Psychogenic nonepileptic seizures are episodes that look like epileptic seizures but are not caused by abnormal electrical activity in the brain. They are a real functional neurological disorder, often linked to stress or past trauma, and the patient is not faking them.
Key symptoms
- Shaking that starts and stops, changes rhythm or moves side to side
- Episodes that last a long time, often more than 2 minutes
- Eyes kept tightly closed during the event
- Crying or memory of the event afterward
- Frequent episodes despite several antiseizure medicines
What you find on exam
- Check airway, breathing and safety first, as for any seizure
- Side-to-side head movements, pelvic thrusting, resistance to eye opening
- Few injuries and little confusion after the event compared with epilepsy
- Normal neurological exam between events
- Ask about trauma, stress, depression and anxiety
Tests
- Video EEG monitoring that captures a typical event: the gold standard
- Normal EEG during the event confirms the diagnosis
- Glucose, electrolytes and ECG to rule out other causes
- Prolactin soon after the event can help in selected cases
Treatment basics
- Explain the diagnosis clearly and kindly: the events are real and can improve
- Cognitive behavioral therapy, the treatment with the best evidence
- Taper antiseizure medicines when epilepsy is excluded
- Treat depression, anxiety or PTSD; avoid unneeded emergency intubation
Red flags
- Event with low oxygen, injury or loss of bladder control that may be epilepsy
- Possible coexisting epilepsy, present in some patients
- Suicidal thoughts or severe depression
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.