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Psychogenic nonepileptic seizures

Alan B Ettinger, MD, MBA
Section Editor
Timothy A Pedley, MD
Deputy Editor
April F Eichler, MD, MPH


Clinicians are regularly challenged to identify the nature of episodic neurologic symptoms. Events associated with prominent motor activity or altered consciousness are often presumed to be epileptic seizures. However, the event may actually represent one of a wide array of nonepileptic paroxysmal events, such as syncope, parasomnias, and movement disorders (table 1).

Another notable type of episodic behavior is a psychogenic nonepileptic seizure (PNES). Characterized by sudden and time-limited disturbances of motor, sensory, autonomic, cognitive, and/or emotional functions, PNES can mimic epileptic seizures. However, in contrast to epileptic seizures, PNES are not associated with physiological central nervous system dysfunction but are instead psychogenically determined [1-4].

Other terms, such as pseudoseizures or hysterical seizures, have been used to describe these episodes. The term "hysterical" seizures or "hysteroepilepsy" is now discouraged as both pejorative and oversimplified, failing to capture the broad range of underlying psychopathology. The term "pseudoseizures" is also discouraged, since the root "pseudo," or false, invalidates the genuine, even if psychogenic, disorder that a patient experiences.

It is important that clinicians consider PNES when evaluating patients with episodic symptoms. Missing this diagnosis may result in inappropriate treatment with antiseizure drugs that are associated with potential morbidity, especially if drug toxicity is incurred in the attempt to suppress episodes [5-7]. Prolonged episodes, "psychogenic status epilepticus" in particular, are often treated with toxic antiseizure drug doses, intubation, and iatrogenically induced coma [6-14]. When PNES occur during pregnancy, these treatments pose additional risks to the fetus [2]. Recurrent visits to the emergency room and hospitalizations for uncontrolled, unrecognized PNES place a cost burden on the healthcare system [15]. Finally, failure to recognize psychiatric issues may promote the persistence of conversion symptoms and deny the patient needed psychiatric interventions.

The diagnosis of PNES can be challenging. In some case series, delay to PNES diagnosis has been as long as 9 to 16 years [16,17]. This is due in part to the broad diversity of PNES presentations and the lack of one single unifying presenting symptom. Other sources of misdiagnosis include an inadequate history, co-occurrence of PNES and epilepsy in the same patient, poor physician-patient rapport, reliance upon clinical observation of the event, discomfort in making a psychiatric diagnosis, and reluctance to obtain a psychiatric evaluation before the clinician feels confident about the diagnosis [18]. While advances in technology, especially the advent of video-electroencephalography, have greatly advanced our ability to recognize PNES, an accurate diagnosis is best achieved by assimilating a wide variety of clues including a detailed history from the patient and observers, the physical examination, selected testing, and a psychiatric evaluation.


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Literature review current through: Sep 2016. | This topic last updated: Nov 17, 2015.
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