PSYCHOGENIC NONEPILEPTIC SEIZURES PNES

Transcription

1 PSYCHOGENIC NONEPILEPTIC SEIZURES PNES Kimberly Vaughn, R.EEG T., Cleveland Clinic Jean-Martin Charcot ( ) Hystero-epilepsy is a historical term that refers to a condition described by 19 th century French Neurologist, where patients acquired symptoms resembling seizures as a result of being treated on the same ward as patient with epilepsy. 1

2 Terminology PNES = Psychogenic Non-epileptic Seizure PNEE = Psychogenic Non-epileptic Events PNEA = Psychogenic Non-epileptic Attacks Pseudoseizures (Malingering) EPILEPSY Is the result of abnormal electrical activity in the brain which, in turn, can stem from a brain malformation, infections, congenital condition (known or unknown) and unknown reason. 2

3 Definition PNES are events that are psychogenic (which means originating from psychological rather then physiological) and non-epileptic and are easily mistaken for epileptic seizures. What are psychogenic non epileptic seizures (PNES)? It is a change in behavior, sensation, or consciousness. They clinically resemble epileptic seizures, but there is no EEG correlation to suggest an epileptic seizure. 3

4 They may appear to be generalized convulsions characterized by falling, shaking and jerking of the body. They can even include tongue biting and urinary incontinence. What causes PNES? Unlike epileptic seizures, PNES are not caused by physical disorders of the brain. They may result from traumatic psychological experiences or unusual stresses, sometimes from those in the forgotten past. 4

5 Somatoform or Conversion Disorders Conversion disorder is a somatoform disorder that is defined as physical symptoms caused by a psychological conflict, unconsciously converted to resemble those of a neurologic disorder. They tend to develop during adolescence or early adulthood, but may occur at any age. Somatoform or Conversion Disorders Somatoform disorders including PNES are real conditions that arise in response to real stresses. Patients are not imagining or inventing them. Common somatoform or conversion disorders are anxiety disorders and especially post traumatic stress disorder (PTSD). 5

6 Common PNES causes: History of trauma or abuse (physical or sexual) Torture Witnessing abuse of a loved one Post traumatic stress disorder (PTSD), this affects 25-50% of patient with PNES Bullying Substance abuse Mood disorders including depression, anxiety and dealing with stress Fibromyalgia, chronic fatigue syndrome or other pain syndromes Weaknesses of memory, attention and language Family or social dysfunction Problems with anger management/assertiveness One or more head injuries or neurologic conditions 6

7 Common clinical signs of PNES Abrupt onset Preserved awareness Ictal eye closure/eye flutter Irregular, asynchronous movements, shaking/twitching, side to side head movement Pelvic thrusting, back arching Events can be interrupted or distracted Events are prolongedwith waxing and waning, lasting minutes to hours Multiple event types Occur in presence of doctors Recurrent status Pseudosleep Whispering during postictal period Bring toy stuffed animals to the EMU Overprotective and excessively attentive family members 7

8 Signs of PNES Events may follow periods of stress Events occur at a high frequency Unusual triggers Frequent event related hospital stays and/or ER visits Lack of responses to anti-epileptic medications Unexplained physical symptoms including diagnosis of fibromyalgia or unexplained chronic pain. Previous abnormal EEG It is very helpful to review previous reported abnormaleeg because of over reading. Frequently wickets are classified as epileptic discharges. WICKETS 6-11 Hz usually short runs but can also be a single sharp transient Arch-like or mu-like, sharp, monophasic symmetric up-slope and down-slope awake and light sleep temporal, usually bilateral and independent arises out of an ongoing rhythm in the background no after going slow wave 8

9 Other events seen in EMU Syncope Neurocardiogenic(vasovagal) Orthostatic Response to Valsalva Maneuver Drop attacks Cardiac or Neurological Transient hypermotor Episodes Myoclonous Tics Tremor 9

10 Neurological Transient ischemic attacks Migraine Attention Deficit disorder Sleep Related Parasomnias Occur during wake-sleep transition Hypnic jerks (commonly seen when falling asleep) Behavioral changes in developmental delayed patients 10

11 Other events in PMU Breath holding spells Daydreaming Munchausen syndrome by proxy Panic attacks Hypnic jerks Rapid eye movement Benign neonatal myoclonus Sandifer syndrome (gastroesophageal reflux) Nodding and rotation of the head, neck extension, gurgling, writhing movements of the limbs, and severe hypotonia has also been noted. Spasms may last for 1 3 minutes and may occur up to 10 times a day. Ingestion of food is often associated with occurrence of symptoms; this may result in reluctance to feed. Migraine and variants (examples: cyclic vomiting, flashing lights) 11

12 Malingering (including Pseudoseizures) Malingering is not considered as a psychiatric illness, is thought of as a conscious process of deception. Malingering is usually epileptic-like symptoms, motivated by internal incentives. Examples of the goals of malingering include fabrication or exaggeration of the symptoms of mental or physical disorders exhibited by individual for secondary gained motives. These may include financial compensation, avoiding school, work or military service, drug-seeking or to attract attention or sympathy. What are the numbers? The prevalence of PNES in the average epilepsy center ranges somewhere from 15-40% of patients.(1) 12

13 CLEVELAND CLINIC MAIN CAMPUS The percentage of patients with psychogenic nonepileptic seizures admitted to the Adult and Pediatric Epilepsy Monitoring Unit Kimberly Vaughn, R.EEG T. Sherry Nehamkin, R.EEG T, EP T., CNIM, CLTM, FASET Cleveland Clinic Main Campus, from May 1, 2014 to May 31, The following information is based on our admissions. 13

14 Total Adult Admission (EMU) 1205 total adult admission, 308 were PNES, accounting for approximately 1540 inpatient days. Total Pediatric Admissions (PMU) 1094 total Peds admission, 146 were PNES, accounting for approximately 730 inpatient days. 14

15 Both PNES and epileptic seizures PNES only 301 Both Epileptic Seizures and PNES 153 Total Male vs Female PNES Admissions Female 285 and Male

16 What is the gold standard to diagnosis PNES? A routine 20 minute EEG is often helpful to diagnosis epilepsy, because it can detect abnormal activity. However, a normal EEG by itself, especially if there is no video EEG and a stereotypic event has not been captured is not enough to diagnosis PNES vs epileptic seizures. Admission to an epilepsy monitoring allowing for simultaneous recording of stereotypic events of concern time-locked to video, EEG, and ECG activity is the gold standard. Conclusion Video EEG Monitoring, now makes it possible for doctors to make a valid diagnosis of PNES based on concrete evidence, rather than simply observing behaviors and making educated guesses. (2) The importance of approximate diagnosis leads to identification of underlying causes, allowing for treatment options for improved quality of life. It allows for discontinuation of unnecessary medication which may have long term side effects. 16

17 Success!!! Acceptance, therapy and treatment is the key It is important that the patient understands that PNES are not purposely produced: it is not their fault that they have these events. It makes sense for them to seek treatment from the professionals that are most able to help them, including Psychiatrist, Psychologist and Psychiatric Social Workers. SADIE AND CHEWIE 17

18 Reference 1. Myers, Lorna, Ph.D., Psychogenic Non- Epileptic Seizures: A Guide, Cleveland Clinic Epilepsy Center, What are Non-Epileptic Seizures? Cleveland Clinic, Syed, Tanvir, M.D., Can Semiology predict psychogenic non-epileptic seizures?,

19 4. Selim R. Benbadis, Psychogenic Nonepileptic Attacks Gates and Rowan s, NonepilepticSeizures, Third edition 19