1. Psychogenic nonepileptic seizure (PNES) Maryann Ryan, RN-C, MSN, APN-C

2. PNES PNES are not associated with physiological central nervous system dysfunction but are instead psychogenically determined. (Uptodate, 2013)

3. PNES Psychiatric conditions associated with PNES include  Depression  Anxiety  Somatoform disorder  Posttraumatic stress disorder  Dissociative disorder  Personality disorders, especially borderline personality disorder, but also narcissistic, histrionic, and antisocial personalities

4. PNES Psychiatric conditions associated with PNES include A history of sexual or physical abuse is reported in one-third to one-half of patients Individuals with a hx of sex abuse may be more like to have clinical events that are more severe and more likely to resemble epileptic seizures They are more likely to exhibit self-harming behaviors and other medically unexplained symptoms (Slekirk, 2008)(Duncan, 2008)

5. PNES Common features distinguishing epileptic seizures and PNES SignEpilepticPNES DurationUsually brief, < 1-2 minutesUsually longer than 2 minutes EyesUsually open during eventOften closed Forced eye closure suggests PNES Motor ActivityStereotyped Synchronized Build, progress Variable Forward pelvic thrusting, rolling side to side, opisthotonus Wax and wane VocalizationUncommon, especially during convulsion May occur Prolonged ictal atonia Very rareMay occur IncontinenceCommon in convulsive seizuresLess common Autonomic signsCyanosis, tachycardia common with major convulsion Uncommon Postictal symptomsUsually confused, drowsy Headache common May rapidly awaken and reorient Headache rare

6. PNES Presenting the Diagnosis The episodes are considered not to be caused by epileptic discharges, but rather represent "the mind playing tricks on the body. Emphasis that this problem is as serious as one caused by epilepsy and deserves the attention and treatment that is accorded any illness. Discussion on how stress afflicts each of us to variable degrees and in different ways. Advise that "the body needs to blow off steam" in some fashion; some people release this stress with the development of headaches, others with tremors, and some with nonepileptic seizures. (Carton, 2003)

7. PNES Presenting the Diagnosis Emphasize that the episodes are experienced as real and disabling, and that although they relate to emotional or psychological causes, we do not dismiss the problem, and we do not consider the patient to be "crazy." Communicate that their disorder warrants different treatments than those administered for epilepsy. (Carton, 2003)

8. PNES Many patients become angry in response to receiving the diagnosis. Some may acknowledge these feelings, while others may not. An angry reaction may forebode a poor prognosis. In my experience, it is useful to anticipate these feelings at the time of revealing the diagnosis. We and others have also found that patients may exhibit exacerbations of their episodes after the diagnosis is revealed and we often warn the patients not to be surprised if this were to occur. (Carton, 2003)(Thompson, 2009)

9. PNES References Carton, S., Thompson, P.J., Duncan, J.S. Non-epileptic seizures: patients’ understanding and reaction to the diagnosis and impact on outcome. Seizure, 12(5). Duncan, R., Oto, M. (2008). Predictors of antecedent factors in psychogenic nonepileptic attacks: multivariate analysis. Neurology, 71(31). Selkirk, M., Duncan, R., Oto, M., Pelosi, A., (2008) Clinical differences between patients with nonepileptic seizures who report antecedent sexual abuse and those who do not. Epilepsia, 49(8):1446. Thompson, R., Isaac, C.L., Rowse, G., Tooth, D.L., Reuber, M.(2009). What is it like to receive a diagnosis of noneplieptic seizures? Epilepsy Behavior, 14(3). Ettinger, A.B. (2013) Psychogenic nonepileptic seizures. Retrieved 8/18/13 http://www.uptodate.com/contents/psychogenic-nonepileptic- seizures?detectedLanguage=en&source=search_result&search=pseudoseizures&selectedTitle=1%7E23 &provider=noProvider. http://www.uptodate.com/contents/psychogenic-nonepileptic- seizures?detectedLanguage=en&source=search_result&search=pseudoseizures&selectedTitle=1%7E23 &provider=noProvider