Evidence-Based Reviews

Eye-opening behaviors help diagnose nonepileptic seizures

Current Psychiatry. 2006 November;5(11):121-130

New techniques supplement traditional methods.

References

1. Reuber M, Fernandez G, Bauer J, et al. Diagnostic delay in psychogenic nonepileptic seizures. Neurology 2002;58(3):493-5.

2. Gates JR, Ramani V, Whalen S, Loewenson R. Ictal characteristics of pseudoseizures. Arch Neurol 1985;42(12):1183-7.

3. LaFrance WC, Jr, Benbadis SR. Avoiding the costs of unrecognized psychological nonepileptic seizures. Neurology 2006;66(11):1730-1.

4. Cragar DE, Berry DT, Fakhory TA, et al. A review of diagnostic techniques in the differential diagnosis of epileptic and nonepileptic seizures. Neuropsychol Rev 2002;(1):31-64.

5. LaFrance WC, Jr, Devinsky O. Treatment of nonepileptic seizures. Epilepsy Behav 2002;3(suppl):S19-S23.

6. Chung SS, Gerber P, Kirlin KA. Ictal eye closure is a reliable indicator for psychogenic nonepileptic seizures. Neurology 2006;66(11):1730-1.

7. Henry JA, Woodruff GHA. A diagnostic sign in states of apparent unconsciousness. Lancet 1978;2(8096):920-1.

8. Donati F, Kollar M, Pihan H, Mathis J. Eyelids position during epileptic versus psychogenic seizures. J Neurol Sciences 2005;238(suppl 1):S82-S83.

9. Flügel D, Bauer J, Kaseborn U, et al. Closed eyes during a seizure indicate psychogenic etiology: A study with suggestive seizure provocation. J Epilepsy 1996;9(3):165-9.

10. Bergen D, Ristanovic R. Weeping as a common element of pseudoseizures. Arch Neurol 1993;50(10):1059-60.

11. Vossler DG, Haltiner AM, Schepp SK, et al. Ictal stuttering: a sign suggestive of psychogenic nonepileptic seizures. Neurology 2004;63(3):516-9.

12. Chabola DR, Shih JJ. Postictal behaviors associated with psychogenic nonepileptic seizures. Epilepsy Behav 2006;9(2):307-11.

13. Wennberg R. Postictal coughing and nose rubbing coexist in temporal lobe epilepsy. Neurology 2001;56(1):133-4.

14. Kanner AM, Morris HH, Luders H, et al. Supplementary motor seizures mimicking pseudoseizures: some clinical differences. Neurology 1990;40(9):1404-7.

15. Jobst BC, Williamson PD. Frontal lobe seizures. Psychiatr Clin North Am 2005;28(3):635-51.

16. Kanner AM. Psychogenic nonepileptic seizures are bad for your health. Epilepsy Curr 2003;3(5):181-2.

17. de Timary P, Fouchet P, Sylin M, et al. Nonepileptic seizures: delayed diagnosis in patients presenting with electroencephalo-graphic (EEG) or clinical signs of epileptic seizures. Seizure 2002;11:193-7.

18. Deacon C, Wiebe S, Blume WT, et al. Seizure identification by clinical description in temporal lobe epilepsy: how accurate are we? Neurology 2003;61(12):1686-9.

19. Lowe MR, De Toledo JC, Rabinstein AA, Giulla MF. Correspondence: MRI evidence of mesial temporal sclerosis in patients with psychogenic nonepileptic seizures. Neurology 2001;56(6):821-3.

20. Reuber M, Fernandez G, Helmstaedter C, et al. Evidence of brain abnormality in patients with psychogenic nonepileptic seizures. Epilepsy Behav 2002;3(3):249-54.

21. Ettinger AB, Coyle PK, Jandorf L, et al. Postictal SPECT in epileptic versus nonepileptic seizures. J Epilepsy 1998;11:67-73.

22. Chen DK, So YT, Fisher RS. Use of serum prolactin in diagnosing epileptic seizures: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2005;65(5):668-75.

23. 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.

24. van Merode T, Twellaar M, Kotsopoulos IA, et al. Psychological characteristics of patients with newly developed psychogenic seizures. J Neurol Neurosurg Psychiatry 2004;75(8):1175-7.

25. Benbadis SR. A spell in the epilepsy clinic and a history of “chronic pain” or “fibromyalgia” independently predict a diagnosis of psychogenic seizures. Epilepsy Behav 2005;6(2):264-5.

26. Binder LM, Kindermann SS, Heaton RK, Salinsky MC. Neuropsychologic impairment in patients with nonepileptic seizures. Arch Clin Neuropsychol 1998;13(6):513-22.

27. Kalogjera-Sackellares D, Sackellares JC. Impaired motor function in patients with psychogenic pseudoseizures. Epilepsia 2001;42(12):1600-6.

28. Binder LM, Salinsky MC, Smith SP. Psychological correlates of psychogenic seizures. J Clin Exp Neuropsychol 1994;16(4):524-30.

29. Cragar DE, Berry DT, Fakhoury TA, et al. A review of diagnostic techniques in the differential diagnosis of epileptic and nonepileptic seizures. Neuropsychol Rev 2002;12(1):31-64.

On average, 7 years elapse between a patient’s first psychological nonepileptic seizure (PNES) and the correct diagnosis.¹

PNES can be difficult to distinguish from epileptic seizures (ES), with both showing alterations in behavior, consciousness, sensation, and perception.² Delayed diagnosis could lead to:

adverse effects from unneeded antiepileptic drugs
iatrogenic complications from invasive procedures in continuous PNES
medical costs due to unnecessary hospitalization treatment and workup
delayed referral to appropriate psychiatric treatment
employment difficulties and disability. Fortunately, researchers are discovering some clinically useful differentiating features to use as adjuncts to video EEG, the diagnostic gold standard.^3,4

Behavioral differences

Differentiating PNES from ES (Table 1) is the first step toward appropriate treatment,⁵ and observing seizure characteristics can be helpful.

Table 1

Behaviors to distinguish psychological nonepileptic and epileptic seizures

Behavior	Psychological nonepileptic seizure	Epileptic seizure
Eye movement	Eyes closed at onset and during seizure; geotropic eye movement may be observed	Eyes open during seizure onset; may close briefly
Post-ictal nose rubbing and cough	Not present	May be present
Weeping	May be present	Not present
Body movements	Pelvic thrusting; out-of-phase or side-to-side oscillatory movements; chaotic and disorganized thrashing; ictal stuttering; post-ictal whispering	Pelvic thrusting; quick, tonic posturing; vocalization
Self-injury	May be present	May be present
Tongue laceration	May be present	May be present
Incontinence	May be present	May be present
Source: References 6-12,16,17

Eyes open or closed? Using data from video-EEG monitoring, researchers found that:

50 of 52 PNES patients (96%) closed their eyes during the seizure
152 of 156 of ES patients (97%) had their eyes open at the beginning of their seizures.⁶

Observing a patient’s eyes during a violent seizure could be difficult, but this information might help clinicians differentiate between PNES and ES, particularly when the two types of seizures occur in the same patient. Also, other observers, such as family members, could report to physicians if the patient’s eyes were open or closed during the ictal event.

Patients with PNES may also exhibit geotropic eye movements, in which the eyes deviate downward to the side that the head is turned.⁷ Eyelids are typically closed for a longer duration (20 seconds) compared with temporal lobe epilepsy (TLE) or frontal lobe seizures (FLS) (~2 seconds).⁸ Weeping also is a characteristic with PNES.^9,10 Ictal stuttering and post-ictal whispering are seen in PNES.^11,12 Post-ictal nose rubbing and cough have been observed in TLE but not in PNES.¹³

Pelvic thrusting reportedly is as common in FLS as in PNES. Other ictal features associated with PNES are out-of-phase or side-to-side oscillatory movements or chaotic and disorganized thrashing.² In contrast, FLS typically arise from sleep, are brief, and often involve vocalization and quick, tonic posturing.^14,15 Occasionally, whole body trembling may be observed with PNES. These behaviors may wax, wane, and change over many minutes, which is atypical for ES.

Injury. Physical injury during an ictus was once thought to occur only in patients with epilepsy, but research shows more than one-half of patients with PNES are injured during seizures.¹⁶ Tongue biting, self-injury, and incontinence are commonly associated with ES but are also reported by two-thirds of PNES patients, rendering these signs less specific than once thought.¹⁷

Diagnostic measures

EEG. PNES diagnosis is most accurately established by registering EEG neurophysiologic testing with video. Video-EEG—where the patient’s seizure is observed visually with simultaneous EEG—allows data about neurobehavior to be coupled with EEG rhythms. The absence of expected ictal patterns during the behavioral event points to a PNES diagnosis. Rarely, EEG-negative epilepsy occurs, where a partial simple seizure, a FLS, or a TLS does not generate an ictal epileptic pattern. Without video-EEG, neurologists’ ability to differentiate ES from PNES by history alone has a specificity of 50%.¹⁸

Neuroimaging. Structural neuroimaging abnormalities neither confirm nor exclude ES or PNES. PNES may occur in the presence of focal lesions, as confirmed by:

case reports of PNES patients who have CNS lesions¹⁹
a study showing that 10% of patients with PNES alone have structural abnormalities on MRI.²⁰

A negative ictal single-photon emission computed tomography (SPECT) scan does not imply a diagnosis of PNES, nor does an abnormal scan mean that epilepsy is present. A small series of ictal and interictal SPECT scans of patients with PNES revealed a few scans with lateralized perfusion abnormalities, but the findings did not change when the ictal and interictal images were compared.²¹ Patients with epilepsy, in contrast, have dynamic changes when ictal and interictal changes on functional neuroimaging are compared.

Neurohumoral testing. Serum prolactin drawn within 30 minutes of ictus onset is helpful for differentiating generalized tonic clonic seizures and partial complex seizures from PNES, as summarized in a recent report from the American Academy of Neurology.²²

Pnes characteristics

Patient characteristics and neuropsychological testing are helpful adjuncts to video EEG to diagnose PNES.