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Previous investigations utilizing the Minnesota Multiphasic Personality Inventory have observed personality differences between patients with epilepsy (ES) and those with psychogenic seizures (PS). This research utilized a shorter, easier-to-administer instrument, the Millon Clinical Multiaxial Inventory (MCMI), to evaluate 27 PS patients and 22 ES patients. Based on the results of EEG/video monitoring, patients were assigned to either strictly ES or strictly PS groups. PS patients scored significantly higher on MCMI Axis I scale of Anxiety, Somatoform, and Dysthymia as well as the Axis II pathological personality disorder, Borderline. Only the Axis I scales, however, showed clinically elevated base rate scores. Classification rules developed from these results correctly indentified 74% of the PS and 72% of the ES patients. These results suggest that MCMI may be a useful instrument for the evaluation of patients with PS.

The only consistent finding in studies of psychogenic seizures is the approximately threefold higher incidence in women. Therefore, why women? Charcot and Freud emphasized the sexual aspects of the seizure as has the current interest in childhood sexual abuse. From case studies and review of the literature the author believes that psychogenic seizures in women express rage, fear, and helplessness against the dominant and abusive male rather than sexual conflicts. Emphasizing the aggressive component of seizures does not minimize the traumatic effects of sexual abuse but rather includes it as leading to rage and helplessness.

A total of 148 patients with a history of probable seizure disorder were studied prospectively with long-term video electroencephalography over a 1-year period. Sixteen (11%) were identified with psychogenic seizures. Eleven (69%) of 16 were boys, with a mean age of 10.5 years. Seven (44%) of the 16 had an antecedent history of head injury prior to the development of these episodes; of these patients 85% were boys. Our results suggest that contrary to findings in the adult population, psychogenic seizures can be commonly seen in boys. The prevalence of antecedent head injury suggests that it is a notable risk factor in children as well as adults in the occurrence of psychogenic seizures. (J Child Neicrol 2000;15:78-80).

An 8-year-old boy with suspected psychogenic seizures was admitted for video-EEG monitoring. A stereotypical spell manifested as bilateral swinging extremity movements, and the patient proclaimed, “I’m doing the disco!” (video on the Neurology ® Web site at www.neurology.org). Right frontal-central rhythmic, sharp, fast activity (figure, A and B) was observed. MRI revealed seizure-related right frontal primary …

This article will review the problem of psychogenic seizures in adolescents and the impact of family therapy and individual therapy on treatment. Why particular individuals are prone to psychogenic seizures, the relationship between psychogenic seizures and family dynamics, and unresolved individual issues will be covered. The article will address a selected case, with a specific clinical paradigm for treatment.

Seven seizures, recorded from three patients, showed electrographic findings suggestive of epileptic seizures. However, careful analysis of the EEGs revealed multiple phase reversals and electrical field inconsistencies. Time-synchronized video recording confirmed that the patterns represented movement artifacts due to the patients shaking their heads, upper extremities, or bodies with secondary movement of electrodes, electrode wires, or electrode boxes. This series of patients highlights the importance of careful analysis of the data in the differentiation of psychogenic from epileptic seizures.

A follow-up study was performed in 33 patients with proven (ictal EEG-CCTV) psychogenic, non-epilptic seizures (PNES). These patients received a questionnaire to evaluate seizures, treatment and rehabilitation. The response group consisted of 21 females (80% response) and seven males (100% response). Follow-up after diagnosis varied from 23–67 months. Seven patients (25%) reported that seizures had ceased and of the patients not seizure-free seven did report a seizure-free period after diagnosis of an average 6.7 months. Eight patients were on antiepileptic drugs again. Of 13 patients referred for psychotherapy, who also did receive treatment, six became free of seizures and seven did not. Of seven patients also referred, but who did not receive psychotherapy, all continued to have seizures. On a self-rating scale to compare "overall function" at the time of diagnosis and follow-up, 75% considered themselves to have "improved", but no improvement could be detected in psychosocial functioning.

Nonepileptic paroxysmal events are behavioral, motor, or sensory episodes that do not result from abnormal cortical electrical activity. They can mimic any type of epileptic seizures including simple partial, complex partial, and generalized tonic-clonic seizures. Nonepileptic paroxysmal events may be physiological or psychogenic in nature. In clinical practice, the most common imitators of epileptic seizures are syncope and psychogenic seizures, but transient ischemic attacks, migraine, movement disorders, and metabolic disturbances must be considered at times in the differential diagnosis. In most cases, the clinical history is enough to make a correct diagnosis. The clinical features suggestive of various types of nonepileptic paroxysmal events, together with useful diagnostic tests, will be reviewed.

A series of technological advances have made it possible to closely monitor electrophysiological and behavioural manifestations of episodic clinical events over prolonged periods of time, with the ability to review the records at leisure or to submit them to computer analysis. The more promising techniques are time-locked video/EEG monitoring, cable telemetry, radiotelemetry, ambulatory cassette recording, intensive plasma anti-epileptic drug monitoring and continuous neuropsychological monitoring. The greatest promise of these techniques is for the diagnosis, research and management of epilepsy. For psychiatry, they offer additional help in the differential diagnosis of non-epileptic events from epilepsy, the most important of which are psychogenic seizures and episodes of aggression. This paper discusses the potential role of these techniques in the assessment of non-epileptic events and transient cognitive impairment in clinical psychiatry.

The natural history and the outcome of psychogenic seizures was studied in 50 patients by retrospective analysis and follow-up after a mean of 2 years. Concomitant epilepsy was definite in only 8% and possible in 14%, while 50% took anticonvulsants. Overall, 66% of patients showed heterogeneous psychiatric abnormalities, most commonly a depressive syndrome (24%), whereas hysterical personality features were rare (8%). Forty-two percent of patients were unemployed. Follow-up of 41 patients (82%) showed that 34% had become seizure free. Outcome was poor in those with a long history of psychogenic seizures and pathological psychiatric findings. In contrast, almost all patients with recent onset of psychogenic seizures and normal psychological status had become seizure free. At follow-up, 56% of patients were found to be in a poor or very poor state, which resulted from a combination of physical, psychic and social problems in most cases.

Psychogenic seizures are a functional phenomena in which a person experiences a paroxysmal event that may be interpreted as epileptiform in nature. By definition, psychogenic seizures imply a sudden episode of change in behaviour or psychic state that is not associated with an identifiable process, either vasculogenic or neurogenic, and during which there is an absence of characteristic epileptiform changes on the electroencephalogram. Prevalence rates range from 5% to 50% in outpatient populations seen in epilepsy clinics. However, approximately 20% of true seizure patients also have psychogenic seizures. As psychogenic seizures are not a pathophysiological phenomena, pharmacological interventions do not alter their aetiology and can cloud the cognitive skills necessary to ameliorate the psychogenic seizure behaviour. In non-aphasic true seizure patients, as well as psychogenic seizure patients, self-control relaxation paradigms have been successful where pharmacological intervention has failed. This case involved an aphasic brain-injured patient who had both psychogenic and true seizures. For this patient, the self-control paradigm was modified to include use of gesture and prosody to achieve similar psychotherapeutic effects. Additionally, family therapy was instituted to provide a constructive means for the patient's family to participate in the reduction of psychogenic seizures. As seizures are a common sequelae of brain injury, the differential diagnosis of seizures and knowledge of standard and alternative treatment is essential for rehabilitation professionals.

Frontal lobe complex partial seizures (FLCPS) may be difficult to distinguish clinically from psychogenic seizures (PS). We analyzed videotaped seizures of two patients with proven FLCPS and two patients whose PS resembled the FLCPS. Special attention was directed to the overall duration of attacks and the sequence and time course of their individual clinical manifestations. We found that the seizures of each of the FLCPS patients had quite stereotyped clinical features, but that the seizures of each PS patient were more varied in appearance. Each patient's FLCPS were brief, and each seizure had the same clinical signs that appeared and disappeared over similar sequences and time courses. In contrast, the PS of each patient varied from brief to long, and individual clinical signs varied not only from attack to attack but also in order of appearance and duration. Additional studies are needed to determine whether or not stereotyped clinical features can be used to reliably identify FLCPS and differentiate them from PS.

Neurological, neurodiagnostic, and neuropsychological aspects of psychogenic nonepileptic seizures (PNES) are reviewed, including psychosocial, psychiatric, cognitive, and MMPI-2 findings.

Summary: Purpose: Patients with psychogenic nonepileptic seizures (PNES) rate their health-related quality of life (HRQOL) more poorly than those with epileptic seizures (ES). This has been explained in part by mood state. We sought to investigate whether HRQOL differences between diagnostic groups (PNES vs. ES) can be explained by additional, perhaps chronic, aspects of mood and personality. An understanding of these relationships may inform treatment designed to improve HRQOL in ES or PNES. Methods: One-hundred fourteen individuals (69 ES and 45 PNES) completed the quality of life in Epilepsy-89. The profile of mood states (POMS) and the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) were employed to measure current and chronic mood symptoms, respectively. Multiple regression analyses determined the contribution of chronic mood symptoms to HRQOL beyond the variance accounted for by current mood state and seizure diagnosis. Results: Similar to previous reports, individuals with PNES reported poorer HRQOL than those with ES. Current mood state was strongly related to HRQOL and appeared to moderate the relationship between seizure diagnosis and HRQOL. However, when more chronic psychological symptoms, such as somatization and emotional distress, were included in a model, the moderating role of mood state was not significant. Conclusion: Analyzed independently, mood state is related to HRQOL, but when chronic indicators of psychological symptoms are included in a model mood is related to HRQOL, but, the moderating effect of mood is no longer significant. Treatments designed to improve HRQOL among individuals with intractable seizures should also address chronic psychological distress and symptoms associated with high levels of somatization.

Purpose: Psychogenic nonepileptic seizures (PNES) are episodes that may resemble epileptic seizures (ES) but are not associated with abnormal electrical discharges in the brain. Video-EEG recording of a typical episode is considered the best diagnostic tool available. PNES are, however, also documented in patients with epilepsy (PNES/ES). The purpose of this study was to assess this comorbid population, focusing on the differences between patients with PNES/ES and patients with PNES alone. Methods: We reviewed 110 PNES episodes, occurring spontaneously or induced by means of suggestion techniques, recorded in our video-EEG laboratory over a period of eight years. We identified two subgroups of patients, consisting of 85 PNES cases and 25 PNES/ES cases, and assessed any differences in their characteristics by reviewing a number of variables (age, sex, clinical features, antiepileptic therapy, age of onset, time to diagnosis, pathological history, and length of follow-up). Results: The comparison between the two subgroups revealed that PNES/ES patients displayed some statistically significant differences when compared with PNES alone patients, i.e., younger age, a higher percentage of spontaneously activated events, a shorter disease duration, a longer time to PNES diagnosis, and a lower percentage lost at follow-up. Conclusions: This study confirms that PNES is a common, though probably underestimated, occurrence in epilepsy services. Our results shed light on some different characteristics between PNES and PNES/ES patients.

Background: A seizure (Latin word which means “to take possession of”) is a paroxysmal event due to abnormal excessive or synchronous neuronal activity in the brain. Seizure is a medical emergency and about 1 in 10 persons will experience a seizure in their lifetime. Etiological contribution to seizures in developing countries is different from developed countries. Epilepsies related to malaria, neuroinfections, tuberculosis, HIV, meningitis, trauma and perinatal difficulties more prevalent in India and other developing countries. Neurocysticercosis is the most common cause of seizures/epilepsy in the developing countries and designated as a “biological marker” of the social and economic development of a community. In India, Single Small Enhancing CT Lesions (SSECTL) being the most common radiological finding and dying cysticercus larva in histopathological studies. Aim: To study the etiological profile in new onset seizures. Methods: This was an observational and prospective study. The present study enrolled 100 patients above 15 years of age with new onset seizures. All the patients and their relatives were interviewed regarding history and thorough clinical examination was done. Routine blood investigations, blood urea, serum creatinine, blood sugar, liver function tests, serum electrolyte were done. Special investigations like electroencephalography (EEG), CT scan brain, MRI, and lumbar puncture were done in selected cases. Results: Out of 100 patients included in the study, neuroinfection is leading cause of seizure in 36%, Cerebrovascular accidents (25%) and metabolic in (12%). Majority of seizures in neuroinfections were due to neurocysticercosis in 15 patients (42%) followed by meningoencephalitis in 14 patients (38%). Among Cerebrovascular accidents, stroke accounted for 84% (21) (Infarct-12, Haemorrhage-9), followed by cerebral venous thrombosis 12% (3). Out of 12 patients with metabolic seizures, hypoglycaemia and hyponatremia constituted 33% each. Conclusions: Etiological spectrum of seizures includes neuroinfection, CVA, tumour, metabolic, poisoning and alcohol withdrawal. Neuroinfection accounted for significant number of seizures in all the age groups. Neurocysticercosis is the most common etiology among neuroinfections. Cerebrovascular accidents common in 4 th & 5 th decades. Limitation: Patients

Psychogenic (nonepileptic) seizures are among the most common and serious of all psychogenic neurological disorders. They account for approximately 20% of all intractable seizure disorders referred to comprehensive epilepsy centers and present with a reported annual incidence of approximately 4% that of true epilepsy. These events are serious and disabling. Indeed, compared with patients with true epilepsy, patients with psychogenic seizures exhibit more frequent, severe, and disabling seizures as well as a poorer quality of life. The diagnosis and management of psychogenic seizures remain challenging, although advances in video electroencephalographic (EEG) monitoring have improved the ability of physicians to identify these disorders accurately. The prognosis of these patients is still relatively poor, and a good outcome seems dependent on a young age at diagnosis, early diagnosis, less severe psychological comorbidities, and continued follow-up and management by the diagnosing neurologist or clinician. Additional psychological or psychiatric assessment may be beneficial, particularly in elucidating the etiology of the disorder as well as identifying comorbid disorders, and may help in the long-term management of these patients. This review presents the history, epidemiology, differential diagnosis, and management of psychogenic seizures, with particular attention to the use of diagnostic testing, including video EEG monitoring.

We report on a male child born in Rumania, adopted by an Italian family, and who at 10 years of age was submitted to interferon-alpha 2a therapy for chronic hepatitis B. About 30 days after the beginning of the treatment he developed hypomanic mood and psychogenic seizures. Psychological evaluation showed hyperactivity, distractibility, excessive talkativeness, grandiosity and racing thoughts. Temperamental traits were characterized by an elevated emotionality. The patient was successfully administered risperidone and cognitive-behavioral therapy; six months of treatment with interferon led to positive outcome of hepatitis B. Since affective symptoms may occur in children treated with IFN, a careful evaluation of psychiatric disturbances and adequate intervention are needed.

Differential diagnosis between epileptic and nonepileptic paroxysmal disorders is fundamental not only to allow correct management of patients but also to avoid the burden of unnecessary antiepileptic medication. The focus of this chapter is limited to imitators of idiopathic generalized epilepsies (IGE) which are expressed through myoclonic, tonic-clonic, tonic, atonic, and absence seizures. Apparent losses of consciousness and drop attacks also have to be considered. Benign myoclonus of early infancy is the main nonepileptic disorder in the differential diagnosis of infantile spasms, but is not dealt with here because West syndrome is not an IGE. Hyperekplexia, metabolic disorders, hypnagogic myoclonus, and disturbed responsiveness caused by the use of drugs are listed in Table 1. Other conditions that may imitate more focal epileptic seizures are omitted. Benign neonatal sleep myoclonus, apnea and apparent life-threatening events in infants, cyanotic and pallid breath-holding spells, syncope, staring spells, psychogenic seizures, hyperventilation syndrome, and narcolepsy have been selected based on frequency or difficulties in differential diagnosis with the intention to cover the most conspicuous imitators of IGE in different ages.

The clinical suspicion for psychogenic nonepileptic seizures (PNES) is based on multiple features obtained in the history. We reviewed the records of all patients evaluated over 5 years in a single epilepsy clinic for refractory seizures who eventually underwent EEG/video monitoring. We designated two groups: (1) patients with a diagnosis of "fibromyalgia" or "chronic pain" and (2) patients who had a seizure during the visit, either in the waiting area or in the examining room. Of 36 patients with "fibromyalgia" or "chronic pain," 27 (75%) were found to have PNES. Of 13 patients who had a "seizure" during their clinic visit, 10 (75%) were found to have PNES. We conclude that each of these findings has a predictive value of 75%.

Psychogenic symptoms are common and pose an uncomfortable challenge. Among psychogenic symptoms, psychogenic nonepileptic seizures (PNES) are common and have been extensively studied. They are unique in that, unlike most other psychogenic symptoms, they can be diagnosed with near certainty. PNES can be used as a model, as almost everything that applies to PNES applies to other psychogenic symptoms. According to DSM-IV, somatic symptoms are the main manifestation of three groups of disorders: somatoform disorders, factitious disorder, and malingering. Treatment is challenging. Unfortunately, psychogenic symptoms tend to be neglected. For example, the American Psychiatric Association has abundant written patient education material available on diverse topics, but none on somatoform disorders. Psychogenic symptoms are also not the subject of much clinical research. A search of the journal Neurology for 1994–2003 for the word psychogenic in the title found 21 articles, only 4 of which on topics other than psychogenic seizures. A similar search for original articles in the New England Journal of Medicine found no articles with psychogenic in the title and two with psychogenic in the abstract. Thus, there seems to be a severe disconnect between the frequency of the problem and the amount of attention devoted to it.

To assess psychopathological symptoms and history of childhood trauma in patients with newly developed psychogenic seizures.Using validated scales, 178 patients from the general population diagnosed with newly developed seizures were assessed, at a point in time when the nature of their seizures was yet unknown to either doctors or patients. After standardised neurological examination, 138 patients were diagnosed with non-psychogenic seizures (NPS), while 40 patients were found to have psychogenic seizures (PS). To evaluate possible differences between the genders and the diagnostic groups, univariate analyses of variance were done.PS patients reported significantly more comorbid psychopathological complaints, dissociative experiences, anxiety, and self-reported childhood trauma than NPS patients. In addition, PS patients had lower quality of life ratings than NPS patients. These effects were not modulated by gender.The results of the present study indicate that patients with newly developed PS constitute a group with complex psychopathological features that warrant early detection and treatment.

To characterize non-epileptic seizures (NES) in the elderly and compare their features with NES of a younger control group. The database of the epilepsy monitoring unit of the Cleveland Clinic Foundation (CCF) was searched for patients aged 60 years and older having undergone long-term video-/EEG monitoring between 1994 and 2002,with the subsequent diagnosis of NES. Videotapes of all events were evaluated by independent observers. NES were classified based on the clinical manifestations recorded on video, EEG and imaging data, and compared with a control group of younger adults with NES. Thirty-nine elderly patients were included. Seventeen of them (44 %) had NES only, six (15 %) had both epilepsy and NES. The control group consisted of 20 patients, two of them had NES and epilepsy. The NES were classified as physiological in 10 elderly patients (43 %) and one control patient. They included TIA, syncope, movement disorders and sleep disorders. Psychogenic NES were found in 13 elderly and 19 control patients and were associated with somatoform disorders, anxiety disorders, mood disorders and reinforced behavior pattern. Psychogenic NES consisted of predominant motor activity in 8 (61 %) elderly and 13 (68 %) control patients, unresponsiveness in 4 (31 %) elderly and 2 (11 %) control patients and subjective symptoms in 1 (8 %) elderly and 4 (21 %) control patients. Twelve (71%) of the patients of each group without evidence for epilepsy were on anticonvulsant drugs at the time of admission. NES are a frequent problem in elderly patients referred to a comprehensive epilepsy center. In contrast to a younger control group, physiological and psychogenic NES are equally frequent in the elderly. Loss of responsiveness was seen in only 20% of patients with psychogenic NES. Although most of the patients did not have any evidence for epilepsy, more than two thirds of these patients had been placed on anticonvulsive drugs.

Epilepsy features, psychiatric profile, psychosocial factors, and outcome are described for six children (three males) aged 5–15 years (mean 12.1) with psychogenic status epilepticus (PSE), i.e., prolonged or repetitive psychogenic seizures (PSs), >30 minutes, simulating status epilepticus. They had epilepsy, they were on chronic anticonvulsants (ACVs), and some had other neurological deficits. All received intravenous and/or rectal ACVs prior to suspicion of PSE. PSE was confirmed via video/EEG, demonstrating no epileptogenic activity during alleged seizures. Provocation and placebo therapy techniques were used in two. Psychiatric assessment identified comorbid disorders such as depression, anxiety disorder, obsessive–compulsive disorder, obsessive–compulsive symptoms, and posttraumatic stress disorder. Psychosocial stressors were almost ubiquitous. Psychiatric intervention included psychotherapy, family therapy, and medical treatment in one patient. Outcome was monitored for an average of 3.6 years (3–5 years). PSE did not recur. PSs recurred in three. Psychiatric comorbidity improved in four, who accepted psychiatric intervention and whose epilepsy also improved. In conclusion, the occurrence of PSE in children and adolescents with epilepsy is stressed. Prompt diagnosis was often missed in the acute care setting, and this carries important implications for iatrogenic complications. PSE diagnosis resulted in identification and management of comorbid psychiatric disorders. This was probably important in reducing the predominating anxiety and affective disorders in most patients as well as PSE recurrence. Epilepsy severity and associated deficits were most likely important factors in determining outcome.

This study examined the frequency of epilepsy in a consecutive series of patients who received a definitive diagnosis of psychogenic nonepileptic seizures (PNES) after completing inpatient video-EEG (VEEG) monitoring. Of the 1,590 patients receiving definitive diagnosis, 514 (32.3%) were diagnosed with PNES. Twenty-nine (5.3%) of these patients were found to have both PNES and epilepsy. When strict diagnostic criteria are applied, there is little overlap between epileptic seizures and PNES among patients referred for VEEG monitoring.

The purpose of this study was to investigate the duration of monitoring, number of seizures recorded, and date and time of occurrence of seizures in different patient groups during video-EEG monitoring (VEEGM). Patients with partial or psychogenic seizures who were admitted to our VEEGM unit between September 1996 and March 2002 were retrospectively evaluated. Duration of monitoring, date and time of occurrence of seizures were identified in each patient. For practical reasons, a day was divided into 3 equal time periods (period I: 08–16; period II: 16–24 and period III: 24–08 hrs), and the period in which the seizure occurred was noted. Patients were classified in 5 groups: 1 -temporal; 2-frontal; 3-parieto-occipital; 4-psychogenic and 5-unclassified. Duration of monitoring, the number of seizures recorded and time distribution of seizures were identified in each group and compared statistically. We evaluated 746 seizures in 209 patients. Seizures were more likely to occur in periods I and III in groups 1 (p=0.004) and 5 (p

Seizure frequency during inpatient video EEG monitoring was examined before and after the diagnosis of psychogenic nonepileptic seizures (PNES) was presented to patients (N=22). A control group of 10 patients with epileptic seizures (ES) were also followed from pre- to postdiagnosis. The number of PNES or ES within the 24-hour period prior to diagnosis was compared with the number of events that occurred within the 24-hour period after presentation of the diagnosis. Findings indicate that patients with PNES had a significant decrease in the frequency of events after diagnosis, while those with ES showed no change in event frequency after diagnosis. Eighteen of twenty-two patients with PNES had no further events during an acute follow-up period. Results suggest that providing patients with a diagnosis of PNES appears to reduce the acute frequency of PNES and may be an important first step in the long-term remediation of PNES. Long-term follow-up is needed to determine if such feedback alters the course of the disorder.

Temporal lobectomy can be complicated by somatoform disorders, psychiatric illnesses and non-epileptic psychogenic seizures. We report a woman who developed astasia–abasia and psychogenic tremor following temporal lobectomy for refractory epilepsy. To our knowledge, this type of conversion reaction following temporal lobectomy has not been previously reported.

Induction by suggestion has previously been reported to be effective in the diagnosis of psychogenic seizures (PS). However, the sensitivity and specificity of this procedure has not previously been studied. Results of induction of PS by suggestion were analyzed in 93 patients with purely PS. The diagnosis of PS was based on the recording of a clinical event on video-electroencephalography, the absence of clinical or electroencephalography the absence of clinical or electroencephalographic evidence of epilepsy, and the subsequent followup and withdrawal of anticonvulsants supporting the diagnosis of PS. A control-group was composed of 20 patients with epilepsy in which induction was tried. Both groups were comparable for age, sex, and educational level. Induction was performed following a standardized protocol. The test was carried out placing a colored patch on the neck. The test was considered positive when the induced clinical events were typical, according to a witness familiar with the patient's seizures. Induction was positive in 72 of 93 cases with PS and in none with epilepsy. Sensitivity of this test for the diagnosis of PS was 77.4%, specificity 100%, positive predictive value 100%, and negative predictive value 48.7%.

Background: Patients with physical brain abnormalities have an increased risk of developing psychogenic nonepileptic seizures (PNES). Here we describe patients who developed PNES after intracranial neurosurgery for indications other than the control of refractory epileptic seizures and explore whether neurosurgical intervention is at risk factor for PNES. Method: We searched the database of 372 patients diagnosed with PNES at our department over the last 10 years and identified 17 patients (4.6%) in whom PNES first started after intracranial neurosurgery. Surgical procedures included the complete or partial resection of a meningioma, AV malformation, cavernoma, plexus papilloma, neurinoma, astrocytoma, oligodendroglioma, dysontogenetic cyst, the drainage of a brain abscess and removal of a subdural hematoma. PNES were documented by ictal video-EEG, ictal EEG, or ictal observation and examination in all cases. The diagnosis of additional epileptic seizures were confirmed by ictal EEG/video-EEG, or made on the basis of a clinical assessment by an experienced epileptologist. Findings: Five patients had purely psychogenic postoperative seizure disorders, twelve had epileptic and psychogenic attacks. Median age at neurosurgery was 32 years (range 5–54), median latency between surgery and onset of PNES was 1 year (range 0–17 years). Interpretation: PNES may develop after intracranial neurosurgery undertaken for other indications than the control of refractory epileptic seizures. Younger patients with a history of pre-operative psychiatric problems or epileptic seizures and surgical complications may be at higher risk. A diagnosis of PNES should be considered in patients who develop refractory seizures after neurosurgery.

In this preliminary clinical investigation, hypnosis was used in the differential diagnosis of epileptic versus psychogenic seizures (PS). Eight patients with a clinical profile suggesting the presence of PS were given a hypnotic suggestion in which they had to go back in time to the exact moment of their last seizure. They were then asked to concentrate their attention on any unusual feeling or bodily sensation. All 8 patients presented a PS during the age regression protocol. In 6 cases, independent testimony from family members corroborated the morphological similarity of the induced attack and the ones presented in their natural environment. Also, the seizures ended abruptly after a command was given to stop them. A control group of 5 epileptic subjects did not present any signs of discomfort or seizure behavior during the hypnotic protocol. It is argued that a simple procedure as the one described in this investigation can be useful as a diagnostic tool in the differentiation of epileptic from PS attacks.

Item does not contain fulltext OBJECTIVE: To assess whether surgery to reduce or control epileptic seizures is safe and effective in patients known to have additional psychogenic seizures. DESIGN: We reviewed our computerized database of 1342 patients examined for epilepsy surgery and identified 13 patients with both epileptic and psychogenic seizures on whom postoperative outcome data were available. Data were gathered from the patients' records. Mean postoperative follow-up was 56 months. RESULTS: Epilepsy surgery led to clinically relevant improvements in 11 of 13 patients. Seven patients became free of epileptic and psychogenic seizures, 2 patients became free of epileptic seizures but continued to have infrequent psychogenic seizures, 1 patient reported more than an 80% improvement in epileptic seizure frequency and an abolishment of psychogenic attacks, and in 1 patient nondisabling epileptic seizures persisted at lower frequency but psychogenic seizures stopped. In 2 of 13 patients, epilepsy surgery failed to produce notable improvements. Although 1 patient became free of epileptic attacks and the other had fewer than 3 epileptic seizures per year, the severity or frequency of psychogenic seizures and pseudo-status epilepticus increased postoperatively. One of these patients had a preoperative diagnosis of somatization disorder; in the other, pathological illness behavior had been noted. CONCLUSION: A diagnosis of additional psychogenic seizures should not be considered an absolute contraindication to epilepsy surgery, although patients should undergo careful preoperative psychiatric evaluation.

Pseudoseizures also known as "psychogenic non-epileptic seizures" are caused because of stress, emotional disturbances or from traumatic psychological experiences of refugees/victims of torture. There are lot of other physical conditions can produce seizures which are not epileptic but it is very important to investigate all possible causes for the seizures. Like epileptic seizures, psychogenic seizures can be very disruptive to a person's life as they have their own stigma, caused mostly by ignorance. The evaluation and treatment of patients with psychogenic pseudoseizures requires a joint collaborative effort of neurologists and psychiatrists. It is important that people, including medical and psychological professionals, learn about psychogenic seizures, their causes, and treatment. Daily life for someone with pseudoseizures can be improved dramatically if therapists or treating professionals like nurses, and doctors know how to treat the underlying cause effectively. Treatment is most successful when the person is encouraged to explore his/her own feelings and assisted in learning to cope with the feelings in new ways.

Many epilepsy centers use provocative techniques (inductions) during EEG-video monitoring to aid in the diagnosis of psychogenic nonepileptic seizures. Provocative techniques are not always necessary, and they should only be used when they help establish the diagnosis. There are several situations where inductions have significant advantages. When attacks do not occur spontaneously, provocative techniques can turn an inconclusive evaluation into a diagnostic one. Triggering an attack with induction can shorten the evaluation, decreasing its cost and reducing waiting time in the monitoring unit. Patients with infrequent episodes (that do not occur frequently enough to obtain a spontaneous event during monitoring) can be scheduled for a brief outpatient monitoring with induction. In clinical scenarios where symptoms are consistent with a ''simple partial" seizure, the very presence of suggestibility is in itself a very strong additional argument to support a psychogenic etiology. The arguments against inductions are mainly based on ethical concerns. While these concerns have some validity, they are, in the real world, far outweighed by the alternatives. It is far more unethical to not obtain a definitive diagnosis when it would be possible, since the consequences of perpetuating the wrong diagnosis are many and serious. Even with placebo the benefits far outweigh the very minor ethical theoretical concerns, and the use of placebo is not even necessary. When correctly performed and interpreted, the specificity of inductions is over 90%. All tests have limitations, with some false positives and false negatives. Like all other tests, inductions must be used appropriately and with awareness of their limitations.

Summary: Purpose: To determine the predictive value of clinical features and medical history in patients with nonepileptic seizures (NESs). Methods: One hundred sixty-one consecutive ictal video-EEGs were reviewed, and 17 patients with 41 NESs identified. NES diagnosis was defined as paroxysmal behavioral changes suggestive of epileptic seizures recorded during video-EEG without any electrographic ictal activity. Clinical features, age, sex, coexisting epilepsy, associated psychiatric disorder, social and economic factors, delay in reaching the diagnosis of NES, previous treatment, and correlation with outcome on follow-up were examined. Results: The study population included 70% female patients with a mean age of 33 years. Mean duration of NESs before diagnosis was 9 years. Forty-one percent had coexisting epilepsy. The most frequent NES clinical features were tonic–clonic mimicking movements and fear/anxiety/hyperventilation. The most common psychiatric diagnosis was conversion disorder and dependent and borderline personality disorder. Seventy-three percent of patients with pure NESs received antiepileptic drugs (AEDs), and 63.5% of this group received new AEDs. Fifty-nine percent of the patients received psychological/psychiatric therapy. At follow-up, 23.5% were free of NESs. Conclusions: All seizure-free patients had two good prognostic factors: having an independent lifestyle and the acceptance of the nonepileptic nature of the episodes. Video-EEG monitoring continues to be the diagnostic method to ensure accurate seizure classification. Establishing adequate health care programs to facilitate access to new technology in public hospitals as well as the implementation of continuous education programs for general practitioners and neurologists could eventually improve the diagnosis and treatment of patients with NESs.

Chronic limbic epilepsy was induced in male albino rats by a single systemic injection of lithium (3 mEq/kg) and pilocarpine (30 mg/kg). During the subsequent months the numbers of spontaneous, paroxysmal stereotyped episodes (analogous to Racine stages 4 and 5) were monitored. The numbers of these "overt seizures" increased within 10 min of the daily presentation of a food stimulus even though food was available ad libitum. The majority of the paroxysmal, stereotyped behaviours occurred within 1 min of the stimulus presentation; they were attenuated by oral prednisolone. Three rats displayed evidence of "conditioned seizures" to specific stimuli. The results suggest that the display of these behaviours can be synchronized and learned in contexts that are associated with the release of CRF (corticotrophin releasing factor) and may involve the disinhibited activity within the central amygdaloid nucleus of these rats. Implications for the occurrence of psychogenic seizures in patients with complex partial (limbic) epilepsy are discussed.

We describe two patients with epilepsy who presented with nonepileptic seizures (NES) when started on levetiracetam (LEV), which disappeared or significantly decreased when LEV was discontinued. NES are traditionally attributed to psychic trauma often after physical or sexual abuse, whereas the psychiatric side effects of levetiracetam largely encompass depression, hallucinations, and psychosis. We conclude that NES are a rare side effect of LEV treatment and part of the spectrum of behavioral changes observed with LEV treatment.

Summary Purpose: To determine whether differences in clinical manifestations of psychogenic nonepileptic events are associated with differences in outcome and whether the length of illness before diagnosis correlates with outcome. Methods: We reviewed ictal videotapes and EEGs in 85 patients diagnosed with exclusively nonepileptic psychogenic seizures during inpatient CCTV-EEG monitoring at the University of Michigan between June 1994 and December 1996. They were classified into groups of similar ictal behaviors. Fifty-seven of these patients were available to respond to a follow-up telephone survey about their condition 2–4 years after discharge. We examined demographics, baseline EEG abnormalities, and outcome of treatment interventions. We also evaluated whether interventions were more likely to succeed if patients were diagnosed early in the course of the illness. Results: We found that the largest groups consisted of patients with motionless unresponsiveness (“catatonic,” n = 19) and asynchronous motor movements with impaired responsiveness (“thrashing,” n = 19). Infrequent signs included tremor, automatisms, subjective events with amnesia, and intermittent behaviors. There was a higher incidence of baseline EEG abnormalities in the thrashing group (31%) than in the catatonic group (0%). There was a higher incidence of complete remission of spells in the catatonic group (53%) than in the thrashing group (21%). Patients who had a more recent onset of seizures (most often within 1 year) were much more likely to have remission of spells after diagnosis. Conclusions: Classification of nonepileptic seizures is useful in predicting outcome and may be valuable in further investigation of this complex set of disorders.

The occurrence of de novo psychogenic seizures after epilepsy surgery is rare, and is estimated in 1.8% to 3.6%. Seizures after epilepsy surgery should be carefully evaluated, and de novo psychogenic seizures should be considered especially when there is a change in the ictal semiology. We report a patient with de novo psychogenic seizures after anterior temporal lobe removal for refractory temporal lobe epilepsy. Once psychogenic seizures were diagnosed and psychiatric treatment was started, seizures stopped.

Article abstract The authors report five patients with recurrent psychogenic seizures (PS) during pregnancy, with multiple emergency room visits and continued intake of antiepileptic drugs obtained from various sources, despite awareness of the psychogenic nature of their attacks and the risks of antiepileptic drug use in pregnancy. These patients demonstrate that preexisting PS may persist during pregnancy, and there will be patients who continue to take antiepileptic drugs despite awareness of the risks inherent to these treatments. New-onset or persisting PS with pregnancy can be indicative of serious emotional conflicts, and the child should be considered at risk.

The occurrence of de novo psychogenic seizures after epilepsy surgery is rare, and is estimated in 1.8% to 3.6%. Seizures after epilepsy surgery should be carefully evaluated, and de novo psychogenic seizures should be considered especially when there is a change in the ictal semiology. We report a patient with de novo psychogenic seizures after anterior temporal lobe removal for refractory temporal lobe epilepsy. Once psychogenic seizures were diagnosed and psychiatric treatment was started, seizures stopped. A ocorrência de crises psicogênicas de novo após cirurgia de epilepsia é rara, e é estimada em 1,8% a 3,6%. Crises após cirurgia de epilepsia devem ser cuidadosamente avaliadas, e crises psicogênicas de novo devem ser consideradas especialmente quando houver uma mudança na semiologia ictal. Relatamos o caso de uma paciente com crises psicogênicas de novo após lobectomia temporal anterior realizada para tratamento de epilepsia temporal de difícil controle. Uma vez feito o diagnóstico de crise psicogênica e iniciado tratamento psiquiátrico, as crises foram controladas.

The authors studied six children with repetitive psychogenic seizures severe enough to mimic status epilepticus. All received IV antiepileptic drugs in an emergency setting. Most had a family history of epilepsy. Affective and anxiety disorders predominated as comorbid psychiatric diagnoses. Acutely stressful situations precipitated all episodes of nonepileptic status epilepticus. With aggressive psychotherapeutic intervention and pharmacologic treatment of their underlying psychiatric diagnosis, the patients improved.

Publisher Summary This chapter discusses the role of etiologic factors in psychogenic seizures. Psychogenic seizures are one subset in a broad category of nonepileptic seizures. Nonepileptic seizures are regarded as a group of paroxysmal events that resemble epileptic seizures but are not caused by neuronal discharges. This broad category includes such diagnoses as cardiac arrhythmia, transient ischemic attacks, migraines, panic disorder, hypoglycemia, and many others. Traumatic life course is another category of patients who are considered to have posttraumatic psychogenic seizure syndrome. This refers to patients who typically come from chaotic or dysfunctional families of origin and may have been victims of mental or psychological abuse. Two etiologic factors can contribute to the development of psychogenic symptoms in this group. First, the trauma causing the injury may lead to posttraumatic stress disorder, which can include symptoms, such as flashbacks or dissociative episodes that may be interpreted as psychogenic seizures. The neuropsychological deficits resulting from the head injury may lead to attention and memory impairments resulting in the patient's inability to function at preinjury capacities. It is found that among the disorders in which dissociative symptoms may occur are acute stress disorder, posttraumatic stress disorder, and somatization disorder.

Publisher Summary Psychogenic seizures have been defined as a sudden episode of change in behavior or psychic state that is not associated with any identifiable physiological etiology. It has been estimated that approximately 20% of outpatients presenting to comprehensive epilepsy centers for evaluation have psychogenic seizures. The use of long-term EEG recording and video monitoring has been a significant advancement in the assessment of patients with both epileptic and nonepileptic seizures. Patients with psychogenic seizures represent a very heterogeneous group, and many factors may lead to the development of the symptom. It is found that when there is a high index of suspicion that the events being evaluated are likely to be psychogenic, it is critical to involve a mental health professional early in the evaluation. However, the major risk to a patient with psychogenic seizures is that of a psychological harm. A wide range of medical, neurologic, and psychiatric disorders can cause paroxysmal events that may resemble epilepsy. Patients with panic disorder experience the sudden and unexpected onset of numerous physical and emotional symptoms that may resemble a seizure. The discussion of the diagnosis with the patient and making recommendations for treatment are also emphasized.

The economic burden of epilepsy is well recognized. However, empirical investigation establishing costs associated with the diagnosis and treatment of non-epileptic psychogenic seizures (NEPS) is lacking. We studied 20 patients with video/EEG monitoring-confirmed NEPS to determine the effect of definitive diagnosis and treatment on medical costs and utilization. A medical resource utilization questionnaire and inpatient medical chart review were employed to calculate utilization information. Medication usage, outpatient visits, emergency room admissions, and diagnostic testing over a 6-month pre-diagnosis and a 6- month post-diagnosis period were compared. There was an 84% average reduction in total seizure-related medical charges in the 6 months following NEPS diagnosis. Average diagnostic testing charges declined 76%, average medication charges decreased 69%, outpatient clinic visits declined 80%, and emergency room visits reduced by 97%. A majority of patients obtaining a definitive inpatient video/EEG-seizure-monitoring-confirmed NEPS diagnosis experience substantial reductions in health care utilization and dollar costs.

Summary: Purpose: Psychogenic seizures (PS) (emotionally based nonelectrical seizures) have been explained by psychodynamics and trauma. However, the family health literature suggests that somatization, of which psychogenic seizures are a form, may run in families and be determined by family patterns of response to distress. This study compared families of patients with PS and those of patients with epilepsy on variables of distress (anxiety and depression) and somatization. Methods: Eighteen patients (9 with PS and 9 with epilepsy) matched for age and education, and their families answered the Health Status Questionnaire (HSQ), the Weinberger Adjustment Inventory (WAI), the Family Emotional Involvement and Criticism Scale (FEICS), Barsky's Somatization Symptom Inventory (SS), and the Dissociation Experience Scale (DES). Family members' scores were averaged to obtain “family scores.” Results: Patients with PS and those with epilepsy did not differ in any of the measures. However, families of patients with PS reported more health problems, distress, and criticism than did families of patients with epilepsy (p < 0.05). Families of patients with PS had increased criticism and somatic problem scores comparable to those of both types of patients. Conclusions: Although epilepsy causes patients physical and emotional problems, their families are relatively healthy. In contrast, families of patients with PS are more troubled and may unwittingly contribute to PS through family distress, criticism, and tendencies to somatize.

Psychogenic seizures or psychogenic nonepileptic seizures occur in various mental disorders. Obsessive-compulsive symptoms can also imitate epileptic partial seizures, but detailed observations of this phenomenon are rare in the literature. A girl of 13 years was referred to the Department of Child Psychiatry because of sudden falls that had occurred during a 1-year period, mainly at school. She had been diagnosed previously as having epilepsy or conversion seizures. After a fall, she demonstrated no response for periods up to 10 minutes, postictal somnolence had occasionally been observed. From the age of 10 years, the patient was reported to have had intrusive recurrent thoughts about dirt and contamination and had also demonstrated some signs of separation anxiety disorder. She was diagnosed as having obsessive-compulsive disorder with poor insight. The chronic falling disappeared completely when behavioral therapy was begun, but the girl still exhibits obsession and separation anxiety.

Eclampsia, or toxemia of pregnancy, is a disorder of pregnancy characterized by seizures associated with hypertension, edema, and proteinuria. Toxemia carries significant maternal and fetal morbidity and mortality. Psychogenic seizures are defined as events that clinically resemble epileptic seizures but are not accompanied by abnormal electrical activity of the cerebral cortex. We report the case of a third trimester pregnant patient who presented with new onset convulsive activity that was associated with peripheral edema, intermittent hypertension, and proteinuria. The initial impression of the treating physicians—emergency medicine, obstetrical, and neurology—was toxemia of pregnancy. After further review and the application of numerous procedures and therapies with potential risk, the diagnosis of psychogenic seizure was made.

Patients who experience episodes with a transient disturbance in perception, memory, mood, and level of anxiety are frequently encountered by neurologists, psychiatrists, and psychologists. The possibilities for differential diagnosis of these episodes include partial complex epilepsy, psychogenic seizures, panic disorder, dissociative states, migraine, and transient global amnesia, among others. The clinical history may be vague and confusing, making it difficult to determine definitively the etiology of the events. This article describes a spectrum of paroxysmal disorders involving limbic structures, highlighting the clinical features and assessment techniques that aid in diagnosis and treatment. Clinical-anatomic correlations are provided whenever possible.