The first-line management of psychogenic non-epileptic seizures (PNES) in adults in the emergency: a practical approach

Abstract

Distinguishing non-epileptic events, especially psychogenic non-epileptic seizures (PNES), from epileptic seizures (ES) constitutes a diagnostic challenge. Misdiagnoses are frequent, especially when video-EEG recording, the gold-standard for PNES confirmation, cannot be completed. The issue is further complicated in cases of combined PNES with ES. In emergency units, a misdiagnosis can lead to extreme antiepileptic drug escalade, unnecessary resuscitation measures (intubation, catheterization, etc.), as well as needless biologic and imaging investigations. Outside of the acute window, an incorrect diagnosis can lead to prolonged hospitalization or increase of unhelpful antiepileptic drug therapy. Early recognition is thus desirable to initiate adequate treatment and improve prognosis. Considering experience-based strategies and a thorough review of the literature, we aimed to present the main clinical clues for physicians facing PNES in non-specialized units, before management is transferred to epileptologists and neuropsychiatrists. In such conditions, patient recall or witness-report provide the first orientation for the diagnosis, recognizing that collected information may be inaccurate. Thorough analysis of an event (live or based on home-video) may lead to a clinical diagnosis of PNES with a high confidence level. Indeed, a fluctuating course, crying with gestures of frustration, pelvic thrusting, eye closure during the episode, and the absence of postictal confusion and/or amnesia are highly suggestive of PNES. Moreover, induction and/or inhibition tests of PNES have a good diagnostic value when positive. Prolactinemia may also be a useful biomarker to distinguish PNES from epileptic seizures, especially following bilateral tonic-clonic seizures. Finally, regardless the level of certainty in the diagnosis of the PNES, it is important to subsequently refer the patient for epileptological and neuropsychiatric follow-up.

Crise não epiléptica: eventos paroxísticos de origem psicogênica

“…Para Toffa et al (2020), "Independentemente do nível de certeza no diagnóstico da CPNE, é importante posteriormente encaminhar o paciente para acompanhamento epiléptico e neuropsiquiátrico." De fato, o encaminhamento à especialistas facilita a descoberta e promove com mais facilidade a investigação de epilepsia associada, a fim de tratar o quanto antes.…”

Nursing a Patient with Nonepileptic Seizures — Case Report

“…traumatic experiences in the past, personality traits, relationships with relatives and frequent complaints about somatic symptom disorders. Studies have shown that over 82% of patients experienced trauma in their childhood, and from 40% to over 84% of patients were victims of sexual violence [9,10]. During the interview, over 44% of patients report craniocerebral trauma [11].…”

“…The most crucial factors include traumatic experiences during childhood (violence, sexual abuse, emotional neglect, loss of a loved one), personality disorders (borderline personality), head injuries, benefits resulting from taking the role of a sick person (compassion, exemption from social roles, financial gratification). When confronted with stressful situations, patients with PNES subconsciously integrate an epileptic seizure [8,10]. This way they learn that an epileptic seizure protects Differentiating between nonepileptic and epileptic seizures [3,4,8,9,10,12,13,14,16,17,21,26] Observation/Symptoms The following are useful in the treatment of PNES [7,16,17]:…”

“…When confronted with stressful situations, patients with PNES subconsciously integrate an epileptic seizure [8,10]. This way they learn that an epileptic seizure protects Differentiating between nonepileptic and epileptic seizures [3,4,8,9,10,12,13,14,16,17,21,26] Observation/Symptoms The following are useful in the treatment of PNES [7,16,17]:…”

“…Clear provision of the diagnosis and explanation of the causes of the disease lead to the cessation of attacks in 30% of cases [9]. More than 40% of patients remain unable to work and live independently for a long time [10]. 4 years after diagnosis, 71% of patients still experience seizures [16].…”