Chapter 14
Diagnosis of psychogenic nonepileptic seizures
CQ 14-1

How are psychogenic nonepileptic seizures differentiated fromepileptic seizures?
Summary(1) Even in the presence of clinical symptoms suggesting psychogenic nonepileptic seizures (PNES), PNES cannot
be diagnosed based on those symptoms alone.
(2) A diagnosis of PNES can be made by an experienced doctor, who confirms typical PNES semiology without any
EEG abnormal findings immediately before, during, and immediately after the seizure in an ictal video-EEG
recording.
(3) However, ictal video-EEG recording may not provide decisive findings for the diagnosis of simple partial
seizures and seizures arising from supplementary motor area, orbital frontal cortex, or cingulate gyrus.
(4) Even if a definite diagnosis of PNES has been established for one of the seizure types in a patient, we should
avoid a hasty conclusion that all other seizures are PNES in the same patient.

Comment
Psychogenic non-epileptic seizures (PNES) are paroxysmal psychosomatic symptoms resembling epileptic seizures, which
is not explainable by already accepted pathophysiological mechanisms. PNES are found in 5‒20% of patients who first visit
a hospital for suspected epilepsy, and in 15‒30% of patients diagnosed with intractable epilepsy with an indication forsurgery1). The male to female ratio varies depending on the subject population; PNES are female-dominant in patients withneither concomitant mental retardation (intellectual disability) nor epilepsy, but show no definite gender difference inpatients with concomitant mental retardation or epilepsy. The frequencies of concomitant mental retardation vary from 17
to 37% depending on report. In PNES with concomitant epileptic seizures or mental retardation, direct inducing factors areoften present. Therefore, we should take detailed history of the patient’s living conditions and focus on any changes inlifestyle just before the onset of PNES. On the other hand, in PNES with neither concomitant epilepsy nor mental
retardation, we should seek advice from psychiatrists and clinical psychologists because the life history such as family
relationship is often critical in those patients.
Typical seizure semiology suggesting PNES includes (1) long duration of seizure, (2) fluctuating symptoms during
seizure, (3) asynchronous (left-right) body movements, (4) pelvic thrusting, (5) side-to-side swinging of the head and body,(6) closed eyes during seizure, (7) crying during seizure, (8) memory recall of seizure event, (9) no postictal confusion, and(10) seizures appear to occur during sleeping, but EEG findings show an arousal state2).
However, no symptoms can lead to a definite diagnosis on their own, and the above symptoms should be considered asreference findings.
In the case of suspected PNES, we should confirm the diagnosis over time while following the clinical symptoms as wellas performing environmental adjustment and psychotherapy.
Urinary incontinence and tongue biting have been reported during seizures in patients with PNES, although the incidence
is low3). Therefore, incontinence and tongue biting do not exclude a diagnosis of PNES4).
Abnormally high prolactin concentration within 10‒20 minutes after the attack indicates the unlikeliness of PNES5).
There are four levels of certainty for a diagnosis of PNES, ranging from possible to documented. Table 1 shows the criteria
for the four levels5). Descriptions from a witness of seizure or a video of the actual seizure with routine EEG finding lead toa “possible”, “probable” or “clinically established” diagnosis, while a “documented” diagnosis requires visit to a specialized
hospital equipped with simultaneous ictal video-EEG recording.

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The main purpose of admission for making a definite diagnosis is to record ictal video-EEG. Moreover, the hospitalization
also provides medical staff a chance to observe the actual seizures.
In the case of dose reduction or cessation of antiepileptic drugs at the hospital, we should pay attention to the following
risks: manifestation of epileptic seizures that have been controlled until the reduction of drugs, withdrawal seizures inpatients treated with phenobarbital and benzodiazepines for a certain period, and induction of status epilepticus.

▪ References1) Kanemoto K, Fujiwara T, Ikeda A, et al. Diagnosis and treatment guideline for psychogenic non-epileptic seizure (so-called pseudo-seizures).
Tenkan Kenkyu. 2009; 26(3): 478-482 (in Japanese).
2) Avbersek A, Sisodiya S. Does the primary literature provide support for clinical signs used to distinguish psychogenic non-epileptic seizures fromepileptic seizures? J Neurol Neurosurg Psychiatry. 2010; 81(7): 719-725.
3) Oliva M, Pattison C, Carino J et al. The diagnostic value of oral lacerations and incontinence during convulsive “seizures”. Epilepsia. 2008; 49(6):962-967.
4) Oto M, Conway P, McGonigal A, et al. Gender differences in psychogenic non-epileptic seizure. Seizure. 2005; 14(1): 33-39.
5) LaFrance WC Jr, Baker GA, Duncan R, et al. Minimum requirements for the diagnosis of psychogenic nonepileptic seizures: a staged approach: areport from the International League Against Epilepsy Nonepileptic Seizures Task Force. Epilepsia. 2013; 54(11): 2005-2018.

▪ Search formula and secondary reference sources(((psychogenic AND (nonepileptic OR non-epileptic)) OR PNES) AND (therapy [sh] OR psychotherapy [mh]) Filters: Publication date from2008/01/01 to 2015/12/31; English; Japanese
PubMed = 92
psychogenic seizures
Cochrane = 3

Table 1. Levels of certainty for diagnosis of PNES.
Diagnostic Level
Possible
Probable

Clinically established

Documented

Source of information
By witness or self-reported descriptions

EEG
No epileptic activities on routine or sleepdeprived interictal EEG
Clinician-confirmed semiology typical of PNES As above
by reviewing a video recording or seeing actualattack
Clinician having much experience with epilepsy No epileptic activities on routine or Holter
patients confirmed semiology typical of PNES EEG recorded at the attack with semiology
by reviewing a video recording or seeing actual resembling epileptic seizures (epileptic EEGattack, but not on ictal EEG
activities would be expected in case of trueepileptic seizure)
Confirmed by clinician having much experience No epileptic activities on video-EEG recordedwith epilepsy patients on ictal video-EEG
immediately before, during or immediately
after the attack with typical PNES symptoms(Modified from: LaFrance WC Jr, Baker GA, Duncan R, et al. Minimum requirements for the diagnosis of psychogenic
nonepileptic seizures : a staged approach : a report from the International League Against Epilepsy Nonepileptic Seizures Task
Force. Epilepsia. 2013; 54(11): 2005-2018.)

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CQ 14-2

How are psychogenic nonepileptic seizures treated?
Summary(1) The management of psychogenic nonepileptic seizures (PNES) includes: (1) clearly disclose the diagnosis tothe patient as a good news, without nuance of condemnation, (2) explain no need for antiepileptic drug, (3) listup the factors that induce seizure and the factors that perpetuate symptoms, (4) offer psychiatric evaluation, (5)implement individual psychotherapy and family psychotherapy, and (6) consider the use of psychotropic drugs
in patients with mood disorder, anxiety disorder, and somatization disorder.
(2) In principle, antiepileptic drugs are tapered and stopped, but this involves risks such as transient deteriorationof the psychological state or manifestation of epileptic seizures masked by antiepileptic drugs.
(3) W hen associated with mental retardation (intellectual disability), disclose the diagnosis to the patient and thefamily, and at the same time adjust the social and psychological environments.
(4) W hen PNES coexist with true epileptic seizures, explain in detail to the patients and their family which typeof seizure is PNES and which type is epileptic seizure.

Comment(1) Even in patients with PNES confirmed by ictal video-EEG, all the seizures are not necessarily PNES. Considering thispoint, we should initially explain it to the patients as follows, “Attacks due to emotional problems, not real epilepsy,
may coexist with attacks due to epilepsy”1).	  In an RCT recruiting patients (IQ 70 or above) without coexisting epileptic seizures who had PNES attacks morethan twice a month, cognitive behavioral therapy (CBT) for 4 months significantly reduced the seizure frequency
with a moderate or greater effect size, and the odds ratio of seizure control for at least 3 months was 3.1252).	  In patients who have taken antiepileptic drugs for long periods of time, some feel that epilepsy is their major
problem in life because they believe “they cannot get a job due to epilepsy” and “they cannot have children because ofepilepsy”. These patients may have severe psychological disturbance due to loss of identity. Negating the diagnosis ofepilepsy needs to go hand in hand with formation of new identity.	  Showing the data of ictal video-EEG recorded during seizure to the patient and family is often educational andeffective. However, care has to be taken not to convey a value judgment that PNES are false seizures. Most of thePNES are not malingering disorders, but are seizures caused by endogenous conflict.	  When referring a patient to a psychiatrist, the message to the patient and family has to be carefully worded so as
not to be perceived as sending them away from one’s care, such as, “To exclude all possible disorders and to try all
possible treatments, let’s also ask the psychiatrist to give us some advice.” It is desirable to follow the patient by both
departments for at least a certain period of time.
(2) In principle, antiepileptic drugs are reduced in dose and stopped3). Particularly at the cessation of drugs, it is necessary
to explain in advance to the patient and family about the possibility of emergence of epilepsy seizures controlled by
medications so far or appearance of withdrawal syndrome1).	  When the patient and family are very anxious about seizure relapse during dose reduction or cessation of antiepileptic
drugs, or when the family has difficulties in coping with urgent situations such as emergency hospital visit, then shortterm inpatient treatment is indicated.
If the patient and family request inpatient treatment because they worry about frequent seizures, explain to themthat he/she will be hospitalized as a part of psychotherapy in collaboration with the psychiatrist. We should try to
prevent long-term hospitalization.
(3) When the patient has coexisting mental retardation (intellectual disability), explain and disclose the diagnosis to thepatient and family and at the same time adjust the psychological and social environments. Full-fledged psychotherapy
accompanied by introspection is often difficult to conduct. Listen carefully to the situations leading to PNES, such as
loss of parents who protected the patient, big changes in workplace, and human relation at work1).	  Maintain an environment that does not encourage gain from illness, such as getting help from many staff members
when seizures occur or admission to a hospital when the patient shows PNES. We should adjust the environment sothat the patient can receive appropriate attention and protection even without showing PNES.

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	  Disclosure of PNES coexisting with epileptic seizures is more easily accepted by the patient and family, because
the presence of PNES does not entail changes in the basic treatment framework such as transfer to another department
and cessation of medications.
(4) When PNES coexist with true epileptic seizures, explain in detail to the patient and family which type of seizure isPNES and which type is epileptic seizure. For the antiepileptic drugs, reduce the doses and change to monotherapy ifpossible.

▪ References
1) Kanemoto K, Fujiwara T, Ikeda A, et al. Diagnosis and treatment guideline for psychogenic non-epileptic seizure (so-called pseudo-seizures).
Tenkan Kenkyu. 2009; 26(3): 478-482 (in Japanese).
2) Goldstein LH, Chalder T, Chigwedere C, et al. Cognitive-behavioral therapy for psychogenic nonepileptic seizures: a pilot RCT. Neurology. 2010;
74(24): 1986-1994.
3) Kerr MP, Mensah S, Besag F, et al. International consensus clinical practice statements for the treatment of neuropsychiatric conditions associatedwith epilepsy. Epilepsia. 2011; 52(11): 2133-2138.

▪ Search formula and secondary reference sources(((psychogenic AND (nonepileptic OR non-epileptic)) OR PNES) AND (therapy [sh] OR psychotherapy [mh]) Filters: Publication date from2008/01/01 to 2015/12/31; English; Japanese
PubMed = 92psychogenic seizures
Cochrane = 3

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