• Do not miss epileptic seizures/status epilepticus. When in doubt, follow standard seizure/status epilepticus resuscitation approaches.
• In known or suspected psychogenic nonepileptic seizure episodes:
  • Monitor airway, breathing, circulation.
  • Provide for patient safety and comfort.
  • Avoid employing noxious stimuli (e.g., Sternal rub) to test responsiveness.

• Psychogenic non-epileptic seizures (PNES), formerly ‘pseudoseizures’, are a functional neurological disorder presenting with paroxysmal, time-limited alterations in motor, sensory, autonomic and/or cognitive signs and symptoms that are not accompanied by ictal epileptiform activity on EEG.
  • This is a psychiatric condition which is not intentionally produced or “faked” and is not to be confused with malingering.
  • Pathophysiology is unclear but likely complex biopsychosocial disorder with strong associations to past/current psychosocial stressors and trauma.
  • Changes in brain activity/functional connectivity seen on functional neuroimaging studies.
• 2 main forms, though clinical presentation is diverse:
  • Convulsive events resembling tonic-clonic seizures.
  • Swoon events resembling syncope.
• Correct diagnosis is essential in preventing harm from either:
  • Unnecessarily treating PNES with escalating antiepileptics and resuscitation measures such as intubation or critical care admission.
  • Misdiagnosing epileptic seizures (ES) as PNES.
• Up to 60% of people presenting with PNES have a concomitant seizure disorder.
• Once a diagnosis of PNES is made, proper communication/education is part of effective management of these patients.

The gold standard in definitive diagnosis of PNES is video EEG, however there are 4 useful clinical tools in differentiating ES from PNES in the ED.

History

• Peak age 15-35, though can be anytime.
• Often onsets/clusters at times of stress, psychological trauma (ES also associated with stress).
  • Epilepsy history diagnosed objectively personally or family history:
    • Observed epileptic seizures in family members or media often influences characteristics of PNES episodes.
  • Other historical factors that suggest PNES vs ES:
    • Patient has strong/detailed recollection of events during episode.
    • Episodes on emergence from anesthesia (due to disinhibition from anesthetic agents).
    • Events frequent from onset.
    • Multiple events per day, especially in an otherwise well appearing patient.

Characteristics of episodes

• Validated differences between PNES and ES to be applied to observation of active episodes/video of prior episodes, summarized in the table below:

Table 1. Observed differences in PNES vs ES episodes supported by literature. Adapted from Avbersek and Sisodiya (2010).

Prolactinemia

• • Prolactin typically rises after ES.
  • Lab draw must be immediately after event, as levels return to baseline by 1 hour after ES.
  • If level normal, provides some support for PNES.

Suggestive Seizure Induction

• Involves the power of suggestion to provoke a PNES episode.
  • For example, tuning fork test: clinician uses tuning fork placed on bony prominences with suggestion that vibration can transmit to areas of the brain responsible for seizures. Provocation of an episode is considered a positive test, as this does not have physiologic basis for ES provocation.

There are ethical considerations as these tests could be considered a form of deception, however, can sometimes obviate the need for EEG. Clinician judgement/discretion must be well-reasoned.

Effective communication is key to treatment, conveying:

1. There is an established diagnosis.
   1. Although exact pathophysiology not well understood, many use the “software vs hardware” analogy in patient education (hardware normal on investigations but “bug in the software” causing the brain to malfunction).
2. In most cases, the diagnosis can be made definitively with history and careful event observation (i.e. not a diagnosis of exclusion).
   1. It often helps to explain objective findings, but do not try to “convince” the patient of your diagnosis. Describe the findings and give them space to reflect.
3. The disorder is potentially reversible with treatment.
   1. Explain important first step is willingness to consider a diagnosis of PNES or functional neurologic disorder.

If effective in communication, the patient can leave validated in the diagnosis and does not feel need to seek alternative diagnoses/testing.

• Encourage patients to review educational material on websites below and consider if their condition resembles what they read about.

Outside ED, CBT is the only evidence-based therapy with efficacy, however optimizing treatment of comorbid psychiatric conditions such as anxiety/depression would likely also improve symptoms.

• Diagnosed PNES generally do not require admission.
• If diagnostic uncertainty, admit for observation and further evaluation of events or refer for urgent neurology assessment.

• There are no indications for transfer to another facility in patients with a diagnosis of PNES.

• All patients with PNES should be followed up, preferably by neurology/neuropsychiatry/practitioners with experience managing functional neurologic disorders.
• Patients with PNES who received anticonvulsants/resuscitation may require monitoring for adverse events.

• Patients with a diagnosis of PNES are safe to discharge home with appropriate follow up plans.

1. Patient friendly websites for explanations of functional neurologic disorders and resources:

   • https://www.neurosymptoms.org/en/
   • https://fndhope.org/
   • https://FNDsociety.org
   
   

2. UpToDate Article: https://www.uptodate.com/contents/psychogenic-nonepileptic-seizures-etiology-clinical-features-and-diagnosis

   
   

1. Toffa DH, Poirier L, Nguyen DK. The first-line management of psychogenic non-epileptic seizures (PNES) in adults in the emergency: a practical approach. Acta Epileptologica. 2020 Jun 3;2(1):7.

   
   

2. Duncan R, Garcia P, Dashe J. Psychogenic nonepileptic seizures: Etiology, clinical features, and diagnosis. In: UpToDate [Internet]. 2022. Available from: https://www.uptodate.com/contents/psychogenic-nonepileptic-seizures-etiology-clinical-features-and-diagnosis

   
   

3. Tilahun BBS, Bautista JF. Psychogenic nonepileptic seizure: An empathetic, practical approach. CCJM. 2022 May 1;89(5):252–9.

   
   

4. LaFrance Jr. WC, Baker GA, Duncan R, Goldstein LH, Reuber M. Minimum requirements for the diagnosis of psychogenic nonepileptic seizures: A staged approach. Epilepsia. 2013;54(11):2005–18.

   
   

5. Avbersek A, Sisodiya S. Does the primary literature provide support for clinical signs used to distinguish psychogenic nonepileptic seizures from epileptic seizures? Journal of Neurology, Neurosurgery & Psychiatry. 2010 Jul 1;81(7):719–25.