Psychogenic Non-Epileptic Seizures

Psychogenic non-epileptic seizures (PNES) are attacks that present like epileptic seizures but lack abnormal brain electrical discharges and do not have an organic cause (Epilepsy Foundation, 2007). Instead, they may be dissociative, due to conditions such as panic disorder, or factitious; of these, dissociative seizures are the most common (Epilepsy Society, 2017). Dissociative seizures are a specific type of conversion disorder and so a manifestation of psychological distress. While some people develop PNES following a trauma and in association with posttraumatic stress disorder (PTSD) or a dissociative disorder (Epilepsy Foundation, 2007), others develop it due to normal life stressors that the individuals lack the ability to cope with. In particular, attempting to use denial to avoid anxiety may exacerbate one's risk for developing PNES (John Hopkins, 2012). Individuals with PNES are likely to be emotionally underreactive or overreactive or to have both characteristics, such as having a tendency to avoid strong emotions and having a poor tolerance for strong emotions when present (Baslet, Seshadri, Bermeo-Ovalle, Willment, & Myers, 2016).

Psychogenic seizures frequently mimic tonic clonic (grand mal) seizures but may also mimic absence or complex partial seizures (Benbadis & Heriaud, n.d.; Epilepsy Foundation, 2007). Some report that for individuals with PNES, periods of unresponsiveness are more common even than stereotypical motor convulsions. Mixed features across or within episodes is common. Other possible symptoms include jerking movements, emotionally charged vocalizations, semi-purposeful repetitive movements (such as fumbling with clothing), aggressive behavior, changes in breathing or heart rate, or headaches. Psychogenic seizures can last minutes to an hour or more in series. Severe bodily injury is a rare result, but 1/3 of individuals with PNES may experience some self injury, including tongue biting, during episodes (Bowman & Markand, 2005).

Psychogenic seizures are most reliably distinguished from epileptic seizures using a video and EEG recording (Benbadis & Heriaud, n.d.; Epilepsy Foundation, 2007). In many cases, individuals with PNES have been previously falsely told by neurologists who do not specialize in epilepsy that their EEGs are abnormal, and they have likely spent years being treated for epilepsy that they do not have. A lack of reaction to antiepileptic drug treatment can provide a clue as to seizure-like symptoms' origins (Benbadis & Heriaud, n.d.; John Hopkins, 2012). Another clue might be that psychogenic non-epileptic seizures have a high comorbidity rate with fibromyalgia and chronic pain (Baslet et al., 2016; Epilepsy Foundation, 2007). Comorbid depressive, anxiety, personality, and other somatic symptom disorders are also common, although these can be found in individuals with epilepsy as well (Baslet et al., 2016). Dissociative seizures are especially common in individuals with dissociative identity disorder or other specified dissociative disorder, particularly in non-Western countries (American Psychiatric Association, 2013).

Women between the ages of 20 and 40 are the most likely to be affected by psychogenic seizures. When present in children or older individuals, males and females are equally likely to be affected. Psychogenic seizures are not exceptionally common in the general population, affecting up to 0.03% (Baslet et al., 2016). However, it's thought that 25% of individuals who are diagnosed with epilepsy but who do not respond to drug therapy actually have PNES instead (Epilepsy Foundation, 2007). As well, some suggest that the prevalence of PNES in American epilepsy clinics is rising. Some epilepsy units may find that up to half of the individuals seeking their help have psychogenic seizures. One potential problem is "social contagion," the risk that if one or more individuals are seen displaying symptoms of PNES, other susceptible individuals might begin manifesting symptoms of PNES (John Hopkins, 2012). However, it is important to note that between 10 to 30% of individuals with PNES also have epilepsy or a history of epileptic seizures. Learning to distinguish between epileptic and psychogenic seizures can be an important part of treatment for these individuals (Baslet et al., 2016; Benbadis & Heriaud, n.d.).

Treatment for PNES often involves therapy, particularly eye movement desensitization and reprocessing (EMDR) for those who experienced trauma (Epilepsy Foundation, 2007) and cognitive behavioral therapy (CBT) in general (Baslet et al., 2016). Over half of those with PNES can eventually become seizure free, and the prognosis is even better for children and teens. Early diagnosis also improves prognosis, which means it's very important to be able to recognize the true cause of individuals' apparent seizures and distress (Benbadis & Heriaud, n.d.). Unfortunately, it takes an average of 5 to 7 years for individuals with PNES to be correctly diagnosed. Additionally, even after diagnosis, 26% of individuals with PNES will still suffer from psychogenic seizures or other psychosomatic symptoms 5 years later. One major problem is that up to 30% of individuals with PNES do not follow through on psychiatric care. Other sources of symptom maintenance or worsening may be an individual refusing to accept the diagnosis, lacking social support, receiving social security benefits for the seizures, or identifying with the "disabled" role (Baslet et al., 2016).

Seizures and Dissociative Disorders

As stated, individuals with DID, OSDD, or PTSD may be especially vulnerable to dissociative seizures. Studies have shown that around 10 to 15% of individuals with DID may have psychogenic seizures compared to around 10% who have epileptic seizures. There is some evidence that switching between alters may be accompanied by changes in brain activity, such as differences in evoked potentials (electrical brain activity in response to stimuli such as light). In some cases, dissociative trance episodes that include unresponsiveness may be mislabeled as complex partial seizures, but these episodes are due to neither epilepsy nor psychogenic seizures (Bowman & Coons, 2000).

In one study of 45 individuals with psychogenic seizures, 62% were diagnosed with DDNOS (what is now known as OSDD), 16% with DID, and 13% with dissociative amnesia (Bowman & Coons, 2000). In other studies, the rate of dissociative amnesia in this population has been as high as 80% (Bowman & Markand, 2005).  When compared to individuals with epilepsy using the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D), individuals with dissociative seizures are more likely to be amnesiac for childhood, to have amnesia in their adult life that is unassociated with seizure events, to suffer from depersonalization, and to have symptoms of identity confusion and alteration. However, only dissociative amnesia was rated as severe rather than mild or moderate for individuals with PNES, and derealization was not shown to differ between the two groups. Other studies have shown that Dissociative Experiences Scale (DES) scores for individuals with psychogenic seizures do not significantly differ from those with epilepsy (Bowman & Coons, 2000).

Sources

American Psychiatric Association. (2013). Dissociative Disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). http://dx.doi.org/10.1176/appi.books.9780890425596.dsm08

Baslet, G., Seshadri, A., Bermeo-Ovalle, A., Willment, K., & Myers, L. (2016). Psychogenic non-epileptic seizures: An updated primer. Psychosomatics, 57(1), 1-17.

Benbadis, S. R. & Heriaud, L. (n.d.). Psychogenic (non-epileptic) seizures [Fact sheet]. Retrieved from http://hsc.usf.edu/COM/epilepsy/PNESbrochure.pdf

Bowman, E. S. & Coons, P. M. (2000). The differential diagnosis of epilepsy, pseudoseizures, dissociative identity disorder, and dissociative disorder not otherwise specified. Bulletin of the Menninger Clinic, 64(2), 164-180.

Bowman, E. S. & Markand, O. N. (2005). Diagnosis and treatment of pseudoseizures. Psychiatric Annals, 35(4), 306-316.

Epilepsy Foundation. (2007, November 1). The truth about psychogenic nonepileptic seizures. Retrieved from http://www.epilepsy.com/article/2014/3/truth-about-psychogenic-nonepileptic-seizures

Epilepsy Society (2017, July). Non-epileptic seizures. Retrieved from https://www.epilepsysociety.org.uk/non-epileptic-seizures

John Hopkins. (2012, April 10). Symptoms that mimic epilepsy linked to stress, poor coping skills. Retrieved from http://www.hopkinsmedicine.org/news/media/releases/symptoms_that_mimic_epilepsy_linked_to_stress_poor_coping_skills