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Introduction Psychogenic nonepileptic seizures (PNES) is a non-epileptic event which needs to be differentiated from epileptic seizures and poses a diagnostic challenge. It has psychological etiology without any associated abnormal electrical discharges in the brain. We have tried to explain in detail the semiology and socioeconomic factors of patients presenting with the diagnosis of PNES to our hospital so that it will help in early diagnosis and prevent unnecessary antiepileptics use. Methods This is a retrospective study. We have included all patients admitted to the Neurology Department of Kalinga Institute of Medical Sciences (KIMS) during 2020-2021 and discharged with a diagnosis of PNES. Those having associated epileptic events were excluded from the study. All events were categorized as hypermotor, hypomotor and sensory symptoms as per the patient’s presentation as there is no universal classification system for PNES. Results A total of 50 patients were included in the study. Of them 70% had PNES of hypermotor and 30% of hypomotor type. The mean number of events in the hypomotor group was significantly higher than that in the hypermotor group. The hypomotor variety was found predominantly in females and hypermotor in males. Overall, 10% of the patients had a history of epilepsy in one of the family members. A total of 74% patients had associated anxiety, depression or post-traumatic stress disorder. Conclusions Hypermotor events were more common than hypomotor events. Hypomotor events were found mostly in females. Most of the patients had pre-existing anxiety, depression, or post-traumatic stress disorder as underlying risk factors.
Psychogenic nonepileptic seizures (PNES) resemble epileptic seizures but are not associated with abnormal electrical discharges in the brain.1They can be sensory, hypermotor or hypomotor. Semiology differs in children from adults.2 They are also called functional seizures or nonepileptic attack disorder. They constitute 10-40% of patients with medically refractory seizures referred to higher centres.3 Most patients are treated for epilepsy with multiple antiepileptic drugs (AEDs) and are exposed to adverse effects of the drugs so proper diagnosis is crucial.4Sometimes it may be confused with status epilepticus if it continues for a long time, and managed accordingly, which can have grave consequences.5 The diagnosis depends solely on proper history taking and close observation and electroencephalogram (EEG) recording during an attack. So proper knowledge of the different presentations of PNES is required to distinguish epileptic seizures from PNES earlier. There are no diagnostic symptoms or signs, but clinical features along with sociocultural history helps in reaching the diagnosis. We have tried to describe the different semiology of PNES and social background of patients presenting to our hospital to aid in early diagnosis and prevent unnecessary investigations and medications.
This is a retrospective study. We have chosen 50 patients with ages in the range of 18-80 years, with a diagnosis of PNES during discharge. Patients with mixed seizures type having both epileptic and nonepileptic seizures were excluded from the study. Routine investigations like complete blood count, renal function test, liver function test, serum calcium, magnesium, serum prolactin drawn at the time of the event, video EEG, brain magnetic resonance imaging (MRI) and electrocardiogram, echocardiography were done in all patients and were normal in our study subjects. Detailed history, clinical features and socioeconomic factors were documented properly from the records and tabulated for analysis. The semiology was primarily classified into hypermotor (tremor, involuntary movement of extremities, pelvic thrusting) and hypomotor (loss of consciousness, repeated fall, remaining unresponsive with slight eyelid blinking) and sensory symptoms like tingling and numbness of extremities. The study was approved by the Institutional Ethics Committee of Kalinga Institute of Medical Sciences.
We have analyzed 50 patients with PNES, out of which 32 (64%) were females and 18 (36%) were males. A total of 35 patients (70%) were in the age group 18-30 years. Only 1 patient was 57 years old. No patient was above 60 years. Patient characteristics are described in Table 1. Overall, 35 (70%) patients had hypermotor events; 15 patients (30%) had hypomotor events (Table 2). Hypomotor movements were common in females. No patient had sensory symptoms, possibly as these patients are usually not admitted and managed on outpatient (OPD) basis. Most of the female patients, 25 (78.1%), were married. In females all were married within 5 years. Most of them (18) were staying in joint family with husband staying outside. The rest, 7 (22%), were students with bad academic performance meaning they had secured less than 30% marks in annual examination. A total of 8 (44.4%) males were in search for a job, the rest doing some business. One male person of 57 years was staying alone with children residing outside the country. All these patients had pre-existing anxiety and depression. Another 3 patients also had pre-existing depression but the determining factors couldn’t be identified. Overall, 10% of patients had history of epilepsy in one of the family members.
The frequency of events per day was higher in the hypomotor variety than in the hypermotor type. In the hypomotor group the mean number of events per day was 7.67 with a standard deviation of 1.3. In the hypermotor group the mean number of events was 3.6 with a standard deviation of 1.18. The p value between these two groups is 0.001 which is statistically significant. Most of the episodes lasted for more than 5 min with fluctuating courses.
The aim of this study was to identify reliable semiology and sociocultural features predictive of PNES. In our study we found that PNES are common in the young population, mostly in females. Other studies also found that it is common in young adults but can be found in any age group. In our study we found it common in newly married females. This is similar to findings in a study by Asadi-Pooya et al.6 Overall, 10% of patients had family history of epilepsy. Asadi-Pooya et al. also found that 5-50% had family history of epilepsy. Preserved consciousness throughout the event, absence of a particular pattern of limb movements, abnormal forward pelvic movements, head and body turning from side to side, and a fluctuating course point in favor of PNES.
The duration of the event is also an important indicator.7 In PNES events usually last longer than 2 minutes, which is very uncommon in epileptic events. Closure of the eyes throughout the event was highly specific for PNES. Similar findings documented by Luther et al. found hyper motor and hypomotor manifestations.7 Groppel et al., in 2000, identified three groups as psychogenic motor seizures, psychogenic minor motor or trembling seizures, and psychogenic atonic seizures.8
Avoidance maneuvers and memory recall in the post ictal period are useful tests. Activation procedure like suggestion or hyperventilation is highly specific to PNES.9 Long duration asynchronous events with a fluctuating course with closed eyes during the episode, forward pelvic thrusting, side to side head and body movements, absence of postictal amnesia and postictal confusion are pointers towards PNES also found in other studies.10As mentioned above, the duration of the ictal episode is longer in nonepileptic than epileptic seizures. Patients with PNES share more similarities.11Similar studies about PNES are lacking in Indian population. The number of participants in our study was too small so further studies are needed with a larger number of patients to explore the different semiology of PNES in the Indian population.
PNES is a disorder with significant social and economic impact. Diagnosing it early is essential to reduce the healthcare expenditure costs significantly by avoiding unnecessary investigations. Also improper use of multiple antiepileptics and drug interactions can be avoided. So proper history taking, close observation during the event and seizure provocation techniques are simple methods commonly used for diagnosis. It is common in young females with underlying anxiety, depression, post-traumatic stress disorder. It can have hypermotor or hypomotor presentation. Hypermotor presentation is more common but the frequency of events in the hypomotor group is higher than in the hypermotor group.
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https://doi.org/10.1016/j.yebeh.2011.07.003
2. Alessi R, Vincentiis S, Rzezak P, Valente KD. Semiology of psychogenic nonepileptic seizures: age-related differences. Epilepsy Behav. 2013;27:292-5. https://doi.org/10.1016/j.yebeh.2013.02.003
3. Benbadis SR. Allen Hauser W. An estimate of the prevalence of psychogenic nonepileptic seizures. Seizure. 2000;9:280-1.
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https://doi.org/10.1212/WNL.58.3.493
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6. Asadi-Pooya AA, Emami M, Emami Y. Gender differences in manifestations of psychogenic non-epileptic seizures in Iran. J Neurol Sci. 2013;332:66-8. https://doi.org/10.1016/j.jns.2013.06.016
7. Luther JS, McNamara JO, Carwile S, Miller P, Hope V. Pseudoepileptic seizures: methods and video analysis to aid diagnosis. Ann Neurol. 1982;12:458-62. https://doi.org/10.1002/ana.410120508
8. Gröppel G, Kapitany T, Baumgartner C. Cluster analysis of clinical seizure semiology of psychogenic nonepileptic seizures. Epilepsia. 2000;41:610-4. https://doi.org/10.1111/j.1528-1157.2000.tb00216.x
9. Benbadis SR, Siegrist K, Tatum WO, Heriaud L, Anthony K. Short-term outpatient EEG video with induction in the diagnosis of psychogenic seizures. Neurology. 2004;63:1728-30.
https://doi.org/10.1212/01.WNL.0000143273.18099.50
10. Avbersek A, Sisodiya S. Does the primary literature provide support for clinical signs used to distinguish psychogenic nonepileptic seizures from epileptic seizures? J Neurol Neurosurg Psychiatry. 2010;81:719-25. https://doi.org/10.1136/jnnp.2009.197996
11. Asadi-Pooya AA, Sperling MR. Epidemiology of psychogenic non-epileptic seizures. Epilepsy Behav. 2015;46:60-5. https://doi.org/10.1016/j.yebeh.2015.03.015
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