This post is part of a series of guest posts on GPS by the graduate students in my Psychopathology course. As part of their work for the course, each student had to demonstrate mastery of the skill of “Educating the Public about Mental Health.” To that end, each student has to prepare two 1,000ish word posts on a particular class of mental disorders.
Differentiating Psychogenic Non Epileptic Seizures from Epileptic Seizures by Sandy Guzman
Imagine waking up one day and not being able to trust your own body. The thought that at any minute you could be unconscious. The struggle of having to make changes in your life because getting behind the wheel puts the lives of others and your own in danger. These are experiences some individuals that have tonic-clonic seizures go through. They may go to a neurologist but they are unable to determine why they are experiencing these symptoms.This is an issue that individuals that have psychogenic seizures (sometimes called pseudo seizures) encounter.
Many questions arise and the lack of explanation leads to frustration and confusion. Typically when an individual starts having tonic-clonic seizures they are given the diagnosis of epilepsy. But what happens to an individual who is given this diagnosis but is not corresponding to the medicinal treatment? Up to 25% of individuals who are given the diagnosis of epilepsy that are not responding to the medicinal treatment are misdiagnosed. Around 1 in 5 patients who believe they have a diagnosis of epilepsy in fact do not have epilepsy. So, how are we truly able to distinguish a person who has epileptic seizures vs a person who is experiencing psychogenic non epileptic seizures (PNES)?
PNES are tonic-clonic convulsions that look very similar to epileptic convulsions. The individual may lose consciousness, fall, and start to convulse. The main thing that differentiates between the two is that epileptic seizures are caused by an abnormal electrical discharge of the brain. Individuals with PNES do not have abnormal electrical discharge in their brains.Typically if another person is present they describe what the seizure looks like based on what they saw. They then begin to run medical tests on the individual. An electroencephalogram (EEG), is usually one of the testing procedures used to determine if an individual has epilepsy because it detects abnormal electrical discharges. A person experiencing PNES will have a normal EEG. An epileptologist is aneurologist who specializes in epilepsy, would have to determine and recognize the features of psychogenic seizure. This could be done with EEG-video monitoring or until the neurologist is present to see the actual seizure. An EEG-video monitor would record an individual for a period of hours to days until the individual has a seizure. These seizures will look like a tonic-clonic seizure but they have a different type of convulsion, and the frequency, duration and trigger are different in psychogenic non epileptic seizures. But what causes PNES?
It is believed that people experiencing PNES do not actually have a neurological disorder, but their seizures are triggered from stress and some individuals may have some kind of previous psychological traumatic event. Psychological stresses can sometimes trigger physical symptoms even when there is no illness. Conversion disorder, also known as functional neurological symptom disorder, is the appropriate diagnoses for an individual who is experiencing PNES. The DSM-5 has criteria in order for an individual to be diagnosed with conversion disorder they must have one or more symptoms that are of altered voluntary motor or sensory function. This symptom is one of the main factors in determining whether or not the individual will have conversion disorder. There must be a clash between the altered voluntary motor or sensory function symptoms and the recognized neurological or medical conditions. These symptoms must not be better explained by another medical or mental disorder and the symptom must cause significant distress that it affects the individual in their daily functioning. If an individual presents these symptoms they may have conversion disorder, and if they are experiencing PNES the individual would receive the diagnosis of conversion disorder with attacks or seizures then they must note how often they occur and if there is a psychological stressor present.
Individuals that have PNES may have had some kind of traumatic event like physical abuse, sexual abuse, divorce, incest, or loss of a loved one are events that are typically seen in individuals that have these seizures. It is important to note that even though these individuals are experiencing something that is physical, PNES is grouped under conversion disorder and it would be a psychiatric diagnosis, not a medical diagnosis. It is something, though, that can be diagnosed with the help of an epileptologist and EEG-video monitoring.
Individuals seeking treatment face the possibility of having a doctor who may be skeptical about the diagnosis. Although PNES are relatively common, it may be useful for the individual to provide their psychiatrist or epileptologist with the EEG-video recording if there is any doubt. Individuals who have been diagnosed with PNES are able to seek treatment and reduce the amount of seizures they are having or eliminate these types of seizures completely.The most effective treatment for PNES so far is cognitive behavioral therapy (CBT). CBT in the case of PNES conceptualizes the pseudoseizures as dissociative responses to stimulation when the individual is faced with circumstances they tend to avoid, whether this is done consciously or not.
CBT may include the following stages: 1) engaging the individual in treatment 2) reinforcing the individual to be independent 3) distraction, relaxation, and refocusing techniques at early signs of an event 4) exposure to situations typically avoided 5) cognitive restructuring and 6) the prevention of relapse. CBT may be combined with SSRIs or other antidepressant medications. One of the more difficult parts of intervention is getting the individual into treatment since it may be difficult for them to think of their seizures needing a psychiatric intervention instead of a medical intervention. It is also very important to note that if the individuals were previously on antiepileptic medications, they should be withdrawn under the supervision and continued consultation of their physician since these antiepileptic drugs can have serious side-effects, especially if they are stopped abruptly.