Psychogenic seizures

Wesley T Kerr PhD (Dr. Kerr of the University of California in Los Angeles and California Institute of Technology Medical Scientist Training Program has no relevant financial relationships to disclose.)
John M Stern MD (Dr. Stern, Director of the Epilepsy Clinical Program at the University of California in Los Angeles, received honorariums from Sunovion and UCB as an advisor and from Cyberonics, Eisai, Lundbeck, and UCB as a lecturer.)
Originally released July 26, 1994; last updated January 30, 2017; expires January 30, 2020

This article includes discussion of psychogenic seizures, hysteroepilepsy, nonepileptic seizures, pseudoseizures, and psychogenic status. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

Psychogenic seizures often challenge even experienced epilepsy experts in their diagnosis because of their behavioral overlap with epileptic seizures and their potential comorbidity with epilepsy. 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.

Key points

 

• 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. The most common term used in the United States is psychogenic nonepileptic seizures (PNES), whereas in Europe the term psychogenic nonepileptic attack disorder (PNEAD) is more common. These terms 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).

The terms pseudoseizures and hysterical seizures are considered pejorative and should be avoided. Some patients and a minority of providers also consider “psychogenic” as a pejorative term and opt for the less specific term of nonepileptic seizures. In all cases, providers should avoid using the terms “real” and “fake” referring to epileptic or nonepileptic seizures.

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