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Understanding psychogenic nonepileptic seizures

By: Susan Tocco, MSN, RN, CNS, CNRN, CCNS

Many nurses feel unprepared to care for patients with seizures or psychiatric illnesses. So dealing with those who have a combination of these disorders, such as psycho­genic nonepileptic seizures (PNES), can be particularly stressful. Understanding the basics of PNES is essential to caring for these vulnerable patients. Read the questions and answers below to boost your knowledge base.

What are psychogenic nonepileptic seizures?

Sometimes inaccurately termed pseudoseizures, PNES are events that mimic epileptic seizures but arise from psychological disturbances rather than abnormal electrical brain activity. Although they can occur in any age-group, they’re most common in persons age 15 to 35. Women account for up to 80% of PNES cases. The reason for this gender disparity is unclear, but the higher incidence of childhood sexual abuse in females (which can cause or contribute to PNES) may offer an explanation.

What causes PNES?

The vast majority of PNES patients don’t intentionally create or fake their symptoms. Instead, they have somatoform or conversion disorders.

  • Somatoform disorders are chronic conditions characterized by recurrent physical complaints involving more than one body part with no apparent cause, or by complaints out of proportion to what one would expect from physical findings.
  • In conversion disorders, repressed emotional conflicts are expressed in neurologic signs and symptoms affecting voluntary motor or sensory function. As with somatoform disorders, no organic cause exists.

Less common causes of PNES are factitious disorders and malingering. Persons with factitious disorders act as though they have a physical or mental illness but are deliberately fabricating or exaggerating their symptoms in the desire to maintain the patient role. Malingeringpatients fake an illness for an identifiable benefit, such as financial gain or release from prison.

Be aware that some nonepileptic seizures can result from physiologic, not psychogenic, causes. For example, such metabolic disturbances as hypoglycemia and hyponatremia can disrupt brain activity and result in a seizure.

How is PNES diagnosed?

Many patients with PNES present in the emergency department, only to be misdiagnosed with a seizure. PNES must be distinguished from epileptic seizures because an incorrect epilepsy diagnosis can lead to unnecessary antiepileptic medication use, adverse drug reactions, and delay in treating the underlying psychological problem. Patients typically go an average of 7 years between the first PNES event and correct diagnosis.

The gold standard for diagnosing PNES is video electroencephalographic (EEG) monitoring in epilepsy monitoring units. In this test, video recordings of the patient’s activities are compared with simultaneous EEG recordings to determine if the events are epileptic. Up to 95% of patients with epileptic seizures have EEG abnormalities. Outpatient video EEG monitoring is appropriate for patients with frequent PNES events; those with less frequent events may have inpatient EEG monitoring.

Estimates suggest that up to 30% of patients referred to epilepsy monitoring units are diagnosed with PNES. The diagnosis is complicated because both PNES and epileptic seizures may occur in the same patient. However, most patients with both seizure types have well-controlled epileptic seizures at PNES onset.

Although less reliable than video EEG monitoring, clinical observations of patient activity during an event can aid diagnosis. Continued eye closure during the ictal period (the period during which the event occurs), weeping, ictal stuttering, and postictal whispering are associated with PNES. Lack of PNES events during sleep, events occurring in the physician’s office, and the “teddy bear” sign (bringing an age-inappropriate toy animal to the epilepsy monitoring unit) also are linked to PNES. Patient self-injury, tongue laceration, and incontinence may occur in both PNES and epileptic seizures.

Serum prolactin levels drawn within 30 minutes of ictus may be used adjunctively to differentiate PNES from generalized tonic-clonic seizures (which cause initial stiffening followed by muscle jerking and loss of consciousness) and partial complex seizures (which typically involve automatic motor movements and impaired consciousness). Several studies show serum prolactin levels are elevated in generalized tonic-clonic seizures and partial complex seizures, but not in PNES.

How is PNES treated?

Once the diagnosis of PNES is confirmed, patients typically are referred to mental health professionals. Antiepileptic drugs are withdrawn unless the patient has coexisting epileptic seizures that require pharmacologic management.

Definitive PNES treatment hasn’t been established. A pilot trial found patients receiving cognitive-behavioral therapy plus standard medical care had fewer PNES events than those receiving standard medical care alone. Another pilot study found a 45% reduction in PNES in patients receiving sertraline (Zoloft) during the 12-week study period, whereas PNES increased 8% in those receiving a placebo.

What are the nursing implications?

Any patient with a seizure or seizure-like activity requires proper nursing assessment and event documentation. On admission, obtain a detailed history of the patient’s previous events and relevant psycho-social history. (See What to assess for during a seizure by clicking the PDF icon above.)

During the seizure, stay with the patient to protect her from injuries. If appropriate, roll her onto her side to reduce the risk of aspiration. Unless she has a confirmed PNES diagnosis, notify the physician of tonic-clonic activity lasting beyond 3 minutes; be prepared to administer I.V. benzodiazepines. The physician may request withdrawal of a blood sample for a prolactin level within 30 minutes of the event to aid diagnosis. If family members or significant others are present, ask them if the patient’s current event resembles her prior PNES events.

During routine patient care, take advantage of opportunities to discuss observed stressors with the patient. For example, if you notice she cries after every phone conversation with her sister, you might say, “You seem upset after talking with your sister.” Give her a chance to explore her feelings if she seems ready. Use available inpatient mental health resources, including social workers, psychiatric advance practiced nurses, and spiritual care providers.

What kind of education do the patient and family need?

PNES can be hard to diagnose, so don’t rush patient teaching until the physician has reached a diagnosis or broached the possibility of PNES with the patient and family. You might want to ask the patient open-ended questions, such as, “What have you been told about your condition?” If she doesn’t state she’s aware she might have PNES, postpone teaching until the physician discusses it with her. Then take a positive approach during teaching. Inform her PNES is real but isn’t caused by epilepsy. Reassure her she doesn’t have epilepsy and doesn’t need lifelong antiepileptic medications. Tell her early diagnosis can improve her outcome.

Because of the stigma of psychological illness, be sensitive about conducting your teaching in the presence of family and visitors. Ask the patient in advance whether she wants others to be involved in her care, and respect her wishes. On discharge, the patient is likely to require follow-up with a mental health professional. If family dynamics seem to contribute to her PNES, encourage family members to participate in treatment, with the patient’s permission. Your knowledge of PNES assessment, diagnosis, and treatment can boost your confidence when providing care and education for these complex patients and their families.

Selected references

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders; Fourth Edition, Text Revision (DSM-IV TR). Washington, DC: American Psychiatric Association; 2000.

Benbadis SR. Psychogenic nonepileptic “seizures” or “attacks”? It’s not semantics:
attacks. Neurology. 2010 Jul 6;75(1):84-6.

Epilepsy Foundation. Nonepileptic seizures. Accessed March 16, 2012.

Goldstein LH, Chalder T, Chigwedere C, et al. Cognitive-behavioral therapy for psycho­genic nonepileptic seizures: a pilot RCT. Neurology. 2010 June 15;74(24):1986-94.

Hoerth MT, Wellik KE, Demaerschalk BM, et al. Clinical predictors of psychogenic non­epileptic seizures: a critically appraised topic. Neurologist. 2008 Jul;14(4);266-70.

Krumholz A. The 10 most commonly asked questions about nonepileptic seizures. Neurologist. 2002 Jan;8(1):51-6.M

Jones SG, O’Brien TJ, Adams SJ, et al. Clinical characteristics and outcome in patients with psychogenic nonepileptic seizures.
Psychosom Med. 2010 June;72(5):487-97.

LaFrance WC. Psychogenic nonepileptic seizures. Curr Opin Neurol. 2008 Apr;21(2):195-201.

Martlew J, Baker GA, Goodfellow L, et al. Behavioural treatments for non-epileptic attack disorder. Cochrane Database of Systematic Reviews. 2007, Issue 1. Art. No.: CD006370. DOI:10.1002/14651858.CD006370.

Rowland LP, Pedley TA, eds. Merritt’s Neurology. 12th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009.

Susan Tocco is a neuroscience clinical nurse specialist at Orlando Regional Medical Center in Orlando, Florida.

1 Comment.

  • “Less common causes of PNES are factitious disorders and malingering.” This is untrue. PNES are a totally different problem and are NOT malingering, and are NOT factitious disorder. Someone may feign a seizure for a secondary gain= malingering, and at the same time be very sick, both physically and mentally or either/or. Or they might actually cause themselves to have seizures, or make their situation worse, or construct a factitious disorder (Munchausens or Munchausen’s by internet/by proxy), = factitious disorder.
    But please do not say that these two are Psychogenic Nonepileptic seizures. Many nurses lacking experience misunderstand this disorder and think it’s funny to laugh and joke and it perpetuates stigma, pain, trauma, and makes it hard to trust medical professionals, when the PNES patient needs support in order to gain control of ther seizures. Thank you for addressing this important topic. I hope that you consider editing it for clarity.

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