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Psychogenic Nonepileptic 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 . 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 , posttraumatic 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 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 , 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 disorders, and vestibular symptoms Hypoglycemia may be mistaken for nonepileptic seizures.4 Dissociative disorders Movement disorders Psychogenic nonepileptic seizures are a 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 rologic in expression.5 This article focuses on psychogenic nonepileptic seizures.

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Evidence Clinical recommendation rating References

Early referral of patients with apparently refractory seizures is critical. C 8, 10, 12 Video- 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 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 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 , 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 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

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during sleep.9 Gelastic seizures (in which Psychogenic nonepileptic seizures have the primary automatism is laughter), reflex serious negative effects on patients’ lives. , 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 seizure patterns Definitive diagnosis of psychogenic non- Closed eyes during seizures epileptic seizures may be therapeutic. After Dystonic posturing (including opisthotonos) being informed unambiguously of the diag- Emotional or situational trigger for the seizures 11 nosis, some patients stop having the events. Gradual onset and cessation of seizures Early diagnosis of psychogenic nonepilep- Ictal crying, weeping tic seizures is important economically. One If tongue biting is present, usually the tip (not the side) of the tongue 12 study demonstrated an 84 percent reduc- Intermittent or waxing and waning motor activity tion in total seizure-related medical charges Nonphysiologic progression in the six months after diagnosis of psycho- Pelvic movements (especially forward thrusting) genic nonepileptic seizures: average diag- Prolonged seizures (duration of 2 to 3 minutes) nostic test charges decreased by 76 percent, Resisted eyelid opening medication charges decreased by 69 percent, Seizures provoked by suggestion outpatient visits decreased by 80 percent, and Side-to-side head movements emergency department visits decreased by Historical features 97 percent. Associated (often multiple) psychiatric disorders Family physicians have an important role Flurries of seizures or recurrent pseudo– that lead to in the timely diagnosis of psychogenic non- multiple emergency department visits or hospitalizations epileptic seizures through early referral of High seizure frequency patients with apparently intractable seizures History of sexual or physical abuse to epilepsy centers. Seizures in about 60 Lack of concern or an excessive or exaggerated emotional response percent of patients with newly diagnosed Multiple unexplained physical symptoms epilepsy are controlled with a moderate No history of injury from seizures dosage of a single antiepileptic drug (usu- No response to antiepileptic drugs or a paradoxical increase in seizures ally the first or second drug chosen); only with antiepileptic drug treatment about 10 percent of patients with inadequate Personal, family, or professional experience with epilepsy control of seizures on the first antiepileptic Seizures that occur only in the presence of others or only when the drug become free of seizures.13,14 Thus, the patient is alone threshold for determining that seizures are Adapted with permission from Reuber M, Elger CD. Psychogenic nonepileptic seizures: intractable should be low, and referral to an review and update. Epilepsy Behav 2003;4:207, with additional information from refer- epilepsy center for clarification of the diag- ences 1 and 9. nosis should be prompt.

September 1, 2005 ◆ Volume 72, Number 5 www.aafp.org/afp American Family Physician 851 drugs.15 These factors further emphasize EEG. These factors suggest that physical the importance of early diagnosis of psy- brain disease may play a role in the develop- chogenic nonepileptic seizures, cessation of ment of the events.19 The events also occur in antiepileptic drug therapy in patients with- patients with central nervous system lesions out concurrent epilepsy, and treatment of that are associated with an increased risk of the underlying psychiatric illness. developing epilepsy, such as stroke, trauma, infection, and malformation,20 as well as in Epidemiology patients with hippocampal sclerosis,21 which The prevalence of nonepileptic seizures often is identified as a cause of temporal lobe ranges from two to 33 cases per 100,000 epilepsy. Thus, the presence of MRI or EEG persons in the general population. Hence, abnormalities may delay diagnosis and treat- these seizures are approximately as com- ment of psychogenic nonepileptic seizures. mon as multiple sclerosis and Estimates of the coexistence of epilepsy 16 Many patients with psy- trigeminal neuralgia. From and psychogenic nonepileptic seizures vary 5 to 10 percent of outpatient from 5 percent to more than 60 percent, chogenic nonepileptic epilepsy populations have psy- depending on the study setting and diagnos- seizures experience sig- chogenic nonepileptic seizures, tic criteria.3 Recent studies17,22 using strict nificant morbidity from compared with 20 to 40 percent criteria for a diagnosis of epilepsy found that inappropriate treatment of inpatient epilepsy popula- only 5 to 10 percent of patients with non- for epileptic seizures. tions (hospitals and specialty epileptic seizures have concurrent epileptic epilepsy centers).3,17 Between seizures. 75 and 85 percent of patients with psy- chogenic nonepileptic seizures are women.18 Etiology Like conversion disorder, psychogenic non- All psychogenic nonepileptic seizures func- epileptic seizures tend to begin in young tion as a coping mechanism.23 Patients with adulthood, although the seizures can occur these events are more likely to use maladap- in a wide range of ages.18 tive coping strategies to handle stress.24 In The prevalence of psychogenic nonepilep- psychogenic nonepileptic seizures, psycho- tic seizures is increased in patients with head logic conflicts are translated into a physical injuries, learning disabilities, or isolated symptom—the seizure. In this way, intoler- neuropsychologic deficits,10 and patients able distress is dissociated from the pain- with psychogenic nonepileptic seizures have ful conscious experience of the trauma or higher than average rates of abnormal results forbidden emotions that are causing the dis- on magnetic resonance imaging (MRI) and tress.25,26 Thus, genuine psychogenic non- epileptic seizures (as opposed to or malingering) are not intentional: The Authors they are created as a psychologic defense TAOUFIK M. ALSAADI, M.D., is assistant professor of clinical neurology at the mechanism to keep internal stressors out of University of California, Davis (UCD), School of Medicine. He also is director conscious awareness.25 of the epilepsy treatment center and director of clinical epilepsy research at UCD Medical Center, Sacramento. Dr. Alsaadi received his medical degree from Psychogenic nonepileptic seizures do not the Damascus University School of Medicine, Syria. He completed a neurology have a single etiology; rather, they are the residency at the Medical College of Wisconsin, Milwaukee, and an epilepsy product of several different causal pathways and electrophysiology fellowship at the University of California, San Francisco, (Table 1). The seizures may be the result of School of Medicine. psychopathologic processes, a response to ANNA VINTER MARQUEZ, M.D., is a resident at UCD Medical Center. acute stress in patients without evidence of She received her medical degree from the UCD School of Medicine, where she psychopathology, or a reinforced behavior also completed a research fellowship in the neuropsychiatric aspects of epilepsy. pattern in cognitively impaired patients. Rarely, malingering or factitious disor- Address correspondence to Taoufik M. Alsaadi, M.D., Department of Neurology, University of California, Davis, Medical Center, 4860 Y St., Suite 3700, Sacramento, der presents as psychogenic nonepileptic 27 CA 95817-2307 (e-mail: [email protected]). Reprints are not seizures. available from the authors. From 43 to 100 percent (median: 73.5 per­

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cent) of patients with psychogenic nonepi- patients. Seizure reduction occurs in about leptic seizures have concurrent psychiatric one third of patients, and chronic, unim- disorders28 (Table 3).25 The disorders tend proved seizures continue in another one to be related to trauma, and include post- third of patients.38 traumatic stress disorder (PTSD) and other In a study11 that assessed one- to 10-year anxiety disorders; depressive disorders; and outcomes in 164 patients with psychogenic conversion, somatization, and dissociation nonepileptic seizures, 44 percent had a poor disorders. Personality pathology, particu- outcome (not free of seizures, dependent larly of the borderline type, is common.29 [i.e., unemployed or retired because of ill Frequently, patients with psychogenic non- health]); 40 percent had an intermediate epileptic seizures also have other dissocia- outcome (free of seizures but dependent, tive and somatization symptoms.18,30 or not free of seizures but living indepen- Patients with psychogenic nonepileptic dently); and 16 percent had a good outcome seizures frequently have a history of (or cur- (free of seizures and living independently). rent) physical or sexual abuse24 or significant At more than 11 years after the onset of psychosocial stressors for which there is no psychogenic nonepileptic seizures and four perceived resolution.31,32 These “unspeak- years after diagnosis, 71 percent of patients able dilemmas”31 often involve dysfunctional still were having seizures, and 56 percent family interaction and communication.18,24 still were dependent. These outcomes are A frequently cited prospective study25 worse than those for newly diagnosed epi- showed that 84 percent of patients with lepsy and are equivalent to the outcomes for psychogenic nonepileptic seizures had expe- other somatoform disorders.11 rienced trauma. One recent study33 found significantly higher rates of PTSD, child- Treatment hood sexual abuse, dissociative symptoms, No randomized controlled studies have been and history of assaultive trauma in patients conducted on the treatment of psychogenic with psychogenic nonepileptic seizures than nonepileptic seizures.27,28 Treatment recom- in patients with epilepsy. Physical and sexual mendations are based on the theory that abuse has been linked to increased rates of several somatization syndromes, including psychogenic nonepileptic seizures.26 TABLE 3 To determine why a patient is having Selected Comorbid Psychiatric Disorders in 45 Patients psychogenic nonepileptic seizures, the phy- with Psychogenic Nonepileptic Seizures sician must identify the psychologic func- 34 tion of the seizure. A detailed, systematic Prevalence (%) psychiatric evaluation and an assessment of family, social, financial, and employment Diagnosis Current* Lifetime 35 problems should provide insight. Causes Any 91 93 and suggested treatments for psychogenic Any somatoform disorder 89 98 nonepileptic seizures are summarized in Any affective disorder 64 98 3,9,25,27,35,36 Table 4. 62 62 PTSD 49 58 Disease Course Major depressive disorder 47 80 Because nonepileptic seizures are not a sin- other than PTSD 47 51 gle entity or disorder, the course is variable Conversion symptoms, but not seizures 4 82 and depends on the underlying cause. Prog- nostic factors also vary (Table 5).9,11,27,37 PTSD = posttraumatic stress disorder. The findings of outcome studies allow *—“Current” indicates within the past month; listed in order of frequency. some generalizations about patients with Adapted with permission from Bowman ES, Markand ON. Psychodynamics and psychi- psychogenic nonepileptic seizures. Seizure atric diagnoses of pseudoseizure subjects. Am J Psychiatry 1996;153:59. cessation occurs in about 40 percent of

September 1, 2005 ◆ Volume 72, Number 5 www.aafp.org/afp American Family Physician 853 because the seizures are psychogenic in ori- Various psychotherapeutic techniques gin, they will respond to psychiatric treat- with proven efficacy in other disorders have ment. Two uncontrolled studies18,39 have been applied to patients with psychogenic shown that psychotherapy is more effective nonepileptic seizures who have similar psy- than no intervention. chiatric profiles. Table 43,9,25,27,35,36 summa-

TABLE 4 Psychogenic Nonepileptic Seizures: Etiologies and Suggested Treatments

Etiology Description Suggested treatments

Acute or situational Seizures develop after multiple or acute stressors Supportive psychotherapy, lifestyle changes, stressors overwhelm the patient’s coping ability; underlying group or family therapy as indicated psychopathology may not be present. Anxiety, panic, physical Atypical symptoms of anxiety or panic are Treatment of panic attacks; reassurance that symptoms misdiagnosed as psychogenic nonepileptic physical symptoms are not seizures seizures, or the patient misinterprets physical sensations or symptoms as seizures. Depression, A specific stressor does not precipitate psychogenic Antidepressant drug therapy, cognitive dissatisfaction nonepileptic seizures; rather, the patient is behavior therapy to challenge the patient’s generally unhappy, and the seizures function as depressive thoughts and basic assumptions distraction or an acceptable way to get support about self and illness; encouragement of and attention. the patient’s active involvement in lifestyle changes and problem solving Poor interpersonal Patients with this profile often are diagnosed with Intensive psychodynamic psychotherapy skills and affect borderline personality disorder and frequently to help identify and express threatening regulation, disturbed have a history of abuse. The patient may come situations or emotions (e.g., conflict, anger, family systems from a family with poor emotional expression and feelings of rejection) and to set realistic therefore may be unable to identify and effectively goals for relationships; family therapy when express strong emotions. The seizures function the family system supports maintenance of to resolve interpersonal crises or threatening psychogenic nonepileptic seizures emotions or situations. Rarely, psychogenic nonepileptic seizures can be Treatment of underlying psychosis a manifestation of psychosis; in most instances, however, the diagnosis of psychosis is clear. PTSD, dissociation The patient has active chronic PTSD and dissociative Exposure-based therapies and selective symptoms. Flashbacks, recollections, or sensory serotonin reuptake inhibitors for PTSD triggers often initiate psychogenic nonepileptic seizures. Often, there is a history of severe childhood or current abuse. Reinforced behavior Reinforced behavior pattern often is the underlying Behavior modification therapy pattern cause of psychogenic nonepileptic seizures in cognitively impaired patients. The patient develops psychogenic nonepileptic seizures because of the functional advantages that are reinforced by the seizures (e.g., attention, avoidance of responsibility). Somatization, The seizures represent emotional distress Cognitive behavior therapy to identify links somatoform disorder, converted into physical symptoms. Often, between stress and psychogenic nonepileptic conversion disorder there is a long history of medical attention for seizures and to develop more adaptive unexplained physical symptoms. The patient coping; for severe somatization, regular often can identify precipitating stressful events; visits not contingent on symptoms but with the seizures therefore are a conversion symptom. a focus on living with the symptoms rather than investigating and treating them

PTSD = posttraumatic stress disorder. Information from references 3, 9, 25, 27, 35, and 36.

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TABLE 5 Prognostic Factors in Patients with Psychogenic Nonepileptic Seizures

Factors for favorable outcome Factors for unfavorable outcome

Acceptance of nonepileptic nature of episodes Coexisting epilepsy Family structure that supports autonomy Disbelief of diagnosis Female gender Family structure that supports Having friends currently dependency and illness Having good relationships with friends as a child Long history of psychiatric disorders Higher ability to express emotions Longer duration of psychogenic Higher intelligence and education nonepileptic seizures Independent lifestyle Male gender Less dramatic psychogenic nonepileptic seizures: Ongoing physical or sexual abuse no positive motor features, no ictal incontinence Ongoing psychosocial stressors or biting, no admissions to intensive care unit, no Pending litigation pseudo–status epilepticus with intubation Persistent somatization Less extreme scores on traits defining emotional Reluctant self-disclosure dysregulation Restricted expression of anger and Less tendency to dissociate positive feelings Shorter duration of psychogenic nonepileptic seizures Unemployment or disability Younger age at diagnosis

Adapted with permission from LaFrance WC, Devinsky O. Treatment of nonepileptic seizures. Epilepsy Behav 2002;3(5S):20; with additional information from references 9, 11, and 37. rizes current treatment recommendations Author disclosure: Nothing to disclose. based on the underlying causes of psycho- genic nonepileptic seizures. All recommen- REFERENCES dations are based on anecdotal evidence or 1. Rowan AJ. Diagnosis of non-epileptic seizures. In: small, uncontrolled studies. Gates JR, Rowan AJ, eds. Non-epileptic seizures. 2d ed. In one model,27 the first step is accurate Boston: Butterworth-Heinemann, 2000:15-30. 2. Krumholz A. Nonepileptic seizures: diagnosis and man- diagnosis of psychogenic nonepileptic sei- agement. Neurology 1999;53(5 suppl 2):S76-83. zures based on a thorough history, a focused 3. Gates JR. Epidemiology and classification of non-epi- physical examination, and inpatient vEEG leptic events. In: Gates JR, Rowan AJ, eds. Non-epilep- monitoring. After the diagnosis is presented tic seizures. 2d ed. Boston: Butterworth-Heinemann, 2000:3-14. to the patient and family, the next step 4. Andermann F. Non-epileptic paroxysmal neurological is to create a list of predisposing factors, events. In: Gates JR, Rowan AJ, eds. Non-epileptic seizures. precipitants, and perpetuating factors for 2d ed. Boston: Butterworth-Heinemann, 2000:51-69. the seizures. This list is used to determine 5. Bourgeois JA, Chang CH, Hilty DM, Servis ME. Clinical manifestations and management of conversion disor- the appropriate psychotherapies and drug ders. Curr Treat Options Neurol 2002;4:487-97. treatments. Antiepileptic drugs are tapered 6. Iriarte J, Parra J, Urrestarazu E, Kuyk J. Controversies in in patients with exclusively nonepileptic sei- the diagnosis and management of psychogenic pseudo­ zures, and appropriate psychotropic drugs seizures. Epilepsy Behav 2003;4:354-9. 7. Shukla G, Bhatia M, Vivekanandhan S, Gupta N, Tripa- are titrated for the treatment of psychiatric thi M, Srivastava A, et al. Serum prolactin levels for dif- comorbidities. ferentiation of nonepileptic versus true seizures: limited An excellent resource for patients with utility. Epilepsy Behav 2004;5:517-21. psychogenic nonepileptic seizures is available 8. Alsaadi TM, Thieman C, Shatzel A, Farias S. Video-EEG telemetry can be a crucial tool for neurologists experi- online (http://www.hsc.usf.edu/~sbenbadi/ enced in epilepsy when diagnosing seizure disorders. PNES_USF.html). Seizure 2004;13:32-4.

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