Psychogenic (Nonepileptic) Seizures

Allan Krumholz; Jennifer Hopp

doi:10.1055/s-2006-945520

Seminars in Neurology, Table of Contents

Semin Neurol 2006; 26(3): 341-350
DOI: 10.1055/s-2006-945520

Psychogenic (Nonepileptic) Seizures

Allan Krumholz¹ , Jennifer Hopp¹

¹Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland

Abstract

ABSTRACT

Psychogenic (nonepileptic) seizures are among the most common and serious of all psychogenic neurological disorders. They account for ~20% of all intractable seizure disorders referred to comprehensive epilepsy centers and present with a reported annual incidence of ~4% that of true epilepsy. These events are serious and disabling. Indeed, compared with patients with true epilepsy, patients with psychogenic seizures exhibit more frequent, severe, and disabling seizures as well as a poorer quality of life. The diagnosis and management of psychogenic seizures remain challenging, although advances in video electroencephalographic (EEG) monitoring have improved the ability of physicians to identify these disorders accurately. The prognosis of these patients is still relatively poor, and a good outcome seems dependent on a young age at diagnosis, early diagnosis, less severe psychological comorbidities, and continued follow-up and management by the diagnosing neurologist or clinician. Additional psychological or psychiatric assessment may be beneficial, particularly in elucidating the etiology of the disorder as well as identifying comorbid disorders, and may help in the long-term management of these patients. This review presents the history, epidemiology, differential diagnosis, and management of psychogenic seizures, with particular attention to the use of diagnostic testing, including video EEG monitoring.

KEYWORDS

Nonepileptic seizures - psychogenic seizures - pseudoseizures

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References

REFERENCES

1 Krumholz A. Nonepileptic seizures: diagnosis and management. Neurology. 1999; 53(suppl 2) S76-S83
2 Meierkord H, Will B, Fish D, Shorvon S. The clinical features and prognosis of pseudoseizures diagnosed using video-EEG telemetry. Neurology. 1991; 41 1643-1646
3 Lesser R P. Psychogenic seizures. Neurology. 1996; 46 1499-1507
4 Sigurdardottir K R, Olafsson E. Incidence of psychogenic seizures in adults: a population-based study in Iceland. Epilepsia. 1998; 39 749-752
5 Szaflarski J P, Szaflarski M, Hughes C, Ficker D M, Cahill W T, Privitera M D. Psychopathology and quality of life: psychogenic non-epileptic seizures versus epilepsy. Med Sci Monit. 2003; 9 CR113-CR118
6 Barry E, Krumholz A, Bergey C, Alemayehu S, Grattan L. Nonepileptic posttraumatic seizures. Epilepsia. 1998; 39 427-431
7 Pakalnis A, Drake M E, Phillips B. Neuropsychiatric aspects of psychogenic status epilepticus. Neurology. 1991; 41 1104-1106
8 Walczak T S, Papacostas S, Williams D T et al.. Outcome after the diagnosis of psychogenic nonepileptic seizures. Epilepsia. 1995; 36 1131-1137
9 Metrick M E, Ritter F J, Gates J R et al.. Nonepileptic events in childhood. Epilepsia. 1991; 32 322-328
10 Wyllie E, Friedman D, Luders H et al.. Outcome of psychogenic seizures in children and adolescents compared to adults. Neurology. 1991; 41 742-744
11 Slavney P R. Perspectives on Hysteria. Baltimore; The Johns Hopkins University Press 1990
12 Veith I. Hysteria: The History of a Disease. Chicago; University of Chicago Press 1965
13 Alper K, Devinsky O, Perrine K, Vazquez B, Luciano D. Nonepileptic seizures and childhood sexual and physical abuse. Neurology. 1993; 43 1950-1953
14 Westbrook L E, Devinsky O, Geocadin R. Nonepileptic seizures after head injury. Epilepsia. 1998; 39 978-982
15 Goetz C G. Charcot the Clinician: The Tuesday Lessons. New York; Raven Press 1987
16 Massey E W, McHenry L C. Hysteroepilepsy in the nineteenth century: Charcot and Gowers. Neurology. 1986; 36 65-67
17 Ziegler F J, Imboden J B, Meyer E. Contemporary conversion reactions: a clinical study. Am J Psychiatry. 1960; 116 901-910
18 Liske E, Forster F M. Pseudoseizures: a problem in the diagnosis and management of epileptic patients. Neurology. 1964; 14 41-49
19 Diagnostic and Statistical Manual of Mental Disorders .DSM-IV. 4th ed. Washington, DC; American Psychiatric Association 1995
20 Krumholz A, Niedermeyer E. Psychogenic seizures: a clinical study with follow-up data. Neurology. 1983; 33 498-502
21 Krumholz A, Ting T. Co-existing epileptic and nonepileptic seizures. In: Kaplan PW, Fisher RS Imitators of Epilepsy. 2nd ed. New York; Demos Medical Publishing 2005: 261-276
22 Gates J R, Ramani V, Whalen S, Loewenson R. Ictal characteristics of pseudoseizures. Arch Neurol. 1985; 42 1183-1187
23 Leis A A, Ross M A, Summers A K. Psychogenic seizures: ictal characteristics and diagnostic pitfalls. Neurology. 1992; 42 95-99
24 Walczak T S, Bogolioubov A. Weeping during psychogenic nonepileptic seizures. Epilepsia. 1996; 37 208-210
25 Bergen D, Ristanovic R. Weeping is a common element during psychogenic nonepileptic seizures. Arch Neurol. 1993; 50 1059-1060
26 Peguero E, Abou-Khalil B, Fakhoury T, Mathews G. Self-injury and incontinence in psychogenic seizures. Epilepsia. 1995; 36 586-591
27 Orbach D, Ritaccio A, Devinsky O. Psychogenic, nonepileptic seizures associated with video-EEG-verified sleep. Epilepsia. 2003; 44 64-68
28 Walczak T S, Williams D T, Berton W. Utility and reliability of placebo infusion in the evaluation of patients with seizures. Neurology. 1994; 44 394-399
29 Bazil C W, Kothari M, Luciano D et al.. Provocation of nonepileptic seizures by suggestion in a general seizure population. Epilepsia. 1994; 35 768-770
30 Devinsky O, Fisher R S. Ethical use of placebos and provocative testing in diagnosing nonepileptic seizures. Neurology. 1996; 47 866-870
31 Lesser R P, Lueders H, Dinner D S. Evidence for epilepsy is rare in patients with psychogenic seizures. Neurology. 1983; 33 502-504
32 Ramsay R E, Cohen A, Brown M C. Coexisting epilepsy and non-epileptic seizures. In: Rowan AJ, Gates JR Non-Epileptic Seizures. Boston; Butterworth-Heinemann 1993: 47-54
33 Benbadis S R, Agrawal V, Tatum W O. How many patients with psychogenic nonepileptic seizures also have epilepsy?. Neurology. 2001; 57 915-917
34 Glosser G, Roberts D, Glosser D S. Nonepileptic seizures after resective epilepsy surgery. Epilepsia. 1999; 40 1750-1754
35 Reuber M, Kral T. New-onset psychogenic seizures after intracranial neurosurgery. Acta Neurochir (Wien). 2002; 144 901-907
36 Bare M A, Burnstine T H, Fisher R S, Lesser R P. Electroencephalographic changes during simple partial seizures. Epilepsia. 1994; 35 715-720
37 Krauss G L, Abdullah A, Lesser R, Thompson R E, Niedermeyer E. Clinical and EEG features of patients with EEG wicket rhythms misdiagnosed with epilepsy. Neurology. 2005; 64 1879-1883
38 Trimble M R. Serum prolactin in epilepsy and hysteria. Br Med J. 1978; 2 1682
39 Laxer K D, Mullooly J P, Howell B. Prolactin changes after seizures classified by EEG monitoring. Neurology. 1985; 35 31-35
40 Pritchard P B, Wannamaker B B, Sagel J, Nair R, DeVillier C. Endocrine function following complex partial seizures. Ann Neurol. 1983; 14 27-32
41 Malkowicz D E, Legido A, Jackel R A et al.. Prolactin secretion following repetitive seizures. Neurology. 1995; 45 448-452
42 Oribe E, Rohullah A, Nissenbaum E, Boal B. Serum prolactin concentrations are elevated after syncope. Neurology. 1996; 47 60-62
43 Henrichs T F, Tucker D M, Farha J, Novelly R A. MMPI indices in the identification of patients evidencing pseudoseizures. Epilepsia. 1988; 29 184-188
44 Wilkus R J, Dodrill C B. Factors affecting the outcome of MMPI and neuropsychological assessments of psychogenic and epileptic seizure patients. Epilepsia. 1989; 30 339-347
45 Aboukasm A, Mahr G, Gahry B R, Thomas A, Barkley G L. Retrospective analysis of the effects of psychotherapeutic interventions on outcomes of psychogenic nonepileptic seizures. Epilepsia. 1998; 39 470-473
46 Shen W, Bowman E S, Markand O N. Presenting the diagnosis of pseudoseizure. Neurology. 1990; 40 756-759
47 Bennet C, So N M, Smith W B, Thompson K. Structured treatment improves the outcome of nonepileptic events [abstract]. Epilepsia. 1997; 38(suppl 8) 214
48 Reuber M, Pukrop T, Bauer J et al.. Outcome in psychogenic nonepileptic seizures: 1 to 10-year follow-up in 164 patients. Ann Neurol. 2003; 53 305-311
49 Bowman E S. Etiology and clinical course of pseudoseizures: relationship to trauma, depression, and dissociation. Psychosomatics. 1993; 34 333-342
50 Bowman E S, Markand O N. Psychodynamics and psychiatric diagnoses of pseudoseizure subjects. Am J Psychiatry. 1996; 153 57-66
51 Vanderzant C W, Giordani B, Berent S, Dreifuss F E, Sackellares J C. Personality of patients with pseudoseizures. Neurology. 1986; 36 664-668
52 Williamson P, Spencer D, Spencer S et al.. Complex partial seizures of frontal lobe origin. Ann Neurol. 1985; 18 497-504
53 Saygi S, Katz A, Marks D et al.. Frontal lobe partial seizures and psychogenic seizures: comparison of clinical and ictal characteristics. Neurology. 1992; 42 1274-1277
54 Waterman K, Purves S, Kosaka B et al.. An epileptic syndrome caused by mesial frontal lobe seizure foci. Neurology. 1987; 37 577-582
55 Sussman N, Jackel R, Kaplan L et al.. Bicycling movements as a manifestation of complex partial seizures of temporal lobe origin. Epilepsia. 1989; 30 527-531

Allan KrumholzM.D.

Department of Neurology, N4W46, University of Maryland Medical Center

22 South Greene Street, Baltimore, MD 21201