Abstract
Psychogenic nonepileptic seizures (PNES) are neurobehavioral conditions positioned in a gray zone, not infrequently a no-man land, that lies in the intersection between Neurology and Psychiatry. According to the DSM 5, PNES are a subgroup of conversion disorders (CD), while the ICD 10 classifies PNES as dissociative disorders. The incidence of PNES is estimated to be in the range of 1.4–4.9/100,000/year, and the prevalence range is between 2 and 33 per 100,000. The International League Against Epilepsy (ILAE) has identified PNES as one of the 10 most critical neuropsychiatric conditions associated with epilepsy. Comorbidity between epilepsy and PNES, a condition leading to “dual diagnosis,” is a serious diagnostic and therapeutic challenge for clinicians. The lack of prompt identification of PNES in epileptic patients can lead to potentially harmful increases in the dosage of anti-seizure drugs (ASD) as well as erroneous diagnoses of refractory epilepsy. Hence, pseudo-refractory epilepsy is the other critical side of the PNES coin as one out of four to five patients admitted to video-EEG monitoring units with a diagnosis of pharmaco-resistant epilepsy is later found to suffer from non-epileptic events. The majority of these events are of psychogenic origin. Thus, the diagnostic differentiation between pseudo and true refractory epilepsy is essential to prevent actions that lead to unnecessary treatments and ASD-related side effects as well as produce a negative impact on the patient's quality of life. In this article, we review and discuss recent evidence related to the neurobiology of PNES. We also provide an overview of the classifications and diagnostic steps that are employed in PNES management and dwell on the concept of pseudo-resistant epilepsy.
Highlights
Psychogenic non-epileptic seizures (PNES) are relatively common disorders managed by epilepsy centers [1] and consist of paroxysmal motor, non-motor, or behavioral alterations that resemble epileptic seizures without EEG correlates
We review and discuss recent evidence related to the neurobiology of PNES; we provide an overview of classifications and diagnostic steps that are employed in PNES management
PNES patients show decreased activity in the right triangular inferior frontal gyrus, an area that is part of the ventrolateral prefrontal cortex and associated with the modulation of response inhibition [50]. These findings suggest that alterations of the functional connectivity of brain regions associated with attention, memory, emotion processing, sensory, and motor functions are compromised in PNES patients
Summary
Psychogenic non-epileptic seizures (PNES) are relatively common disorders managed by epilepsy centers [1] and consist of paroxysmal motor, non-motor, or behavioral alterations that resemble epileptic seizures without EEG correlates. PNES patients show decreased activity in the right triangular inferior frontal gyrus, an area that is part of the ventrolateral prefrontal cortex and associated with the modulation of response inhibition [50] These findings suggest that alterations of the functional connectivity of brain regions associated with attention, memory, emotion processing, sensory, and motor functions are compromised in PNES patients. A word of caution is required as, according to recent evidence, the prevalence of aura, subjective symptoms, urinary incontinence, night occurrence of ictal events, and self-injury in PNES patients is higher than what previously researches reported, thereby making challenging to discriminate PNES and epileptic seizures only based on clinical signs. There is no evidence that any of these invasive procedures are more effective than an intranasal tickle with a cotton swab [90]
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