Evidence-Based Reviews

Psychogenic or epileptic seizures? How to clinch the diagnosis

Current Psychiatry. 2004 November;3(11):25-35

References

1. Riley TL, Brannon WL, Jr. Recognition of pseudoseizures. Acta Neurol Scand 1991;83(2):129-32.

2. Goodwin J, Simms M, Bergman R. Hysterical seizures: a sequel to incest. Am J Orthopsychiatry 1979;49:698-703.

3. Krawetz P, Fleisher W, Pillay N, et al. Family functioning in subjects with pseudoseizures and epilepsy. J Nerv Ment Dis 2001;189(1):38-43.

4. Gates JR, Luciano D, Devinsky O. The classification and treatment of nonepileptic events. In: Devinsky O, Theodore WH (eds). Epilepsy and behavior. New York: Wiley-Liss, 1991;251-63.

5. Vossler DG. Nonepileptic seizures of physiologic origin. J Epilepsy 1995;8:1-10.

6. Wyllie E, Glazer JP, Benbadis S, et al. Psychiatric features of children and adolescents with pseudoseizures. Arch Pediatr Adolesc Med 1999;153(3):244-8.

7. Luciano D, Perrine K, Clayton B, Devinsky O. Stress as a seizure precipitant and its relationship to ictal focus [abstract]. Epilepsia 1992;33(suppl 3):130.-

8. Betts T. Epilepsy and stress [editorial]. BMJ 1992;305:378-9.

9. Chabolla DR, Krahn LE, So EL, Rummans TA. Psychogenic nonepileptic seizures. Mayo Foundation for Medical Education and Research (symposium, part Ii, vol. 71[5]). May 1996;493-500.

10. Slavney PR. In defense of pseudoseizure (comment). Gen Hosp Psychiatry 1994;16(4):243-5.

11. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (4th ed, text rev). Washington, DC: American Psychiatric Association, 2000.

12. Matsuura M, Oana Y, Kato M, et al. A multicenter study on the prevalence of psychiatric disorders among new referrals for epilepsy in Japan. Epilepsia 2003;44(1):107-14.

13. Oommen KJ. Pseudoseizures: Diagnostic guidelines. Comprehensive Oklahoma Program for Epilepsy (COPE), 2000. Available at w3.ouhsc.edu/neuro/division/cope/pseudosz.htm. Accessed Oct. 14, 2004.

14. Walczak TS, Bogolioubov A. Weeping during psychogenic non-epileptic seizures. Epilepsia 1996;37(2):208-10.

15. Mohan KK, Markand ON, Salanova V. Diagnostic utility of video EEG monitoring in paroxysmal events. Acta Neurol Scand 1996;94(5):320-5.

16. Reuber M, Fernandez G, Bauer J, et al. Interictal EEG abnormalities in patients with psychogenic nonepileptic seizures. Epilepsia 2002;43(9):1013-20.

17. Laxer KD, Mullooly JP, Howell B. Prolactin changes after seizures classified by EEG monitoring. Neurology 1985;35:31-5.

18. Alving J. Serum prolactin levels are elevated also after pseudoepileptic seizures. Seizure 1998;7(2):85-9.

19. Henrichs TF, Tucker DM, Farha J, Novelly RA. MMPI indices in the identification of patients evidencing pseudoseizures. Epilepsia 1988;29:184-7.

20. Lelliott PT, Fenwick P. Cerebral pathology in pseudoseizures. Acta Neurol Scand 1992;85(3):177-80.

21. Guberman A. Psychogenic pseudoseizures in non-epileptic patients. Can J Psychiatry 1982;27:401-4.

22. Kuyk J, Jacobs LD, Aldenkamp AP, et al. Pseudoepileptic seizures: hypnosis as a diagnostic tool. Seizure 1995;4(2):123-8.

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Psychological testing may help distinguish PNES from epileptic seizure:

Minnesota Multiphasic Personality Inventory (MMPI) is fairly sensitive and shows statistically significant differences between PNES and epileptic seizures in hypochondriasis, depression, hysteria, and schizophrenia.¹⁹
Washington Psychosocial Seizure Inventory helps identify etiologic subgroups among PNES patients.⁹

Others. As in Ms. X’s case, CT and MRI for cerebral pathology may not help.²⁰ Provocative techniques²¹ based on suggestibility also may have little value because PNES can be provoked in patients with documented epileptic seizures. Hypnosis has been used in attempts to demonstrate the psychogenic component of nonepileptic seizures by reversing ictal and postictal amnesia. Patients with PNES seem to be more responsive to hypnosis than those with epileptic seizures.²²

CASE CONTINUED: EXPLAINING THE DIAGNOSIS

The psychiatric team concluded that even though Ms. X has a seizure disorder, this particular episode was psychogenic. This conclusion was based on the emotional precipitant, her brother’s collateral history, video EEG recordings, and her history of depression.

The psychiatrist explained to Ms. X that PNES and seizure disorders can coexist and that a PNES diagnosis does not imply that a patient is lying. It simply means that some seizures are precipitated by psychoemotional events.

Unlike some patients with PNES, Ms. X accepted the diagnosis without anger. Because her epilepsy and depression were stable, the psychiatrist did not change her phenytoin or paroxetine dosages. She was discharged, with follow-up care by a psychiatrist and neurologist.

TELLING AND TREATING THE PATIENT

It is important to present a PNES diagnosis with care because some patients react with aggressive denial and suicidal behavior. A patient who believes he or she has been perceived as a liar or “fake” may feel humiliated,⁹ which is why we prefer the term “PNES” rather than “pseudoseizure.”

PNES treatment calls for collaboration among the neurologist, psychiatrist, psychologist, therapists, support workers, and family. When PNES is clearly the only cause of seizures, avoid treating with anticonvulsants. If PNES coexists with a treated seizure disorder, no change in anticonvulsant dosage is necessary, especially if blood levels are normal.

Target the underlying psychiatric disorder, using medication and cognitive-behavioral therapy as appropriate. Advise patients and families that the seizure-like events may continue for some time but will disappear as the patient develops more-effective and appropriate coping strategies.

Prognosis. Favorable prognostic factors include being female, effective early intervention, normal premorbid psychological make-up, and good family support. Studies have shown that:

up to 40% of treated PNES patients remained event-free for a median of 5 years.²³
prognosis may depend on spell type (catatonic is more favorable than “thrashing”) and illness duration (<1 year is more favorable than >1 year).²⁴

Related resources

Riley LT, Roy A. Pseudoseizures. Baltimore: Lippincott, Williams and Wilkins, 1982.
Epilepsy.com. Psychogenic seizures. Resource for patients. www.epilepsy.com/epilepsy/seizure_psychogenic.html Accessed Oct. 14, 2004.
Epilepsy Foundation. Information for patients and families. www.epilepsyfoundation.org. Search for nonepileptic seizures. Accessed Oct. 14, 2004.

Drug brand names

Chlorpromazine • Thorazine
Haloperidol • Haldol
Phenytoin • Dilantin
Paroxetine • Paxil

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.