Psychogenic non-epileptic seizures (PNES) in the context of concurrent epilepsy \u2013 making the right diagnosis

Andreas Liampas,Sofia Markoula,Panagiotis Zis,Markus Reuber

doi:10.1186/s42494-021-00057-x

Abstract

Epilepsy is a risk factor for the development of psychogenic non-epileptic seizures (PNES) and comorbid epilepsy is recognized as a comorbidity in about 10–30% of patients with PNES. The combination of epileptic and nonepileptic seizures poses a particular diagnostic challenge. In patients with epilepsy, additional PNES may be suspected on the basis of their typical semiology. The possibility of additional PNES should also be considered if seizures fail to respond to antiepileptic drug treatment, in patients with frequent emergency admissions with seizures and in those who develop new types of seizures. The description of semiological details by patients and witnesses can suggest additional PNES. Home video recordings can support an initial diagnosis, however, especially in patients with mixed seizure disorders it is advisable to seek further diagnostic confirmation by capturing all habitual seizure types with video-EEG. The clinical features of PNES associated with epilepsy are similar to those in isolated PNES disorders and include longer duration, fluctuating course, asynchronous movements, pelvic thrusting, side-to-side head or body movement, persistently closed eyes and mouth, ictal crying, recall of ictal experiences and absence of postictal confusion. PNES can also present as syncope-like episodes with unresponsiveness and reduced muscle tone. There is no unique epileptological or brain pathology profile putting patients with epilepsy at risk of additional PNES. However, patients with epilepsy and PNES typically have lower educational achievements and higher levels of psychiatric comorbidities than patients with epilepsy alone. Psychological trauma, including sexual abuse, appears to be a less relevant aetiological factor in patients with mixed seizure disorders than those with isolated PNES, and the gender imbalance (i.e. the greater prevalence in women) is less marked in patients with PNES and additional epilepsy than those with PNES alone. PNES sometimes develop after epilepsy surgery. A diagnosis of ‘known epilepsy’ should never be accepted without (at least brief) critical review. This narrative review summarises clinical, electrophysiological and historical features that can help identify patients with epilepsy and additional PNES.

Highlights

Psychogenic non-epileptic seizures (PNES) are experiential and behavioral responses to adverse internal and external stimuli involving loss of self-control and arousal
A recent systematic review and metaanalysis of a large number of cohort studies reported that a mean of 22% of patients with PNES have additional epilepsy and a mean of 12% of patients in cohorts with a primary diagnosis of epilepsy have comorbid PNES [4]
The early recognition of PNES in individuals who have previously been diagnosed with epilepsy is of great importance for safe medical management [12]. In this narrative review we initially summarize demographic, etiological and clinical features of patients with PNES and comorbid or pre-existing epilepsy before focusing on the diagnostic methods available to clinicians to help with the recognition of comorbid PNES disorders among their patients with epilepsy

Summary

Introduction

Psychogenic non-epileptic seizures (PNES) are experiential and behavioral responses to adverse internal and external stimuli involving loss of self-control and arousal. Several studies suggest that a history of trauma (including sexual abuse) is less often identified as a potential etiological factor in patients with a concurrent diagnosis of PNES and epilepsy than in those being diagnosed only with PNES, especially in populations in which PNES arise in the context of ID and epilepsy [20, 29].

Results

Conclusion