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TABLE 6-2 Clinical Signs and Examination Findings Used to Help Distinguish Psychogenic
Nonepileptic Seizures From Epileptic Seizuresa,b
KEY POINTS video-EEG monitoring and, to a lesser clonic PNES may demonstrate unchang-
h Over the lifetime extent, home video recording. ing frequency and variable amplitude
of patients with In distinguishing PNES from epileptic throughout the ictus.17 Some PNES
psychogenic nonepileptic seizures, clinical features are generally show poorly discernible ictal onset from
seizures, about half
more specific than sensitive,14 and no a setting of apparent sleep, during
have been diagnosed
individual feature is definitively diag- which EEG activity discordantly corre-
with depression, about
half have comorbid
nostic of PNES.15 Instead, the degree of lates with wakefulness or light drows-
posttraumatic stress diagnostic confidence correlates with iness.18 On the other hand, paroxysms
disorder, and about concordant features favoring PNES. For with clear-cut emergence from EEG-
two-thirds have example, assessment of the characteris- documented sleep would have a high
personality disorders. tic seizure temporal evolution is often likelihood of being physiologic in origin
h The diagnosis of helpful. Ictal vocalization in epileptic (ie, epileptic seizures or parasomnias).
psychogenic nonepileptic seizures is usually restricted to the PNES have been classified into dis-
seizures requires the beginning of the seizure, primitive in tinct groups according to the predom-
demonstration of ictal nature (laryngeal sound), and highly inant clinical features. These groupings
features that favor a stereotyped. In PNES, the vocalization include rhythmic motor, hypermotor,
psychogenic process; are may be present not only at the begin- complex motor, dialeptic (impaired
not consistent with ning of the seizure but may persist or awareness), subjective, and mixed.19
epilepsy; and occur even intensify through the course of the
in the context of While such categorization can contrib-
ictus. Vocalization in PNES can be more ute to pattern recognition useful in the
supportive historical,
complex, with affective content re-
physical examination, evaluation of PNES, it is presently uncer-
flecting somatic expression of emo-
and ictal/interictal tain whether such categorization is
video-EEG findings.
tional distress (eg, weeping, moaning,
and coughing).16 The generalized tonic- useful to distinguish psychological un-
h Patients’ and witnesses’ clonic epileptic features can inform di- derpinnings or inform prognosis. Fur-
descriptions of the thermore, unlike stereotyped epileptic
agnosis, where ictal features evolve
ictal features have seizures arising from a singular epilep-
been known to
through an organized fashion such that
clonic frequency progressively declines togenic substrate, the ictal features of
correlate poorly with
observed features while amplitude increases through the patients with PNES can often change,
of video-EEGY course of the convulsion. In contrast, the transforming into other clinical presen-
captured seizures. convulsive activity in generalized tonic- tations or unrelated somatic symptoms.20
KEY POINTS
h Only 21% of simple components (simple partial symptom- EEG activation procedures (hyperven-
partial epileptic seizures atology) may arise from only a small pool tilation and photic stimulation) with-
have been shown to of neuronal tissue. As such, only 21% out placebo. Asking the patient or
correlate with ictal EEG of simple partial epileptic seizures have family if they know of a trigger that
epileptiform changes, been shown to correlate with ictal epi- can be reproduced in the unit is fre-
while some frontal lobe leptiform changes on scalp EEG.26 Some quently helpful (eg, scrolling on a com-
epileptic seizures can frontal lobe epileptic seizures arise from puter screen). Comparable success rates
demonstrate very subtle, deep-seated foci (eg, orbitofrontal or in- have been demonstrated between PNES
falsely lateralizing, or terhemispheric regions) such that ictal activation procedures with placebo ver-
undiscernible ictal EEG epileptiform discharges can conduct/ sus without placebo.32
epileptiform correlates.
distribute over a widespread area bilat- Ambulatory EEG and home video
h When confronted with erally, demonstrate a contralateral max- recordings. Some patients with PNES
enigmatic paroxysms of imum, or become obscured by copious may not experience seizures in a hospital
uncertain etiologies, artifacts related to hypermotor activity. setting that secludes patients from ha-
the demonstration
Therefore, ictal EEG epileptiform cor- bitual stressors of their indigenous mi-
of inducibility (ie,
relates of some frontal lobe epileptic lieu. Under such circumstances, outpatient
provocative induction)
would strongly (but not
seizures can be very subtle, falsely lat- ambulatory EEG (sometimes with con-
entirely) support a eralizing, or undiscernible. current video recordings) can be useful.
psychogenic etiology. Within 2 days after admission for Because of less-standardized recording
video-EEG monitoring, the majority of settings and greater susceptibility to arti-
patients with PNES will have experienced facts, the qualities of the ambulatory
a spontaneous and characteristic seizure EEG and video data can be quite var-
of interest.27 For those who do not ex- iable. For cases in which supportive clin-
perience spontaneous seizures, use of ical or historic contexts are not available,
suggestion techniques (ie, provocative ambulatory EEG should be interpreted
inductions) can improve the rate of sei- with caution.
zure capture28 and shorten the duration The frequency of some patients’ PNES
of video-EEG admission.29 The success may be too rare to be practically captured
rate of induction is higher among pa- during limited time frames of video-EEG
tients who demonstrate preinduction or ambulatory EEG recordings. Consid-
characteristics of hypermotor ictal symp- ering the common availability of mobile
tomatology, prevalent self-reporting devices that can record video, home
of uncommon cognitive and affective video documentation of some patients’
symptoms, and absence of prior induc- infrequent seizures may be able to pro-
tion exposure.30 Moreover, when con- vide useful diagnostic data. Video data
fronted with enigmatic cases for which
alone (without EEG) have been shown to
frontal lobe epileptic seizures, simple
provide reasonably robust sensitivity and
partial epileptic seizures, or other phys-
specificity in distinguishing epileptic sei-
iologic nonepileptic events have not
zures from PNES.33 A key interpretive
been conclusively excluded, the dem-
onstration of inducibility would strongly caution is that home video recordings
(but not entirely) support a psychogenic may frequently miss the moment of sei-
etiology. Ethical concerns are raised by zure onset and instead capture the mid-
the use of placebos during induction dle or recovery phase of the seizure.
(eg, saline injection or alcohol wipes), Moreover, the neurobehavioral man-
which inherently reflect a deceptive in- ifestations during the postictal recov-
tervention to the patient.31 Such con- ery phase of epileptic seizures can highly
cerns can be circumvented by performing resemble the ictal symptomatology of
induction techniques that utilize routine some PNES.
120 www.ContinuumJournal.com February 2016
KEY POINT
h Whereas DSM-IV Diagnostic and Statistical Manual of surgeries/anesthesia37Y39) can provoke
approached conversion Mental Disorders, Fourth Edition conversion symptoms and may involve
disorder as a diagnosis (DSM-IV) required the presence of psy- processes that are physiologic as much
of exclusion, the chological factors to precede or exac- as psychological (Case 6-1).
updated DSM-5 guides erbate conversion symptoms, such DSM-IV approached conversion dis-
users to make a positive requirement has been relegated to a order as a diagnosis of exclusion from
conversion disorder note in DSM-5.34,35 The reason for this other pathophysiologic conditions. To
diagnosis based on change is that while psychological fac- circumvent this problem, DSM-5 guides
inclusion of clinical tors are important in the evolution of users to make a positive conversion
features that are conversion disorders, they are not always disorder diagnosis based on inclusion
incongruent to known
immediately apparent from the history. of clinical findings that are incongruent
anatomy, physiology,
Some patients’ readiness to discuss psy- to known anatomy, physiology, or dis-
or disease.
chological factors may depend on the eases (Table 6-2). The criterion on exclud-
strength of the clinician-patient alliance. ing other pathophysiologic conditions
Even when psychological factors are has been revised to a criterion that re-
readily identified, it may not be clear quires that the symptom in question is
that they are etiologically relevant to “not better explained by another dis-
the symptoms at hand.36 Moreover, evi- ease.” This revision encourages clinical
dence exists that physical factors (such investigation for an alternative medical/
as traumatic brain injuries, undergoing neurologic explanation for the symptom,
Case 6-1
A 57-year-old man presented with a 10-year history of seizures involving
abrupt loss of awareness with falls, followed by postictal disorientation/
confusion. Considering his known left frontal encephalomalacia from a
stroke that also occurred about 10 years ago, he had been treated for
(presumed) epilepsy with antiepileptic drugs. Since some of his paroxysms
were preceded by coughing fits, posttussive syncope was within the
differential diagnosis. However, he continued to experience frequent
seizures, despite trials of three antiepileptic drugs and measures to treat
his obstructive airway disease. He was referred for video-EEG monitoring,
which confirmed the diagnosis of psychogenic nonepileptic seizures (PNES)
(Supplemental Digital Content 6-1, links.lww.com/CONT/A169). This seizure
was induced by routine activation procedures that included photic stimulation
and provocation with verbal suggestion, but no placebo. PNES was
supported by the documented features of suggestibility (increasing seizure
intensity with higher photic frequency), ictal eye closure at ictal onset,
side-to-side head movements, illness-affirming behaviors (retching cough,
semifetal posture), and incongruence of intact EEG alpha rhythm (a
neurophysiologic correlate of alertness) during dialeptic symptomatology
with clinical unresponsiveness.
Comment. While strokes are associated with epilepsy and epileptogenic
foci, this case illustrates that the emotional affliction from significant
health-related adverse events should not be overlooked. Moreover,
evidence exists that physical factors (such as brain injuries) can provoke
conversion symptoms and may involve processes that are physiologic as much
as psychological. This case also exemplifies the importance of considering a
wide differential diagnosis in patients with paroxysmal disorders, which
includes epilepsy, physiologic nonepileptic events, and PNES.
KEY POINTS
h An important prognostic life, including transient dizziness, limb approach to PNES diagnosis may be
factor of psychogenic numbness, or head sensations that may beneficial in prompting earlier discus-
nonepileptic seizures is briefly disrupt attention. The misinter- sion regarding potential psychological
the duration of illness, in pretation of benign symptoms as being contributions to seizures, as soon as
which the prognosis more pathologic may be more common minimum criteria for the diagnosis of
worsens the longer the in patients who have had personal expe- PNES have been met. Deferring such
patient’s illness has been riences with seizures or who have other discussions until video-EEGYdocumented
mistreated as epilepsy. neurologic/medical conditions. Another diagnostic certainty may lead to sig-
h In children with scenario that falls within the border zones nificant delay, considering the afore-
psychogenic nonepileptic of PNES is the purposeless and repetitive mentioned diagnostic challenges and
seizures, serious behavioral mannerisms (learned behav- limited video-EEG availability in some
psychosocial issues (eg, locations. Factors that may prognosti-
ior) that occur not infrequently in some
physical or sexual abuses) cate better outcomes among adults
can be ongoing at the
cognitively impaired patients.45
include higher level of education; youn-
time of presentation and PROGNOSIS ger age at both time of seizure onset
should be explored in
When considering the overall popula- and time of diagnosis; seizures with
every case.
tion of patients with PNES, seizure less- dramatic symptomatology; fewer
cessation is reported to occur in about additional psychosomatic symptoms;
40% of patients over time. About one- and neuropsychological measures sup-
third of patients experience seizure porting lower dissociative, inhibitive,
reduction, while the remaining approx- emotional dysregulating, and compul-
imately one-third of patients undergo a sive tendencies.50,51
chronically intractable course.46 A com-
prehensive assessment of PNES out- PSYCHOGENIC NONEPILEPTIC
comes should encompass not only SEIZURES IN CHILDREN
seizure burden, but also the state of While much of the earlier discussions
psychosocial comorbidities, functionality, regarding PNES in adults also apply to
and overall quality of life.47 Upon pursu- children, some differences are notable
ing a more complete outcome assess- in light of varying psychosocial elements
ment of PNES as such, one study showed across developmental stages in children.
the following observations: 44% of pa- PNES can emerge in children as young
tients were not seizure free and re- as 5 years old, and their frequency in-
mained dependent (poor outcome); creases with age, becoming the most
40% of patients were either seizure free common type of nonepileptic seizure in
but dependent or not seizure free but adolescents.52 Conversely, comorbid
independent (intermediate outcome); epilepsy (mixed disorder) is more prev-
and 16% of patients were seizure free alent in younger children with PNES
and independent (good outcome).48 than in older children or adolescents
The above results suggest that patients with PNES.52 Compared to adults with
with PNES, in general, may have a poorer PNES, differences in psychiatric comor-
course than those with newly diag- bidities include lower rates of mood
nosed epilepsy.48 disorders (32%) and PTSD (10%) and a
Several patient-specific characteristics higher rate of significant family stressors
are identified as influencing the disease (44%) for children with PNES.53 Impor-
course of PNES. An important prognos- tantly, serious psychosocial issues (eg,
tic factor is duration of illness, in which physical or sexual abuses) can be on-
the prognosis worsens the longer the going at the time of presentation and
patient’s illness has been mistreated as should be explored in every case. Risk
epilepsy.49 Correspondingly, a staged factors for pediatric PNES are noted,
124 www.ContinuumJournal.com February 2016
Case 6-2
A 27-year-old man presented with near-daily seizures that involved diffuse
shaking with varying degree of unconsciousness. Given his high seizure
frequency, a brief 23-hour inpatient video-EEG was able to capture his
habitual seizure, and he received the diagnosis of psychogenic nonepileptic
seizures (PNES). He then sought additional referrals, endorsing the
frustration that, “My family thinks it’s all in my head,” and “It has to come
from something else.” During a subsequent video-EEG monitoring course,
efforts were made to capture the full spectrum of the patient’s seizures.
The diagnosis of PNES was explained to the patient and family members,
emphasizing PNES as a real, albeit nonepileptic, type of seizure. This
explanation of the diagnosis took place across two inpatient visits to allow
the patient and his family the opportunity to process their understanding
and ask questions. An explanation letter (addressed to the patient) and PNES
brochures were encouraged to be shared with other clinicians or individuals
pertinent to the patient’s care.
Comment. For patients with PNES, establishing the correct diagnosis is the
first step of treatment. Optimal management begins with comprehensive
evaluation (ie, neurologic and psychiatric assessment, description of the
events and psychosocial history taking, video-EEG monitoring). The
clinician-patient rapport and legitimization of PNES established through
these efforts can enhance the patient’s acceptance of diagnosis. In this
sense, neurologists can be a factor not only in the diagnosis, but also in the
initial treatment of patients with PNES as they prepare patients for
collaborative care with a mental health professional.
KEY POINTS
h Medications do not fully insight across the patient’s milieu. Not more open-mindedness toward accep-
treat psychogenic providing the diagnosis with patient or tance of this diagnosis.64,65 Because
nonepileptic seizures. providers has been shown to be associ- driving is an issue for patients with
Moreover, antiepileptic ated with no improvement or even seizures, barriers to treatment delivery
drugs may worsening of symptoms.60 Likewise, are being overcome with computer
make psychogenic merely sharing the diagnosis (without video telemedicine, which is being used
nonepileptic seizures further dedicated therapeutic efforts) is in the US Department of Veterans Af-
worse. Selective frequently insufficient, as other somatic fairs to provide live-remote therapy for
serotonin reuptake and affective symptoms often develop veterans with either epileptic seizures
inhibitors (SSRIs) help the if the core issues are not addressed.13 or PNES.66
comorbidities (eg,
Letting the patient and family know that The working relationship between
depression and anxiety)
they are not alone in that many people the neurologist and patient should not
but do not
stop psychogenic
have the same disorder; that treatment abruptly end after a diagnosis of PNES
nonepileptic seizures. involves addressing predisposing, pre- has been established, for several reasons.
cipitating, and perpetuating factors; and For some patients with PNES, especially
h Targeted psychotherapy
that effective treatment is available pro- those who have been chronically mis-
appears to be the
mainstay of treatment
vides hope to patients and empowers diagnosed as having epileptic seizures,
for psychogenic treating clinicians to engage.50 a proper understanding of the diagnosis
nonepileptic seizures. The mainstay of effective treatment may not be achievable with a “one-shot”
To date, two pilot for PNES is psychotherapy directed at disclosure. Instead, iterative explanation
randomized controlled the known pathologies in the population. of the diagnosis via a supportive/
trials for psychogenic Pharmacologic interventions are used to noncoercive tone across serial visits may
nonepileptic seizures address common comorbidities (eg, se- gradually foster the patient’s acceptance
have shown clinically lective serotonin reuptake inhibitors for mental health treatment referrals.
meaningful results using [SSRIs] for depression and anxiety). Once the transition to mental health
either traditional However, psychotropics may reduce care is complete, then discussion can
cognitive-behavioral
seizures but do not lead to seizure commence regarding the patient’s dis-
therapy or a
cessation in PNES.3,61 Among psycho- charge from the neurologist’s practice.
seizure-treatment
workbook based
therapeutic approaches for patients with If a specific AED has no alternative
on a multimodality PNES, cognitive-behavioral therapy has beneficial indication (eg, mood stabili-
cognitive-behavioral the most substantial body of controlled zation or migraine prophylaxis), then a
therapyYinformed efficacy data. To date, two pilot random- timely taper of the drug is advisable.
psychotherapy for ized controlled trials for PNES have Early, as opposed to delayed, AED
psychogenic nonepileptic shown clinically meaningful results. One withdrawal portends greater beneficial
seizures and for epilepsy. study used conventional cognitive- effects on a range of clinical out-
behavioral therapy,62 while the other comes.57 Patients with normal video-
study used a multimodality cognitive- EEG findings should be followed by a
behavioral therapyYinformed psycho- neurologist for at least 6 months after
therapy3 based on a workbook used discontinuing AEDs. This consideration
by therapists and patients to treat is because of the small but ever-present
both epileptic seizures and PNES possibility of coexisting epilepsy and
(Table 6-4).63 Some patients may con- the fact that breakthrough epileptic
tinue to maintain some ambivalence re- seizures can occur several months
garding the nature of the PNES diagnosis after discontinuation of AEDs. Patients
and express reluctance toward in-depth with PNES who also have known
individual psychotherapies. In such cases, interictal or ictal epileptiform abnormal-
group psychoeducational approaches ities on their video-EEG should continue
have been shown to consolidate patients’ to be followed by a neurologist. Patients
understanding of PNES and promote with mixed epilepsy/PNES should be
126 www.ContinuumJournal.com February 2016
treated with the lowest effective AED a positive conversion disorder diagnosis KEY POINT
dose for the epilepsy, noting that AEDs based on identifying incongruent exam- h For the 10% of patients
do not treat PNES, and behavioral in- ination and laboratory findings in rela- with mixed epilepsy/
psychogenic nonepileptic
terventions should target the PNES. tion to known anatomy or physiology.
seizures, use the lowest
Continued follow-up by the neurologist Neurologists can work collaboratively with
effective antiepileptic drug
during the transition to mental health mental health providers to adequately dose for the epileptic
providers mitigates repeat workups with address the psychological underpinnings seizure and use mental
other providers. of these challenging patients. This team health treatments for
approach highlights the importance of the psychogenic
CONCLUSION interdisciplinary dialogue and transition nonepileptic seizures.
Conversion disorder is usually not diag- in the care of patients with PNES. To
nosed by the mental health provider this end, better communication by neuro-
alone; the neurologist is integral in the logists can overcome past diverging in-
evaluation and diagnosis. Indeed, patients terdisciplinary perspectives regarding
with conversion disorder frequently pres- PNES, with psychiatrists frequently be-
ent to neurologists first in search of a ing uncertain about the accuracy of video-
neurologic explanation to their symp- EEG.68 Further efforts are necessary to
toms.67 As such, neurologists have ac- augment this vital interdisciplinary part-
quired substantial experience in making nership. Recent diagnostic and treatment
studies have shown momentum in shift- 6. Benbadis SR, O’Neill E, Tatum WO, et al.
Outcome of prolonged video-EEG monitoring
ing PNES to a neuropsychiatric inter- at a typical referral epilepsy center. Epilepsia
disciplinary (shared-care) model with 2004;45(9):1150Y1153. doi:10.1111/j.
a mind/brain perspective.66 As research 0013-9580.2004.14504.x.
in PNES advances, cognizance of and, 7. LaFrance WC Jr, Baker GA, Duncan R, et al.
hence, empathy for patients with this Minimum requirements for the diagnosis of
psychogenic nonepileptic seizures: a staged
challenging condition can advance,
approach: a report from the International
in parallel. League Against Epilepsy Nonepileptic
Seizures Task Force. Epilepsia 2013;54(11):
VIDEO LEGEND 2005Y2018. doi:10.1111/epi.12356.
Supplemental Digital 8. Jedrzejczak J, Owczarek K, Majkowski J.
Content 6-1 Psychogenic pseudoepileptic seizures:
clinical and electroencephalogram (EEG)
Psychogenic nonepileptic seizure in-
video-tape recordings. Eur J Neurol 1999;6
duced by photic stimulation and verbal (4):473Y479. doi:10.1046/j.
suggestion. The documented features 1468-1331.1999.640473.x.
of suggestibility (intensifying ictal mani- 9. Reuber M, Pukrop R, Mitchell AJ, et al.
festations with increasing photic fre- Clinical significance of recurrent psychogenic
quency), somatic expression of distress nonepileptic seizure status. J Neurol
2003;250(11):1355Y1362. doi:10.1007/
(coughing, semifetal posture), and clin- s00415-003-0224-z.
ical unresponsiveness despite EEG
10. Frucht MM, Quigg M, Schwaner C, Fountain NB.
demonstration of an intact posterior Distribution of seizure precipitants among
dominant rhythm (reflecting an awake epilepsy syndromes. Epilepsia 2000;41(12):
state) are all supportive of a psycho- 1534Y1539. doi:10.1111/j.1528-1167.
genic etiology to this captured nonepi- 2000.01534.x.
27. Parra J, Kanner AM, Iriarte J, Gil-Nagel A. When 39. Reuber M, Kral T, Kurthen M, Elger CE.
should induction protocols be used in the New-onset psychogenic seizures after
diagnostic evaluation of patients with intracranial neurosurgery. Acta Neurochir
paroxysmal events? Epilepsia 1998;39(8):863Y867. (Wien) 2002;144(9):901Y907. doi:10.1007/
doi:10.1111/j.1528-1157.1998.tb01181.x. s00701-002-0993-7.
28. Benbadis SR, Siegrist K, Tatum WO, et al. 40. Stone J, LaFrance WC Jr, Brown R, et al.
Short-term outpatient EEG video with induction Conversion disorder: current problems and
in the diagnosis of psychogenic seizures. potential solutions for DSM-5. J Psychosom
Neurology 2004;63(9):1728Y1730. Res 2011;71(6):369Y376. doi:10.1016/j.
doi:10.1212/01.WNL.0000143273.18099.50. jpsychores.2011.07.005.
41. LaFrance WC Jr, Bjornaes H. Designing 53. Wyllie E, Glazer JP, Benbadis S, et al.
treatment based on etiology of psychogenic Psychiatric features of children and adolescents
nonepileptic seizures. In: Schachter SC, with pseudoseizures. Arch Pediatr Adolesc
LaFrance WC Jr, editors. Gates and Rowan’s Med 1999;153(3):244Y248. doi:10.1001/
nonepileptic seizures. 3rd ed. Cambridge, UK: archpedi.153.3.244.
Cambridge University Press, 2010:266Y280.
54. Plioplys S, Doss J, Siddarth P, et al. A
42. Kalogjera-Sackellares D. Psychodynamics and multisite controlled study of risk factors in
psychotherapy of pseudoseizures. Wales, UK: pediatric psychogenic nonepileptic seizures.
Crown House Publishing, 2004:3Y42. Epilepsia 2014;55(11):1739Y1747.
43. Betts T, Boden S. Diagnosis, management and doi:10.1111/epi.12773.
prognosis of a group of 128 patients with 55. Wyllie E, Friedman D, Luders H, et al.
non-epileptic attack disorder. Part II. Previous Outcome of psychogenic seizures in children
childhood sexual abuse in the aetiology of and adolescents compared with adults.
these disorders. Seizure 1992;1(1):27Y32. Neurology 1991;41(5):742Y744. doi:10.
doi:10.1016/1059-1311(92)90050-B. 1212/WNL.41.5.742.
44. Jawad SS, Jamil N, Clarke EJ, et al. Psychiatric 56. Teitjen G. Office assessment for abuse and
morbidity and psychodynamics of patients management of the battered patient.
with convulsive pseudoseizures. Seizure Neurol Clin Pract 2012;2:5Y13. doi:10.1212/
1995;4(3):201Y206. doi:10.1016/S1059-1311 CPJ.0b013e31824c6c8a.
(05)80061-5.
57. LaFrance WC Jr, Reuber M, Goldstein LH.
45. Kim SH, Kim H, Lim BC, et al. Paroxysmal Management of psychogenic nonepileptic
nonepileptic events in pediatric patients seizures. Epilepsia 2013;54(suppl 1):53Y67.
confirmed by long-term video-EEG doi:10.1111/epi.12106.
monitoringVsingle tertiary center review of
58. Shen W, Bowman ES, Markand ON. Presenting
143 patients. Epilepsy Behav 2012;24(3):
the diagnosis of pseudoseizure. Neurology
336Y340. doi:10.1016/j.yebeh.2012.03.022.
1990;40(5):756Y759. doi:10.1212/WNL.40.5.756.
46. Bowman ES. Nonepileptic seizures: psychiatric
59. Hall-Patch L, Brown R, House A, et al.
framework, treatment, and outcome.
Acceptability and effectiveness of a strategy
Neurology 1999;53(5 suppl 2):S84YS88.
for the communication of the diagnosis of
47. Reuber M, Mitchell AJ, Howlett S, Elger CE. psychogenic nonepileptic seizures. Epilepsia
Measuring outcome in psychogenic nonepileptic 2010;51(1):70Y78. doi:10.1111/j.1528-
seizures: how relevant is seizure remission? 1167.2009.02099.x.
Epilepsia 2005;46(11):1788Y1795. doi:10.1111/
60. Aboukasm A, Mahr G, Gahry BR, et al.
j.1528-1167.2005.00280.x.
Retrospective analysis of the effects of
48. Reuber M, Pukrop R, Bauer J, et al. Outcome in psychotherapeutic interventions on outcomes
psychogenic nonepileptic seizures: 1 to of psychogenic nonepileptic seizures.
10-year follow-up in 164 patients. Ann Neurol Epilepsia 1998;39(5):470Y473. doi:10.1111/
2003;53(3):305Y311. doi:10.1002/ana.3000. j.1528-1157.1998.tb01407.x.
49. Selwa LM, Geyer J, Nikakhtar N, et al. 61. LaFrance WC Jr, Keitner GI, Papandonatos
GD, et al. Pilot pharmacologic randomized
Nonepileptic seizure outcome varies by type
controlled trial for psychogenic nonepileptic
of spell and duration of illness. Epilepsia
seizures. Neurology 2010;75(13):1166Y1173.
2000;41(10):1330Y1334. doi:10.1111/j.
doi:10.1212/WNL.0b013e3181f4d5a9.
1528-1157.2000.tb04613.x.
62. Goldstein LH, Chalder T, Chigwedere C, et al.
50. LaFrance WC Jr, Devinsky O. Treatment of
Cognitive-behavioral therapy for psychogenic
nonepileptic seizures. Epilepsy Behav 2002;3 nonepileptic seizures: a pilot RCT. Neurology
(5 supp):19Y23. 2010;74(24):1986Y1994. doi:10.1212/
51. Cragar DE, Schmitt FA, Berry DT, et al. A WNL.0b013e3181e39658.
comparison of MMPI-2 decision rules in the 63. Reiter J, Andrews D, Reiter C, LaFrance WC Jr.
diagnosis of nonepileptic seizures. J Clin Exp Taking control of your seizures: workbook.
Neuropsychol 2003;25(6):793Y804. New York, NY: Oxford University Press, 2015.
doi:10.1076/jcen.25.6.793.16471.
64. Zaroff CM, Myers L, Barr WB, et al.
52. Kotagal P, Costa M, Wyllie E, Wolgamuth B. Group psychoeducation as treatment for
Paroxysmal nonepileptic events in children psychological nonepileptic seizures.
and adolescents. Pediatrics 2002;110(4):e46. Epilepsy Behav 2004;5(4):587Y592.
doi:10.1542/peds.110.4.e46. doi:10.1016/j.yebeh.2004.03.005.