Neuropsychology of Psychogenic Nonepileptic Seizures

  • Daniel L. Drane
  • Erica L. Coady
  • David J. Williamson
  • John W. Miller
  • Selim Benbadis


Nonepileptic seizures (NES) are operationally defined as episodes of ­involuntary movement, altered responsiveness, or subjective experience that resemble epileptic seizures (ES), but are not accompanied by the abnormal electrical discharges in the brain that is a seizure. (Lesser, 1996; Reuber and Elger, 2003). When these episodes are caused by psychological processes, they are termed psychogenic nonepileptic seizures (PNES). Other terms, such as psychogenic nonepileptic attacks (PNEA) (Duncan and Oto, 2008a) or episodes, have been suggested more recently. The reasoning behind replacing the term “seizure” in PNES is twofold: (1) decrease the confusion among physician and other healthcare providers that the events are not electroneurophysiological (and do not require antiepileptic medication or acute emergent medical intervention when presenting to an emergency department/emergency room), and (2) decrease confusion among patients and their families that the events are not “seizures” and are not due to neurologic disease. Because PNES is currently the most prevalent term, we will use it throughout the rest of this chapter. However, it is likely that further changes in terminology will be made over the next decade in an effort to minimize pejorative connotations and improve descriptive accuracy.

Patients with PNES utilize considerable medical resources via emergency departments, hospitalizations, physician visits, and unnecessary pharmaceutical treatment. The lifetime cost of treating undiagnosed PNES may be equivalent to that of epilepsy, estimated to be $231,432 per patient in 1995 (Begley et al., 2000). Overall, psychogenic symptoms (inclusive of PNES as well as other conversion and factitious disorders) account for 10% of all medical visits. Patients with PNES are often treated similarly to patients with epilepsy and receive antiepileptic drugs (AEDs) that are unnecessary for many years before an accurate diagnosis is achieved (Abubakr et al., 2003; Reuber et al., 2002). The exposure of patients to AEDs is not inconsequential (see Chap. 16, this volume for review of AED medication side-effects). Prevalence of PNES varies by setting, with rates as high as 44% in tertiary epilepsy centers (Szaflarski et al., 2000). Thus, for the neuropsychologist who interacts regularly with an epilepsy team, patients with PNES are likely to be part of clinical practice.

Obtaining a better understanding of the etiology of PNES and its clinical features is important for several reasons. Foremost, this diagnosis is typically associated with genuine suffering that in many cases can be alleviated. Improved diagnosis of PNES events is critical to developing appropriate treatments for this disorder. Some clinicians have suggested that 75–95% of patient with PNES show improvement in their condition if an accurate diagnosis can be established, with 19–52% of these patients seeing their PNES events resolve (Ettinger et al., 1999; Ettinger et al., 1999; Walczak et al., 1995). The likelihood of improvement is particularly good for those patients whose PNES began relatively recently and who have few comorbid psychiatric diagnoses (Kanner et al., 1999; Lempert and Schmidt, 1990).

Another benefit of understanding patients with PNES is the unique perspective they provide in the development, diagnosis, and treatment of medically-unexplained symptom presentations. Within neuropsychology, such presentations are often seen in the context of litigation or other forms of compensation seeking. This is far less often the case in patients with PNES. Furthermore, there exists a “gold standard” diagnostic technology for PNES that simply does not exist for other such disorders. Thus, we are able to gain insight and understanding into the cause and course of PNES unobscured by confounds related to compensation-seeking or ambiguous diagnoses.

This chapter provides an overview of PNES, including diagnosis, semiology, prevalence, etiology, neuropsychological features, associated psychopathology, and treatment. We encourage healthcare providers to approach these patients with care and respect. While PNES poses many challenges, neuropsychology is uniquely suited to help patients, their families, and their healthcare providers.


Chronic Fatigue Syndrome Personality Disorder Conversion Disorder Multiple Chemical Sensitivity Functional Somatic Syndrome 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


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Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Daniel L. Drane
    • 1
    • 2
  • Erica L. Coady
  • David J. Williamson
  • John W. Miller
  • Selim Benbadis
  1. 1.Emory University School of MedicineAtlantaUSA
  2. 2.School of MedicineUniversity of WashingtonSeattleUSA

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