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Review Article

Address correspondence
to Dr W. Curt LaFrance Jr,
Rhode Island Hospital, Brown
University, 593 Eddy Street,
Providence, RI 02903,
william_lafrance_jr@brown.
edu.
Relationship Disclosure:
Dr Chen reports no disclosure.
Dr LaFrance serves on the
Epilepsy Foundation
Professional Advisory Board;
has served as a clinic
development consultant for
the Cleveland Clinic, Emory
University, Spectrum Health,
and the University of Colorado
Denver; and has provided
expert medicolegal testimony.
Dr LaFrance receives royalties
from Cambridge University
Press and Oxford University
Press and has received research
support from the American
Epilepsy Society, the Epilepsy
Foundation, the Matthew Siravo
Memorial Foundation Inc, the
National Institutes of Health,
and Rhode Island Hospital.
Unlabeled Use of
Products/Investigational
Use Disclosure:
Drs Chen and LaFrance report
no disclosures.
* 2016 American Academy
of Neurology.

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116

Diagnosis and Treatment
of Nonepileptic Seizures
David K. Chen, MD; W. Curt LaFrance Jr, MD, MPH, FAAN, FANPA, DFAPA
ABSTRACT
Purpose of Review: This article details the evaluation process involved in the diagnosis
of psychogenic nonepileptic seizures (PNES). The psychological underpinnings, prognostic factors, and recent treatment advances of PNES are also reviewed.
Recent Findings: The diagnosis of PNES is determined based on concordance of
the composite evidence available, including historical and physical examination
findings, seizure symptoms and signs, and ictal/interictal EEG. No single clinical data
point is definitively diagnostic of PNES. The diagnosis of PNES can be challenging
at times, such as when seizure documentation on video-EEG cannot be readily
obtained. Yet, delayed diagnosis of PNES portends poor outcome. A multicomponent approach to the diagnosis of PNES, with use of an aggregate of available evidence, may facilitate diagnosis and then care of patients with PNES. Emerging evidence
supports the effectiveness of cognitive-behavioralYbased therapy in the treatment of
these patients.
Summary: The diagnosis of PNES can be made reliably, and evidence-based treatment
now exists. Continued efforts remain necessary to enhance prompt recognition and
interdisciplinary management for patients with PNES.
Continuum (Minneap Minn) 2016;22(1):116–131.

INTRODUCTION
Nonepileptic seizures are episodes of
altered movement, sensation, or experience distinguished from epileptic seizures by the lack of associated ictal
abnormal electrical brain discharges.
About one-quarter of patients referred
to specialist centers for apparent “drugresistant epilepsy” are found to be misdiagnosed.1 After an average delay of
about 1 to 7 years to establish the correct
diagnosis,2,3 patients with nonepileptic
seizures will frequently have taken higher
doses of antiepileptic drugs (AEDs), utilized greater health care resources, and
sustained more iatrogenic adverse effects than patients with epilepsy.4
Nonepileptic seizures are further categorized as physiologic or psychogenic
in origin. Physiologic nonepileptic events
result from systemic alterations or disease states that produce an ictus (eg,

convulsive syncope, cataplexy, or alcoholwithdrawal seizure) (Table 6-15). Treating
the underlying pathology of physiologic
nonepileptic events addresses the event.
In contrast, psychogenic nonepileptic
seizures (PNES) represent physical manifestations derived from psychological
underpinnings. In epilepsy specialty
centers, 88% of patients with nonepileptic seizures are deemed to have a psychogenic etiology for their events.6
This review therefore focuses primarily on the diagnosis and management
of PNES.
DIAGNOSIS OF PSYCHOGENIC
NONEPILEPTIC SEIZURES
The diagnosis of PNES can be challenging. When comprehensive neurologic
and psychiatric assessment and videoEEG are not available in one setting, an
iterative assessment process over time

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Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited.

February 2016

about half have comorbid posttraumatic stress disorder (PTSD). Long-term video-EEG monitoring is also not readily available in some locations. would be unusual for epilepsy and should raise suspicion for PNES. symptoms and signs. An important caveat is that the features described by the patient and witnesses poorly correspond with the observed PNES documented during video-EEG monitoring. and video-EEG evaluations that support the PNES diagnosis and differentiate it from epilepsy. Historical Features Differentiating Psychogenic Nonepileptic Seizures and Epileptic Seizures At the outset.22(1):116–131 history are useful in raising the suspicion for PNES. failing to respond to adequate trials of two or more antiepileptic drugs) are found to have physiologic or psychogenic nonepileptic seizures rather than epilepsy. utilized greater health care resources. 117 . patients with nonepileptic seizures will frequently have taken higher doses of antiepileptic drugs.11 The presence of psychogenic disorders is a strong risk factor for other forms of comorbid or future psychosomatic symptoms.15 Therefore.7 Habitual seizures of interest.12 Accordingly. sounds. hence contributing to the frequent time delay (an average of 1 to 7 years) before patients with psychogenic nonepileptic seizures are correctly diagnosed. Each of these two elements should be considered separately.com Copyright © American Academy of Neurology. such as intractable pain. h The diagnosis of psychogenic nonepileptic seizures can be challenging. and sustained more iatrogenic adverse effects than patients with epilepsy. ictal features described by patients’ or witnesses’ report alone should be interpreted with less diagnostic certainty than those visually documented from KEY POINTS h About one-quarter of patients referred to specialist centers for apparent drug-resistant epilepsy (ie.TABLE 6-1 Physiologic Causes of Nonepileptic Seizuresa b Syncope Vasovagal Cardiogenic b Neurologic Cerebrovascular Migraine Vertigo Cataplexy Parasomnias Movement disorders b Metabolic Hypoglycemia Electrolyte disturbances Toxicity (eg. are sometimes not captured during an initial video-EEG monitoring study. especially if the reported association is strikingly consistent.ContinuumJournal.com/content/ 81/958/498. Studies have shown that similar stressors can also provoke epileptic seizures. such as certain lighting level conditions.14). and about two-thirds have personality disorders. drugs and alcohol) a Modified with permission from Mellers JD.full. h After an average delay of about 1 to 7 years to establish the correct diagnosis. or foods. may be necessary to establish the diagnosis of PNES. B 2005 British Medical Journal Publishing Group. a predominant majority (about 88%) of patients with nonepileptic seizures are deemed to have a psychogenic etiology for their events (ie.5 pmj.13 Clinical Features Differentiating Psychogenic Nonepileptic Seizures and Epileptic Seizures Key elements in the evaluation of PNES include the recognition of ictal features that are: (1) suggestive of a psychogenic process and (2) not in favor of an epileptic source (Table 6-25. Of note.9 While stimuli-specific reflex epilepsies exist. Unauthorized reproduction of this article is prohibited. this article first details relevant features from clinical history. in terms of both seizure frequency8 and duration.bmj. about half have been diagnosed with depression. body movements.10 Over the lifetime of patients with PNES. Appreciating these diagnostic challenges and the importance of prompt recognition of this disorder. h In epilepsy specialty centers. the endorsement of more pedestrian triggers. seizure exacerbation by emotional stressors is not pathognomonic for PNES. psychogenic nonepileptic seizures). The seizure burden of patients with PNES is generally more pronounced than that of those with epilepsy. about 70% of patients with PNES endorse comorbid experiences with medically unexplained symptoms. Postgrad Med J. especially in patients with multiple independent event types. a number of peculiar features uncovered from a carefully elicited Continuum (Minneap Minn) 2016. www.

postictal obtundation/confusion. PNES have been classified into distinct groups according to the predominant clinical features. and occur in the context of supportive historical. Postgrad Med. Vocalization in PNES can be more complex. the vocalization may be present not only at the beginning of the seizure but may persist or even intensify through the course of the ictus.14 jnnp.5 pmj. For example. Unauthorized reproduction of this article is prohibited. complex motor. during which EEG activity discordantly correlates with wakefulness or light drowsiness. In distinguishing PNES from epileptic seizures.com/content/81/7/719. In contrast. the convulsive activity in generalized tonic- clonic PNES may demonstrate unchanging frequency and variable amplitude throughout the ictus. and highly stereotyped.15 Instead. dialeptic (impaired awareness). 118 video-EEG monitoring and. b No single sign distinguishes psychogenic nonepileptic seizures from epileptic seizures.ContinuumJournal. with affective content reflecting somatic expression of emotional distress (eg. side-to-side head or body movement. weeping. the ictal features of patients with PNES can often change.b Signs Examination Findings Psychogenic nonepileptic seizures Long duration.14 and no individual feature is definitively diagnostic of PNES. Mellers JD. and mixed. a Data from Avbersek A. primitive in nature (laryngeal sound).17 Some PNES show poorly discernible ictal onset from a setting of apparent sleep.16 The generalized tonicclonic epileptic features can inform diagnosis. stertorous breathing postictally Very severe tongue biting. it is presently uncertain whether such categorization is useful to distinguish psychological underpinnings or inform prognosis.abstract. where ictal features evolve through an organized fashion such that clonic frequency progressively declines while amplitude increases through the course of the convulsion. evidence of visual fixationc Epileptic seizures Occurrence from EEG-confirmed sleep. J Neurol Neurosurg Psychiatry.18 On the other hand. hypermotor. epileptic seizures or parasomnias). the degree of diagnostic confidence correlates with concordant features favoring PNES. guarding of hand dropping over face. memory recall for period of unresponsiveness Resists eyelid opening.full. and coughing). h Patients’ and witnesses’ descriptions of the ictal features have been known to correlate poorly with observed features of video-EEGY captured seizures. Furthermore.19 While such categorization can contribute to pattern recognition useful in the evaluation of PNES. about half have comorbid posttraumatic stress disorder. asynchronous movements. transforming into other clinical presentations or unrelated somatic symptoms.bmj. KEY POINTS h Over the lifetime of patients with psychogenic nonepileptic seizures. extensor plantar response EEG = electroencephalogram.com Copyright © American Academy of Neurology.com/content/81/958/498.Nonepileptic Seizures to Help Distinguish Psychogenic TABLE 6-2 Clinical Signs and Examination Findings Used Nonepileptic Seizures From Epileptic Seizuresa. These groupings include rhythmic motor. paroxysms with clear-cut emergence from EEGdocumented sleep would have a high likelihood of being physiologic in origin (ie. home video recording. and ictal/interictal video-EEG findings. pelvic thrusting. fluctuating course. ictal crying/weeping.bmj. physical examination. about half have been diagnosed with depression. to a lesser extent. Ictal vocalization in epileptic seizures is usually restricted to the beginning of the seizure. c Visual fixation can be elicited by placing a mirror in front of the patient or rolling the patient from one side to the other. clinical features are generally more specific than sensitive. h The diagnosis of psychogenic nonepileptic seizures requires the demonstration of ictal features that favor a psychogenic process. ictal eye closure. Sisodiya S. subjective. unlike stereotyped epileptic seizures arising from a singular epileptogenic substrate. moaning. are not consistent with epilepsy. and about two-thirds have personality disorders. February 2016 .20 www. In PNES. assessment of the characteristic seizure temporal evolution is often helpful. impaired corneal reflex.

A concordant impression from each of these data elements with the video-EEG provides the diagnostic gold standard with high levels of certainty as well as excellent interrater reliability. video-EEG offers a diagnostic gold standard with high levels of certainty and reliability. h The EEG during syncope proceeds through a stereotyped pattern. Unauthorized reproduction of this article is prohibited. or after the seizure indicates that the captured event is likely nonepileptic in origin but does not necessarily distinguish a psychogenic versus physiologic etiology. The most commonly observed movement pattern in this study was multifocal arrhythmic jerks in both proximal and distal muscles. 119 . whereas those of epileptic seizures would not be influenced by body position. www. If the patient’s historical features suggest more than one type of event. physiologic causes can be excluded by concurrent presence of an intact alpha rhythm on the EEG (a neurophysiologic correlate of alertness). Indeed. autonomic. then delta slowing followed by suppression. then delta slowing followed by suppression. Confirming the Diagnosis of Psychogenic Nonepileptic Seizures Diagnostic tools used to help support the diagnosis of PNES include inpatient video-EEG monitoring. It has been suggested that patients with recurrent “syncope of unknown origin” despite a thorough evaluation (about 20% to 30% of patients with syncope) should undergo video-EEG monitoring as some of them may.23 The motor symptoms of syncope terminate when the patient assumes a horizontal position that facilitates cerebral perfusion. have PNES. approximately 10% of patients with PNES also have an independent diagnosis of epilepsy.22 The presence of convulsionlike motor accompaniments does not preclude the consideration of syncope. further diagnostic caution is warranted as the percentage of mixed PNES with epilepsy cases can be up to 30%. h In the setting of an unconscious patient. the etiology of the nondocumented event type should be diagnosed with a more cautious level of certainty.22(1):116–131 and EEG documentation of the habitual seizures of interest. beginning with theta slowing. 38 (90%) of the episodes were associated with motor symptoms.15 Nuances of video-EEG interpretation. any recorded event should be confirmed by an eyewitness to be typical of the habitual seizures of interest. In other scenarios. during. physiologic causes can be excluded by concurrent presence of an intact alpha rhythm on the EEG (a neurophysiologic correlate of alertness). For some patients with PNES who experience dense amnesia for the details of their seizures. h Upon demonstrating psychogenic nonepileptic seizureYconsistent clinical event features in the context of supportive historical and physical examination findings. h Assessing the characteristics of the temporal evolution of a seizure can frequently yield helpful clues in differentiating psychogenic nonepileptic seizures from epileptic seizures.Distinguishing Syncope From Other Causes of Drop Attacks The mean duration of vasovagal syncope (the most common mechanism for syncope) from the moment of event onset to recovery of full consciousness has been shown to be 41. the EEG during syncope proceeds through a stereotyped pattern.21 Therefore.22 Contrasting with the absence of significant EEG background change for PNES. Video-EEG entails prolonged continuous monitoring of the patient. then an occurrence of each type should be recorded.ContinuumJournal. If not. the absence of an epileptiform ictal EEG correlate before. usually lasting only a few seconds. In the setting of an unconscious patient. Consideration of a psychogenic etiology requires the demonstration of PNESYconsistent clinical event features in the context of supportive historical and ictal/ peri-ictal physical examination findings (Table 6-2). ambulatory EEG recording. allowing for simultaneous video Continuum (Minneap Minn) 2016.com Copyright © American Academy of Neurology. as independent event types may reflect distinct etiologies. the clinical relevance of the recorded event remains uncertain.25 Focal epileptic seizures with preserved consciousness and rather restricted motor. in fact. Otherwise. or sensory/psychic KEY POINTS h No feature in itself is definitively diagnostic of psychogenic nonepileptic seizures. In a study involving video analysis of 42 episodes of syncope. Video-EEG.4 seconds. and home video recording of habitual seizures.24 For patients with a learning disability. paroxysms of swoons that last longer than 1 minute should raise suspicion for other etiologies. beginning with theta slowing.

120 components (simple partial symptomatology) may arise from only a small pool of neuronal tissue.27 For those who do not experience spontaneous seizures.33 A key interpretive caution is that home video recordings may frequently miss the moment of seizure onset and instead capture the middle or recovery phase of the seizure. Considering the common availability of mobile devices that can record video. outpatient ambulatory EEG (sometimes with concurrent video recordings) can be useful. Therefore. when confronted with enigmatic cases for which frontal lobe epileptic seizures. Within 2 days after admission for video-EEG monitoring. the demonstration of inducibility (ie. orbitofrontal or interhemispheric regions) such that ictal epileptiform discharges can conduct/ distribute over a widespread area bilaterally. or undiscernible ictal EEG epileptiform correlates. or other physiologic nonepileptic events have not been conclusively excluded. ambulatory EEG should be interpreted with caution. only 21% of simple partial epileptic seizures have been shown to correlate with ictal epileptiform changes on scalp EEG. while some frontal lobe epileptic seizures can demonstrate very subtle.ContinuumJournal. which inherently reflect a deceptive intervention to the patient. use of suggestion techniques (ie. Asking the patient or family if they know of a trigger that can be reproduced in the unit is frequently helpful (eg. Video data alone (without EEG) have been shown to provide reasonably robust sensitivity and specificity in distinguishing epileptic seizures from PNES. www. and absence of prior induction exposure. For cases in which supportive clinical or historic contexts are not available. the qualities of the ambulatory EEG and video data can be quite variable. saline injection or alcohol wipes). February 2016 . The frequency of some patients’ PNES may be too rare to be practically captured during limited time frames of video-EEG or ambulatory EEG recordings. Under such circumstances. Ethical concerns are raised by the use of placebos during induction (eg.29 The success rate of induction is higher among patients who demonstrate preinduction characteristics of hypermotor ictal symptomatology. the majority of patients with PNES will have experienced a spontaneous and characteristic seizure of interest. provocative inductions) can improve the rate of seizure capture28 and shorten the duration of video-EEG admission. falsely lateralizing. prevalent self-reporting of uncommon cognitive and affective symptoms.com Copyright © American Academy of Neurology. provocative induction) would strongly (but not entirely) support a psychogenic etiology.30 Moreover. Because of less-standardized recording settings and greater susceptibility to artifacts. As such. falsely lateralizing. scrolling on a computer screen). the demonstration of inducibility would strongly (but not entirely) support a psychogenic etiology. home video documentation of some patients’ infrequent seizures may be able to provide useful diagnostic data.32 Ambulatory EEG and home video recordings.31 Such concerns can be circumvented by performing induction techniques that utilize routine EEG activation procedures (hyperventilation and photic stimulation) without placebo. h When confronted with enigmatic paroxysms of uncertain etiologies. Comparable success rates have been demonstrated between PNES activation procedures with placebo versus without placebo. Unauthorized reproduction of this article is prohibited.26 Some frontal lobe epileptic seizures arise from deep-seated foci (eg. Moreover. demonstrate a contralateral maximum. or become obscured by copious artifacts related to hypermotor activity. simple partial epileptic seizures. Some patients with PNES may not experience seizures in a hospital setting that secludes patients from habitual stressors of their indigenous milieu. the neurobehavioral manifestations during the postictal recovery phase of epileptic seizures can highly resemble the ictal symptomatology of some PNES. or undiscernible. ictal EEG epileptiform correlates of some frontal lobe epileptic seizures can be very subtle.Nonepileptic Seizures KEY POINTS h Only 21% of simple partial epileptic seizures have been shown to correlate with ictal EEG epileptiform changes.

7 onlinelibrary. Unauthorized reproduction of this article is prohibited. b Captured ictus should not resemble types of epileptic seizures that may not show ictal epileptiform correlate on EEG (eg. and enhance care of patients with PNES worldwide. + = history characteristics consistent with PNES. facilitate prompt recognition of this disorder. showing semiology typical of PNES. and video-EEG. so different levels of diagnostic certainty were delineated based on the available data. Based on varying combinations of the available aforementioned data reflective of scenarios commonly encountered in clinical practice. during. Fifth Edition (DSM-5)34 provides revised diagnostic criteria for conversion disorder in accordance with updated insights regarding this disorder.7 The ILAE task force recognized that different settings may not have access to video-EEG. The clinical data utilized in this staged approach include patients’ historical presentation. the Nonepileptic Seizure Task Force of the International League Against Epilepsy (ILAE) delineated a staged approach to PNES diagnosis.com Copyright © American Academy of Neurology. With this approach. a diagnosis of PNES can be made with several levels of diagnostic certainty. simple partial epileptic seizures). while on video EEG No epileptiform activity immediately before.1111/epi.22(1):116–131 www. showing semiology typical of psychogenic nonepileptic seizures (PNES) No epileptiform activity in routine or sleep-deprived interictal EEG Clinically established + By clinician experienced in diagnosis of seizure disorders (on video or in person).12356/full. et al.com/doi/10. the highest level being “documented” (Table 6-3).Levels of Certainty in the Diagnosis of Psychogenic Nonepileptic Seizures In acknowledging that video-EEG is not readily available to every patient worldwide and that it may not always capture seizures characteristic of the patient’s single or multiple independent event types.wiley.ContinuumJournal. B 2013 International League Against Epilepsy. or after ictus captured on ictal video EEG with typical PNES semiology EEG = electroencephalogram. KEY POINT h Psychogenic nonepileptic seizures are a subtype of conversion (somatoform) disorder in which psychological conflicts are manifested with symptoms resembling epileptic seizures. while not on EEG No epileptiform activity in routine EEG or ambulatory ictal EEG. showing semiology typical of PNES. Continuum (Minneap Minn) 2016. interictal EEG. 121 . and clinicians’ observation in person or via review of video recordings during ictus. capturing a typical ictusb Documented + By clinician experienced in diagnosis of seizure disorders. The Diagnostic and Statistical Manual of Mental Disorders. Whereas the TABLE 6-3 Overview of Proposeda Diagnostic Levels of Certainty for Psychogenic Nonepileptic Seizures Diagnostic Level History Witnessed Event EEG Possible + By witness or self-report/description No epileptiform activity in routine or sleep-deprived interictal EEG Probable + By clinician who reviewed video recording or in person. witness accounts. PSYCHOPATHOLOGY PNES are most commonly conceptualized as a subtype of conversion disorder in which psychological conflicts are manifested as symptoms resembling epileptic seizures. the task force aims to provide greater clarity regarding the evaluation process for PNES. Epilepsia. a Modified with permission from LaFrance WC Jr.

com Copyright © American Academy of Neurology. This seizure was induced by routine activation procedures that included photic stimulation and provocation with verbal suggestion. PNES was supported by the documented features of suggestibility (increasing seizure intensity with higher photic frequency). he continued to experience frequent seizures. Even when psychological factors are readily identified. evidence exists that physical factors (such as traumatic brain injuries. ictal eye closure at ictal onset. Fourth Edition (DSM-IV) required the presence of psychological factors to precede or exacerbate conversion symptoms. posttussive syncope was within the differential diagnosis. or diseases (Table 6-2). despite trials of three antiepileptic drugs and measures to treat his obstructive airway disease. such requirement has been relegated to a note in DSM-5. 122 www. it may not be clear that they are etiologically relevant to the symptoms at hand. followed by postictal disorientation/ confusion. and incongruence of intact EEG alpha rhythm (a neurophysiologic correlate of alertness) during dialeptic symptomatology with clinical unresponsiveness. or disease. To circumvent this problem. physiologic nonepileptic events.lww.” This revision encourages clinical investigation for an alternative medical/ neurologic explanation for the symptom. Since some of his paroxysms were preceded by coughing fits. Considering his known left frontal encephalomalacia from a stroke that also occurred about 10 years ago. semifetal posture).35 The reason for this change is that while psychological factors are important in the evolution of conversion disorders. this case illustrates that the emotional affliction from significant health-related adverse events should not be overlooked. physiology. Moreover. which includes epilepsy. illness-affirming behaviors (retching cough. DSM-IV approached conversion disorder as a diagnosis of exclusion from other pathophysiologic conditions. links. Comment. they are not always immediately apparent from the history. He was referred for video-EEG monitoring. and PNES. Some patients’ readiness to discuss psychological factors may depend on the strength of the clinician-patient alliance. side-to-side head movements. evidence exists that physical factors (such as brain injuries) can provoke conversion symptoms and may involve processes that are physiologic as much as psychological.com/CONT/A169).36 Moreover. undergoing surgeries/anesthesia37Y39) can provoke conversion symptoms and may involve processes that are physiologic as much as psychological (Case 6-1).Nonepileptic Seizures KEY POINT h Whereas DSM-IV approached conversion disorder as a diagnosis of exclusion. Diagnostic and Statistical Manual of Mental Disorders. the updated DSM-5 guides users to make a positive conversion disorder diagnosis based on inclusion of clinical features that are incongruent to known anatomy. which confirmed the diagnosis of psychogenic nonepileptic seizures (PNES) (Supplemental Digital Content 6-1. he had been treated for (presumed) epilepsy with antiepileptic drugs. This case also exemplifies the importance of considering a wide differential diagnosis in patients with paroxysmal disorders. physiology. but no placebo. However. While strokes are associated with epilepsy and epileptogenic foci. February 2016 . DSM-5 guides users to make a positive conversion disorder diagnosis based on inclusion of clinical findings that are incongruent to known anatomy. Unauthorized reproduction of this article is prohibited.34. Case 6-1 A 57-year-old man presented with a 10-year history of seizures involving abrupt loss of awareness with falls.ContinuumJournal. The criterion on excluding other pathophysiologic conditions has been revised to a criterion that requires that the symptom in question is “not better explained by another disease.

hence showing a notable parallel to seizures. such requirement is problematic. 123 . or depersonalization can be quite prominent in some panic attacks. rather than in a healthy verbal manner. The other notable change for conversion disorder in DSM-5 is that the former requirement for exclusion of feigning has been abandoned. as exclusion of malingering may be difficult to validate with absolute certainty without surveillance or forensic evaluation. Several etiologic models have been proposed in the effort to explain the inception and evolution of conversion disorder manifesting as PNES. nausea and abdominal discomfort. present mostly in at-risk groups.40 Volitionally feigned symptoms. Careful exploration of the overall presentation should uncover other key features meeting DSM-5 criteria for panic attacks. as described above. then the additional diagnosis of conversion disorder should not be made. Symptoms of tremulousness.42 Posttraumatic PNES develop in response to psychological or physical trauma(s) that the patient struggles to adequately process or integrate. and the aforementioned seizurelike symptoms. both posttraumatic and developmental types of psychological etiologies may coexist. Panic attacks can be the paroxysmal manifestation of panic disorder or other conditions associated with anxiety.41 One model stipulates two main types of psychological difficulties that underlie PNES: posttraumatic and developmental. dizziness. Upon careful evaluation.ContinuumJournal. in which intense fear is accompanied by at least four of the following symptoms: palpitations. are not PNES (ie.44 hence hindering appropriate maturation of psychosocial development. For some patients with PNES. if the patient’s overall symptomatology can be better explained by PTSD per DSM-5 criteria. as in the cases of malingering or factitious disorders. all of which can resemble seizure activities. Similar to panic attacks.com Copyright © American Academy of Neurology. shortness of breath. depersonalization. In fact.” some authors postulate that PNES reflects an automatic cutoff phenomenon in response to spontaneous intrusion into consciousness of such intolerable memories. or affective numbing. chest discomfort. diaphoresis. not psychogenic). In clinical practice.40 Most of these cases likely represent anxious misinterpretation of common nonspecific paroxysmal symptoms of everyday www.but also allows for a conversion disorder diagnosis even if a potentially related disease is present. where Continuum (Minneap Minn) 2016. shaking. derealization. Unauthorized reproduction of this article is prohibited. PNES (and other conversion disorders) are a disorder of communication. the DSM-5 designates a PTSD subtype with prominent dissociative symptoms.22(1):116–131 distress is expressed somatically. Studies have shown that some patients with PNES rely on avoidant coping responses (denial and repression) to perceived threats. behavioral manifestations of PTSD frequently entail derealization. BORDER ZONES OF PSYCHOGENIC NONEPILEPTIC SEIZURES (PSYCHIATRIC DIFFERENTIAL DIAGNOSIS) Border zones of PNES represent neurobehavioral paroxysms with psychological underpinnings but are not considered to be conversion disorders. Some authors contend that the presentation of exclusively subjective sensory symptoms (albeit neurologic symptoms. relational neglect). In the face of “unspeakable dilemmas. such as paresthesia or numbness) are not sufficiently reliable in themselves to meet the criteria for PNES. and are rare. In essence.43 Developmental PNES derives from difficulties coping with complex life tasks and milestones along the patient’s continuum of psychosocial development in an environment of emotional privation (eg.

seizure cessation is reported to occur in about 40% of patients over time. and 16% of patients were seizure free and independent (good outcome).51 PSYCHOGENIC NONEPILEPTIC SEIZURES IN CHILDREN While much of the earlier discussions regarding PNES in adults also apply to children. some differences are notable in light of varying psychosocial elements across developmental stages in children.47 Upon pursuing a more complete outcome assessment of PNES as such.48 Several patient-specific characteristics are identified as influencing the disease course of PNES. h In children with psychogenic nonepileptic seizures. physical or sexual abuses) can be ongoing at the time of presentation and should be explored in every case. PNES can emerge in children as young as 5 years old.52 Conversely. 40% of patients were either seizure free but dependent or not seizure free but independent (intermediate outcome). a staged approach to PNES diagnosis may be beneficial in prompting earlier discussion regarding potential psychological contributions to seizures.Nonepileptic Seizures KEY POINTS h An important prognostic factor of psychogenic nonepileptic seizures is the duration of illness. Unauthorized reproduction of this article is prohibited. functionality. serious psychosocial issues (eg.46 A comprehensive assessment of PNES outcomes should encompass not only seizure burden. seizures with less. in which the prognosis worsens the longer the patient’s illness has been mistreated as epilepsy. The misinterpretation of benign symptoms as being more pathologic may be more common in patients who have had personal experiences with seizures or who have other neurologic/medical conditions. including transient dizziness. but also the state of psychosocial comorbidities. emotional dysregulating. Another scenario that falls within the border zones of PNES is the purposeless and repetitive behavioral mannerisms (learned behavior) that occur not infrequently in some cognitively impaired patients. differences in psychiatric comorbidities include lower rates of mood disorders (32%) and PTSD (10%) and a higher rate of significant family stressors (44%) for children with PNES. Deferring such discussions until video-EEGYdocumented diagnostic certainty may lead to significant delay. limb numbness. one study showed the following observations: 44% of patients were not seizure free and remained dependent (poor outcome).50.dramatic symptomatology. or head sensations that may briefly disrupt attention. inhibitive. in which the prognosis worsens the longer the patient’s illness has been mistreated as epilepsy. while the remaining approximately one-third of patients undergo a chronically intractable course. may have a poorer course than those with newly diagnosed epilepsy.com Copyright © American Academy of Neurology. Factors that may prognosticate better outcomes among adults include higher level of education. becoming the most common type of nonepileptic seizure in adolescents.49 Correspondingly. younger age at both time of seizure onset and time of diagnosis.53 Importantly. and neuropsychological measures supporting lower dissociative. www.48 The above results suggest that patients with PNES. Risk factors for pediatric PNES are noted. serious psychosocial issues (eg. and compulsive tendencies. and overall quality of life. About onethird of patients experience seizure reduction.45 PROGNOSIS When considering the overall population of patients with PNES. considering the aforementioned diagnostic challenges and limited video-EEG availability in some locations. as soon as minimum criteria for the diagnosis of PNES have been met. physical or sexual abuses) can be ongoing at the time of presentation and should be explored in every case. An important prognostic factor is duration of illness. comorbid epilepsy (mixed disorder) is more prevalent in younger children with PNES than in older children or adolescents with PNES. in general. February 2016 .ContinuumJournal. 124 life. fewer additional psychosomatic symptoms.52 Compared to adults with PNES. and their frequency increases with age.

empathetic. Case 6-2 A 27-year-old man presented with near-daily seizures that involved diffuse shaking with varying degree of unconsciousness. emphasizing PNES as a real. endorsing the frustration that. which includes a developmental history and review of past trauma and abuse in the intake neurologic assessment. nonpejorative. An explanation letter (addressed to the patient) and PNES brochures were encouraged to be shared with other clinicians or individuals pertinent to the patient’s care. and unequivocal approach. This explanation of the diagnosis took place across two inpatient visits to allow the patient and his family the opportunity to process their understanding and ask questions. He then sought additional referrals.22(1):116–131 www.com Copyright © American Academy of Neurology.” and “It has to come from something else. “My family thinks it’s all in my head. a brief 23-hour inpatient video-EEG was able to capture his habitual seizure.55 MANAGEMENT OF PSYCHOGENIC NONEPILEPTIC SEIZURES Management of patients with PNES begins with a comprehensive evaluation (ie. In turn.” During a subsequent video-EEG monitoring course.57 Hence. Neurologists who continue to use the outdated pejorative terminology of “pseudoseizures. The diagnosis of PNES was explained to the patient and family members. empathetic. seizure history. so conveying to the patient that the seizures in PNES are just as real as those in epilepsy is essential. Optimal management begins with comprehensive evaluation (ie. the patient’s acceptance of the PNES diagnosis has been shown to be associated with seizure improvement. video-EEG monitoring). create a distance between patients and clinicians. video-EEG). and he received the diagnosis of psychogenic nonepileptic seizures (PNES). neurologic and psychiatric assessment. Unauthorized reproduction of this article is prohibited.56 Many times. description of the events and psychosocial history taking.” with connotations of being false or fake. and unequivocal approach. perhaps contributed to in part by a generally briefer duration of illness or that dysfunctional patterns have become less engrained.59 Communication with family and the referring physician regarding this diagnosis can also augment the uniformity of diagnostic KEY POINT h The neurologist’s explanation of the diagnosis of psychogenic nonepileptic seizures is vital and should be communicated to the patient via a tactful. positive. but also in the initial treatment of patients with PNES as they prepare patients for collaborative care with a mental health professional. Continuum (Minneap Minn) 2016. neurologists can be a factor not only in the diagnosis. Given his high seizure frequency. In this sense. For patients with PNES. The clinician-patient rapport and legitimization of PNES established through these efforts can enhance the patient’s acceptance of diagnosis.54 The clinical outcome of PNES is better in children than adults.58 Provision of supplementary written information may help consolidate (and further legitimize) the PNES diagnosis. albeit nonepileptic. efforts were made to capture the full spectrum of the patient’s seizures. 125 . and should be communicated to the patient via a tactful. the neurologist’s explanation of this diagnosis is vital.ContinuumJournal.including somatopsychic and adversity components related to maladaptive coping. type of seizure. Legitimization and confirmation of PNES through these efforts can enhance the patient’s acceptance of the subsequent diagnostic explanation (Case 6-2). Comment. establishing the correct diagnosis is the first step of treatment. psychosocial assessment. patients have been dismissed in prior emergency department and neurologic encounters.

two pilot randomized controlled trials for PNES have shown clinically meaningful results. Patients with mixed epilepsy/PNES should be www. antiepileptic drugs may make psychogenic nonepileptic seizures worse. Once the transition to mental health care is complete. merely sharing the diagnosis (without further dedicated therapeutic efforts) is frequently insufficient. One study used conventional cognitivebehavioral therapy.62 while the other study used a multimodality cognitivebehavioral therapyYinformed psychotherapy3 based on a workbook used by therapists and patients to treat both epileptic seizures and PNES (Table 6-4). iterative explanation of the diagnosis via a supportive/ noncoercive tone across serial visits may gradually foster the patient’s acceptance for mental health treatment referrals. In such cases.3. then a timely taper of the drug is advisable. group psychoeducational approaches have been shown to consolidate patients’ understanding of PNES and promote more open-mindedness toward acceptance of this diagnosis. depression and anxiety) but do not stop psychogenic nonepileptic seizures. for several reasons. If a specific AED has no alternative beneficial indication (eg. precipitating.63 Some patients may continue to maintain some ambivalence regarding the nature of the PNES diagnosis and express reluctance toward in-depth individual psychotherapies. as opposed to delayed. Pharmacologic interventions are used to address common comorbidities (eg. cognitive-behavioral therapy has the most substantial body of controlled efficacy data.57 Patients with normal videoEEG findings should be followed by a neurologist for at least 6 months after discontinuing AEDs. February 2016 . selective serotonin reuptake inhibitors [SSRIs] for depression and anxiety).61 Among psychotherapeutic approaches for patients with PNES. two pilot randomized controlled trials for psychogenic nonepileptic seizures have shown clinically meaningful results using either traditional cognitive-behavioral therapy or a seizure-treatment workbook based on a multimodality cognitive-behavioral therapyYinformed psychotherapy for psychogenic nonepileptic seizures and for epilepsy. especially those who have been chronically misdiagnosed as having epileptic seizures. Selective serotonin reuptake inhibitors (SSRIs) help the comorbidities (eg. psychotropics may reduce seizures but do not lead to seizure cessation in PNES. To date. However. as other somatic and affective symptoms often develop if the core issues are not addressed. Unauthorized reproduction of this article is prohibited. that treatment involves addressing predisposing. barriers to treatment delivery are being overcome with computer video telemedicine.Nonepileptic Seizures KEY POINTS h Medications do not fully treat psychogenic nonepileptic seizures.50 The mainstay of effective treatment for PNES is psychotherapy directed at the known pathologies in the population.66 The working relationship between the neurologist and patient should not abruptly end after a diagnosis of PNES has been established. Not providing the diagnosis with patient or providers has been shown to be associated with no improvement or even worsening of symptoms. Early. and perpetuating factors. h Targeted psychotherapy appears to be the mainstay of treatment for psychogenic nonepileptic seizures. AED withdrawal portends greater beneficial effects on a range of clinical outcomes. mood stabilization or migraine prophylaxis).64. which is being used in the US Department of Veterans Affairs to provide live-remote therapy for veterans with either epileptic seizures or PNES.com Copyright © American Academy of Neurology. For some patients with PNES. Instead. Patients with PNES who also have known interictal or ictal epileptiform abnormalities on their video-EEG should continue to be followed by a neurologist.ContinuumJournal. To date. a proper understanding of the diagnosis may not be achievable with a “one-shot” disclosure.65 Because driving is an issue for patients with seizures. and that effective treatment is available provides hope to patients and empowers treating clinicians to engage. then discussion can commence regarding the patient’s discharge from the neurologist’s practice.13 Letting the patient and family know that they are not alone in that many people have the same disorder.60 Likewise. Moreover. 126 insight across the patient’s milieu. This consideration is because of the small but ever-present possibility of coexisting epilepsy and the fact that breakthrough epileptic seizures can occur several months after discontinuation of AEDs.

22(1):116–131 a positive conversion disorder diagnosis based on identifying incongruent examination and laboratory findings in relation to known anatomy or physiology. linked to unbearable feelings of fear and distress.67 As such. and goal setting. treated with the lowest effective AED dose for the epilepsy. This team approach highlights the importance of interdisciplinary dialogue and transition in the care of patients with PNES. CONCLUSION Conversion disorder is usually not diagnosed by the mental health provider alone.TABLE 6-4 Cognitive-Behavioral Approaches Evaluated in Randomized Controlled Trials for Psychogenic Nonepileptic Seizures Therapeutic approach Outcomes Goldstein et al. When compared to baseline. Recent diagnostic and treatment KEY POINT h For the 10% of patients with mixed epilepsy/ psychogenic nonepileptic seizures. promotion of ongoing health and wellness. linking triggers. although the CBT group was 3 times more likely to be seizure free.ContinuumJournal. support seeking. negative states. between-group differences in seizure frequency were not significant. 20143 Based on traditional cognitive-behavioral therapy (CBT) and fear escape-avoidance model: Psychogenic nonepileptic seizures (PNES) as dissociative responses to cues associated with extremely distressing or life-threatening experiences. quality of life. relaxation. conducting a functional behavioral analysis. better communication by neurologists can overcome past diverging interdisciplinary perspectives regarding PNES. 127 . 201061 LaFrance et al. aura identification. examining external stressors and internal conflicts. Continued follow-up by the neurologist during the transition to mental health providers mitigates repeat workups with other providers. To this end. neurologists have acquired substantial experience in making Continuum (Minneap Minn) 2016. and global functioning measures. Neurologists can work collaboratively with mental health providers to adequately address the psychological underpinnings of these challenging patients. Based on CBT-informed psychotherapy model initially aimed to enhance self-control of epileptic seizures: PNES as the somatic manifestations of maladaptive core beliefs (negative schemas) that have been derived chronically from life experiences and traumas. dealing with avoidance behaviors.68 Further efforts are necessary to augment this vital interdisciplinary partnership.com Copyright © American Academy of Neurology. the neurologist is integral in the evaluation and diagnosis. and target symptoms. When compared to before treatment. CBT group experienced fewer seizures than the control group at the end of treatment. in turn. use the lowest effective antiepileptic drug dose for the epileptic seizure and use mental health treatments for the psychogenic nonepileptic seizures. noting that AEDs do not treat PNES. patients with conversion disorder frequently present to neurologists first in search of a neurologic explanation to their symptoms. relaxation. the treatment as usual/standard medical care control group showed no significant difference in seizure frequency or any secondary outcome measures. with psychiatrists frequently being uncertain about the accuracy of videoEEG. Main topics include seizure-directed techniques. and other factors key toward engendering PNES. www. anxiety. Main topics include healthy communication. Unauthorized reproduction of this article is prohibited. and behavioral interventions should target the PNES. These experiences are. Indeed. CBT-informed psychotherapy workbook group showed significant seizure reduction and improvement in depression. During the last 3 months of a 6-month follow-up period. attention refocusing. negative cognitions.

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