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Patients who display the neurological phenomena variously referred to as pseudoseizures, dissociative seizures, or psychogenic non-epileptic seizures present an important problem in the treatment of epilepsy. Their convulsive or non-convulsive episodes show no epileptiform activity on electroencephalography but are distressing and debilitating to patients so afflicted, and can be difficult to distinguish from classical epilepsy. It is important to make this distinction, as the treatment for pseudoseizures is typically cognitive behavioral therapy rather than anticonvulsant medication. This review describes the clinical differences in the signs and symptoms of patients with pseudoseizures vs classical epileptic seizures, as well as the underlying mechanisms triggering pseudoseizures, and the outcomes achieved with the treatment paradigms currently available for them., (Copyright © 2022 Elsevier B.V. All rights reserved.)

The purpose of this review is to provide an update of the research regarding the etiology, diagnosis and management of psychogenic non-epileptic seizures (PNES). A literature search using Pubmed, Ovid MEDLINE and EMBASE database was performed from 2000 up to August 2017. We have evaluated the different factors leading to PNES as well as the diagnostic approach and management of this disorder which continue to be very difficult. The coexistence of epilepsy and PNES poses special challenges and requires the coordinated efforts of the family physicians, psychiatrists, psychologists and neurologists. Although this condition has an overall poor prognosis, a multidisciplinary approach in the diagnosis and management of this disorder would likely improve the outcomes. We have proposed a diagnostic and treatment algorithm for PNES and suggested a national registry of patients suffering from this condition. The registry would contain data regarding treatment and outcomes to aid in the understanding of this entity.

Purpose: The aim of this meta-analysis is to evaluate and synthesize the available evidence from the previous 20 years regarding the utility of psychological interventions in the management of psychogenic non-epileptic seizures (PNES)., Method: Studies were retrieved from MEDLINE via OvidSP and PsychINFO. Selection criteria included controlled and before-after non-controlled studies including case series, using seizure frequency as an outcome measurement. Studies were required to assess one or more types of psychological intervention for the treatment of PNES in adults. Data from 13 eligible studies was pooled to examine the effectiveness of psychological interventions in treating PNES on two primary outcomes: seizure reduction of 50% or more and seizure freedom. A meta-analysis was conducted with data extracted from 228 participants with PNES., Results: Interventions reviewed in the analysis included CBT, psychodynamic therapy, paradoxical intention therapy, mindfulness and psychoeducation and eclectic interventions. Meta-analysis synthesized data from 13 studies with a total of 228 participants with PNES, of varied gender and age. Results showed 47% of people with PNES are seizure free upon completion of a psychological intervention. Additional meta-analysis synthesized data from 10 studies with a total of 137 participants with PNES. This analysis found 82% of people with PNES who complete psychological treatment experience a reduction in seizures of at least 50%., Conclusion: The studies identified for this analysis were diverse in nature and quality. The findings highlight the potential for psychological interventions as a favorable alternative to the current lack of treatment options offered to people with PNES., (Copyright © 2016 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

Objective: Video electroencephalography (vEEG) is the gold-standard method for diagnosing psychogenic nonepileptic seizures (PNES), but such assessment is expensive, unavailable in many centers, requires prolonged hospitalization, and many times is unable to capture an actual seizure episode. This paper systematically reviews other non-vEEG candidate biomarkers that may facilitate both diagnosis and study of PNES as differentiated from epileptic seizures (ES)., Methods: PubMed database was searched to identify articles between 1980 and 2015 (inclusion: adult PNES population with or without controls, English language; exclusion: review articles, meta-analyses, single case reports)., Results: A total of 49 studies were examined, including neuroimaging, autonomic nervous system, prolactin, other (non-prolactin) hormonal, enzyme, and miscellaneous marker studies. Functional MRI studies have shown PNES is hyperlinked with dissociation and emotional dysregulation centers in the brain, although conflicting findings are seen across studies and none used psychiatric comparators. Heart rate variability suggests increased vagal tone in PNES when compared to ES. Prolactin is elevated in ES but not PNES, although shows low diagnostic sensitivity. Postictal cortisol and creatine kinase are nonspecific. Other miscellaneous biomarkers (neuron specific enolase, brain derived neurotropic factor, ghrelin, leptin, leukocytosis) showed no conclusive evidence of utility. Many studies are limited by lack of psychiatric comparators, size, and other methodological issues., Conclusion: No single biomarker successfully differentiates PNES from ES; in fact, PNES is only diagnosed via the negation of ES. Clinical assessment and rigorous investigation of psychosocial variables specific to PNES remain critical, and subtyping of PNES is warranted. Future investigational and clinical imperatives are discussed., (Copyright © 2015 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

Purpose: Clinical observations suggest that psychogenic non-epileptic seizure (PNES) patients often have severe migraine, more severe than epilepsy patients. Investigations into migraine characteristics in patients with PNES are lacking. In this study we tested the hypothesis that, compared to epilepsy patients, PNES patients have more severe migraine, with more frequent and longer duration attacks that cause greater disability., Method: In this observational study, 633 patients with video-EEG proven epilepsy or PNES were identified from the Mayo Clinic Epilepsy Monitoring Unit database. Contacted patients were screened for migraine via a validated questionnaire, and when present, data regarding migraine characteristics were collected. Two-sample t-tests, chi square analyses, and Mann-Whitney U tests were used to compare migraine characteristics in PNES patients to those of epilepsy patients., Results: Data from 43 PNES patients with migraine and 29 epilepsy patients with migraine were available. Compared to epilepsy patients, PNES patients reported having more frequent headaches (mean 15.1 ± 9.8 vs. 8.1 ± 6.6 headache days/month, p<.001), more frequent migraine attacks (mean 6.5 ± 6.3 vs. 3.8. ± 4.1 migraines/month, p=.028), longer duration migraines (mean 39.5 ± 28.3 vs. 27.3 ± 20.1h, p=.035), and more frequently had non-visual migraine auras (78.6% vs. 46.7% of patients with migraine auras, p=.033). Migraine-related disability scores were not different between PNES and epilepsy patients (median 39, interquartile range 89 vs. 25, interquartile range 60.6, p=.15)., Conclusion: Compared to epilepsy patients with migraine, PNES patients with migraine report having a more severe form of migraine with more frequent and longer duration attacks that are more commonly associated with non-visual migraine auras., (Copyright © 2015 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

IntroductionYouth with psychogenic non-epileptic seizures (PNES) are an understudied group associated with significant medical and psychiatric morbidity. Several studies have examined characteristics associated with youth's development of this disorder, though the exploration of family factors including psychiatric illness, has been lacking. This study sought to establish the need for a more comprehensive future study.MethodsA retrospective chart review was conducted on patients who had been admitted and diagnosed with PNES at the epilepsy monitoring unit at Children's Hospitals and Clinics of Minnesota. A total of 62 patients were included. All patients were evaluated by an epileptologist and psychologist during their diagnostic admission. “Spells” in question were captured via video EEG monitoring. PNES youth and family risk factors were assessed.ResultsMean age of PNES symptom onset was 13.9 years. Patients (73%) were diagnosed within 6 months of onset of symptoms. Histories of other impairing somatic complaints were present in the youth (54%), with 67% having prior psychiatric diagnoses. Experiencing suicidal ideation or thoughts of self-harm occurred in 47% of this sample. Family members were unaware of the history of these symptoms with 12% of the parent's reporting awareness. Family history of psychiatric disorders (first-degree relatives of patient) was present in 54% of the sample, with anxiety, depression and conversion disorder being the most commonly endorsed diagnoses.ConclusionsYouth with PNES present with comorbid psychiatric disorders, though prior assessment and treatment for these disorders was not common. Youth with PNES have history of suicidal ideation and thoughts of self-harm, though parental awareness of these co-occurring symptoms is limited. Family risk factors, such as history of psychiatric disorder in first degree relatives, was high. The impact of these family risk factors is understudied and should be further evaluated to better understand the impact on development and maintenance of this disorder in youth.

Purpose: Psychogenic nonepileptic seizures (PNES) are one of the most common differential diagnoses of epilepsy. Our objective is to describe current medical care in Canada and identify patterns of practice and service gaps.Methods: In 2015, a 36-question survey was sent via email to the 131 members of the Canadian League Against Epilepsy. The questions were designed after literature review and discussion with the ILAE PNES Task Force. Questions were separated into 5 sections: 1) the role of the respondent and their exposure to PNES, 2) diagnostic methods, 3) management of PNES, 4) etiological factors, and 5) problems accessing health care.Results: Sixty-two questionnaires were analyzed (response rate: 47%). Most respondents were epileptologists (76%). The majority of respondents personally diagnosed PNES and communicated the diagnosis to the patient, but only 55% provided follow-up within their practice and only 50% recommended or arranged treatment. Many (35%) were either unfamiliar with the diagnosis of PNES or inexperienced in arranging or offering treatment. Most (79%) provided follow-up to patients with concomitant epilepsy, but when PNES was the sole diagnosis follow-up rates were low. Although 84% of respondents felt that individualized psychological therapy was the most effective treatment, 40% of patients were not referred to psychotherapy and in most cases availability such therapy was low (30-60%).Conclusions: Canadian health professionals' understanding of PNES mostly reflects current international expert opinion. Once diagnosis is made however, the majority of patients are discharged from neurological services without appropriate psychological care. [ABSTRACT FROM AUTHOR]

The linear mixed-effects model effect size (mean divided by standard error) of 90 patients with functional seizures (FS) compared to 576 seizure-naïve and psychiatric controls on cortical thickness in each region of interest on a cortical surface map. After Bonferroni–Holm correction, only bilateral superior temporal thinning and left lateral occipital thickening were significant. [Display omitted] • Structural correlates of functional seizures exist, but are inconsistent. • We examined MRI morphometry in 90 FS versus 576 psychiatric- and other- controls. • Differences were in superior temporal and occipital cortex, and cerebellum. • Magnetic resonance imaging quality was lower in FS, but this did not account for differences. • Further comparison to other relevant populations is needed. Functional seizures (FS), also known as psychogenic nonepileptic seizures (PNES), are physical manifestations of acute or chronic psychological distress. Functional and structural neuroimaging have identified objective signs of this disorder. We evaluated whether magnetic resonance imaging (MRI) morphometry differed between patients with FS and clinically relevant comparison populations. Quality-screened clinical-grade MRIs were acquired from 666 patients from 2006 to 2020. Morphometric features were quantified with FreeSurfer v6. Mixed-effects linear regression compared the volume, thickness, and surface area within 201 regions-of-interest for 90 patients with FS, compared to seizure-naïve patients with depression (n = 243), anxiety (n = 68), and obsessive–compulsive disorder (OCD, n = 41), respectively, and to other seizure-naïve controls with similar quality MRIs, accounting for the influence of multiple confounds including depression and anxiety based on chart review. These comparison populations were obtained through review of clinical records plus research studies obtained on similar scanners. After Bonferroni–Holm correction, patients with FS compared with seizure-naïve controls exhibited thinner bilateral superior temporal cortex (left 0.053 mm, p = 0.014; right 0.071 mm, p = 0.00006), thicker left lateral occipital cortex (0.052 mm, p = 0.0035), and greater left cerebellar white-matter volume (1085 mm3, p = 0.0065). These findings were not accounted for by lower MRI quality in patients with FS. These results reinforce prior indications of structural neuroimaging correlates of FS and, in particular, distinguish brain morphology in FS from that in depression, anxiety, and OCD. Future work may entail comparisons with other psychiatric disorders including bipolar and schizophrenia, as well as exploration of brain structural heterogeneity within FS. [ABSTRACT FROM AUTHOR]

Abstract: This review by three established clinicians/researchers and two ''rising stars'' in the field of psychogenic nonepileptic seizures (PNES) describes recent progress in this area and highlights priorities for future research. Empirically testable models of PNES are emerging but many questions about the aetiology of PNES remain unanswered at present. Video-EEG has made it possible for doctors to make secured diagnoses of PNES in more cases. However, unacceptable diagnostic delays and misdiagnoses are still common. Non-specific EEG changes are often misinterpreted as evidence of epilepsy. A better understanding of the symptomatology of PNES may allow earlier and more accurate diagnoses using self-report questionnaires. The communication of the diagnosis and the engagement of patient in psychological treatment can be difficult. A recent pilot RCT has demonstrated the effectiveness of a psychological treatment in reducing seizures in the short term, but longer-term effectiveness is yet to be demonstrated. [Copyright &y& Elsevier]

Background: To study the prevalence, clinical correlates and outcome of Conversion Disorders (CD) in children and adolescents. Methods: All the children and adolescents receiving ICD-10 diagnosis of Conversion Disorder during the period of July 2008 to June 2009 constituted the study sample. Results: During the 12 months period, a total of 332 children and adolescents were evaluated. 41 (12.5%) received the ICD-10 diagnosis of CD. 53% of the subjects were in the age group of 12- 16 years. Majority (61%) of them were girls. 56% had an acute onset of illness (<2 weeks). Most common conversion symptom noticed was convulsions (pseudoseizures) followed by dissociative motor symptoms. About ninety percent of the subjects had one or more significant psychosocial stressor. 12 (30%) had positive family history of mood disorder and dissociative disorder. 93% showed remission within a month. During the period of next 18 months a total of 6 children were lost to follow-up. Out of remaining 35 children, 3 had relapsed; 2 presented with the same symptoms as that of initial presentation and one with different symptoms. Rest of the children were functioning normally and had resumed schooling. Conclusion: CD in Indian children and adolescents is not uncommon as is shown by Western literature. It has a good outcome. Early diagnosis and presence of precipitating factor are predictors of good outcome [ABSTRACT FROM AUTHOR]

Abstract: Minnesota Multiphasic Inventory 2 (MMPI-2) scale 3, duration of illness, and routine EEGs have been used to predict nonepileptic events (NEEs) with a high degree of accuracy in patients referred for video/EEG (vEEG) monitoring. This study tested the Storzbach logistic regression equation in our patients with definitive epileptic seizures (n =57) or NEEs without evidence of epileptiform activity (n =51) during vEEG monitoring, yielding an overall classification accuracy of 81%, sensitivity of 80%, and specificity of 81%. This study also replicated previous findings of significant group differences in duration (years) of spells, number of elevations on the MMPI-2, MMPI-2 elevations on scales 1, 2, 3, and 8, and incidence of the conversion valley on the MMPI-2. Our findings indicated that combined use of the MMPI-2 and clinical variables was most predictive of patients with NEEs. [Copyright &y& Elsevier]

Abstract: Objective: The goal of this article was to describe the clinical characteristics and outcomes of patients diagnosed with psychogenic nonepileptic seizures (PNES). Methods: We conducted a retrospective review of patients diagnosed with PNES in a 5-year period. Results: Fifty patients with PNES were identified, giving an estimated incidence of 0.91/100,000 per annum. Thirty-eight were included for review, 15 of whom were male (39%). Eighteen patients had been diagnosed with epilepsy as well as PNES (47%). We demonstrated a gender difference in our patients, with males having higher seizure frequencies, more antiepileptic drug use, and a longer interval before diagnosis of PNES. Females were diagnosed with other conversion disorders more often than males. Impaired social function was observed in PNES, as was resistance to psychological interventions with a subsequent poor response to treatments. Conclusions: PNES remains a difficult condition to treat, and may affect males in proportions higher than those described in previous studies. [Copyright &y& Elsevier]

Abstract: Objective: The goal of this study was to estimate the frequency of psychogenic pseudosyncope in patients with “syncope of unknown origin.” Twenty to thirty percent of patients referred to epilepsy centers for refractory seizures have psychogenic seizures. With syncope, about 20–30% of the cases remain unexplained after a complete evaluation, but, unlike in seizures, a psychogenic etiology is not usually investigated. Methods: We prospectively evaluated patients referred to our epilepsy center for evaluation of recurrent syncope-like episodes, that is, limp, motionless fainting. All patients had a negative syncope workup. We performed EEG-video monitoring with activation by suggestion (“induction”), similar to what is used for diagnosis of psychogenic seizures. Activation was performed with patients standing or sitting up. The diagnosis of psychogenic pseudosyncope required: (1) an activation procedure that triggered the habitual event; (2) a clinical event of loss of postural tone and limp, motionless unresponsiveness with eyes closed; (3) normal EEG before, during, and after the clinical event, that is, no epileptiform abnormalities, a normal α rhythm during unresponsiveness, and no suppression of background or slowing as is typically seen in syncope. Results: Ten patients were recruited over an 18-month period. Habitual syncope-like episodes were triggered in 9 of 10 (90%) patients, and all 9 were shown to have psychogenic pseudosyncope (eyes closed, motionless, unresponsive with normal EEG including normal α rhythm). In one patient, no episode was triggered, so a diagnosis could not be made. Among the 9 patients for whom episodes were recorded, age ranged from 21 to 60 (mean=36). Five were women. Duration of symptoms ranged from 6 months to 15 years (mean=4.2 years). Event frequency ranged from four per day to two per month. Prior evaluations for syncope included ECG in all patients, two-dimensional echocardiogram in three, Holter monitoring in two, and tilt-table test in five. Four patients had undergone cardiac catheterization, and one had received a pacemaker. Neurologic tests included CT of the head in seven and MRI of the brain in eight. Conclusion: Many patients with “syncope of unknown origin” may have psychogenic pseudosyncope, but most such patients do not undergo EEG-video monitoring, which is the only way to demonstrate a psychogenic etiology. Psychogenic pseudosyncope is not simply a diagnosis of exclusion, and can be firmly diagnosed. As is usually recommended for seizure-like events, patients with syncope-like events and a negative evaluation should undergo EEG-video monitoring with induction, specifically looking for a possible psychogenic etiology. [Copyright &y& Elsevier]

Markers of brain abnormalities in patients with psychogenic nonepileptic seizures (PNES) were studied to explore whether physical brain disorder is associated with an increased risk of PNES. Evidence of epileptiform EEG changes, MRI abnormalities, and neuropsychological (NPS) deficits was obtained from the records of 329 consecutive patients in whom the diagnosis of PNES was established at our center between 1991 and 2001. Two hundred six patients had PNES alone, and 123 PNES and epilepsy (PNES + E). In the PNES-only group, at least one marker of brain disorder was detected in 22.3% of patients (epileptiform potentials in 8.7%, MRI changes in 9.7%, NPS deficits in 9.7%). The actual prevalence of abnormalities is likely to be higher because 54.9% of the patients with only psychogenic seizures did not undergo MRI or neuropsychological testing. Evidence of brain abnormality was found more frequently in the PNES + E group (epileptiform potentials in 70.7%, MRI changes in 60.2%, NPS deficits in 52.8%). Although markers of brain abnormality were detected much less commonly in the PNES than in the PNES + E group, they were still found in a substantial proportion of patients with PNES alone. This suggests that physical brain disease plays a role in the development of PNES. Markers of physical abnormality were not more common in the right hemisphere. [Copyright &y& Elsevier]

• Outcome of PNES is positively correlated with earlier age of diagnosis in an EMU. • Employment and possibly co-habiting are other positive baseline predictors in PNES. • Discontinuation of ASM in PNES is more likely if initiated during an EMU stay. • Having children and absence of structural brain lesions also predict ASM withdrawal. • Repeated EMU visits and absence of minor head trauma may predict ASM withdrawal. To identify predictors of Psychogenic NonEpileptic Seizure (PNES) improvement and anti-seizure medication (ASM) discontinuation in patients with PNES only. This is a retrospective study of a consecutively enrolled cohort of 271 patients diagnosed with PNES by video-EEG (vEEG) telemetry in our Epilepsy Monitoring Unit (EMU) between May 2000 and February 2010. Patients with any possibility of past or present comorbid epilepsy based on clinical, EEG, and neuroimaging, or less than one year of follow-up after discharge were excluded. A total of 109 subjects were included. The mean age at PNES onset was 33 (range 6–89), mean age at EMU admission was 38.3 (16–89.8), 70.6% were female mean video-EEG length was 6.1 days, and the median time of final follow-up 3.3 (CI 1.6–6.4) years. 51/108 patients (47.2%) reported a PNES decrease and 29 (26.8%) experienced PNES resolution. 59/73 (81.9%) subjects on ASM at the time of EMU admission were able to discontinue them by the final visit. On univariate analysis, patients whose PNES frequency improved were significantly younger at time of admission, more likely married or cohabiting, less likely unemployed, less likely to have migraine, and had a higher frequency of PNES. On hierarchical regression analysis, younger age and employment remained significant predictors of PNES improvement and resolution. Patients who achieved ASM discontinuation had significantly more children and subsequent EMU visits, were less likely to have history of minor head trauma immediately preceding PNES onset and structural brain lesions, experienced a greater reduction of ASMs during the EMU admission, and had a greater improvement of their PNES frequency at the final visit (p ≤ 0.05). On hierarchical regression analysis, higher number of children, absence of structural brain lesions, fewer ASMs at EMU discharge, and improvement of PNES frequency remained significant predictors of ASM discontinuation. The outcome of PNES is positively correlated with earlier age of diagnosis in an EMU, especially in patients with better social resources. Furthermore, discontinuation of ASM is more likely if the process is initiated during the EMU stay and in the absence of structural brain lesions. [ABSTRACT FROM AUTHOR]

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