Volume 7 Issue 11 November, 2017
Consultation Liaison Psychiatry : Neurology
Non epileptic attack disorder is an observable abrupt paroxysmal change in behavior or consciousness that resembles an epileptic seizure, but is not accompanied by the electrophysiological changes or clinical evidence for epilepsy. Some of the other synonymous terms used are pseudoseizures, psychogenic non epileptic seizure, non-epileptic disorder, non epileptic seizures and psychogenic seizures.
Seizures can be divided into three major categories. They are epileptic seizures (ES), PNES, and physiologic nonepileptic events (NEEs).
Physiologic nonepileptic events (PhysNEE) that are often confused with epileptic seizures include: Syncopal episodes, Movement disorders, Sleep disorders, vascular events, Gastro-intestinal disturbances and Migraine.
According to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the Diagnostic Criteria PNES is a psychiatric disorder; more specifically it is a conversion disorder, which falls under the diagnostic category of somatic symptom disorders in the . According to the classification, neurological symptoms that are found, after appropriate neurological assessment, to be incompatible with neurological pathophysiology can fall under conversion disorder, factitious disorder, or malingering.
The person with epilepsy spends huge amount of money for diagnosis and management. Thus a misdiagnosis of NEAD as epilepsy will also have a huge financial implication.
Approximately 5–25% of patients referred to an outpatient epilepsy center have PNES, and approximately 20–30% of inpatients evaluated for intractable seizures. PNES has female preponderance overall. About 5% undergoing evaluation have a definitive diagnosis of epilepsy during VEEG monitoring. A few patients with epilepsy develop PNES after epilepsy surgery. It occurs in two peaks: 19-22 years and 25-35 years. However it can occur in other age groups including children. Some of the precipitating factors in children are academic difficulties, bullying family/ interpersonal conflict, and physical/sexual abuse.
PNES are typically non-stereotyped events, while the reverse is a clinical sign that supports a diagnosis of epilepsy and events are of long duration with rapid recovery of cognitive functions following a prolonged non-convulsive-like event and most of the times PNES occur in awake state. Convulsive PNES manifestation include Clonic, myoclonic, tonic movements, Violent thrashing of the extremities and/or of the entire body, Opisthotonic arching of the back, Pelvic thrusting motions, Side-to-side head movements, the absence of facial clonic activity in the presence of generalized clonic-like activity, Eyes closed with resistance to eye opening, normal respiratory rate during the event and postictally (as opposed to a labored breathing in GTC) Vocalizations that include shouting, screaming, often associated with understandable speech and shedding of tears more likely to occur in the middle of the event unlike epileptic seizures, where vocalizations usually occur at the onset of the event. However there Some of the common misconceptions of PNES are that patients do not get injured, will not have tongue bite or sphincter disturbances as these are also reported in individuals with PNES. PNES can mimic either complex partial or generalized absence seizures.
The PNES manifestations in children can be divided into 2 groups, one group consisting of Unresponsive events where child become unresponsive with reduction or the absence of spontaneous movement and other group with motor events consisting of bizarre, irregular, jerking, or thrashing movements of the extremities, not typical of any of the known types of epileptic seizures.
Assessment, diagnosis and treatment
Accurately identifying and diagnosing PNES is a challenge for both psychiatrists and neurologists, and the diagnosis of PNES currently relies on the exclusion of epilepsy. Up to one fourth of patients with suspected epilepsy seen at epilepsy centers who had failed to achieve seizure control after two or more antiepileptic drugs (AEDs) had been tried were found to not have epileptic seizures after video-EEG. Epilepsy is usually ruled out using video-EEG telemetry to analyze typical events, and video-EEG has been considered the gold standard for the diagnosis of PNES. Some of the Provocative techniques used to aid in the diagnosis of PNES are use of a tuning fork hyperventilation, and photic stimulation.
The therapeutic options include psychotherapy, group therapy, cognitive behavioral therapy, use of anxiolytics and antidepressants.
Dr. Pradeep, Post Doctoral Fellow in Epilepsy, KIMS hospital Secundarabad
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