Psychogenic Nonepileptic Attack: (Dissociative Convulsions)

Presentation

The patient with psychogenic nonepileptic attack (PNEA), also known as psychogenic nonepileptic seizure (PNES), typically presents with the appearance of having tonic-clonic seizure activity or can develop this during a visit.

There may be a history of sexual abuse, eating disorders, depression, substance abuse, anxiety disorders, or personality disorders, and the episode may be preceded by a stressful event. The terminology “pseudoseizure” or “hysterical seizure” is outdated and considered counterproductive as it may give the patient the perception that medical professionals consider this faked or voluntary behavior. Head turning from side to side and pelvic thrusting are common with PNEA, and it may be difficult to determine initially whether the patient is manifesting a true epileptic seizure.

A patient with true seizures usually has abdominal contractions but lacks corneal reflexes, whereas a patient with PNEA usually has corneal reflexes but lacks abdominal contractions. The patient’s general color and vital signs are normal, without any evidence of airway obstruction. Consciousness is often partially preserved and sometimes regained very quickly after the convulsive period with PNEA. Commonly, the patient is fluttering the eyelids or resists having the eyes opened. With eyelids closed, a patient with rapid (saccadic) eye movements is awake. On the other hand, a patient with slow, roving eye movements may have a depressed level of consciousness. Tearfulness during the event argues against epileptic seizure (ES). Ictal eye closure is a highly reliable indicator for PNES, while ictal eye opening is generally an indicator of ES.

With PNEA, there is typically no fecal or urinary incontinence, self-induced injury, or lateral tongue biting. Most true seizures are accompanied by a postictal state of disorientation and altered level of arousal and responsiveness. During an epileptic seizure, the plantar response is often extensor, whereas during a PNEA event it is usually flexor.

Noxious stimuli are not reliable in discriminating between PNEA and epileptic seizure. The remainder of the physical examination should be unremarkable.