Psychogenic seizures

Abstract

BACKGROUND- The diagnosis and management of patients with psychogenic seizures is one of the most challenging tasks facing the clinician. Few absolutes describe the clinical features, neuropsychological profile, treatment or prognosis of these patients. Nonetheless, there are historical, clinical, and laboratory findings that can aid in the diagnosis and management of these complex psychological events. REVIEW SUMMARY- Ictal characteristics may provide clues in distinguishing psychogenic from epileptic seizures, although no single pattern is unique to psychogenic seizures. Several bedside tests can aid in the diagnosis; sensory stimulation and avoidance maneuvers will often elicit obvious volitional movements from the psychogenic seizure group. Patients with psychogenic seizures are also susceptible to suggestion; typical events can often be precipitated and terminated by simple verbal suggestion, either alone or in combination with a maneuver such as vibration or placebo infusion. Video-electroencephalogram monitoring has become invaluable for evaluation because differentiation of psychogenic from epileptic seizures on the basis of history or observation alone is often incorrect. An emergent electroencephalogram during the ictus may also quickly distinguish an epileptic from a psychogenic seizure. Blood gas analysis or pulse oximetry immediately after a seizure may be very useful because patients with generalized epileptic seizures, but not psychogenic seizures, develop acidosis and decreased oxygen saturation. Serum prolactin levels at 20 and 60 minutes postictus can also help to distinguish generalized epileptic seizures from psychogenic seizures; prolactin levels do not increase after psychogenic seizures, whereas peak levels are reached 20 minutes after tonic-clonic epileptic seizures, with a gradual return to baseline during the subsequent hour. Neuropsychological testing is less helpful because of conflicting information regarding the extent to which psychogenic seizure patients have emotional disorders and neuropsychological deficits. Treatment of patients with psychogenic seizures generally focuses on intensive psychotherapy that is highly individualized and based on a detailed review of the patient's psychosocial history. CONCLUSIONS- Historical, clinical, and laboratory findings can properly identify patients with psychogenic seizures. Misdiagnosis exposes patients to potentially dangerous pharmacologic treatment and the serious social implications of being labeled with epilepsy. A consistent team approach should be used in dealing with the patient and family. Neurologists, psychiatrists, and the health professional responsible for the patient's follow-up care need to collaborate to ensure the most appropriate management of these complex cases.