Sekilas tentang pseudosizure^^

1. Pseudoseizure
Ersifa Fatimah, dr.
PPDS Neurologi
RSUD Dr Soetomo - Universitas Airlangga
Surabaya, 2012

2. An epileptic seizure is defined as a transient
neurological dysfunction resulting from an
excessive abnormal electrical discharge of
cerebral neurons
The clinical manifestations are numerous,
including disturbances of consciousness,
changes in emotions, changes in sensation,
abnormal movements, and changes in visceral
functions or behavior
(Bradley, 2004)
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3. Systemic Disturbances Neurologic Disturbances
• Migraine
• Metabolic, Endocrine
• Cerebrovascular disorder
• Syncope
• Sleep disorder
• Myoclonus
• Movement disorder
Disorders That
Can Be Confused
with Epilepsy
Engel & Pedley,
Psychiatric Disturbance
Epilepsy: A Comprehensive Textbook,
• PNES 2nd Ed, 2008
• Episodic dyscontrol
• Discociative disorder
• Panic disorder
• OCD
• Psychoses
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4. • Can be the expression of organic or psychogenic processes.
• Can mimic convulsive and nonconvulsive epileptic seizures
• A clear distinction cannot always be made between
PNES somatization disorder, conversion disorder, factitious disorder,
and malingering as the conditions blur into each other (it can
be difficult to decide sometimes whether someone's
motivation is truly unconscious). Apparent motivation is also
based to some extent on a clinician's subjective interpretation
• Rare but severe form of human aggressive behavior
Episodic • Paroxysmal
• Often is accompanied by other neurologic or psychiatric
disorders
Dyscontrol • The question of whether IED is pathogenetically related to
epilepsy is unresolved
Engel & Pedley, Epilepsy: A Comprehensive Textbook, 2nd Ed, 2008
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5. • Disruption in the usually integrated functions of consciousness,
Dissociative memory, identity, or perception of the environment (DSM-IV), the
loss of control over bodily movements (ICD-10)
• Temporary disruption in consciousness or volition
Disorder • Amnesia, fugue, déjà vu, etc
• Certain aspects of epilepsy are dissociative, but they do not involve
(esp. Conversion) the same type of dissociation as that underlying nonepileptic
attacks
Panic • “Discrete period of intense fear or discomfort”  many of the
symptoms of panic attacks are reminiscent of symptoms that may
appear during some types of epileptic seizures
Disorder (Fear is a commonly encountered component of partial seizures
and is the most common ictal psychiatric symptom)
Engel & Pedley, Epilepsy: A Comprehensive Textbook, 2nd Ed, 2008
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6. • The symptoms of senseless repetitive actions
Obsessive- (compulsions) or recurrent intrusive thoughts
(obsessions) on some occasions might resemble
compulsive the automatisms that occur with complex partial
Behavior seizures arising from the temporal or frontal
lobes.
Nonaffective • The symptoms of psychosis (hallucinations, delusions),
suggest deviant neurologic processing, and underlying
Psychoses, this will be disturbances of neurologic function, often
secondary to structural disease.
Schizophrenia • There are biologic underpinnings to the psychotic
& disorders of epilepsy …. the discussions revolve
around similar anatomic deviations as in schizophrenia
Schizophrenia- in the absence of epilepsy and involve medial temporal
structures, the amygdala and hippocampus in
like Psychoses particular, and their efferent projections.
Engel & Pedley, Epilepsy: A Comprehensive Textbook, 2nd Ed, 2008
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7. Pseudoepileptic
Pseudoseizure
seizure
Psychogenic
Non-Epileptic Seizure Non-Epileptic
Seizure
Non-Epileptic
Attack Nonepileptic events
Disorder
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8. Nonepileptic seizures (NESs)
Paroxysmal events that mimic (or are confused
with) epileptic seizures, but which do not result
from epileptic activity.
NESs can be the expression of organic or
psychogenic processes.
Engel & Pedley, Epilepsy: A Comprehensive Textbook, 2nd Ed, 2008
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9. http://www.dana.org
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10. Johnson: Current Therapy in Neurologic Disease (7/E)
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11. Pseudoepileptic seizures
Paroxysmal episodes of altered behavior that
superficially resemble epileptic seizures but lack
the expected EEG epileptic changes
(Ettinger et al. 1999)
Bradley, 2004
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12. The Challenge
The decision whether a patient's seizures belong in the
domain of epilepsy or nonepileptic events  may have to be
based on various sets of criteria + EEG data.
The distinction between epilepsy and nonepilepsy cannot
always be made with complete confidence, and the physician
working in this field must be able to tolerate some degree of
uncertainty.
Epileptic and nonepileptic seizures also may coexist.
Engel & Pedley, Epilepsy: A Comprehensive Textbook, 2nd Ed, 2008
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13. Epidemiology
Approximately 40% of patients with pseudoepileptic / nonepileptic seizures also
experience true epileptic seizures. [Bradley, 2004]
(PNES) It is by far the most frequent nonepileptic condition seen in epilepsy
centers, where they represent 20-30% of referrals. About 50-70% of patients
become seizure-free after diagnosis, and about 15% also have epilepsy. [Medscape,
2011]
Occur in children and adults, more common in females [Bradley, 2004] (70%) .
[Medscape, 2011]
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14. Risk Factor
Age
• Epilepsy: Bimodal age curve
• PNES: Inverse unimodal age curve  70% at
decade 2-4th
Obese
Chronic pain, anxiety, PTSD
• Male veterans with PNES
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15. Risk factors
Age Epilepsy PNES
Infant / Genetic-metabolic Difficulties in school - 46%
Children disorder Family discord – 42 %
Infection Interpersonal conflict – 25 %
Physical abuse – 12%
Sexual abuse – 5%
Elderly Stroke Traumatic experience
Neurodegenerative (female < 55 ys  prior sexual abuse)
disorder (elder adult: severe physical-health
Tumor problem, health-related traumatic
experience)
Developmental factors
Adolescent: depression
Prepubescent: cognitive dysfunction,
epilepsy (comorbid)
Devinsky, O. et al. Nat. Rev. Neurol. 7, 210–220 (2011);
published online 8 March 2011; doi:10.1038/nrneurol.2011.24
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16. Pathogenesis
Developmental insult/trauma 
psychological stress > coping capacity
• Janet: Psychosocial automatism
• Freud: unconscious conflict symbolically converted into somatic
symptoms  reduce anxiety, shield conscious self from painful
emotion  Primary & secondary gain
May have abnormality in brain structure, but seizure
not associated with specific area/type of lesion
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17. What causes my attacks? - www.nonepilepticattacks.com
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18. Bradley: Neurology in Clinical Practice, 5th ed
ATTACK FEATURE PSYCHOGENIC SEIZURE EPILEPTIC SEIZURE
Stereotypy of attack May be variable Usually stereotypical
Duration May be prolonged Brief
Diurnal variation Daytime Nocturnal or daytime
Injury Rare Can occur with tonic-
clonic seizures
Tongue biting Rare Can occur with tonic-
clonic seizures
Ictal eye closure Common Rare (eyes generally open)
Urinary incontinence Rare Frequent
Motor activity Prolonged, uncoordinated; pelvic Automatisms or coordinated tonic-
thrusting clonic activity
Prolonged loss of muscle tone Common Rare
Postictal confusion Rare Common
Postictal crying Common Rare
Relation to medication changes Unrelated Usually related
Triggers Emotional disturbances No
Interictal EEG findings Normal Frequently abnormal
Reproduction of attack by Sometimes No
suggestion
Ictal EEG findings Normal Abnormal
Presence of secondary gain Common Uncommon
Psychiatric disturbances Common Uncommon
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20. Ersifa's 20

21. Ersifa's 21

22. Differentiating between nonepileptic and epileptic seizures
Orrin Devinsky, Deana Gazzola and W. Curt LaFrance Jr
Devinsky, O. et al. Nat. Rev. Neurol. 7, 210–220 (2011);
published online 8 March 2011; doi:10.1038/nrneurol.2011.24
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23. Differentiating between nonepileptic and epileptic seizures
Orrin Devinsky, Deana Gazzola and W. Curt LaFrance Jr
Devinsky, O. et al. Nat. Rev. Neurol. 7, 210–220 (2011);
published online 8 March 2011; doi:10.1038/nrneurol.2011.24
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24. Differentiating between nonepileptic and epileptic seizures
Orrin Devinsky, Deana Gazzola and W. Curt LaFrance Jr
Devinsky, O. et al. Nat. Rev. Neurol. 7, 210–220 (2011);
published online 8 March 2011; doi:10.1038/nrneurol.2011.24
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25. Differentiating between nonepileptic and epileptic seizures
Orrin Devinsky, Deana Gazzola and W. Curt LaFrance Jr
Devinsky, O. et al. Nat. Rev. Neurol. 7, 210–220 (2011);
published online 8 March 2011; doi:10.1038/nrneurol.2011.24
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26. Differentiating between nonepileptic and epileptic seizures
Orrin Devinsky, Deana Gazzola and W. Curt LaFrance Jr
Devinsky, O. et al. Nat. Rev. Neurol. 7, 210–220 (2011);
published online 8 March 2011; doi:10.1038/nrneurol.2011.24
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27. Pseudoseizure
Factitious disorder
(a Somatoform Disorder)
a condition where patients Malingering
Conversion, Somatization
intentionally fake disease, or the intentional faking or
a psychiatric condition that intentionally cause disease in creating of illness in order to
results in order to play the ‘patient obtain secondary gain (e.g.
a neurological complaint or role’. workers compensation,
symptom, without any
characterized by patients disability payments, avoiding
underlying neurological
frequently feigning illness to work or jail time, pain
cause.
obtain attention, sympathy, medication, etc.)
or other emotional feedback
[1] Simon, Greenberg, Aminoff, Clinical Neurology 7th ed, 2008
[2] http://shortwhitecoats.com/2011/conversion-vs-factitious-disorder-vs-malingering
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28. Pseudoseizure
Conversion, Somatization Malingering
Px unaware of Factitious disorder
Conscious awareness of
psychogenic nature of Px recognize te spells are production of symptoms
symptoms & motivation self-induced, but not the & underlying motivation
of their production [1] reason for doing so
Intentional, secondary
Unintentional, due to Intentional, primary or and often monetary gain
emotional stressors, no ‘emotional’ gain
‘gain’ to the patient [2]
[1] Simon, Greenberg, Aminoff, Clinical Neurology 7th ed, 2008
[2] http://shortwhitecoats.com/2011/conversion-vs-factitious-disorder-vs-malingering
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29. Ersifa's 29

30. What epileptic seizures are most likely
to be mistaken for NESs?
Frontal lobe seizures
• Unsual midline movement (pelvic thrusting,
bicycling)
• Very brief post-ictal states
• Ictal EEG abnormality may escape detection
Simon, Greenberg, Aminoff, Clinical Neurology 7th ed, 2008
http://shortwhitecoats.com/2011/conversion-vs-factitious-disorder-vs-malingering
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31. Diagnosis
• In px with epilepsy NES should be considered
when previously controlled seizures become
medically refractory.
• Other psychiatric disturbances  high frequency
of hysteria, depression, and personality
disturbances Px should have a psychological
assessment
• A secondary gain can be identified.
• Can frequently be precipitated by suggestion &
certain clinical tests
Bradley, 2004
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32. Benbadis, Medscape, 2011
Laboratory Studies
• Useful only in excluding metabolic or toxic causes of
seizures (eg, hyponatremia, hypoglycemia, drugs).
• Prolactin & creatine kinase (CK) levels rise after
generalized tonic-clonic seizures and not after other
types of episodes. However, sensitivity is too low to be
of any practical value (ie, lack of elevation does not
exclude epileptic seizures).
Imaging Studies
• Normal in psychogenic nonepileptic seizures (PNES),
images should be obtained to exclude organic pathology.
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33. Benbadis, Medscape, 2011
EEG and ambulatory EEG
• Because of its low sensitivity, routine EEG is not helpful in confirming a
diagnosis of PNES. However, repeatedly normal EEG findings, especially in
light of frequent attacks and resistance to medications, can be viewed as a
red flag.
• Ambulatory EEG is increasingly used, it is cost effective, and it can contribute
to the diagnosis by recording the habitual episode and documenting the
absence of EEG changes.
EEG video monitoring
• the criterion standard for diagnosis and indicated in all patients who have
frequent seizures despite taking medications.
• combined electroclinical analysis of both the clinical semiology of the ictus
and the ictal EEG findings allows for a definitive diagnosis in nearly all cases.
• The principle is to record an episode and demonstrate that no change in the
EEG occurs during the clinical event and that the clinical episode is not
consistent with seizures unaccompanied by EEG changes.
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34. MRI
• up to 30% of patients with PNES were identified as
having MRI abnormalities (most often non-specified
gliosis), other studies have indicated that imaging
abnormalities—the most common being postoperative
defects—are present in 10% of these patients
• Patients with PNES and patients with epileptic seizures
can both have normal brain MRI findings
• MRI findings support, but cannot confirm, a diagnosis
of epilepsy
• MRI may not differentiate between these two types of
seizures
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35. SPECT
• The capability of SPECT to differentiate
between PNES and epileptic seizures remains
unknown.
• Patients with epileptic seizures or PNES can
have normal ictal and interictal SPECT
findings.
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36. Subtraction of interictal from ictal
SPECT coregistered to MRI (SISCOM)
• No changes in SPECT abnormalities occur
during episodes in 85% of patients with PNES
 negative finding on SISCOM are considered
to support a diagnosis of PNES
• Px with epileptic seizures may also have non-
localizing findings on SISCOM  SISCOM of
little value in diagnosing PNES.
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37. Psychiatric Evaluation
• Comorbid psychiatric disorders (most often):
depression, anxiety, PTSD & personality disorders 
significantly impact quality of life
• Identify conflicts or traumatic experiences  aid
diagnosis of PNES
• Psychiatric consultations facilitate the appropriate
inpatient or outpatient follow-up after discharge
• Might be a first step to helping patients with seizures
cope with their condition but, at present, psychiatric
assessments in seizure evaluations are underutilized
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38. Therapy
• Education
• Some px with pseudoseizure also have
genuine epileptic seizure that require
anticonvulsant
• Psychiatric referral may be helpful
Simon, Greenberg, Aminoff, Clinical Neurology 7th ed, 2008
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39. The End