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Psychogenic non-epileptic seizures: a diagnostic problem difficult to solve in clinical practice/ Non-epileptik psikojen nobetler: klinik pratikte cozulmesi zor tanisal bir problem.


Psychogenic non-epileptic seizures (PNES) are defined as episodes of altered movements, sensations, and behaviours that resemble epileptic seizures but that are not associated with abnormal electrical brain discharges (1,2,3,4). Over the years, a variety of terms has been used in the literature to describe these events: pseudoseizures, psychogenic seizures, hysterical epilepsy, pseudoepileptic seizures, or functional seizures. The term non-epileptic seizure is preferable because it includes both organic and psychological events and carries no pejorative connotation (5).

The right collocation of these patients in specific medical services is difficult because of the coexistence of somatic and psychological or psychiatric problems. In most cases, they are observed in patients referred to epilepsy centres (6). Probably for this reason, although the incidence of PNES in the general population is relatively low (about 1.5/100.000 persons per year) (7), the data from epilepsy centres show a much higher incidence rate. In fact, it is possible to obtain a diagnosis of PNES in 25-30% of patients referred to epilepsy centres for refractory epilepsy (8,9). Some authors also point out that a concomitant diagnosis of PNES and epilepsy, or past history of epileptic seizures is possible in 5 to 40% of patients (10,11). Other authors find out that the coexistence of PNES and epilepsy has a frequency ranging from 20 to 60% (12,13,14,15,16,17). The identification of this pathological entity has significantly increased in the last years, also thanks to the setting-up of video-electroencephalography (EEG).

The aim of this review was to analyse the clinical aspects and the diagnostic issues in PNES in epileptic patients in order to give practical advices for the physicians who face this problem in these patients.

Historical Review

Since ancient times, it is known that seizures can be of either epileptic or non-epileptic (hysterical) origin (18). Charcot and Gowers are the first clinicians who differentiated PNES from epileptic seizures by establishing phenomenological criteria which are still used in the clinical practice (19). Charcot first described non-epileptic seizure as a clinical disorder, calling it "hysteroepilepsy" and "epileptiform hysteria" (16). These terms focused attention on the psychological origin of the disorder, considering that hysteria is an unconscious somatization of emotional conflicts. The concept of conversion was introduced by Breuer and Freud as an extension of Janet's dissociative framework (20,21). This theory suggests that repression serves to protect against memories of personal trauma and that negative affect is "converted" into a somatic symptom.

PNES have long challenged both psychiatrists and neurologists. Only since 1980s, onward knowledge on PNES has been growing largely through the use of intensive video-EEG monitoring.

Epidemiological Data

Few data are available about the real incidence of PNES in epileptic patients. In general, the prevalence of PNES varies depending on the diagnostic setting. Pakalnis et al. (22) established that the frequency of PNES is about 5-20% in the epileptic population. Betts and Boden (23) reported 24% of patients with PNES per year in a highly specialized psychiatric ward. Gaining inspiration from the data of epilepsy centres, Cragar et al. (24) found out a prevalence of up to 33% while other authors reported that the diagnosis of PNES is obtained in approximately 25-30% of patients with refractory epilepsy (8,9,25). The prevalence appears to be much lower in outpatient units, with a percentage of only 5% (8). Benbadis et al. (10) reported the frequency of concomitant epilepsy in 9 to 32% of patients with PNES. Muller et al. (26) reported that the onset of PNES in epileptic patients occurred years later than epileptic seizures (even more than ten years later), but no other studies confirmed this result. Betts and Boden (23) also underlined that the group of patients with coexistence of PNES and epilepsy is the most challenging for diagnosis and treatment.

Concerning paediatric patients, some authors supposed a lower risk of PNES for children than adults (27), but this may represent underdiagnosis because of the limited number of studies on this population. Some studies reported coexisting epilepsy in 15-72% of children with PNES (28,29,30,31,32). Patel et al. (33) found out that concomitant epilepsy is more common in the younger age group than in adolescents. They also reported a higher correlation of focal epilepsy with PNES, as also noted by Holmes et al. in 1980 (30). In a recent study, Vincentiis et al. (34) identified PNES in 21 of 69 patients (30.4%), aged between 4 and 18 years, who have been referred to an epilepsy centre for current epileptic seizures or for previous history of well-controlled epilepsy. The authors also pointed out that these results probably overestimate the real incidence of the problem in the general population. Clinical Apects

PNES should be suspected whenever EEG is repeatedly normal, the attacks are frequent despite appropriate medical management, have atypical clinical features, and are exacerbated by stress. It is possible to distinguish physiologic non-epileptic seizures from PNES (35). Physiologic non-epileptic seizures may be related to: cardiac arrhythmias, complicated migraines, dysautonomia, effects of drugs and toxins, hypoglycaemia, movement disorders, panic attacks, sleep disorders, syncopal episodes, transient ischemic attacks, and vestibular symptoms (35). Even if a psychopathological definition of the disease underlying PNES lacks, PNES are a physical manifestation of a psychological distress. They may be due to: anxiety disorders (including post-traumatic stress disorder), conversion disorders, dissociative disorders, hypochondriases, psychoses, somatization disorders, or reinforced behaviour patterns in cognitively impaired patients (36) (Table 1). Usually, physiologic non-epileptic seizures are less common than PNES.

A careful history and a clinical analysis are essential for the differential diagnosis between PNES and epilepsy and for a correct classification. The clinical events have often a gradual onset, and they occur in the presence of others (37,38). Patients often preserve their consciousness, even if it may be fluctuating in some cases (8). Movements are predominantly represented by asynchronous and purposeful movements such as thrashing movements of the entire body, opisthotonic posturing of the trunk or rigidity for extended periods, out-of-phase limb movements, side-to-side head movements, and forward pelvic thrusting (11,39,40,41). In most cases, PNES patients have jaw clenching in the tonic phase of the convulsion and forcefully sustained eye closing at any stage of the seizure (6). Throughout the events, it is common to experience moaning and crying (ictal weeping) (11). Because of the presence of high variability in behaviour, there is great variability of ictal events in PNES, and many other types of clinical manifestations can be possible.


It is very difficult to classify PNES because they can imitate any type of seizure (9). Some authors suggested the subdivision of these ictal events in different types. Betts and Boden described three types of seizures: 1) "Swoons": consisting of a non-injuring, relaxed fall to the ground, without convulsions, with closed eyes and apparent unconsciousness, followed by a rapid recovery but not by post-ictal confusion; 2) "Tantrums": in this case, the fall on the ground is predicted by a cry, patients thrash about with a convulsive struggle if restrained, they may kick and bite, and they are commonly noisy, crying, and shouting; 3) "Abreactive attacks": rather long form (many hours), whose first sign may be overbreathing, often unrecognized, followed by sudden movements and stiffening of the body and then by breath holding, gasping, uncoordinated jerking of the body with pelvic thrusting, and back arching (23,42). Abubakr et al. divided PNES into two seizure types: 1) "major" motor manifestations resembling generalized tonic or clonic seizures, and 2) limpness, unresponsiveness, flaccidity, or "minor" seizures resembling absence-like or short focal seizures (25,43). Also Riggio (39) distinguished between a motor type and a non-motor type, whose main characteristic is the change in behaviour. Some authors used a classification system for the clinical manifestations of PNES such as the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) or the International Classification of Disease, Tenth Revision (ICD-10) (44). Seizures are then diagnosed as either "dissociative disorders" (ICD-10) or as DSM-IV axis I, axis II, or both. The most frequent DSM-IV diagnosis for PNES appears to be somatoform disorder (conversion disorder). The second most common diagnosis is anxiety disorder.

Alper proposed an important distinction between consciousness and unconsciousness and intentional and non-intentional PNES (8,45), identifying three different groups: in the first group, PNES are defined as a conversion disorder, in which patients are not conscious of intentionally producing symptoms or of the unconscious conflict underlying their occurrence; in the second group (PNES as factitious disorder), patients are aware of the intentionality of their symptoms but not of their reason for pursuing the sick role in their lives; in the last group, PNES occur in the context of malingering and patients are aware of intentional symptoms and of the underlying reasons. In another classification, Alper (8) distinguished PNES that are conversion symptoms (conversion PNES) from PNES that are non-conversion and are paroxysmal behaviour features of other syndromes (non-conversion PNES).

Some specific relationships were reported between psychological mechanisms and seizure presentation. Galimberti et al. (46) reported that PNES mimicking generalized tonic-clonic seizures are associated with a low educational level. Meierkord et al. (47) reported that pelvic thrusting can occur as prominent feature only in women with a history of childhood sexual abuse.

Differentiation between PNES and Seizures

Early diagnosis of PNES is as important as difficult and elaborate. The main difficulty is in distinguishing PNES from epileptic seizures. In addition to the clinical aspects considered above, there are some other issues that can help in the differentiation of these two ictal events. The pattern of symptoms and the sequence of events vary between seizures in PNES patients, while stereotyped behaviours are more characteristic of epileptic seizures (8,48). Another main aspect of epileptic seizures is the possible occurrence of injuries during ictal events. In PNES patients, the occurrence of injuries is not common due to the patients' self-protection before fall (49). It is important to underline that not always the presence of injuries is surely associated with seizures. The duration of the events is variable but longer than epileptic seizures (10-15 minutes instead of 1-2 minutes) (49), and the recovery is quite abrupt (43). Another important distinctive sign of PNES has been highlighted by Sirven and Glosser in 1998 (38). They reported that at the onset of a seizure, the patient seems to be asleep despite the EEG evidence of wakefulness, a finding specific for PNES.

Another challenge for physicians consists in distinguishing epileptic seizures from PNES in patients with cognitive impairment or mental retardation (45). Frequently, these patients have repetitive or stereotyped behaviours, and they also have poor verbal skills that limit their ability to report symptoms. Moreover, patients with cognitive disability have an increased incidence of epilepsy and a higher number of medical conditions that can be confused with epilepsy.

The main aspects that may be useful in the diagnosis of PNES in epileptic patients are summarised in Table 2.


Patients with PNES remain one of the most challenging patient populations. PNES cases develop between the second and fourth decades of life, but this disease can also affect children. PNES resemble epileptic seizures and are often misdiagnosed and mistreated as the latter. Conversely, epileptic seizures may be misdiagnosed and mistreated as PNES. PNES may be the sole paroxysmal event, but usually patients with PNES have concurrent epileptic seizures or have had epileptic seizures before. PNES always translate a psychopathological distress. In the history of a patient with epilepsy, the risk of the occurrence of PNES should always be taken into account. Unfortunately, a diagnostic tool that leads to a definite diagnosis of PNES is still missing, with the exception of video-EEG, whose validity is, however, subject to the frequency of seizures. Moreover, the demographic and clinical predictors of PNES are not yet defined. Nevertheless, an assessment of the social, cultural, and familial environment of the patient is mandatory to identify those with presumptive psychopathological risk. The misdiagnosis of PNES is costly to patients, to the health care system, and to the society. In fact, if not early diagnosed, PNES may confuse the clinical picture and lead to medication errors, both in terms of epileptology and psychopathology.

The first step in the treatment, of course, is proper diagnosis. Some clinical features can help to distinguish PNES from epileptic seizures, but other features associated with PNES are nonspecific and occur during both types of seizures. Since there are no clinical diagnostic criteria of certainty, and since differentiating focal epileptic seizures from PNES can be difficult, the video-EEG with provocation techniques remains the gold standard for PNES diagnosis.

Drug treatment can be very variable. In addition to any pharmacological treatment, a psychological support is invariably recommended.

Conflict of interest: The authors reported no conflict of interest related to this article

Cikar gatismasi: Yazarlar bu makale ile ilgili olarak herhangi bir cikar catismasi bildirmemiflerdir.

DOI: 10.4274/npa.y6687


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Alberto VERROTTI [1], Piero PAVONE [2], Sergio AGOSTINELLI [1], Giuliana NANNI [1], Giuseppe GOBBI [3]

[1] University of Chieti, Department of Paediatrics, Italy

[2] AOU OVE-Policlinico, University of Catania, Department of Paediatrics, Italy

[3] Child Neurology Unit, Department of Neuroscience, Bologna, Italy

Correspondence Address/Yazisma Adresi: Alberto Verrotti MD, AOU OVE-Policlinico, University of Catania, Department of Paediatrics, Italy

Gsm: +90 39 0871 358015 E-mail: Received/Gelis tarihi: 27.05.2012 Accepted/Kabul tarihi: 21.06.2012
Table 1. Aetiology of Psychogenic
Non-epileptic Seizures (PNES)

Post-traumatic stress:
 physical or sexual abuse
 severe family stressor
Conversion disorders
Dissociative disorders
Psychiatric comorbidity:
 panic disorder
 affective disorders
 obsessive-compulsive disorders
Somatization disorders
Personality factors:
 borderline personality disorders
 overly controlled personality

Table 2. Main Differences Between Psychogenic Non-epileptic
Seizures (PNES) and True Epileptic Seizures

 PNES True epileptic

Onset Gradual Usually abrupt

Duration 10-15 minutes Usually no more than
 2-3 minutes

Recovery Abrupt Frequent post-ictal

Occurrence In the presence of Unpredictable

Consciousness Preserved but From different degree
 fluctuating in some of consciousness
 cases impairment to loss of

Post-ictal No Frequent

Movements Non-synchronous Variable for each
 movements of the epilepsy type; in most
 entire body cases, generalized
 (opisthotonic tonic-clonic movements
 position, prolonged starting with fast,
 rigidity, out of phase small amplitude
 limb movements, side movements to slower,
 to side head larger movements or
 movements, forward brief rigidity
 pelvic thrusting, jaw
 clenching in the tonic
 phase of the ictal
 event, closed eyes at
 any stage of the

Behaviour Highly variable Stereotyped

Cry Ictal weeping Monotonous epileptic
 associated with cry
 moaning and screaming

Vocalization Rich in emotive Monotonous

Injury No because of self- Frequent (tongue
 protection before fall biting, head and limb

Emotional Patients deny a More seizures when
stress connection between patients are angry or
 their events and the anxious
 subjective experience
 of emotional stress

Occurrence No Possible
in sleep

EEG No association with
 abnormal brain Abnormal brain
 discharge; maintenance discharges
 of alpha rhythm with
 only discontinuous
 muscle activity

Response to No Frequent

Treatment No response Frequent

PNES, psychogenic non-epileptic seizure;
EEG, electroencephalography; HV, hyperventilation;
IPS, intermittent photic stimulation
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Author:Verrotti, Alberto; Pavone, Piero; Agostinelli, Sergio; Nanni, Giuliana; Gobbi, Giuseppe
Publication:Archives of Neuropsychiatry
Article Type:Report
Date:Dec 1, 2012
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