Updated Review on the Diagnosis and Primary Management of Psychogenic Nonepileptic Seizure Disorders

Abstract

Psychogenic nonepileptic seizures (PNES) are paroxystic and episodic events associated with motor, sensory, mental or autonomic manifestations, which resemble epileptic seizures (ES), but are not caused by epileptogenic activity. PNES affect between 20% and 30% of patients attending at epilepsy centers and constitute a serious mental health problem. PNES are often underdiagnosed, undertreated and mistaken with epilepsy. PNES are diagnosed after medical causes (epilepsy, syncope, stroke, etc.) have been ruled out, and psychological mechanisms are involved in their genesis and perpetuation. For psychiatry, there is not a single definition for PNES; the DSM-IV and ICD-10/11 describe the conversion and dissociative disorders, and the DSM-5 describes the functional neurological disorders. However, patients with PNES also have a high frequency of other comorbidities like depression, particularly trauma and post-traumatic stress disorder. It has been postulated that PNES are essentially dissociations that operate as a defensive psychological mechanism that use the mind as a defense to deal with traumas. With the advent of VEEG in the 90s, the recognition of PNES has significantly increased, and several psychological treatments have been developed. In this manuscript, we carried out a state-of-the-art review, with the aim to provide a critical approach to the extensive literature about PNES, focusing on diagnostic aspects, the primary management, and the available treatments that have been shown to be effective for the improvement of PNES.

Randomized Trials of Psychotherapeutic Treatment for Psychogenic Seizures: Scoping Review

“…PNES symptoms significantly improve with psychotherapy. While before and after measures have been reviewed along with RCTs, 2 , 8 no study had reviewed only RCTs to mention the benefits and effectiveness of different psychotherapies for PNES. Further, while a before-and-after design may show that the treatment used is significant, bias can affect the determined results.…”

“…However, recent reviews have stressed the importance of suitable methodology 1 : especially, need for controlled trials have been stressed upon. 2 Several psychotherapies such as paradoxical intention therapy, 3 psychodynamically oriented therapy, 4 group therapy, 5 , 6 and psychoeducational therapy 7 have shown positive results in reducing seizures. Despite the existence of so many types of psychotherapies and their ability to reduce seizure frequency and cause psychosocial improvements, no study has reviewed only randomized controlled trials (RCTs) that can clearly indicate the effectiveness of different psychotherapies.…”

Functional seizures are not less important than epilepsy

“…People with FS are at higher risk for psychiatric comorbidities compared to the general population; this is comparable with that in the people with epilepsy [5] , [6] , [7] . Co-existing psychiatric disorders have a complex and intricate relationship with FS.…”

“…Co-existing psychiatric disorders have a complex and intricate relationship with FS. They may represent a predisposing risk factor, a precipitant, an underlying cause, or a consequence of this chronic and disabling disorder [5] , [6] , [7] . While there are many similarities between patients with FS and those with functional movement disorders [8] , people with FS have greater levels of depressive and anxiety symptoms, more frequent history of sexual abuse, greater levels of alexithymia, higher levels of dissociative symptoms, and distressing traumatic events occurring at an earlier age compared to those in people with functional movement disorders [9] .…”

Psychogenic nonepileptic seizures

“…Diagnostic delay of years with PNES is common. [ 1 ] The evolution of epilepsy monitoring units and the ability to utilize simultaneous video and electroencephalography EEG recordings may be a key to diagnosis. [ 2 3 ] Video EEG of a typical event showing the absence of epileptiform activity during the spell with a compatible history is regarded as the gold standard for diagnosis.…”