Psychogenic Nonepileptic Seizures: An Overview

Psychogenic non-epileptic seizures (PNES), also referred to as pseudo-seizures, are sudden episodes that resemble epileptic seizures. PNES have a psychological cause and do not result from changes in brain activity, like epileptic seizures. PNES is a complex disorder that is difficult to diagnose and treat.

This article explains the condition and describes the symptoms and causes. It also addresses diagnosis and treatment options for PNES.

What Are Psychogenic Non-Epileptic Seizures?

Epileptic seizures are caused by changes in the electric activity of the brain, while non-epileptic seizures (NES) are caused by mental stress or a physical condition. PNES are non-epileptic seizures with a psychological cause.

The term "psychogenic non-epileptic seizures" describes the experience. People who have PNES often feel as if they are having seizures, although the episodes are not correlated with altered EEG activity. Many healthcare providers prefer to avoid using the term "pseudo-seizure" because it could imply that people who have this experience could be faking it or do not want to get better.

While the electrical activity in the brain is not the same as an epileptic seizure, a person suffering from pseudoseizures is not faking their symptoms. Typically, the spells are not voluntary (on purpose), cannot be deliberately controlled or stopped, and the seizure feels as real as an epileptic one.

PNES Symptoms

The symptoms of pseudo-seizures are similar to those of seizures, but there are some important distinctions. PNES more closely matches the stereotypical concept of a seizure than an epileptic seizure does. For example, seizures portrayed on television involve a person thrashing around with no particular pattern, but true epileptic seizures are usually rhythmic and brief.

• Preceding Events: PNES seizure-like activity can come on after an emotionally charged event, such as being fired from a job or arrested. Stress can trigger an epileptic seizure as well, which makes the distinction challenging.
• Duration: Seizures generally last for a few seconds, and are followed by a period of physical and mental exhaustion, lasting for up to 24 hours. Pseudo-seizures can last for a long time and may be followed by a full recovery.
• Convulsions: The convulsions of a pseudo-seizure tend to be more dramatic than convulsions of an epileptic seizure, but rarely cause physical injuries, while epileptic seizures can result in injuries.
• Loss of Bowel or Bladder Control: An epileptic seizure frequently causes loss of bowel or bladder control, drooling, or tongue biting. While this can happen during a pseudo-seizure, it is far less likely to occur. 

What Causes Psychogenic Nonepileptic Seizures?

Psychogenic seizures may occur in any age group. Women are three times more likely than men to have PNES. It is not always clear why someone develops PNES. The conditions associated with PNES are far more common than PNES, and most people who have these conditions do not experience pseudo-seizures.

Conditions associated with PNES include:

• History of Trauma: With PNES, there is frequently a history of abuse or sexual trauma, typically without proper therapy, support, or even acknowledgment of the traumatic events.
• Psychological Conditions: Pseudo-seizures are often thought of as a type of conversion disorder, which is a physical symptom or manifestation of a psychological condition. Some psychological conditions, such as borderline personality disorder, bipolar disorder, severe anxiety, and depression, are associated with PNES.
• Chronic Pain: Conditions that cause chronic, unrelenting pain, such as fibromyalgia, and chronic fatigue syndrome increase the probability of PNES.

Diagnosing Psychogenic Nonepileptic Seizures

Distinguishing between epilepsy and PNES is a challenge. PNES is often misdiagnosed as epilepsy. This makes the true cause of peculiar seizure-like activity very difficult to sort out. This grey area is stressful for patients and their loved ones, who may feel uncertain about whether the seizures will ever resolve.

There are a few strategies that help to distinguish epileptic seizures from PNES:

• Observation: Diagnosis is often based on observation, and experienced healthcare providers can usually tell the difference between an epileptic seizure and a pseudo-seizure. Often, unusual characteristics of the convulsions or stressful precipitating factors raise the possibility of pseudo-seizures. For example, when both sides of the body are involved in an epileptic seizure, the person loses consciousness, but this does not always happen with pseudo-seizures. A person having a pseudo-seizure can be distracted by loud noises, such as a fire alarm, or a fear of danger, which is not the case with epileptic convulsions.
• Medication Response: People who suffer from pseudo-seizures are often resistant to anti-epileptic medication.
• Electroencephalogram (EEG): The most reliable way to distinguish a psychogenic from an epileptic seizure is to use an EEG that records the electrical activity of the brain. Epileptic seizures cause patterns on an EEG that are not seen during a psychogenic seizure, and the EEG often shows slowing of electrical activity after a seizure that is not seen with pseudoseizures. Often, people with epilepsy have minor alterations on EEG even in between seizures or when seizure-free.

How Do You Stop a Psychogenic Nonepileptic Seizure?

Learning about this conversion disorder often helps with recovery. Many people who suffer from PNES initially react to a diagnosis of any conversion disorder with disbelief, denial, anger, and even hostility.

However, people who experience pseudo-seizures are truly suffering, and, once the diagnosis sinks in, there is often a sense of relief that the condition is not life-threatening. Treatment is usually based on counseling, which can take years, particularly if the pseudo-seizures were triggered by trauma or abuse.

Between 20% and 50% of those who experience PNES stop having symptoms after diagnosis, without any specific treatment.

Summary

Psychogenic non-epileptic seizures have a psychological cause unrelated to the changes in brain activity associated with epilepsy. While there are ways to distinguish between a psychogenic and an epileptic seizure, PNES is often misdiagnosed and unresponsive to seizure medication. Once a definitive diagnosis is made, treatment addresses the underlying psychological problem. Some cases resolve spontaneously after a proper diagnosis is made.