Psychogenic Nonepileptic Seizures TAOUFIK M. ALSAADI, M.D., and ANNA VINTER MARQUEZ, M.D. University of California, Davis, Medical Center, Sacramento, California Psychogenic nonepileptic seizures are episodes of movement, sensation, or behaviors that are similar to epileptic seizures but do not have a neurologic origin; rather, they are somatic manifestations of psychologic distress. Patients with psychogenic nonepileptic seizures frequently are misdiagnosed and treated for epilepsy. Video-electroencepha- lography monitoring is preferred for diagnosis. From 5 to 10 percent of outpatient epilepsy patients and 20 to 40 per- cent of inpatient epilepsy patients have psychogenic nonepileptic seizures. These patients inevitably have comorbid psychiatric illnesses, most commonly depression, posttraumatic stress disorder, other dissociative and somatoform disorders, and personality pathology, especially borderline personality type. Many patients have a history of sexual or physical abuse. Between 75 and 85 percent of patients with psychogenic nonepileptic seizures are women. Psycho- genic nonepileptic seizures typically begin in young adulthood. Treatment involves discontinuation of antiepileptic drugs in patients without concurrent epilepsy and referral for appropriate psychiatric care. More studies are needed to determine the best treatment modalities. (Am Fam Physician 2005;72:849-56. Copyright© 2005 American Academy of Family Physicians.) onepileptic seizures are invol- Since ancient times, nonepileptic seizures untary episodes of movement, have been recognized as a form of hysteria. In sensation, or behaviors (e.g., vocal- the late 1800s, Charcot first described non- izations, crying, other expressions epileptic seizure as a clinical disorder, call- N of emotion) that do not result from abnormal ing it “hysteroepilepsy” and “epileptiform cortical discharges. The seizures can mimic hysteria.”2 The term “nonepileptic seizure” any kind of epileptic seizure and thus can be is preferable to the older terms “hysterical mistaken for generalized tonic-clonic seizure, seizure” and “pseudoseizure,” which are absence seizure, and simple or complex par- considered pejorative.3 tial seizures.1 Early recognition and appro- Nonepileptic seizures are classified as phys- priate treatment of nonepileptic seizures can iologic or psychogenic in origin (Table 1). In prevent significant iatrogenic harm and may specialty epilepsy center patients, physiologic result in a better outcome. nonepileptic seizures are less common than psychogenic nonepileptic seizures. Physiologic nonepileptic seizures have TABLE 1 multiple causes. They may be related to Classification of Nonepileptic Seizures syncopal episodes, complicated migraines, panic attacks, or transient ischemic attacks. Psychogenic Physiologic They may be due to autonomic dysfunction, Misinterpretation of physical symptoms Cardiac arrhythmias cardiac arrhythmias, hypoglycemia, drug Psychopathologic processes Complicated migraines intoxication or withdrawal, or alcohol intox- Anxiety disorders, including Dysautonomia ication or withdrawal. Movement disorders, posttraumatic stress disorder Effects of drugs and toxins sleep disorders, and vestibular symptoms Conversion disorder Hypoglycemia may be mistaken for nonepileptic seizures.4 Dissociative disorders Movement disorders Psychogenic nonepileptic seizures are a Hypochondriasis Panic attacks physical manifestation of psychologic dis- Psychoses Sleep disorders tress. They are grouped into the category of Somatization disorders Syncopal episodes psychoneurologic illnesses (e.g., conversion Reinforced behavior patterns in Transient ischemic attacks cognitively impaired patients disorder, somatization disorders), in which Vestibular symptoms Response to acute stress without symptoms are psychiatric in origin but neu- evidence of psychopathology rologic in expression.5 This article focuses on psychogenic nonepileptic seizures. Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright© 2005 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References Early referral of patients with apparently refractory seizures is critical. C 8, 10, 12 Video-electroencephalography monitoring is the gold standard for the diagnosis of psychogenic nonepileptic seizures. No single clinical or historical feature is diagnostic of psychogenic C 1-3, 9, 10 nonepileptic seizures. If the number of features that are unusual for epileptic seizures increases, psychogenic nonepileptic seizures should be considered more seriously. Treatment of psychogenic nonepileptic seizures should address the C 3, 9, 25, 27, underlying cause(s). 35, 36 A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evi- dence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 736 or http://www.aafp.org/afpsort.xml. Diagnosis for characterization of their seizures. The The presence or absence of self-injury and study found that 24 percent of the patients incontinence, the ability to induce seizures had been misdiagnosed: 22 patients previ- by suggestion, psychologic tests, histori- ously diagnosed with epilepsy were found to cal factors, and ambulatory electroenceph- have nonepileptic seizures, and four patients alography (EEG) have been found to be previously diagnosed with nonepileptic sei- insufficient for the diagnosis of psychogenic zures were found to have epileptic seizures. nonepileptic seizures.1,6 Postictal prolactin All of the patients in the study had been levels greater than two times the upper limit referred by epileptologists or by neurologists of normal once were thought to differenti- with experience in diagnosing and treat- ate generalized and complex partial seizures ing epilepsy. Thus, even epilepsy specialists from psychogenic nonepileptic seizures but misdiagnosed seizure types in nearly one recently have been shown to be unreliable.7 fourth of cases. VIDEO-ELECTROEncEPHALOGRAPHY HISTORICAL And cLINICAL FEATURES Inpatient video-electroencephalography Features that are suggestive, but not diagnos- (vEEG) monitoring is the preferred test for tic, of psychogenic nonepileptic seizures are the diagnosis of psychogenic nonepileptic listed in Table 2.1,9,10 Typical features of these seizures. Definitive diagnosis is achieved events include gradual onset, long duration, when a patient is observed hav- a waxing and waning course, and disor- ing typical seizures without ganized, asymmetric motor activity.9 The Inpatient video-electro- accompanying EEG abnormali- events lack the stereotypy of epileptic sei- encephalography is the ties. Family members or wit- zures because the pattern of symptoms and preferred test for the nesses who are familiar with sequence of events vary between seizures. diagnosis of psychogenic the patient’s seizures must agree Not all seizures with these features are nonepileptic seizures. that the recorded episodes are psychogenic nonepileptic seizures, however. Definitive diagnosis is typical events. Frontal lobe seizures often are mistaken for achieved when a patient is The importance of using nonepileptic seizures because of the associ- observed having typical sei- vEEG monitoring recently was ated dramatic motor and vocal outbursts, zures without accompanying underscored in a study8 that possible retained consciousness, and short electroencephalographic evaluated diagnoses in patients postictal period. Frontal lobe seizures may abnormalities. who had been referred to an be distinguished by their brief duration, inpatient vEEG monitoring unit stereotypical nature, and tendency to begin 850 American Family Physician www.aafp.org/afp Volume 72, Number 5 ◆ September 1, 2005 Nonepileptic Seizures during sleep.9 Gelastic seizures (in which Psychogenic nonepileptic seizures have the primary automatism is laughter), reflex serious negative effects on patients’ lives. epilepsies, and myoclonic jerks also have Health-related quality of life is significantly been mistaken for psychogenic nonepileptic lower in patients with these seizures than in seizures.9 patients with epilepsy, even intractable epi- lepsy.15 Decreased quality of life in patients ImpORTAncE OF EARLY dIAGNOSIS with psychogenic nonepileptic seizures is Early diagnosis of psychogenic nonepileptic associated with the presence of psychopathol- seizures is critical. Unfortunately, the diag- ogy and the adverse effects of antiepileptic nosis often is delayed. One review10 reported a mean of 7.2 years between manifesta- tion and accurate diagnosis of psychogenic TABLE 2 nonepileptic seizures. Because of this delay, Clinical and Historical Features Suggesting many patients with these events experience a Diagnosis of Psychogenic Nonepileptic Seizures significant morbidity from inappropriate treatment for epileptic seizures, including Clinical features adverse effects of antiepileptic drugs and Ability of observer to modify the patient’s motor activity aggressive, potentially harmful interventions Asynchronous limb movements (e.g., intubation) for pseudo–status epilepti- Avoidance behavior during seizures cus during emergency department visits. Change in symptomatology, or nonstereotypical