Diagnosis and Treatment of Nonepileptic Seizures (Epilepsy 2016)

Educational Objectives

The goal of this lecture is to improve diagnosis and treatment of epilepsy. After hearing and assimilating this lecture, the clinician will be better able to:

1. Diagnose and manage a patient with psychogenic nonepileptic seizures.

Summary

Psychogenic nonepileptic seizures (PNES): Neurologic manifestation of underlying psychological conflict or stressor; classified in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), as conversion disorder or functional neurologic disorder; 5% to 20% of Americans diagnosed with seizures have PNES.

Diagnosis of nonepileptic seizures: Based on triad of medical history, characteristics of seizure, and coregistration of symptoms with findings on EEG; historical features — commonly affects young women, many of whom have history of trauma or abuse; some have cognitive compromise or history of previous precipitant (eg, head injury); however, patients of any age or either sex may have PNES; most have comorbid psychiatric disorders (eg, depression, posttraumatic stress disorder, personality disorder); seizures — no single feature distinguishes nonepileptic seizure from epilepsy; findings that favor nonepileptic seizures include resistance to opening of eyelids, self-protection when hand dropped over face while patient appears unconscious, long duration of events, fluctuating course, asynchronous movements, and side-to-side movements of head or body.

Differential diagnosis: Epilepsy — presentation of nonepileptic seizure may resemble epileptic seizure of any type; atypical features nonspecific sign of nonepileptic seizures because some frontal lobe epileptic seizures bizarre in character, with movements that appear to be nonepileptic; classification — nonepileptic seizures psychogenic or physiologic; physiologic events include syncope secondary to vasovagal or cardiogenic processes and vertiginous episodes associated with movement disorders; ECG and EEG used to differentiate between physiologic and psychogenic nonepileptic seizures.

Diagnosis: May not be possible in one admission; event should be coregistered with video-EEG; provocative techniques — eg, rubbing alcohol on patient’s skin or giving saline infusion while suggesting that this may induce seizures; speaker discourages these methods because patient may feel duped, causing relationship between physician and patient to be compromised; however, conventional techniques for inducing seizures (eg, hyperventilation, photic stimulation) considered reasonable.

Case: A 57-year-old man presented with 10-year history of seizures involving abrupt loss of awareness with falls, with postictal disorientation and confusion; patient had left frontal encephalomalacia secondary to stroke that occurred 10 years ago; patient on anticonvulsant therapy; posttussive syncope considered because some seizures preceded by coughing; frequent seizures persisted despite trials of three anticonvulsant drugs and treatment of obstructive airway disease; video-EEG monitoring confirmed diagnosis of PNES; seizures induced by photic stimulation and verbal suggestion; assessment — although encephalomalacia and cough syncope part of differential diagnosis for this patient, video-EEG monitoring permits high level of confidence in diagnosis.

EEG monitoring: Ambulatory EEG with video may be offered when video-EEG monitoring not available; alternatively, physician may ask witnesses use smartphone to record events.

Conversion disorders: Previous criteria included psychological stressor related to presenting symptom and exclusion of malingering; these criteria difficult to fulfill based on brief psychological consultation; although these elements important and still noted in DSM-5, current definition of conversion disorder no longer includes them (ie, conversion disorder no longer treated as “rule-out diagnosis”); instead, diagnosis made on basis of inconsistency between neuroanatomic pathways and findings on examination.

Management: Randomized controlled trial — compared selective serotonin reuptake inhibitor (SSRI) with placebo in PNES population; SSRI group had fewer seizures; placebo group had 8% increase in seizures; SSRI may help with comorbidities but does not adequately treat seizures; workbook for patients with epilepsy — text used in Andrews/Reiter Epilepsy Research Program modified for patients with nonepileptic seizures; in open-label trial, use of workbook significantly reduced seizures and improved comorbidities and quality of life; randomized clinical trial — compared psychotherapy plus workbook, psychotherapy plus SSRI, SSRI alone, and standard medical care; psychotherapy groups had significantly fewer seizures as well as improvements in comorbidities, quality of life, and function; group treated with SSRI alone had trend toward improvement in seizures and significant improvement in depression; no improvement observed in arm receiving standard care.

Prognosis: No prospective long-term trials performed, but available data show that one-third of patients with PNES report reduction or cessation of symptoms over time; patients who do not engage in active targeted treatment unlikely to improve.

Readings

Chen DK, LaFrance WC. Diagnosis and treatment of nonepileptic seizures. Continuum (Minneap Minn) 2016;22(1).

LaFrance WC Jr, Baird GL, Barry JJ, et al. Multicenter pilot treatment trial for psychogenic nonepileptic seizures: a randomized clinical trial. JAMA Psychiatry 2014 Sep;71(9):997-1005.

LaFrance WC Jr, Keitner GI, Papandonatos GD, et al. Pilot pharmacologic randomized controlled trial for psychogenic nonepileptic seizures. Neurology 2010 Sep 28;75(13):1166-73.

Disclosures

For this program, the following was disclosed: Dr. LaFrance serves on the Epilepsy Foundation Professional Advisory Board; has served as a clinic development consultant for the Cleveland Clinic, Emory University, Spectrum Health, and University of Colorado, Denver; and has provided expert medicolegal testimony. Dr. LaFrance receives royalties from Cambridge University Press and Oxford University Press and has received research support from the American Epilepsy Society, the Epilepsy Foundation, the Matthew Siravo Memorial Foundation Inc, National Institutes of Health, and Rhode Island Hospital. Unlabeled Use of Products/Investigational Use Disclosure: Dr. LaFrance report nothing to disclose. To view disclosures of planning committee members with relevant financial relationships, visit: audiodigest.org/continuumaudio/committee. All other members of the planning committee report nothing to disclose.

Acknowledgements

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

CA050204

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.