Hi Gaross,

Hi Gaross,

I agree that the term is confusing. Especially, when there is translation
needed between several languages :-( So, here comes a complete article on
this topic written by Raj D Sheth, MD, Director Comprehensive Epilepsy
Program, Chief, Professor, Departments.
http://www.emedicine.com/neuro/topic403.htm
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Background: Pseudoseizures are paroxysmal episodes that resemble and are
often misdiagnosed as epileptic seizures. The term pseudoseizure refers to
any nonepileptic episode that simulates an epileptic seizure.
Paroxysmal nonepileptic episodes can be either organic or psychogenic.
Syncope, migraine, and transient ischemic attacks (TIAs) are examples of
organic, nonepileptic paroxysmal symptoms. This article only covers
psychogenic seizure.
The terminology on the topic has been variable and, at times, confusing.
Various terms are used, including pseudoseizures, nonepileptic seizures,
nonepileptic events, and psychogenic seizures. Psychogenic nonepileptic
seizures (PNES) has become the preferred term and is the term used
throughout this article.
PNES are common at epilepsy centers, where they are seen in 20-30% of
patients referred for refractory seizures. PNES are probably also common in
the general population, with an estimated prevalence of 2-33 per 100,000,
making PNES nearly as prevalent as multiple sclerosis or trigeminal
neuralgia.
Pathophysiology: Unlike epileptic seizures, PNES do not result from an
abnormal electrical discharge from the brain; they are a physical
manifestation of a psychological disturbance. They are a type of conversion
disorder and are usually involuntary.
Frequency:
In the US: PNES are commonly misdiagnosed as epilepsy. It is the most
frequent nonepileptic condition seen in epilepsy centers, where they often
represent 15-22% of referrals.
Internationally: The prevalence internationally is similar to that in the
United States.
Sex: Like most manifestations of conversion and other somatoform disorders,
PNES occur more frequently in women (approximately 70% of cases) than in
men.
Age:
PNES (similar to conversion disorders) typically begin in young adulthood.
PNES do occur in children and adolescents and have been reported in elderly
people. One should be particularly cautious in diagnosing PNES (and
psychogenic symptoms in general) with onset in early childhood or old age.
In these age groups, nonepileptic physiologic events may be more common. For
example, in children, parasomnias (eg, night-terrors), breath-holding
episodes, and shuddering attacks may occur.

    CLINICAL     Section 3 of 9    
Author Information Introduction Clinical Differentials Workup Treatment
Follow-up Miscellaneous Bibliography            
History: The misdiagnosis of epilepsy is common. Approximately 25% of
patients who have a previous diagnosis of epilepsy and are not responding to
drugs are found to be misdiagnosed. Most cases of misdiagnosed epilepsy are
eventually shown to be PNES or, more rarely, syncope. Occasionally, other
paroxysmal conditions can be misdiagnosed as epilepsy, but PNES is by far
the most common condition. Often, EEGs interpreted as providing evidence for
epilepsy contribute to this misdiagnosis.
As is true in other chronic conditions, reversing a misdiagnosis of epilepsy
can be difficult. Unfortunately, once the diagnosis of seizures is made, it
is easily perpetuated without being questioned, which explains the usual
diagnostic delay and cost associated with PNES. Despite the ability to make
a diagnosis of PNES with near-certainty, the time to diagnosis remains long
at about 7-10 years; this indicates that neurologists may not have a high
enough index of suspicion for the diagnosis of PNES. This article first
examines the steps involved in making the diagnosis and then reviews
management considerations.
The diagnosis can be suspected on the basis of the history. Several red
flags are useful in clinical practice and should raise the suspicion that
seizures may be psychogenic rather than epileptic.
Resistance to AEDs can be the first clue and is usually the reason for
referral to the epilepsy center.
Approximately 80% of patients with PNES have been treated with AEDs before
the correct diagnosis is made. A psychogenic etiology should be considered
in patients who are completely unaffected by AEDs (ie, no difference when
taking AEDs).
The presence of specific triggers that are unusual for epilepsy can be
suggestive of PNES, and this should be specifically asked about during
history taking. For example, emotional triggers such as ?stress" or
"becoming upset" are commonly reported in PNES. Other triggers that suggest
PNES may include pain, certain movements, sounds, and lights, especially if
they are alleged to consistently trigger a "seizure."
The circumstances in which attacks occur can be very helpful. Like other
psychogenic symptoms, PNES usually occur in the presence of an "audience,"
and (although this has not been studied) occurrence in the physician's
office or the waiting room is suggestive of PNES. Similarly, PNES usually do
not occur during sleep.
Detailed description of the spells often includes characteristics that are
inconsistent with epileptic seizures. In particular, some characteristics of
the motor (ie, convulsive) phenomena are associated with PNES (see EEG-video
monitoring).
The past medical history can be useful. Although this has not been
documented, coexisting poorly defined and probably psychogenic conditions,
such as fibromyalgia, chronic pain, or chronic fatigue, are associated with
psychogenic symptoms. In a population of patients with refractory seizures,
a history of fibromyalgia or chronic pain has a high predictive value
(~70-80%) for a diagnosis of PNES. Similarly, a florid review of systems
suggests somatization.
The psychosocial history with evidence for maladaptive behaviors or
associated psychiatric diagnoses should raise the suspicion of PNES. Pay
particular attention to mental status evaluation, including the general
demeanor and appropriate level of concern, overdramatization, and hysterical
features.
By contrast to the above, certain symptoms, when present, argue in favor of
epileptic seizures. These include significant injury. In particular, tongue
biting is highly specific to generalized tonic-clonic seizures and a helpful
sign when present.
Physical:
Physical and neurological examination findings are usually normal.
Psychological features (consistent with psychogenic episodes) include
anxiety, depression, inappropriate affect or lack of concern (la belle
indifference), multiple and vague somatic complaints suggestive of
somatization, or abnormal interaction with family members.
Causes: PNES is, by definition, a psychiatric disorder. According to the
Diagnostic and Statistical Manual for Mental Disorders (DSM) classification,
physical symptoms caused by psychological causes can fall under 3
categories: somatoform disorder, factitious disorder, and malingering.
A somatoform disorder is the unconscious production of physical symptoms due
to psychological factors. This means that symptoms are not under voluntary
control, ie, the patient is not faking and not intentionally trying to
deceive. Somatoform disorders are subdivided into several disorders
depending on the characteristics of the physical symptoms and their time
course. The 2 somatoform disorders relevant to PNES are conversion disorder
and somatization disorder. The Diagnostic and Statistical Manual for Mental
Disorders, Fourth Edition (DSM-IV) added a new subcategory of conversion
disorder (from the Diagnostic and Statistical Manual for Mental Disorders,
Revised Third Edition [DSM-III-R]) specifically termed conversion disorder
with seizures.
By contrast to the unconscious (ie, unintentional) production of symptoms of
somatoform disorders (including conversion), factitious disorder and
malingering imply that the patient is purposely deceiving the physician, ie,
faking the symptoms. The difference between factitious disorder and
malingering is that, in malingering, the reason for the deception is
tangible and rationally understandable (albeit possibly reprehensible); in
factitious disorder, the motivation is a pathologic need for the sick role.
An important corollary is that malingering is not considered a mental
illness, whereas factitious disorder is.
A generally accepted view is that most patients with PNES fall under the
somatoform category rather than the malingering or factitious category.
However, although the DSM classification is simple in theory, knowing
whether a given patient is faking it is nearly impossible. In some
circumstances, intentional faking can only be diagnosed by catching a person
in the act of faking (eg, self-inflicting injuries, ingesting medications or
eye drops to cause signs, putting blood in the urine to simulate hematuria).
Malingering may be underdiagnosed, partly because the diagnosis of
malingering is essentially an accusation.
From a practical point of view, the role of the neurologists and other
medical specialists is to determine whether organic disease exists. Once the
symptoms are shown to be psychogenic, the exact psychiatric diagnosis and
its treatment are best handled by the psychiatrist.
The role of antecedent sexual trauma or abuse is thought to be important in
the psychopathology of psychogenic seizures and psychogenic symptoms in
general. A history of abuse may be more frequent in convulsive rather than
limp type of PNES.
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