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

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

Pnes Epileptic seizure

Investigations

EEG

CT

MRI

Video EEG

Inter episodic EEG of 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

Unipolar montage for patient with pnes

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