Can someone with conversion disorder have seizures, specifically psychogenic non-epileptic seizures (PNES)?

Psychogenic Non-Epileptic Seizures in Conversion Disorder

Yes, people with conversion disorder can have seizures, specifically psychogenic non-epileptic seizures (PNES), which are a common manifestation of conversion disorder and can significantly impact morbidity, mortality, and quality of life.

Understanding PNES in Conversion Disorder

Conversion disorder (also called functional neurological symptom disorder) can manifest as seizure-like episodes that clinically resemble epileptic seizures but have no corresponding epileptiform activity in the brain. According to current diagnostic frameworks:

• PNES are classified as a subtype of conversion disorder in the DSM-5 1
• The ICD-10 classifies PNES as dissociative disorders 1
• PNES have been identified by the International League Against Epilepsy as one of the 10 most critical neuropsychiatric conditions associated with epilepsy 1

Epidemiology and Clinical Significance

• Incidence of PNES: 1.4-4.9 per 100,000 per year 1
• Prevalence: 2-33 per 100,000 1
• PNES represent a significant proportion of patients with apparent treatment-resistant seizures:
  • 1 in 4-5 patients admitted to video-EEG monitoring units with presumed refractory epilepsy are later found to have non-epileptic events, most of psychogenic origin 1

Diagnostic Features of PNES

PNES can be distinguished from epileptic seizures by several key features:

Clinical Characteristics

• Eyes often closed during unconsciousness (unlike epileptic seizures where eyes are typically open) 2
• Pelvic thrusting movements may be present 2
• Eye fluttering is more likely in PNES than epileptic seizures 2
• Apparent loss of consciousness lasting 10-30 minutes (epileptic seizures typically shorter) 2
• Repeated waxing and waning in intensity and changes in movement patterns 2
• Many movements that cannot be easily counted (versus the limited movements in true syncope) 2

Diagnostic Gold Standard

• Video-EEG monitoring capturing a typical event is the definitive diagnostic test 3
• Normal EEG during a typical seizure event strongly suggests PNES 2

Comorbidity with Epilepsy

An important clinical consideration is that PNES and epilepsy can coexist in the same patient:

• Coexisting NES and epileptic seizures (CENES) represent approximately 75% of NES cases in patients with refractory seizures 4
• Pure conversion disorder without epilepsy accounts for about 25% of cases 4
• This comorbidity creates significant diagnostic challenges and can lead to inappropriate treatment escalation 1

Clinical Impact and Risks

Misdiagnosis of PNES has serious consequences:

• Unnecessary and potentially harmful increases in anti-seizure medications 1
• Erroneous diagnosis of refractory epilepsy leading to inappropriate treatments 1
• Delayed appropriate psychological intervention 5
• Extensive medical testing, invasive procedures, and hospital admissions 2
• Significant impact on quality of life and psychosocial functioning 5

Treatment Approach

Evidence supports a multidisciplinary approach with psychological interventions as the cornerstone of treatment:

• Cognitive Behavioral Therapy (CBT) has demonstrated effectiveness in:

  • Reducing seizure frequency
  • Improving psychiatric symptoms
  • Enhancing psychosocial functioning and quality of life 5

• Clear, multidisciplinary diagnosis announcement is an essential therapeutic step 3

• Supervised withdrawal of antiepileptic medications when appropriate 5

Risk Factors and Associated Conditions

Several factors are associated with PNES in conversion disorder:

• History of trauma or abuse 6
• Comorbid depression and anxiety 6
• Previous or concurrent other conversion symptoms (especially neurological) 6
• Difficulty with emotional regulation and management 3

Clinical Pearls and Pitfalls

• Pitfall: Assuming all seizure-like events in psychiatric patients are psychogenic

  • Always conduct appropriate neurological workup to rule out epilepsy

• Pitfall: Missing the dual diagnosis of epilepsy and PNES

  • Consider video-EEG monitoring in patients with treatment-resistant seizures

• Pearl: Children with multiple conversion manifestations may require more intensive psychological therapy and may be at risk for long-term pathology 6

• Pearl: In adults with apparent drug-resistant seizures who have normal neuroimaging and interictal EEG, consider conversion disorder as a possible diagnosis 4

Proper diagnosis and treatment of PNES in conversion disorder is essential for reducing unnecessary medical interventions, preventing medication side effects, and improving overall quality of life for affected individuals.