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