differentials of non epileptiform seizures, with special refrence to psuedoseizures or dissociative seizures by anant kumar rathi

1. NON EPILEPTIFORM SEIZURES
Dr. Anant Kumar Rathi
Deptt. Of Neuropsychiatry
Govt. Medical College, Kota, (Raj)
26/03/2012

2. Epileptic seizure
 “A transient occurrence of signs and/or
symptoms due to abnormal excessive or
synchronous neuronal activity in the brain."
International League Against Epilepsy (ILAE)
 Epileptic seizures can occur in someone who
does not have epilepsy – as a consequence of
Head injury
Drugs
Toxins
Eclampsia
Febrile convulsions

3. Seizure imitators
MOVEMENT
IMITATORS
LOC IMITATORS
NO ONE HAVE
Each have
EPILEPTIFORM
some
BRAIN
features of
DISCHARGE
epilepsy
CONFUSION
IMITATORS
PSYCHOLOGICAL
IMITATORS

4. Movement imitators
 Unusual movements or postures – twisting & twitching
 Tremors – rhythmic shake like movements of body part
 Dystonia – continuous maintenance of abnormal posture
 Chorea – hands looks like actually dancing
 Athetosis – arms & legs move like swimming
 Hemiballismus – violent flying movements usually restricted to one
side of body
 Tics - habitual quick abnormal movements, semi voluntary

5. Loss of consciousness imitators
 Fainting/ Syncope – blood flow to brain suddenly decrease
 Panic attack – blood pooled to muscles- brain temporarily
shut down – vasovagal attack
 Loss of body fluid – hypovolemia, dehydration
 Cardiac disease – infarction, heart failure
 Hypoglycemia – prolonged fasting, excess insulin, medication
S/E, reaction to high carbohydrate load
 Hypoxia – lung disease, choking, high altitude

6. Confusion imitators
 TIA – Blood flow to brain interrupted briefly
Symptoms depends on area involved
TIA affecting speech, memory or sensory-motor area may
produce confusion, tingling, weakness
 Uncontrollable sleepiness –
Missed interrupted sleep
Medication side effect
Sleep disorders – sleep apnea, narcolepsy, night terror
 Migraine aura – Dizziness, lightheadedness, colors & lights
 Transient global amnesia – Loss of ability to form new memory
 Delirium/ encephalopathy - Prolonged confusion that waxes & wanes

7. Psychological imitators
 Breath holding spells
 Temper tantrums
 Night terrors – child screams & do not remember the episode
 Panic attacks – extreme anxiety – rapid ventilation – CO2 wash
out – dizziness, numbness, confusion, tremors – looks like
seizures
 Psychological Non Epileptic Seizures (PNES)

8. History
 Misdiagnosis of epilepsy is common - Approximately
25% of patients with a previous diagnosis of epilepsy
that does not respond to drugs
 PNES is by far the most commonly misdiagnosed
condition, accounting for >90% of misdiagnoses
 EEGs misinterpreted as providing evidence for epilepsy
often contribute to this misdiagnosis

9.  Reversing a misdiagnosis of epilepsy can be difficult
-After the diagnosis of seizures is made, it is
easily perpetuated without being questioned
-Treating Doctor does not want to stop AED

10. Pseudoseizures
 Paroxysmal episodes that resemble and often
misdiagnosed as epileptic seizures
 Paroxysmal nonepileptic episodes can be either
organic or psychogenic
 Syncope, migraine, and transient ischemic
attacks (TIAs) are examples of organic
nonepileptic paroxysmal symptoms

11. Psychogenic Non Epileptiform
Seizures (PNES)/ DS
 No abnormal electrical discharge from the brain
 Physical manifestation of a psychological disturbance
 Most frequent nonepileptic condition seen in epilepsy centers
 They are a type of conversion disorder
 Pt. is not aware & can not control
 PNES can also result from voluntary faking (feigning), as
in malingering and factitious disorder

12. PNES/DS causes
 Physical symptoms caused by psychological
causes can fall under 3 categories:
-Somatoform disorder
-Factitious disorder
-Malingering

13. Somatoform disorder
 Unconscious production of physical symptoms due to
psychological factors
 2 somatoform disorders relevant to PNES are
-conversion disorder
-somatization disorder
 Majority of patients with PNES have conversion disorder
 DSM-IV added a new subcategory conversion disorder
with seizures

14. Factitious disorder and malingering
 Patient is purposely deceiving the physician,
i.e. faking the symptoms
 Malingering - the reason for the deception is
tangible and rationally understandable
 Factitious disorder- the motivation is a
pathologic need for the sick role

15. Who has dissociative seizures?
 Can happen to anyone, at any age
 Some factors make DS more likely
-Women (>70%)
-Young adults
-History of injury or disease
-Severe emotional upset or stressful life events
-People with other psychiatric conditions
depression anxiety
personality disorders self-harm

16. What causes dissociative seizures?
 Often caused by traumatic events such as:
-accidents
-severe emotional upset
-psychological stress (such as a divorce)
-difficult relationships
-physical or sexual abuse
-being bullied

17. Sudden Dissociative seizures
remembering
traumatic
experience
Too difficult to
cope with
Person splits off
Emotional
reaction causes
Seizures
a physical effect
unconscious
reaction
uncontrolled

18. Clues which should raise the
suspicion
 Resistance to antiepileptic drugs (AED) is usually the 1st clue
 Presence of specific triggers that are unusual for epilepsy
 Emotional triggers - stress, pain, certain movements, sounds,
and seeing of lights
 Circumstances in which attacks occur
 Presence of audience, sleep

19. PNES/Dissociative seizures
 Details of the episodes - often inconsistent with epileptic seizures
 Common and helpful symptoms include -
-side-to-side shaking of the head
-bilateral asynchronous movements (e.g. bicycling)
-weeping, stuttering, and arching of the back
-pelvic thrusting
-preserved awareness
-eye flutter
-episodes affected by bystanders (intensified or alleviated)

20.  Psychosocial history with evidence of maladaptive
behaviors or associated psychiatric diagnoses
 Patient's medical history - Coexisting, poorly
defined, and probably psychogenic conditions,
such as fibromyalgia, chronic pain, and chronic
fatigue
Certain symptoms suggest epileptic seizures
-tongue biting
-ictal cry

21. Physical and neurologic
findings –
 Anxiety/ depression
 Inappropriate affect
 la belle indifference
 Multiple and vague somatic complaints

22. How are NES diagnosed?
 Try and rule out possible physical causes first, including epilepsy
 Taking a personal history
 Neurological history
 Psychological development and mental health family history
 What happens during the seizure
 What situations ?
 Any warning ?
 What happens during seizure or a witness ?
 How long the seizures last ?
 What you remember ?
 How you feel afterwards and recovery ?

23. How are NES diagnosed?
 Laboratory Studies
 Blood tests - excluding metabolic or toxic causes of seizures (e.g.
hyponatremia, hypoglycemia, drugs/toxins)
 Level of AED in Pt’s blood, whether AED is being taken? Proper dose?
 Imaging Studies
 Should be obtained to exclude physical cause
 Normal in psychogenic nonepileptic seizures
 Electroencephalogram
 Records the electrical activity of the brain
 Often used to see if seizures are caused by disrupted brain activity

24. Epilepsy & prolactin level elevation
 > 2-3 fold prolactin elevation measured within 10 – 20 mins of
seizure suggests presence of epileptic seizure
 The lack of such an elevation makes it unlikely that an ictal event
was epileptic if the event was a tonic-clonic seizure
 Limitations :-
-Cannot be used to differentiate simple partial seizures or
absence seizures from nonepileptic seizures
-Prolactin levels may increase during syncope
-Complex partial seizures that do not arise from the temporal
lobe do not lead to prolactin elevation
-10% to 20% of patients with tonic-clonic seizures may not
show a postictal prolactin rise
-Level rises predictably only after a single seizure, patients
having > 2 seizures in 12 hours have progressively smaller
elevations, presumably because stored prolactin from
pituitary lactotrophs is exhausted

25. How are PNES diagnosed?
 Routine EEG is not helpful in confirming diagnosis of PNES
 Repeatedly normal EEG findings
 Frequent attacks May be
PNES
 Resistance to medications
 EEG video monitoring
Standard for diagnosis
Indicated in all patients having frequent seizures despite AED

26. EEG video monitoring
 Principle is to record an episode and
demonstrate that no change in the EEG
occurs during the clinical event
 Inductions - Provocative techniques -
intravenous injection of saline - principle is
suggestibility

27. Treatment
Medical Care
 Most important step is delivering the diagnosis
to patients and their families
 Obstacle to effective treatment- Physicians are
uncomfortable with the diagnosis of PNES
 They may write, "no EEG change during the
episode, no evidence for epilepsy," or "seizures
were nonepileptic.“

28. Treatment
Role of the Neurologists
 Determine whether organic disease exists
 Once the symptoms are shown to be
psychogenic, the exact psychiatric diagnosis and
its treatment are best handled by the
psychiatrist

29. Treatment
Role of the Psychiatrist
 Psychotherapy
 Treatment coexisting anxiety or depression
 Patient education
 Family members education
Patient & Family members education
 Thorough patient education is the first step in treatment
 Patients and their families must understand about the
disease
 Necessity to comply with the recommendations of the
psychiatric caregiver

30. Prognosis
 Duration of illness is probably most important prognostic factor in PNES
 Early & definite diagnosis of PNES is critical
 Generally better in children and adolescents than in adults
-duration of illness is shorter
-psychopathology or stressors are different in pediatric
patients than in adults
 Prognosis depends on
-Pt’s motivation
-Treatment of underlying psychological illness
-Good medical help

31. Activity
 Patients with PNES usually do not require any
limitation of activities
 Nevertheless, restrictions on potentially
hazardous activities may be appropriate in
some cases

32. Take home message
 Everything which moves is not seizure
 Rule out other possible physical cause
 Take proper history
 Most common cause of non epileptic seizures is PNES
Susceptible person
Presence of stress
Frequent attacks
Repeatedly normal EEG
Not responding to AED
 Video EEG showing no abnormal electrical discharges
during attack confirms the diagnosis

33. Take home message
 Early diagnosis is essential
 Best to be managed by a psychiatrist
 Delivering the diagnosis is usually the first step
 Explain the disease to patient as well family members
 Treatment of co morbid psychiatric illness is necessary
 Psychotherapy is given
 Advised to follow up with Psychiatrist