**Treatment and Diagnosis of Psychogenic Nonepileptic Seizures Seizures**

**Treatment and Diagnosis of Psychogenic Nonepileptic** 

DOI: 10.5772/intechopen.70779

#### Cicek Hocaoglu Cicek Hocaoglu Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.70779

#### **Abstract**

Psychogenic nonepileptic seizure (PNES) is one of the most common clinical conditions in which the diagnostic complexity is experienced. Misdiagnosis leads to many years of wrong treatment regimens, side effects of drugs, additional financial burdens and adverse effects on social life. Differential diagnosis with epileptic seizures (ES) is one of the most common problems in neurology clinics as well as other health centers. A careful history from the patient and his relatives, detailed neurological and psychiatric examination are very important in reaching the correct diagnosis and treatment. Although imaging advances such as video electroencephalography (vEEG) have improved the ability of physicians to accurately identify these disorders, the diagnosis and treatment of PNES is still a challenging issue. Early diagnosis, young age, less psychiatric comorbidity have a positive effect on prognosis. Psychiatric evaluation of patients with PNES may be particularly helpful in elucidating the etiology and detecting comorbid diseases and may be helpful in the long-term treatment of these patients.

**Keywords:** psychogenic nonepileptic seizures, diagnosis, treatment

#### **1. Introduction**

Psychogenic nonepileptic seizures (PNESs) are neuropsychiatric disorders caused by the combination of neurological findings and basic psychological conflicts [1–3]. Over a period of a century, medical community collects data and information about the phenomenology, epidemiology, risks, comorbidities and prognosis of PNES [4–9]. However, information about PNES is insufficient. Video electroencephalography (vEEG) has become a gold standard in diagnostic examination to distinguish neurological seizures from PNES [10–15]. For this reason, video electroencephalography is preferred for diagnosis. In this section, we

Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons

systematically reviewed our current knowledge about diagnosis, differential diagnosis and treatment of PNES.

and the most important information is obtained in order to distinguish from the patient and the relatives who witnessed it during the seizure. Although any other diagnostic methods are available for diagnosis of epilepsy such as electroencephalogram (EEG), vEEG, cerebral magnetic resonance imaging (MRI), cerebral perfusion scintigraphy and, the most important first step in diagnosis is accurate history from patients and their relatives, and careful neurological examination, as well as semiologic recording of the seizure [38]. In cases where anamnesis is not sufficient, the differential diagnosis of the patient becomes difficult. With good history, information can be obtained to suggest whether there is a nonepileptic seizure. For example, many reasons may be useful for differential diagnosis such as the onset and the duration of seizure, the appearance pattern, motor movements and reflex changes, the induction property of seizure [16, 39, 40]. If the seizures happen very often and repeat several times a day, this is a more common finding for PNES. Furthermore, while patients are normal in the period between the seizures due to the absence of postictal confusion in PNES, there may be consciousness disorders during the period between seizures in patients with ES due to prolonged confusion and sleepiness in frequent seizures. While epileptic seizures generally last a few minutes, PNESs tend to last much longer [41, 42]. Patients with epilepsy generally respond to treatment with one antiepileptic drug at around 50%, while patients with PNES do not respond to treatment with antiepileptic drugs [41]. During examination, it is often learned that patients with PNESs received prior antiepileptic treatment and no response obtained to treatment. If the seizures are in a specific place, time and crowded environment, it is favorable for PNES. In ES, such a place and time difference is generally absent. While ES is seen in sleep and awake state, PNESs are seen awake state [17, 18]. A careful history can be used to determine that the patient is not asleep, although the patients report that they are asleep. vEEG can be used as an assistant method in cases where sleep and awake state cannot be distinguished [40]. The type of seizure is generally the same with the reason that the discharge is in the same region in the brain in ES. In PNES, seizure types can be seen in different forms in the same patient [43]. While seizures are usually sudden onset in epileptic patients, it starts gradually in patients with PNES. While there are complaints such as screaming, palpitations, hyperventilation, numbness in the hands and feet before the seizure in PNES, epigastric sen sations, deja vu, swallowing, swallowing and automatisms in the hands may occur in ES [17, 18]. A complete loss of consciousness is observed according to type of seizure in ES, no loss of consciousness is seen in PNES, the patient hears around, and cannot respond. There may be physical injuries in ES due to fall. Even the patients with PNES fall, they usually have controlled falls and injuries are not often experienced [23, 42, 44]. In ES, contractions occurring in the extremities are tonic, clonic or tonic-clonic and rhythmic, whereas PNES is more tonic in contraction and not rhythmic. When the eyelids are attempted to open, patients with PNES show resistance, but this is not observed with ES. At ES, abnormal alignment of the eyes and unilateral clonic contractions in the eyelid can be seen [43]. In patients with epilepsy, pupil dilatation and reflex changes are observed, however, these neurological findings are not seen in patients with PNES. In patients with PNES, pelvic pushing is a frequent finding, while it may be seen much less and lighter in epileptic patients [16]. Urinary incontinence is a more common finding in ES, although it is rarely reported in patients with PNES [42]. In the differential diagnosis, sudden onset of seizures, pupillary dilation during seizure and postictal confusion are semiologic findings in favor of ES, awareness of the environment, influencing the severity of seizures by the presence of people around and blinking of the eyes are

Treatment and Diagnosis of Psychogenic Nonepileptic Seizures

http://dx.doi.org/10.5772/intechopen.70779

139
