View source for Psychogenic nonepileptic seizure

==Background==
*Psychogenic nonepileptic seizure (PNES) characterized disturbances of motor, sensory, autonomic, cognitive, and/or emotional functions that can mimic epileptic seizures. 
*In contrast to epileptic seizures, PNES are not associated with abnormally excessive neuronal activity but are instead derived from psychologic causes. 
*The term pseudoseizures and hysterical seizures are historical terms that are now discouraged.
*Accurate diagnosis is best achieved via a detailed history, physical examination, selected testing, and neurology and/or psychiatry evaluation.
*Epidemiology
**Estimated incidence rate ranges from 1.5 to 5 per 100,000 persons per year. 
**Estimate prevalence 2 to 33 per 100,000 persons.
**More common in women
*Etiology
**There may be a history of sexual abuse, eating disorders, depression, substance abuse, anxiety disorders or personality disorders, and the episode may be preceded by a stressful event
**Dissociative disorders and conversion disorders are felt to be the underlying cause to most episodes of PNES.
*Some patients may have both psychogenic nonepileptic seizures '''and''' true epileptiform [[seizures]]

==Clinical Features==
*Symptoms specific to PNES: 
**Duration > 2 minutes 
**Pelvic thrusting 
**Side to side head rocking 
**Crying/shrieking 
**Voluntary eye movements away from the examiner/forceful closing of the eyes 
**Stuttering/stammering 
**ABSENT postictal confusion 
**ABSENT physical injury 
*Symptoms similar to an epileptic seizure: 
**Drooling 
**Rapid eye movements 
**Tongue biting 
**[[urinary incontinence|Loss of bladder]]/bowel control 
**Grunting 
**[[syncope|Loss of consciousness]] 
**[[Altered mental status]]

==Differential Diagnosis==
[[File:Seizure Causes.png|thumb|Differential diagnosis of seizures]]
{{Seizure DDX}}

==Evaluation==
*May be a clinical diagnosis
*Consider standard [[seizure]] workup
**Always check glucose
**Lactic acid may be able to differentiate from true generalized tonic-clonic seizure<ref>Ebru Apaydın Doğan, Ali Ünal, Aslıhan Ünal, Çağla Erdoğan, Clinical utility of serum lactate levels for differential diagnosis of generalized tonic–clonic seizures from psychogenic nonepileptic seizures and syncope, Epilepsy & Behavior, Volume 75, 2017, Pages 13-17, ISSN 1525-5050, https://doi.org/10.1016/j.yebeh.2017.07.003. (http://www.sciencedirect.com/science/article/pii/S1525505017304821)</ref>
*Consider obtaining a drug screen (and a pregnancy test in women)
*If unsure, an urgent neuro consult with EEG can determine the diagnosis

==Management==
*Avoid invasive medical procedures 
*Some patients will improve after they are told the diagnosis in a compassionate, non-judgmental fashion.
*If new diagnosis or diagnostic uncertainty consider admission for neurology consult and video EEG. 
*Psychiatric intervention is the main treatment modality (e.g. outpatient cognitive behavioral therapy).
**The purpose of psychiatric consultation is to identify underlying psychiatric conditions that can help direct treatment.
*In case of significant emotional stress, administer a mild tranquilizing agent (e.g. [[lorazepam]] 1-2mg IM/IV; [[hydroxyzine]] 50-100mg IM)

==Disposition==
*If symptoms improve consider discharge with close neurology and psychiatry follow-up to rule out epilepsy and identify and treat the underlying psychiatric origin of symptoms.
*If symptoms cannot be controlled or patient/family are not accepting of diagnosis. Consider admission for observation and further evaluation. 

==Prognosis==
*25-38 percent of patients achieve "seizure" freedom
*Children have a better prognosis than adults, with 70-80% achieving remission

==See Also==
*[[Seizure]]

==External Links==

==References==
<references/>
*Chen DK. Psychogenic Non-epileptic Seizure.  Uptodate. Updated May 18, 2018. Accessed June 1, 2018. https://www.uptodate.com/contents/psychogenic-nonepileptic-seizures?search=psychogenic%20nonepileptic%20seizures&source=search_result&selectedTitle=1~31&usage_type=default&display_rank=1

[[Category:Neurology]]