES are also reviewed.
and the University of Colorado
Denver; and has provided Recent Findings: The diagnosis of PNES is determined based on concordance of
expert medicolegal testimony. the composite evidence available, including historical and physical examination
Dr LaFrance receives royalties findings, seizure symptoms and signs, and ictal/interictal EEG. No single clinical data
from Cambridge University
Press and Oxford University point is definitively diagnostic of PNES. The diagnosis of PNES can be challenging
Press and has received research at times, such as when seizure documentation on video-EEG cannot be readily
support from the American obtained. Yet, delayed diagnosis of PNES portends poor outcome. A multicompo-
Epilepsy Society, the Epilepsy
Foundation, the Matthew Siravo nent approach to the diagnosis of PNES, with use of an aggregate of available evi-
Memorial Foundation Inc, the dence, may facilitate diagnosis and then care of patients with PNES. Emerging evidence
National Institutes of Health, supports the effectiveness of cognitive-behavioralYbased therapy in the treatment of
and Rhode Island Hospital.
Unlabeled Use of
these patients.
Products/Investigational Summary: The diagnosis of PNES can be made reliably, and evidence-based treatment
Use Disclosure: now exists. Continued efforts remain necessary to enhance prompt recognition and
Drs Chen and LaFrance report
no disclosures.
interdisciplinary management for patients with PNES.
* 2016 American Academy
of Neurology. Continuum (Minneap Minn) 2016;22(1):116–131.

INTRODUCTION convulsive syncope, cataplexy, or alcohol-


Nonepileptic seizures are episodes of withdrawal seizure) (Table 6-15). Treating
altered movement, sensation, or expe- the underlying pathology of physiologic
rience distinguished from epileptic sei- nonepileptic events addresses the event.
zures by the lack of associated ictal In contrast, psychogenic nonepileptic
abnormal electrical brain discharges. seizures (PNES) represent physical mani-
About one-quarter of patients referred festations derived from psychological
to specialist centers for apparent “drug- underpinnings. In epilepsy specialty
resistant epilepsy” are found to be mis- centers, 88% of patients with nonepilep-
diagnosed.1 After an average delay of tic seizures are deemed to have a psy-
about 1 to 7 years to establish the correct chogenic etiology for their events.6
diagnosis,2,3 patients with nonepileptic This review therefore focuses primar-
seizures will frequently have taken higher ily on the diagnosis and management
Supplemental digital content:
doses of antiepileptic drugs (AEDs), uti- of PNES.
Videos accompanying this ar- lized greater health care resources, and
ticle are cited in the text as sustained more iatrogenic adverse ef- DIAGNOSIS OF PSYCHOGENIC
Supplemental Digital Content.
Videos may be accessed by fects than patients with epilepsy.4 NONEPILEPTIC SEIZURES
clicking on links provided in the Nonepileptic seizures are further cat- The diagnosis of PNES can be challeng-
HTML, PDF, and app versions of
this article; the URLs are pro- egorized as physiologic or psychogenic ing. When comprehensive neurologic
vided in the print version. Video in origin. Physiologic nonepileptic events and psychiatric assessment and video-
legends begin on page 128.
result from systemic alterations or dis- EEG are not available in one setting, an
ease states that produce an ictus (eg, iterative assessment process over time

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KEY POINTS
history are useful in raising the suspicion h About one-quarter of
TABLE 6-1 Physiologic Causes for PNES. The seizure burden of patients patients referred to
of Nonepileptic with PNES is generally more pronounced
Seizuresa specialist centers for
than that of those with epilepsy, in terms apparent drug-resistant
of both seizure frequency8 and du- epilepsy (ie, failing to
b Syncope
ration.9 While stimuli-specific reflex epi- respond to adequate
Vasovagal lepsies exist, the endorsement of more trials of two or more
Cardiogenic pedestrian triggers, such as certain light- antiepileptic drugs) are
ing level conditions, body movements, found to have physiologic
b Neurologic or psychogenic
sounds, or foods, would be unusual for
Cerebrovascular nonepileptic seizures
epilepsy and should raise suspicion for
rather than epilepsy.
Migraine PNES, especially if the reported associ-
ation is strikingly consistent. Of note, sei- h After an average delay
Vertigo of about 1 to 7 years to
zure exacerbation by emotional stressors
Cataplexy establish the correct
is not pathognomonic for PNES. Studies
diagnosis, patients with
Parasomnias have shown that similar stressors can
nonepileptic seizures
Movement disorders also provoke epileptic seizures.10 will frequently have
Over the lifetime of patients with taken higher doses of
b Metabolic
PNES, about half have been diagnosed antiepileptic drugs,
Hypoglycemia with depression, about half have co- utilized greater health
Electrolyte disturbances morbid posttraumatic stress disorder care resources, and
(PTSD), and about two-thirds have sustained more
Toxicity (eg, drugs and alcohol)
personality disorders.11 The presence iatrogenic adverse
a
Modified with permission from Mellers JD, of psychogenic disorders is a strong risk effects than patients
Postgrad Med J.5 pmj.bmj.com/content/ with epilepsy.
81/958/498.full. B 2005 British Medical factor for other forms of comorbid or
Journal Publishing Group. future psychosomatic symptoms.12 Ac- h In epilepsy specialty
cordingly, about 70% of patients with centers, a predominant
PNES endorse comorbid experiences majority (about 88%)
with medically unexplained symptoms, of patients with
may be necessary to establish the diag-
such as intractable pain.13 nonepileptic seizures
nosis of PNES.7 Habitual seizures of in-
are deemed to have a
terest, especially in patients with multiple psychogenic etiology
independent event types, are sometimes Clinical Features Differentiating
for their events
not captured during an initial video-EEG Psychogenic Nonepileptic
(ie, psychogenic
monitoring study. Long-term video-EEG Seizures and Epileptic Seizures
nonepileptic seizures).
monitoring is also not readily available Key elements in the evaluation of PNES
h The diagnosis of
in some locations. Appreciating these include the recognition of ictal features
psychogenic nonepileptic
diagnostic challenges and the importance that are: (1) suggestive of a psychogenic seizures can be
of prompt recognition of this disorder, process and (2) not in favor of an epi- challenging, hence
this article first details relevant features leptic source (Table 6-25,14). Each of contributing to the
from clinical history, symptoms and these two elements should be consid- frequent time delay
signs, and video-EEG evaluations that ered separately. An important caveat is (an average of 1 to 7 years)
support the PNES diagnosis and differ- that the features described by the pa- before patients with
entiate it from epilepsy. tient and witnesses poorly correspond psychogenic nonepileptic
with the observed PNES documented seizures are
Historical Features Differentiating during video-EEG monitoring.15 There- correctly diagnosed.
Psychogenic Nonepileptic fore, ictal features described by patients’
Seizures and Epileptic Seizures or witnesses’ report alone should be in-
At the outset, a number of peculiar fea- terpreted with less diagnostic certainty
tures uncovered from a carefully elicited than those visually documented from
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Nonepileptic Seizures

TABLE 6-2 Clinical Signs and Examination Findings Used to Help Distinguish Psychogenic
Nonepileptic Seizures From Epileptic Seizuresa,b

Signs Examination Findings


Psychogenic nonepileptic Long duration, fluctuating course, asynchronous Resists eyelid opening, guarding
seizures movements, pelvic thrusting, side-to-side head of hand dropping over face,
or body movement, ictal eye closure, ictal evidence of visual fixationc
crying/weeping, memory recall for period
of unresponsiveness
Epileptic seizures Occurrence from EEG-confirmed sleep, postictal Very severe tongue biting,
obtundation/confusion, stertorous impaired corneal reflex, extensor
breathing postictally plantar response
EEG = electroencephalogram.
a
Data from Avbersek A, Sisodiya S, J Neurol Neurosurg Psychiatry,14 jnnp.bmj.com/content/81/7/719.abstract; Mellers JD, Postgrad
Med.5 pmj.bmj.com/content/81/958/498.full.
b
No single sign distinguishes psychogenic nonepileptic seizures from epileptic seizures.
c
Visual fixation can be elicited by placing a mirror in front of the patient or rolling the patient from one side to the other.

KEY POINTS video-EEG monitoring and, to a lesser clonic PNES may demonstrate unchang-
h Over the lifetime extent, home video recording. ing frequency and variable amplitude
of patients with In distinguishing PNES from epileptic throughout the ictus.17 Some PNES
psychogenic nonepileptic seizures, clinical features are generally show poorly discernible ictal onset from
seizures, about half
more specific than sensitive,14 and no a setting of apparent sleep, during
have been diagnosed
individual feature is definitively diag- which EEG activity discordantly corre-
with depression, about
half have comorbid
nostic of PNES.15 Instead, the degree of lates with wakefulness or light drows-
posttraumatic stress diagnostic confidence correlates with iness.18 On the other hand, paroxysms
disorder, and about concordant features favoring PNES. For with clear-cut emergence from EEG-
two-thirds have example, assessment of the characteris- documented sleep would have a high
personality disorders. tic seizure temporal evolution is often likelihood of being physiologic in origin
h The diagnosis of helpful. Ictal vocalization in epileptic (ie, epileptic seizures or parasomnias).
psychogenic nonepileptic seizures is usually restricted to the PNES have been classified into dis-
seizures requires the beginning of the seizure, primitive in tinct groups according to the predom-
demonstration of ictal nature (laryngeal sound), and highly inant clinical features. These groupings
features that favor a stereotyped. In PNES, the vocalization include rhythmic motor, hypermotor,
psychogenic process; are may be present not only at the begin- complex motor, dialeptic (impaired
not consistent with ning of the seizure but may persist or awareness), subjective, and mixed.19
epilepsy; and occur even intensify through the course of the
in the context of While such categorization can contrib-
ictus. Vocalization in PNES can be more ute to pattern recognition useful in the
supportive historical,
complex, with affective content re-
physical examination, evaluation of PNES, it is presently uncer-
flecting somatic expression of emo-
and ictal/interictal tain whether such categorization is
video-EEG findings.
tional distress (eg, weeping, moaning,
and coughing).16 The generalized tonic- useful to distinguish psychological un-
h Patients’ and witnesses’ clonic epileptic features can inform di- derpinnings or inform prognosis. Fur-
descriptions of the thermore, unlike stereotyped epileptic
agnosis, where ictal features evolve
ictal features have seizures arising from a singular epilep-
been known to
through an organized fashion such that
clonic frequency progressively declines togenic substrate, the ictal features of
correlate poorly with
observed features while amplitude increases through the patients with PNES can often change,
of video-EEGY course of the convulsion. In contrast, the transforming into other clinical presen-
captured seizures. convulsive activity in generalized tonic- tations or unrelated somatic symptoms.20

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KEY POINTS
Distinguishing Syncope From and EEG documentation of the habitual h No feature in itself is
Other Causes of Drop Attacks seizures of interest. In the setting of an definitively diagnostic
The mean duration of vasovagal syn- unconscious patient, physiologic causes of psychogenic
cope (the most common mechanism for can be excluded by concurrent presence nonepileptic seizures.
syncope) from the moment of event of an intact alpha rhythm on the EEG h Assessing the
onset to recovery of full consciousness (a neurophysiologic correlate of alert- characteristics of the
has been shown to be 41.4 seconds.21 ness). In other scenarios, the absence temporal evolution of a
Therefore, paroxysms of swoons that of an epileptiform ictal EEG correlate seizure can frequently
last longer than 1 minute should raise before, during, or after the seizure in- yield helpful clues in
suspicion for other etiologies. It has dicates that the captured event is likely differentiating
been suggested that patients with re- nonepileptic in origin but does not nec- psychogenic nonepileptic
current “syncope of unknown origin” essarily distinguish a psychogenic versus seizures from
physiologic etiology. Consideration of epileptic seizures.
despite a thorough evaluation (about
20% to 30% of patients with syncope) a psychogenic etiology requires the h The EEG during syncope
should undergo video-EEG monitoring demonstration of PNESYconsistent proceeds through a
as some of them may, in fact, have clinical event features in the context stereotyped pattern,
beginning with theta
PNES.22 Contrasting with the absence of supportive historical and ictal/
peri-ictal physical examination find- slowing, then delta
of significant EEG background change
slowing followed
for PNES, the EEG during syncope pro- ings (Table 6-2). A concordant impres-
by suppression.
ceeds through a stereotyped pattern, sion from each of these data elements
beginning with theta slowing, then delta with the video-EEG provides the diag- h In the setting of an
unconscious patient,
slowing followed by suppression.22 nostic gold standard with high levels
physiologic causes
The presence of convulsionlike mo- of certainty as well as excellent inter-
can be excluded by
tor accompaniments does not preclude rater reliability.15
concurrent presence
the consideration of syncope. In a study Nuances of video-EEG interpretation. of an intact alpha
involving video analysis of 42 episodes For some patients with PNES who rhythm on the EEG
of syncope, 38 (90%) of the episodes experience dense amnesia for the details (a neurophysiologic
were associated with motor symptoms. of their seizures, any recorded event correlate of alertness).
The most commonly observed move- should be confirmed by an eyewitness h Upon demonstrating
ment pattern in this study was multi- to be typical of the habitual seizures of psychogenic nonepileptic
focal arrhythmic jerks in both proximal interest. Otherwise, the clinical relevance seizureYconsistent clinical
and distal muscles, usually lasting only a of the recorded event remains uncertain. event features in the
few seconds.23 The motor symptoms of If the patient’s historical features sug- context of supportive
syncope terminate when the patient as- gest more than one type of event, then historical and physical
sumes a horizontal position that facili- an occurrence of each type should be examination findings,
tates cerebral perfusion, whereas those recorded, as independent event types video-EEG offers a
may reflect distinct etiologies. If not, the diagnostic gold standard
of epileptic seizures would not be in-
etiology of the nondocumented event with high levels of
fluenced by body position.
certainty and reliability.
type should be diagnosed with a more
Confirming the Diagnosis of cautious level of certainty. Indeed, ap-
Psychogenic Nonepileptic Seizures proximately 10% of patients with PNES
Diagnostic tools used to help support also have an independent diagnosis of
the diagnosis of PNES include inpatient epilepsy.24 For patients with a learning
video-EEG monitoring, ambulatory EEG disability, further diagnostic caution is
recording, and home video recording of warranted as the percentage of mixed
habitual seizures. PNES with epilepsy cases can be up to
Video-EEG. Video-EEG entails pro- 30%.25 Focal epileptic seizures with pre-
longed continuous monitoring of the served consciousness and rather restricted
patient, allowing for simultaneous video motor, autonomic, or sensory/psychic
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Nonepileptic Seizures

KEY POINTS
h Only 21% of simple components (simple partial symptom- EEG activation procedures (hyperven-
partial epileptic seizures atology) may arise from only a small pool tilation and photic stimulation) with-
have been shown to of neuronal tissue. As such, only 21% out placebo. Asking the patient or
correlate with ictal EEG of simple partial epileptic seizures have family if they know of a trigger that
epileptiform changes, been shown to correlate with ictal epi- can be reproduced in the unit is fre-
while some frontal lobe leptiform changes on scalp EEG.26 Some quently helpful (eg, scrolling on a com-
epileptic seizures can frontal lobe epileptic seizures arise from puter screen). Comparable success rates
demonstrate very subtle, deep-seated foci (eg, orbitofrontal or in- have been demonstrated between PNES
falsely lateralizing, or terhemispheric regions) such that ictal activation procedures with placebo ver-
undiscernible ictal EEG epileptiform discharges can conduct/ sus without placebo.32
epileptiform correlates.
distribute over a widespread area bilat- Ambulatory EEG and home video
h When confronted with erally, demonstrate a contralateral max- recordings. Some patients with PNES
enigmatic paroxysms of imum, or become obscured by copious may not experience seizures in a hospital
uncertain etiologies, artifacts related to hypermotor activity. setting that secludes patients from ha-
the demonstration
Therefore, ictal EEG epileptiform cor- bitual stressors of their indigenous mi-
of inducibility (ie,
relates of some frontal lobe epileptic lieu. Under such circumstances, outpatient
provocative induction)
would strongly (but not
seizures can be very subtle, falsely lat- ambulatory EEG (sometimes with con-
entirely) support a eralizing, or undiscernible. current video recordings) can be useful.
psychogenic etiology. Within 2 days after admission for Because of less-standardized recording
video-EEG monitoring, the majority of settings and greater susceptibility to arti-
patients with PNES will have experienced facts, the qualities of the ambulatory
a spontaneous and characteristic seizure EEG and video data can be quite var-
of interest.27 For those who do not ex- iable. For cases in which supportive clin-
perience spontaneous seizures, use of ical or historic contexts are not available,
suggestion techniques (ie, provocative ambulatory EEG should be interpreted
inductions) can improve the rate of sei- with caution.
zure capture28 and shorten the duration The frequency of some patients’ PNES
of video-EEG admission.29 The success may be too rare to be practically captured
rate of induction is higher among pa- during limited time frames of video-EEG
tients who demonstrate preinduction or ambulatory EEG recordings. Consid-
characteristics of hypermotor ictal symp- ering the common availability of mobile
tomatology, prevalent self-reporting devices that can record video, home
of uncommon cognitive and affective video documentation of some patients’
symptoms, and absence of prior induc- infrequent seizures may be able to pro-
tion exposure.30 Moreover, when con- vide useful diagnostic data. Video data
fronted with enigmatic cases for which
alone (without EEG) have been shown to
frontal lobe epileptic seizures, simple
provide reasonably robust sensitivity and
partial epileptic seizures, or other phys-
specificity in distinguishing epileptic sei-
iologic nonepileptic events have not
zures from PNES.33 A key interpretive
been conclusively excluded, the dem-
onstration of inducibility would strongly caution is that home video recordings
(but not entirely) support a psychogenic may frequently miss the moment of sei-
etiology. Ethical concerns are raised by zure onset and instead capture the mid-
the use of placebos during induction dle or recovery phase of the seizure.
(eg, saline injection or alcohol wipes), Moreover, the neurobehavioral man-
which inherently reflect a deceptive in- ifestations during the postictal recov-
tervention to the patient.31 Such con- ery phase of epileptic seizures can highly
cerns can be circumvented by performing resemble the ictal symptomatology of
induction techniques that utilize routine some PNES.
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KEY POINT
Levels of Certainty in the available aforementioned data reflec- h Psychogenic nonepileptic
Diagnosis of Psychogenic tive of scenarios commonly encoun- seizures are a subtype of
Nonepileptic Seizures tered in clinical practice, a diagnosis of conversion (somatoform)
In acknowledging that video-EEG is not PNES can be made with several levels disorder in which
readily available to every patient world- of diagnostic certainty, the highest level psychological conflicts
wide and that it may not always capture being “documented” (Table 6-3). With are manifested with
seizures characteristic of the patient’s this approach, the task force aims to symptoms resembling
single or multiple independent event provide greater clarity regarding the epileptic seizures.
types, the Nonepileptic Seizure Task evaluation process for PNES, facili-
Force of the International League tate prompt recognition of this dis-
Against Epilepsy (ILAE) delineated a order, and enhance care of patients
staged approach to PNES diagnosis.7 with PNES worldwide.
The ILAE task force recognized that dif-
ferent settings may not have access to PSYCHOPATHOLOGY
video-EEG, so different levels of diag- PNES are most commonly conceptual-
nostic certainty were delineated based ized as a subtype of conversion disorder
on the available data. in which psychological conflicts are mani-
The clinical data utilized in this fested as symptoms resembling epileptic
staged approach include patients’ his- seizures. The Diagnostic and Statisti-
torical presentation, witness accounts, cal Manual of Mental Disorders, Fifth
and clinicians’ observation in person Edition (DSM-5)34 provides revised diag-
or via review of video recordings during nostic criteria for conversion disorder
ictus, interictal EEG, and video-EEG. in accordance with updated insights
Based on varying combinations of the regarding this disorder. Whereas the

TABLE 6-3 Overview of Proposeda Diagnostic Levels of Certainty for Psychogenic


Nonepileptic Seizures

Diagnostic Level History Witnessed Event EEG


Possible + By witness or self-report/description No epileptiform activity in routine
or sleep-deprived interictal EEG
Probable + By clinician who reviewed video No epileptiform activity in routine
recording or in person, showing or sleep-deprived interictal EEG
semiology typical of psychogenic
nonepileptic seizures (PNES)
Clinically established + By clinician experienced in diagnosis No epileptiform activity in routine
of seizure disorders (on video or in EEG or ambulatory ictal EEG,
person), showing semiology typical capturing a typical ictusb
of PNES, while not on EEG
Documented + By clinician experienced in diagnosis No epileptiform activity immediately
of seizure disorders, showing before, during, or after ictus
semiology typical of PNES, while captured on ictal video EEG with
on video EEG typical PNES semiology
EEG = electroencephalogram; + = history characteristics consistent with PNES.
a
Modified with permission from LaFrance WC Jr, et al, Epilepsia.7 onlinelibrary.wiley.com/doi/10.1111/epi.12356/full. B 2013 International
League Against Epilepsy.
b
Captured ictus should not resemble types of epileptic seizures that may not show ictal epileptiform correlate on EEG (eg, simple partial
epileptic seizures).

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Nonepileptic Seizures

KEY POINT
h Whereas DSM-IV Diagnostic and Statistical Manual of surgeries/anesthesia37Y39) can provoke
approached conversion Mental Disorders, Fourth Edition conversion symptoms and may involve
disorder as a diagnosis (DSM-IV) required the presence of psy- processes that are physiologic as much
of exclusion, the chological factors to precede or exac- as psychological (Case 6-1).
updated DSM-5 guides erbate conversion symptoms, such DSM-IV approached conversion dis-
users to make a positive requirement has been relegated to a order as a diagnosis of exclusion from
conversion disorder note in DSM-5.34,35 The reason for this other pathophysiologic conditions. To
diagnosis based on change is that while psychological fac- circumvent this problem, DSM-5 guides
inclusion of clinical tors are important in the evolution of users to make a positive conversion
features that are conversion disorders, they are not always disorder diagnosis based on inclusion
incongruent to known
immediately apparent from the history. of clinical findings that are incongruent
anatomy, physiology,
Some patients’ readiness to discuss psy- to known anatomy, physiology, or dis-
or disease.
chological factors may depend on the eases (Table 6-2). The criterion on exclud-
strength of the clinician-patient alliance. ing other pathophysiologic conditions
Even when psychological factors are has been revised to a criterion that re-
readily identified, it may not be clear quires that the symptom in question is
that they are etiologically relevant to “not better explained by another dis-
the symptoms at hand.36 Moreover, evi- ease.” This revision encourages clinical
dence exists that physical factors (such investigation for an alternative medical/
as traumatic brain injuries, undergoing neurologic explanation for the symptom,

Case 6-1
A 57-year-old man presented with a 10-year history of seizures involving
abrupt loss of awareness with falls, followed by postictal disorientation/
confusion. Considering his known left frontal encephalomalacia from a
stroke that also occurred about 10 years ago, he had been treated for
(presumed) epilepsy with antiepileptic drugs. Since some of his paroxysms
were preceded by coughing fits, posttussive syncope was within the
differential diagnosis. However, he continued to experience frequent
seizures, despite trials of three antiepileptic drugs and measures to treat
his obstructive airway disease. He was referred for video-EEG monitoring,
which confirmed the diagnosis of psychogenic nonepileptic seizures (PNES)
(Supplemental Digital Content 6-1, links.lww.com/CONT/A169). This seizure
was induced by routine activation procedures that included photic stimulation
and provocation with verbal suggestion, but no placebo. PNES was
supported by the documented features of suggestibility (increasing seizure
intensity with higher photic frequency), ictal eye closure at ictal onset,
side-to-side head movements, illness-affirming behaviors (retching cough,
semifetal posture), and incongruence of intact EEG alpha rhythm (a
neurophysiologic correlate of alertness) during dialeptic symptomatology
with clinical unresponsiveness.
Comment. While strokes are associated with epilepsy and epileptogenic
foci, this case illustrates that the emotional affliction from significant
health-related adverse events should not be overlooked. Moreover,
evidence exists that physical factors (such as brain injuries) can provoke
conversion symptoms and may involve processes that are physiologic as much
as psychological. This case also exemplifies the importance of considering a
wide differential diagnosis in patients with paroxysmal disorders, which
includes epilepsy, physiologic nonepileptic events, and PNES.

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but also allows for a conversion dis- distress is expressed somatically, rather
order diagnosis even if a potentially than in a healthy verbal manner.
related disease is present. The other
notable change for conversion disorder BORDER ZONES OF PSYCHOGENIC
in DSM-5 is that the former require- NONEPILEPTIC SEIZURES
ment for exclusion of feigning has been (PSYCHIATRIC DIFFERENTIAL
abandoned. In clinical practice, such DIAGNOSIS)
requirement is problematic, as exclu- Border zones of PNES represent neuro-
sion of malingering may be difficult behavioral paroxysms with psychologi-
to validate with absolute certainty cal underpinnings but are not considered
without surveillance or forensic evalu- to be conversion disorders, as described
ation.40 Volitionally feigned symptoms, above. Panic attacks can be the paroxys-
as in the cases of malingering or fac- mal manifestation of panic disorder or
titious disorders, are not PNES (ie, not other conditions associated with anxiety.
psychogenic), and are rare, present Symptoms of tremulousness, shaking,
mostly in at-risk groups. derealization, or depersonalization can
Several etiologic models have been be quite prominent in some panic at-
proposed in the effort to explain the tacks, hence showing a notable parallel
inception and evolution of conversion to seizures. Careful exploration of the
disorder manifesting as PNES.41 One overall presentation should uncover
model stipulates two main types of other key features meeting DSM-5 crit-
psychological difficulties that underlie eria for panic attacks, in which intense
PNES: posttraumatic and developmen- fear is accompanied by at least four of
tal.42 Posttraumatic PNES develop in
the following symptoms: palpitations,
response to psychological or physical
diaphoresis, shortness of breath, chest
trauma(s) that the patient struggles
discomfort, nausea and abdominal dis-
to adequately process or integrate. In
comfort, dizziness, and the aforemen-
the face of “unspeakable dilemmas,”
tioned seizurelike symptoms. Similar to
some authors postulate that PNES re-
panic attacks, behavioral manifestations
flects an automatic cutoff phenomenon
of PTSD frequently entail derealization,
in response to spontaneous intrusion
depersonalization, or affective numbing,
into consciousness of such intolerable
memories.43 Developmental PNES de- all of which can resemble seizure activ-
rives from difficulties coping with com- ities. In fact, the DSM-5 designates a
plex life tasks and milestones along the PTSD subtype with prominent dissocia-
patient’s continuum of psychosocial de- tive symptoms. Upon careful evaluation,
velopment in an environment of emo- if the patient’s overall symptomatology
tional privation (eg, relational neglect). can be better explained by PTSD per
Studies have shown that some patients DSM-5 criteria, then the additional di-
with PNES rely on avoidant coping agnosis of conversion disorder should
responses (denial and repression) to not be made. Some authors contend that
perceived threats,44 hence hindering the presentation of exclusively subjective
appropriate maturation of psychosocial sensory symptoms (albeit neurologic
development. For some patients with symptoms, such as paresthesia or numb-
PNES, both posttraumatic and devel- ness) are not sufficiently reliable in them-
opmental types of psychological etiol- selves to meet the criteria for PNES.40
ogies may coexist. In essence, PNES Most of these cases likely represent anx-
(and other conversion disorders) are a ious misinterpretation of common non-
disorder of communication, where specific paroxysmal symptoms of everyday

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Nonepileptic Seizures

KEY POINTS
h An important prognostic life, including transient dizziness, limb approach to PNES diagnosis may be
factor of psychogenic numbness, or head sensations that may beneficial in prompting earlier discus-
nonepileptic seizures is briefly disrupt attention. The misinter- sion regarding potential psychological
the duration of illness, in pretation of benign symptoms as being contributions to seizures, as soon as
which the prognosis more pathologic may be more common minimum criteria for the diagnosis of
worsens the longer the in patients who have had personal expe- PNES have been met. Deferring such
patient’s illness has been riences with seizures or who have other discussions until video-EEGYdocumented
mistreated as epilepsy. neurologic/medical conditions. Another diagnostic certainty may lead to sig-
h In children with scenario that falls within the border zones nificant delay, considering the afore-
psychogenic nonepileptic of PNES is the purposeless and repetitive mentioned diagnostic challenges and
seizures, serious behavioral mannerisms (learned behav- limited video-EEG availability in some
psychosocial issues (eg, locations. Factors that may prognosti-
ior) that occur not infrequently in some
physical or sexual abuses) cate better outcomes among adults
can be ongoing at the
cognitively impaired patients.45
include higher level of education; youn-
time of presentation and PROGNOSIS ger age at both time of seizure onset
should be explored in
When considering the overall popula- and time of diagnosis; seizures with
every case.
tion of patients with PNES, seizure less- dramatic symptomatology; fewer
cessation is reported to occur in about additional psychosomatic symptoms;
40% of patients over time. About one- and neuropsychological measures sup-
third of patients experience seizure porting lower dissociative, inhibitive,
reduction, while the remaining approx- emotional dysregulating, and compul-
imately one-third of patients undergo a sive tendencies.50,51
chronically intractable course.46 A com-
prehensive assessment of PNES out- PSYCHOGENIC NONEPILEPTIC
comes should encompass not only SEIZURES IN CHILDREN
seizure burden, but also the state of While much of the earlier discussions
psychosocial comorbidities, functionality, regarding PNES in adults also apply to
and overall quality of life.47 Upon pursu- children, some differences are notable
ing a more complete outcome assess- in light of varying psychosocial elements
ment of PNES as such, one study showed across developmental stages in children.
the following observations: 44% of pa- PNES can emerge in children as young
tients were not seizure free and re- as 5 years old, and their frequency in-
mained dependent (poor outcome); creases with age, becoming the most
40% of patients were either seizure free common type of nonepileptic seizure in
but dependent or not seizure free but adolescents.52 Conversely, comorbid
independent (intermediate outcome); epilepsy (mixed disorder) is more prev-
and 16% of patients were seizure free alent in younger children with PNES
and independent (good outcome).48 than in older children or adolescents
The above results suggest that patients with PNES.52 Compared to adults with
with PNES, in general, may have a poorer PNES, differences in psychiatric comor-
course than those with newly diag- bidities include lower rates of mood
nosed epilepsy.48 disorders (32%) and PTSD (10%) and a
Several patient-specific characteristics higher rate of significant family stressors
are identified as influencing the disease (44%) for children with PNES.53 Impor-
course of PNES. An important prognos- tantly, serious psychosocial issues (eg,
tic factor is duration of illness, in which physical or sexual abuses) can be on-
the prognosis worsens the longer the going at the time of presentation and
patient’s illness has been mistreated as should be explored in every case. Risk
epilepsy.49 Correspondingly, a staged factors for pediatric PNES are noted,
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KEY POINT
including somatopsychic and adversity who continue to use the outdated pe- h The neurologist’s
components related to maladaptive jorative terminology of “pseudoseizures,” explanation of the
coping.54 The clinical outcome of PNES with connotations of being false or fake, diagnosis of psychogenic
is better in children than adults, per- create a distance between patients and nonepileptic seizures
haps contributed to in part by a gen- clinicians. Legitimization and confirma- is vital and should be
erally briefer duration of illness or that tion of PNES through these efforts can communicated to the
dysfunctional patterns have become enhance the patient’s acceptance of patient via a tactful,
less engrained.55 the subsequent diagnostic explanation empathetic, and
(Case 6-2). In turn, the patient’s ac- unequivocal approach.
MANAGEMENT OF PSYCHOGENIC ceptance of the PNES diagnosis has
NONEPILEPTIC SEIZURES been shown to be associated with sei-
Management of patients with PNES be- zure improvement.57
gins with a comprehensive evaluation Hence, the neurologist’s explanation
(ie, seizure history, psychosocial assess- of this diagnosis is vital, and should be
ment, video-EEG), which includes a de- communicated to the patient via a tact-
velopmental history and review of past ful, empathetic, positive, nonpejorative,
trauma and abuse in the intake neuro- and unequivocal approach.58 Provision
logic assessment.56 Many times, patients of supplementary written information
have been dismissed in prior emergency may help consolidate (and further legit-
department and neurologic encounters, imize) the PNES diagnosis.59 Commu-
so conveying to the patient that the nication with family and the referring
seizures in PNES are just as real as those physician regarding this diagnosis can
in epilepsy is essential. Neurologists also augment the uniformity of diagnostic

Case 6-2
A 27-year-old man presented with near-daily seizures that involved diffuse
shaking with varying degree of unconsciousness. Given his high seizure
frequency, a brief 23-hour inpatient video-EEG was able to capture his
habitual seizure, and he received the diagnosis of psychogenic nonepileptic
seizures (PNES). He then sought additional referrals, endorsing the
frustration that, “My family thinks it’s all in my head,” and “It has to come
from something else.” During a subsequent video-EEG monitoring course,
efforts were made to capture the full spectrum of the patient’s seizures.
The diagnosis of PNES was explained to the patient and family members,
emphasizing PNES as a real, albeit nonepileptic, type of seizure. This
explanation of the diagnosis took place across two inpatient visits to allow
the patient and his family the opportunity to process their understanding
and ask questions. An explanation letter (addressed to the patient) and PNES
brochures were encouraged to be shared with other clinicians or individuals
pertinent to the patient’s care.
Comment. For patients with PNES, establishing the correct diagnosis is the
first step of treatment. Optimal management begins with comprehensive
evaluation (ie, neurologic and psychiatric assessment, description of the
events and psychosocial history taking, video-EEG monitoring). The
clinician-patient rapport and legitimization of PNES established through
these efforts can enhance the patient’s acceptance of diagnosis. In this
sense, neurologists can be a factor not only in the diagnosis, but also in the
initial treatment of patients with PNES as they prepare patients for
collaborative care with a mental health professional.

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Nonepileptic Seizures

KEY POINTS
h Medications do not fully insight across the patient’s milieu. Not more open-mindedness toward accep-
treat psychogenic providing the diagnosis with patient or tance of this diagnosis.64,65 Because
nonepileptic seizures. providers has been shown to be associ- driving is an issue for patients with
Moreover, antiepileptic ated with no improvement or even seizures, barriers to treatment delivery
drugs may worsening of symptoms.60 Likewise, are being overcome with computer
make psychogenic merely sharing the diagnosis (without video telemedicine, which is being used
nonepileptic seizures further dedicated therapeutic efforts) is in the US Department of Veterans Af-
worse. Selective frequently insufficient, as other somatic fairs to provide live-remote therapy for
serotonin reuptake and affective symptoms often develop veterans with either epileptic seizures
inhibitors (SSRIs) help the if the core issues are not addressed.13 or PNES.66
comorbidities (eg,
Letting the patient and family know that The working relationship between
depression and anxiety)
they are not alone in that many people the neurologist and patient should not
but do not
stop psychogenic
have the same disorder; that treatment abruptly end after a diagnosis of PNES
nonepileptic seizures. involves addressing predisposing, pre- has been established, for several reasons.
cipitating, and perpetuating factors; and For some patients with PNES, especially
h Targeted psychotherapy
that effective treatment is available pro- those who have been chronically mis-
appears to be the
mainstay of treatment
vides hope to patients and empowers diagnosed as having epileptic seizures,
for psychogenic treating clinicians to engage.50 a proper understanding of the diagnosis
nonepileptic seizures. The mainstay of effective treatment may not be achievable with a “one-shot”
To date, two pilot for PNES is psychotherapy directed at disclosure. Instead, iterative explanation
randomized controlled the known pathologies in the population. of the diagnosis via a supportive/
trials for psychogenic Pharmacologic interventions are used to noncoercive tone across serial visits may
nonepileptic seizures address common comorbidities (eg, se- gradually foster the patient’s acceptance
have shown clinically lective serotonin reuptake inhibitors for mental health treatment referrals.
meaningful results using [SSRIs] for depression and anxiety). Once the transition to mental health
either traditional However, psychotropics may reduce care is complete, then discussion can
cognitive-behavioral
seizures but do not lead to seizure commence regarding the patient’s dis-
therapy or a
cessation in PNES.3,61 Among psycho- charge from the neurologist’s practice.
seizure-treatment
workbook based
therapeutic approaches for patients with If a specific AED has no alternative
on a multimodality PNES, cognitive-behavioral therapy has beneficial indication (eg, mood stabili-
cognitive-behavioral the most substantial body of controlled zation or migraine prophylaxis), then a
therapyYinformed efficacy data. To date, two pilot random- timely taper of the drug is advisable.
psychotherapy for ized controlled trials for PNES have Early, as opposed to delayed, AED
psychogenic nonepileptic shown clinically meaningful results. One withdrawal portends greater beneficial
seizures and for epilepsy. study used conventional cognitive- effects on a range of clinical out-
behavioral therapy,62 while the other comes.57 Patients with normal video-
study used a multimodality cognitive- EEG findings should be followed by a
behavioral therapyYinformed psycho- neurologist for at least 6 months after
therapy3 based on a workbook used discontinuing AEDs. This consideration
by therapists and patients to treat is because of the small but ever-present
both epileptic seizures and PNES possibility of coexisting epilepsy and
(Table 6-4).63 Some patients may con- the fact that breakthrough epileptic
tinue to maintain some ambivalence re- seizures can occur several months
garding the nature of the PNES diagnosis after discontinuation of AEDs. Patients
and express reluctance toward in-depth with PNES who also have known
individual psychotherapies. In such cases, interictal or ictal epileptiform abnormal-
group psychoeducational approaches ities on their video-EEG should continue
have been shown to consolidate patients’ to be followed by a neurologist. Patients
understanding of PNES and promote with mixed epilepsy/PNES should be
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TABLE 6-4 Cognitive-Behavioral Approaches Evaluated in Randomized Controlled Trials for
Psychogenic Nonepileptic Seizures

Goldstein et al, 201061 LaFrance et al, 20143


Therapeutic Based on traditional cognitive-behavioral therapy Based on CBT-informed psychotherapy model
approach (CBT) and fear escape-avoidance model: initially aimed to enhance self-control of
Psychogenic nonepileptic seizures (PNES) as epileptic seizures: PNES as the somatic
dissociative responses to cues associated with manifestations of maladaptive core beliefs
extremely distressing or life-threatening (negative schemas) that have been derived
experiences. These experiences are, in turn, linked chronically from life experiences and traumas.
to unbearable feelings of fear and distress.
Main topics include seizure-directed Main topics include healthy communication,
techniques; attention refocusing; relaxation; support seeking, and goal setting; conducting
dealing with avoidance behaviors, negative a functional behavioral analysis; aura
cognitions, and other factors key toward identification; linking triggers, negative
engendering PNES. states, and target symptoms; relaxation;
examining external stressors and internal
conflicts; promotion of ongoing health
and wellness.
Outcomes CBT group experienced fewer seizures than When compared to before treatment,
the control group at the end of treatment. CBT-informed psychotherapy workbook
group showed significant seizure reduction
and improvement in depression,
anxiety, quality of life, and global
functioning measures.
During the last 3 months of a 6-month follow-up When compared to baseline, the treatment
period, between-group differences in seizure as usual/standard medical care control group
frequency were not significant, although the CBT showed no significant difference in seizure
group was 3 times more likely to be seizure free. frequency or any secondary outcome measures.

treated with the lowest effective AED a positive conversion disorder diagnosis KEY POINT
dose for the epilepsy, noting that AEDs based on identifying incongruent exam- h For the 10% of patients
do not treat PNES, and behavioral in- ination and laboratory findings in rela- with mixed epilepsy/
psychogenic nonepileptic
terventions should target the PNES. tion to known anatomy or physiology.
seizures, use the lowest
Continued follow-up by the neurologist Neurologists can work collaboratively with
effective antiepileptic drug
during the transition to mental health mental health providers to adequately dose for the epileptic
providers mitigates repeat workups with address the psychological underpinnings seizure and use mental
other providers. of these challenging patients. This team health treatments for
approach highlights the importance of the psychogenic
CONCLUSION interdisciplinary dialogue and transition nonepileptic seizures.
Conversion disorder is usually not diag- in the care of patients with PNES. To
nosed by the mental health provider this end, better communication by neuro-
alone; the neurologist is integral in the logists can overcome past diverging in-
evaluation and diagnosis. Indeed, patients terdisciplinary perspectives regarding
with conversion disorder frequently pres- PNES, with psychiatrists frequently be-
ent to neurologists first in search of a ing uncertain about the accuracy of video-
neurologic explanation to their symp- EEG.68 Further efforts are necessary to
toms.67 As such, neurologists have ac- augment this vital interdisciplinary part-
quired substantial experience in making nership. Recent diagnostic and treatment

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Nonepileptic Seizures

studies have shown momentum in shift- 6. Benbadis SR, O’Neill E, Tatum WO, et al.
Outcome of prolonged video-EEG monitoring
ing PNES to a neuropsychiatric inter- at a typical referral epilepsy center. Epilepsia
disciplinary (shared-care) model with 2004;45(9):1150Y1153. doi:10.1111/j.
a mind/brain perspective.66 As research 0013-9580.2004.14504.x.
in PNES advances, cognizance of and, 7. LaFrance WC Jr, Baker GA, Duncan R, et al.
hence, empathy for patients with this Minimum requirements for the diagnosis of
psychogenic nonepileptic seizures: a staged
challenging condition can advance,
approach: a report from the International
in parallel. League Against Epilepsy Nonepileptic
Seizures Task Force. Epilepsia 2013;54(11):
VIDEO LEGEND 2005Y2018. doi:10.1111/epi.12356.
Supplemental Digital 8. Jedrzejczak J, Owczarek K, Majkowski J.
Content 6-1 Psychogenic pseudoepileptic seizures:
clinical and electroencephalogram (EEG)
Psychogenic nonepileptic seizure in-
video-tape recordings. Eur J Neurol 1999;6
duced by photic stimulation and verbal (4):473Y479. doi:10.1046/j.
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