Psychogenic non-epileptic seizures—Definition, etiology, treatment and prognostic issues: A critical review

Abstract

In this review we systematically assess our currently available knowledge about psychogenic non-epileptic seizures (PNES) with an emphasis on the psychological mechanisms that underlie PNES, possibilities for psychological treatment as well as prognosis. Relevant studies were identified by searching the electronic databases. Case reports were not considered. 93 papers were identified; 65 of which were studies. An open non-randomized design, comparing patients with PNES to patients with epilepsy is the dominant design. A working definition for PNES is proposed. With respect to psychological etiology, a heterogeneous set of factors have been identified. Not all factors have a similar impact, though. On the basis of this review we propose a model with several factors that may interact in both the development and prolongation of PNES. These factors involve psychological etiology, vulnerability, shaping, as well as triggering and prolongation factors. A necessary first step of intervention in patients with PNES seems to be explaining the diagnosis with care. Although the evidence for the efficacy of additional treatment strategies is limited, variants of cognitive (behavioural) therapy showed to be the preferred type of treatment for most patients. The exact choice of treatment should be based on individual differences in the underlying factors. Outcome can be measured in terms of seizure occurrence (frequency, severity), but other measures might be of greater importance for the patient. Prognosis is unclear but studies consistently report that 1/3rd to 1/4th of the patients become chronic.

Anxiety and avoidance in psychogenic nonepileptic seizures: The role of implicit and explicit anxiety

“…Such inconsis-tencies may be explained, in part, by the use of explicit measures, which not only are susceptible to social desirability biases but also as-sume a level of insight and awareness and an ability to accurately report on internal states -skills that may be diminished in individuals with neurological disorders or individuals who tend to avoid interoceptive experiences. Self-report measures such as the MMPI, which attempt to circumvent these problems, have been more likely to find group differences [29,31], although findings have not been consistently repli-cated and have been questioned in terms of sensitivity and specificity for the differential diagnosis of epilepsy and PNESs [32] (also discussed in [33]). What is more, while the MMPI has been used extensively, it does not separate clearly between psychopathology and normal findings, does not specifically describe different types of avoidance be-haviors, and cannot measure implicit cognition.…”

The semiology of tilt-induced psychogenic pseudosyncope

“…PNES is relatively well known, with a reported prevalence of up to 30% in patients in epilepsy clinics. 5 In contrast, PPS is rarely mentioned in the literature on syncope, and the reported prevalence of PPS in those analyzed for presumed syncope is lower, ranging from 0% to 8%. [6][7][8] Some authors suspect that it is insufficiently recognized.…”

“…When episodes involve pronounced movements, they resemble epilepsy and are frequently labeled psychogenic nonepileptic seizures (PNES). 5 Episodes without pronounced movements resemble syncope and are generally labeled psychogenic pseudosyncope (PPS). 3 PNES and PPS are probably manifestations of the same underlying psychiatric disorder, but their different presentation has important consequences for diagnosis.…”

Psychogenic non-epileptic seizures and psychoanalytical treatment: results

“…14,15 Various treatments for PNES patients have been reported in the literature: biofeedback, 16 hypnosis, 17 acupuncture, 18 transcranial magnetic stimulation 19 and psychotherapy. 2,5,20,21,22,23,24 Nevertheless, the amount of studies encountered with a focus on psychological treatment is limited. 20 A study 25 conducted with the purpose of verifying the method considered most effective in the treatment of PNES by health professionals showed that 91% of these professionals would prefer psychotherapy.…”

“…2,5,20,21,22,23,24 Nevertheless, the amount of studies encountered with a focus on psychological treatment is limited. 20 A study 25 conducted with the purpose of verifying the method considered most effective in the treatment of PNES by health professionals showed that 91% of these professionals would prefer psychotherapy. Prigatano et al 21 assessed the effectiveness of a psychotherapeutic intervention and verified the importance of individual therapeutic work.…”