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Evaluation and Management of Psychogenic Nonepileptic Attacks

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Handbook on the Neuropsychology of Epilepsy

Part of the book series: Clinical Handbooks in Neuropsychology ((CHNEURO))

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Abstract

Psychologists are frequently called upon to help evaluate and manage patients with psychogenic nonepileptic attacks (PNEAs), seizure-like events that are psychologically based. Psychologists’ diagnostic and therapeutic skills uniquely qualify them to discover the life circumstances that have given rise to these events and to communicate this understanding in a supportive and effective way. This chapter provides an overview of PNEA, with a focus on current etiologic theories that will prepare the psychologist to address the confusion that often surrounds this diagnosis. It also describes in detail, using case vignettes, an approach to making and delivering the diagnosis that is designed to promote understanding and acceptance and facilitate the treatment plan.

Dr. Langfitt, a clinical neuropsychologist, and Dr. Watson, a family psychologist, have evaluated and treated patients with PNEA admitted to the Strong Epilepsy Center for 30 years combined.

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Notes

  1. 1.

    A number of terms have been used to describe these events, including “pseudoseizures,” “psychogenic nonepileptic seizures,” “nonepileptic attacks,” or “stress seizures” (Benbadis, 2010; LaFrance, 2010). We prefer the term “psychogenic nonepileptic attacks” (PNEA), because it clearly communicates the assumption that the events are generated from the mind and unequivocally distinguishes them from “seizures” (which most people associate with epilepsy).

  2. 2.

    Of course, they may be more common than we believe. Only when the patient admits that the symptoms are voluntarily produced can these diagnoses be made with absolute certainty.

  3. 3.

    It is also more appropriate if one accepts that making the PNEA diagnosis requires positive evidence of psychogenic risk factors, not just absence of ictal epileptiform activity.

References

  • Ainsworth, M. D. S. (1967). Infancy in Uganda: Infant care and the growth of love. Baltimore, MD: Johns Hopkins University Press.

    Google Scholar 

  • Alper, K., Devinsky, O., Perrine, K., Vazquez, B., & Luciano, D. (1993). Nonepileptic seizures and childhood sexual and physical abuse. Neurology, 43(10), 1950–1953.

    Google Scholar 

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

    Google Scholar 

  • Ataoglu, A., Ozcetin, A., Icmeli, C., & Ozbulut, O. (2003). Paradoxical therapy in conversion reaction. Journal of Korean Medical Science, 18(4), 581–584.

    Google Scholar 

  • Bakvis, P., Roelofs, K., Kuyk, J., Edelbroek, P.M., Sinkels, W.A., & Spinhoven, P. (2009). Trauma, stress, and preconscious threat processing in patients with psychogenic nonepileptic seizures. Epilepsia, 50(5), 1001–1011.

    Google Scholar 

  • Bakvis, P., Spinhoven, P., & Roelofs, K. (2009). Basal cortisol is positively correlated to threat vigilance in patients with psychogenic nonepileptic seizures. Epilepsy & Behavior, 16(3), 558–560.

    Article  Google Scholar 

  • Bartholomew, R. E. (1997). Epidemic hysteria: A dialogue with François Sirois. Medical Principles and Practice, 6, 38–44.

    Article  Google Scholar 

  • Bartholomew, K., & Horowitz, L. M. (1991). Attachment styles among young adults: A test of a four-category model. Journal of Personality and Social Psychology, 61(2), 226–244.

    Article  PubMed  Google Scholar 

  • Benbadis, S. R. M. (2010). Psychogenic nonepileptic "seizures" or "attacks"?: It's not just semantics: Attacks. [Miscellaneous]. Neurology, 75, 84–86.

    Article  PubMed  Google Scholar 

  • Benbadis, S. R., & Hauser, W. A. (2000). An estimate of the prevalence of psychogenic non-epileptic seizures. Seizure, 9(4), 280–281.

    Article  PubMed  Google Scholar 

  • Betts, T., & Boden, S. (1992). Diagnosis, management and prognosis of a group of 128 patients with non-epileptic attack disorder. Part II. Previous childhood sexual abuse in the aetiology of these disorders. Seizure, 1(1), 27–32.

    Article  PubMed  Google Scholar 

  • Bewley, J., Murphy, P. N., Mallows, J., & Baker, G.A. (2005). Does alexithymia differentiate between patients with nonepileptic seizures, patients with epilepsy, and nonpatient controls? Epilepsy & Behavior, 7(3), 430–437.

    Google Scholar 

  • Binzer, M., Stone, J., & Sharpe, M. (2004). Recent onset pseudoseizures – Clues to aetiology. Seizure, 13(3), 146–155.

    Article  PubMed  Google Scholar 

  • Bodde, N. M., Brooks, J. L., Baker, G. A., Boon, P.A., Hendriksen, J.G., Mulder, O.G., et al. (2009). Psychogenic non-epileptic seizures–definition, etiology, treatment and prognostic issues: A critical review. [Review] [95 refs]. Seizure, 18(8), 543–553.

    Google Scholar 

  • Bowlby, J. (1969). Attachment and loss, vol 1: Attachment. New York, NY: Basic Books.

    Google Scholar 

  • Bowman, E. S., & Markand, O. N. (1996). Psychodynamics and psychiatric diagnoses of pseudoseizure subjects. American Journal of Psychiatry, 153(1), 57–63.

    PubMed  Google Scholar 

  • Brooks, J. L., Goodfellow, L., Bodde, N. M., Aldenkamp, A., & Baker, G.A. (2007). Nondrug treatments for psychogenic nonepileptic seizures: What's the evidence. [Review] [80 refs]. Epilepsy & Behavior, 11(3), 367–377.

    Google Scholar 

  • Brown, R. J. (2004). Psychological mechanisms of medically unexplained symptoms: An integrative conceptual model. [Review] [168 refs]. Psychological Bulletin, 130(5), 793–812.

    Article  PubMed  Google Scholar 

  • Carton, S., Thompson, P. J., & Duncan, J. S. (2003). Non-epileptic seizures: Patients' understanding and reaction to the diagnosis and impact on outcome. Seizure, 12(5), 287–294.

    Article  PubMed  Google Scholar 

  • Ciechanowski, P. S., Walker, E. A., Katon, W. J., & Russo, J.E. (2002). Attachment theory: A model for health care utilization and somatization. Psychosomatic Medicine, 64(4), 660–667.

    Google Scholar 

  • Cragar, D. E., Berry, D. T., Schmitt, F. A., & Fakhoury, T.A. (2005). Cluster analysis of normal personality traits in patients with psychogenic nonepileptic seizures. Epilepsy & Behavior, 6(4), 593–600.

    Google Scholar 

  • Dodrill, C. B., Wilkus, R. J., & Batzel, L. W. (1993). The MMPI as a diagnostic tool in non-epileptic seizures. In A. J. Rowan & J. R. Gates (Eds.), Non-epileptic seizures (1st ed.). Boston, MA: Butterworth-Heinemann.

    Google Scholar 

  • Drane, D. L., Williamson, D. J., Stroup, E. S., Holmes, M.D., Jung, M., Koerner, E., et al. (2006). Cognitive impairment is not equal in patients with epileptic and psychogenic nonepileptic seizures. Epilepsia, 47(11), 1879–1886.

    Google Scholar 

  • Escobar, J. I., Waitzkin, H., Silver, R. C., Gara, M., & Holman, A. (1998). Abridged somatization: A study in primary care. Psychosomatic Medicine, 60(4), 466–472.

    Google Scholar 

  • Ettinger, A. B., Devinsky, O., Weisbrot, D. M., Ramakrishna, R.K., & Goyal, A. (1999). A comprehensive profile of clinical, psychiatric, and psychosocial characteristics of patients with psychogenic nonepileptic seizures. Epilepsia, 40(9), 1292–1298.

    Google Scholar 

  • Evans, H., & Bartholomew, R. E. (2009). Outbreak: The encyclopedia of extraordinary social behavior. San Antonio, TX: Anomalist Books.

    Google Scholar 

  • Farias, S. T., Thieman, C., & Alsaadi, T. M. (2003). Psychogenic nonepileptic seizures: Acute change in event frequency after presentation of the diagnosis. Epilepsy & Behavior, 4(4), 424–429.

    Article  Google Scholar 

  • Ford, C. V. (1977). A type of disability neurosis: The humpty dumpty syndrome. International Journal of Psychiatry in Medicine, 8, 285–294.

    Article  PubMed  Google Scholar 

  • Galimberti, C. A., Ratti, M. T., Murelli, R., Marchioni, E., Manni, R., & Tartara, A. (2003). Patients with psychogenic nonepileptic seizures, alone or epilepsy-associated, share a psychological profile distinct from that of epilepsy patients. Journal of Neurology, 250(3), 338–346.

    Google Scholar 

  • Gay, P. (1988). Freud: A life for our time. New York, NY: WW Norton’s.

    Google Scholar 

  • Goldstein, L. H., Chalder, T., Chigwedere, C., Kondoker, M.R., Moriarty, J., Toone, B.K., et al. (2010). Cognitive-behavioral therapy for psychogenic nonepileptic seizures: A pilot RCT. Neurology, 74(24), 1986–1994.

    Google Scholar 

  • Griffith, J. L., Polles, A., & Griffith, M. E. (1998). Pseudoseizures, families, and unspeakable dilemmas. Psychosomatics, 39(2), 144–153.

    Article  PubMed  Google Scholar 

  • Gumnit RJ, Walczak TS, National Association of Epilepsy Centers. (2001). Guidelines for essential services, personnel, and facilities in specialized epilepsy centers in the United States. Epilepsia, 42(6), 804–814.

    Article  Google Scholar 

  • Halligan, P. W., Athwal, B. S., Oakley, D. A., & Frackowiak, R.S. (2000). Imaging hypnotic paralysis: Implications for conversion hysteria. Lancet, 355(9208), 986–987.

    Google Scholar 

  • Harden, C. L., Burgut, F. T., & Kanner, A. M. (2003). The diagnostic significance of video-EEG monitoring findings on pseudoseizure patients differs between neurologists and psychiatrists. Epilepsia, 44(3), 453–456.

    Article  PubMed  Google Scholar 

  • Hermann, B. P. (1993). Neuropsychological assessment in the diagnosis of non-epileptic seizures. In A. J. Rowan & J. R. Gates (Eds.), Non-epileptic seizures (1st ed.). Boston, MA: Butterworth-Heinemann.

    Google Scholar 

  • Hilgard, E. R. (1977). Divided consciousness: Multiple controls in human thought and action. New York, NY: Wiley.

    Google Scholar 

  • Hiller, W., Rief, W., & Brahler, E. (2006). Somatization in the population: From mild bodily misperceptions to disabling symptoms. Social Psychiatry and Psychiatric Epidemiology, 41(9), 704–712.

    Article  PubMed  Google Scholar 

  • Hotopf, M. (2002). Childhood experience of illness as a risk factor for medically unexplained symptoms. [Review] [51 refs]. Scandinavian Journal of Psychology, 43(2), 139–146.

    Article  PubMed  Google Scholar 

  • Janet, P. (1907). The major symptoms of hysteria. New York, NY: Macmillan.

    Book  Google Scholar 

  • Kozlowska, K. (2001). Good children presenting with conversion disorder. Clinical Child Psychology and Psychiatry, 6, 575–591.

    Article  Google Scholar 

  • Kroenke, K. (2007). Efficacy of treatment for somatoform disorders: A review of randomized controlled trials. [Review] [64 refs]. Psychosomatic Medicine, 69(9), 881–888.

    Article  PubMed  Google Scholar 

  • Kroenke, K., Spitzer, R. L., deGruy, F. V., III, Hahn, S.R., Linzer, M., Williams, J.B., et al. (1997). Multisomatoform disorder. An alternative to undifferentiated somatoform disorder for the somatizing patient in primary care. Archives of General Psychiatry, 54(4), 352–358.

    Google Scholar 

  • Kuyk, J., Spinhoven, P., & van Dyck, R. (1999). Hypnotic recall: A positive criterion in the differential diagnosis between epileptic and pseudoepileptic seizures. Epilepsia, 40(4), 485–491.

    Article  PubMed  Google Scholar 

  • LaFrance, W. C. J. (2010). Psychogenic nonepileptic "seizures" or "attacks"?: It's not just semantics: Seizures. [Miscellaneous]. Neurology, 75, 87–88.

    Article  PubMed Central  PubMed  Google Scholar 

  • LaFrance, W. C. Jr., Baird, G. L., Barry, J. J., Blum, A.S., Webb, F., Keitner, G.I., et al. (2014) Multicenter pilot treatment trial for psychogenic nonepileptic seizures: A randomized clinical trial. JAMA Psychiatry, doi:10.1001/jamapsychiatry.2014.817, Published online July 2, 2014.

  • LaFrance, W. C., Jr., Alper, K., Babcock, D., Barry, J.J., Benbadis, S., Caplan, R., et al. (2006). Nonepileptic seizures treatment workshop summary. Epilepsy & Behavior, 8(3), 451–461.

    Google Scholar 

  • LaFrance, W. C., Jr., Keitner, G. I., Papandonatos, G. D., Blum, A.S., Machan, J.T., Ryan, C.E., et al. (2010). Pilot pharmacologic randomized controlled trial for psychogenic nonepileptic seizures. Neurology, 75(13), 1166–1173.

    Google Scholar 

  • Lamberty, G. J. (2008). Understanding somatization in the practice of clinical neuropsychology. Oxford: Oxford University Press.

    Google Scholar 

  • Lesser, R. P. (1996). Psychogenic seizures. [Review] [84 refs]. Neurology, 46(6), 1499–1507.

    Article  PubMed  Google Scholar 

  • Lieb, R., Zimmermann, P., Friis, R. H., Hofler, M., Tholen, S., & Wittchen, H.U. (2002). The natural course of DSM-IV somatoform disorders and syndromes among adolescents and young adults: A prospective-longitudinal community study. European Psychiatry, 17(6), 321–331.

    Google Scholar 

  • Lilienfeld, S. O., Van, V. C., Larntz, K., & Akiskal, H.S. (1986). The relationship of histrionic personality disorder to antisocial personality and somatization disorders. American Journal of Psychiatry, 143(6), 718–722.

    Google Scholar 

  • Mace, C. J., & Trimble, M. R. (1996). Ten-year prognosis of conversion disorder. British Journal of Psychiatry, 169(3), 282–288.

    Article  PubMed  Google Scholar 

  • Mailis-Gagnon, A., Giannoylis, I., Downar, J., Kwan, C.L., Mikulis, D.J., Crawley, A.P., et al. (2003). Altered central somatosensory processing in chronic pain patients with "hysterical" anesthesia. Neurology, 60(9), 1501–1507.

    Google Scholar 

  • Marchetti, R. L., Kurcgant, D., Neto, J. G., von Bismark, M.A., Marchetti, L.B., & Fiore, L.A. (2008). Psychiatric diagnoses of patients with psychogenic non-epileptic seizures. Seizure, 17(3), 247–253.

    Google Scholar 

  • Marshall, J. C., Halligan, P. W., Fink, G. R., Wade, D.T., & Frackowiak, R.S. (1997). The functional anatomy of a hysterical paralysis. Cognition, 64(1), B1–B8.

    Google Scholar 

  • Martin, R. C., Gilliam, F. G., Kilgore, M., Faught, E., & Kuzniecky, R. (1998). Improved health care resource utilization following video-EEG-confirmed diagnosis of nonepileptic psychogenic seizures. Seizure, 7(5), 385–390.

    Google Scholar 

  • Moene, F. C., Spinhoven, P., Hoogduin, K. A., & van Dyck, R. (2002). A randomised controlled clinical trial on the additional effect of hypnosis in a comprehensive treatment programme for in-patients with conversion disorder of the motor type. Psychotherapy and Psychosomatics, 71(2), 66–76.

    Google Scholar 

  • Moene, F. C., Spinhoven, P., Hoogduin, K. A., van Dyck, R. (2003). A randomized controlled clinical trial of a hypnosis-based treatment for patients with conversion disorder, motor type. International Journal of Clinical and Experimental Hypnosis., 51(1), 29–50.

    Google Scholar 

  • Mokleby, K., Blomhoff, S., Malt, U. F., Dahlstrom, A., Tauboll, E., & Gjerstad, L. (2002). Psychiatric comorbidity and hostility in patients with psychogenic nonepileptic seizures compared with somatoform disorders and healthy controls. Epilepsia, 43, 193–198.

    Google Scholar 

  • Norman, D. A., & Shallice, T. (1986). Attention to action: Willed and automatic control of behavior. In R. J. Davidson, G. E. Schwartz, & D. Shapiro (Eds.), Consciousness and self-regulation, vol 4. Advances in research and theory. New York, NY: Plenum.

    Google Scholar 

  • Reuber, M. (2009). The etiology of psychogenic non-epileptic seizures: Toward a biopsychosocial model. [Review] [115 refs]. Neurologic Clinics, 27(4), 909–924.

    Article  PubMed  Google Scholar 

  • Reuber, M., & Elger, C. E. (2003). Psychogenic nonepileptic seizures: Review and update. [Review] [185 refs]. Epilepsy & Behavior, 4(3), 205–216.

    Article  Google Scholar 

  • Reuber, M., Fernandez, G., Bauer, J., Helmstaedter, C., & Elger, C.E. (2002). Diagnostic delay in psychogenic nonepileptic seizures. Neurology, 58(3), 493–495.

    Google Scholar 

  • Reuber, M., Pukrop, R., Bauer, J., Helmstaedter, C., Tessendorf, N., & Elger, C.E. (2003). Outcome in psychogenic nonepileptic seizures: 1 to 10-year follow-up in 164 patients. Annals of Neurology, 53, 305–311.

    Google Scholar 

  • Reuber, M., Pukrop, R., Bauer, J., Derfuss, R., & Elger, C.E. (2004). Multidimensional assessment of personality in patients with psychogenic non-epileptic seizures. [See comment]. Journal of Neurology, Neurosurgery & Psychiatry, 75(5), 743–748.

    Google Scholar 

  • Roelofs, K., Hoogduin, K. A., Keijsers, G. P., Naring, G.W., Moene, F.C., & Sandijck, P. (2002). Hypnotic susceptibility in patients with conversion disorder. Journal of Abnormal Psychology, 111(2), 390–395.

    Google Scholar 

  • Rosenberg, H. J., Rosenberg, S. D., Williamson, P. D., & Wolford, G.L., II (2000). A comparative study of trauma and posttraumatic stress disorder prevalence in epilepsy patients and psychogenic nonepileptic seizure patients. Epilepsia, 41(4), 447–452.

    Google Scholar 

  • Shen, W., Bowman, E. S., & Markand, O. N. (1990). Presenting the diagnosis of pseudoseizure. [See comment]. Neurology, 40(5), 756–759.

    Article  PubMed  Google Scholar 

  • Shih, J. J., LeslieMazwi, T., Falcao, G., & Van Gerpen, J. (2009). Directed aggressive behaviors in frontal lobe epilepsy: A video-EEG and ictal SPECT case study. Neurology, 73, 1804–1806.

    Google Scholar 

  • Temkin, O. (1971). The falling sickness (2nd ed.). Baltimore, MD: Johns Hopkins Press.

    Google Scholar 

  • Vuilleumier, P. (2005). Hysterical conversion and brain function. [Review] [123 refs]. Progress in Brain Research, 150, 309–329.

    Article  PubMed  Google Scholar 

  • Waldinger, R. J., Schulz, M. S., Barsky, A. J., & Ahern, D.K. (2006). Mapping the road from childhood trauma to adult somatization: The role of attachment. Psychosomatic Medicine, 68(1), 129–135.

    Google Scholar 

  • Watson, W. (2007). Bridging the mind–body split: Towards an integrative framework for thinking about somatoform symptoms. The Family Psychologist, 23, 30–33.

    Google Scholar 

  • Watson, W., & Langfitt, J. T. (2010). Psychogenic non-epileptic attacks. Family Therapy Magazine, 9, 30–38.

    Google Scholar 

  • Wood, B. L., McDaniel, S., Burchfiel, K., & Erba, G. (1998). Factors distinguishing families of patients with psychogenic seizures from families of patients with epilepsy. Epilepsia, 39(4), 432–437.

    Google Scholar 

  • Wyler, A. R., Hermann, B. P., Blumer, D., & Richey, E.T. (1993). Pseudo-pseudoepileptic seizures. In A. J. Rowan & J. R. Gates (Eds.), Non-epileptic seizures (1st ed.). Boston, MA: Butterworth-Heinemann.

    Google Scholar 

  • Wyllie, E., Friedman, D., Luders, H., Morris, H., Rothner, D., & Turnbull, J.(1991). Outcome of psychogenic seizures in children and adolescents compared with adults. Neurology, 41(5), 742–744.

    Google Scholar 

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Authors and Affiliations

  1. Departments of Neurology and Psychiatry, University of Rochester Medical Center, 601 Elmwood Avenue, Box 673, Rochester, NY, 14642, USA

    John T. Langfitt Ph.D., A.B.P.P.

  2. Deptartment of Psychiatry and Neurology, School of Medicine and Dentistry, University of Rochester Medical Center, University of Rochester, 601 Elmwood Ave, Box PSYCH, Rochester, NY, 14642, USA

    John T. Langfitt Ph.D., A.B.P.P.

  3. Departments of Psychiatry and Neurology, University of Rochester Medical Center, 601 Elmwood Ave, Box PSYCH, Rochester, NY, 14642, USA

    William Watson Ph.D.

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Correspondence to John T. Langfitt Ph.D., A.B.P.P. .

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Editors and Affiliations

  1. Dept. Neurosurgery, New York University School of Medicine, New York, New York, USA

    William B. Barr

  2. Dept. Neurosurgery, New York University School of Medicine, New York, New York, USA

    Chris Morrison

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Langfitt, J.T., Watson, W. (2015). Evaluation and Management of Psychogenic Nonepileptic Attacks. In: Barr, W., Morrison, C. (eds) Handbook on the Neuropsychology of Epilepsy. Clinical Handbooks in Neuropsychology. Springer, New York, NY. https://doi.org/10.1007/978-0-387-92826-5_12

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