Psychogenic Nonepileptic Seizures

Background

• Psychogenic nonepileptic seizures (PNES) are episodes of paroxysmal behavior resembling epileptic seizures, but are caused by psychological factors rather than ictal epileptiform activity in the brain.
• PNES can occur at any age, but most often present in the third and fourth decade of life, and are more common in women than men.
• Seizures usually present in 1 of 3 patterns:
  • a convulsive or thrashing pattern (common)
  • a swoon, catatonic, or pseudosyncope pattern (common)
  • an absence-like or dialeptic pattern (less common)
• Many seizure features typical of PNES are atypical for epileptic seizures (for example, absence of heart rate elevation from the preictal state, motor features lasting > 10 minutes, and abrupt seizure termination) and can be helpful in differentiating between the two.
• Risk factors for PNES include a history of physical, sexual, or other trauma, or a family history of epilepsy.
• Patients with PNES frequently have comorbid neuropsychiatric disorders, such as depression, anxiety, personality disorders, eating disorders, and posttraumatic distress disorder; about 10% of patients have comorbid epilepsy.

Evaluation

• Diagnose PNES by confirming that a seizure event has features typical of PNES (confirmation by a clinician experienced in seizure disorder diagnosis is preferred) and documenting the absence of epileptiform activity on electroencephalography (EEG).
  • Video electroencephalography (video EEG) before, during, and after the seizure event is the gold-standard diagnostic test.
  • If video EEG during the event is not feasible, consider video of the event without EEG, plus routine or ambulatory ictal EEG.
  • If ictal EEG is not possible, consider routine or sleep-deprived interictal EEG.
• Perform electrocardiography (ECG) concurrently with EEG; lack of heart rate elevation during the event suggests PNES, and a normal ECG also helps rule out a cardiac etiology.
• Consider measuring serum prolactin levels (a lack of postictal prolactin elevation suggests PNES).
• Consider hypnosis (hypnotic recall of seizures suggests PNES).

Management

• Obtain a consultation with a psychiatrist.
• Psychotherapy is considered the treatment of choice for psychogenic nonepileptic seizures (PNES), but has limited evidence for reducing seizure frequency.
• In patients taking antiseizure medications:
  • Taper and discontinue antiseizure medications in patients without epileptic seizures (unless the drug has a documented beneficial psychopharmacologic effect for a nonepileptic comorbid condition).
  • Reduce antiseizure medications or polytherapy, if possible, in patients with both psychogenic nonepileptic seizures and epileptic seizures.
• There is only limited and low-quality evidence regarding medications to reduce PNES frequency.
• Consider psychopharmacologic agents to treat comorbid mood, anxiety, or psychotic disorders, and possibly somatoform symptoms.