Psychogenic Nonepileptic Seizures - American Family Physician
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Psychogenic Nonepileptic Seizures
TAOUFIK M. ALSAADI, M.D., and ANNA VINTER MARQUEZ, M.D.
University of California, Davis, Medical Center, Sacramento, California
Psychogenic nonepileptic seizures are episodes of movement, sensation, or behaviors that are similar to epileptic
seizures but do not have a neurologic origin; rather, they are somatic manifestations of psychologic distress. Patients
with psychogenic nonepileptic seizures frequently are misdiagnosed and treated for epilepsy. Video-electroencepha-
lography monitoring is preferred for diagnosis. From 5 to 10 percent of outpatient epilepsy patients and 20 to 40 per-
cent of inpatient epilepsy patients have psychogenic nonepileptic seizures. These patients inevitably have comorbid
psychiatric illnesses, most commonly depression, posttraumatic stress disorder, other dissociative and somatoform
disorders, and personality pathology, especially borderline personality type. Many patients have a history of sexual
or physical abuse. Between 75 and 85 percent of patients with psychogenic nonepileptic seizures are women. Psycho-
genic nonepileptic seizures typically begin in young adulthood. Treatment involves discontinuation of antiepileptic
drugs in patients without concurrent epilepsy and referral for appropriate psychiatric care. More studies are needed
to determine the best treatment modalities. (Am Fam Physician 2005;72:849-56. Copyright© 2005 American Academy
of Family Physicians.)
N
onepileptic seizures are invol- Since ancient times, nonepileptic seizures
untary episodes of movement, have been recognized as a form of hysteria. In
sensation, or behaviors (e.g., vocal- the late 1800s, Charcot first described non-
izations, crying, other expressions epileptic seizure as a clinical disorder, call-
of emotion) that do not result from abnormal ing it “hysteroepilepsy” and “epileptiform
cortical discharges. The seizures can mimic hysteria.”2 The term “nonepileptic seizure”
any kind of epileptic seizure and thus can be is preferable to the older terms “hysterical
mistaken for generalized tonic-clonic seizure, seizure” and “pseudoseizure,” which are
absence seizure, and simple or complex par- considered pejorative.3
tial seizures.1 Early recognition and appro- Nonepileptic seizures are classified as phys-
priate treatment of nonepileptic seizures can iologic or psychogenic in origin (Table 1). In
prevent significant iatrogenic harm and may specialty epilepsy center patients, physiologic
result in a better outcome. nonepileptic seizures are less common than
psychogenic nonepileptic seizures.
Physiologic nonepileptic seizures have
TABLE 1
multiple causes. They may be related to
Classification of Nonepileptic Seizures
syncopal episodes, complicated migraines,
Psychogenic panic attacks, or transient ischemic attacks.
Physiologic
Misinterpretation of physical symptoms They may be due to autonomic dysfunction,
Cardiac arrhythmias
Psychopathologic processes cardiac arrhythmias, hypoglycemia, drug
Complicated migraines
Anxiety disorders, including intoxication or withdrawal, or alcohol intox-
Dysautonomia
posttraumatic stress disorder ication or withdrawal. Movement disorders,
Effects of drugs and toxins
Conversion disorder sleep disorders, and vestibular symptoms
Hypoglycemia
Dissociative disorders may be mistaken for nonepileptic seizures.4
Movement disorders
Hypochondriasis Psychogenic nonepileptic seizures are a
Panic attacks
Psychoses physical manifestation of psychologic dis-
Sleep disorders
Somatization disorders tress. They are grouped into the category of
Syncopal episodes
Reinforced behavior patterns in psychoneurologic illnesses (e.g., conversion
Transient ischemic attacks
cognitively impaired patients disorder, somatization disorders), in which
Vestibular symptoms
Response to acute stress without symptoms are psychiatric in origin but neu-
evidence of psychopathology rologic in expression.5 This article focuses
on psychogenic nonepileptic seizures.
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use of one individual user of the Web site. All other rights reserved. Contact copyrights@aafp.org for copyright questions and/or permission requests.SORT: KEY RECOMMENDATIONS FOR PRACTICE
Evidence
Clinical recommendation rating References
Early referral of patients with apparently refractory seizures is critical. C 8, 10, 12
Video-electroencephalography monitoring is the gold standard for
the diagnosis of psychogenic nonepileptic seizures.
No single clinical or historical feature is diagnostic of psychogenic C 1-3, 9, 10
nonepileptic seizures. If the number of features that are unusual for
epileptic seizures increases, psychogenic nonepileptic seizures should
be considered more seriously.
Treatment of psychogenic nonepileptic seizures should address the C 3, 9, 25, 27,
underlying cause(s). 35, 36
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evi-
dence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information
about the SORT evidence rating system, see page 736 or http://www.aafp.org/afpsort.xml.
Diagnosis for characterization of their seizures. The
The presence or absence of self-injury and study found that 24 percent of the patients
incontinence, the ability to induce seizures had been misdiagnosed: 22 patients previ-
by suggestion, psychologic tests, histori- ously diagnosed with epilepsy were found to
cal factors, and ambulatory electroenceph- have nonepileptic seizures, and four patients
alography (EEG) have been found to be previously diagnosed with nonepileptic sei-
insufficient for the diagnosis of psychogenic zures were found to have epileptic seizures.
nonepileptic seizures.1,6 Postictal prolactin All of the patients in the study had been
levels greater than two times the upper limit referred by epileptologists or by neurologists
of normal once were thought to differenti- with experience in diagnosing and treat-
ate generalized and complex partial seizures ing epilepsy. Thus, even epilepsy specialists
from psychogenic nonepileptic seizures but misdiagnosed seizure types in nearly one
recently have been shown to be unreliable.7 fourth of cases.
video-electroencephalography historical and clinical features
Inpatient video-electroencephalography Features that are suggestive, but not diagnos-
(vEEG) monitoring is the preferred test for tic, of psychogenic nonepileptic seizures are
the diagnosis of psychogenic nonepileptic listed in Table 2.1,9,10 Typical features of these
seizures. Definitive diagnosis is achieved events include gradual onset, long duration,
when a patient is observed hav- a waxing and waning course, and disor-
ing typical seizures without ganized, asymmetric motor activity.9 The
Inpatient video-electro-
accompanying EEG abnormali- events lack the stereotypy of epileptic sei-
encephalography is the
ties. Family members or wit- zures because the pattern of symptoms and
preferred test for the
nesses who are familiar with sequence of events vary between seizures.
diagnosis of psychogenic
the patient’s seizures must agree Not all seizures with these features are
nonepileptic seizures. that the recorded episodes are psychogenic nonepileptic seizures, however.
Definitive diagnosis is typical events. Frontal lobe seizures often are mistaken for
achieved when a patient is The importance of using nonepileptic seizures because of the associ-
observed having typical sei- vEEG monitoring recently was ated dramatic motor and vocal outbursts,
zures without accompanying underscored in a study8 that possible retained consciousness, and short
electroencephalographic evaluated diagnoses in patients postictal period. Frontal lobe seizures may
abnormalities. who had been referred to an be distinguished by their brief duration,
inpatient vEEG monitoring unit stereotypical nature, and tendency to begin
850 American Family Physician www.aafp.org/afp Volume 72, Number 5 ◆ September 1, 2005Nonepileptic Seizures
during sleep.9 Gelastic seizures (in which Psychogenic nonepileptic seizures have
the primary automatism is laughter), reflex serious negative effects on patients’ lives.
epilepsies, and myoclonic jerks also have Health-related quality of life is significantly
been mistaken for psychogenic nonepileptic lower in patients with these seizures than in
seizures.9 patients with epilepsy, even intractable epi-
lepsy.15 Decreased quality of life in patients
importance of early diagnosis with psychogenic nonepileptic seizures is
Early diagnosis of psychogenic nonepileptic associated with the presence of psychopathol-
seizures is critical. Unfortunately, the diag- ogy and the adverse effects of antiepileptic
nosis often is delayed. One review10 reported
a mean of 7.2 years between manifesta-
tion and accurate diagnosis of psychogenic TABLE 2
nonepileptic seizures. Because of this delay, Clinical and Historical Features Suggesting
many patients with these events experience a Diagnosis of Psychogenic Nonepileptic Seizures
significant morbidity from inappropriate
treatment for epileptic seizures, including Clinical features
adverse effects of antiepileptic drugs and Ability of observer to modify the patient’s motor activity
aggressive, potentially harmful interventions Asynchronous limb movements
(e.g., intubation) for pseudo–status epilepti- Avoidance behavior during seizures
cus during emergency department visits. Change in symptomatology, or nonstereotypical seizure patterns
Definitive diagnosis of psychogenic non- Closed eyes during seizures
epileptic seizures may be therapeutic. After Dystonic posturing (including opisthotonos)
being informed unambiguously of the diag- Emotional or situational trigger for the seizures
nosis, some patients stop having the events.11 Gradual onset and cessation of seizures
Early diagnosis of psychogenic nonepilep- Ictal crying, weeping
tic seizures is important economically. One If tongue biting is present, usually the tip (not the side) of the tongue
study12 demonstrated an 84 percent reduc- Intermittent or waxing and waning motor activity
tion in total seizure-related medical charges Nonphysiologic progression
in the six months after diagnosis of psycho- Pelvic movements (especially forward thrusting)
genic nonepileptic seizures: average diag- Prolonged seizures (duration of 2 to 3 minutes)
nostic test charges decreased by 76 percent, Resisted eyelid opening
medication charges decreased by 69 percent, Seizures provoked by suggestion
outpatient visits decreased by 80 percent, and Side-to-side head movements
emergency department visits decreased by Historical features
97 percent. Associated (often multiple) psychiatric disorders
Family physicians have an important role Flurries of seizures or recurrent pseudo–status epilepticus that lead to
in the timely diagnosis of psychogenic non- multiple emergency department visits or hospitalizations
epileptic seizures through early referral of High seizure frequency
patients with apparently intractable seizures History of sexual or physical abuse
to epilepsy centers. Seizures in about 60 Lack of concern or an excessive or exaggerated emotional response
percent of patients with newly diagnosed Multiple unexplained physical symptoms
epilepsy are controlled with a moderate No history of injury from seizures
dosage of a single antiepileptic drug (usu- No response to antiepileptic drugs or a paradoxical increase in seizures
ally the first or second drug chosen); only with antiepileptic drug treatment
about 10 percent of patients with inadequate Personal, family, or professional experience with epilepsy
control of seizures on the first antiepileptic Seizures that occur only in the presence of others or only when the
drug become free of seizures.13,14 Thus, the patient is alone
threshold for determining that seizures are
Adapted with permission from Reuber M, Elger CD. Psychogenic nonepileptic seizures:
intractable should be low, and referral to an review and update. Epilepsy Behav 2003;4:207, with additional information from refer-
epilepsy center for clarification of the diag- ences 1 and 9.
nosis should be prompt.
September 1, 2005 ◆ Volume 72, Number 5 www.aafp.org/afp American Family Physician 851drugs.15 These factors further emphasize EEG. These factors suggest that physical
the importance of early diagnosis of psy- brain disease may play a role in the develop-
chogenic nonepileptic seizures, cessation of ment of the events.19 The events also occur in
antiepileptic drug therapy in patients with- patients with central nervous system lesions
out concurrent epilepsy, and treatment of that are associated with an increased risk of
the underlying psychiatric illness. developing epilepsy, such as stroke, trauma,
infection, and malformation,20 as well as in
Epidemiology patients with hippocampal sclerosis,21 which
The prevalence of nonepileptic seizures often is identified as a cause of temporal lobe
ranges from two to 33 cases per 100,000 epilepsy. Thus, the presence of MRI or EEG
persons in the general population. Hence, abnormalities may delay diagnosis and treat-
these seizures are approximately as com- ment of psychogenic nonepileptic seizures.
mon as multiple sclerosis and Estimates of the coexistence of epilepsy
Many patients with psy-
trigeminal neuralgia.16 From and psychogenic nonepileptic seizures vary
chogenic nonepileptic
5 to 10 percent of outpatient from 5 percent to more than 60 percent,
epilepsy populations have psy- depending on the study setting and diagnos-
seizures experience sig-
chogenic nonepileptic seizures, tic criteria.3 Recent studies17,22 using strict
nificant morbidity from
compared with 20 to 40 percent criteria for a diagnosis of epilepsy found that
inappropriate treatment
of inpatient epilepsy popula- only 5 to 10 percent of patients with non-
for epileptic seizures.
tions (hospitals and specialty epileptic seizures have concurrent epileptic
epilepsy centers).3,17 Between seizures.
75 and 85 percent of patients with psy-
chogenic nonepileptic seizures are women.18 Etiology
Like conversion disorder, psychogenic non- All psychogenic nonepileptic seizures func-
epileptic seizures tend to begin in young tion as a coping mechanism.23 Patients with
adulthood, although the seizures can occur these events are more likely to use maladap-
in a wide range of ages.18 tive coping strategies to handle stress.24 In
The prevalence of psychogenic nonepilep- psychogenic nonepileptic seizures, psycho-
tic seizures is increased in patients with head logic conflicts are translated into a physical
injuries, learning disabilities, or isolated symptom—the seizure. In this way, intoler-
neuropsychologic deficits,10 and patients able distress is dissociated from the pain-
with psychogenic nonepileptic seizures have ful conscious experience of the trauma or
higher than average rates of abnormal results forbidden emotions that are causing the dis-
on magnetic resonance imaging (MRI) and tress.25,26 Thus, genuine psychogenic non-
epileptic seizures (as opposed to factitious
disorder or malingering) are not intentional:
The Authors they are created as a psychologic defense
TAOUFIK M. ALSAADI, M.D., is assistant professor of clinical neurology at the mechanism to keep internal stressors out of
University of California, Davis (UCD), School of Medicine. He also is director conscious awareness.25
of the epilepsy treatment center and director of clinical epilepsy research at
UCD Medical Center, Sacramento. Dr. Alsaadi received his medical degree from
Psychogenic nonepileptic seizures do not
the Damascus University School of Medicine, Syria. He completed a neurology have a single etiology; rather, they are the
residency at the Medical College of Wisconsin, Milwaukee, and an epilepsy product of several different causal pathways
and electrophysiology fellowship at the University of California, San Francisco, (Table 1). The seizures may be the result of
School of Medicine. psychopathologic processes, a response to
ANNA VINTER MARQUEZ, M.D., is a psychiatry resident at UCD Medical Center. acute stress in patients without evidence of
She received her medical degree from the UCD School of Medicine, where she psychopathology, or a reinforced behavior
also completed a research fellowship in the neuropsychiatric aspects of epilepsy. pattern in cognitively impaired patients.
Rarely, malingering or factitious disor-
Address correspondence to Taoufik M. Alsaadi, M.D., Department of Neurology,
University of California, Davis, Medical Center, 4860 Y St., Suite 3700, Sacramento,
der presents as psychogenic nonepileptic
CA 95817-2307 (e-mail: taoufik.alsaadi@ucdmc.ucdavis.edu). Reprints are not seizures.27
available from the authors. From 43 to 100 percent (median: 73.5 per
852 American Family Physician www.aafp.org/afp Volume 72, Number 5 ◆ September 1, 2005Nonepileptic Seizures
cent) of patients with psychogenic nonepi- patients. Seizure reduction occurs in about
leptic seizures have concurrent psychiatric one third of patients, and chronic, unim-
disorders28 (Table 3).25 The disorders tend proved seizures continue in another one
to be related to trauma, and include post- third of patients.38
traumatic stress disorder (PTSD) and other In a study11 that assessed one- to 10-year
anxiety disorders; depressive disorders; and outcomes in 164 patients with psychogenic
conversion, somatization, and dissociation nonepileptic seizures, 44 percent had a poor
disorders. Personality pathology, particu- outcome (not free of seizures, dependent
larly of the borderline type, is common.29 [i.e., unemployed or retired because of ill
Frequently, patients with psychogenic non- health]); 40 percent had an intermediate
epileptic seizures also have other dissocia- outcome (free of seizures but dependent,
tive and somatization symptoms.18,30 or not free of seizures but living indepen-
Patients with psychogenic nonepileptic dently); and 16 percent had a good outcome
seizures frequently have a history of (or cur- (free of seizures and living independently).
rent) physical or sexual abuse24 or significant At more than 11 years after the onset of
psychosocial stressors for which there is no psychogenic nonepileptic seizures and four
perceived resolution.31,32 These “unspeak- years after diagnosis, 71 percent of patients
able dilemmas”31 often involve dysfunctional still were having seizures, and 56 percent
family interaction and communication.18,24 still were dependent. These outcomes are
A frequently cited prospective study25 worse than those for newly diagnosed epi-
showed that 84 percent of patients with lepsy and are equivalent to the outcomes for
psychogenic nonepileptic seizures had expe- other somatoform disorders.11
rienced trauma. One recent study33 found
significantly higher rates of PTSD, child- Treatment
hood sexual abuse, dissociative symptoms, No randomized controlled studies have been
and history of assaultive trauma in patients conducted on the treatment of psychogenic
with psychogenic nonepileptic seizures than nonepileptic seizures.27,28 Treatment recom-
in patients with epilepsy. Physical and sexual mendations are based on the theory that
abuse has been linked to increased rates of
several somatization syndromes, including
psychogenic nonepileptic seizures.26 TABLE 3
To determine why a patient is having Selected Comorbid Psychiatric Disorders in 45 Patients
psychogenic nonepileptic seizures, the phy- with Psychogenic Nonepileptic Seizures
sician must identify the psychologic func-
tion of the seizure.34 A detailed, systematic Prevalence (%)
psychiatric evaluation and an assessment of
family, social, financial, and employment Diagnosis Current* Lifetime
problems should provide insight.35 Causes Any dissociative disorder 91 93
and suggested treatments for psychogenic Any somatoform disorder 89 98
nonepileptic seizures are summarized in Any affective disorder 64 98
Table 4.3,9,25,27,35,36 Personality disorder 62 62
PTSD 49 58
Disease Course
Major depressive disorder 47 80
Because nonepileptic seizures are not a sin- Anxiety disorder other than PTSD 47 51
gle entity or disorder, the course is variable Conversion symptoms, but not seizures 4 82
and depends on the underlying cause. Prog-
nostic factors also vary (Table 5).9,11,27,37 PTSD = posttraumatic stress disorder.
The findings of outcome studies allow *—“Current” indicates within the past month; listed in order of frequency.
some generalizations about patients with Adapted with permission from Bowman ES, Markand ON. Psychodynamics and psychi-
psychogenic nonepileptic seizures. Seizure atric diagnoses of pseudoseizure subjects. Am J Psychiatry 1996;153:59.
cessation occurs in about 40 percent of
September 1, 2005 ◆ Volume 72, Number 5 www.aafp.org/afp American Family Physician 853because the seizures are psychogenic in ori- Various psychotherapeutic techniques
gin, they will respond to psychiatric treat- with proven efficacy in other disorders have
ment. Two uncontrolled studies18,39 have been applied to patients with psychogenic
shown that psychotherapy is more effective nonepileptic seizures who have similar psy-
than no intervention. chiatric profiles. Table 43,9,25,27,35,36 summa-
TABLE 4
Psychogenic Nonepileptic Seizures: Etiologies and Suggested Treatments
Etiology Description Suggested treatments
Acute or situational Seizures develop after multiple or acute stressors Supportive psychotherapy, lifestyle changes,
stressors overwhelm the patient’s coping ability; underlying group or family therapy as indicated
psychopathology may not be present.
Anxiety, panic, physical Atypical symptoms of anxiety or panic are Treatment of panic attacks; reassurance that
symptoms misdiagnosed as psychogenic nonepileptic physical symptoms are not seizures
seizures, or the patient misinterprets physical
sensations or symptoms as seizures.
Depression, A specific stressor does not precipitate psychogenic Antidepressant drug therapy, cognitive
dissatisfaction nonepileptic seizures; rather, the patient is behavior therapy to challenge the patient’s
generally unhappy, and the seizures function as depressive thoughts and basic assumptions
distraction or an acceptable way to get support about self and illness; encouragement of
and attention. the patient’s active involvement in lifestyle
changes and problem solving
Poor interpersonal Patients with this profile often are diagnosed with Intensive psychodynamic psychotherapy
skills and affect borderline personality disorder and frequently to help identify and express threatening
regulation, disturbed have a history of abuse. The patient may come situations or emotions (e.g., conflict, anger,
family systems from a family with poor emotional expression and feelings of rejection) and to set realistic
therefore may be unable to identify and effectively goals for relationships; family therapy when
express strong emotions. The seizures function the family system supports maintenance of
to resolve interpersonal crises or threatening psychogenic nonepileptic seizures
emotions or situations.
Psychosis Rarely, psychogenic nonepileptic seizures can be Treatment of underlying psychosis
a manifestation of psychosis; in most instances,
however, the diagnosis of psychosis is clear.
PTSD, dissociation The patient has active chronic PTSD and dissociative Exposure-based therapies and selective
symptoms. Flashbacks, recollections, or sensory serotonin reuptake inhibitors for PTSD
triggers often initiate psychogenic nonepileptic
seizures. Often, there is a history of severe
childhood or current abuse.
Reinforced behavior Reinforced behavior pattern often is the underlying Behavior modification therapy
pattern cause of psychogenic nonepileptic seizures in
cognitively impaired patients. The patient develops
psychogenic nonepileptic seizures because of the
functional advantages that are reinforced by the
seizures (e.g., attention, avoidance of responsibility).
Somatization, The seizures represent emotional distress Cognitive behavior therapy to identify links
somatoform disorder, converted into physical symptoms. Often, between stress and psychogenic nonepileptic
conversion disorder there is a long history of medical attention for seizures and to develop more adaptive
unexplained physical symptoms. The patient coping; for severe somatization, regular
often can identify precipitating stressful events; visits not contingent on symptoms but with
the seizures therefore are a conversion symptom. a focus on living with the symptoms rather
than investigating and treating them
PTSD = posttraumatic stress disorder.
Information from references 3, 9, 25, 27, 35, and 36.
854 American Family Physician www.aafp.org/afp Volume 72, Number 5 ◆ September 1, 2005Nonepileptic Seizures
TABLE 5
Prognostic Factors in Patients with Psychogenic Nonepileptic Seizures
Factors for favorable outcome Factors for unfavorable outcome
Acceptance of nonepileptic nature of episodes Coexisting epilepsy
Family structure that supports autonomy Disbelief of diagnosis
Female gender Family structure that supports
Having friends currently dependency and illness
Having good relationships with friends as a child Long history of psychiatric disorders
Higher ability to express emotions Longer duration of psychogenic
nonepileptic seizures
Higher intelligence and education
Male gender
Independent lifestyle
Ongoing physical or sexual abuse
Less dramatic psychogenic nonepileptic seizures:
no positive motor features, no ictal incontinence Ongoing psychosocial stressors
or biting, no admissions to intensive care unit, no Pending litigation
pseudo–status epilepticus with intubation Persistent somatization
Less extreme scores on traits defining emotional Reluctant self-disclosure
dysregulation Restricted expression of anger and
Less tendency to dissociate positive feelings
Shorter duration of psychogenic nonepileptic seizures Unemployment or disability
Younger age at diagnosis
Adapted with permission from LaFrance WC, Devinsky O. Treatment of nonepileptic seizures. Epilepsy Behav 2002;3(5S):20;
with additional information from references 9, 11, and 37.
rizes current treatment recommendations Author disclosure: Nothing to disclose.
based on the underlying causes of psycho-
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