Are you sure its a pseudoseizure? Check again. 50% of people with pseudoseizures may also have epilepsy.

Arq Neuropsiquiatr. 2010 Apr;68(2):168-73.

Epilepsy in patients with psychogenic non-epileptic seizures.

Marchetti RL, Kurcgant D, Gallucci-Neto J, Von Bismark MA, Fiore LA.

Source

University of São Paulo School of Medicine, São Paulo, SP, Brazil. rlmarche@bighost.com.br

Abstract

The aim of this study was to evaluate the frequency of epilepsy in patients who presented psychogenic non-epileptic seizures (PNES). The evaluation was carried out during intensive VEEG monitoring in a diagnostic center for epilepsy in a university hospital. The difficulties involved in reaching this diagnosis are discussed. Ninety-eight patients underwent intensive and prolonged video-electroencephalographic (VEEG) monitoring; out of these, a total of 28 patients presented PNES during monitoring. Epilepsy was defined as present when the patient presented epileptic seizures during VEEG monitoring or when, although not presenting epileptic seizures during monitoring, the patient presented unequivocal interictal epileptiform discharges. The frequency of epilepsy in patients with PNES was 50% (14 patients). Our findings suggest that the frequency of epilepsy in patients with PNES is much higher than that of previous studies, and point out the need, at least in some cases, for prolonging the evaluation of patients with PNES who have clinical histories indicating epilepsy.

PMID:

 

20464279

 

[PubMed - indexed for MEDLINE] 

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DISCUSSION

Surely, one of the clinical situations that produce the greatest polemics is the association of epilepsy and PNES. The prevalence of epilepsy in patients with PNES has been estimated as ranging from 5.3 to 73%^3,11-16. This variability in different studies may reflect several methodological characteristics, such as the different inclusion criteria when determining epilepsy and PNES, the presence or not of ictal/interictal EEG abnormalities, the diagnostic environment (inpatient or outpatient), the presence of prolonged monitoring by VEEG, the monitoring duration and the sample size.

This diagnostic issue is extremely important. In the first place, omission of the PNES diagnosis may be very harmful and damaging to patients. Martin et al.²⁰ estimated that the lifetime costs borne by a person with PNES, in diagnostic tests, procedures and treatments would be around US$ 100,000. They also calculated that US$ 100 to 900 million are spent yearly in the USA on the PNES patient population. Several studies have shown that early and appropriate diagnosis of PNES, followed by adequate treatment, may lead to remission in 19 to 52% of cases, or to improvement in 75 to 95% of cases. Therefore, a significant reduction in the use of healthcare systems and in costs is involved^20-23. PNES leads to severe social and psychological consequences. These patients and their families face the same problems as patients with epilepsy: stigmatization, poor schooling, unemployment, difficulties in interpersonal relationships and social exclusion²⁴. From the medical point of view, patients are exposed to iatrogenic procedures, such as the use of high doses of AED²⁵, venous punctures, intravenous AED, and orotracheal intubation²⁶. Moreover, the rate of comorbidity with depressive and anxiety disorders is high^14,21, and the quality of life of these patients is worse than that of patients with difficult-to-control epilepsy²⁷.

On the other hand, to omit the diagnosis of epilepsy may be just as damaging, or even more so. Patients with a diagnosis of PNES may be counseled to halt their AED use and reduce their visits to emergency healthcare facilities, so as to reduce iatrogenic levels and costs^28,29. The treatment may be adapted to a condition of psychogenic nature³⁰. Wyler et al.³¹ dramatically pointed out the possible consequences of these procedures when reporting the case of a 15-year-old girl who perished as a result of an ES that occurred after PNES had been diagnosed by means of VEEG and after medical discharge following AED withdrawal.

This prevalence of epilepsy among patients with PNES was 50% in an epidemiological study carried out in Iceland⁶, but in two recent studies^12,16, relatively low frequencies of epilepsy were found, respectively 5.3 and 9.4%. In our study, this association occurred in 14 patients (50%), a high association level, even though our criteria for diagnosing epilepsy were more restrictive than in both of the abovementioned studies. As in these studies, epilepsy was defined as present when the patient presented ES during VEEG monitoring or otherwise, when unequivocal interictal epileptiform discharges were observed (sharp waves, spikes or complex spike-waves) although no ES occurred. Benign variants were not considered to be epileptiform conditions. However, unlike the two previous studies, interictal epileptiform discharges were considered to be present only when corroborated by clinical validation. Even if we had considered the presence of ES during VEEG monitoring as the one and only criterion for epilepsy, we would have had five patients (18%) under these conditions, i.e. approximately twice the number of both previous studies, presenting relatively low rates of epilepsy.

Following the validation criteria of our study, we concluded that out of the 14 patients with epilepsy, eight (57.1%) were in remission under treatment with AED or after AED withdrawal. Ramsay et al.³² drew attention to the need to distinguish between simultaneous and sequential presence of epilepsy and PNES, when these conditions coexist. According to these authors, their simultaneous presence is easier to establish, due to the probable occurrence of ES during VEEG monitoring, whereas that may not happen when their occurrence is sequential. Usually, in these cases, existence of epilepsy precedes PNESD, complicates it and may, as these authors suggest, be related to the appearance of PNES.

PNES is usually considered to be present when the patient presents complete absence of therapeutic response to AED, or loss of response (therapeutic failure), or perhaps paradoxical responses to AED (worsening or spontaneous and unexpected remission). Moreover, it can occur eventually in function of atypical, multiple, inconsistent or changing pattern seizures, or when these are unleashed by an evident and specific stressful event with close timing connections with the occurrence of seizures³³. The previous elements are particularly considered when the patient presents normal ancillary examinations (interictal routine EEGs and imaging studies such as CT, MRI and SPECT)^34,35. These situations lead the attentive physician to consider the possibility of referral to a center specializing in differential diagnosis and intensive monitoring by VEEG. Out of 22 patients from our sample who were referred for suspected PNES, nine (41%) presented associated epilepsy. Out of six patients in our sample who were referred for other reasons, the presence of epilepsy was not confirmed or observed in only one of them. In these cases, the patients presented PNES as an unexpected phenomenon set within an investigative process directed towards other aims, such as pre-surgical evaluation or diagnostic evaluation of refractory epileptic syndromes. This draws attention to the importance of PNES as a clinical phenomenon that complicates the diagnostic process and treatment of patients with epilepsy.

In one of our cases, the patient presented both spontaneous and suggestion-induced CNEP during VEEG monitoring, but its occurrence was not validated by the medical history data (clinical validation), or by observation of video-recorded events by an external observer with close ties to the patient (observer validation). In this case, although PNES occurred during intensive monitoring by VEEG, we do not believe these represented a real clinical problem. The patient also presented complex partial epileptic seizures during intensive VEEG monitoring, originating from the frontal lobe, which was validated by both clinical and observer validation. This case points out the possibility of isolated PNES occurrence in some gullible individuals, especially when exposed to a favorable situation such as VEEG monitoring¹⁷. It also points out the risk of giving up the investigation far too early because of PNES occurrence, thereby leading to failure to diagnosed epilepsy.

As previously reported, although our criteria may be considered more restrictive than the two previous studies with relatively low rates of epilepsy, our findings suggest that the frequency of epilepsy in patients with PNES is much higher. What might be responsible for these differences? In these three studies, the populations received care in tertiary centers, with patients evaluated for similar reasons. Martin et al.¹⁶ drew attention to the size of their sample (514 patients with CNEP) and to a high rate of referral of patients for suspected PNES. However, out of 22 patients in our sample who were referred on these grounds, nine (41%) presented associated epilepsy. This indicates that, even when the level of suspicion is high for PNES, coexistence of epilepsy may be a significant problem.

One significant difference between our study and others is the period of VEEG monitoring. In previous studies, evaluations typically lasted three days^12,16, and did not exceed five days to one week. In our study, the typical duration of VEEG monitoring was three weeks, with a range from one to six weeks. What was the result of this prolonged monitoring? In most of our patients, PNES presented spontaneous or provoked occurrence, by induction with our protocol of suggestive techniques over the first days of evaluation. Epileptic seizures occurred generally some time after reduction or complete withdrawal of AEDs. In some cases, interictal discharges were registered only after AED withdrawal and a delayed observation period. Lengthening of the monitoring period was usually guided by medical history information, suggesting epilepsy as well as PNES. Possibly, early ending of VEEG monitoring after occurrence of PNES would lead to failure in the diagnosis of epilepsy.

In conclusion, our findings point out the need, at least in some cases, for prolonging the evaluation of patients with PNES and clinical histories indicating epilepsy.

Conversion Disorder? Hysteria? "Real" Illness? The Twitching Girls in Le Roy, NY

Something strange happened shortly after school started last year in Le Roy, a tiny town of 7,500 people in Western New York. A handful of girls were stricken with bizarre twitches, tics, and spasms — all apparently involuntary. Soon the condition spread,and to date 19 people have exhibited symptoms Environmentalists descended on Le Roy, claiming pollution had to be to blame. But as New York Times Magazine staff writer Susan Dominus tells weekends on All Things Considered host Guy Raz, what happened to the girls in Le Roy may be more complicated than that.

Listen to the NPR broadcast or see the transcript here

See the NY Times story mentioned here: http://www.nytimes.com/2012/03/11/magazine/teenage-girls-twitching-le-roy.html?_r=2&pagewanted=1&ref=us

Like everything else in high school, the girls’ symptoms were broken down by status: there were the kids who were really sick and then the kids whose illness was “psychological” and then the kids who were faking it so they could get on the news. No matter how many times the doctors explained that these symptoms were real, something the girls could not control, the finger-pointing persisted. One mother even went on Facebook to publicly accuse her daughter’s best friend of faking, before apologizing the next day. “If they were faking it, I’d like to know how they can cause it,” said Dave Watson, guardian for one of the affected cheerleaders. “It’s not like any one movement is more exaggerated than the next. It’s pretty damn consistent. I’d like someone to explain to me how they could walk around all day and do it consciously.”

Conversion disorder presents something of a paradox in that it engages some voluntary pathways in the brain but is experienced by the patient as wholly involuntary. One study found overlapping, but distinctly different, brain activity in patients diagnosed with conversion disorder and patients asked to “fake” the same illness, in this case a limp ankle, suggesting “more complex mental activity” in patients with conversion disorder. The very notion of what makes a movement feel voluntary — and whether movements actually are voluntary, or only feel that way as a result of some post hoc coordinating that happens in the brain — is another philosophical and neurological question.

Researchers think the illness might have something to do with the amygdala, a locus of startle and fear responses in the brain, which has been shown to be overactive in patients with conversion disorder. “Ordinarily, the amygdala might create psychological distress, but instead, in these cases, it would create an involuntary movement,” says Mark Hallett, a senior investigator at the National Institute of Neurological Disorders and Stroke. He added, though, that while the theory is plausible, “we’re at a primitive level” in terms of understanding how it works.

Conversion disorder is somewhat better understood now than it was when the French neurologist Jean Martin Charcot displayed his patients’ fainting fits to hundreds of dazzled audience members in the 1870s. Fainting and nonepileptic seizures are common symptoms, as are seemingly paralyzed limbs; less common, but still well represented, are certain types of tics and twitches. Recent research has confirmed some of Freud’s early theorizing on the subject, finding that a history of trauma is higher in patients with conversion disorder than in other kinds of psychiatric patients.

Part of what is baffling about the Le Roy case is that it seems to combine two equally poorly understood phenomena: conversion disorder and mass psychogenic illness. Jennifer McVige, a doctor at the Dent Neurologic Institute in Buffalo who has seen 14 patients from Le Roy (neither Katie nor Thera is her patient), has said that most of them are dealing with serious stressors or trauma. That history is somewhat unusual for mass psychogenic illness, which is not generally thought to target people with a particular psychological background. In other ways, however, the case in Le Roy is a textbook example. Half of mass psychogenic illnesses occur in schools, and they are far more common in young women than any other category. Simon Wessely, an epidemiologist at King’s College in London and chairman of the department of psychological medicine, estimates that hundreds of outbreaks occur every year in the United States — just this past November, 22 students fell ill with stomach complaints at a football game in Houston, and no one so much as noticed outside the local news. Motor mass hysterias — twitching, fainting, stuttering — are more rare and draw more attention. In the past 10 years there have been three such outbreaks in the United States, which Robert Bartholomew, a sociologist specializing in the subject at Botany Downs Secondary College in Auckland, New Zealand, says is a surprising number for so short a period of time.

How could one person’s illness be reflected in another person’s neural pathways, playing a trick on consciousness, convincing the host that it originated in her own body? In the last decade, scientists have begun to explore the concept that regions in our brain once thought to activate only our own activity or sensations are also firing what are known as mirror neurons when we witness someone else perform an action or feel a sensation. Mass psychogenic illness could be thought of as the maladaptive version of the kind of empathy that finds expression in actual physical sensation: the contagious yawn or sympathetic nausea or the sibling who grabs his own finger when he sees his brother’s bleed.

Any two people, as they try to delicately disagree or flirt or compare notes on the best route to Boston, might unwittingly match vocal tones or even frequency of eye blinks. In one study, researchers found that subjects trying to form an alliance with someone else subconsciously tap their feet to match the tapping of that person’s foot, or touch their faces with the same frequency. “It’s happening unconsciously, but it is serving the goals you need it to serve,” says Jessica Lakin, the chairwoman of the psychology department at Drew University in New Jersey, who studies what’s known as the chameleon effect. Another study contrived to make subjects feel excluded from an online game; when those subjects were next introduced to someone new, they matched foot-tapping even more assiduously (and equally subconsciously) as if all the more motivated, at some primal level, to bond through physical mimicry. Mass psychogenic illness, whatever its mysterious mechanism, seems deeply connected to empathy and to a longing for what social psychologists call affiliation: belonging.