Psychogenic Nonepileptic Spells

Question 1

Risk factors for PNES

Answer 1

• History of abuse
• History of head injury
• Presence of an acute stressor
• Pre-existing anxiety disorder, stress disorder, or personality disorder

Question 2

Gold standard for differentiating PNES from epileptic seizures

Answer 2

Prolonged video EEG monitoring

Question 3

Features of a spell that are suggestive of PNES

Answer 3

• Forceful eye closing
• Maintained consciousness in the presence of generalized motor activity
• Asynchronous convulsive movements (fluctuates in intensity or on/off fluctuation)
• Pelvic thrusting or opisthotonus
• Side-to-side head movements
• Controlled falling
• Prolonged unresponsiveness after a spell despite normal EEG
• Predictable occurrence in the presence of a witness and in response to a psychological trigger
• Longer duration of events (most PNES are > 10 minutes while most seizures are < 3 minutes)

Question 4

Post-ictal confusion in PNES

Answer 4

Less likely to be present, but is not entirely out of the question. Some patients do exhibit symptoms that mimic a post-ictal state after PNES.

Question 5

Bilatreal seizure activity without ___ is rarely organic

Answer 5

Bilatreal seizure activity without confusion or loss of consciousness is rarely organic

Bilatreal involvement pratically necessitates altered consciousness because both hemispheres in the brain are compromised.

Question 6

Main epileptic mimic of PNES

Answer 6

Frontal lobe epilepsy

Frontal lobe epilepsy can produce dramatic motor manifestations with relatively preserved consciousness

Accurate differentiation really requires a video EEG, which will typically be positive in frontal lobe epilepsy and negative in psychogenic spells.

Question 7

Treatment for psychogenic nonepileptic spells

Answer 7

• Psychoeducation
• Cognitive behavoral therapy
• Treatment of contributing comorbidities (anxiety, depression, PTSD)