|Year : 2020 | Volume
| Issue : 1 | Page : 1-4
The etiology behind pseudoseizures
Neena S Sawant
Department of Psychiatry, Seth GSMC and KEM Hospital, Mumbai, Maharashtra, India
|Date of Submission||16-Mar-2020|
|Date of Acceptance||23-Mar-2020|
|Date of Web Publication||30-May-2020|
Dr. Neena S Sawant
Department of Psychiatry, Seth GSMC and KEM Hospital, Parel, Mumbai - 400 012, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sawant NS. The etiology behind pseudoseizures. Ann Indian Psychiatry 2020;4:1-4
Pseudoseizures also called as psychogenic nonepiletic seizures (PNES) have been described since ages with Hippocrates postulating the relation between emotion and motive to manifest bodily and mental symptoms. The understanding of these phenomena over centuries varied with associating them to the possession of demons, exorcism, to being considered as a psychological disorder of the mind named “hysteria,” whereby the anxiety caused by repressed impulses and feelings is “converted” into a physical complaint such as motor or sensory symptoms like paralysis, anesthesia, mutism, visual symptoms, sensory symptoms, movement disorders, gait or balance problems, pain or seizure like episodes. Today modern day psychiatry classifies them as “Dissociative convulsions in the Dissociative disorders” in ICD-10 whereas DSM-V labels it under “Somatic Symptom and Related Disorders-Conversion disorder (functional neurological symptom disorder).”
Psychoanalysts have defined dissociation as a temporary and drastic modification of one's self-image to avoid emotional distress which includes disconnection from full awareness of self, time and/or external circumstances. Dissociative disorders are presumed to be “psychogenic” in origin, being associated closely in time with traumatic events, insoluble and intolerable problems, or disturbed relationships. Most of the dissociative states tend to remit after a few weeks or months, particularly if their onset was associated with a traumatic life event. Dissociative states of more than 2 years duration are often resistant to therapy. Individuals with dissociative disorders often show a striking denial of problems or difficulties which is called as la belle indifference.,,
| Epidemiology|| |
The prevalence of PNES was found to be 2.9/1000 population in a study in rural India  and currently estimated as 2–50/100,000 in the general population. The prevalence of coexistent epilepsy and pseudoseizures is estimated around 5%–40%, with around 11% of them presenting with seizures to emergency services  and 2% of new referrals in neurology clinics.
Pseudo seizures have been associated with lower socioeconomic status, lower education, rural background, and lack of psychological sophistication,, with a female preponderance. However, as countries develop, there may be a declining incidence seen in relation to time due to improved education and medical and psychological sophistication. Patients having PNES are seen to be better educated than other motor conversion disorders. Patients with pseudoseizures frequently report to come from chaotic families  and may have a relative with conversion disorder or epilepsy.
| Etiology|| |
Several theories have been postulated to help in the understanding of psychogenic seizures.
• Psychodynamic theory
It is based on Freud's postulate that unconscious intrapsychic conflict between instinctual impulses and the prohibition against its expression results in anxiety which gets converted into a physical symptom. This promotes the partial expression of the instinct in at least a disguised way causing relief from the anxiety, which acts as a primary gain. However, pseudoseizure patients have been found to have high state and trait anxiety.
• Autohypnosis theory
Pierre Janet emphasized on the relation between conversion disorder and childhood trauma. He attributed the dissociation of cognitive, sensory, and motor processes to the adaptation of an overwhelming traumatic experience. The resultant unbearable emotional reactions would result in an altered state of consciousness.
• Neurophysiological theory
There is increased cortical arousal which causes reactive inhibition of signal at synapses in sensory motor pathways by negative feedback relationship between the brainstem reticular formation and cerebral cortex. This can explain the diminished awareness of bodily symptoms in some patients.
• Interpersonal theory
The conversion symptoms may be a means of nonverbal interpersonal communication of stress or nonverbal means of controlling or manipulating others. Some of the culture bound syndromes have been found to be means of expressing anger and rage when it is not culturally permissible to do so verbally. Interpersonal relationships are often insecure with social anxiety and avoidance seen in patients with psychogenic seizures.
• Learning theory
Social learning, suggestion or modeling often influences the choice of symptoms. Modeling is noted more is patients with concomitant neurological disorders who observe symptoms in others as well as themselves, which they may simulate as conversion symptoms.
• Neurobiological theory
A modern neurobiological model of conversion disorder has been postulated since the recent advances in neuroimaging. Single-photon emission computerized tomography (SPECT) studies of patients with conversion disorder with sensorimotor loss have revealed consistent decrease of regional cerebral blood flow in the thalamus and basal ganglia contralateral to the deficit which resolves after recovery, suggesting a dysfunction of the striatothalamocortical circuits. However, no blood flow changes are noted on quantitative SPECT analysis with injections performed during the seizure-like event even when visual interpretation of ictal SPECT may be suggestive of localized increased or decreased perfusion, thus suggesting the diagnosis of PNES. Neuroimaging studies have also been inconclusive to finding any structural abnormalities in psychogenic seizures though there are some reports of altered structural frontolimbic connectivity possibly due to disruption of age-dependent maturation processes.
• Integrative Cognitive model
This is a recently proposed model, which looks at experiential, psychological, and biological risk factors for the development of psychogenic seizures where the seizures occur due to the activation of a learnt mental representation called as “seizure scaffold” combined with physiological arousal. The seizure scaffold contains elements of instinctive automatisms (e.g., freezing or thrashing movements), personal illness experiences (e.g. syncope or epilepsy), or illness beliefs (e.g. derived from witnessed seizures) which often gets triggered by perceived threat and/or conditioned cues, and facilitated by a failure of inhibitory systems. The physiological component includes a calming effect of dissociation through detachment and emotional numbing and a psychosocial component i.e. an escape from the trigger.
• Relationship with Trauma and Abuse
The impact of abuse on the psyche is universal; whether it is physical, verbal, or sexual. Freud hypothesized the role of childhood abuse in the pathogenesis of conversion. The repressed memories of childhood could trigger the intra psychic conflicts. Researchers have found a high incidence of sexual abuse in their studies with preponderance in women. Patients of psychogenic seizures frequently report a history of physical abuse as well and their trauma-related profiles are similar to those of individuals with a history of traumatic experiences.
The fact that nonepileptic attack disorder does occur in individuals without a history of childhood sexual abuse expands the range of the potential causal conflicts beyond incestuous sexual abuse. The higher frequency of physical abuse in these patients indicates that antecedent trauma need not be exclusively sexual in nature. Abundant literature suggests the development of dissociative symptoms in relation to a history of childhood physical and sexual abuse. Maternal dysfunction is seen to be associated with cognitive and somatoform dissociative experiences whereas physical abuse is associated with higher incidence of pseudoneurological symptoms., A study by Thaman et al. in their comparative study between PNES, epilepsy patients and healthy controls reported a highly significant difference with sexual and physical abuse being experienced by more than 50% of PNES group along with a high incidence of child sexual abuse. In physical abuse, almost all PNES group patients expressed that a weapon was used for assault. Their findings are keeping in with those of other researchers with the prevalence for sexual abuse being between 5% and 85% and physical abuse being between 0% and 52%.,
Among the psychogenic seizures, trauma is more prevalent in those having psychiatric co morbidities and strong dissociative tendencies. Patients with severe initial numbing response to trauma can be strong predictors to development of dissociative symptoms and posttraumatic stress disorder., Women with self-reported sexual or physical abuse histories had significantly higher dissociation and severe pseudo seizures characterized by emotional triggers and prodromal symptoms.
The potential for developing epileptic posttraumatic seizures after head injury is well known and may begin months or years after the head injury. However, some studies have also found an association between head injury and nonepileptic attacks at rates of 16%–83%.
• Relationship with stressful life events
The onset of pseudo seizures is frequently related to a stressor and many patients report more stressful life events experienced a year prior to the onset and often perceive these events as more negative. The events usually are illness of self and family member, trauma, physical abuse during adulthood, and death of a close friend. As per the stress-diathesis model individuals with high biological susceptibility to stress related pathology can get psychogenic seizures with even a mild stressor.
• Cultural aspects
The cultural taboo, to expression of intense emotions may predispose women to conversion symptoms as a means of nonverbal communication of distress. Even in the Indian subcontinent, social stigma is attached to depressive symptoms and inversely related to somatic symptoms thereby explaining the higher prevalence of somatization and possession.
• Psychiatric comorbidities
Psychogenic seizures are commonly associated with other dissociative and conversion disorders  with many patients having higher somatization tendencies. Fiszman et al. reported that nearly 38% had PTSD as a comorbidity. Borderline personality disorder or Cluster B and C traits are also common in these patients. Higher rates of depressive and anxiety disorders are found in patients with PNES as compared to the general population.,
Patients with pseudo seizures tend to have more frequent and disabling seizures than those which true epilepsy and often receive inappropriate, ineffective, and expensive treatment as they are often misdiagnosed as epilepsy. Most patients with psychogenic seizures present to the emergency with an acute onset and it often necessitates admission to a medical or neurological unit rather than in psychiatry. A better understanding of the causative factors and a good liaison with the neurologist is needed to tackle this group of patients which are often described as difficult to treat.
| References|| |
King H. Once upon a text: Hysteria from Hippocrates. In: Gilman S, King H, Porter R, Gousseau GS, Showalter E, editors. Hysteria in Western Civilization. Berkeley, CA: University of California Press; 1993. p. 3-90.
Escobar JI, Dimsdale J. Somatic symptom and related disorders. In: Sadock BJ, Sadock VA, Gregory MS, Ruiz P, Editor. Kaplan and Sadock's Comprehensive Textbook of Psychiatry. 10th
ed. China: Wolters Kluwer; 2018. p. 4684-728.
Ali S, Jabeen S, Pate RJ, Shahid M, Chinala S, Nathani M, et al
. Conversion disorder-mind versus body: A review. Innov Clin Neurosci 2015;12:27-33.
Kokkat AJ, Verma AK. Prevalence of seizures and paralysis in a rural community. J Indian Med Assoc 1998;96:43-5.
Kanemoto K, LaFrance WC Jr., Duncan R, Gigineishvili D, Park SP, Tadokoro Y, et al
. PNES around the world: Where we are now and how we can close the diagnosis and treatment gaps-an ILAE PNES Task Force report. Epilepsia Open 2017;2:307-16.
Benbadis SR, Agrawal V, Tatum WO 4th
. How many patients with psychogenic nonepileptic seizures also have epilepsy? Neurology 2001;57:915-7.
Dickson JM, Dudhill H, Shewan J, Mason S, Grünewald RA, Reuber M. Cross-sectional study of the hospital management of adult patients with a suspected seizure (EPIC2). BMJ Open 2017;7:e015696.
Stone J, Carson A, Duncan R, Roberts R, Warlow C, Hibberd C, et al
. Who is referred to neurology clinics? The diagnoses made in 3781 new patients. Clin Neurol Neurosurg 2010;112:747-51.
Duncan R, Razvi S, Mulhern S. Newly presenting psychogenic nonepileptic seizures: Incidence, population characteristics, and early outcome from a prospective audit of a first seizure clinic. Epilepsy Behav 2011;20:308-11.
Folks DG, Ford CV, Regan WM. Conversion symptoms in a general hospital. Psychosomatics 1984;25:285-9, 291, 294-5.
Nandi DN, Banerjee G, Nandi S, Nandi P. Is hysteria on the wane? A community survey in West Bengal, India. Br J Psychiatry 1992;160:87-91.
Stone J, Sharpe M, Binzer M. Motor conversion symptoms and pseudoseizures: A comparision of clinical characteristics. Psychosomatics 2004;45:492-9.
Moore PM, Baker GA, McDade G, Chadwick D, Brown S. Epilepsy, pseudoseizures and perceived family characteristics: A controlled study. Epilepsy Res 1994;18:75-83.
Tojek TM, Lumley M, Barkley G, Mahr G, Thomas A. Stress and other psychosocial characteristics of patients with psychogenic nonepileptic seizures. Psychosomatics 2000;41:221-6.
van Merode T, Twellaar M, Kotsopoulos IA, Kessels AG, Merckelbach H, de Krom MC, et al
. Psychological characteristics of patients with newly developed psychogenic seizures. J Neurol Neurosurg Psychiatry 2004;75:1175-7.
Janet P. The Major Symptoms of Hysteria: Fifteen Lectures Given in the Medical School of Harvard University. 2nd
ed. New York: Macmillan; 1907.
Behrman J, Levy R. Neurophysiological studies on patients with hysterical disturbances of vision. J Psychosom Res 1970;14:187-94.
Ford CV, Folks DG. Conversion disorders: An overview. Psychosomatics 1985;26:371-4, 380-3.
Wardrope A, Green B, Norman P, Reuber M. The influence of attachment style and relationship quality on quality of life and psychological distress in carers of people with epileptic and nonepileptic seizures. Epilepsy Behav 2019;93:16-21.
Lazare A. Current concepts in psychiatry. Conversion symptoms. N
Engl J Med 1981;305:745-8.
Vuilleumier P, Chicherio C, Assal F, Schwartz S, Slosman D, Landis T. Functional neuroanatomical correlates of hysterical sensorimotor loss. Brain 2001;124:1077-90.
Spanaki MV, Spencer SS, Corsi M, MacMullan J, Seibyl J, Zubal IG. The role of quantitative ictal SPECT analysis in the evaluation of nonepileptic seizures. J Neuroimaging 1999;9:210-6.
Perez DL, Williams B, Matin N, LaFrance WC Jr, Costumero-Ramos V, Fricchione GL, et al
. Corticolimbic structural alterations linked to health status and trait anxiety in functional neurological disorder. J Neurol Neurosurg Psychiatry 2017;88:1052-9.
Reuber M, Brown RJ. Understanding psychogenic nonepileptic seizures-Phenomenology, semiology and the Integrative Cognitive Model. Seizure 2017;44:199-205.
Bowman ES. Posttraumatic stress disorder, abuse, and trauma: Relationships to psychogenic nonepileptic seizures. In: Curt LaFrance W Jr., Schachter SC, editors. Gates and Rowan's Nonepileptic Seizures. 4th
ed. UK: Cambridge University Press; 2018. p. 231-44.
Bermeo-Ovalle A, Kanner AM. Comorbidities in psychogenic nonepileptic seizures. Depressive, Anxiety and Personality Disorders. In: Curt LaFrance W Jr., Schachter SC, editors. Gates and Rowan's nonepileptic Seizures. 4th
ed. UK: Cambridge University Press; 2018. p. 245-56.
Khandelwal D, Sharma NK. The clinical, psychological and neurological profile and assessing of outcome predictors of patients with psychogenic nonepileptic seizures: A study of 74 cases. Int J Sci Res 2018;7:24-9.
Fleisher W, Staley D, Krawetz P, Pillay N, Arnett JL, Maher J. Comparative study of trauma-related phenomena in subjects with pseudoseizures and subjects with epilepsy. Am J Psychiatry 2002;159:660-3.
Thaman A, Sharma N, Gupta R. Sexual and physical abuse among patients with psychogenic nonepileptic seizures: A comparative study. Ann Indian Psychiatry 2020;4:76-80. [Full text]
Sharpe D, Faye C. Non-epileptic seizures and child sexual abuse: A critical review of the literature. Clin Psychol Rev 2006;26:1020-40.
Hingray C, Maillard L, Hubsch C, Vignal JP, Bourgognon F, Laprevote V et al
. Psychogenic nonepileptic seizures: Characterization of two distinct patient profiles on the basis of trauma history. Epilepsy Behav 2011;22:532-6.
Selkirk M, Duncan R, Oto M, Pelosi A. Clinical differences between patients with nonepileptic seizures who report antecedent sexual abuse and those who do not. Epilepsia 2008;49:1446-50.
Popkirov S, Carson AJ, Stone J. Scared or scarred: Could 'dissociogenic' lesions predispose to nonepileptic seizures after head trauma? Seizure 2018;58:127-32.
Keynejad RC, Frodl T, Kanaan R, Pariante C, Reuber M, Nicholson TR. Stress and functional neurological disorders: Mechanistic insights. J Neurol Neurosurg Psychiatry 2018;90:813-21.
Raguram R, Weiss MG, Channabasavanna SM, Devins GM. Stigma, depression, and somatization in South India. Am J Psychiatry 1996;153:1043-9.
Brown RJ, Reuber M. Psychological and psychiatric aspects of psychogenic non-epileptic seizures (PNES): A systematic review. Clin Psychol Rev 2016;45:157-82.
Fiszman A, Alves-Leon SV, Nunes RG, D'Andrea I, Figueira I. Traumatic events and posttraumatic stress disorder in patients with psychogenic nonepileptic seizures: a critical review. Epilepsy Behav 2004;5:818-25.
Walsh S, Levita L, Reuber M. Comorbid depression and associated factors in PNES versus epilepsy: Systematic review and meta-analysis. Seizure 2018;60:44-56.