PSYCHOGENIC NON-EPILEPTIC SEIZURES

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PSYCHOGENIC NON-EPILEPTIC SEIZURES L.L. Hryhorczuk, M.D. September 28, 2013

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PSYCHOGENIC NON-EPILEPTIC SEIZURES. L.L. Hryhorczuk, M.D. September 28, 2013. DEFINITIONS. PAROXYSMAL NONEPILEPTIC EPISODES ORGANIC – SYNCOPE,MIGRAINE, TRANSIENT ISCHEMIC ATTACKS (TIAs) PSYCHOLOGIC-PSYCHOGENIC NON-EPILEPTIC SEIZURES (PNES) SYNONYMS FOR PSYCHOGENIC NON-EPILEPTIC SEIZURES - PowerPoint PPT Presentation

Transcript of PSYCHOGENIC NON-EPILEPTIC SEIZURES

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PSYCHOGENIC NON-EPILEPTIC SEIZURES

L.L. Hryhorczuk, M.D.September 28, 2013

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DEFINITIONS

PAROXYSMAL NONEPILEPTIC EPISODES• ORGANIC – SYNCOPE,MIGRAINE, TRANSIENT ISCHEMIC ATTACKS (TIAs)• PSYCHOLOGIC-PSYCHOGENIC NON-EPILEPTIC SEIZURES (PNES)

SYNONYMS FOR PSYCHOGENIC NON-EPILEPTIC SEIZURES• PSEUDOSEIZURES• PSYCHOGENIC SEIZURES• NON-EPILEPTIC SEIZURES• NON-EPILEPTIC EVENTS

PREFERRED TERM FOR PATIENTS AND FAMILIES• PSYCHOGENIC NON-EPILEPTIC EVENTS

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PSYCHIATRIC DIAGNOSES OF PNES

DSM IV-R

•SOMATOFORM DISORDERS CONVERSION DISORDER WITH SEIZURES OR CONVULSIONS

CRITERIA:1. SYMPTOM AFFECTING MOTOR/SENSORY SYSTEM SUGGESTING

NEUROLOGIC /MEDICAL CONDITION2. PSYCHOLOGICAL FACTORS ASSOCIATED BECAUSE SYMPTOM IS

PRECEDED BY CONFLICT/STRESSOR3. SYMPTOM IS NOT INTENTIONALLY PRODUCED4. SYMPTOM CANNOT BE EXPLAINED BY A MEDICAL CONDITION5. SYMPTOM CANNOT BE EXPLAINED BY A SUBSTANCE EFFECT6. SYMPTOM CANNOT BE EXPLAINED BY A CULTURAL BEHAVIOR

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PSYCHIATRIC DIAGNOSIS OF PNESCONTINUED

SOMATIZATION DISORDERCRITERIA:1. HISTORY OF MULTIPLE COMPLAINTS BEGINNING BEFORE

AGE 302. 4 PAIN SYMPTOMS3. 2 GASTROINTESTINAL SYMPTOMS4. 1 SEXUAL SYMPTOM5. ONE PSEUDONEUROLOGICAL SYMPTOM SUCH AS SEIZURE 6. SYMPTOM CANNOT BE EXPLAINED BY A MEDICAL

CONDITION OR DIRECT EFFECT OF A SUBSTANCE

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PSYCHIATRIC DIAGNOSIS OF PNESCONTINUED

• FACTITIOUS DISORDERSWITH PREDOMINANTLY PHYSICAL SIGNS AND SYMPTOMSWITH COMBINED PSYCHOLOGICAL AND PHYSICAL SIGNS AND SYMPTOMS CRITERIA:

1. INTENTIONAL PRODUCTION OF PHYSICAL/PSYCHOLOGICAL SYMPTOMS2. MOTIVATION FOR BEHAVIOR TO ASSUME A SICK ROLE FOR SELF/OTHER3. EXTERNAL INCENTIVES FOR BEHAVIOR ARE ABSENT

• MALINGERING CRITERIA:

1. MEDICOLEGAL CONTEXT OF PRESENTATION2. MARKED DISCREPANCYCLAIMED DISABILITY AND FINDINGS3. LACK OF COOPERATION WITH EVALUATION/TREATMENT4. PRESENCE OF ANTISOCIAL PERSONALITY DISORDER

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PSYCHIATRIC DIAGNOSIS OF PNESCONTINUED

DSM V

•SOMATIC SYMPTOM AND RELATED DISORDERS FUNCTIONAL NEUROLOGICAL SYMPTOM DISORDER SOMATIC SYMPTOM DISORDER

•FACTITIOUS DISORDERS FACTITIOUS DISORDER IMPOSED ON SELF FACTITIOUS DISORDER IMPOSED ON ANOTHER

•MALINGERING

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CONSEQUENCES AND COSTS FOR MISDIAGNOSIS OF PNES

PATIENT CONSEQUENCES• PATIENTS WITH PNES USUALLY TAKE ANTIEPILEPTIC DRUGS UNNECESSARILY FOR

MANY YEARS BEFORE THE DIAGNOSIS IS REVISED.• THIS EXPOSES PATIENTS TO UNTOWARD EFFECTS OF MEDICATION WITH NO

BENEFIT TO THEM WHATSOEVER.• A SMALL NUMBER RECEIVE IV MEDICATIONS FOR STATUS EPILEPTICUS THAT

MAY HAVE RESULTED IN INTUBATION AND POSSIBLE ADMISSION TO ICU.• THIS LEVEL OF MEDICAL CARE HAS EXPOSED THE PATIENT AND FAMILY TO A

HIGH LEVEL OF STRESS WITH NO PROSPECT OF RELIEF FROM THE PROBLEM.

UNNECESSARY MEDICAL COSTS• NEUROLOGIST SERVICES• MEDICATION• ELECTROENCEPHALOGRAMS• EXTENDED EEG MONITORING AND VIDEO MONITORING• IMAGING STUDIES• INPATIENT HOSPITAL DAYS

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EPIDEMIOLOGY OF PNES

FREQUENCY•PREVALENCE IN THE UNITED STATES AND WORLD ARE SIMILAR•20 TO 30% OF REFERRALS TO EPILEPSY CENTERS ARE PNES•50 TO 70% BECOME SEIZURE FREE AFTER DIAGNOSIS•15% ALSO HAVE A COMORBID SEIZURE DISORDER

GENDER•WOMEN 70% OF DIAGNOSED PNES•MEN 30% OF DIAGNOSED PNES

AGE•TYPICALLY BEGIN IN YOUNG ADULTHOOD•CAN OCCUR IN CHILDREN AND ELDERLY•IN THESE AGE GROUPS NON-EPILEPTIC PHYSIOLOGIC EVENTS ARE MORE COMMON

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MISDIAGNOSIS OF PNES

• MISDIAGNOSIS OF EPILEPSY IS COMMON• 25% OF PATIENTS WITH A PREVIOUS DIAGNOSIS OF EPILEPSY WHO DO

NOT RESPOND TO DRUGS ARE MISDIAGNOSED• PNES ACCOUNTS FOR 90% OF MISDIAGNOSED PATIENTS • OTHER CONDITIONS INCLUDE PAROXYSMAL EVENTS LIKE SYNCOPE • EEGS MISINTERPRETED AS PROVIDING EVIDIENCE FOR EPILEPSY

CONTRIBUTE TO THIS PROBLEM• REVERSING A DIAGNOSIS CAN BE VERY DIFFICULT• DIAGNOSIS IS OFTEN PERPETUATED WITHOUT QUESTION• DELAY IN MAKING THE CORRECT DIAGNOSIS OFTEN TAKES 7 TO 10

YEARS

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SUGGESTIVE PNES PRESENTATION

• RESISTANCE TO ANTIEPILEPTIC DRUGS (AED)

• PRESENCE OF SPECIFIC TRIGGERS LIKE CONFLICT, UPSET OR STRESS

• OTHER TRIGGERS LIKE PAIN, SOUNDS, SPECIFIC MOVEMENTS/ LIGHT

• UNUSUAL CIRCUMSTANCES LIKE ALWAYS IN THE PRESENCE OF AN AUDIENCE OR IN A DOCTOR’S OFFICE

• USUALLY DO NOT OCCUR DURING SLEEP

• CHARACTERISTICS OF EVENT ARE INCONSISTENT WITH EPILEPSY, SUCH AS SIDE-TO-SIDE HEAD SHAKING, BICYCLING, WEEPING, STUTTERING AND ARCHING OF THE BACK

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SUGGESTIVE PNES PRESENTATIONCONTINUED

• COMORBID DIAGNOSES LIKE FIBROMYALGIA, CHRONIC PAIN, CHRONIC FATIGUE OR A FLORID REVIEW OF SYSTEMS

• PSYCHOSOCIAL HISTORY OF MALADAPTIVE BEHAVIOR OR OTHER PSYCHIATRIC DIAGNOSES

• PATIENT’S DEMEANOR OF OVERDRAMATIZATION OR LACK OF CONCERN

• HISTORY OF SEXUAL TRAUMA OR PHYSICAL ABUSE WITH EPISODES MORE OFTEN CONVULSIVE THAN LIMP IN PNES

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PREDICTABLE DIFFERENCES

EPILEPTIC SEIZURE•ABRUPT ONSET•LOSS OF AWARENESS•EYE OPENING/WIDENING•TONGUE BITING OR ICTAL CRY SPECIFIC TO GENERALIZED TONIC-CLONIC SEIZURES

PSYCHOGENIC NON-EPILEPTIC SEIZURE•PRESERVED AWARENESS•EYE FLUTTER•EPISODES INTENSIFIED OR ALLEVIATED BY OBSERVERS•ABLE TO BE PROVOKED BY AN INDUCTION TECHNIQUE

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DIFFERENTIAL DIAGNOSIS

• ABSENCE SEIZURES• BRAINSTEM GLIOMAS• COMPLEX PARTIAL SEIZURES• DIZZINESS, VERTIGO AND IMBALANCE• EPILEPSY IN ADULTS WITH COGNITIVE IMPAIRMENT• EPILEPSY IN CHILDREN WITH COGNITIVE DELAY• EPILEPTIFORM DISCHARGES• FOCAL EEG WAVEFORM ABNORMALITIES• FRONTAL LOBE EPILEPSY• JUVENILE MYOCLONIC EPILEPSY• MYASTHENIA GRAVIS• STATUS EPILEPTICUS

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PHYSICAL EXAMINATION

PHYSICAL AND NEUROLOGIC EXAMINATIONS USUALLY NORMALSUGGESTIVE FEATURES

• OVERLY DRAMATIC BEHAVIOR• GIVE AWAY WEAKNESS• WEAK VOICE• STUTTERING

MENTAL STATUS EXAMINATIONSUGGESTIVE FEATURES

• ANXIETY• DEPRESSION• INAPPROPRIATE AFFECT• LACK OF CONCERN (LA BELLE INDIFFERENCE)

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MEDICAL WORKUP

LABORATORY STUDIES• STUDIES TO EXCLUDE METABOLIC/TOXIC CAUSES (HYPONATREMIA, HYPOGLYCEMIA, DRUGS)• PROLACTIN AND CREATINE KINASE LEVELS THAT MAY RISE AFTER

GENERALIZED CLONIC-TONIC SEIZURES

IMAGING STUDIES• IMAGING STUDIES ARE NORMAL IN PNES• INCIDENTAL FINDINGS SHOULD NOT CONFOUND THE DIAGNOSIS OF

PNES

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MEDICAL WORKUPCONTINUED

EEG AND AMBULATORY EEG• ROUTINE EEG HAS A LOW SENSITIVITY BUT REPEATED NORMAL RESULTS

WITH REPEATED ATTACKS AND RESISTANCE TO MEDICATION IS A RED FLAG• AMBULATORY EEG IS USED MORE FREQUENTLY , IS COST EFFECTIVE AND

CAN RECORD A HABITUAL EPISODE DOCUMENTING NO EEG CHANGES

EEG VIDEO MONITORING• CRITERION STANDARD FOR DIAGNOSIS AND INDICATED FOR PATIENTS WHO

HAVE FREQUENT SEIZURES DESPITE MEDICATION• PRINCIPLE IS TO RECORD AN EVENT AND DEMONSTRATE NO EEG CHANGES• EEG HAS LIMITATIONS BECAUSE OF OCCASIONAL FALSE NEGATIVE RESULTS

OR MOVEMENTS CAUSING EXCESSIVE ARTIFACT• ANALYSIS OF THE VIDEO (ICTAL SEMIOLOGY) IS AS IMPORTANT AS EEG

BECAUSE IT SHOWS BEHAVIORS INCOMPATIBLE WITH EPILEPTIC SEIZURES• USEFUL SIGN IS PRESERVED AWARENESS DURING BILATERAL MOTOR

ACTIVITY A SPECIFIC INDICATION OF PNES

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MEDICAL WORKUPCONTINUED

SHORT TERM OUTPATIENT EEG VIDEO MONITORING WITH ACTIVATION

• COST EFFECTIVE WITH SAME SPECIFICITY AS OTHER TESTS AND HIGH SENSITIVITY

• TYPICAL EPISODE OBSERVED IN 70 TO 80% OF PATIENTS

INDUCTION• PROVOCATIVE TECHNIQUES ARE USEFUL WHEN DIAGNOSIS IS

UNCERTAIN AND NO SPONTANEOUS EPISODES OCCUR DURING MONITORING

• PRINCIPLE BEHIND INDUCTION IS SUGGESTIBILITY• INTRAVENOUS INJECTION OF SALINE WITH SUGGESTION IS

COMMONLY USED

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MEDICAL CARE OF PNES

PATIENT EDUCATION• MOST IMPORTANT STEP IS DELIVERING THE DIAGNOSIS TO THE

PATIENT AND FAMILY• PATIENT’S REACTION WILL BE DISBELIEF AND OFTEN ANGER

BECAUSE OF PREVIOUS ORGANIC DIAGNOSIS• MAY COMMENT “ARE YOU ACCUSING ME OF FAKING?” OR “ARE

YOU SAYING I’M CRAZY?”

WRITTEN INFORMATION• UNLESS PATIENT AND THEIR FAMILY UNDERSTAND THE DIAGNOSIS,

THEY WILL NOT FOLLOW THROUGH WITH TREATMENT• HANDOUT “PSYCHOGENIC (NON-EPILEPTIC) SEIZURES: A GUIDE FOR

PATIENTS A& FAMILIES”

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MEDICAL CARE OF PNESCONTINUED

OBSTACLES TO TREATMENT• PHYSICIANS ARE UNCOMFORTABLE WITH THE DIAGNOSIS OF

PNES AND MAY GIVE UNCLEAR EXPLANATIONS OR WRITE VAGUE REPORTS

• CLINICIANS RECEIVING THESE REPORTS DON’T FIND THEM HELPFUL AND THE PATIENT CONTINUES WITH THE DIAGNOSIS OF SEIZURE DISORDER

• DIAGNOSIS SHOULD BE EXPLAINED CLEARLY AS PSYCHOLOGICAL, STRESS INDUCED OR CAUSED BY EMOTIONS

• MOST PHYSICIANS ARE TIMID, UNCLEAR AND CONFUSING BECAUSE OF THEIR DISCOMFORT

• APPROACH NEEDS TO BE COMPASSIONATE BUT ALSO FIRM AND CONFIDENT

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MEDICAL CARE OF PNESCONTINUED

• TREATMENT IS PROVIDED BY A MENTAL HEALTH PROFESSIONAL • USE OF PSYCHOTROPIC MEDICATIONS TO TREAT COMORBID

ANXIETY AND DEPRESSIVE DISORDERS IS APPROPRIATE• PILOT STUDY USING SELECTIVE SEROTONIN INHIBITORS HAS SHOWN

A REDUCTION IN PNES• COGNITIVE BEHAVIORAL THERAPY HAS BEEN HELPFUL IN REDUCING

PNES• ACCESS TO MENTAL HEALTH SERVICES MAY BE DIFFICULT

PARTICULARILY FOR THE UNINSURED• IF A PSYCHIATRIST IS SKEPTICAL ABOUT THE DIAGNOSIS OF PNES, A

CONSULTATION WITH THE NEUROLOGIST TO VIEW THE VIDEO RECORDING MAY BE MORE HELPFUL THAN A WRITTEN REPORT

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CONSULTATIONS FOR PNES

INPATIENT CONSULTATION• NEUROLOGIST AND A ELECTRONIC VIDEO MONITORING UNIT

SHOULD WORK WITH A PSYCHIATRIST WHO UNDERSTANDS PNES• REFERRALS TO PSYCHOLOGISTS, MENTAL HEALTH SOCIAL WORKERS

AND MENTAL HEALTH NURSE PRACTITIONERS SHOULD BE MADE AT DISCHARGE FOR SUBSEQUENT PSYCHOTHERAPY

OUTPATIENT CONSULTATION• NEUROLOGIST NEEDS TO REMAIN INVOLVED WITH THE 15% OF PNES

PATIENTS WHO HAVE A COMORBID DIAGNOSIS OF SEIZURE DISORDER

• NEUROLOGIC CONSULTATION MAY BE NEEDED TO DEAL WITH PATIENTS WHO ARE RESISTIVE TO PSYCHIATRIC TREATMENT AND REQUIRE A “BOOSTER SESSION” REVIEWING THEIR FINDINGS AGAIN

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ACTIVITY RESTRICTIONS WITH PNES

• PATIENTS WITH PNES USUALLY DO NOT REQUIRE LIMITATIONS OF ACTIVITIES

• RECOMMENDATIONS REGARDING DRIVING VARY• PRELIMINARY STUDY WITH PNES PATIENTS SHOWED NO INCREASED

RISK OF MOTOR VEHICLE ACCIDENTS• RESTRICTIONS ON POTENTIALLY HAZARDOUS ACTIVITIES SUCH AS

SWIMMING OR CLIMBING MAY BE APPRORIATE FOR SOME PATIENTS• THE PSYCHIATRIST WISH TO SPEAK WITH THE NEUROLOGIST FOR

RECOMMENDATIONS

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PROGNOSIS FOR PNES

ADULTS

• DURATION OF ILLNESS IS THE MOST IMPORTANT PROGNOSTIC FACTOR IN PNES

• SYMPTOMS MORE THAN 10 YEARS, MORE THAN 50% CONTINUE WITH SEIZURES AND ARE DEPENDENT ON SOCIAL SECURITY BENEFITS

• PATIENTS WITH LIMP OR CATATONIC TYPE EVENTS HAVE A BETTER PROGNOSIS THAN THOSE WITH A CONVULSIVE OR THRASHING TYPE

• OUTCOMES IMPROVE WITH PATIENT EDUCATION, FEWER ADDITIONAL SOMATIC COMPLAINTS, NONDRAMATIC PRESENTATIONS, ONSET AND DIAGNOSIS AT A YOUNGER AGE

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PROGNOSIS FOR PNESCONTINUED

CHILDREN AND ADOLESCENTS• OUTCOMES ARE BETTER THAN WITH ADULTS BECAUSE OF SHORTER

DURATION OF THE ILLNESS• PHYSICAL/SEXUAL ABUSE AND SERIOUS MOOD DISORDERS ARE

MORE COMMON AND MAY COMPLICATE TREATMENT• PNES MAY LEAD TO SCHOOL REFUSAL AND FAMILY DISCORD THAT

REFERENCE: Selim R. Benbadis, M.D., “Psychogenic Nonepileptic Seizures” Medscape Reference Drugs, Diseases and Procedures updated March 19, 2013