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atypical seizure; psychogenenic non-epileptic spell; hysterical seizure; pseudoseizure; psychogenic seizure

Etiology: - conversion disorder - post-traumatic stress disorder (PTSD) - factitious disorder, malingering (rare) [1] - psychiatric comorbidity common - depression, 76%; anxiety, 60%, abuse, 69% [12] - sexual assault [14] - pain syndrome (fibromyalgia) [15] - stroke [14] Clinical manifestations: 1) often occur in patient with real seizures 2) bizarre, usually witnessed, without self-injury or incontinence 3) pupils remain reactive 4) patient often responds to pain 5) movements do not appear involuntary - aynchronous movement of arms & legs 6) post-ictal state brief or absent 7) pelvic thrusting is common 8) seizures are often slow rather than abrupt in onset 9) seizures may be precipitated or terminated by suggestion or emotional cues 10) long duration, 5-30 minutes with on & off time course - compare with 1-2 minutes for epileptic seizure [2] 11) preserved awareness* 12) eye flutter* (forced eye closure) 13) crying 14) ability of bystander to intensify or alleviate seizure* * best differentiating signs from epileptic seizure [7] Laboratory: 1) serum prolactin levels increase by 20-50 ng/mL within 15 minutes after generalized tonic-clonic seizures & return tobaseline of 5-10 ng/mL after 1 hour, but do NOT increase after psychogenic seizure 2) the increase in serum prolactin is transient & may be missed, thus a normal serum prolactin after a seizure is useful information, but does NOT make the diagnosis of psychogenic seizure Special laboratory: 1) electroencephalogram (EEG) is unaltered during an event [2] 2) inpatient video EEG monitoring required for diagnosis [2,3,8]* Management: - psychotherapy is helpful - many patients do not follow through [12] Notes: - eyewitness reports tend to be inaccurate [7]

General

seizure; epileptic seizure conversion disorder/functional neurologic symptom disorder

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1034-35
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2012, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  3. Bazil CW et al Provocation of non epileptic seizures by suggestion in a general seizure population, Epilepsia 35:68, 1994 PMID: 8082620
  4. Cohen RJ, Suter C, Hysterical seizure: suggestion as provocative EEG test, Ann Neurol 11:391, 1982 PMID: 7103418
  5. Desai BT, Porter RJ, Penry JK, Psychgenic seizures: a study of 42 attacks in six patients, with intensive monitoring, Arch Neurol 39:202, 1983
  6. Dreifus F, Personality of Patients with Pseudoseizures, Neurol 36:662, 1986
  7. Syed TU et al. Can semiology predict psychogenic nonepileptic seizures? A prospective study. Ann Neurol 2011 Jun; 69:997. PMID: 21437930
  8. Reuber M. Psychogenic nonepileptic seizures: answers and questions. Epilepsy Behav. 2008 May;12(4):622-35 PMID: 18164250
  9. Wikipedia: Psychogenic non-epileptic seizures http://en.wikipedia.org/wiki/Psychogenic_non-epileptic_seizures
  10. Salinsky M, Spencer D, Boudreau E, Ferguson F. Psychogenic nonepileptic seizures in US veterans. Neurology. 2011 Sep 6;77(10):945-50 PMID: 21893668
  11. LaFrance WC Jr, Baker GA, Duncan R, Goldstein LH, Reuber M. Minimum requirements for the diagnosis of psychogenic nonepileptic seizures: a staged approach: a report from the International League Against Epilepsy Nonepileptic Seizures Task Force. Epilepsia. 2013 Nov;54(11):2005-18. Review. PMID: 24111933 Free Article
  12. Tolchin B, Dworetzky BA, Martino S et al. Adherence with psychotherapy and treatment outcomes with psychogenic nonepileptic seizures. Neurology 2019 Jan 4; PMID: 30610097 - Benbadis SR. Psychogenic nonepileptic seizures, conversion, and somatic symptom disorders. Neurology 2019 Jan 4; PMID: 30610096
  13. Tolchin B, Martino S, Hirsch LJ. Treatment of Patients With Psychogenic Nonepileptic Attacks. JAMA. Published online April 26, 2019 PMID: 31026015 https://jamanetwork.com/journals/jama/fullarticle/2732484
  14. George J Stroke, Sexual Assault Trauma Tied to Psychogenic Seizures - Large study finds novel link with cerebrovascular disease MedPage Today December 8, 2020 https://www.medpagetoday.com/meetingcoverage/aes/90075 - Goleva S, et al The clinical epidemiology of psychogenic nonepileptic seizures in a hospital sample of 2,346,808 patients. Amercian Epilepsy Society (AES) 2020; Abstract 407.
  15. NEJM Knowledge+