Dr. Kerr of Eisenhower Medical Center has no relevant finanacial relationships to disclose.)
Dr. Stern, Director of the Epilepsy Clinical Program at the University of California in Los Angeles, received honorariums from Greenwish, Sunovion, and UCB as an advisor and from Greenwich, Eisai, LivaNova, and UCB as a lecturer.)
This article includes discussion of psychogenic seizures, dissociative seizures, hysteroepilepsy, nonepileptic seizures, pseudoseizures, and psychogenic status. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.
Psychogenic seizures often challenge even experienced epilepsy experts in their diagnosis because of their behavioral overlap with epileptic seizures, their potential comorbidity with epilepsy, and the limited quality of patient/witness descriptions of seizures. Once diagnosed, they pose the additional challenges of understanding their cause and providing effective treatment. In this review, the fundamental clinical aspects of psychogenic seizures are surveyed, including issues of differential diagnosis, prognosis, and management.
• Psychogenic nonepileptic seizures mimic epileptic seizures and often result in misdiagnosis as epilepsy.
• Psychogenic seizures are involuntary and often disabling.
• Accurate diagnosis of psychogenic seizures leads to more appropriate and effective healthcare resource utilization.
Historical note and terminology
Until the writings of the great European neurologists of the mid-19th century, most Western physicians considered all epileptic phenomena to be psychiatric, and patients with epilepsy were commonly committed to institutions for the insane. Following recognition of a number of ictal phenomena as reflecting neurologic disease processes and acceptance of epilepsy as an organic cerebral disorder, Charcot, in 1886, described psychogenically-induced signs and symptoms and included certain epileptic-like ictal events among them (Charcot 1886). The classical hysterical seizures illustrated in Charcot's writings are still regularly encountered today.
There is significant debate as to appropriate and sensitive terminology regarding patients events. Each of the following phrases are acceptable for clinical practice:
• Psychogenic nonepileptic seizures
The most common term used in the United States is psychogenic nonepileptic seizures (PNES), whereas in Europe the term psychogenic nonepileptic attacks (PNEA) is more common. Some patients and a minority of providers consider “psychogenic” a pejorative term because it is connected to the stigma of psychological disease. In these cases, the term “dissociative seizures” is appropriate because during events the patient s physical movements or mental status dissociates from conscious control.
The terms psychogenic nonepileptic seizures and psychogenic nonepileptic attacks often are shortened to psychogenic seizure, psychogenic attack, or psychogenic event. Although the definition of the word “seizure” does not require that the event is epileptic, the debate regarding terminology focuses on whether a patient s events should be called seizures because of the practical problem that nonexpert providers frequently assume all seizures are epileptic, resulting in inappropriate sedation and/or intubation for psychogenic status in emergency departments and inappropriate treatment with antiseizure medication by other physicians (LaFrance and Benbadis 2006).
In general, we recommend choosing the terminology that the provider feels can be understood and accepted by the patient as descriptive of their seizures. If patients are especially sensitive to the stigma of psychiatric disease or interpret psychogenic to imply that they are “faking” or purposely “creating” their events, then it is appropriate to avoid that terminology.
We recommend using these terms over the less specific term of nonepileptic seizures because lack of specificity can lead future providers to inappropriately consider nonpsychogenic and nonepileptic causes of events like complex migraines or cardiogenic syncope even after the diagnosis of psychogenic nonepileptic seizures has been documented or clinically established. Similarly, the term “functional seizures” can indicate to healthcare providers that the events are nonepileptic, but its interpretation is unnecessarily opaque to patients.
The terms pseudoseizures and hysterical seizures are considered pejorative and should be avoided. In all cases, providers should avoid using the terms “real” and “fake” referring to epileptic or nonepileptic seizures. Although these terms are pervasive, their use causes real harm to the therapeutic relationship between patient and provider, especially in the emergency setting (Robson and Lian 2017).
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