Pseudoseizures (PNES)

Walker Foland is an emergency physician practicing in Michigan and in this episode breaks down why pseudoseizures, now termed PNES (Psychogenic Nonepileptic Seizures), are a real disease.

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Are patients with PNES ‘faking it’?

PNES is a conversion disorder: an unconscious manifestation of psychological trauma.
Walker treats PNES patients with haloperidol or olanzapine with the thinking that this is psychological, not true epilepsy
PNES is not ‘faking it’ or lying

Challenges

Patients with PNES may also have true epileptic seizures
Diagnosing PNES, or separating it from epilepsy, may take video EEG monitoring, a neurologist, and sometimes prolonged periods of time to figure things out

How to tell the difference between an grand mal epileptic seizure vs PNES vs faking it?

PNES

Seizures related to a specific stimulus (sound foods, body movement)
Frequency and amplitude of concussions: same frequency through the seizure with varying amplitude.
Maintenance of consciousness and may have some of the below
- may guard the face with passive hand drop
- resist eyelid opening
- visual fixation on a mirror
- Whit Fisher, Dr Procedurettes, squirts water in the face of patients where there is thought of PNES. If they grimace, probably not an epileptic seizure.

Faking Seizures

Talking
Purposeful movement
Avoids injury
May use convulsions as a way of harming staff
Intermittently awake and vocal during the episode

Epileptic seizure

Convulsive frequency decreases, amplitude increases as seizure progresses
No response to pain
Allow passive eye opening

A 2010 article from the Journal of Neurology Neurosurgery and Psychiatry broke down the evidence of what other elements can help distinguish PNES from epileptic seizures.

Duration over 2 minutes suggests PNES, but we’ve all seen epileptic seizures last for a long time, status, and some PNES can be super short
Happens in sleep. Evidence suggests that if the event happens in sleep, that is probably episode. PNES episodes happen when awake
Fluctuating course such as a pause in the rhytmic movement, epileptic seizures usually don’t pause and then restart, a pause favors PNES
Flailing. You’d think the flailing patient has PNES for sure because epilepsy doesn’t flail, but it does! Flailing is much more common in PNES, but not so much so that it’s a clear distinguishing factor
Urinary incontinence, more common in epilepsy, but does happen in PNES.
Post-ictal recovery period. Surely, this is the sine qua non of epilepsy. It is way way more common following generalized epileptic seizures but happens in around 15% of PNES.
The sterterous breathing (noisy, labored) that we see after generalized tonic clonic epileptic seizures suggests epilepsy and is not a characteristic of PNES

Walker’s take home points

PNES patients aren’t ‘faking it’
This is a real disorder, it's just not epilepsy

References

Chen, David K., and W. Curt LaFrance Jr. "Diagnosis and treatment of nonepileptic seizures." CONTINUUM: Lifelong Learning in Neurology 22.1, Epilepsy (2016): 116-131. PMID:26844733

Avbersek, Andreja, and Sanjay Sisodiya. "Does the primary literature provide support for clinical signs used to distinguish psychogenic nonepileptic seizures from epileptic seizures?." Journal of Neurology, Neurosurgery & Psychiatry 81.7 (2010): 719-725.Full Text PMID:20581136

Shen, Wayne, Elizabeth S. Bowman, and Omkar N. Markand. "Presenting the diagnosis of pseudoseizure." Neurology 40.5 (1990): 756-756. Full Text PMID:2330101