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Nonepileptic Behavioral
Address correspondence to
Dr Selim R. Benbadis,
University of South Florida
and Tampa General Hospital.
KEY POINTS
h Psychogenic nonepileptic such as psychogenic nonepileptic high enough index of suspicion. This
events or episodes are events or episodes (PNEE), which will article will first review the steps involved
very commonly seen be used here.3,4 Psychogenic simply in making the diagnosis and then turn
at epilepsy centers, means ‘‘generated by the psyche’’ or to management considerations.
where patients with ‘‘of psychological origin’’ and does
psychogenic nonepileptic not imply a specific type of psychological SUSPECTING THE DIAGNOSIS
events or episodes disturbance or diagnosis (eg, somatoform, The diagnosis is initially suspected in
represent about 30% conversion, dissociative, factitious, ma- the clinic on the basis of the history
of those referred for lingering, or anxiety disorder). and examination. A number of ‘‘red
refractory seizures. In PNEE are very commonly seen at flags’’ are useful and should raise the
addition to being
epilepsy centers, where patients with suspicion that so-called seizures may
common, psychogenic
PNEE represent about 30% of those be psychogenic rather than epileptic
nonepileptic events or
episodes may represent
referred for refractory seizures.1 In ad- (Table 8-1). Of course, resistance to
a challenge in diagnosis dition to being common, PNEE may antiepileptic drugs (AEDs) is usually
and management, represent a challenge in diagnosis and the reason for referral to the epilepsy
and many health care management, and many health care center, but the features shown in
professionals are professionals are uncomfortable deal- Table 8-1 should raise the suspicion
uncomfortable dealing ing with them. In addition, regardless that the episodes in question may be
with them. of the condition that was misdiagnosed psychogenic rather than indicative of
h Despite the ability to as seizures (psychogenic or not), the intractable epilepsy. Knowledge of the
make a diagnosis of misdiagnosis of epilepsy has serious circumstances in which attacks occur
psychogenic consequences. Unfortunately, a diag- can be very helpful. Like other psy-
nonepileptic events nosis of seizures is easily perpetuated chogenic symptoms, PNEE tend to
or episodes with near without being questioned and is diffi- occur in the presence of an audience,
certainty, the average cult to undo, which explains the usual and occurrence in the physician’s office
delay in diagnosis diagnostic delay5,6 and its cost.7 De- or the waiting room or during the
remains long at about
spite the ability to make a diagnosis of examination is suggestive of PNEE.8 A
7 to 10 years.
PNEE with near certainty, the average detailed description of the events
delay in diagnosis remains long at often includes characteristics that are
about 7 to 10 years,5,6 which suggests inconsistent with epileptic seizures.
that treating neurologists do not have a However, description by witnesses may
that may lack characteristic EEG tioned21 but remains high in predicting
changes. Ictal EEG has limitations be- PNEE,22 especially when prolonged
cause it may be negative in some partial and with complete unresponsiveness.
seizures, especially those without alter- Most patients with PNEE show more
ation of awareness.19,20 Ictal EEG may than one of these behavioral character-
also be uninterpretable or difficult if istics, often making the diagnosis rel-
movements generate excessive artifact atively easy. A simple and practical
(see below under Pitfalls of Video EEG). semiologic classification divides PNEE
Analysis of the ictal semiology (ie, into six types: rhythmic motor, hyper-
video) is at least as important as the motor, complex motor, dialeptic, sub-
ictal EEG because the video often jective, and mixed.23 The presentation
shows behaviors that are obviously as limp immobile unresponsiveness
nonorganic and incompatible with with eyes closed (ie, pseudosyncope)
epileptic seizures. The most important presents unusual challenges, because
behavioral features of PNEE are shown such patients often see cardiologists
in Table 8-2. None of these features rather than neurologists and are rarely
has 100% specificity or is completely sent for video-EEG monitoring. Many
diagnostic, and all should be interpreted cases of ‘‘syncope of unknown origin’’
with caution. For example, preserved could possibly be undiagnosed psycho-
awareness during bilateral motor activ- genic episodes.24 When recorded in
ity is very useful because unrespon- the epilepsy monitoring unit (EMU),
siveness is almost always present during the diagnosis of psychogenic syncope
epileptic bilateral motor activity, al- is not difficult, because these episodes
though a notable exception is supple- can be induced by suggestion whereas
mentary motor area seizures. Similarly, true syncope shows a reliable series of
the value of eye closure has been ques- ictal EEG changes.24
b Pseudosleep
b Discontinuous (stop-and-go) activity
b Irregular or asynchronous (out-of-phase) activity including side-to-side
head movement
b Nonclonic shaking with variable rhythm and direction
b Pelvic thrusting
b Opisthotonic posturing
b Stuttering
b Weeping
b Preserved awareness during bilateral motor activity
b Ictal eye closure
b Prolonged immobile unresponsiveness with eyes closed (pseudosyncope)
b Postictal whispering or other partial motor responses
KEY POINTS
h Many patients with changes are those without impairment curate. A negative EEG can only be
psychogenic nonepileptic of awarenessVthat is, ‘‘simple partial’’ interpreted in the context of the
events or episodes seen seizures having purely subjective phe- semiology of the attack in question.
at epilepsy centers have nomena (ie, auras). Motor simple Therefore, both the video and EEG
had previous EEGs, and partial seizures may include focal must be availableVin fact the diagno-
often at least one of clonic seizures and brief tonic sei- sis would probably be more accurate
these was interpreted zures, typically of frontal lobe origin; with video alone than with EEG alone.
as epileptiform. they are usually brief (5 to 30 seconds) When used properly, video EEG al-
h When reviewed, the and tonic, or may be hypermotor, but lows the diagnosis of paroxysmal
vast majority of not usually as dramatically flailing or seizurelike events, and in particular
EEGs interpreted as thrashing as PNEE. If multiple episodes the diagnosis of PNEE, with a high
epileptiform in patients are recorded, stereotypy (ie, highly degree of confidence. A study of the
with psychogenic similar behavioral features between inter-rater reliability of the diagnosis
nonepileptic events or seizures) is a feature that strongly by video EEG, sampling a group of
episodes will turn out to
suggests epileptic seizures rather than epileptologists, found a good inter-
show overinterpreted
PNEE. Ictal EEG may be uninterpretable rater agreement,17 indicating that
normal variants.
if movements generate excessive arti- there is a certain component of sub-
fact. In those situations, it can be im- jective artful judgment. Results also
possible to ‘‘prove’’ that such episodes confirmed that there was very good
are psychogenic. For example, brief epi- agreement on the vast majority of
sodes of déjà vu or fear or tonic stiffening cases, which indicates that the merely
with no EEG changes can never be ‘‘good’’ agreement was accounted for
proven to be psychogenic. Arguments by a small handful of difficult cases.
in favor of PNEE include suggestibility
(triggered by placebo maneuvers), or DIFFICULT AND SPECIAL ISSUES
events that never progress to clear IN DIAGNOSIS
seizures. Lastly, PNEE episodes do not Previous Abnormal EEG
occur during sleep, so attacks that arise A very common problem, illustrated in
out of EEG-verified sleep may reliably Case 8-1, is previous abnormal EEG
be diagnosed as organic (ie, epileptic results. Many patients with PNEE seen
seizures or parasomnias). Epileptic sei- at epilepsy centers have had previous
zures with altered awareness and no EEGs, and often at least one was
EEG changes are very rare but exist, and interpreted as epileptiform. In this
if the clinical events are strongly sug- situation, illustrated by Case 8-2, it is
gestive of seizures, it is best to err on essential to obtain and review the actual
the side of treating them as epileptic. tracing previously read as epileptiform,
Of course, nonepileptic does not since no amount of normal subsequent
always mean psychogenic, and other EEGs will invalidate the supposedly
diagnoses must be considered before abnormal one. When reviewed, the vast
making a diagnosis of PNEE.1 Com- majority will turn out to show over-
mon nonepileptic organic causes to interpreted normal variants.34 By far the
consider are syncope and paroxysmal most common errors in EEG interpreta-
movement disorders for episodes that tion, and the main source of over-reading,
occur while awake and parasomnias are benign temporal sharp transients
for episodes that occur in sleep. or wicket rhythms that are read as tem-
A common misconception is that a poral spikes. The same errors in diag-
recorded episode with a negative EEG nosis occur for benign, nonspecific
is all it takes to make a diagnosis of episodic symptoms not even sugges-
PNEE. This is of course grossly inac- tive of seizures (eg, lightheadedness,
720 www.ContinuumJournal.com June 2013
Case 8-2
A 46-year-old woman was diagnosed (with video EEG) with clear psychogenic nonepileptic
events or episodes (PNEE) but had a prior EEG that reportedly ‘‘showed epilepsy.’’ The report
indicated ‘‘rare right temporal spikes,’’ so a doubt about coexisting epilepsy persisted. With
some difficulties (eg, software compatibility), the author was able to obtain and view the
EEG in question, and the ‘‘spikes’’ are shown here (Figure 8-1). These benign fluctuations on
background activity in the temporal region are the most common over-read patterns
(see reference 34 for further discussion).
FIGURE 8-1 Routine bipolar ‘‘double banana’’ montage. This sample shows the benign sharp transient with
phase reversal at T4, which was over-read as a ‘‘spike.’’
better characterized as behavioral. Pan- PNEE than they are for other psycho-
ic attacks are paroxysmal manifestations genic symptoms.71
of anxiety or panic disorder, typically Psychogenic (ie, nonorganic, ‘‘func-
include intense autonomic symptoms tional’’) symptoms are common in
(especially cardiovascular and respira- all of medicine. Conservative esti-
tory in nature), and may be mistaken for mates consider that at least 10% of
seizures.67 In these attacks, abrupt, all medical services are provided for
intense fear is accompanied by at least psychogenic symptoms.25 Common
four of the following symptoms: palpi- neurologic symptoms that are found
tations, diaphoresis, tremulousness or to be psychogenic include paralysis,
shaking, shortness of breath or sensa- mutism, visual symptoms, sensory
tion of choking, chest discomfort, symptoms, movement disorders, gait
nausea or abdominal discomfort, dizzi- or balance problems, and pain. Several
ness or lightheadedness, derealization neurologic symptoms, signs, or ma-
or depersonalization, fear of losing neuvers have been described to help
control, fear of dying, paresthesias, differentiate organic from nonorganic
and chills or hot flashes. The symp- symptoms. Among psychogenic symp-
toms typically peak within 10 minutes. toms, PNEE are unique in one princi-
Other manifestations of anxietyVsuch pal characteristic: with video-EEG
as agoraphobia, social phobia, and de- monitoring, they can be diagnosed
pressive disorderVoften coexist with with near certainty. This is in sharp
panic disorder. Similarly, if the symp- contrast to other psychogenic symp-
toms of post-traumatic stress disorder toms, which are almost always a
resemble seizures, they can be viewed diagnosis of exclusion. This feature
as a variant of PNEE and lead to a allows a clarity and confidence of
misdiagnosis.68 Unusual repetitive and diagnosis that may assist in the critical
purposeless behaviors or mannerisms step of convincing the patient and his
are common in neurologically impaired or her family of the nonorganic nature
patients,65,69 and abnormal motor be- of the PNEE. Once the diagnosis of
haviors are often observed in the PNEE has been established by video
intensive care unit.70 Rather than truly EEG, the role of the neurologist is to
psychogenic, these manifestations are convey the diagnosis clearly and com-
often simply misinterpreted by fami- passionately and to mediate referral
lies and physicians and are easily diag- for mental health management. Un-
nosable with video-EEG recordings. fortunately, difficulty in access to ap-
propriate mental health management
CONCLUSION: A MORE GENERAL of somatoform or somatic symptom
PERSPECTIVE ON PSYCHOGENIC disorders remains a vexing and frus-
SYMPTOMS trating limitation for clinicians and
The literature on PNEE often implies patients with PNEE alike.
that they represent a unique disorder.
In reality, PNEE are but one type of USEFUL WEBSITES
somatoform disorder. How the psy-
PNEE Patient Information brochure.
chopathology is expressed (seizurelike
health.usf.edu/NR/rdonlyres/C4AD7955-
episodes, paralysis, diarrhea, or pain)
E93A-4702-BB3A-C5F5A5381B44/0/
is only different in the diagnostic
PNESbrochure.pdf
aspects. Fundamentally, the underly-
ing psychopathology and its prognosis American Psychiatric Association.
and management are no different for www.psych.org.
726 www.ContinuumJournal.com June 2013
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