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Walker Foland, an emergency physician practicing in Michigan, breaks down why pseudoseizures, now termed PNES (Psychogenic Nonepileptic Seizures), are a real disease.
Walker Foland is an emergency physician practicing in Michigan and in this episode breaks down why pseudoseizures, now termed PNES (Psychogenic Nonepileptic Seizures), are a real disease.
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Are patients with PNES ‘faking it’?
- PNES is a conversion disorder: an unconscious manifestation of psychological trauma.
- Walker treats PNES patients with haloperidol or olanzapine with the thinking that this is psychological, not true epilepsy
- PNES is not ‘faking it’ or lying
- Patients with PNES may also have true epileptic seizures
- Diagnosing PNES, or separating it from epilepsy, may take video EEG monitoring, a neurologist, and sometimes prolonged periods of time to figure things out
How to tell the difference between a grand mal epileptic seizure vs PNES vs faking it?
- Seizures related to a specific stimulus (sound foods, body movement)
- Frequency and amplitude of concussions: same frequency through the seizure with varying amplitude.
- Maintenance of consciousness and may have some of the below
- may guard the face with passive hand drop
- resist eyelid opening
- visual fixation on a mirror
- Whit Fisher, Dr. Procedurettes, squirts water in the face of patients where there is thought of PNES. If they grimace, probably not an epileptic seizure.
- Purposeful movement
- Avoids injury
- May use convulsions as a way of harming staff
- Intermittently awake and vocal during the episode
- Convulsive frequency decreases, amplitude increases as seizure progresses
- No response to pain
- Allow passive eye opening
A 2010 article from the Journal of Neurology Neurosurgery and Psychiatry broke down the evidence of what other elements can help distinguish PNES from epileptic seizures.
- Duration over 2 minutes suggests PNES, but we’ve all seen epileptic seizures last for a long time, status, and some PNES can be super short
- Happens in sleep. Evidence suggests that if the event happens in sleep, that is probably episode. PNES episodes happen when awake
- Fluctuating course such as a pause in the rhythmic movement, epileptic seizures usually don’t pause and then restart, a pause favors PNES
- Flailing. You’d think the flailing patient has PNES for sure because epilepsy doesn’t flail, but it does! Flailing is much more common in PNES, but not so much so that it’s a clear distinguishing factor
- Urinary incontinence, more common in epilepsy, but does happen in PNES.
- Post-ictal recovery period. Surely, this is the sine qua non of epilepsy. It is way-way more common following generalized epileptic seizures but happens in around 15% of PNES.
- The stertorous breathing (noisy, labored) that we see after generalized tonic-clonic epileptic seizures suggests epilepsy and is not a characteristic of PNES
Walker’s take-home points
- PNES patients aren’t ‘faking it’
- This is a real disorder, it’s just not epilepsy
Photo Credit Hal Gatewood
Chen, David K., and W. Curt LaFrance Jr. “Diagnosis and treatment of nonepileptic seizures.” CONTINUUM: Lifelong Learning in Neurology 22.1, Epilepsy (2016): 116-131. PMID:26844733
Avbersek, Andreja, and Sanjay Sisodiya. “Does the primary literature provide support for clinical signs used to distinguish psychogenic nonepileptic seizures from epileptic seizures?.” Journal of Neurology, Neurosurgery & Psychiatry 81.7 (2010): 719-725.Full-Text PMID:20581136