Nonepileptic Posttraumatic Seizures

Summary: Purpose: Epileptic posttraumatic seizures (PTSs) are a well-recognized consequence of head injury (HI), but HI and nonepileptic seizures (NESs) have not been related. We describe a significant subset of patients with NESs who had their seizures attributed to HI.
Methods: We reviewed the records of all patients diagnosed with NES at the University of Maryland Medical Center over a 6-year period (1989–1995) and selected patients with seizures attributed to a head injury occurring ≥3 years before the onset of their seizures.
Results: Of 157 patients with video-EEG confirmed NES, 37 (24%) had the onset of their seizures attributed to an HI. Their average age was 34 years (range, 15–56 years); 68% were women. Nonepileptic PTS usually developed within the first year after HI (89%). Convulsive symptoms were present in 54%. Whereas epileptic PTSs characteristically follow severe HI, the majority (78%) of our patients with nonepileptic PTSs sustained only mild HI. Before their HI, 76% of our patients were employed, working in the home, or students, but only 11% could continue those activities after developing nonepileptic PTSs.
Conclusions: Nonepileptic PTSs are frequently mistaken for epileptic PTSs and result in serious disability. The misdiagnosis of nonepileptic PTSs leads to ineffective and inappropriate treatment. Patients with intractable seizures after HIS, articularly mild HIS, should be carefully evaluated for NESs.     

Postictal SPECT in Epileptic Versus Nonepileptic Seizures

Despite advances in video-electroencephalogram (EEG) technology, in many patients distinguishing epileptic seizures from nonepileptic seizures (NES) remains a challenge. Reliable methods to make this distinction are needed. In a pilot study, we performed postictal and interictal single photon emission computed tomography (SPECT) in 22 patients undergoing video-EEG monitoring who had altered responsiveness during an episode. Eleven had seizures, defined as episodes associated with EEG seizure patterns or postictal prolactin (PRL) elevations greater than 1.5 times the highest interictal baseline PRL; 11 had NES. Among the 11 seizures, postictal SPECT was abnormal in seven (regions of hypoperfusion in six and hyperperfusion in one) and normal in four. In six cases (55%), the interictal and postictal SPECT changed. Among the 11 NES cases, postictal SPECT was abnormal in three cases (all hypoperfusion abnormalities) and normal in eight cases. In no case did the interictal and postictal SPECT change. This small sample revealed a trend toward greater hypometabolism (postictal versus interictal) on SPECT for epileptic seizures compared to NES (p < 0.12). There were postictal SPECT changes in two of five seizures unassociated with postictal PRL elevation. Prolactin was elevated in two cases unassociated with change on SPECT. Comparision of postictal to interictal SPECT may help distinguish epileptic seizures from NES. Results from SPECT may also help identify epileptic seizures unassociated with PRL elevation.     

Characteristics of patients with nonepileptic seizures

The personality features, neuropsychological data, and ictal characteristics of 23 patients with nonepileptic seizures (NES) were compared to 25 patients with EEG-confirmed epileptic seizure (ES) disorders. A distinctive pattern of seizure, behavior, and personality features was evident in NES patients. NES was characterized by later disease onset and shorter disease duration. NES tends to last significantly longer than ES and rarely results in tongue-biting or self-injury. Patients who develop NES frequently have witnessed seizures prior to developing the disorder and have greater somatic concerns than patients with ES. Neuropsychological group data failed to differentiate NES from ES. However, the absence of group differences may reflect heterogeneity within the NES population. Although many NES patients performed well within normal limits on all neuropsychological measures, most were mildly to severely impaired. Qualitative analysis of neuropsychological data also revealed inconsistencies within the NES group. These findings suggest that a more global neurobehavioral profile may be useful in the diagnosis of NES. Future studies of NES must also recognize that important individual differences may be masked within group data.     

De Novo Psychogenic Nonepileptic Seizures After Epilepsy Surgery

Summary: Purpose: The occurrence of de novo nonepileptic seizures (NES) after epilepsy surgery have been reported only twice in the literature (one article and one abstract).
Methods: We report three patients whose de novo NES were documented by video-EEG telemetry after epilepsy surgery. These patients were drawn from a sample of 166 consecutive patients who underwent epilepsy surgery at our center between 1989 and 1996.
Results: Two patients became seizure free after surgery, and one had significant improvement of her seizures. The interval between the date of surgery and the development of the symptoms was variable (8, 10, and 47 months, respectively). The clinical phenomena of NES differed from those of the epileptic seizures preceding surgery. Their diagnosis had not been suspected in two patients before the diagnostic video-EEG monitoring study. After the diagnosis of NES, spells stopped in two patients and recurred rarely in one.
Conclusions: We conclude that de novo NES appears to occur rarely after epilepsy surgery. Given that the possibility of NES was suspected in only one patient, its incidence after surgery may be higher than so far reported. Physicians should therefore consider NES in the differential diagnosis of recurrent seizures after a seizure-free period after epilepsy surgery.     

Posttraumatic stress disorder, dissociation, and sexual abuse history in epileptic and nonepileptic seizure patients

Rates of posttraumatic stress disorder (PTSD), dissociative symptoms, and childhood sexual abuse (CSA) are believed to be higher among patients with nonepileptic seizures (NES) than those with epileptic seizures (ES). However, women have higher rates of CSA and sexual assault than men. Comparisons of seizure type controlling for gender may produce different results. Data from an opportunity sample of 34 patients with ES and 17 with NES evaluated during or following phase 1 video-EEG monitoring demonstrated that patients with NES had statistically higher rates of PTSD and CSA and higher Dissociative Experiences Scale (DES) scores than patients with ES. No differences were found between women with NES and ES for histories of PTSD or CSA. Mean between-group DES score differences remained. Results indicated that PTSD, dissociation, and CSA may be common among women presenting to a tertiary epilepsy referral center for both ES and NES. Neither a positive history of CSA nor a history of PTSD was evidence against epilepsy.     

A comparative study of trauma and posttraumatic stress disorder prevalence in epilepsy patients and psychogenic nonepileptic seizure patients

PURPOSE: This study tests the hypothesis that trauma histories, including histories of physical and sexual abuse, and posttraumatic stress disorder (PTSD) are more prevalent in psychogenic non-epileptic seizure (NES) patients than in epilepsy patients. METHODS: Thirty-five inpatients with intractable seizures were evaluated for trauma history and PTSD. After these assessments, patients were diagnosed as having either epileptic or nonepileptic seizures through EEG monitoring. RESULTS: NES diagnosis correlated with PTSD and total number of lifetime traumas, adult traumas, and abuse traumas. Contrary to previous hypotheses, reported childhood sexual abuse (CSA) did not correlate significantly with NES diagnosis. However, CSA predicted PTSD in a discriminant analysis. CONCLUSIONS: We found evidence for the hypothesized relations between trauma, abuse, PTSD, and NES diagnosis. However, elevated levels in both seizure-disorder groups suggest that routine assessment for abuse, trauma, and PTSD might facilitate medical care and treatment for all intractable seizure patients.     

Evidence That Emotional Maladjustment Is Worse in Men Than in Women with Psychogenic Nonepileptic Seizures

The purpose of this study is to examine the effects of gender on adjustment and cognition in patients with psychogenic nonepileptic seizures (NES) and on patients with epilepsy. We compared 57 women and 27 men, all at least 16 years old, with only NES as documented by long-term EEG-video monitor studies, to equal numbers of randomly selected women and men with only epileptic seizures. Variables examined included age, age of onset, education, scales from the MMPI, the WAIS-R, and the number of tests outside normal limits from the Neuropsychological Battery for Epilepsy. We found no significant differences in mean age, intelligence, or percentage of neuropsychological tests outside normal limits across the four groups. Women and men with NES had significantly later age of onset of attacks compared with subjects of either gender with epilepsy (26 years vs 13 years, P < 0.001) and men with NES had greater educational achievement than women with NES or patients with epilepsy (P < 0.02). However, the most important findings were seen on the MMPI. Men with NES exhibited significantly greater elevations on multiple scales (especially Hysteria, Depression, Hypochondriasis, Psychoasthenia, Schizophrenia) compared with men with epilepsy or women with either epilepsy or NES. We conclude that men with NES have significantly worse patterns of emotional adjustment, as measured by the MMPI, than women with NES or subjects of either gender with epilepsy.     

Nonepileptic seizures after resective epilepsy surgery

PURPOSE: To identify factors that are associated with the emergence of nonepileptic seizures (NES) after resective epilepsy surgery. METHODS: Twenty-two patients with medically refractory epilepsy in whom NESs were documented by EEG after resective surgery were compared with a larger series of epilepsy surgery patients on demographic, neurologic, and psychiatric variables. RESULTS: NES tended to become apparent in the first few months after surgery. Patients who developed NESs did not differ from other epilepsy surgery patients in terms of age, IQ, or preoperative psychiatric diagnoses. However, surgical NES patients' neurologic problems and seizures began later in life, the NES group included a larger proportion of female subjects and patients with right hemisphere surgery, and NES patients were more likely to develop non-NES psychiatric problems after surgery. CONCLUSIONS: The heterogeneous collection of behaviors subsumed under the label NESs are determined by multiple factors. Several variables were found to be specifically associated with the development of NES after resective epilepsy surgery: A disproportionate number of postsurgical NES patients are female, they have primary neurologic dysfunction in the right hemisphere, and their epileptic seizures often began after adolescence. We propose that at least one group of patients with somatoform tendencies develop NESs as part of the psychiatric instability that occurs often in the few months after resective surgery.     

Postictal symptoms help distinguish patients with epileptic seizures from those with non-epileptic seizures.

The aim of the study was to assess whether post-ictal symptoms can help distinguish patients who have epileptic seizures from those with non-epileptic seizures (NES). We reviewed the spontaneous responses to the question 'What symptoms do you have after a seizure?' in 16 patients with epileptic seizures (predominantly focal with secondary generalization or generalized tonic-clonic) and 23 NES patients. Six of the 16 patients (38%) vs. only one of 23 NES patients (4.3%) noted post-ictal headache (P = 0.008). Nine epilepsy patients (56%) vs. three NES patients (13%) reported post-ictal fatigue (P = 0.004). Confusion or other symptoms did not distinguish epilepsy patients from those with NES. All epilepsy patients had at least one post-ictal symptom while 12 NES patients (52%) had none (P = 0.001). Therefore, patients evaluated for epileptic vs. non-epileptic seizures who have post-ictal fatigue or headache, are more likely to have epileptic seizures. Patients with a diagnosis of NES who note post-ictal fatigue or headache should be investigated further.     

What is the Significance of Subjective Events Recorded During Long-Term EEG Video Monitoring?

Summary: Purpose : Purely subjective events, identified as "seizures" by patients but not accompanied by any clinical or EEG changes, commonly occur during evaluation of patients for intractable epilepsy. We wished to determine the significance of such events.
Methods : We analyzed the frequency of subjective episodes in 379 adults who underwent EEG video monitoring as part of their evaluation for intractable epilepsy and the relationship of these experiences to epileptic and psychogenic nonepileptic (NES) seizures. We examined the results of tests of mental ability and of emotional, psychosocial, and quality of life (QOL) adjustment to determine if individuals with subjective events alone could be distinguished from those with epileptic seizures only, NES only, or no events, by these measures.
Results : We noted subjective events in 39% (147 of 379) of the patients. Of patients with subjective episodes, 52% also had epileptic seizures, 7% had NES, 1% had both epileptic seizures and NES, and 40% had subjective events alone. As a group, patients with subjective events alone were slightly more intelligent and less impaired neuropsychologically than people in the other groups, hut they performed more poorly on several important measures of adjustment.
Conclusions : The identification of persons with purely subjective episodes apart from all other episodes is important both phenomenologically and from a practical viewpoint.     

The experience of earthquakes by patients with epileptic and psychogenic nonepileptic seizures

PURPOSE: We sought to understand better the experience of seizures by studying differences in the subjective experience of being in an earthquake between patients with epileptic (EP) and nonepileptic (NES) seizures. METHODS: Forty-eight patients with CCTV/EEG-documented EP or NES who were in the Seattle metropolitan area during the February 28, 2001 Nisqually earthquake were randomly selected for telephone interviews on their earthquake experiences, including whether they thought they were having a seizure during the event. RESULTS: Twenty-three percent of EP patients spontaneously volunteered that they initially thought they were having a seizure during the earthquake as compared with none of the NES individuals (p = 0.03). However, 35% of EP and 23% of NES patients thought they were having a seizure during it when asked directly (p = 0.37). The most common reasons given, regardless of seizure type, were shaking and feelings of losing control. Of those responding negatively, 100% of EP and 47% of NES patients said that movement of their environment indicated that it was not a seizure (p = 0.001). EP patients took an average of 42 s to realize that the earthquake was not a seizure compared with 105 s for the NES group (p = 0.06). The earthquake precipitated seizures in both groups (11.5% EP, 9.1% NES). CONCLUSIONS: EP patients were more likely to mistake the earthquake spontaneously for a seizure. This indicates these two experiences are similar and provides a glimpse into the subjective experience of a seizure for those who have never had one but have experienced an earthquake.     

Video-EEG telemetry can be a crucial tool for neurologists experienced in epilepsy when diagnosing seizure disorders.

We retrospectively reviewed the charts of 121 patients consecutively admitted to our epilepsy-monitoring unit (VET) during the period of 01 July 2001 to 31 December 2002. We excluded patients with a confirmed diagnosis of epilepsy who were admitted for invasive pre-surgical monitoring. Medical records were reviewed to collect demographic and clinical information that lead to the initial referral for VET by neurologists with expertise in epilepsy or by an epileptologist. We identified 29 patients (24%), whose diagnosis changed after VET. Their seizure duration ranged from 1 to 46 years. A diagnosis of epileptic seizures (ES) was made in four of the patients who were initially felt to have nonepileptic seizures (NES). The diagnosis of NES was made in 22 patients who were initially felt to have ES. All of these 29 patients had failed at least two or more antiepileptic drugs (AEDs). A misclassification of epilepsy syndrome was found in three patients. Eleven of the NES patients had risk factors that would increase the likelihood of ES, including significant head injury (n=6), febrile seizures (n=2), meningioencephalitis (n=2), and tumours (n=1). Four of these 11 patients had abnormal interictal EEGs. We conclude that VET is crucial in establishing a diagnosis in patients with seizures. Without VET, patients can be misclassified or receive ineffective treatment, even when being treated by specialists in epilepsy. Thus, VET, can help facilitate the most appropriate type of therapy in difficult to control patients.     

Use of the Personality Assessment Inventory as an efficacious and cost-effective diagnostic tool for nonepileptic seizures

Video electroencephalographic monitoring (VEEG) is considered the "gold standard" for making the differential diagnosis between epileptic seizures (ES) and nonepileptic seizures (NES), but is a costly, time-consuming procedure and not readily available in all communities. Of the various diagnostic techniques and measures that have been used, the Personality Assessment Inventory (PAI) has shown promise as an effective psychological screening tool to aid in the differential diagnosis of ES/NES. Using VEEG results as the outcome measure, this study examined the diagnostic effectiveness of the PAI in a group of adults with treatment-refractory seizures. Results indicated that, on psychological screening, patients with NES endorse significantly greater functional consequences of their seizure-like episodes than participants with ES. A "NES Indicator" score, calculated from the PAI Somatization subscales, provided a sensitivity of 84% and specificity of 73% for the diagnosis of NES versus ES. The PAI appears to be a useful screening tool prior to hospital admission for VEEG.     

Psychopathologies in patients with nonepileptic seizures with and without comorbid epilepsy: how different are they?

The underlying psychopathology in patients with nonepileptic seizures (NES) is diverse and poorly understood. The prevalence of epilepsy in NES patients is higher than in the general population, so epilepsy can be understood as a risk factor for NES. The question emerges if psychopathology differs in NES patients with and without epilepsy. Retrospective data concerning psychopathology and personality in both groups show two differences: (1) somatoform disorders are more prevalent in NES-only patients and (2) personality disorders are more typical in NES patients with epilepsy and resemble the pattern of psychopathology found in epilepsy-only patients. If true, then NES in epilepsy patients may be associated with an epilepsy condition. Consequently, in studies of psychopathology in epilepsy patients, patients with comorbid nonepileptic seizures have to be included.     

MMPI-2 profiles of persons with multiple chemical sensitivity

We compared the MMPI-2 profiles of adults with multiple chemical sensitivity (MCS), epileptic seizures (ES), and nonepileptic seizures (NES). Both NES and MCS are medically unexplained conditions. In previous studies profiles associated with NES were elevated on scales Hs and Hy, compared with profiles associated with ES. We predicted that profiles associated with MCS would be elevated on Hs and Hy compared with the ES group. Patients with ES and NES were diagnosed after intensive EEG monitoring using published criteria. MCS was diagnosed if there was a complaint of illness in response to multiple common odors at levels that are not noxious to most people. All the MCS cases had legal claims for injury related to chemical exposures. The results showed that on MMPI-2 scales Hs, D, and Hy the MCS group had means significantly higher than both the ES and NES groups. Fake Bad Scale scores were elevated in 11 MCS cases, and regression-based estimates of Fake Bad Scale scores showed elevation in the MCS group compared with both seizure groups. We conclude that MMPI-2 data, obtained from people seeking financial compensation, indicate that there is a strong psychological component to MCS symptoms.     

MMPI-2 Profiles of Persons with Multiple Chemical Sensitivity

We compared the MMPI-2 profiles of adults with multiple chemical sensitivity (MCS), epileptic seizures (ES), and nonepileptic seizures (NES). Both NES and MCS are medically unexplained conditions. In previous studies profiles associated with NES were elevated on scales Hs and Hy, compared with profiles associated with ES. We predicted that profiles associated with MCS would be elevated on Hs and Hy compared with the ES group. Patients with ES and NES were diagnosed after intensive EEG monitoring using published criteria. MCS was diagnosed if there was a complaint of illness in response to multiple common odors at levels that are not noxious to most people. All the MCS cases had legal claims for injury related to chemical exposures. The results showed that on MMPI-2 scales Hs, D, and Hy the MCS group had means significantly higher than both the ES and NES groups. Fake Bad Scale scores were elevated in 11 MCS cases, and regression-based estimates of Fake Bad Scale scores showed elevation in the MCS group compared with both seizure groups. We conclude that MMPI-2 data, obtained from people seeking financial compensation, indicate that there is a strong psychological component to MCS symptoms.     

Conversion disorder and coexisting nonepileptic seizures in patients with refractory seizures

Nonepileptic seizures (NES) are commonly observed in patients with seizures resistant to antiepileptic drugs (AEDs). However, NES may be symptomatic of different diagnoses, in particular, conversion disorder (CD) and coexisting NES and epileptic seizures (CENES). We compared the clinical characteristics of these disorders in 219 patients with refractory seizures. The prevalence of NES was similar in children (11%) and adults (16%). In both groups, CENES represented the most frequent cause of NES (75%). In adults, CD was associated with a shorter duration of illness and normal neuroimaging and interictal EEG compared with the other groups. Patients with CD represented one-quarter of all patients with AED-resistant seizures with normal presentation during interictal investigations. In both children and adults with AED-resistant seizures, NES are frequently observed and are three times more likely to be CENES than CD.     

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).     

Cluster analysis of clinical seizure semiology of psychogenic nonepileptic seizures

PURPOSE: To develop an objective classification of psychogenic nonepileptic seizures (NES) based on cluster analysis of clinical seizure semiology. METHODS: We studied the clinical seizure semiology in 27 patients with psychogenic NES documented by prolonged video-EEG monitoring. We analyzed the following clinical symptoms: clonic and hypermotor movements as well as trembling of the upper and/or lower extremities, pelvic thrusting, head movements, tonic posturing backward of the head, and falling. We used cluster analysis to identify symptoms occurring together in a systematic way and thus tried to achieve a clinical classification of psychogenic NES. RESULTS: We could identify three symptom clusters. Cluster 1 was characterized by clonic and hypermotor movements of the extremities, pelvic thrusting, head movements, and tonic posturing of the head, and therefore was named "psychogenic motor seizures." Cluster 2 comprised trembling of the upper and lower extremities and was termed "psychogenic minor motor or trembling seizures." Cluster 3 consisted of falling to the floor as the only symptom and was referred to as "psychogenic atonic seizures." CONCLUSIONS: Our study represents the first study to analyze the clinical semiology of psychogenic NES by cluster analysis, which should be useful for an objective classification of psychogenic NES. This classification should allow both a better characterization of psychogenic NES and an easier differential diagnosis against specific epileptic seizures.     

Video-EEG monitoring in the elderly: a review of 94 patients

PURPOSE: We sought to determine the utility and results of video-EEG monitoring in elderly patients. There is an increased incidence of epilepsy in the elderly population. Few studies have assessed the characteristics of epileptic and nonepileptic seizures in this age group. Diagnostic evaluation with video-EEG monitoring is a means to distinguish these different types of events. METHODS: The authors reviewed all patients aged 60 years and older who were admitted to the epilepsy monitoring unit at Columbia-Presbyterian Medical Center from January 21, 1991, to April 12, 1999. RESULTS: A total of 94 patients and 99 patient admissions were identified, accounting for 8% of all admissions. The average age was 70 years, and the mean length of stay was 3.8 days. Typical events were recorded in 75 of the 99 patient admissions. A total of 118 seizures was recorded in 46 patients, and 98 nonepileptic events were seen in 27 patients. Of the patients with nonepileptic events, 13 had psychogenic seizures. The majority of patients with nonepileptic events were taking antiepileptic medication. Whereas 76% of the patients with epileptic events had interictal epileptiform discharges, 26% of the patients with nonepileptic events had epileptiform discharges as well. CONCLUSIONS: Video-EEG monitoring in the elderly leads to a definitive diagnosis in the majority of patients in a relatively short time. Interictal recordings are inadequate in determining the nature of paroxysmal events. Nonepileptic events are common in the elderly, including psychogenic seizures, and these are often misdiagnosed and mistreated as epileptic seizures.