The Treatment of Nonepileptic Seizures: Historical Perspectives and Future Directions

Summary:  Nonepileptic seizures (NES) are neuropsychiatric disorders presenting with a combination of neurologic signs and underlying psychological conflicts. For more than a century, the medical community has accumulated data and insights about the phenomenology, epidemiology, risks, comorbidities, and prognosis of NES. However, we have not progressed much beyond anecdotal reports of treatments for NES, and no randomized, controlled trials of treatment for the disorder have been conducted. We review the diagnosis and treatment of NES and suggest directions for future research in these areas.     

Psychogenic Seizures in Old Age: A Case Report

Psychogenic seizures are unusual after age 60 years, A 73-year-old woman had onset of psychogenic seizures at age 69 years. Five to six attacks occurred each month, usually at night, characterized by an initial subjective sensation and headache followed by generalized stiffening and shaking. Continuous EEG-closed circuit television (EEG-CCTV) monitoring clearly showed these episodes to be nonepileptic. Discontinuation of antiepileptic drugs (AEDs) did not increase the frequency or severity of attacks. Epileptiform discharges were not recorded during the awake, drowsy, or sleeping states. Psychiatric evaluation identified significant turmoil in the patient's life and a history of childhood sexual and physical abuse. Psychogenic seizures may begin in old age and should be considered in the differential diagnosis of intractable seizures in the elderly. Predominantly nocturnal occurrence should not exclude the diagnosis.     

Comparison of two types of dissociation in epileptic and nonepileptic seizures

Dissociation is regarded as a possible psychological mechanism in nonepileptic seizures (NES), although existing evidence for this is equivocal. It has been suggested that the contradictory findings in this area reflect the use of measures that conflate qualitatively distinct types of dissociation, and provide inadequate coverage of the aspects of dissociation most closely related to NES. The study described here addressed this shortcoming by measuring the occurrence of two different types of dissociation, “detachment” (measured using the Cambridge Depersonalisation Scale) and “compartmentalization” (measured using the Somatoform Dissociation Questionnaire), in patients with NES (n = 32) and epilepsy controls (n = 37). As predicted, patients with NES scored significantly higher on the measure of compartmentalization only; contrary to prediction, however, this difference was no longer significant when anxiety and depression were controlled for. The conceptual and methodological implications of the study are discussed.     

Practitioner Review: Recognition of Pseudoseizures in Children and Adolescents

Pseudoseizures or their possibility remain a troublesome clinical issue with serious implications as, particularly in older children and adolescents, they can take various forms so that their differential diagnosis is wide. Many of the traditional criteria do not, in fact, discriminate well between pseudoseizures and other episodic disorders, especially those involving dramatic behavioural manifestations. These include certain forms of epilepsy (notably mesial frontal seizures) and some other organic and psychiatric conditions. A number of more reliable diagnostic criteria remain. These include selective clinical criteria and certain findings from carefully conducted EEG monitoring with informed analysis of the results.     

Impaired motor function in patients with psychogenic pseudoseizures

PURPOSE: To evaluate motor speed and grip strength in patients with well-documented psychogenic pseudoseizures. METHODS: We analyzed manual motor speed and grip strength in a group of 40 patients with confirmed psychogenic pseudoseizures (without evidence of concomitant epilepsy) and a group of 40 normal controls matched for handedness and gender, and of comparable age. The two groups were compared with respect to manual motor performance with the dominant hand, nondominant hand, and asymmetry between the dominant and nondominant hands. For the patient sample, we reviewed the neurologic history. RESULTS: Patients with pseudoseizures performed more poorly than controls with both dominant and nondominant hands. In addition, pseudoseizure patients failed to demonstrate the dominant-hand advantage observed in the normal control subjects on both tasks. The patient group had a high incidence of head trauma and other antecedent neurologic risk factors, and the proportion of left-handers was 3 times higher than expected. CONCLUSIONS: Bilaterally reduced motor speed and grip strength, reduced intermanual performance asymmetry, the high percentage of left-handers, and historical evidence of antecedent insults to the brain indicate that frontal lobe impairment may be common in patients with psychogenic pseudoseizures.     

Neuron-Specific Enolase Is Increased After Single Seizures During Inpatient Video/EEG Monitoring

Neuron-specific enolase (NSE) is a marker of brain injury after acute neurologic insults. We report changes in serum NSE (s-NSE) in 25 patients (15 with epilepsy and 10 patients with nonepileptic events) during continuous inpatient video/EEG monitoring. s-NSE was significantly increased as compared with baseline and normal controls after the first ictal event in the epileptic group, especially in patients with secondarily generalized tonic-clonic seizures (p = 0.01), but s-NSE was not increased in patients with nonepileptic events. These preliminary data indicate that s-NSE may be increased after complex partial seizures-and generalized tonic-clonic seizures (GTCS).     

When Should Induction Protocols Be Used in the Diagnostic Evaluation of Patients with Paroxysmal Events?

Summary: Purpose: To determine the timing of spontaneous psychogenic nonepileptic events (PNEE) during video-EEG telemetry (VEEG), and the need to use induction protocols (IP).
Methods: We studied 100 consecutive patients (75 females, 25 males) admitted to our inpatient VEEG unit from July 1994 to June 1996 for differential diagnosis of paroxysmal events. We recorded the time to the first diagnostic spontaneous event, identified by the patient or a family member as typical. Episodes were classified as PNEE, physiologic nonepileptic events (PhysNEE), and epileptic seizures (ES).
Results: The mean duration of VEEG was 74 ± SD 54.1 h. In 82 patients, a diagnostic event occurred spontaneously. The first event was an ES in 22 patients, a PNEE in 53, and a PhysNEE in 7. The time to first diagnostic event was significantly shorter for PNEE than for ES [15.0 ± SD 16.3 h (range 5 min to 58 h) vs. 28.6 ± SD 34.0 h (range 1–110 h) F = 15.621, p <0.00011. In the first 24 h, 77.4% of the patients with PNEE had an event. By 48 h, all but 2 (96.2%) had had diagnostic events. After the first 58 h of monitoring, all patients with PNEE experienced a spontaneous diagnostic event.
Conclusion: Spontaneous events can be expected to occur within 48 h in most patients with PNEE. Therefore, if IP are to be used as a diagnostic tool, we suggest that they be withheld during the initial 48 h of VEEG monitoring.     

Epileptic Seizures and Pseudoseizures from the Viewpoint of the Hierarchy of Consciousness

Summary: Epileptic seizures and pseudoseizures in temporal lobe epilepsies were studied from the viewpoint of the hierarchy of consciousness. Twenty-two patients with temporal lobe epilepsies (TLE) who showed true amnesia or impairment of consciousness developing from the dreamy state, even though their actions and movement continued, were selected among 160 patients with TLE. nine patients with manifested pseudo-seizures, pseudoseizure status, and complex partial seizure status (CPSE) were investigated. Twelve, patients in whom impairment of consciousness followed the dreamy state recognized their own existence and maintained some self-directed consciousness. The other 10 patients with amnesia were aware of their goals. Furthermore, pseudostatus ranged from epileptic seizures during pseudoseizure status to pseudoseizures during status epilepticus (SE). In some cases of CPS, awareness and self-directed consciousness were only partially pseudoseizures, disorders of self-directed consciousness are assumed to influence awareness and arousal.     

The spectrum of nonepileptic events in children

Nonepileptic events (NEE) are common in children, and can be difficult to distinguish from epileptic events. Several strategies can assist in differentiation. The first is an age-based approach to the differential of commonly presenting EEs in neonates, infants, and adolescents. The next strategy is to identify key elements of the patient's history to narrow the possibilities, and third is a rational approach to ancillary testing. There are additional challenges to the diagnosis and evaluation of NEEs in patients with cognitive impairments or mental retardation (MR). Twenty to 25% of neurologically normal patients (34), and up to 60% of children with MR (35) referred for an evaluation of seizures, have NEE. In most instances, the clinical history leads to the diagnosis, and ancillary testing serves as confirmation. But in certain populations, neonates, children with concurrent epilepsy, children in whom pseudoseizures are suspected, and children with MR, early use of video-EEG telemetry is indicated to establish the diagnosis and avoid overtreatment with antiepileptic drugs (AEDs).     

Bicycling Movements as a Manifestation of Complex Partial Seizures of Temporal Lobe Origin

Alternating movements of the limbs during a seizure, especially bicycling movements of the legs, are often taken as strong evidence for the psychogenic origin of seizure activity in an adult population. A recent review of pseudoseizure manifestations concluded that alternating limb movements were "highly characteristic of pseudoseizures." We report two adult patients with complex partial seizures of temporal lobe origin, confirmed by ictal video EEG recording, in whom bicycling movements were the prominent ictal manifestation. Bicycling occurred 5-30 s after ictal onset and lasted 15-30 s. Use of video EEG recording continues to increase our understanding of the wide range of behaviors which may occur in the course of an epileptic seizure, particularly complex partial seizures. Few absolute clinical criteria remain to distinguish epileptic seizures from pseudoseizures. These two cases and one other reported case clearly remove bicycling movements from that category.