The topic of Psychogenic non-epileptic seizures (PNES) is not easy to discuss with patients who may be suffering from this condition. It is challenging to diagnose and treat, due to the confounding symptoms which make it difficult for both healthcare professionals and their patients. Yet, the prevalence of PNES rivals that of trigeminal neuralgia and multiple sclerosis, with a rate among the general population of 2-33 per 100,000. Once a conversation that was largely kept behind closed doors, as more conversations about mental health find their way into the light, so are discussions about PNES. And everyone benefits.

A Difficult Diagnosis

The 2018 review article, An Overview of Psychogenic Non-Epileptic Seizures: Etiology, Diagnosis, and Management, describes PNES as a “sudden event characterized by paroxysmal changes in consciousness, movement and/or behavior that are similar to the ones seen in epileptic seizures. However, they are not associated with epileptiform activity as detected through VEEG and there are psychological underpinnings and causes that lead to the seizure.”

Though this general description is widely accepted, there has never been complete agreement on a definition or on the causes. Many PNES cases have been misdiagnosed as epilepsy or the healthcare professional had erroneously determined that the patient was “faking it” which had led to the informal term “pseudo-seizures”.

Confusing PNES for Epilepsy

Diagnosing PNES is very difficult and misdiagnosis of the condition, most commonly mistaking it for epilepsy, can cause lasting harm to the patient. Still, there are many symptoms of PNES that mimic those of epilepsy:

• Anxiety and panic
• Parasomnias
• Transient ischemic attacks
• Syncope
• Migraine with aura
• Hyperventilation attacks

This and other issues such as a stigma surrounding PNES, lack of physician knowledge of the condition, and shortage of properly equipped, diagnostic facilities contribute to a common delay in diagnosis of 7 to 10 years – sometimes longer.

Abnormal EEG readings are another reason for misdiagnosis and delay in diagnosis. Not all neurologists have the specialized training to read EEGs, leading to the reports being misread as “abnormal.” This is not uncommon when they are trying to evaluate epileptic seizures versus PNES. This is why all EEG studies must be reviewed and interpreted by a trained specialist.

This underlines a primary reason why reading and consulting services can save both neurologists and patients time, money, and frustration.

Psychogenic Symptoms are More Common Than We Want to Admit

Conservative estimates attribute at least 10% of all medical services to the treatment of psychogenic symptoms which are very common in neurology, making up about 9% of inpatient neurology admissions. There is a high probability that in outpatient visits, the percentage is even higher.

Psychogenic symptoms are not exclusive to neurology; they are very common in many areas of medicine including gastroenterology, cardiology, and pain syndromes. Psychogenic symptoms frequently seen in neurological patients include:

• Pain
• Paralysis
• Balance problems
• Mutism
• Gait problems
• Visual symptoms
• Movement disorders
• Sensory problems
• Limb weakness
• Numbness or loss of sensation

However, psychogenic symptoms can be triggered by trauma, stress, and mental health conditions that go hand in hand with other conditions. It is imperative to discern whether a PNES is the actual condition or is itself a symptom of an underlying condition.

The dual nature of psychogenic symptoms makes them difficult to form a diagnosis because they present in both psychiatric and non-psychiatric cases. This makes them more difficult to identify and treat as well as find the root cause. This is what makes the EEG, more pointedly the video EEG, an invaluable diagnostic tool.

A video EEG records what the patient is experiencing or doing while they are undergoing the EEG. This allows it to match the pattern of brainwaves during the event to the task, sounds, or experience that correspond to it. This allows the specialist who reads the EEG to compare the records to the task and experience and determine if the seizure was related to electrical activity in the brain which would classify it as an epilepsy seizure.

Outpatient, or in-home, ambulatory video EEGs have proven invaluable in evaluating patients suffering from suspected PNES. Video EEG is by far the diagnostic tool of choice because it captures the brain electrical activity of the patient while recording the behaviors that correspond to that behavior. It is almost always a part of the diagnostic process in patients who continue to experience frequent paroxysmal events even though they are taking medication for seizures. With the video EEG conducted on an outpatient basis, the clinician can observe the patient in daily life while the patient can do the things they normally do – including coming into contact with triggers.

Final Word

Conditions like PNES with confounding symptoms often make the diagnostic course long and challenging, but CortiCare can streamline the process, making it easier and more precise. CortiCare’s in-home ambulatory EEG services provide doctors the assessment tools to evaluate their patients and help identify and diagnose if the patient’s spells are epileptic seizures, PNES, or something else.  Without video-EEG, PNES can go undetected or be misdiagnosed. In addition to the ambulatory EEG services, CortiCare’s EEG reading and consulting services are available to review and interpret the EEG studies. Our EEG reading specialists are highly trained and board-certified. This can mean a shorter time to properly diagnose and treat patients and improve patient outcomes.