From the Guidelines
Pseudoseizures, or psychogenic non-epileptic seizures (PNES), should be treated with psychological therapy, specifically cognitive behavioral therapy (CBT) or dialectical behavior therapy (DBT), as the primary intervention, rather than antiepileptic medications, to address the underlying psychological distress. Pseudoseizures are episodes that resemble epileptic seizures but are not caused by abnormal electrical activity in the brain, instead having psychological origins [ 1 ]. These events typically manifest as convulsions, staring spells, or unusual movements that can be mistaken for epileptic seizures. Diagnosis requires video-EEG monitoring, which shows normal brain activity during these episodes, distinguishing them from true epileptic seizures.
Some key points to consider in the management of pseudoseizures include:
- The importance of a multidisciplinary approach involving neurologists, psychiatrists, and psychologists to yield the best outcomes [ 1 ].
- The use of occupational therapy (OT) skills to help individuals with pseudoseizures, including creating a seizure plan, identifying triggers and warning signs, and teaching strategies such as sensory grounding techniques to prevent dissociation [ 1 ].
- The need to address underlying psychological factors such as trauma, anxiety, or depression, which may require appropriate psychiatric medications [ 1 ].
- The distinction between pseudoseizures and other conditions, such as paroxysmal kinesigenic dyskinesia (PKD), which can manifest with similar symptoms but have different underlying causes [ 1 ].
In terms of specific interventions, a DS plan can help put clinicians at ease and make the person feel safer, which may prevent escalation and reduce duration of the episode [ 1 ]. This plan should include strategies such as helping the person to a safe space, avoiding constant reassurance and physical contact or restraint, and advising others to behave as they would if someone is having a panic attack. Additionally, sensory grounding techniques, such as noticing the detail in the environment, cognitive distractions, and sensory-based distractors, can be helpful in preventing dissociation and reducing the frequency of pseudoseizures [ 1 ].
From the Research
Definition and Prevalence of Pseudoseizures
- Pseudoseizures are paroxysmal alterations in behavior that resemble seizures but are without any organic cause 2.
- They are recognized by various terms and are found in about one fourth of all patients seen with hysteria and 20% of those referred to epilepsy clinic 2.
- Pseudoseizures can occur in patients with conversion syndromes, and they can be difficult to diagnose and treat 3.
Diagnosis of Pseudoseizures
- Diagnosis of pseudoseizures is a complex process, depending primarily on clinical neurologic observation of the spell pattern and negative response to anticonvulsant therapy 4.
- Simultaneous video-EEG monitoring has allowed pseudoseizures to be effectively diagnosed 5, 6, 3.
- Comparative studies of patients with true convulsive seizures and patients with pseudoseizures have revealed some 'typical' ictal features of pseudoseizures, including longer ictal duration, less stereotypy, asynchronous extremity movements, atypical vocalization, alternating head movements and pelvic thrusting 6.
- Psychiatric and personality examination, different techniques of suggestion and determination of serum prolactin may provide additional diagnostic evidence 6.
Treatment and Management of Pseudoseizures
- Management consists of making the patient and relatives aware about the causation and diagnosis 2.
- Treatment options include psychotherapy (supportive and psycho-dynamic), behavior therapy (biofeedback, relaxation), drugs (anxiolytic and anti-depressants), hypnosis and placebo 2.
- Discussing the results of the monitoring with the patient is the 1st step in treatment, and a protocol for presenting the diagnosis of pseudoseizure can be helpful in conveying to the patient the importance of knowing the nonepileptic nature of the spells and the need for psychiatric follow-up 5.