PSYCHOGENIC NON EPILEPTIC EVENTS Dr. M.Almohammadi

Outlines  Definition  Is it a problem  Epidemiology  Etiology  Presentation  investigations  Diagnosis  Management  prognosis

Definition  Paroxysmal psychological events that mimic epileptic seizures  Has various terms pseudoseizures Non epileptic seizures Non epileptic events Psychogenic seizures Psychogenic attacks{events}

Is it a problem?  Misdiagnosis occurs in approximately 25% of patients with a previous diagnosis of epilepsy that does not respond to drugs.  PNES is by far the most commonly misdiagnosed condition, accounting for >90% of misdiagnoses at epilepsy centers  Comorbidity presence of both epilepsy & pnes Benbadis SR, Tatum WO. Overintepretation of EEGs and misdiagnosis of epilepsy. J Clin Neurophysiol. Feb 2003;20(1):42-4. [Medline].[Medline] Benbadis SR, Lin K. Errors in EEG interpretation and misdiagnosis of epilepsy. Which EEG patterns are overread?. Eur Neurol. 2008;59(5): [Medline].[Medline] Benbadis SR. Errors in EEGs and the misdiagnosis of epilepsy: importance, causes, consequences, and proposed remedies. Epilepsy Behav. Nov 2007;11(3): [Medline].[Medline]

Epidemiology  20-30% of patient referred for refractory seizures  3-33 per100,000population  More in young adulthood&old age  More in women 70% than men  Prevalent as MS Trigeminal neuralgia more in our homeland

Etiology  theories  psycho analytic( 1ry gain&2ry gain)  Social theory(family discord,stressors, abuse)  Behavioral theory (modeling)  Cognitive theory(communication)

Presentation  marked involvement of the truncal muscles with opisthotonos  lateral rolling of the head or body is present  4 limbs may exhibit random thrashing movements  Bicycling limb movements  Shouting, stuttering, weeping  Happened in presence of audience. waiting room physician office  Intensified by holding of bystanders

Comparison Pnes&Epil.seizures  Cyanosis is rare  Tongue biting -ve  incontinence –ve  In presence of others  Injury rare  Long duration  Labelle indifference  Eyes closed, flickering  Increase by others holding  Recovered immediately after sei  EEG mostly negative  Video EEG negative  Common  Frequent  Alone &others presence  Injury more frequent  Short duration few minutes  Stressed  Opened  No  Drowsy,confused post ictal  Mostly positive  positive PnesEpileptic seizure

Investigations  EEG  CT  MRI  Video EEG

Inter episodic EEG of pnes

Records of these 2female young patient s are confusing unless you haven't seen the patients talking full history and detail description about the seizures Unipolar montage for patient with pnes

Diagnosis  Pay more attention to history -abuse -family discord  Look for triggers - emotional -stressors  Comorbid psychiatric disorders -anxiety -depression -others  Presentation during suggestion  Inter-ictal EEG  Video EEG

Treatment  Delivering diagnosis to patient &family Disbeliefs -patient -family, -referral sour anger hostility  Family&patient education  Psychotherapy  Cognitive-behavioral therapy  Medication(SSRIs) depression and anxiety

Prognosis  Unfavorable outcome Long duration 7 years and more Adult subject Mores somatic symptoms Long duration on AEDs

Thanks for your attention