What is a psychogenic non-epileptic seizure (PNES)?

 

An epileptic seizure is caused by an abnormal electrical discharge in brain. A PNES attack may look like an epileptic attack or an epileptic seizure, but without an identifiable abnormal brain electrical discharge.

 

 

Is PNES intentional or non-intentional?

 

The term intentional implies a fictitious or a fake disorder. PNES is not intentional, nor fake or fictitious. In that way, it is like epilepsy.

 

 

What are pseudo seizures?

 

It is an old term for psychogenic non-epileptic seizures. For many reasons, this term has been discarded and should be avoided.

 

 

What is conversion disorder?

 

It is another term sometimes used for PNES, implying that psychological stress is converted into physical seizure-like symptoms. Because of its non-specific nature, this term should also be avoided.

 

 

 

Is PNES a new condition?

 

No. It probably has impacted humans for centuries, if not forever.

 

 

How common is PNES?

 

In a neurology practice, and especially in epilepsy clinics, it is not that uncommon. Fair number of patients with diagnosis of epilepsy may have PNES, while some have combination of both epileptic and non-epileptic attacks.

 

 

What are symptoms of PNES?

 

PNES symptoms are usually like epileptic motor seizures. Many times, it is difficult to differentiate between the two, and further testing is needed for precise definition.

 

 

How is PNES diagnosed?

 

Any astute observer with medical training may suspect this condition. At the same time, there is no specific clinical feature and observing an attack or reviewing its video is never enough to make its diagnosis. This is because some epileptic attacks may look like PNES, or vice versa. An EEG is required to differentiate between epileptic and non-epileptic seizures or spells. One EEG or a routine EEG may not be enough, and the patient may require long-term or specialized EEG monitoring. Long-term EEG monitoring increases the chance of obtaining EEG while patient is having an attack or a spell. Nowadays, a home 24 to 72-hour EEG with a camera may be helpful. In some cases, it may be better to admit the patient in hospital for a few days to obtain continuous video and EEG. More difficult cases may require a referral to an epilepsy center.

 

 

Is there a particular pattern of EEG for PNES?

 

EEG stays normal during an attack of PNES.

 

 

Is there any other test to diagnose PNES, other than EEG?

 

No.

 

 

What are the risk factors for PNES? Or what may lead to PNES?

 

Following are some known risk factors:

 

1. Sexual abuse.
2. Emotional abuse.
3. Exposure to certain stresses, e.g., children in a parental conflict or divorce.
4. Family history of PNES.
5. Genetic factors, which currently are not well defined.
6. Depression, anxiety disorder, or personality disorder.
7. Female gender.

 

 

What exactly is the biological mechanism resulting in PNES?

 

Exact biological cause or mechanism is not known. Despite its clear association with it, it is not clear why and how certain types of psychological stress leads to PNES. Routine tests such as neuropsychological testing, EEG, CT scan or MRI do not reveal any specific abnormal finding. Prolactin level, which is usually done in emergency room setting has no meaningful diagnostic value. There is no specific clinical feature that can make the diagnosis. Research done with PET scan has revealed dysfunction in the limbic parts of brain, but the finding is non-specific and is not usable to make a definitive diagnosis of PNES.

 

 

Is PNES a psychiatric or a neurological condition?

 

The distinction between psychiatric and neurological is artificial and arbitrary, and mostly due to historical or practical reasons. A neurological test, EEG, is used to make the diagnosis. Not able to find a neurological abnormality, many neurologists feel uncomfortable or inept treating this condition and refer the patient to a psychiatrist.

 

 

How is PNES treated?

 

Several means have been tried with varying degrees of success.  Following is my experience with this condition:

 

1. Probably the most important factor helpful to the patient is the correct diagnosis: Epilepsy vs PNES vs combination of both. This is the first critical step.
2. Once the diagnosis of PNES is made, the next critical step is its proper and equivocal communication to the patient. It must be communicated confidently but in an empathetic and non-judgmental manner. At least immediately, many patients believe that they are being diagnosed with a fictitious disorder. Clinician should choose words carefully to convey the right message that PNES is not a fictitious disorder, and the patient is not diagnosed with malingering.

• Many patients stop having symptoms after the diagnostic process, but many others do not.
• The next step is proper behavioral exploration, counseling, and therapy. Finding the right behavioral professional or therapist is an uphill task. Not enough therapists are available who specialize in psychological trauma. Many patients with this condition, frequently due to associated circumstances, lack material resources and proper insurance, further limiting their access to proper care.

1. Anxiety and depression are common associated symptoms, which should be properly treated. SSRI type of meds can be helpful.
2. Part of the treatment may require a physical distance from the stress inducing person, location or situation.

• To come out of the vicious cycle of ongoing psychological stress of the disturbing memory causing physical symptoms, the patient can be helped by what we may call, a lifeline or coping mechanism. Based upon their personal, social, or religious value system, the choice of lifeline may be different for different people. Some improve with physical or geographical change in their personal situation, some with compassionate logical intervention, others with a spiritual or religious intervention, and many with psychotherapy and prescription medicines. Frequently, their partners and family members may also need counseling.
• Formally speaking, cognitive behavioral therapy with an antidepressant can be helpful.

 

 

What conditions may look like PNES?

 

Following conditions may look like PNES:

 

. Epilepsy

. Convulsive syncope

. Parasomnias

. Functional movement disorder

. Fictitious disorder

 

What is the prognosis of PNES?

 

In my experience, despite available treatment methods, more than 50% of patients do not recover well. Death rate is higher in PNES with significant possibility of suicide.

 

 

Where may I find more information about this condition?

 

American Academy of Neurology

American Psychiatry Association