Nonepileptic Seizures

Nonepileptic seizures are behavioral events that resemble epileptic seizures but are not caused by electrical disruptions of the cerebral cortex. Although these episodes are sometimes called pseudoseizures, this term should be avoided, because there is nothing false, fake or insincere about nonepileptic seizures to the patients who have them. In their view, they experience real seizures.

Even experienced epileptologists can mistake nonepileptic seizures for electrically-based (epileptic) seizures and vice versa. Epileptic seizures of frontal lobe origin are those most commonly mistaken for nonepileptic seizures. Up to 20 percent of patients evaluated at adult epilepsy centers have nonepileptic seizures. Some of these patients also have epileptic seizures, which complicates the diagnosis. nonepileptic seizures in some patients can be misdiagnosed as epileptic seizures and patients exposed unnecessarily to anti-epileptic drugs (AEDs). While AEDs are often helpful in treating epileptic seizures, they are of no benefit in treating nonepileptic seizures. Other potential consequences of inaccurate diagnosis are delayed psychological therapeutic intervention and the social stigma that is often associated with epilepsy.

Classification of Nonepileptic Seizures

Nonepileptic seizures are classified as having a physiologic or a psychogenic basis.

• Physiologic nonepileptic seizures are caused by a sudden disruption of brain function, from a metabolic disturbance such as profound hypoglycemia or hyponatremia, or ischemia from cardiac arrhythmia.
• Psychogenic nonepileptic seizures result from stressful psychological conflicts or major emotional trauma, often stemming from sexual and/or physical abuse, current or in the past, especially in childhood. Other causes include major life events such as death or divorce.

Diagnosis of Nonepileptic Seizures

The differential diagnosis of physiologic nonepileptic seizures should include organic brain lesions, cardiac arrhythmias, hypoglycemia, syncopal episodes, migraines and transient ischemic attacks.

Accurate diagnosis of psychogenic nonepileptic seizures requires a high index of suspicion. Patients whose seizures are resistant to appropriate pharmacotherapy and who have a history of significant traumatic events, such as sexual or physical abuse, should be considered for further evaluation with electroencephalographic (EEG) monitoring. Other diagnostic clues are previous encounters with persons having epileptic seizures, frequent emergency room visits or hospitalizations for seizures, and a history of anxiety, panic attacks or depression.

The nature of the events should be considered as well. Behaviors that occur during psychogenic nonepileptic seizures may be very similar to those associated with epileptic seizures, but they can differ in several important respects:

• Epileptic seizures occur whether or not anyone else is present; psychogenic nonepileptic seizures are usually (although not always) witnessed.
• Seizure-related injuries, such as broken bones, are more typical of epileptic seizures.
• Psychogenic nonepileptic seizures may begin gradually, with motor activity that slowly escalates in intensity; epileptic tonic-clonic seizures begin abruptly.
• A cry or shriek in the middle or at the end of the seizure is suggestive of a psychogenic cause, as are motor movements that come and go, that alternately affect the left and right sides of the body, or that look like sexual behaviors, such as pelvic thrusting.
• Unusual posturing may occur during psychogenic nonepileptic seizures; facial muscle contractions are uncommon.
• An apparent convulsive seizure that extends for many minutes, even an hour or longer, may be nonepileptic, especially if there is no cyanosis and the patient wakes up immediately after the seizure movements stop.
• The recovery period (postictal state) following a psychogenic nonepileptic seizure is brief; recovery from an epileptic tonic-clonic seizure lasts minutes to hours, characterized by confusion, headache, exhaustion and sleep.

Electroencephographic Monitoring

None of the above clues are diagnostically foolproof; thus ultimately, the diagnosis of psychogenic nonepileptic seizures depends on the results of simultaneous video/EEG monitoring. The goal of EEG monitoring is to record several typical events.

• Simultaneous video recording of the patient during a typical seizure allows family and other observers to verify that this event looks the same as ones they have previously witnessed.
• If necessary, AEDs are decreased or discontinued to precipitate seizures.
• Patients may be encouraged to carry out activities that are likely to bring on seizures (e.g., arguing with a family member, or staying up all night).
• If no seizures occur for several days, the physician may try to induce a seizure with special suggestive or provocative tests, such as saline infusion.
• If no typical events occur while in hospital, no firm diagnosis of psychogenic nonepileptic seizures can be made.
• A psychiatric evaluation is an important part of the diagnostic evaluation, particularly if the EEG testing shows no electrical disturbance associated with typical events.
• EEG monitoring can be scheduled as an outpatient if: 1) the patient has seizures every one to two days or only has seizures in a particular environment outside the hospital; 2) the patient will be closely watched by a trained observer who is willing to write down seizure observations on a log sheet that accompanies the EEG monitoring device; and 3) it is not necessary to stop AEDs.
• It is important to remember that some types of epileptic-based seizures may not show definite electrographic changes on standard, scalp surface recordings (such as frontal lobe seizures).

Treatment of Psychogenic Nonepileptic Seizures

The attitude of the physician and other health care providers in discussing the finding of psychogenic NESs is crucial to the patient’s acceptance of the diagnosis and willingness to enter into treatment. There is a significant chance of complete recovery, and it is important to approach the patient with empathy and understanding.

• Positive implications include: 1) AEDs, with possible untoward side effects, will not be necessary (unless the patient also has seizures that are epileptic in origin); and 2) with supportive care, involving psychological therapeutic intervention, events will very likely improve.
• Early diagnosis and referral to a psychotherapist, preferably one knowledgeable about psychogenic nonepileptic seizures and their treatment, will enhance the outlook for recovery.
• Goals of therapy are restoration of function with cessation of nonepileptic seizures.
• Medications may be indicated for associated depression or anxiety disorders.
• Stress management techniques such as relaxation exercises or biofeedback may also be of benefit.

CONTACT

For additional information, contact the Women and Epilepsy Initiative of the Epilepsy Foundation at (800) 332-4050.

REFERENCES

Alper K, Devinsky O, Perrine K, Vazquez B, Luciano D. Nonepileptic seizures and childhood sexual and physical abuse. Neurology. 1993;43:1950-1953.

Chabolla DR, Krahn LE, So EL, Rummans TA. Psychogenic nonepileptic seizures. Mayo Clin Proc. 1996;71:493-500.

Rowan AJ. Nonepileptic seizures. In: Schachter SC, Schomer DL, eds. The Comprehensive Evaluation and Treatment of Epilepsy. Academic Press;1997:173-183.

Trimble MR. Pseudoseizures. Neurol Clin. 1986;4(3):531-548.