Psychogenic Nonepileptic Episodes



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Psychogenic Nonepileptic Episodes


Vaishali S. Phatak


Department of Neurology, UW Regional Epilepsy Center, University of Washington, Seattle, WA, USA






Introduction: Clinical features


Psychogenic nonepileptic episodes (PNEE) are characterized by paroxysmal episodes of behavioral, sensory, motor, or psychic dyscontrol without the electrographic abnormalities seen with epileptic seizures. Symptoms are (1) involuntary and (2) of psychological origin. Although it is common practice to call these events “nonepileptic seizures,” in fact, they are not seizures at all, so they are sometimes alternately referred to as “nonepileptic episodes” or “nonepileptic events.”


Psychogenic nonepileptic episode semiology is diverse. No single sign or symptom is pathognomonic of the condition. However, signs that are more commonly observed during a PNEE include a fluctuating course, asynchronous movements, side-to-side head movements, pelvic thrusting, closing of the eyes, and an ictal cry. Suspicion of a nonepileptic event should also be raised if the event lasts longer than 2 min or there is forced eye closure when the patient is examined during the event.







image CAUTION!

Although pelvic thrusting, asynchronous movements, and side-to-side head movements can occur in PNEE, they are also seen with frontal lobe seizures.





Risk factors for PNEE in adults include female gender and a history of abuse. There are some conflicting reports on which type of abuse (i.e., emotional, physical, or sexual) is the strongest predictor of PNEE. Environmental stress underlying PNEE is typically more evident in children compared to adults. Risk factors for PNEE in children include difficulties in school or with family and other social relationship dysfunction such as bullying. Unexpectedly, physical and sexual abuse is not as highly associated with PNEE in children as in adults.


Psychogenic nonepileptic episodes tend to have a delayed diagnosis. Patients are, on average, diagnosed 7 years after the initial onset of seizures. PNEE is often a functionally debilitating condition that correlates with low employment rates.


Approximately 38% of individuals achieve complete PNEE remission. However, a sizeable minority of patients (19%) have an increase in the frequency of PNEE at followup. Predictors of better outcomes include younger age, positive reactions, such as relief or acceptance, on receiving the diagnosis of PNEE, and events characterized by unresponsiveness rather than dramatic motor activity. Predictors of poor outcomes are co-occurrence of epilepsy; comorbid psychiatric conditions; and anger, denial, or confusion after receiving PNEE diagnosis.


Epidemiology


Psychogenic nonepileptic episodes most commonly occur between the ages of 15 and 35. They are more common in women than men. There is no predilection to specific ethnic groups. The true incidence and prevalence of nonepileptic seizures has not been well identified. Extrapolation modeling suggests a 0.03% annual incidence in the general population. However, presentation of PNEEs in electroencephalogram (EEG) monitoring units is significantly higher at 20–40%.


Diagnosis


Psychogenic nonepileptic seizures are classified in the Diagnostic and Statistical Manual-IV (DSM-IV) taxonomy under the larger category of somatoform disorders and more specifically under conversion disorders.


Video–EEG monitoring is the gold standard for diagnosis of PNEE. Representative events in the absence of epileptiform activity are considered indicative of a PNEE diagnosis, although it must be recognized that most simple partial seizures and some frontal lobe complex partial seizures may not have visible ictal EEG discharges on scalp EEG recording. Video–EEG monitoring is superior to standard EEG in part because of the existence of these seizure types that are not associated with EEG change.


Personality testing can help identify somatizing tendencies, poor social support, or other coping vulnerabilities as well as presence of other psychiatric disorders; however, it cannot be used as a stand-alone diagnostic test of PNEE. Neither cognitive nor effort testing has been found to be reliable in diagnosing PNEE.


A serum prolactin level test taken within 10–20 min after an event is a useful adjunct for distinguishing PNEE from generalized epileptic seizures or complex partial seizures. However, prolactin levels are not reliably useful in distinguishing between epileptic seizures and syncope.


Provocative testing is a controversial topic in diagnosis of PNEE. Provocative testing consists of a variety of methods used to induce a representative nonepileptic event. The most commonly used provocative method has been a placebo injection, although other methods including hypnosis, photic stimulation, hyperventilation, and placement of dermal alcohol patch have also been used. All these methods are intended to produce a PNEE. The ethics of using deception in diagnostic testing raises concerns about provocative testing. There is a serious risk of damaging the doctor–patient relationship because of the intentional deception. There is also the possibility of inducing a PNEE that is not a representative event in suggestible patients with epilepsy.


Differential diagnosis


Although both epileptic seizures and PNEEs are paroxysmal, epileptic seizures are discrete stereotyped events that most often are associated with electrophysiological abnormalities that can be detected on video–EEG. PNEE are more likely to be longer in duration and have more variable behavior manifestations.





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Mar 12, 2017 | Posted by in NEUROLOGY | Comments Off on Psychogenic Nonepileptic Episodes

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