Diagnosis and Treatment

Review Article Address correspondence to Dr W. Curt LaFrance Jr, Rhode Rhod e Island Hospital, Brown University, Unive rsity, 593 Eddy Street, Providence, RI 02903, william_lafrance_jr@brown. edu. Relationship Disclosure:

Dr Chen reports no disclosure. Dr LaFrance serves on the Epilepsy Foundation Professional Advisory Board; has served as a clinic development consultant for the Cleveland Clinic, Emory University, Spectrum Health, and the Univers University ity of Colorad Colorado o Denver; and has provided expert medicolegal testimony. Dr LaFrance receives royalties from Cambridge University Press and Oxford University Press Pre ss andhas rec receive eived d rese research arch support from the American Epilepsy Society, the Epilepsy Foundation, the Matthew Siravo Memorial Foundation Inc, the National Institutes of Health, and Rhode Island Hospital. Unlabeled Unlabe led Use of Products/Investigational Use Disclosure: Drs Chen and LaFrance report no disclosures. * 2016 American Academy of Neurology.

Diagno Diag nosi sis s an and d Tr Trea eatm tmen entt of Nonepileptic Seizures David K. Chen, MD; W. Curt LaFrance LaFrance Jr, MD, MPH, FAAN, FANPA, DFAPA ABSTRACT Purpose of Review: Thi Thiss art articl icle e det detail ailss the eva evalua luatio tion n pr proce ocess ss inv involv olved ed in the dia diagn gnosi osiss of psychogenic nonepileptic seizures (PNES). The psychological underpinnings, prognostic factors, factors, and recent treatment treatment advances of PNES are also reviewed reviewed.. Recent Findings: The diagnosis of PNES is determined based on concordance of the composite evidence available, including historical and physical examination findin fin dings, gs, sei seizu zure re sym sympt ptom omss and sig signs, ns, an and d ict ictal/ al/int inter erict ictal al EEG EEG.. No sin single gle cli clinic nical al dat data a point is definitively diagnostic of PNES. The diagnosis of PNES can be challenging at times, such as when seizure documentation on video-EEG cannot be readily obtained. Yet, delayed diagnosis of PNES portends poor outcome. A multicomponent approach to the diagnosis of PNES, with use of an aggregate of available evidence, den ce, may faci facilita litate te diag diagnos nosis is and thencare of pati patients ents with PNE PNES. S. Emer Emerging ging evid evidence ence supports the effectiveness of cognitive-behavioral Y based based therapy in the treatment of these patients. Summary: The diag diagnos nosis is of PNES can be mad made e reli reliably ably,, and evid evidence ence-ba -based sed trea treatmen tmentt now exists. Continued efforts remain necessary to enhance prompt recognition and interdisciplinary management for patients with PNES. Continuum Continuu m (Minneap Minn) 2016;22(1): 2016;22(1):116 116–131.

INTRODUCTION Nonepileptic seizures are episodes of altered movement, sensation, sensation, or experience distinguished from epileptic seizures zur es by the lac lack k of ass associ ociate ated d ict ictal al abnormal abnorm al electri electrical cal brain discharges. About one-quart one-quarter er of patients referred to specialist centers for apparent drugresistant epilepsy are found to be misdiagnosed.1 After an average delay of abou ab outt 1 to 7 ye year arss to es esta tabl blis ish h th the e co corr rrec ectt 2,3 diagnosis, patients with nonepileptic seizure seiz uress wil willl fre freque quentl ntlyy hav have e tak taken en hig higher her doses of antiepileptic drugs (AEDs), utiutilized greater health care resources, and sustained more iatrogenic adverse effects than patients with epilepsy.4 Nonepile None pileptic ptic seiz seizures ures are furt further her categorized as physiologic or psychogenic in orig origin. in. Phys Physiolo iologic gic none nonepile pileptic ptic even events ts result from systemic alterations or disease states that produce an ictus (eg, “

”

Supplemental digital content: Videos accompanying this article are cited in the text as Supplemental Digital Content. Videos Vid eos may be acc access essed ed by clicking on links provided in the HTML HT ML,, PDF PDF,, an and d appver appversio sions ns of this article; article; the URLs are provided vide d in the prin printt ver versio sion. n. Vide Video o legends begin on page 128.

116

www.ContinuumJournal.com

convuls con vulsive ive sync syncope ope,, cat catapl aplexy, exy, or alco alcohol hol- withdr with draw awal al seiz seizur ure) e) ( Table Treating ing Table 6-15 ). Treat the underlying pathology of physiologic nonepileptic nonepil eptic events addresses the event. In contrast, psychogenic nonepileptic seizures (PNES) represent physical manifest fe stati ation onss deri derived ved from psych psychological ological underpinni under pinnings. ngs. In epil epilepsy epsy speci specialty alty centers, 88% of patients with nonepileptic seizures are deemed to have a psychogen cho genic ic eti etiolo ology gy for the their ir eve events nts..6 This review therefore focuses primarily on the diagnosis and management of PNES.

DIAGNOSIS OF PSYCHOGENIC NONEPILEPTIC SEIZURES The diagnosis of PNES can be challenging. When comprehensive neurologic and psychiatric assessment and videoEEG are not availabl available e in one setting, setting, an iterative assessment process over time February 2016

history are useful in raising the suspicion Physiologic Causes for PNES. The seizure burden of patients TABLE 6-1 of Nonepileptic with PNES is generally more pronounced Seizuresa than that of those with epilepsy, in terms of both seizure frequency 8 and dub Syncope ration.9 While stimuli-specific reflex epiVasovagal lepsies exist, the endorsement of more pedestrian triggers, such as certain lightCardiogenic ing level conditions, body movements, b Neurologic sounds, or foods, would be unusual for Cerebrovascular epilepsy and should raise suspicion for PNES, especially if the reported associMigraine ation is strikingly consistent. Of note, seiVertigo zure exacerbation by emotional stressors Cataplexy is not pathognomonic for PNES. Studies Parasomnias have shown that similar stressors can also provoke epileptic seizures.10 Movement disorders Over the lifetime of patients with b Metabolic PNES, about half have been diagnosed Hypoglycemia with depression, about half have comorbid posttraumatic stress disorder Electrolyte disturbances (PTSD), and about two-thirds have Toxicity (eg, drugs and alcohol) personality disorders.11 The presence Modified with permission from Mellers JD, of psychogenic disorders is a strong risk Postgrad Med J. pmj.bmj.com/content/ factor for other forms of comorbid or 81/958/498.full. B 2005 British Medical Journal Publishing Group. future psychosomatic symptoms.12 Accordingly, about 70% of patients with PNES endorse comorbid experiences may be necessary to establish the diag- with medically unexplained symptoms, 13 nosis of PNES.7 Habitual seizures of in- such as intractable pain. terest, especially in patients with multiple independent event types, are sometimes Clinical Features Differentiating not captured during an initial video-EEG Psychogenic Nonepileptic monitoring study. Long-term video-EEG Seizures and Epileptic Seizures monitoring is also not readily available Key elements in the evaluation of PNES in some locations. Appreciating these include the recognition of ictal features diagnostic challenges and the importance that are: (1) suggestive of a psychogenic of prompt recognition of this disorder, process and (2) not in favor of an epi5,14 this article first details relevant features leptic source ( Table 6-2 ). Each of from clinical history, symptoms and these two elements should be considsigns, and video-EEG evaluations that ered separately. An important caveat is support the PNES diagnosis and differ- that the features described by the patient and witnesses poorly correspond entiate it from epilepsy. with the observed PNES documented Historical Features Differentiating during video-EEG monitoring.15 TherePsychogenic Nonepileptic fore, ictal features described by patients Seizures and Epileptic Seizures or witnesses report alone should be in At the outset, a number of peculiar fea- terpreted with less diagnostic certainty tures uncovered from a carefully elicited than those visually documented from a

5

KEY POINTS h About one-quarter of

patients referred to specialist centers for apparent drug-resistant epilepsy (ie, failing to respond to adequate trials of two or more antiepileptic drugs) are found to have physiologic or psychogenic nonepileptic seizures rather than epilepsy. h After an average delay

of about 1 to 7 years to establish the correct diagnosis, patients with nonepileptic seizures will frequently have taken higher doses of antiepileptic drugs, utilized greater health care resources, and sustained more iatrogenic adverse effects than patients with epilepsy. h In epilepsy specialty

centers, a predominant majority (about 88%) of patients with nonepileptic seizures are deemed to have a psychogenic etiology for their events (ie, psychogenic nonepileptic seizures). h The diagnosis of

psychogenic nonepileptic seizures can be challenging, hence contributing to the frequent time delay (an average of 1 to7 years) before patients with psychogenic nonepileptic seizures are correctly diagnosed.

’

’

Continuum (Minneap Minn) 2016;22(1):116 –131


117

Nonepileptic Seizures

to Help Distinguish Psychogenic TABLE 6-2 Clinical Signs and Examination Findings Used Nonepileptic Seizures From Epileptic Seizures a,b Signs

Examination Findings

Psychogenic nonepileptic seizures

Long duration, fluctuatingcourse, asynchronous movements, pelvic thrusting, side-to-side head or body movement, ictal eye closure, ictal crying/weeping, memory recall for period of unresponsiveness

Resists eyelid opening, guarding of hand dropping over face, evidence of visual fixationc

Epileptic seizures

Occurrencefrom EEG-confirmed sleep, postictal obtundation/confusion, stertorous breathing postictally

Very severe tongue biting, impaired corneal reflex, extensor plantar response

EEG = electroencephalogram. a Data from Avbersek A, Sisodiya S, J Neurol Neurosurg Psychiatry, 14 jnnp.bmj.com/co ntent/81/7/719 .abstract ; Mellers JD, Postgrad Med.5 pmj.bmj.com/con tent/81/958/49 8.full . b No single sign distinguishes psychogenic nonepileptic seizures from epileptic seizures. c Visual fixation can be elicited by placing a mirror in front of the patient or rolling the patient from one side to the other.

KEY POINTS h Over the lifetime

of patients with psychogenic nonepileptic seizures, about half have been diagnosed with depression, about half have comorbid posttraumatic stress disorder, and about two-thirds have personality disorders. h The diagnosis of

psychogenic nonepileptic seizures requires the demonstration of ictal features that favor a psychogenic process; are not consistent with epilepsy; and occur in the context of supportive historical, physical examination, and ictal/interictal video-EEG findings. h Patients’ and witnesses’

descriptions of the ictal features have been known to correlate poorly with observed features of video-EEG Y captured seizures.

118

video-EEG monitoring and, to a lesser extent, home video recording. In distinguishing PNES from epileptic seizures, clinical features are generally more specific than sensitive,14 and no individual feature is definitively diagnostic of PNES.15 Instead, the degree of diagnostic confidence correlates with concordant features favoring PNES. For example, assessment of the characteristic seizure temporal evolution is often helpful. Ictal vocalization in epileptic seizures is usually restricted to the beginning of the seizure, primitive in nature (laryngeal sound), and highly stereotyped. In PNES, the vocalization may be present not only at the beginning of the seizure but may persist or even intensify through the course of the ictus. Vocalization in PNES can be more complex, with affective content reflecting somatic expression of emotional distress (eg, weeping, moaning, and coughing).16 The generalized tonicclonic epileptic features can inform diagnosis, where ictal features evolve through an organized fashion such that clonic frequency progressively declines while amplitude increases through the course of the convulsion. In contrast, the convulsive activity in generalized tonic-


clonic PNES may demonstrate unchanging frequency and variable amplitude throughout the ictus.17 Some PNES show poorly discernible ictal onset from a setting of apparent sleep, during which EEG activity discordantly correlates with wakefulness or light drowsiness.18 On the other hand, paroxysms with clear-cut emergence from EEGdocumented sleep would have a high likelihood of being physiologic in origin (ie, epileptic seizures or parasomnias). PNES have been classified into distinct groups according to the predominant clinical features. These groupings include rhythmic motor, hypermotor, complex motor, dialeptic (impaired awareness), subjective, and mixed.19 While such categorization can contribute to pattern recognition useful in the evaluation of PNES, it is presently uncertain whether such categorization is useful to distinguish psychological underpinnings or inform prognosis. Furthermore, unlike stereotyped epileptic seizures arising from a singular epileptogenic substrate, the ictal features of patients with PNES can often change, transforming into other clinical presentations or unrelated somatic symptoms.20 February 2016

Distinguishing Syncope From Other Causes of Drop Attacks The mean duration of vasovagal syncope (the most common mechanism for syncope) from the moment of event onset to recovery of full consciousness has been shown to be 41.4 seconds.21 Therefore, paroxysms of swoons that last longer than 1 minute should raise suspicion for other etiologies. It has been suggested that patients with recurrent syncope of unknown origin despite a thorough evaluation (about 20% to 30% of patients with syncope) should undergo video-EEG monitoring as some of them may, in fact, have PNES.22 Contrasting with the absence of significant EEG background change for PNES, the EEG during syncope proceeds through a stereotyped pattern, beginning with theta slowing, then delta slowing followed by suppression.22 The presence of convulsionlike motor accompaniments does not preclude the consideration of syncope. In a study involving video analysis of 42 episodes of syncope, 38 (90%) of the episodes were associated with motor symptoms. The most commonly observed movement pattern in this study was multifocal arrhythmic jerks in both proximal and distal muscles, usually lasting only a few seconds.23 The motor symptoms of syncope terminate when the patient assumes a horizontal position that facilitates cerebral perfusion, whereas those of epileptic seizures would not be influenced by body position. “

”

Confirming the Diagnosis of Psychogenic Nonepileptic Seizures Diagnostic tools used to help support the diagnosis of PNES include inpatient video-EEG monitoring, ambulatory EEG recording, and home video recording of habitual seizures. Video-EEG. Video-EEG entails prolonged continuous monitoring of the patient, allowing for simultaneous video Continuum (Minneap Minn) 2016;22(1):116 –131

and EEG documentation of the habitual seizures of interest. In the setting of an unconscious patient, physiologic causes can be excluded by concurrent presence of an intact alpha rhythm on the EEG (a neurophysiologic correlate of alertness). In other scenarios, the absence of an epileptiform ictal EEG correlate before, during, or after the seizure indicates that the captured event is likely nonepileptic in origin but does not necessarily distinguish a psychogenic versus physiologic etiology. Consideration of a psychogenic etiology requires the demonstration of PNES Y c onsistent clinical event features in the context of supportive historical and ictal/ peri-ictal physical examination findings ( Table 6-2 ). A concordant impression from each of these data elements with the video-EEG provides the diagnostic gold standard with high levels of certainty as well as excellent interrater reliability.15 Nuances of video-EEG interpretation. For some patients with PNES who experience dense amnesia for the details of their seizures, any recorded event should be confirmed by an eyewitness to be typical of the habitual seizures of interest. Otherwise, the clinical relevance of the recorded event remains uncertain. If the patient s historical features suggest more than one type of event, then an occurrence of each type should be recorded, as independent event types may reflect distinct etiologies. If not, the etiology of the nondocumented event type should be diagnosed with a more cautious level of certainty. Indeed, approximately 10% of patients with PNES also have an independent diagnosis of epilepsy.24 For patients with a learning disability, further diagnostic caution is warranted as the percentage of mixed PNES with epilepsy cases can be up to 30%.25 Focal epileptic seizures with preserved consciousness and rather restricted motor, autonomic, or sensory/psychic ’

KEY POINTS h No feature in itself is

definitively diagnostic of psychogenic nonepileptic seizures. h Assessing the

characteristics of the temporal evolution of a seizure can frequently yield helpful clues in differentiating psychogenic nonepileptic seizures from epileptic seizures. h The EEG during syncope

proceeds through a stereotyped pattern, beginning with theta slowing, then delta slowing followed by suppression. h In the setting of an

unconscious patient, physiologic causes can be excluded by concurrent presence of an intact alpha rhythm on the EEG (a neurophysiologic correlate of alertness). h Upon demonstrating

psychogenic nonepileptic seizure Y consistent clinical event features in the context of supportive historical and physical examination findings, video-EEG offers a diagnostic gold standard with high levels of certainty and reliability.


119

Nonepileptic Seizures KEY POINTS h Only 21% of simple

partial epileptic seizures have been shown to correlate with ictal EEG epileptiform changes, while some frontal lobe epileptic seizures can demonstrate very subtle, falsely lateralizing, or undiscernible ictal EEG epileptiform correlates. h When confronted with

enigmatic paroxysms of uncertain etiologies, the demonstration of inducibility (ie, provocative induction) would strongly (but not entirely) support a psychogenic etiology.

120

components (simple partial symptomatology) may arise from only a small pool of neuronal tissue. As such, only 21% of simple partial epileptic seizures have been shown to correlate with ictal epileptiform changes on scalp EEG.26 Some frontal lobe epileptic seizures arise from deep-seated foci (eg, orbitofrontal or interhemispheric regions) such that ictal epileptiform discharges can conduct/ distribute over a widespread area bilaterally, demonstrate a contralateral maximum, or become obscured by copious artifacts related to hypermotor activity. Therefore, ictal EEG epileptiform correlates of some frontal lobe epileptic seizures can be very subtle, falsely lateralizing, or undiscernible. Within 2 days after admission for video-EEG monitoring, the majority of patients with PNES will have experienced a spontaneous and characteristic seizure of interest.27 For those who do not experience spontaneous seizures, use of suggestion techniques (ie, provocative inductions) can improve the rate of seizure capture28 and shorten the duration of video-EEG admission.29 The success rate of induction is higher among patients who demonstrate preinduction characteristics of hypermotor ictal symptomatology, prevalent self-reporting of uncommon cognitive and affective symptoms, and absence of prior induction exposure.30 Moreover, when confronted with enigmatic cases for which frontal lobe epileptic seizures, simple partial epileptic seizures, or other physiologic nonepileptic events have not been conclusively excluded, the demonstration of inducibility would strongly (but not entirely) support a psychogenic etiology. Ethical concerns are raised by the use of placebos during induction (eg, saline injection or alcohol wipes), which inherently reflect a deceptive intervention to the patient.31 Such concerns can be circumvented by performing induction techniques that utilize routine


EEG activation procedures (hyperventilation and photic stimulation) without placebo. Asking the patient or family if they know of a trigger that can be reproduced in the unit is frequently helpful (eg, scrolling on a computer screen). Comparable success rates have been demonstrated between PNES activation procedures with placebo versus without placebo.32 Ambulatory EEG and home video recordings. Some patients with PNES may not experience seizures in a hospital setting that secludes patients from habitual stressors of their indigenous milieu. Under such circumstances, outpatient ambulatory EEG (sometimes with concurrent video recordings) can be useful. Because of less-standardized recording settings and greater susceptibility to artifacts, the qualities of the ambulatory EEG and video data can be quite variable. For cases in which supportive clinical or historic contexts are not available, ambulatory EEG should be interpreted with caution. The frequency of some patients PNES may be too rare to be practically captured during limited time frames of video-EEG or ambulatory EEG recordings. Considering the common availability of mobile devices that can record video, home video documentation of some patients infrequent seizures may be able to pro vide useful diagnostic data. Video data alone (without EEG) have been shown to provide reasonably robust sensitivity and specificity in distinguishing epileptic seizures from PNES.33 A key interpretive caution is that home video recordings may frequently miss the moment of seizure onset and instead capture the middle or recovery phase of the seizure. Moreover, the neurobehavioral manifestations during the postictal recovery phase of epileptic seizures can highly resemble the ictal symptomatology of some PNES. ’

’

February 2016

Levels of Certainty in the Diagnosis of Psychogenic Nonepileptic Seizures In acknowledging that video-EEG is not readily available to every patient world wide and that it may not always capture seizures characteristic of the patient s single or multiple independent event types, the Nonepileptic Seizure Task Force of the International League Against Epilepsy (ILAE) delineated a staged approach to PNES diagnosis.7 The ILAE task force recognized that different settings may not have access to video-EEG, so different levels of diagnostic certainty were delineated based on the available data. The clinical data utilized in this staged approach include patients historical presentation, witness accounts, and clinicians observation in person or via review of video recordings during ictus, interictal EEG, and video-EEG. Based on varying combinations of the ’

’

’

available aforementioned data reflective of scenarios commonly encountered in clinical practice, a diagnosis of PNES can be made with several levels of diagnostic certainty, the highest level being documented ( Table 6-3 ). With this approach, the task force aims to provide greater clarity regarding the evaluation process for PNES, facilitate prompt recognition of this disorder, and enhance care of patients wit h PNES worldwide. “

”

KEY POINT h Psychogenic nonepileptic

seizures are a subtype of conversion (somatoform) disorder in which psychological conflicts are manifested with symptoms resembling epileptic seizures.

PSYCHOPATHOLOGY PNES are most commonly conceptualized as a subtype of conversion disorder in which psychological conflicts are manifested as symptoms resembling epileptic seizures. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)34 provides revised diagnostic criteria for conversion disorder in accordance with updated insights regarding this disorder. Whereas the

TABLE 6-3 Overview of Proposeda Diagnostic Levels of Certainty for Psychogenic Nonepileptic Seizures Diagnostic Level

History

Witnessed Event

EEG

Possible

+

By witness or self-report/description

No epileptiform activity in routine or sleep-deprived interictal EEG

Probable

+

By clinician who reviewed video recording or in person, showing semiology typical of psychogenic nonepileptic seizures (PNES)

No epileptiform activity in routine or sleep-deprived interictal EEG

Clinically established

+

By clinician experienced in diagnosis of seizure disorders (on video or in person), showing semiology typical of PNES, while not on EEG

No epileptiform activity in routine EEG or ambulatory ictal EEG, capturing a typical ictusb

Documented

+

By clinician experienced in diagnosis of seizure disorders, showing semiology typical of PNES, while on video EEG

No epileptiform activity immediately before, during, or after ictus captured on ictal video EEG with typical PNES semiology

EEG = electroencephalogram; + = history characteristics consistent with PNES. a Modified with permission from LaFrance WC Jr, et al, Epilepsia. 7 onlinelibrary.wiley.com/doi/10.1111/epi.12356/full. B 2013 International League Against Epilepsy. b Captured ictus should not resemble types of epileptic seizures that may not show ictal epileptiform correlate on EEG (eg, simple partial epileptic seizures).



121

Nonepileptic Seizures KEY POINT h Whereas DSM-IV

approached conversion disorder as a diagnosis of exclusion, the updated DSM-5 guides users to make a positive conversion disorder diagnosis based on inclusion of clinical features that are incongruent to known anatomy, physiology, or disease.

Diagnostic and Statistical Manual of Mental Disorder s, Fourth Edi tion (DSM-IV) required the presence of psychological factors to precede or exacerbate conversion symptoms, such requirement has been relegated to a note in DSM-5.34,35 The reason for this change is that while psychological factors are important in the evolution of conversion disorders, they are not always immediately apparent from the history. Some patients readiness to discuss psychological factors may depend on the strength of the clinician-patient alliance. Even when psychological factors are readily identified, it may not be clear that they are etiologically relevant to the symptoms at hand.36 Moreover, evidence exists that physical factors (such as traumatic brain injuries, undergoing ’

surgeries/anesthesia37 Y 39 ) can provoke conversion symptoms and may involve processes that are physiologic as much as psychological ( Case 6-1 ). DSM-IV approached conversion disorder as a diagnosis of exclusion from other pathophysiologic conditions. To circumvent this problem, DSM-5 guides users to make a positive conversion disorder diagnosis based on inclusion of clinical findings that are incongruent to known anatomy, physiology, or diseases ( Table 6-2 ). The criterion on excluding other pathophysiologic conditions has been revised to a criterion that requires that the symptom in question is not better explained by another disease. This revision encourages clinical investigation for an alternative medical/ neurologic explanation for the symptom, “

”

Case 6-1 A 57-year-old man presented with a 10-year history of seizures involving abrupt loss of awareness with falls, followed by postictal disorientation/ confusion. Considering his known left frontal encephalomalacia from a stroke that also occurred about 10 years ago, he had been treated for (presumed) epilepsy with antiepileptic drugs. Since some of his paroxysms were preceded by coughing fits, posttussive syncope was within the differential diagnosis. However, he continued to experience frequent seizures, despite trials of three antiepileptic drugs and measures to treat his obstructive airway disease. He was r eferred for video-EEG monitoring, which confirmed the diagnosis of psychogenic nonepileptic seizures (PNES) (Supplemental Digital Content 6-1, links.lww.com/CONT/A169). This seizure was induced by routine activation procedures that included photic stimulation and provocation with verbal suggestion, but no placebo. PNES was supported by the documented features of suggestibility (increasing seizure intensity with higher photic frequency), ictal eye closure at ictal onset, side-to-side head movements, illness-affirming behaviors (retching cough, semifetal posture), and incongruence of intact EEG alpha rhythm (a neurophysiologic correlate of alertness) during dialeptic symptomatology with clinical unresponsiveness. Comment. While strokes are associated with epilepsy and epileptogenic foci, this case illustrates that the emotional affliction from significant health-related adverse events should not be overlooked. Moreover, evidence exists that physical factors (such as brain injuries) can provoke conversion symptoms and may involve processes that are physiologic as much as psychological. This case also exemplifies the importance of considering a wide differential diagnosis in patients with paroxysmal disorders, which includes epilepsy, physiologic nonepileptic events, and PNES.

122


February 2016

but also allows for a conversion disorder diagnosis even if a potentially related disease is present. The other notable change for conversion disorder in DSM-5 is that the former requirement for exclusion of feigning has been abandoned. In clinical practice, such requirement is problematic, as exclusion of malingering may be difficult to validate with absolute certainty without surveillance or forensic evaluation.40 Volitionally feigned symptoms, as in the cases of malingering or factitious disorders, are not PNES (ie, not psychogenic), and are rare, present mostly in at-risk groups. Several etiologic models have been proposed in the effort to explain the inception and evolution of conversion disorder manifesting as PNES.41 One model stipulates two main types of psychological difficulties that underlie PNES: posttraumatic and developmental.42 Posttraumatic PNES develop in response to psychological or physical trauma(s) that the patient struggles to adequately process or integrate. In the face of unspeakable dilemmas, some authors postulate that PNES reflects an automatic cutoff phenomenon in response to spontaneous intrusion into consciousness of such intolerable memories.43 Developmental PNES derives from difficulties coping with complex life tasks and milestones along the patient s continuum of psychosocial de velopment in an environment of emotional privation (eg, relational neglect). Studies have shown that some patients with PNES rely on avoidant coping responses (denial and repression) to perceived threats,44 hence hindering appropriate maturation of psychosocial development. For some patients with PNES, both posttraumatic and developmental types of psychological etiologies may coexist. In essence, PNES (and other conversion disorders) are a disorder of communication, where “

’


”

distress is expressed somatically, rather than in a healthy verbal manner.

BORDER ZONES OF PSYCHOGENIC NONEPILEPTIC SEIZURES (PSYCHIATRIC DIFFERENTIAL DIAGNOSIS) Border zones of PNES represent neurobehavioral paroxysms with psychological underpinnings but are not considered to be conversion disorders, as described above. Panic attacks can be the paroxysmal manifestation of panic disorder or other conditions associated with anxiety. Symptoms of tremulousness, shaking, derealization, or depersonalization can be quite prominent in some panic attacks, hence showing a notable parallel to seizures. Careful exploration of the overall presentation should uncover other key features meeting DSM-5 criteria for panic attacks, in which intense fear is accompanied by at least four of the following symptoms: palpitations, diaphoresis, shortness of breath, chest discomfort, nausea and abdominal discomfort, dizziness, and the aforementioned seizurelike symptoms. Similar to panic attacks, behavioral manifestations of PTSD frequently entail derealization, depersonalization, or affective numbing, all of which can resemble seizure activities. In fact, the DSM-5 designates a PTSD subtype with prominent dissociative symptoms. Upon careful evaluation, if the patient s overall symptomatology can be better explained by PTSD per DSM-5 criteria, then the additional diagnosis of conversion disorder should not be made. Some authors contend that the presentation of exclusively subjective sensory symptoms (albeit neurologic symptoms, such as paresthesia or numbness) are not sufficiently reliable in themselves to meet the criteria for PNES.40 Most of these cases likely represent anxious misinterpretation of common nonspecificparoxysmal symptomsof everyday ’


123

Nonepileptic Seizures KEY POINTS h An important prognostic

factor of psychogenic nonepileptic seizures is the duration of illness, in which the prognosis worsens the longer the patient’s illness has been mistreated as epilepsy. h In children with

psychogenic nonepileptic seizures, serious psychosocial issues (eg, physical or sexual abuses) can be ongoing at the time of presentation and should be explored in every case.

life, including transient dizziness, limb numbness, or head sensations that may briefly disrupt attention. The misinterpretation of benign symptoms as being more pathologic may be more common in patients who have had personal experiences with seizures or who have other neurologic/medical conditions. Another scenario that falls within the border zones of PNES is the purposeless and repetitive behavioral mannerisms (learned behavior) that occur not infrequently in some cognitively impaired patients.45

PROGNOSIS When considering the overall population of patients with PNES, seizure cessation is reported to occur in about 40% of patients over time. About onethird of patients experience seizure reduction, while the remaining approximately one-third of patients undergo a chronically intractable course.46 A comprehensive assessment of PNES outcomes should encompass not only seizure burden, but also the state of psychosocial comorbidities, functionality, and overall quality of life.47 Upon pursuing a more complete outcome assessment of PNES as such, one study showed the following observations: 44% of patients were not seizure free and remained dependent (poor outcome); 40% of patients were either seizure free but dependent or not seizure free but independent (intermediate outcome); and 16% of patients were seizure free and independent (good outcome).48 The above results suggest that patients with PNES, in general, may have a poorer course than those with newly diagnosed epilepsy.48 Several patient-specific characteristics are identified as influencing the disease course of PNES. An important prognostic factor is duration of illness, in which the prognosis worsens the longer the patient s illness has been mistreated as epilepsy.49 Correspondingly, a staged ’

124


approach to PNES diagnosis may be beneficial in prompting earlier discussion regarding potential psychological contributions to seizures, as soon as minimum criteria for the diagnosis of PNES have been met. Deferring such discussions until video-EEG Y documented diagnostic certainty may lead to significant delay, considering the aforementioned diagnostic challenges and limited video-EEG availability in some locations. Factors that may prognosticate better outcomes among adults include higher level of education; younger age at both time of seizure onset and time of diagnosis; seizures with less- dramatic symptomatology; fewer additional psychosomatic symptoms; and neuropsychological measures supporting lower dissociative, inhibitive, emotional dysregulating, and compulsive tendencies.50,51

PSYCHOGENIC NONEPILEPTIC SEIZURES IN CHILDREN While much of the earlier discussions regarding PNES in adults also apply to children, some differences are notable in light of varying psychosocial elements across developmental stages in children. PNES can emerge in children as young as 5 years old, and their frequency increases with age, becoming the most common type of nonepileptic seizure in adolescents.52 Conversely, comorbid epilepsy (mixed disorder) is more prevalent in younger children with PNES than in older children or adolescents with PNES.52 Compared to adults with PNES, differences in psychiatric comorbidities include lower rates of mood disorders (32%) and PTSD (10%) and a higher rate of significant family stressors (44%) for children with PNES.53 Importantly, serious psychosocial issues (eg, physical or sexual abuses) can be ongoing at the time of presentation and should be explored in every case. Risk factors for pediatric PNES are noted, February 2016

including somatopsychic and adversity components related to maladaptive coping.54 The clinical outcome of PNES is better in children than adults, perhaps contributed to in part by a generally briefer duration of illness or that dysfunctional patterns have become less engrained.55

who continue to use the outdated pejorative terminology of pseudoseizures, with connotations of being false or fake, create a distance between patients and clinicians. Legitimization and confirmation of PNES through these efforts can enhance the patient s acceptance of the subsequent diagnostic explanation ( Case 6-2 ). In turn, the patient s acceptance of the PNES diagnosis has been shown to be associated with seizure improvement.57 Hence, the neurologist s explanation of this diagnosis is vital, and should be communicated to the patient via a tactful, empathetic, positive, nonpejorative, and unequivocal approach.58 Provision of supplementary written information may help consolidate (and further legitimize) the PNES diagnosis.59 Communication with family and the referring physician regarding this diagnosis can also augment the uniformity of diagnostic “

”

’

’

MANAGEMENT OF PSYCHOGENIC NONEPILEPTIC SEIZURES Management of patients with PNES begins with a comprehensive evaluation (ie, seizure history, psychosocial assessment, video-EEG), which includes a de velopmental history and review of past trauma and abuse in the intake neurologic assessment.56 Many times, patients have been dismissed in prior emergency department and neurologic encounters, so conveying to the patient that the seizures in PNES are just as real as those in epilepsy is essential. Neurologists

KEY POINT h The neurologist’s

explanation of the diagnosis of psychogenic nonepileptic seizures is vital and should be communicated to the patient via a tactful, empathetic, and unequivocal approach.

’

Case 6-2 A 27-year-old man presented with near-daily seizures that involved diffuse shaking with varying degree of unconsciousness. Given his high seizure frequency, a brief 23-hour inpatient video-EEG was able to capture his habitual seizure, and he received the diagnosis of psychogenic nonepileptic seizures (PNES). He then sought additional referrals, endorsing the frustration that, My family thinks it s all in my head, and It has to come from something else. During a subsequent video-EEG monitoring course, efforts were made to capture the full spectrum of the patient s seizures. The diagnosis of PNES was explained to the patient and family members, emphasizing PNES as a real, albeit nonepileptic, type of seizure. This explanation of the diagnosis took place across two inpatient visits to allow the patient and his family the opportunity to process their understanding and ask questions. An explanation letter (addressed to the patient) and PNES brochures were encouraged to be shared with other clinicians or individuals pertinent to the patient s care. Comment. For patients with PNES, establishing the correct diagnosis is the first step of treatment. Optimal management begins with comprehensive evaluation (ie, neurologic and psychiatric assessment, description of the events and psychosocial history taking, video-EEG monitoring). The clinician-patient rapport and legitimization of PNES established through these efforts can enhance the patient s acceptance of diagnosis. In this sense, neurologists can be a factor not only in the diagnosis, but also in the initial treatment of patients with PNES as they prepare patients for collaborative care with a mental health professional. “

’

”

“

”

’

’

’



125

Nonepileptic Seizures KEY POINTS h Medications do not fully

treat psychogenic nonepileptic seizures. Moreover, antiepileptic drugs may make psychogenic nonepileptic seizures worse. Selective serotonin reuptake inhibitors (SSRIs) help the comorbidities (eg, depression and anxiety) but do not stop psychogenic nonepileptic seizures. h Targeted psychotherapy

appears to be the mainstay of treatment for psychogenic nonepileptic seizures. To date, two pilot randomized controlled trials for psychogenic nonepileptic seizures have shown clinically meaningful results using either traditional cognitive-behavioral therapy or a seizure-treatment workbook based on a multimodality cognitive-behavioral therapy Y informed psychotherapy for psychogenic nonepileptic seizures and for epilepsy.

insight across the patient s milieu. Not providing the diagnosis with patient or providers has been shown to be associated with no improvement or even worsening of symptoms.60 Likewise, merely sharing the diagnosis (without further dedicated therapeutic efforts) is frequently insufficient, as other somatic and affective symptoms often develop if the core issues are not addressed.13 Letting the patient and family know that they are not alone in that many people have the same disorder; that treatment involves addressing predisposing, precipitating, and perpetuating factors; and that effective treatment is available pro vides hope to patients and empowers treating clinicians to engage.50 The mainstay of effective treatment for PNES is psychotherapy directed at the known pathologies in the population. Pharmacologic interventions are used to address common comorbidities (eg, selective serotonin reuptake inhibitors [SSRIs] for depression and anxiety). However, psychotropics may reduce seizures but do not lead to seizure cessation in PNES.3,61 Among psychotherapeutic approaches for patients with PNES, cognitive-behavioral therapy has the most substantial body of controlled efficacy data. To date, two pilot randomized controlled trials for PNES have shown clinically meaningful results. One study used conventional cognitivebehavioral therapy,62 while the other study used a multimodality cognitivebehavioral therapy Y informed psychotherapy 3 based on a workbook used by therapists and patients to treat both epileptic seizures and PNES ( Table 6-4 ). 63 Some patients may continue to maintain some ambivalence regarding the nature of the PNES diagnosis and express reluctance toward in-depth individual psychotherapies. In such cases, group psychoeducational approaches have been shown to consolidate patients understanding of PNES and promote ’

’

126


more open-mindedness toward acceptance of this diagnosis.64,65 Because driving is an issue for patients with seizures, barriers to treatment delivery are being overcome with computer video telemedicine, which is being used in the US Department of Veterans Affairs to provide live-remote therapy for veterans with either epileptic seizures or PNES.66 The working relationship between the neurologist and patient should not abruptly end after a diagnosis of PNES has been established, for several reasons. For some patients with PNES, especially those who have been chronically misdiagnosed as having epileptic seizures, a proper understanding of the diagnosis may not be achievable with a one-shot disclosure. Instead, iterative explanation of the diagnosis via a supportive/ noncoercive tone across serial visits may gradually foster the patient s acceptance for mental health treatment referrals. Once the transition to mental health care is complete, then discussion can commence regarding the patient s discharge from the neurologist s practice. If a specific AED has no alternative beneficial indication (eg, mood stabilization or migraine prophylaxis), then a timely taper of the drug is advisable. Early, as opposed to delayed, AED withdrawal portends greater beneficial effects on a range of clinical outcomes.57 Patients with normal videoEEG findings should be followed by a neurologist for at least 6 months after discontinuing AEDs. This consideration is because of the small but ever-present possibility of coexisting epilepsy and the fact that breakthrough epileptic seizures can occur several months after discontinuation of AEDs. Patients with PNES who also hav e known interictal or ictal epileptiform abnormalities on their video-EEG should continue to be followed by a neurologist. Patients with mixed epilepsy/PNES should be “

”

’

’

’

February 2016

TABLE 6-4 Cognitive-Behavioral Approaches Evaluated in Randomized Controlled Trials for Psychogenic Nonepileptic Seizures

Therapeutic approach

Outcomes

Goldstein et al, 2010 61

LaFrance et al, 2014 3

Based on traditional cognitive-behavioral therapy (CBT) and fear escape-avoidance model: Psychogenic nonepileptic seizures (PNES) as dissociative responses to cues associated with extremely distressing or life-threatening experiences. These experiences are,in turn, linked to unbearable feelings of fear and distress.

Based on CBT-informed psychotherapy model initially aimed to enhance self-control of epileptic seizures: PNES as the somatic manifestations of maladaptive core beliefs (negative schemas) that have been derived chronically from life experiences and traumas.

Main topics include seizure-directed techniques; attention refocusing; relaxation; dealing with avoidance behaviors, negative cognitions, and other factors key toward engendering PNES.

Main topics include healthy communication, support seeking, and goal setting; conducting a functional behavioral analysis; aura identification; linking triggers, negative states, and target symptoms; relaxation; examining external stressors and internal conflicts; promotion of ongoing health and wellness.

CBT group experienced fewer seizures than the control group at the end of treatment.

When compared to before treatment, CBT-informed psychotherapy workbook group showed significant seizure reduction and improvement in depression, anxiety, quality of life, and global functioning measures.

During the last 3 months of a 6-month follow-up period, between-group differences in seizure frequency were not significant, although the CBT group was 3 times more likely to be seizure free.

When compared to baseline, the treatment as usual/standard medical care control group showed no significant difference in seizure frequency or any secondary outcome measures.

treated with the lowest effective AED dose for the epilepsy, noting that AEDs do not treat PNES, and behavioral interventions should target the PNES. Continued follow-up by the neurologist during the transition to mental health providers mitigates repeat workups with other providers.

a positive conversion disorder diagnosis based on identifying incongruent examination and laboratory findings in relation to known anatomy or physiology. Neurologists can work collaboratively with mental health providers to adequately address the psychological underpinnings of these challenging patients. This team approach highlights the importance of CONCLUSION interdisciplinary dialogue and transition Conversion disorder is usually not diag- in the care of patients with PNES. To nosed by the mental health provider this end, better communication by neuroalone; the neurologist is integral in the logists can overcome past diverging inevaluation and diagnosis. Indeed, patients terdisciplinary perspectives regarding with conversion disorder frequently pres- PNES, with psychiatrists frequently beent to neurologists first in search of a ing uncertain about the accuracy of videoneurologic explanation to their symp- EEG.68 Further efforts are necessary to toms.67 As such, neurologists have ac- augment this vital interdisciplinary partquired substantial experience in making nership. Recent diagnostic and treatment Continuum (Minneap Minn) 2016;22(1):116 –131

KEY POINT h For the 10% of patients

with mixed epilepsy/ psychogenic nonepileptic seizures, use the lowest effective antiepileptic drug dose for the epileptic seizure and use mental health treatments for the psychogenic nonepileptic seizures.


127


studies have shown momentum in shifting PNES to a neuropsychiatric interdisciplinary (shared-care) model with a mind/brain perspective.66 As research in PNES advances, cognizance of and, hence, empathy for patients with this challenging condition can advance, in parallel.

VIDEO LEGEND Supplemental Digital Content 6-1 Psychogenic nonepileptic seizure induced by photicstimulation and verbal suggestion. The documented features of suggestibility (intensifying ictal manifestations with increasing photic frequency), somatic expression of distress (coughing, semifetal posture), and clinical unresponsiveness despite EEG demonstration of an intact posterior dominant rhythm (reflecting an awake state) are all supportive of a psychogenic etiology to this captured nonepileptic seizure. links.lww.com/CONT/A169 B 2016

American Academy of Neurology.

REFERENCES 1. Smith D, Defalla BA, Chadwick DW. The misdiagnosis of epilepsy and the management of refractory epilepsy in a specialist clinic. QJM 1999;92(1):15 Y 23. doi:10.1093/qjmed/92.1.15. 2. Reuber M, Fernandez G, Bauer J, et al. Diagnosis delay in psychogenic nonepileptic seizures. Neurology 2002;58(3):493 Y 495. doi:10.1212/WNL.58.3.493. 3. LaFrance WC Jr, Baird GL, Barry JJ, et al. Multicenter pilot treatment trial for psychogenic nonepileptic seizures: a randomized clinical trial. JAMA Psychiatry 2014;71(9):997 Y 1005. doi:10.1001/ jamapsychiatry.2014.817. 4. Reuber M, Baker GA, Gill R, et al. Failure to recognize psychogenic nonepileptic seizures may cause death. Neurology 2004;62(5):834 Y 835. doi:10.1212/01.WNL. 0000113755.11398.90. 5. Mellers JD. The approach to patients with non-epileptic seizures. Postgrad Med J 2005;81(958):498 Y 504. “

128


”

6. Benbadis SR, O Neill E, Tatum WO, et al. Outcome of prolonged video-EEG monitoring at a typical referral epilepsy center. Epilepsia 2004;45(9):1150 Y 1153. doi:10.1111/j. 0013-9580.2004.14504.x. ’

7. LaFrance WC Jr, Baker GA, Duncan R, et al. Minimum requirements for the diagnosis of psychogenic nonepileptic seizures: a staged approach: a report from the International League Against Epilepsy Nonepileptic Seizures Task Force. Epilepsia 2013;54(11): 2005 Y 2018. doi:10.1111/epi.12356. 8. Jedrzejczak J, Owczarek K, Majkowski J. Psychogenic pseudoepileptic seizures: clinical and electroencephalogram (EEG) video-tape recordings. Eur J Neurol 1999;6 (4):473 Y 479. doi:10.1046/j. 1468-1331.1999.640473.x. 9. Reuber M, Pukrop R, Mitchell AJ, et al. Clinical significance of recurrent psychogenic nonepileptic seizure status. J Neurol 2003;250(11):1355 Y 1362. doi:10.1007/ s00415-003-0224-z. 10. Frucht MM, Quigg M, Schwaner C, Fountain NB. Distribution of seizure precipitants among epilepsy syndromes. Epilepsia 2000;41(12): 1534 Y 1539. doi:10.1111/j.1528-1167. 2000.01534.x. 11. Bowman ES, Markand ON. Psychodynamics and psychiatric diagnoses of pseudoseizure subjects. Am J Psychiatry 1996;153(1):57 Y 63. doi:10.1176/ajp.153.1.57. 12. Binzer M, Andersen PM, Kullgren G. Clinical characteristics of patients with motor disability due to conversion disorder: a prospective control group study. J Neurol Neurosurg Psychiatry 1997;63(1):83 Y 88. doi:10.1136/jnnp.63.1.83. 13. Ettinger AB, Devinsky O, Weisbrot DM, et al. Headaches and other pain symptoms among patients with psychogenic non-epileptic seizures. Seizure 1999;8(7):424 Y 426. doi:10.1053/seiz.1999.0334. 14. Avbersek A, Sisodiya S. Does the primary literature provide support for clinical signs used to distinguish psychogenic nonepileptic seizures from epileptic seizures? J Neurol Neurosurg Psychiatry 2010;81(7):719 Y 725. doi:10.1136/jnnp.2009.197996. 15. Syed TU, LaFrance WC Jr, Kahriman ES, et al. Can semiology predict psychogenic nonepileptic seizures? A prospective study. Ann Neurol 2011;69(6):997 Y 1004. doi:10.1002/ana.22345. 16. Elzawahry H, Do CS, Lin K, Benbadis SR. The diagnostic utility of the ictal cry. Epilepsy Behav 2010;18(3):306 Y 307. doi:10. 1016/j.yebeh.2010.04.041. February 2016

17. VintonA, Carino J, VogrinS, et al. Convulsive nonepileptic seizures have a characteristic pattern of rhythmic artifact distinguishing them from convulsive epileptic seizures. Epilepsia 2004;45(11):1344 Y 1350. doi:10. 1111/j.0013-9580.2004.04704.x. “

”

18. Benbadis SR, Lancman ME, King LM, Swanson SJ. Preictal pseudosleep: a new finding in psychogenic seizures. Neurology 1996;47(1):63 Y 67. 19. Seneviratne U, Reutens D, D Souza W. Stereotypy of psychogenic nonepileptic seizures: insights from video-EEG monitoring. Epilepsia 2010;51(7):1159 Y 1168. doi:10.1111/ j.1528-1167.2010.02560.x. ’

29. McGonigal A, Russell AJ, Mallik AK, et al. Use of short term video EEG in the diagnosis of attack disorders. J Neurol Neurosurg Psychiatry 2004;75(5):771 Y 772. doi:10.1136/ jnnp.2003.024893. 30. Chen DK, Izadyar S, Collins RL, et al. Induction of psychogenic nonepileptic events: success rate influenced by prior induction exposure, ictal semiology, and psychological profiles. Epilepsia 2011;52(6):1063 Y 1070. doi:10.1111/ j.1528-1167.2011.02985.x. 31. Stagno SJ, Smith ML. The use of placebo in diagnosing psychogenic seizures: who is being deceived? Semin Neurol 1997;17(3):213 Y 218.

20. LaFrance WC Jr, Plioplys S. Neuropsychiatric disorders: does semiology of psychogenic nonepileptic seizures matter? Nat Rev Neurol 2012;8(6):302 Y 303. doi:10.1038/ nrneurol.2012.79.

32. Benbadis SR, Johnson K, Anthony K, et al. Induction of psychogenic nonepileptic seizures without placebo. Neurology 2000;55(12): 1904 Y 1905. doi:10.1212/WNL.55.12.1904.

21. Ammirati F, Colivicchi F, Di Battista G, et al. Electroencephalographic correlates of vasovagal syncope induced by head-up tilt testing. Stroke 1998;29(11):2347 Y 2351. doi:10.1161/01.STR.29.11.2347.

33. Chen DK, Graber KD, Anderson CT, Fisher RS. Sensitivity and specificity of video alone versus electroencephalography alone for the diagnosis of partial s eizures. Epilepsy Behav 2008;13(1):115 Y 118. doi:10.1016/j. yebeh.2008.02.018.

22. Benbadis SR, Chichkova R. Psychogenic pseudosyncope: an underestimated and provable diagnosis. Epilepsy Behav 2006;9(1): 106 Y 110. doi:10.1016/j.yebeh.2006.02.011. 23. Lempert T, Bauer M, Schmidt D. Syncope: a videometric analysis of 56 episodes of transient cerebral hypoxia. Ann Neurol 1994;36(2): 233 Y 237. doi:10.1002/ana.410360217. 24. Benbadis SR, Agrawal V, Tatum WO. How many patients with psychogenic nonepileptic seizures also have epilepsy? Neurology 2001;57(5):915 Y 917. doi:10.1212/WNL.57.5.915. 25. Duncan R, Oto M. Psychogenic nonepileptic seizures in patients with learning disability: comparison with patients with no learning disability. Epilepsy Behav 2008;12(1): 183 Y 186. doi:10.1016/j.yebeh.2007.09.019.

34. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fifth edition (DSM-5). Washington, DC: American Psychiatric Association, 2013. 35. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fourth edition (DSM-IV). Washington, DC: American Psychiatric Association, 2000. 36. StoneJ, LaFrance WCJr, LevensonJL, SharpeM. Issues for DSM-5: conversion disorder. Am J Psychiatry 2010;167(6):626 Y 627. doi:10.1176/ appi.ajp.2010.09101440. 37. Lichter I, Goldstein LH, Toone BK, Mellers JD. Nonepileptic seizures following general anesthetics: a report of five cases. Epilepsy Behav 2004;5(6):1005 Y 1013. doi:10.1016/j. yebeh.2004.09.003.

26. Devinsky O, Kelley K, Porter RJ, Theodore WH. Clinical and electroencephalographic features of simple partial seizures. Neurology 1988;38(9):1347 Y 1352. doi:10.1212/WNL. 38.9.1347.

38. Westbrook LE, Devinsky O, Geocadin R. Nonepileptic seizures after head injury. Epilepsia 1998;39(9):978 Y 982. doi:10.1111/ j.1528-1157.1998.tb01447.x.

27. Parra J, KannerAM, Iriarte J, Gil-NagelA. When should induction protocols be used in the diagnostic evaluation of patients with paroxysmal events?Epilepsia1998;39(8):863 Y 867. doi:10.1111/j.1528-1157.1998.tb01181.x.

39. Reuber M, Kral T, Kurthen M, Elger CE. New-onset psychogenic seizures after intracranial neurosurgery. Acta Neurochir (Wien) 2002;144(9):901 Y 907. doi:10.1007/ s00701-002-0993-7.

28. Benbadis SR, Siegrist K, Tatum WO, et al. Short-term outpatient EEG video with induction in the diagnosis of psychogenic seizures. Neurology 2004;63(9):1728 Y 1730. doi:10.1212/01.WNL.0000143273.18099.50.

40. Stone J, LaFrance WC Jr, Brown R, et al. Conversion disorder: current problems and potential solutions for DSM-5. J Psychosom Res 2011;71(6):369 Y 376. doi:10.1016/j. jpsychores.2011.07.005.



129


41. LaFrance WC Jr, Bjornaes H. Designing treatment based on etiology of psychogenic nonepileptic seizures. In: Schachter SC, LaFrance WC Jr, editors. Gates and Rowan s nonepileptic seizures. 3rd ed. Cambridge, UK: Cambridge University Press, 2010:266 Y 280. ’

42. Kalogjera-Sackellares D. Psychodynamics and psychotherapy of pseudoseizures. Wales, UK: Crown House Publishing, 2004:3 Y 42. 43. Betts T, Boden S. Diagnosis, management and prognosis of a group of 128 patients with non-epileptic attack disorder. Part II. Previous childhood sexual abuse in the aetiology of these disorders. Seizure 1992;1(1):27 Y 32. doi:10.1016/1059-1311(92)90050-B. 44. Jawad SS, Jamil N, Clarke EJ, et al. Psychiatric morbidity and psychodynamics of patients with convulsive pseudoseizures. Seizure 1995;4(3):201 Y 206. doi:10.1016/S1059-1311 (05)80061-5. 45. Kim SH, Kim H, Lim BC, et al. Paroxysmal nonepileptic events in pediatric patients confirmed by long-term video-EEG monitoring V single tertiary center review of 143 patients. Epilepsy Behav 2012;24(3): 336 Y 340. doi:10.1016/j.yebeh.2012.03.022. 46. Bowman ES. Nonepileptic seizures: psychiatric framework, treatment, and outcome. Neurology 1999;53(5 suppl 2):S84 Y S88. 47. Reuber M, Mitchell AJ, Howlett S, Elger CE. Measuringoutcome in psychogenic nonepileptic seizures: how relevant is seizure remission? Epilepsia 2005;46(11):1788 Y 1795. doi:10.1111/ j.1528-1167.2005.00280.x. 48. Reuber M, Pukrop R, BauerJ, et al. Outcome in psychogenic nonepileptic seizures: 1 to 10-year follow-up in 164 patients. Ann Neurol 2003;53(3):305 Y 311. doi:10.1002/ana.3000. 49. Selwa LM, Geyer J, Nikakhtar N, et al. Nonepileptic seizure outcome varies by type of spell and duration of illness. Epilepsia 2000;41(10):1330 Y 1334. doi:10.1111/j. 1528-1157.2000.tb04613.x. 50. LaFrance WC Jr, Devinsky O. Treatment of nonepileptic seizures. Epilepsy Behav 2002;3 (5 supp):19 Y 23. 51. Cragar DE, Schmitt FA, Berry DT, et al. A comparison of MMPI-2 decision rules in the diagnosis of nonepileptic seizures. J Clin Exp Neuropsychol 2003;25(6):793 Y 804. doi:10.1076/jcen.25.6.793.16471. 52. Kotagal P, Costa M, Wyllie E, Wolgamuth B. Paroxysmal nonepileptic events in children and adolescents. Pediatrics 2002;110(4):e46. doi:10.1542/peds.110.4.e46.

130


53. Wyllie E, Glazer JP, Benbadis S, et al. Psychiatric features of children and adolescents with pseudoseizures. Arch Pediatr Adolesc Med 1999;153(3):244 Y 248. doi:10.1001/ archpedi.153.3.244. 54. Plioplys S, Doss J, Siddarth P, et al. A multisite controlled study of risk factors in pediatric psychogenic nonepileptic seizures. Epilepsia 2014;55(11):1739 Y 1747. doi:10.1111/epi.12773. 55. Wyllie E, Friedman D, Luders H, et al. Outcome of psychogenic seizures in children and adolescents compared with adults. Neurology 1991;41(5):742 Y 744. doi:10. 1212/WNL.41.5.742. 56. Teitjen G. Office assessment for abuse and management of the battered patient. Neurol Clin Pract 2012;2:5 Y 13. doi:10.1212/ CPJ.0b013e31824c6c8a. 57. LaFrance WC Jr, Reuber M, Goldstein LH. Management of psychogenic nonepileptic seizures. Epilepsia 2013;54(suppl 1):53 Y 67. doi:10.1111/epi.12106. 58. Shen W, Bowman ES, Markand ON. Presenting the diagnosis of pseudoseizure. Neurology 1990;40(5):756 Y 759. doi:10.1212/WNL.40.5.756. 59. Hall-Patch L, Brown R, House A, et al. Acceptability and effectiveness of a strategy for the communication of the diagnosis of psychogenic nonepileptic seizures. Epilepsia 2010;51(1):70 Y 78. doi:10.1111/j.15281167.2009.02099.x. 60. Aboukasm A, Mahr G, Gahry BR, et al. Retrospective analysis of the effects of psychotherapeutic interventions on outcomes of psychogenic nonepileptic seizures. Epilepsia 1998;39(5):470 Y 473. doi:10.1111/ j.1528-1157.1998.tb01407.x. 61. LaFrance WC Jr, Keitner GI, Papandonatos GD, et al. Pilot pharmacologic randomized controlled trial for psychogenic nonepileptic seizures. Neurology 2010;75(13):1166 Y 1173. doi:10.1212/WNL.0b013e3181f4d5a9. 62. Goldstein LH, Chalder T, Chigwedere C, et al. Cognitive-behavioral therapy for psychogenic nonepileptic seizures: a pilot RCT. Neurology 2010;74(24):1986 Y 1994. doi:10.1212/ WNL.0b013e3181e39658. 63. Reiter J, Andrews D, Reiter C, LaFrance WC Jr. Taking control of your seizures: workbook. New York, NY: Oxford University Press, 2015. 64. Zaroff CM, Myers L, Barr WB, et al. Group psychoeducation as treatment for psychological nonepileptic seizures. Epilepsy Behav 2004;5(4):587 Y 592. doi:10.1016/j.yebeh.2004.03.005.

February 2016

65. Chen DK, Maheshwari A, Franks R, et al. Brief group psychoeducation for psychogenic nonepileptic seizures: a neurologist-initiated program in an epilepsy center. Epilepsia 2014;55(1): 156 Y 166. doi:10.1111/epi.12481. 66. McMillan KK, Pugh MJ, Hamid H, et al. Providers perspectives on treating psychogenic nonepileptic seizures: frustration and hope. Epilepsy Behav 2014;37:276 Y 281. doi:10.1016/ j.yebeh.2014.07.001. ’


67. Stone J, Binzer M, Sharpe M. Illness beliefs and locus of control: a comparison of patients with pseudoseizures and epilepsy. J Psychosom Res 2004;57(6):541 Y 547. doi:10.1016/j. jpsychores.2004.03.013. 68. Harden CL, Burgut FT, Kanner AM. The diagnostic significance of video-EEG monitoring findings on pseudoseizure patients differs between neurologists and psychiatrists. Epilepsia 2003;44(3):453 Y 456. doi:10.1046/ j.1528-1157.2003.33002.x.


131

Diagnosis and Treatment

Recommend Documents