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 Table of Contents  
Year : 2018  |  Volume : 2  |  Issue : 2  |  Page : 80-87

Diagnostic perspective in psychogenic nonepileptic seizures: An overview

1 Department of Psychology, Banaras Hindu University, Varanasi, Uttar Pradesh, India
2 Department of Neurology, Institute of Medical Science, Banaras Hindu University, Varanasi, Uttar Pradesh, India
3 Department of Anatomy, Institute of Medical Science, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Date of Web Publication30-Nov-2018

Correspondence Address:
Priyesh Kumar Singh
Department of Psychology, Banaras Hindu University, Varanasi, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aip.aip_20_18

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Psychogenic nonepileptic seizures (PNESs) are the episodes altered movement, sensation, or experience similar to epilepsy but caused by psychological process and not associated with abnormal discharges in the neurons. Diagnosing PNES is extremely a tough work for a neurologist because of its psychological etiology and somatic manifestation. The patients with PNES are frequently misdiagnosed for epilepsy and exposed to antiepileptic drugs for several years which risk their life and put unnecessary economic burden on them. Majorly, while diagnosing PNES, the neurologist has to rule out several neurological and psychological disorders. PNES multiple etiologies and lack of quantifiable biomarkers make its diagnosis more difficult and inaccurate. Although the gold standard measure to diagnosis PNES is video-encephalography, it is always not available for the assessment and is too costly. Therefore, neurologists go for other diagnostic procedures to distinguish PNES from epilepsy. Psychological assessment of the patients; semiological and historical details of the patients; postictal observation; and provocation techniques such as saline injection, verbal suggestion, moist swab application, tuning fork application, and compressed temple region are being used in a substantial way to diagnose PNES. Besides, these neuroimaging techniques such as electroencephalography and magnetic resonance imaging and chemical biomarker such as serum prolactin are also being measured to be sure for PNES diagnosis. Further, it must be understood that above assessment procedures are not independent but are complementary to each other, and hence, PNES etiology is still going through elucidation process. Therefore, diagnosing PNES is a cumbersome task. However, if diagnosis of PNES is made with joint efforts of neurologist, psychologist, and psychiatrist, although usually not practiced, only then one can arrive at a definite conclusion.

Keywords: Epilepsy, etiology, psychogenic nonepileptic seizures, seizures

How to cite this article:
Singh PK, Singh T, Mishra VN, Chaurasia RN, Tiwari T, Singh IL, Singh A. Diagnostic perspective in psychogenic nonepileptic seizures: An overview. Ann Indian Psychiatry 2018;2:80-7

How to cite this URL:
Singh PK, Singh T, Mishra VN, Chaurasia RN, Tiwari T, Singh IL, Singh A. Diagnostic perspective in psychogenic nonepileptic seizures: An overview. Ann Indian Psychiatry [serial online] 2018 [cited 2022 Oct 6];2:80-7. Available from: https://www.anip.co.in/text.asp?2018/2/2/80/246528

  Introduction Top

Among various pseudoneurological conditions, psychogenic nonepileptic seizures (PNESs) are the major one and pose difficulty in differentiating it from other neurological and psychiatric pathology mainly because of its somatic occurrence and psychological etiology. One of the most important points should be addressed here is that PNES finds home neither in psychology nor in medical settings because of its pseudoneurological and psychological characteristics,[1] and therefore, diagnosis of PNES, remains an issue because its management requires a joint effort of psychologist, psychiatrist, as well as neurologist. In India, this poses difficulty for rural as well as urban masses who are less informed about the correct procedure.

Although PNES has been classified under diagnostic category of somatic symptoms disorders in DSM 5[2],[3] and dissociative disorder under International Classification of Diseases-10, this categorization is controversial.[4] PNES has close resemblance with epilepsy as seizures semiology and postictal characteristics because several ictal signs are similar in both and the difference is only in the degree of their occurrence.[5] However, the main difference between PNES and epilepsy is that in epilepsy, seizures are caused due to abnormal electrical discharges in the neurons, whereas in PNES, it is due to emotional conflict and turmoil.[6],[7],[8] It is very challenging for professionals to differentiate between PNES and epilepsy; failing to do so can cost unnecessary financial burden to patients and make them vulnerable to take antiepileptic drugs which risk their life.[9],[10] Despite the advancement in the current diagnostic procedures, the mean latency period to diagnose PNES is 7.2 years.[7] To prevent patients and their attendants from unnecessary problem and hassles, it is very important to make correct diagnosis of PNES. This overview focuses on the various procedures which used to make diagnosis of PNES. It begins with a brief description of the epidemiology of PNES followed by the diagnostic procedures used to distinguish PNES from epilepsy.

  Occurrence of Psychogenic Nonepileptic Seizures Top

There are mixed findings regarding the incidence and prevalence of PNES. In general, the incidence of PNES is reported only 4% as that of epilepsy.[4] Data gathered from epilepsy centers provide an estimate of the proportion of PNES among patients admitted to a hospital for diagnosis of PNES and it has been reported as 1.4/100,000 or 3/100,000/year.[11],[12] The prevalence of PNES also varies widely among general population and within clinical samples[10] with 2–33/100,000 in the general population[11],[12] and 5%–20% among outpatient epileptic population. Approximately 25%–30% of the patients referred to epilepsy centers for refractory epilepsy have been found actually patients of PNES.[13] Reports also indicate that 24% of patients of epilepsy admitted to highly specialized psychiatry and 14% of patients admitted to specialized hospital were actually patients of PNES.[14] Recently,[15] it has been confirmed that 33% of the patients admitted to epileptic ward are actually PNES patients. However, this percentage is only true for clinical referrals and the prevalence is much lower (5%) in outpatient units.[16]

  Diagnostic Perspective Top

Psychological etiology and epileptic-like manifestation pose difficulty in correct diagnosis of PNES. Diagnosing PNES is mostly based on exclusion of epilepsy and other physiological disorders,[1] in which clinicians may make error in diagnosis because excluding epilepsy does not mean that the patient is of PNES. There are other pseudoneurological and psychological disorders which must be ruled out to make correct diagnoses. However, due to lack of single agreed protocol, it remains up to the professionals that how he/she makes diagnosis. As a result, PNES sometimes goes undetected.

Currently, the gold standard to evaluate PNES is video- encephalography (V-EEG).[17] However, where facility of V-EEG is limited, the clinicians depend primarily on semiological details[18] and noninvasive techniques.[19] Other than neuroimaging investigation, clinicians may use semiological details, postictal observations such as respiration pattern, motor movement, body postures, neurophysiological measures, interactional pattern, psychological measures, and various induction/provocating techniques to ensure PNES diagnosis. Following is the detailed description of some of these techniques.

  Semiological Details Top

Semiological details are the first-hand information on which professionals rely to get rough idea about the patient's complaint. Semiology literally means the ”study of signs,” and thus, in case of PNES, it refers to the signs and symptoms of seizures which patients manifest behaviorally during ictal and postictal episodes. Both PNES and epilepsy differ on the basis of clinical signs and symptoms. Usually, when first time, a patient comes to epileptic clinic and complains that he or she has encountered the episodes of seizures, the clinician's first goal is to find out whether the type of seizure that occurred in the patient, was of epileptic origin or psychogenic in nature. For this, clinicians ask certain questions to classify seizure category and gain on idea about the patient's seizure. Commonly, professionals ask questions about the onset of seizure and how it occurred, body movement, limb movement, pelvic movement, tongue bite, face position, and eyes opening and closer. They also ask questions about behavior after seizure is over. These include questions about their memory, vocalization, awareness during seizures, duration and frequencies of the seizures, injury, incontinence, respiration pattern, etc.

Broadly, there is peculiar behavioral difference in seizure semiology among PNES and epileptic patients. For example, seizure onset is gradual among PNES, whereas in epilepsy, it is abrupt and PNES patients show purposeful movements as compared to epilepsy. In PNES, there are rhythmic pelvic movement, asynchronous limb movement, opisthotonus movement, tongue biting (tip), prolonged ictal atonia, and ictal crying as compared to epileptic patients.[4],[6],[20] Moreover, gradual onset of seizure, undulating motor activity, and asynchronous movement are common and frequently observed among nonepileptic patients. Longer seizure episode (usually more than 2 min) and resistant eye-opening are common in PNES than epilepsy. Pupillary light reflexes are retained in PNES, whereas it is almost absent in epilepsy. Rapid postictal orientations are commonly observed with PNES rather than epileptic patients.[4],[6] Thus, after asking preliminary questions and using basic assessment procedure, the professionals decide the seizure type and then employed other diagnostic procedures such as induction or psychological measures or brain imaging techniques to make its diagnosis more clear.

  Postictal Observation Top

Ictal and postictal signs are of utmost important states which are minutely investigated by professionals because it is the most important and robust first-hand information to differentiate between PNES and epilepsy. Further, ictal states are the seizure episodes and postictal state is the state of altered consciousness after a seizure episode. In case of PNES, investigation of postictal state gives an important clue about the type of seizure the patient has encountered.

Postictal signs encompass various signs and symptoms which include changes at cognitive and behavioral level with prominent changes in the body postures and motor movement. These postictal changes are much informative and helpful for professionals to differentiate between PNES and epilepsy seizures. In addition, certain changes in somatic features, respiration pattern, and interactional features are also promising postictal sign to distinguish PNES from epilepsy. Apart from these changes, serum prolactin (PRL) and certain electrolytes can also be an important postictal physiological biomarkers signs to diagnose PNES from epilepsy.

However, there are mixed findings regarding the postictal signs observed among PNES and epilepsy. There are some postictal signs which are common among both epileptic and PNES patients; the only difference lies in the degree of their occurrence. For example, out-of-phase movements of upper and lower extremities, thrashing violent movements of the entire body, side-to-side head movements, and side-to-side unilateral head turning including pelvis thrusting are such bodily features which are common in both PNES and epilepsy. Moreover, solely by observing these signs, one cannot label patients with PNES or epilepsy because such labeling can be erroneous and misleading.[21] Therefore, professionals must be careful while diagnosing PNES from that of epilepsy, using postictal bodily features.

Similarly, postictal confusion and prolonged unresponsiveness without prominent motor features with postictal headache, fatigue, or lethargy are occasional among PNES than epilepsy.[21],[22] Fecal and urinary incontinence are very rare among PNES while it may be common, sometimes occasional in epilepsy.[22] Besides, resistant eyes opening and hyperventilation are some of the refractory postictal observations robust in distinguishing PNES from epilepsy. In one study,[23] it has been found that PNES patients breathe more rapidly than epileptic patients. Moreover, hyperventilation has been found to be an important and placebo suggestive induction protocol to diagnose PNES.[24] In addition, at present, professionals are using wristband movement to differentiate between PNES and epilepsy and have concluded that wristband movement can be used with ease to distinguish PNES with motor manifestation from that of epilepsy.[25]

Moreover, there are some postictal signs which specifically differ in PNES than epilepsy. For example, response to verbal stimulus is common among PNES, whereas it is not possible or rarely possible in epileptic patients. Similarly, professionals can also differentiate between PNES and epilepsy on the basis of how they interact, communicate, or do conversation about their problem[26] Usually, PNES patients feel difficulty in describing their seizure event, for which they depend on their caregivers or attendants, whereas epileptic patients give detailed account of their seizure which is self-initiated.[22] Patients with PNES cannot describe what happened during seizure and avoids detail questioning about seizure activity, whereas in epilepsy, patients describe what happened when seizure was coming, their memory of seizure event, and that they tried to stop their seizure but could not do. They are interested in talking about their seizure event and give detail, comprehensive, contextualized, extensive account of their seizure.[26]

  Postictal Chemical Base Top

With recent advances in PNES research, professionals are now heading toward more definite and conclusive results by finding chemical bases of this disorder. A number of biomarkers such as PRL, creatine kinase, neuron-specific enolase (NSE), cortisol, neuropeptides (ghrelin and nesfatin-1), brain-derived neurotrophic factor (BDNF), leukocytosis, and platelet membrane serotonin transporter have been identified which help differentiate epilepsy from PNES.[27] Among these biomarkers, certain biomarkers such as leukocytosis, serotonin transporter, BDNF, NSE, and PRL are of much importance and their increased level has been found among epileptic patients as compared to PNES patients. Apart from these, cortisol is the main and widely accepted biomarker which helps differentiate between PNES and epilepsy. Because elevated level of cortisol is found among patients, if he/she has encountered real seizure within 20 min of seizure activity, but if seizure is of psychogenic origin, then there will be no such elevated level of cortisol. Moreover, this has been confirmed in one of the recent studies where an investigator has found increased level of basal diurnal cortisol level among PNES patients compared to healthy controls.[28]

  Induction/Provocation Top

Provocative techniques are techniques which help in inducing seizure during V-EEG monitoring and help in establishing the diagnosis of PNES. Provocative techniques include such maneuver or activity which has the capacity to induce seizure in individual if it were of psychogenic in nature. Further, provocative techniques provide aid in diagnosis of PNES where prolonged V-EEG monitoring becomes inconclusive and attacks do not occur spontaneously. Moreover, solely, using provocative techniques for diagnostic purpose can be erroneous and misleading. However, if it is used complementarily with other diagnostic measures, it has been found very conclusive.[19],[21],[29]

Apart from semiological and postictal observation, professionals use a number of provocative techniques such as compressed temple region (CTR), verbal suggestion (VS), tuning fork application (TFA), moist swab application (MSA), torchlight stimulation (TLS), and saline injection (SI).[19],[30] The benefit of induction protocol with V-EEG monitoring is that if a patient suffers from PNES, then induction may provoke seizure in the individual, confirming that he/she is the patient of PNES. In CTR, temple region of the client is gently massaged and the client is told that this activity will cause seizure episode in you, if it is really present. In VS, client is asked to close eyes and think about the seizure, if it is present, then it will come. Next, in TFA, vibrating tuning fork is applied to the vertex of the client explaining that this movement will cause seizure, if it is present. Further, in MSA, moist swab is put on the temple region of the client for a short duration and client is informed that this exercise will provoke seizures. Similarly, in TLS, professionals often use torchlight to provoke seizure in client, while in SI, professionals inject simple saline water in patients who is told that this will provoke seizure.[19],[30] As a whole, the essence of provocative technique is that it aims to induce seizure in patients as it is based on the theory that if the seizure were of psychogenic in nature, then the provocative maneuver will induce seizure in the individual because patients himself/herself want to seek attention and would fell prey to faking fits or seizures, although that is unconsciously deliberated effort.

  Neurophysiological Measures Top

Recent decade has witnessed such researches which have based their presumption that entropy or degeneration in particular brain area is associated with PNES, and thus, they have explained neurophysiological base of PNES. Neuroimaging techniques are those techniques which gives the structural and functional information about the brain either in the form of image or function. At present, with the help of these advance neuroimaging techniques such as computerized tomography scan, positron emission techniques, electroencephalography (EEG), magnetic resonance imaging (MRI), and V-EEG, professionals are able to figure out structural and functional anomalies inside the individuals' brain. Therefore, along with semiological details, postictal observation, and induction techniques, PNES individuals are also examined with these neuroimaging techniques, because first of all before making diagnosis of PNES, they have to rule out epilepsy, which can be known using EEG or MRI, if the seizure is of epileptic origin. Hence, with the help of neuroimaging techniques, mainly EEG or MRI, professionals are able to distinguish between PNES and epilepsy.

In epilepsy, the epileptiform discharges in the brain cause temporary dysfunction in the central nervous system, which can be traced through EEG and MRI, but in PNES, there are no such discharges, and the seizures are psychologically determined.[21] However, this belief has been challenged by a number of researchers that PNES is psychologically determined. A number of studies have investigated the organic pathology of PNES and concluded that PNES is caused due to organic brain pathology and dissociation between neural networks.[21],[32],[33],[34],[35],[36] In line of the research,[37] one researcher has studied the markers of brain abnormalities with EEG, MRI, and neuropsychological test to investigate whether physical brain disorder is associated with increased risk of PNES and the results showed that out of 329 (206 – PNES-only group, 123 – PNES and epilepsy [PNES + E]) patients, 22.3% of PNES-only group has at least one marker of brain disorder. Further, one other study[7] found interictal abnormalities in 53.8% (PNES only) and 92.9% (PNES + E) patients and concluded that PNES often occurs in patients with organic brain disease and interictal changes are common in PNES and should not be confused with epilepsy.

Further, PNES patient exhibits spells of altered movement, sensation, and experience caused due to disruption in connection between thought, memories, feelings, and sense of identity with loss in their ability to properly integrate and channelize their emotion. Moreover, all these have a neurological base because each of these entities is governed by specific brain areas such as somatosensory area, insular area, orbitofrontal area, frontal area, parietal area, and many other brain circuits, which work in integrated fashion and help individuals to deal with the current demand of the situation. Therefore, any structural or functional changes or alteration/atrophy/degeneration detected through neuroimaging techniques in these areas can be potential neurophysiological markers to distinguish between epilepsy and PNES, and professionals may consider during PNES diagnosis. Recent studies provide substantial evidence that brain pathology plays an important role in its genesis. In one study among PNES patients,[35] altered network properties in the form of decreased clustering coefficient of gamma band and decreased long linkage between frontal region and posterior region associated with information transfer and executive control, respectively, have been found. This has been reconfirmed by another study[9] in which alteration in resting-state network, frontoparietal network, sensorimotor network, default-mode network were found associated with executive control, perception of pain-somesthesis, execution and self-reflection/self-awareness respectively more in PNES compared to healthy controls. Furthermore,[34] using resting-state functional MRI, alteration in both functional and structural connectivity network involving attention, sensorimotor, subcortical, and default-mode network has been found. Further, cortical atrophy of motor and premotor region in the right hemisphere[32] and cerebellum bilaterally with orbitofrontal cortex dysfunction[31] have been reported among PNES patients.

Thus, on the whole, we can summarize that alteration or atrophy in medial-frontal areas, cingulate, para-cingulate, insular region, supplementary motor area, sensorimotor cortex, secondary somatosensory cortex, precuneal, posterior cingulate, ventromedial frontal cortex, motor area, premotor area, and orbitofrontal area plays a major role in the pathology of PNES, and professionals may find it useful while diagnosing PNES patients and may consider it during diagnosing and treatment of PNES.

  Psychological Measures Top

Majorly, psychological factors are assumed behind the cause of PNES and are equivocally accepted by everyone since considerable number of investigations done to know the etiology of PNES have emphasized that PNES is caused due to psychological factors. Moreover, a plethora of studies has been done to explain the role of psychological factors in the development and maintenance of PNES and nonpsychological factors accounting only 5% of the cases.[38] Till today, psychodynamic orientation dominates the field while explaining the etiology of PNES and its internal mechanism.

Patients who are suffering from PNES experience episodes of severe dissociation which affects their thought, feelings, memories, and their sense of identity. They are also unable to identify[39] and regulate their emotion.[40] Since they are unable to recognize and regulate their emotion (majorly negative and painful) and when these emotion remains suppressed for a long time, there it gets converted into bodily symptoms and manifested in the form of pseudoneurological symptoms.[10] Moreover, PNES patients have tendency to dissociate; such dissociating mechanism helps them confront with painful situation in turn reducing their anxiety and getting the attention of their loved ones. Moreover, one study[9] has reported that almost in 90% of the cases, PNES is associated with dissociative disorder. Further, substantial numbers of studies have been done which reveals that PNES is associated with a large number of psychiatric disorders such as mood, anxiety, fictitious, somatoform, personality, and posttraumatic.[41],[42],[43] Similarly, in one more study,[44] PNES has been regarded as a subtype of conversion disorder. Further, in line with this investigation, researchers[44] have found significantly higher level of psychopathology among PNES patients as compared to epileptic patients on somatoform dissociation scale and traumatic history questionnaire. The incidence of traumatic history has been reported widely,[45] and 88% of the PNES patients reported a history of traumatic experience, which has been reconfirmed by another group of researchers[46] where they found 84% out of 45 PNES patients being reported to have gone through traumatic experiences. Similarly,[47] articles were reviewed from 1945 to 2004, from which 17 relevant studies were selected which concluded that PNES sample shows very high rates of trauma almost from 44% to 100%, confirming that traumatic experience can be the potential predisposing risk factor in the pathology of PNES. However, studies refuting the connection between PTSD and PNES motor seizure semiology had also been investigated where the research did not found any association between PNES and traumatic experiences.[43]

Moreover, personality of an individual acts as a moderator in handling day-to-day problems and dealing with the stressors. Therefore, it is worth to find out the personality dimension of PNES patients to see how significantly it can help in predicting PNES.[48] One study reviewed paper on PNES from 1996 to 2006 and found co-occurrence personality disorder with PNES ranging from 10% to 86% of the case, which has been again reconfirmed in other study,[49] where personality disorder has been found a significant predictor PNES. Compared to epilepsy, anxiety, stress, breakdown, dissociation, and depression were more common among PNES.[38],[50] Thus, we see that more or less PNES is associated with psychiatric disorders and may be helpful in differentiating PNES with epilepsy. Therefore, professionals may go for it and can take help of the questionnaire along with brain imaging techniques to make his/her diagnosis more robust.

Further, it can be concluded that, in recent decades, research has emphasized the role of psychological and psychiatric factors to be more dominant in elucidating the etiology of PNES, which emphasizes the psychodynamic explanation more, but the present decade has also witnessed a number of studies that have identified the role of brain pathology in PNES which is still in its infancy and will need time to gain consensus among the researchers who strongly believe the PNES etiology from the psychodynamic and behavioral perspective.[38],[41],[42],[51]

  Management and Prognosis of Psychogenic Nonepileptic Seizures Top

It is tough to treat and manage PNES because there is no generally accepted treatment protocol, and till date, whatever the knowledge is gained about the treatment of PNES is through numerous case reports, case series, and retrospective case reports. To manage PNES, patient's neurological, psychological, and social factors which cause PNES should be considered, and treatment plan should be meant accordingly. Further, the underlying psychopathologies among PNES patients vary greatly among patients, and the existing treatment protocol does not promise 100% cure although significant reduction in seizure frequency is seen if the treatment protocol is individualized.[53]

Treatment of PNES goes back to 1730 century where Mandeville has described the full description PNES attack and has suggested the treatment plan to cure PNES patients. In one of his patients who was suffering from pseudoseizure, surprisingly, she has assisted a course of exercise and no medication at all for her trouble.[54] During time course, in the 19th century, PNES got its acceptance as neuropsychiatric syndrome among medical community by the name of hysteroepilepsy, and thereafter, professionals from various field started to come up with the theories and intervention to understand and cure PNES patients. At the same time, Charcot and Gowers came up with their unique intervention strategies to manage PNES. Charcot has advocated the use of hypnosis and ovarian compression for the treatment of PNES.[55] Gowers too has suggested some techniques such as faradization (electric shock to the skin) and hydrotherapy (patients' mouth and nose are closed with towel and affusion is employed until the patient is at the point of asphyxia) to treat PNES patients and was much favored at that time.[56] As the time progresses, multiple theories regarding PNES came into existence to explain its etiology with multiple intervention strategies to manage PNES patients.

Numerous techniques such as cognitive behavioral therapy (CBT), group psychoeducation, psychotherapy, progressive relaxation, systematic desensitization, eye movement desensitization, psychodynamic psychotherapy, hypnosis, group therapy, family therapy, and a combination of these psychological interventions came into existence to treat/manage PNES patients by professionals.[57],[58],[59],[60],[61] Another practical problem with the management of PNES is that till today, it has not been entirely embraced by any field whether it is neurology or psychiatry or psychology. Neurologist who makes the diagnosis but fails to provide medical treatment, and therefore, the patients are referred to psychiatry where he/she gets the medication assistance. However, to get rid of his/her emotional trouble and faulty processing, PNES patients need psychological treatment. Therefore, it is hard for patients simultaneously to visit all these three professionals and in India where already the outpatient departments are overcrowded pose further problem in their treatment which makes them vulnerable to be ill-treated/ill-advised/faulty prescription putting them in more trouble causing one more stressor for them.

Before the start of therapeutic procedure primarily, it should be understood that till now, there is no single known etiology and professionals have multiple opinions regarding cause of this disease. Therefore, PNES patients should be managed individually and intervention strategy should be tailored according to individual complaint. In line with this research,[54] it has found very encouraging result in which patients were intervened according to patients complaints such as patients complain with acute anxiety and panic symptoms received CBT; those with impaired affect regulation and deficits in interpersonal skills in managing conflict were treated with intensive psychotherapy; those with conversion symptoms received insight-oriented treatment; patients with depression and life situation dissatisfaction received CBT; those with posttraumatic stress disorder had exposure treatment; and patients with reinforced behavior pattern behavior with secondary gain received behavioral management strategies.

Further, majority of researches have evidenced the etiology behind PNES to be emotional turmoil condition; therefore, majority of the professionals advocate the use of various psychodynamic and behavioral techniques to manage PNES patients followed by drug treatment for the underlying psychiatric disorder. Moreover, to speculate how and in which way patients are more benefitted, few studies have been conducted[62],[63],[64] which show that there are certain therapeutic step if followed then can be helpful in managing PNES patients. The very first step is to communicate diagnosis to the patients and to their attendants. The second step is to initiate the therapeutic procedure which is highly dependent upon the etiology behind seizure occurrence and the comorbid psychiatric disorder. Like if the cause of patient's seizure is panic attack/poor interpersonal relation/family dysfunction/family disharmony/affect dysregulation/disturbed family pattern/dissatisfaction/acute or situational stressors, then therapists go for supportive psychotherapy, lifestyle changes, intensive psychodynamic therapy, CBT, and family therapy to manage PNES patients.[65] For psychiatric comorbidity, anti-depressant (for depression), anti-anxietic (for anxiety), and serotonin reuptake inhibitors (in case of PTSD) are prescribed to PNES patients.[65] It is noteworthy that psychotherapies and drugs are complementary to each other as and when used simultaneously facilitates each work. There is no such any specific drug especially for treating PNES. However, during management procedure, it is very important to figure out the predisposing, precipitating, and perpetuating factors to deliver the correct therapeutic intervention to the patients.[66]

Prognosis of PNES patients varies and is highly dependent upon the psychopathology associated with the seizure, age of the patients, other issues such as duration, patient's history, onset, previous medical condition, and social and family support system. Patients whose seizure is associated with stress or anxiety have chance of good improvement whereas patients whose seizure is associated with conversion/dissociation or personality disorders there is less chance for improvement.[67] Prognosis is better when patients is managed in inpatient setting by professionals having multidisciplinary approach[68] and has family as well as social support. Further, prognosis varies with age as prognosis is better in children as compared to adults, because in children, the problem is easily identifiable and is amenable to intervention, whereas in adults, the possibility is less.[69] It can be concluded that still psychopathology and knowledge about PNES are increasing; therefore, more advanced treatment plan and strategy are yet to come.

  Conclusion Top

When painful thought, memories, feelings, and emotion are repressed for a long time and do not find its void verbally, it is communicated through bodily gestures in the form of psychogenic seizures, which are paroxysmal events similar to epilepsy-like episodes.[32] The problem concerned with PNES diagnosis is that there is no commonly agreed cause of seizure among PNES and varied number of explanation is given about its etiology. Its etiological explanation is mainly based on two perspectives, and these are psychological and physiological. Among these, psychological perspective is widely accepted. Each perspective has its own explanation. Physiological perspective said that PNES is caused due to alteration/atrophy in particular brain region/circuits whereas psychological perspective focuses on the psychodynamic explanation. Thus, these two perspectives have given deep understanding about the etiology of PNES at their level and helping in devising treatment strategy.

Further, semiological, psychological, physiological, and neurobrain imaging techniques are approached complementarily to diagnose PNES. Still PNES diagnoses are challenging and currently V-EEG is the only gold standard to differentiate between epilepsy and PNES; however, one problem with this technique is that it too costly and always not available. Further, popular belief about epilepsy is that there are abnormal discharges in the brain, but this are not always the cases because simple partial seizure or mesial frontal lobe seizure also does not show epileptic discharges in the brain and may be confused with PNES.[21] Therefore, EEG cannot be promising tool for diagnosing PNES. Further, a comprehensive semiological detail may be useful to diagnose epilepsy, but semiological features differ from individuals to individuals, and there are many ictal characteristics common with epilepsy and PNES, which poses difficulty to health professional to distinguish between PNES and epilepsy. However, semiological characteristics in addition to brain imaging techniques can provide a satisfactory diagnosis. Moreover, on the basis of psychopathology associated with PNES, one can only be sure about the psychiatric disorder associated with PNES, but this cannot be considered as a base to distinguish between epilepsy and PNES because epilepsy has also been investigated with known psychiatric disorders.[52],[42] Therefore, with the help of psychiatry, diagnosis does not guarantee the absence of another form of epilepsy-like frontal lobe epilepsy because there is subtle difference in the semiological characteristics of frontal lobe seizures and epilepsy.[6],[4] Therefore, it is not easy for its forerunner to challenge the belief and fraternity of Freud and Janet, who explained the psychodynamic behind this disorder which previously has been called hesteroepilepsy.[10]

Moreover, if one goes for distinguishing epilepsy and PNES on physiological base, then it needs very sophisticated and advanced technology with highly trained professional; in addition, it will need experts from field of neurology, psychology, psychiatric, statistics, radiology, and computer expert including high-quality software to analyze the results and graph whatever computational logic will come. Further, it will need a world-class infrastructure and laboratory and will need huge amount of time and money. We think that it is tough in medical setting where huge crowd comes and is not possible for every patient to go through such costly procedures. However, this does not mean that such physiological investigation findings are in vain, but it has given a valuable insight to understand the organic pathology of PNES and has contributed to the fundamental understanding the pathology of PNES. Finally, we can conclude that diagnosing PNES is a cumbersome task because none of the profession either neurology or psychiatry considers PNES in their realm and this is the disadvantage a person suffers when he/she is suspected of PNES because none of the profession offers accurate diagnosis. However, when a suspected PNES is encountered with psychiatrist, he/she is usually labeled with dissociation or conversion type, and treatment plan is devised accordingly. Moreover, when suspected PNES is seen in neurology ward, then there is maximum possibility that he/she is suspected with partial seizure and/or frontal lobe seizure and the situation is more worse when the seizure is of mixed type, where diagnosis is vulnerable to be faulty evaluation. Hence, we can be conclusive that diagnosing PNES case can be the best possible if all three professionals (i.e., neurologist, psychiatrist, and psychologist) sit together and frame a protocol for PNES diagnosis; then only, we can correctly diagnose and treat PNES patients.

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