Psychogenic Nonepileptic Seizures PNES

What are Psychogenic Nonepileptic Seizures?

Psychogenic Nonepileptic Seizures are attacks that may look like epileptic seizures but are not caused by abnormal brain electrical discharges. It was previously misreferred as pseudoseizures, but now, with the advancement of science, it is recognized as a condition with a psychiatric or psychological pathology that manifests as physical symptoms. They are also described as functional seizures, dissociative seizures or functional neurological disorders, and is classified under conversion disorders, in which a psychiatric issue disrupts normal brain function.

PNES are involuntary, experiential and behavioral responses to internal or external triggers. They can be identified as neurological manifestations of underlying psychological conflict or behavioral presentation of abnormal neuronal networks of the brain circuits without a particular focal brain lesion being the source of seizures. PNES is rather a common condition. Almost 30% of people coming to the epilepsy monitoring unit are diagnosed with PNES.

What Triggers Psychogenic Nonepileptic Seizures?

PNES may be related to some underlying comorbidity like depression or anxiety, related to a traumatic incident experienced in the past, or may not have an apparent underlying cause. They can be triggered by physical, mental, or emotional stressors encountered during daily life.

How to Differentiate Between Epileptic Seizures and Psychogenic Nonepileptic Seizures?

PNES is a common condition and is often misdiagnosed as epileptic seizures due to inadequate examination or gaps of knowledge.

There are certain differences in the way people with PNES present to people with epilepsy. In general, nonepileptic seizures will be of slow or gradual onset, interrupted, and have asynchronous and arrhythmic movements with pelvic thrusting, back arching, and rolling over the stomach with eyes closed. There will be episodes of emotional expressions and crying as well.

Some of the differences between PNES and epileptic seizures are mentioned below.

PNES can be suspected with the proper review of the course of the event alone, but to establish a definitive diagnosis, without doubt, video EEG monitoring at the occurrence of the seizures is required.

On brain imaging with MRI of a person with epilepsy, a focal lesion (usually in the hippocampus) is seen that is most of the time the source of epilepsy. However, in a person with PNES such a lesion cannot be identified on MRI, although in a few, there may be some abnormalities that are not associated with the actual focus of seizures.

How is Psychogenic Nonepileptic Seizures diagnosed? 

A careful history, including a description of the seizure addressing neurological and psychiatric aspects and a neurological examination is performed. Reviewing the course of the seizure attack that occurred at the ward or a video of a similar attack is important to identify the characteristic features of PNES. If you or your friend is having PNES, the best thing you can do to help diagnose the condition is to get the event recorded so that your doctor can analyze it and see whether it is compatible with PNES features. Although by looking at the seizure occurring, PNES or epileptic seizures can be suggested, it is insufficient for a 100% diagnosis. Nobody can tell you whether you have PNES of epilepsy just by looking at the course of seizures. To make a definitive diagnosis performing an EEG is recommended. 

The gold standard for diagnosis of PNES is in-patient video EEG monitoring. Patients will be brought into the EEG monitoring unit and any anti-seizure medications they are on at the moment will be tapered off. If they would have typical seizure events during the admission EEG will be recorded during the event. It is important to confirm that the seizure event that is being recorded at the hospital is a representation of the seizures that happened before. If the EEG happens to show the normal electrical wave pattern of the brain continuously during the seizure, PNES is confirmed as a confident, positive diagnosis.

There are other nonspecific methods of diagnosing PNES such as prolactin and MRI. The basis of using prolactin is the finding of prolactin secretion during epileptic seizures and thus the presence of high serum prolactin levels during epileptic seizures. However, this method was found to be less reliable in the clinical setting as the prolactin level shows high fluctuation depending on factors like time of the day, and sex. Moreover, this method has practical issues such as having to measure prolactin levels exactly 15-20 minutes after seizure occurrence and in 1 hour for baseline levels, and for these reasons it is no longer in use for the diagnosis of PNES.  

The brain MRI doesn’t indicate anything in PNES, yet doctors perform it as an additional test to comfort their patients. It is important not to be misled by the nonspecific white spots on MRI that may occur in migraine, diabetes, hypertension, or arachnoid cysts that are incidental findings on MRI.

Pitfalls in diagnosis

Although we say that EEG is the gold standard for PNES diagnosis, there can be very rare cases of epilepsy with a normal EEG as well. Usually for an EEG to pick up the abnormal signals of the brain, the focus or the responsible structural part of the brain has to be at least 10-20 cm^3 cubic area and for this reason, EEG is sometimes regarded as a low-quality test. Therefore if the seizure focus is very small, (in such cases you might be having symptoms in a small part of the body i.e. a finger or hand), or is deeply situated in the brain (e.g.: causing very short episodes of fear or Deja vu) which are too far to be caught up on EEG, the EEG can be normal even though there is an actual electrical abnormality of the brain. 

In frontal lobe epilepsy, the seizure is very explosive and short-lasting and is associated with bizarre shaking and jerking movements, screaming, flipping around, and dramatic movements. The EEG in this case would be normal because the abnormal signals are from deep areas of the frontal lobe or the EEG will be obscured by myogenic artifacts caused by the dramatic muscular movements. 
However, if you are completely unconscious during the seizures and your EEG is normal during the seizure, the diagnosis of PNES is confirmed. It is because the unconscious state in epilepsy implies that the whole brain is involved in the seizures and the EEG has to be abnormal. 

Some variants in EEG called wicket waves, benign small spikes, or benign sporadic sleep spikes are indicative of tiny sharp activity and they are completely normal. However, they can be misdiagnosed as abnormal electrical waves and cause to label a PNES patient as an epileptic patient. Therefore, it is very important not to over-read an EEG to avoid such dangerous mistakes.  

Another common mistake done by untrained, inexperienced doctors is pinching or inflicting pain on the patients with the wrong knowledge of patients “faking the seizure”. The patient feels the pain but cannot respond because there is a dissociation between the mind and the body. In addition to that PNES patients that are misdiagnosed as epilepsy patients are intubated and given sedative medications at the emergency department. Thus, it is very important to arrive at the proper diagnosis of a patient coming with seizures.

What causes Psychogenic Nonepileptic Seizures? Is it just stress?

The answer is NO. The recent advancements in the field of neuroscience have shown that there are structural changes in the brain associated with PNES, more specifically an imbalance in the neuronal networks of conflict resolution. For example, the amygdala and the limbic system which are the emotional processing areas of the brain have direct connections with the motor cortex which controls the movements of the body. The signals of emotional conflicts in the brain will be carried to the motor areas and will manifest as movements. Due to the imbalances in the neuronal circuits between those areas in PNES, abnormal movements will manifest as seizures. Also, other structural abnormalities like differences in the thickness of structures are more or less responsible for PNES. 

Repeated emotional stresses, and mental traumas accumulating within oneself, after reaching the threshold, may explode as physical manifestations leading to PNES. This especially pertains to those who do not expose themselves and try to cover up their concerns not seeking help from others. Those who have got less support or not much of a healthier environment to manage the struggle and overcome the distress caused by the particular event, or have tried to manage things by themselves without sharing them with others are more likely to develop PNES later in their life.

According to Dr. Curt Lafrance, the world expert on nonepileptic seizures, still there is no known definitive cause for PNES. However, there are many commonalities in people who have PNES, and it is suggested to be a conversion disorder in which underlying psychological conflict or stressor manifests neurologically or a behavioral presentation of abnormal neuronal circuits of the brain.

What is the association of Psychogenic Nonepileptic Seizures with anxiety and depression?

It is important to understand that PNES is not the same as anxiety, depression, or PTSD (Post-Traumatic Stress Disorder). However, a considerable proportion of patients with PNES have underlying psychiatric comorbidities. In terms of numbers, 30-50% of patients with PNES have suffered a history of depression, some type of anxiety disorder, or PTSD.

Trauma also plays a big role in the occurrence of PNES. About 30-80% of people with PNES present with some kind of history of trauma. For example, a trauma that you have experienced as a child may later present as PNES in adulthood or sometimes a trauma encountered as an adult too may cause PNES. However, not everyone who is experiencing trauma will develop PNES. There are differences in neural networks which are related to structural and functional connectivity of the brain in patients with Traumatic brain injuries (TBI) alone and patients with PNES and TBI. 

Development of PNES following trauma is greatly influenced by a lot of factors like the personality (there is more chance of a sensitive person, trying to keep everything concealed in themselves, not very easily expressing their emotions being subjected to more stress, and developing PNES), family environment and relationships, ongoing life challenges, genetics and biological susceptibility of the brain to trauma. Sometimes a hidden trauma that passed without much burden arises decades later with PNES and sometimes the trauma which is the trigger of PNES may be so trivial that you can’t even remember it. And sometimes multiple traumatic experiences that keep on happening repeatedly with the last one causing more damage may lead to PNES. Furthermore, Dr. LaFrance by his studies, shows that traumatic brain injury (caused by physical trauma) can cause PNES. The theory known as “double-hit phenomena” suggests that physical trauma superimposed on psychological trauma increases the chance of developing PNES.

PNES is not necessarily associated with some type of psychological trauma or psychiatric disorder and also experiencing trauma or suffering from anxiety or depression doesn’t necessarily mean that you have some form of PNES. However, identifying and treating such comorbidities is very important for the proper recovery from PNES.

How is Psychogenic Nonepileptic Seizures treated?

The most striking question that arises after knowing all those facts about PNES is whether it can be cured and how? The answer is yes and with the recent findings on the disease and a better understanding of the underlying causes, the treatments have improved a lot. Even after the PNES diagnosis is established, the patient should be followed by their neurologist, not only the psychiatrist even though the underlying trigger of PNES lies there. If there is no evidence of epilepsy and once epilepsy is ruled out, anti-epilepsy medications will be tapered off. Consulting the psychiatrist and psychologist is important for targeting underlying comorbidities like PTSD and depression. Thus, a multidisciplinary team for medical therapy and psychotherapy will be involved in managing PNES patients. 

The mainstay of treating PNES is psychotherapy. There are two main treatment modalities of PNES going in parallel- Cognitive Behavioral Therapy (CBT) and treating other comorbid psychiatric conditions. CBT allows you to channel out the stresses and conflicts in the mind in a healthier way without leading to seizures. It is important to keep in mind that initially with CBT the symptoms may get worse before they improve, as a result of entering uncomfortable traumatizing areas of a person. Talk therapy may be stressful to you at first for the same reason, but later on, you will be comfortable with it once you master the skills of dealing with the stresses more healthily. It is important to build up a good rapport with the patient before letting him open up and talk about the trauma or the stressors at the most appropriate time. Being sensitive to the concerns of the patient and taking the patient as a whole considering his underlying conditions like previous trauma, psychiatric conditions, pains, sleeping disorders, relationship issues, family environment, or whatever the problem that has led to the development of PNES is important.

“Some people have benefited from an intervention we developed called neurobehavioral therapy”, further explains Dr. LaFrance. Neurobehavioral therapy consists of 12 sessions of one hour per week. The patients get a seizure workbook called “Taking Control of Your Seizures” on which they get a to-do list and complete the information on the work they’ve done over the course to control their seizures which they discuss with the therapist at the sessions. This helps them transform their maladaptive behaviors into adaptive healthy coping mechanisms. They may also help their comorbidities like depression and anxiety. This workbook allows you to consult your local therapist without having to reach out to a specialist in PNES who may be sometimes difficult to find in your area. There is a version of the same book for the psychotherapist called “Treating Nonepileptic Seizures: Therapist Guide” which helps the therapist to become thorough in the field of PNES and treat their patients better.

The other main component of PNES management is treating other comorbid psychiatric conditions. This may involve psychotherapy, medical management, or both. Medications like SSRIs and SNRIs help restore the normal chemistry of the neurons and improve psychiatric conditions such as depression, anxiety, or PTSD which trigger PNES.

Other treatment modalities used in treating PNES include EMDR (Eye Movement Desensitization and Reprocessing) designed to treat conditions like PTSD by alleviating the distress caused by traumatic experiences, motivational interviewing which is a counseling approach helping people achieve positive behavioral changes, psychoanalysis, etc.

Does everybody with Psychogenic Nonepileptic Seizures improve with treatments?

Unfortunately, not everyone treated for PNES shows significant improvement.

Depending on the response to treatment, the individuals fall into one of the three groups. The first group is those who have their symptoms resolved immediately after knowing their diagnosis. Their trigger of seizures may be the added stress of the fact of having epilepsy and after knowing their diagnosis their symptoms may resolve. The second group consists of those who improve with the treatments and the third, with resistant PNES that continue to have symptoms despite treatments. The individuals of the third group have certain characteristics: personality disorder making it harder for them to interact with other people, having acute or remote trauma they are not ready to deal with, and ongoing significant family discord. A group therapy approach targeting the individual, his family, and close relatives would help overcome most of the issues in this category of patients. A systematic, step-by-step treatment strategy helps the patients to come out of the trauma more comfortably.

Can you have Psychogenic Nonepileptic Seizures and epilepsy at the same time?

Yes, these two conditions can co-exist in an individual. This is a quite rare presentation happening only in about 10% of patients. It is important to identify whether a given seizure is epileptic or nonepileptic as the treatments vary from one condition to the other.  Development of PNES following successful epilepsy surgery has been observed in about 4% of cases. 

Another important thing to keep in mind is that there can be conditions other than epilepsy or PNES that present as seizures with a normal EEG that are mimics of seizures. They may be physiological, heart-related, or associated with other conditions like sleep disorders.