Last week, we talked about what it’s like to have epilepsy. This week, I am joined by Dr. Taneeta “Mindy” Ganguly to discuss what it’s like for people who look like they are having seizures but they’re not having seizures. Before I go on, I will admit there is an overlap between epileptic and non-epileptic events, and clinically they may be indistinguishable. We chatted a bit about these features in a prior episode from April Fool’s Day, but we’re expanding our scope this week as we review the features and treatment of psychogenic non-epileptic seizures.
Dr. Ganguly opens her episode with the story of a patient who presented with abnormal, uncontrollable movements, and they were thought to be seizure-like activity. In many cases like this, the patient has no pertinent history that would be associated with an increased risk of seizure (e.g., preterm delivery, perinatal complications, history of meningitis or encephalitis, brain tumor, etc.). But some features in the history may be suggestive of non-epileptic seizures–like history of a psychiatric condition and seizures that worsen despite anti-epileptic drug therapy.
But what does it mean to be “seizure-like”? The spectrum of a clinical seizure is incredibly broad and cannot possibly be covered in a single podcast episode. But here is a list of some of the more common seizure subtypes:
- Absence seizure: Brief staring (<10 seconds), with or without oral automatisms, and associated loss of consciousness or incontinence, but no aura or post-ictal state
- Atonic seizure: Brief (<1 second) loss of muscle tone with collapse and often head injury, loss of consciousness, but no aura or post-ictal state
- Myoclonic seizure: Brief (<1 second), often full body jerk without loss of consciousness, aura, or post-ictal state, often occurring in the morning in JME
- Simple partial seizure: A.k.a. Focal motor seizure, with intermittent, rhythmic movements of one (or multiple unilateral) extremity and preserved consciousness, no post-ictal state or incontinence
- Focal dyscognitive seizure: Previously called complex partial seizure, where there is rhythmic or semi-rhythmic movements and loss of consciousness, with or without incontinence, and associated post-ictal state
- Generalized tonic-clonic seizure: A.k.a. “grand mal” seizure, may begin with preceding aura then focal movements and may secondarily generalize, or may begin with whole body stiffening (tonic component) followed by (often rhythmic) convulsions (clonic component) and loss of consciousness with incontinence, tongue biting, and post-ictal state
Considering all of these abnormalities in behavior, it stands to reason that many “funny looking” movements may be mistaken for seizure. Hopefully this table from Reuber and Elger can help you distinguish features of non-epileptic seizures from epileptic seizures. They aren’t hard and fast rules but they can raise or lower your pretest probability that the patient has true epilepsy.
How should patients with non-epileptic seizures be treated? Not by brain surgery, although 1 in 5 patients with psychogenic seizures will be referred for epilepsy surgery. One problem is that there is often a delay in diagnosis of non-epileptic events by 7-10 years. So that’s nearly a decade of anti-epileptic drug trials, imaging, invasive testing, and other interventions that are likely to yield little benefit for these patients. Or worse, will actually hurt the patient. More importantly, these patients benefit from face time with their doctor(s), addressing underlying stressors, and avoiding anti-epileptic drugs which pose more risk than benefit.
The trouble is that one-third of patients with epilepsy will have non-epileptic events. So just because you are seeing “funny movements” the EEG is normal, it doesn’t mean your patient is safe from seizures. There is still a chance your patient has epilepsy. At this point, continuous EEG monitoring (either as an outpatient, or a dedicated hospital admission) may be helpful to identify which events are not electrographic seizures and which ones may have an electrographic correlate. If they are seizures, anti-epileptic drug therapy should be helpful. If they aren’t, then it’s time to make some management changes.
BrainWaves podcasts and online content are intended for medical education purposes only and should not be used in routine clinical decision making. For official tips on how to safely monitor a patient who is seizing, you’d be smart to take advice from the Epilepsy Foundation.
1. Reuber M and Elger CE. Psychogenic nonepileptic seizures: review and update. Epilepsy Behav. 2003;4:205-16.
2. Mostacci B, et al. Ictal characteristics of psychogenic non-epileptic seizures: What we have learned from video/EEG recordings—A literature review. Epilepsy & Behavior. 2011;22:144-153.