Psychogenic non epileptic events

Psychogenic non epileptic events Dr. M.Almohammadi

Outlines • Definition • Is it a problem • Epidemiology • Etiology • Presentation • investigations • Diagnosis • Management • prognosis

Definition • Paroxysmal psychological events that mimic epileptic seizures • Has various terms pseudoseizures Non epileptic seizures Non epileptic events Psychogenic seizures Psychogenic attacks{events}

Is it a problem? • Misdiagnosis occurs in approximately 25% of patients with a previous diagnosis of epilepsy that does not respond to drugs. • PNES is by far the most commonly misdiagnosed condition, accounting for >90% of misdiagnoses at epilepsy centers • Comorbidity presence of both epilepsy & pnes • Benbadis SR, Tatum WO. Overintepretation of EEGs and misdiagnosis of epilepsy. J Clin Neurophysiol. Feb 2003;20(1):42-4. [Medline]. • Benbadis SR, Lin K. Errors in EEG interpretation and misdiagnosis of epilepsy. Which EEG patterns are overread?. Eur Neurol. 2008;59(5):267-71. [Medline]. • Benbadis SR. Errors in EEGs and the misdiagnosis of epilepsy: importance, causes, consequences, and proposed remedies. Epilepsy Behav. Nov 2007;11(3):257-62. [Medline].

Epidemiology • 20-30% of patient referred for refractory seizures • 3-33 per100,000population • More in young adulthood&old age • More in women 70% than men • Prevalent as MS Trigeminal neuralgia more in our homeland

Etiology • theories • psycho analytic( 1ry gain&2ry gain) • Social theory(family discord ,stressors, abuse) • Behavioral theory (modeling) • Cognitive theory(communication)

Presentation • marked involvement of the truncal muscles with opisthotonos • lateral rolling of the head or body is present • 4 limbs may exhibit random thrashing movements • Bicycling limb movements • Shouting , stuttering, weeping • Happened in presence of audience. waiting room physician office • Intensified by holding of bystanders

ComparisonPnes&Epil.seizures Pnes Epileptic seizure • Cyanosis is rare • Tongue biting -ve • incontinence –ve • In presence of others • Injury rare • Long duration • Labelle indifference • Eyes closed, flickering • Increase by others holding • Recovered immediately after sei • EEG mostly negative • Video EEG negative • Common • Frequent • Frequent • Alone &others presence • Injury more frequent • Short duration few minutes • Stressed • Opened • No • Drowsy ,confused post ictal • Mostly positive • positive

Investigations • EEG • CT • MRI • Video EEG

Inter episodic EEG of pnes

Unipolar montage for patient with pnes Records of these 2female young patient s are confusing unless you haven't seen the patients talking full history and detail description about the seizures

Diagnosis • Pay more attention to history -abuse -family discord • Look for triggers - emotional -stressors • Comorbid psychiatric disorders -anxiety -depression -others • Presentation during suggestion • Inter-ictal EEG • Video EEG

Treatment • Delivering diagnosis to patient &family • Disbeliefs -patient -family, -referral sour • anger • hostility • Family&patient education • Psychotherapy • Cognitive-behavioral therapy • Medication(SSRIs) depression and anxiety

Prognosis • Unfavorable outcome • Long duration 7 years and more • Adult subject • Mores somatic symptoms • Long duration on AEDs

Thanks for your attention

Psychogenic non epileptic events