Is it a seizure or something else? Here are 5 tips to assess and treat psychogenic non-epileptic seizures.
Dr. Abbasi is Assistant Professor in the Department of Psychiatry and Human Behavior, Assistant Clerkship Director for Psychiatry, Sidney Kimmel College of Medicine, and Consulting Psychiatrist, Jefferson Comprehensive Epilepsy Center at Thomas Jefferson University Hospitals in Philadelphia.
Is it a Seizure or Something Else?
Psychogenic non-epileptic seizures (PNES) are paroxysmal episodes that are not due to excessive electrical activity in the brain, as typically seen in epileptic seizures. Current research has not shed light on what exactly causes this phenomenon. We do know that certain risk factors are associated with PNES.
Here are 5 tips to assess and treat psychogenic non-epileptic seizures.
1. The current gold standard for the diagnosis of PNES is video EEG (vEEG), accompanied by a thorough seizure history. If there are multiple seizure semiology, it is vital that the neurologist obtain a description of each type, making sure to interview family or friends who may have witnessed the seizures. If a patient is to undergo vEEG, it is important that the neurologist corroborate all described seizure semiology with the presence or absence of epileptic activity on the EEG.
In some cases, if vEEG monitoring is not available, convulsive-type PNES may be differentiated based on history and observation of the seizure episodes by a seasoned neurologist. For additional details on how to differentiate psychogenic from epileptic seizures using methods other than vEEG, please see the report from the International League Against Epilepsy referenced below.
2. Make sure to rule out other causes, such as neurocardiogenic syncope and periodic limb movements of sleep. If seizures seem to escalate when patient is not having demands met or is informed that he or she is nearing discharge from their hospital stay, consider factitious disorder or malingering as possible differentials.
3. Patients with PNES have a high psychiatric co-morbidity. Most endorse symptoms of PTSD. An inpatient or outpatient psychiatric consult can be very helpful in assessing the patient for co-occurring symptoms. Treatment of co-morbid psychiatric disorders may result in better quality of life and possible reduction in seizure frequency.
If a psychiatrist is not readily available, bed-side screening tools such as the PHQ-9 (depression), PC-PTSD (PTSD), and the GAD-7 (anxiety) may help identify a potential diagnosis and encourage the patient to seek treatment.
4. Collaborating with a psychiatrist to create a leaflet or psychoeducational group program may provide significant benefit. Please see tips on “How to break the news” below.
5. Cognitive behavioral therapy and group therapy are considered first-line treatments. These interventions have been shown to be efficacious in decreasing seizure frequency and improving quality of life.
Tips on How to Break the News
Step 1: Explain what this isn’t.
Make sure to sit down with the patient and review the EEG if possible. It is usually helpful to have the patient's family member present, as they may be able to help the patient understand the diagnosis and provide additional information. Explain that there is no abnormal electrical activity seen during these events and why it is unlikely that the patient is having epileptic seizures.
Step 2: Explain what it is.
This is usually the most difficult step for most neurologists. The most common mistake is when a neurologist informs the patient that his or her symptoms are due to “stress.” There is a natural desire for doctors to provide some sort of causative agent to appease the patient. Avoid making this interpretation right off the bat as it may alienate the patient, especially if he or she doesn’t readily relate to the idea. I usually recommend an alternative approach, along these lines:
“Unfortunately, we don’t really know what causes PNES. There is no identifiable pathogen, virus, lesion, or other injury that leads to these symptoms. Essentially all the “hardware” of your nervous system is functioning correctly and there seems to be more of a “software” problem. Your brain is communicating with your body, but the message is being altered.
What we DO know, is that are certain risk factors that can make people more susceptible to developing PNES. This includes a history of adverse events that may have occurred in childhood or adulthood that could include possible abuse, neglect, bullying, or other forms of trauma. We also know that PNES attacks usually arise when a person is under some form of chronic or acute stress. This could be things like the loss of a loved one, workplace difficulty, relationship difficulty, or a recent health-related event that has caused impairment in a person’s life. Now these factors may not apply to everyone, but many people with PNES can identify experiencing some of the factors I mentioned.
Step 3: Focus on the good news.
It is important to reinforce to the patient that he or she does not have epilepsy. Let the patient know that epilepsy in and of itself is a difficult diagnosis for patients to manage. Anticonvulsants have several side effects and many patients have to take multiple medications to gain relief. In addition, while non-epileptic seizures are distressing for the patient and their loved ones, they will not cause brain damage, unlike uncontrolled epileptic seizures. This usually provides some relief to the patient.
Step 4: Have the patient focus on moving forward with treatment.
Let patients know there is a frequent psychiatric co-morbidity with PNES. Make sure to clarify that you are not insinuating that the patient has a psychiatric disorder, but explain that it would be prudent to speak with a psychiatrist or psychologist to fully assess for possible symptoms. In many cases, patients are not able to readily make a connection between stress, trauma, and PNES when they first receive a diagnosis. Working with a therapist may help the patient explore possible connections between stress and seizures.
In addition, PNES often imparts a feeling of helplessness: a therapist may assist the patient in being able to feel more in control of the seizures. Patients can be taught to identify when a seizure is about to occur by identifying triggers and potential prodromal symptoms. This allows the patient to reach a point of safety (a couch, the floor) to avoid injury from the attack.
With time, patients may find that they can avert seizures and reduce frequency. In addition, therapy can assist in preventing behaviors that further isolate the patient (ie, becoming reclusive out of fear or embarrassment from seizures) and reduce quality of life.
Further reading on diagnosing PNES:
. LaFrance, WC, Jr, Baker GA, Duncan R, et al. “Minimum Requirements for the Diagnosis of Psychogenic Nonepileptic Seizures: A Staged Approach: A Report from the International League Against Epilepsy Nonepileptic Seizures Task Force.” Epilepsia. 2013;54(11):2005–2018.
Therapy workbooks and guidebooks:
. Psychogenic Non-Epileptic Seizures: A Guide
Lorna Myers, PhD
. Treating Nonepileptic Seizures: Therapist Guide*
. Taking Control of Your Seizures: Workbook*
*With both of the above by W. Curt LaFrance, the patient must complete the workbook under the supervision of a therapist.
Here’s the link to the Academy of Psychosomatic Medicine, where you might be able to get in touch with psychiatrists who have an understanding of PNES.
Books highlighting patient perspective and experiences:
. A View from the Floor
Kate Berger and Lorna Myers, PhD
For more information, see Psychogenic Non-Epileptic Seizures, on which this slideshow was based.