**4. Treatment**

after simple partial and frontal lobe seizures. Postictal serum prolactin level measurement is recommended to distinguish between epileptic and nonepileptic seizures, but it should be remembered that after half an hour following the seizure, it returns to normal level rapidly and is affected by stress, hypoglycemia, exercise, drug intake. Sundararajan et al. have evaluated 49 studies conducted between 1980 and 2015 on use of biomarkers in the diagnosis of psychogenic nonepileptic seizures. It has been indicated in this review study that neuroimaging (BT, fMRI, SPECT, etc.), autonomic nervous system, prolactin, postictal cortisol, creatine kinase, neuron specific enolase, brain-derived neurotropic factor, ghrelin, leptin, leukocytosis, heart rate have been studied as a biomarker to distinguish psychogenic nonepileptic seizures and epileptic seizures. However, it was reported that none of them could obtain sufficient evidence level. In addition, the authors noted that studies have significant limitations due to small sample and methodological differences and subtypes of psychogenic nonepileptic

Although there is no standardized protocol yet, it is thought that psychological tests may also be helpful for the differential diagnosis of ES-PNES in cases where necessary. It is reported that psychiatric disorders such as anxiety and depression are more frequent in patients with psychogenic seizures than epileptic patients, these patients have a higher incidence of suicide attempts and story of psychiatric treatment. In addition, researchers have also observed that patients with psychogenic seizures have a lower quality of life, more frequent long-term health problems and more dysfunctional family relationships than epileptic patients [57]. Personality problems that occur in patients with psychogenic nonepileptic seizures have been the subject of many investigations. The Minnesota Multiphasic Personality Inventory (MMPI) is a very sensitive but nonspecific test in this area. There were statistically significant differences between the patients with epileptic seizures and psychogenic seizures with MMPI especially in hypochondriasis, depression, hysteria and schizophrenia scales, pathologic elevation (T-score ≥ 70) was detected in patients with psychogenic seizures [58]. However, no significant difference was found in cases with ES and PNES in the other two studies [59, 60]. In other words, there are conflicting results about the clinical benefits of MMPI in the differential diag-

Alexithymia is a Greek term which is used to describe individuals who have difficulty to define and verbalize their emotions or which means "no words for emotions", emerged in order to explain the symptoms of psychosomatic patients and gained a quick recognition among psychiatrists. It was first observed in psychosomatic patients who were also been seen on several psychiatric disorders such as depression, posttraumatic stress disorder, substance abuse and dependence [61]. Patients exposed to trauma are reported to exhibit alexithymia more frequently than control group without trauma experience [62]. A significant portion of PNES patients have a trauma history, so alexithymia is also common. On the other hand, alexithymia is not a common condition in patients with ES, so alexithymia can be helpful to

Despite not being overworked, it is reported that the tendency of hypnosis is relatively increased in patients with PNES. High tendency of hypnosis has been found in a study conducted on 24 patients with ES and PNES by Kuyk et al. with Stanford Hypnotic Clinical Scale measurements in patients with PNES compared to general population and patients with ES [63].

seizures have not been investigated [56].

nosis of ES/PNES.

142 Seizures

distinguish ES/PNES.

Historically, the use apomorphine, saline injection as a placebo, or mouth and nose closure for 20–30 s have been seen for the treatment of PNESs, defined as 'hysterical seizures'. It is also known that Charcot tried different abdominal compressions that failed in PNES treatment [29]. A more acceptable approach is to ensure that the patient speaks about seizures and distress created by seizures in order to provide self-control rather than strengthening their dependence on others [65]. In this way, the patients experiencing seizures alerts generally learn how to control seizures using external focus and abdominal breathing techniques.

The results of treatment trials are contradictory because patients with PNES form a heterogeneous group. It has been reported in some studies that the psychogenic nonepileptic seizures of approximately one-third of the patients stopped after the diagnosis was told to them, better results were obtained for a group of patients who received psychotherapy than those who did not take, in some cases, 34–53% of patients recovered without treatment [66–69]. One of the most important issues in treatment is to report the diagnosis to the patient, because the transmission of the diagnosis can cause some problems. Some patients evaluate the current situation as 'no physical cause' or 'a mental illness'. At the same time, this can be unacceptable for them [70]. On the other hand, seizures may discontinue with a successful communication in 10% patients who were informed about diagnosis [71]. It is reported in a study that the patients were confronted first their diagnosis, then underwent psychotherapeutic approaches and early diagnosis and therapeutic interventions increased the chances of success of treatment [72]. In another study, the health expenditure of the patient, health institution applications and the vEEG costs decreased within 6 months after the diagnosis [10].

The preliminary aim of treatment is to inform and educate the patient and his/her family about the diagnosis. Thus, it will be possible for the patient to be directed to psychiatric care. In addition, unnecessary admission to emergency services, unnecessary treatments and possible adverse effects will be avoided. Antiepileptic drugs may be useful to prevent return in patients with severe abuse or posttraumatic stress disorder, and sometimes it may be appropriate to continue antiepileptic drugs as a mood stabilizer. Although it will continue to be used, the intended use of the antiepileptic drug should be clearly explained to the patient and his/her family in order not to give a double message. It is necessary to cut the antiepileptic drugs gradually when diagnosed except for these conditions [73, 74]. In a prospective study, epileptic seizures were observed in only 3 of 64 patients that antiepileptic medication was discontinued and those informed that seizures were not due to a brain disorder [26]. Especially for patients with dissociative features it is not possible to say that they will certainly not be harmed by seizures. There was no consensus on the recommendation of restrictions on certain activities (such as driving) until these patients had their seizures controlled [64]. PNES treatment has been reviewed by various authors [29, 75, 76]. Most of the studies related to the subject are in the form of small sample case reports and there are few enough powerful or reliable controlled studies. In a study involving psychopharmacological treatment approaches in this area, inpatient group treated with psychological intervention (paradoxical intention) and outpatient group treated with diazepam (5–15 mg/day) were compared. It has been reported that the anxiety is reduced and the symptoms are controlled more effectively in the group treated with paradoxical intention [77]. However, it should be noted that the control group was formed by 15 cases in the study and only 9 cases completed the study. Despite the fact that antidepressants may be effective in other medically unexplained symptoms, there is no adequate data and studies on the use of antidepressant drugs in patients with psychogenic nonepileptic episodes [29, 78, 79]. In all other studies, individual or group-specific psychological treatment methods were discussed [29]. Especially in these studies, cognitive behavioral therapy (CBT), psychodynamic approaches, interpersonal therapy, operant conditioning, eye movement desensitization and reprocessing (EMDR), biofeedback, hypnotherapy, family therapy and multidisciplinary therapies are at the forefront [80–83]. A significant decrease in seizure frequency, anxiety and depression levels, an increase in psychosocial functioning with CBT targeting fear and avoidance behavior have been reported in a 12-session prospective study which is one of the best study done up to this day [84].

alliance is a priority. After that the meaning of the symptoms can be focused in depth [64]. However, it should be remembered that psychotherapy may be beneficial for some patients

Treatment and Diagnosis of Psychogenic Nonepileptic Seizures

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

145

As a result, epileptic and psychogenic nonepileptic seizures are two pathological conditions that should be evaluated separately in terms of both etiological, formation mechanism and treatment approach. Detailed history of seizures and careful neurological, psychiatric examination, as it provides for the correct diagnosis and treatment for the patients, it will also prevent many negative consequences that the wrong treatment may bring. Since it has been named as hysterical seizure, there has been considerable progress in the diagnosis of PNES with the use of EEG and vEEG in clinical practice. However, focusing on differential diagnosis for the PNES diagnosis by comparing with cases with epileptic seizure only, and the lack of comparison of the clinical appearance of the different subtypes of PNES are the shortcoming of the work done up to this day. Also, the effects of cultural differences on PNES are unknown. For a better understanding of treatment approaches, there is a need for studies

and the same results cannot be achieved in all patients.

with a large sample involving the control group.

I offer thanks to my patients for teaching me lot of things.

Address all correspondence to: cicekh@gmail.com

Behavior. 2003;**4**(3):205-216

Medical School, Recep Tayyip Erdogan University, Rize, Turkey

2008;**21**(2):195-201. DOI: 10.1097/WCO.0b013e3282f7008f

[1] LaFrance WC Jr. Psychogenic nonepileptic seizures. Current Opinion in Neurology.

[2] Reuber M, Elger CE. Psychogenic nonepileptic seizures: Review and update. Epilepsy &

**Acknowledgements**

**Author details**

Cicek Hocaoglu

**References**

**5. Conclusion**

Psychoanalytically, psychogenic nonepileptic seizures are an attempt to counteract/defend the traumatic experience of the patient, and at the same time to resolve conflicts related to this experience. At the same time, it is a defense that serves also in the control of the anger, instead of harming someone else, they prefer to hurt themselves. Therefore, it will be appropriate to shape treatment in the direction of these principles, especially in patients who have trauma or unresolved grievances in the past. In other words, patients diagnosed with PNES form a heterogeneous group, and psychodynamic psychotherapy may be a good treatment option for the patients with psychic trauma stories and those who could not mourn. The story of what happened to the patient needs to be formed and the meanings of it should be studied. At the outset of treatment, psychoeducation, prevention of secondary gains, raising awareness of the patient about the relation of psychic processes and seizures and developing a good therapeutic alliance is a priority. After that the meaning of the symptoms can be focused in depth [64]. However, it should be remembered that psychotherapy may be beneficial for some patients and the same results cannot be achieved in all patients.
