For 8 years, she’s been ‘spellbound’
A longstanding seizure disorder has left Ms. A disabled, dependent, and depressed. Neurologists say she has epilepsy. Is this diagnosis correct?
Few systematic studies have addressed how life events contribute to PNES. Associated life events—described mostly in case reports—fall into three general categories:
- childhood and adult trauma
- bereavement or loss
- acute or situational stressors.3
Table 1
Physiologic and psychological causes of nonepileptic seizures
| Physiologic |
| Autonomic disorders |
| Cerebrovascular disease |
| Cardiac disorders |
| Vasovagal syncope |
| Ischemic heart disease |
| Valvular heart disease |
| Arrythmias |
| Drug toxicity |
| Endocrine disturbance |
| Metabolic disorders |
| Migraines |
| Paroxysmal movement disorder |
| Sleep disorder |
| Psychological |
| Anxiety disorders |
| Conversion disorder |
| Dissociative disorder |
| Factitious disorder |
| Malingering |
| Victim of physical, emotional, or sexual abuse |
| Posttraumatic stress disorder |
| Psychotic disorder |
| Somatoform disorder |
| Substance abuse/dependence |
Continued treatment: Wasted years
Two weeks after our referral, Ms. A reports that the neurologist discontinued topiramate and phenytoin after VEEG showed no epileptic activity.
Ms. A now realizes she does not have epilepsy. She is angry that her first neurologist had misdiag-nosed her, effectively sentencing her to 8 years of needless dependency and disability.
We prescribe escitalopram, starting at 10 mg/d and titrating to 20 mg/d, to address Ms. A’s depressive/PTSD symptoms. We also refer her to a psychotherapist, who schedules twice-weekly supportive psychotherapy sessions. The therapist plans to teach her coping techniques and provide ego support and encouragement.
Ms. A’s psychotherapy progresses slowly at first, but by the fourth session she sets goals, which include getting off disability as soon as possible. With careful ego strengthening, she resumes driving and searches for a job. During one session, she tells her therapist she has long wanted to become a nurse, so she is encouraged to see a nursing school counselor for advice on selecting prerequisite nursing classes.
The authors’ observations
As with Ms. A, an erroneous epilepsy diagnosis can cause physical, psychosocial, and socioeconomic grief for the patient and can lead to needless restrictions, unemployment or underemployment, and dependence on disability benefits. After the misdiagnosis, Ms. A lost control of her future and considered her life a burden, leading to depression and anxiety. Her seizures caused most of her physical and psychological disturbances and diminished her overall function.
PNES are often mistaken for epileptic seizures, and 26% of seizure patients experience both.6 In a study of 50 patients, between 5% and 20% of patients evaluated for epilepsy and 10% to 40% of patients referred to comprehensive epilepsy centers were later found to have PNES.7
Like Ms. A, many patients with undiagnosed PNES receive antiepileptics to treat apparent epilepsy. These medications can cause troublesome side effects—from GI problems, to respiratory arrest in patients with pseudostatus, to potential teratogenicity.
In addition, comorbid epilepsy often goes undetected in patients with PNES. This could lead to inadequate treatment, increasing the patient’s morbidity and mortality risk.8
poll here
The authors’ observations
Patient history. Take a thorough history for patients with a history of seizures.
Too often, doctors assume a previous epilepsy diagnosis is correct, especially if rendered by a neurologist. In the United Kingdom, 20% to 31% of epilepsy diagnoses are incorrect because of incomplete history and misinterpreted EEG findings.8 When taking a patient’s seizure history, clinicians often do not get:
- a detailed history of seizures or seizurelike events, including onset, frequency, observations from family or friends, and seizure duration
- information on whether the patient remembers seizure details; has had prespell aura or loss of consciousness, or cries during the spells
- history of physical and/or sexual abuse.
Refer patients with features that may suggest PNES to a neurologist for VEEG to confirm or rule out epilepsy, because roughly one-quarter of seizure patients can have both.
Table 2
Patient features that suggest nonepileptic seizures
| Comorbid psychiatric disorder(s) |
| Events occur only in presence of others or only when alone |
| Lack of concern or excessive emotional response to seizures |
| Minimal or no response to antiepileptics |
| Multiple daily seizures |
| No history of injury resulting from seizures |
| Normal neurologic history and examination |
| Repeated hospitalizations or emergency room visits |
| Unremarkable EEG and MRI findings |
| Victim of sexual abuse |
The Minnesota Multiphasic Personality Inventory (MMPI) is often used to discriminate PNES from epilepsy. Wilkus et al9 reported significant differences in scores of MMPI hypochondriasis, hysteria, and schizophrenia scales among patients with PNES and epilepsy. Patients with PNES may have higher MMPI hypochondriasis, hysteria, schizophrenia, and psychopathic deviate scores than do patients with epilepsy.
