Difference between revisions of "Psychogenic nonepileptic seizure"

(Evaluation)
(Evaluation)
Line 34: Line 34:
  
 
==Evaluation==
 
==Evaluation==
*Urgent EEG
+
*May be a clinical diagnosis
*Drug screen
+
*Consider standard [[seizure]] workup
*History
+
*If unsure, an urgent neuro consult with EEG can determine the diagnosis
**[[Depression]]
 
**[[Panic attack]]
 
**PTSD
 
**Chronic pain
 
**[[Substance abuse]]  
 
**[[Borderline personality disorder]]
 
**Dissociative disorder
 
**[[Epilepsy]]
 
***Especially with prior [[status epilepticus]]
 
  
 
==Management==
 
==Management==

Revision as of 02:40, 11 June 2018

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.

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:
    • Drooling
    • Rapid eye movements
    • Tongue biting
    • Loss of bladder/bowel control
    • Grunting
    • Loss of consciousness
    • Altered mental status

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 for PNES. (e.g. outpatient cognitive behavioral therapy (CBT)).
    • 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 to 80 percent achieving seizure remission

See Also

External Links

References