By: Clara O’Hara
Introduction
Psychogenic nonepileptic seizures (PNES) are attacks that look like epileptic seizures, but are not caused by abnormal electrical charges (University of South Florida Health, 2013). They are, instead, a physical reaction to stress-related, psychological, or emotional issues. People with PNES cannot control their seizures
The psychiatric diagnosis for PNES is conversion disorder, as mental stress is converted to a physical symptom. Conversion disorder is also known as functional neurological symptom disorder.
Other names for this condition include Psychogenic nonepileptic spells, Psychogenic nonepileptic episodes (PNEE), and Psychogenic nonepileptic attacks (Professional, n.d.).
Signs and Symptoms of PNES
PNES symptoms are often similar to those of a generalized epileptic seizure. This may include:
1. Convulsions
2. Crying aloud or making noises
3. Stiffening
4. Jerky, rhythmic or twitching motions
5. Falling down
6. Loss of Consciousness
7. Confusion after returning to consciousness
8. Loss of bladder control
9. Biting the tongue
NES can also be similar to partial seizures. These symptoms may include:
1. Jerky or rhythmic movements
2. Sensations such as tingling, dizziness, feeling full in the stomach
3. Repetitive motions
4. Staring
5. Confusion
6. Changes in emotions
7. Altered senses
(Professional, n.d.-b)
PNES and Epilepsy
ES+PNES patients, in a study of quality of life for patients with ES, patients with PNES, and patients with ES+PNES, exhibited more anxiety and depression and worse overall quality of life compared to ES patients. In addition, the prevalence of PNES among adults with epilepsy is ∼5%. They are frequently misdiagnosed and treated as epilepsy. Multidisciplinary neurology and psychiatric assessments will help in the patient’s therapeutic plan.
Diagnosis
Distinguishing PNES from epileptic seizures may be difficult at the bedside even to experienced observers. In theory, almost any recurrent behavior may represent epileptic seizures.
Delay in diagnosis for years with psychogenic nonepileptic seizures is common.
Therefore, correct diagnosis is necessary for successful treatment. Patients with psychogenic nonepileptic spells, frequently being misdiagnosed as having epilepsy, have been prescribed multiple medications.
Observations that suggest a PNES event, to an epileptic seizure, are waxing and waning consciousness, out-of-phase shaking movements, pelvic thrusting, side-to-side head shaking, and eye closure.
Consultation with neurology may be helpful. Admission to a monitoring unit may be in order if the diagnosis is uncertain. Long-term video EEG monitoring is the most important diagnostic test. Recently, short-term video-EEG has been found useful in the diagnosis of PNES. Video electroencephalography (video-EEG) of a typical event showing the absence of epileptiform activity during the spell with a compatible history is regarded as the gold standard for diagnosis.
(Huff, 2022)
Treatment
Unfortunately, there is a lack of research on determining whether certain medications are helpful for patients with PNES and epilepsy. Consultation with a medical professional is needed in discussing treatment options.
Some antidepressants may be helpful for treating patients with PNES and epilepsy. Research in using selective serotonin reuptake inhibitors (SSRIs) have proven to be safe for patients with epilepsy at therapeutic doses and effective in treating patients with PNES. Therefore, it may be effective and safe to patients with both epilepsy and PNES. An example of a safe and effective SSRI is using citalopram. Benzodiazepines have proven to be safe for patients with epilepsy, however, studies in proving their safeness and effectiveness in patients with PNES vary.
Cognitive behavioral therapy (CBT) is a recommended treatment for someone with PNES and epilepsy. In research examining CBT among people with PNES and epilepsy, it has shown to in-directly, possibly decrease PNES and epileptic seizures. The therapy treats the etiology of the PNES of the person, which is often major depressive disorder, whilst increasing quality of life experience in seizures (De Barros et al., 2018).
Conclusion
Psychogenic nonepileptic seizures (PNES) are attacks that look like epileptic seizures, but are not caused by abnormal electrical charges and a response to psychological, emotional, or stress-related events. Quality of life in people with PNES and epilepsy, representing less than 5% in a study group, is significantly worse, and exhibit more anxiety and depression. Correct and early diagnosis, with neurological and psychological assessment, will be helpful for people with epilepsy and PNES. Some treatments that may be most helpful in treating people with epilepsy and PNES are SSRIs.
References
Benbadis, S., & Dunn, G. (2013, June). Defining Psychogenic Non-epileptic seizures. USF Health. Retrieved June 18, 2023, from https://health.usf.edu/medicine/neurology/epilepsy/~/media/Files/Medicine/Neurology/Comprehensive%20Epilepsy%20Program/PNESBrochureNew.pdf
Campbell, G. (2022, August 12). Psychogenic Nonepileptic Seizure: Associated Factors and Treatment. Consult QD. https://consultqd.clevelandclinic.org/psychogenic-nonepileptic-seizure-associated-factors-and-treatment/
De Barros, A. C. S., Furlan, A. E. R., Marques, L. H. N., & De Araújo Filho, G. M. (2018). Effects of a psychotherapeutic group intervention in patients with refractory mesial temporal lobe epilepsy and comorbid psychogenic nonepileptic seizures: A nonrandomized controlled study. Seizure-european Journal of Epilepsy, 58, 22–28. https://doi.org/10.1016/j.seizure.2018.03.023
Huff, J. S. (2022, May 8). Psychogenic Nonepileptic Seizures. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK441871/
Kanner, A. M. (2016). Most antidepressant drugs are safe for patients with epilepsy at therapeutic doses: A review of the evidence. Epilepsy & Behavior, 61, 282–286. https://doi.org/10.1016/j.yebeh.2016.03.022
LaFrance, W. C., Keitner, G. I., Papandonatos, G. D., Blum, A. S., Machan, J. T., Ryan, C., & Miller, I. (2010). Pilot pharmacologic randomized controlled trial for psychogenic nonepileptic seizures. Neurology, 75(13), 1166–1173. https://doi.org/10.1212/wnl.0b013e3181f4d5a9
Professional, C. C. M. (n.d.-b). Psychogenic Nonepileptic Seizure (PNES). Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/24517-psychogenic-nonepileptic-seizure-pnes
Risman, A. (2021, April 13). Psychogenic non-epileptic seizures with comorbid epilepsy: insights from patient and caregiver characteristics (2082). Neurology. https://n.neurology.org/content/96/15_Supplement/2082.abstract
Riss, J., Cloyd, J. M., Gates, J. C., & Collins, S. P. (2008). Benzodiazepines in epilepsy: pharmacology and pharmacokinetics. Acta Neurologica Scandinavica, 118(2), 69–86. https://doi.org/10.1111/j.1600-0404.2008.01004.x
