Difference between revisions of "Psychogenic nonepileptic seizure"

(Disposition)
 
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==Background==
 
==Background==
 
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*Psychogenic nonepileptic seizure (PNES) characterized disturbances of motor, sensory, autonomic, cognitive, and/or emotional functions that can mimic epileptic seizures.
 +
*In contrast to epileptic seizures, PNES are not associated with abnormally excessive neuronal activity but are instead derived from psychologic causes.
 +
*The term pseudoseizures and hysterical seizures are historical terms that are now discouraged.
 +
*Accurate diagnosis is best achieved via a detailed history, physical examination, selected testing, and neurology and/or psychiatry evaluation.
 +
*Epidemiology
 +
**Estimated incidence rate ranges from 1.5 to 5 per 100,000 persons per year.
 +
**Estimate prevalence 2 to 33 per 100,000 persons.
 +
*Etiology
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**Dissociative disorders and conversion disorders are felt to be the underlying cause to most episodes of PNES.
 +
*Some patients may have both psychogenic nonepileptic seizures '''and''' true epileptiform [[seizures]]
  
 
==Clinical Features==
 
==Clinical Features==
 
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*Symptoms specific to PNES:
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**Duration > 2 minutes
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**Pelvic thrusting
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**Side to side head rocking
 +
**Crying/shrieking
 +
**Voluntary eye movements away from the examiner/forceful closing of the eyes
 +
**Stuttering/stammering
 +
**ABSENT postictal confusion
 +
**ABSENT physical injury
 +
*Symptoms similar to an epileptic seizure:
 +
**Drooling
 +
**Rapid eye movements
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**Tongue biting
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**[[urinary incontinence|Loss of bladder]]/bowel control
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**Grunting
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**[[syncope|Loss of consciousness]]
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**[[Altered mental status]]
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
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==Evaluation==
 
==Evaluation==
 
+
*May be a clinical diagnosis
 +
*Consider standard [[seizure]] workup
 +
*If unsure, an urgent neuro consult with EEG can determine the diagnosis
  
 
==Management==
 
==Management==
 
+
*Avoid invasive medical procedures
 +
*Some patients will improve after they are told the diagnosis in a compassionate, non-jugdemental fashion.
 +
*If new diagnosis or diagnostic uncertainty consider admission for neurology consult and video EEG.
 +
*Psychiatric intervention is the main treatment modality (e.g. outpatient cognitive behavioral therapy).
 +
**The purpose of psychiatric consultation is to identify underlying psychiatric conditions that can help direct treatment.
  
 
==Disposition==
 
==Disposition==
 
*If symptoms improve consider discharge with close neurology and psychiatry follow-up to rule out epilepsy and identify and treat the underlying psychiatric origin of symptoms.
 
*If symptoms improve consider discharge with close neurology and psychiatry follow-up to rule out epilepsy and identify and treat the underlying psychiatric origin of symptoms.
 
*If symptoms cannot be controlled or patient/family are not accepting of diagnosis. Consider admission for observation and further evaluation.  
 
*If symptoms cannot be controlled or patient/family are not accepting of diagnosis. Consider admission for observation and further evaluation.  
*Prognosis:
+
 
**25-38 percent of patients achieve seizure freedom
+
==Prognosis==
**Children have a better prognosis than adults, with 70 to 80 percent achieving seizure remission
+
*25-38 percent of patients achieve "seizure" freedom
 +
*Children have a better prognosis than adults, with 70-80% achieving remission
  
 
==See Also==
 
==See Also==
 
+
*[[Seizure]]
  
 
==External Links==
 
==External Links==
 
  
 
==References==
 
==References==
 
<references/>
 
<references/>
 +
*Chen DK. Psychogenic Non-epileptic Seizure.  Uptodate. Updated May 18, 2018. Accessed June 1, 2018. https://www.uptodate.com/contents/psychogenic-nonepileptic-seizures?search=psychogenic%20nonepileptic%20seizures&source=search_result&selectedTitle=1~31&usage_type=default&display_rank=1
  
 
[[Category:Neurology]]
 
[[Category:Neurology]]

Latest revision as of 04:38, 3 October 2019

Background

  • Psychogenic nonepileptic seizure (PNES) characterized disturbances of motor, sensory, autonomic, cognitive, and/or emotional functions that can mimic epileptic seizures.
  • In contrast to epileptic seizures, PNES are not associated with abnormally excessive neuronal activity but are instead derived from psychologic causes.
  • The term pseudoseizures and hysterical seizures are historical terms that are now discouraged.
  • Accurate diagnosis is best achieved via a detailed history, physical examination, selected testing, and neurology and/or psychiatry evaluation.
  • Epidemiology
    • Estimated incidence rate ranges from 1.5 to 5 per 100,000 persons per year.
    • Estimate prevalence 2 to 33 per 100,000 persons.
  • Etiology
    • Dissociative disorders and conversion disorders are felt to be the underlying cause to most episodes of PNES.
  • Some patients may have both psychogenic nonepileptic seizures and true epileptiform seizures

Clinical Features

  • Symptoms specific to PNES:
    • Duration > 2 minutes
    • Pelvic thrusting
    • Side to side head rocking
    • Crying/shrieking
    • Voluntary eye movements away from the examiner/forceful closing of the eyes
    • Stuttering/stammering
    • ABSENT postictal confusion
    • ABSENT physical injury
  • Symptoms similar to an epileptic seizure:

Differential Diagnosis

Differential diagnosis of seizures

Seizure

Evaluation

  • May be a clinical diagnosis
  • Consider standard seizure workup
  • If unsure, an urgent neuro consult with EEG can determine the diagnosis

Management

  • Avoid invasive medical procedures
  • Some patients will improve after they are told the diagnosis in a compassionate, non-jugdemental fashion.
  • If new diagnosis or diagnostic uncertainty consider admission for neurology consult and video EEG.
  • Psychiatric intervention is the main treatment modality (e.g. outpatient cognitive behavioral therapy).
    • The purpose of psychiatric consultation is to identify underlying psychiatric conditions that can help direct treatment.

Disposition

  • If symptoms improve consider discharge with close neurology and psychiatry follow-up to rule out epilepsy and identify and treat the underlying psychiatric origin of symptoms.
  • If symptoms cannot be controlled or patient/family are not accepting of diagnosis. Consider admission for observation and further evaluation.

Prognosis

  • 25-38 percent of patients achieve "seizure" freedom
  • Children have a better prognosis than adults, with 70-80% achieving remission

See Also

External Links

References