Psychogenic Nonepileptic Seizures

| December 20, 2013 | 0 Comments

Gillig_Nov-Dec_2013_Artby Paulette Marie Gillig, MD, PhD
Dr. Gillig is Professor of Psychiatry and Faculty of the Graduate School, Department of Psychiatry, Boonshoft School of Medicine, Wright State University, Dayton, Ohio.

Innov Clin Neurosci. 2013;10(11–12):15–18

Series Editor: Paulette M. Gillig, MD, PhD, Professor, Department of Psychiatry, Boonshoft School of Medicine, Wright State University, Dayton, Ohio

Funding: No funding was received for the development of this article.

Financial Disclosures: The authors have no conflicts of interest relevant to the content of this article.

Key words: psychogenic seizures, nonepileptic seizures, dissociation, psychogenic seizures

In this series, Dr. Gillig explains how aspects of the neurological examination can aid in differential diagnosis of some common (and some uncommon) disorders seen in psychiatric practice.

Abstract: Objective: All patients who exhibit seizure-like behavior cannot be evaluated by video-electroencephalography if their routine EEGs are negative, as this would be impractical and cost-prohibitive. The present article reviews a decision-making process that can be used for determining if further neurological evaluation is needed, the differential diagnoses and potential comorbidities involved when making this determination, and an approach to conveying the psychogenic nonepileptic seizure diagnosis to the patient that may help reduce symptom frequency. Design: Literature review. Conclusion: Psychogenic seizures are not caused by abnormal brain electrical activity. The symptoms of psychogenic seizures usually reflect a psychological conflict or a psychiatric disorder. However, psychogenic seizures are not “purposely” produced by the patient, and the patient is not aware that the seizures are non-epileptic, so the patient may become very anxious over having these symptoms. The presentation of the differential diagnosis should be done early in the course of treatment for better patient acceptance, and treatment options should be presented early in the evaluation period.

Composite Examples

Example #1. An honors-level college student, the son of two prominent physicians, failed an introductory biology examination. He subsequently developed seizure-like episodes that persisted despite treatment with anticonvulsant medication, and he felt that he had to drop out of college. Video-electroencephalography revealed no abnormal brain electrical activity. Anticonvulsants were tapered by neurology, despite persistence of seizure-like episodes. The patient was advised by the neurologist that the spells were not electrically induced, and he was referred to mental health services. During two consultations with a psychiatrist, the patient argued for and defended the value of other careers besides medicine, and he was surprised that he was validated by the doctor for his other interests. Psychogenic non-epileptic seizures decreased in frequency and patient was able to complete college successfully, ultimately majoring in biology with a minor in fine arts.

Example #2. A young woman, who had a history of physical and sexual abuse by her father and abandonment by both parents, became emotionally involved with a young man who suffered from recurrent depression. The young man withdrew emotionally from their relationship due to his illness. As he became emotionally unavailable, the patient began to experience spells where she would suddenly drop to a fetal position on the sidewalk and shake her limbs in an apparent tonic-clonic manner, when she and her boyfriend were walking down the street, with no recollection of the event. Generally she was transported by the life squad to an emergency department. Anticonvulsants helped with mood stability but the seizures persisted. Video-electroencephalography revealed no abnormal brain activity. Psychotherapy focused on learning coping strategies, respecting the intensity and depth of the patient’s emotional experiences, facing her abandonment fears, and helping her to establish a clearer sense of individual identity.

Example #3. A married middle-aged man had functioned adequately in his job but with perfectionistic standards, as a store clerk for 22 years. He had never received psychotherapy or other treatment for his history of childhood abuse and subsequent abandonment by his mother, of which he was very ashamed. After 22 years, his wife abruptly left him for another man. After their divorce, he developed seizure-like episodes, and for the next five years he suffered seizures and on several occasions, he fell and injured himself, sometimes involving lacerations to the face and body. Repeated video-electroencephalography including during his seizure episodes revealed no abnormal brain activity. The patient had great difficulty during psychotherapy making any connection between ongoing events and psychogenic seizure episode frequency, and he had always looked outside himself for explanations of events and interpersonal experiences. Despite the absence of brain electrical activity that would indicate seizures, he did benefit partially from stabilization of mood with lamotrigine. Despite significant improvement and four years of psychotherapy with a psychologist, he was never able to return to employment and eventually received disability status.

Discussion

Psychogenic seizures (PNES) are not caused by abnormal brain electrical activity. The symptoms of PNES usually reflect a psychological conflict or a psychiatric disorder. These symptoms can be precipitated by an acute event in the life of a previously traumatized person, most commonly those who have been traumatized during childhood. PNES seizures usually occur in adults or adolescents, and are three times more common in women and girls. Approximately 20 percent of persons referred to comprehensive epilepsy centers are found to have non-epileptic seizures on video-electroencephalogram monitoring.[1] PNES symptoms are perpetuated by ongoing or recurrent stressors, often related to job or interpersonal issues.[2] Psychiatric comorbidities are common for patients with PNES, and only five percent of PNES patients do not have associated comorbidities.[3] Patients with PNES tend to be less likely than other patients to accept that negative life experiences could be relevant to the seizures.[4–7] They tend to have difficulty understanding, processing, or describing emotions (which may be why they are reflecting their feelings in somatic ways).

PNES episodes are not “purposely” produced by the patient, and the patient is not aware that the seizures are non-epileptic, so the patient may become very frightened and anxious over having these symptoms. In my experience, patients are not typically indifferent to their seizure-like episodes, in contrast to the la belle indifference said to characterize many other conversion disorders. Non-epileptic seizures can resemble partial or generalized convulsions, and diagnosis and treatment can be complex, particularly in cases where PNES co-occurs with true epileptic seizures. For example, when is it appropriate to change anticonvulsant management? When a patient has both types of spells? Although pelvic thrusting, bicycling leg movements, and violent thrashing formerly were thought to be hallmarks of non-epileptic seizures, it has now been determined by video-encephalography that frontal-lobe (and occasionally, temporal lobe) partial seizures can contain some of these signs and be based on abnormal brain electrical activity.[8,2]

From a practical point of view, all patients who exhibit seizure-like behavior cannot be evaluated by video-electroencephalography if their routine EEGs are negative. When selecting patients to refer for video-electroencephalography, it is useful to know that the most reliable predictors of psychogenic non-epileptic seizures probably include at least two normal electroencephalography studies in the face of at least two seizures per week and resistance to two antiepileptic drugs,[9] and that for psychogenic non-epileptic generalized convulsions there is an absence of elevated prolactin within 30 minutes of a generalized convulsion, in contrast to generalized convulsions that are based on abnormal brain electrical activity.[2]

The most effective strategies for communicating the diagnosis of PNES include showing the patient a video-recording of the seizure, presenting the diagnosis as good news (absence of epilepsy), acknowledging that the precise cause of the seizures is not known at this time, acknowledging that it is known that the patient is not deliberately having these seizures, and that more spells could still occur at some time or they could stop, and that epilepsy medication, unless needed for another comorbid condition (such as bipolar disorder) will not help and might have serious side-effects.[2] Before referral to a psychiatrist or other mental health professional, the neurologist may also describe a few examples of potential interventions (e.g., relaxation therapy; supportive, cognitive behavioral, and/or insight-oriented approaches; explanations to the patient how this form of treatment can help.[2,10–14] In some patients, the seizure frequency sometimes decreases immediately after the diagnosis is presented. I believe that this may occur because the externally focused patient reassesses the meaning of some internal somatic or emotional symptoms that the patient thought had been associated with a “seizure”.

Since most of these patients do not immediately stop having PNES and are referred for psychotherapy, what shall be our working hypothesis about what is going on? One recent study of functional connectivity of dissociation in patients with PNES15 was based on the hypothesis that the cause of PNES was that the patient used an abnormal coping strategy similar to dissociation. The authors investigated resting-state brain networks in PNES patients. Functional connectivity (as measured by the resting state fMRI was reportedly different for PNES patients than controls, in that PNES patients displayed stronger resting state connectivity between areas involved in emotion (insula), executive control (inferior frontal gyrus and parietal cortex), and movement (precentral sulcus). The authors argued that this increased resting state level could represent a neurophysiological correlate for an underlying dissociation mechanism that was involved in PNES, where emotion influenced executive control, resulting in altered motor function. Interestingly, a related study on general conversion disorder patients (of which PNES often is considered a subset)[16] found that conversion disorder patients also had greater functional connectivity between the right amygdala and right supplementary motor area compared to normal subjects.

A reduction in symptom rate has been reported with various interventions. The few PNES patients that stop the seizures immediately after an explanation of their video-encephalography findings are the least likely to have a recurrence.[17] Without further intervention, PNES seizures persisted in 66 to 87 percent of patients.[18,19] The use of emergency departments for these episodes also decreased after video-encephalography and disclosure of diagnosis.[20] Predictors of persistence of PNES included depression, personality disorder, and abuse history.[21]

Psychotherapeutic treatment interventions have included cognitive behavioral therapy. In some cases, treatment is based on the idea that the development of PNES was a “strategy” for harm-avoidance by some patients when they experienced perceived threats.[22–24] Other practitioners have used a schema-based approach with an effort to change maladaptive core beliefs and related cognitive distortions.[25] Psychodynamic approaches have incorporated trauma work[26] and interpersonal concepts[27] and have included the assumption that in some cases PNES may be related to a disturbance of interpersonal relationships.[28]

From this writer’s point of view, I would say that different approaches combining selected aspects of these treatments have been successful for different patients, and at this point it probably would be best to view PNES as a “symptom” rather than a specific “disorder;” as such, PNES can have different etiologies (often with abandonment as a fundamental theme in my view, as illustrated in the composite cases) that require tailoring the psychotherapeutic approach to the individual patient’s situation. In my clinical observations, PNES spells seem often to have resembled the catastrophic reaction that one might have seen earlier in the patient’s development, if that patient (at that age) had been confronted with a situation that totally overwhelmed his or her capacity to process the experience (e.g., parental abandonment, severe physical trauma). The PNES patient’s inability to process the details of the current experience (because of perceived threat, usually) could explain why the PNES patient usually cannot remember the PNES episode or the events leading up to it, and therefore cannot spontaneously derive the association between emotionally charged experiences and their PNES episodes.

References
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Category: Anxiety Disorders, Epilepsy, Mental Disorders, Neurology, Past Articles, Psychiatry

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