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April 26, 2019

Treatment of Patients With Psychogenic Nonepileptic Attacks

Author Affiliations
  • 1Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
  • 2Epilepsy Center of Excellence, Neurology Service, VA Connecticut Healthcare System, Connecticut
  • 3Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut
  • 4Psychology Service, VA Connecticut Healthcare System, West Haven, Connecticut
JAMA. 2019;321(20):1967-1968. doi:10.1001/jama.2019.3520

Psychogenic nonepileptic attacks (PNEA), also known as psychogenic nonepileptic seizures, dissociative seizures, or pseudoseizures (a term now widely considered pejorative), can be terrifying and frustrating for patients and their families. PNEA are transient episodes of involuntary movements or altered consciousness caused by psychological mechanisms, often involving intense stress. They are the most common form of functional neurological disorder, the preferred term for what was previously known as conversion disorder. Unlike factitious disorder or malingering, PNEA are not consciously produced or controlled by the patient, ie, they are not “faked.” Individuals with PNEA may thrash and jerk their limbs, fall to the floor, roll back and forth, or simply close their eyes and become unresponsive as if asleep. PNEA can appear very much like epileptic seizures, in which abnormal electrical discharges in the brain cause similar episodes of involuntary movements and altered consciousness.

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    4 Comments for this article
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    Conversion Disorder (psychogenic seizures) vs. Auto immune cataplexy
    Eric Peterson, Ph.D, J.D. | None
    What you describe as psychogenic nonepileptic attacks (conversion disorder) actually sounds like it could be autoimmune disorder narcolepsy with cataplexy, with the "seizure component" simply being cataplexy. I would be curious as to effect of sodium oxybate on these individuals, or simply venlafaxine (serotonin-norepinephrine reuptake inhibitor (SNRI)), a standard treatment for cataplexy. Much has been discovered of the auto-immune mechanism of narcolepsy and cataplexy in last few years, while the mechanism of psychogenic seizures is undefined beyond a neurologist diagnosis of last choice often excluding a diagnosis of sleep disorders. The effect of behavioral modification could be patients' learning to adjust to environments to diminish chances of triggering cataplexy. Recent studies of verified narcolepsy and cataplexy in individuals with low CSF hypocretin levels show many cataplexy triggers other than emotion, many related to a startle stimulus of some type (sound, light, touch etc). All seem present in your review, and the responses you describe are what I would expect for cataplexy responses.

    It appears to me that the diagnostic tree might be modified to include a more refined look at autoimmune disorders, specifically sleep disorders.

    I had previously been labeled with a conversion disorder and simple self-directed medical treatment led to a  cataplexy diagnosis and effective treatment.
    CONFLICT OF INTEREST: None Reported
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    An Excellent Resource to Complement This Paper
    Kit Byatt, MBBS, FRCP | Hereford, UK
    Over my years in clinical practice, not least during acute medical intakes and doing tilt tests, I have found it invaluable to refer patients with functional disorders to the website www.neurosymptoms.org. 

    The site, a resource for patients with functional neurological disorders, validates their symptoms, explains (as far as we know) what's going on, and acts as a useful source of 'non-volatile' explanation to complement a sympathetic explanation in the consult.
    CONFLICT OF INTEREST: None Reported
    PNEA and Trauma
    Henrik Jordan, MD | Psychiatry, Psychotherapy, Public Health
    I'd like to quote Sigmund Freud and a recent paper, confirming my experiences when I worked as a liaison psychiatrist and psychotherapist in a specialized hospital for epilepsy.

    Patients with PNEA had mostly a combination of trauma, anxiety, sleep deficit, and sometimes brain damage in the patient's history (higher vulnerability). I told them that they are kind people, a bit too kind for this world. Sigmund Freud wished these patients a bit more courage and described them as hesitating (Studies on Hysteria, 1895).

    I had seen a single patient with "narcolepsy." He was traumatized. The trauma
    was treated by a colleague. 4 weeks later I barely recognized this man because he eventually had sufficient sleep and his expression was drastically improved.

    Actually, the cause(s) for PNEA are known for more than a hundred years (1). Read Sigmund Freud, and no, I'm not a psychoanalyst.

    REFERENCES

    1. Salpekar J. Seizures, Nonepileptic Events, Trauma, Anxiety, or All of the Above. Epilepsy Curr. 2019 Jan;19(1):29-30. doi: 10.1177/1535759718822842. Epub 2019 Jan 30.
    CONFLICT OF INTEREST: None Reported
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    Trust
    Paul Nelson, M.D., M.S. | Family Health Care, P.C. retired
    During a forty year practice as a primary care physician, the phenomena of a conversion disorder was a likely contributor to a host of clinical problems. Without any basis for diagnostic precision I often worried about its contribution to asthma, childhood onset obesity, hypertension and chronic pain. Most of these folks were intellectually superior to my own analytic skills, so the nuances of a true caring relationship were always susceptible to inadvertent missteps. During my career, the dozen folks with either pseudo-seizures or globus hystericus responded ultimately to a persistently scheduled effort to form a fully engaged set of caring relationships, with and for the patient. This was not successful for anorexia nervosa.

    The phenomenon of a personal support network has many demonstrated examples of therapeutic benefit, having been shown to reduce the incidence of suicide death after an initial gesture by 80% (1) 

    References

    King CA, Arango A, Kramer A, et al. Association of the Youth-Nominated Support Team Intervention for Suicidal Adolescents With 11- to 14-Year Mortality OutcomesSecondary Analysis of a Randomized Clinical TrialJAMA Psychiatry. 2019;76(5):492–498. doi:10.1001/jamapsychiatry.2018.4358
    CONFLICT OF INTEREST: None Reported
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