Mar 21, 2018
Walker Foland is an emergency physician practicing in Michigan
and in this episode breaks down why pseudoseizures, now termed PNES
(Psychogenic Nonepileptic Seizures), are a real disease.
Sign up for the
ERcast mailing list
Are patients with PNES ‘faking it’?
- PNES is a conversion disorder: an unconscious manifestation of
- Walker treats PNES patients with haloperidol or olanzapine with
the thinking that this is psychological, not true epilepsy
- PNES is not ‘faking it’ or lying
- Patients with PNES may also have true epileptic seizures
- Diagnosing PNES, or separating it from epilepsy, may take video
EEG monitoring, a neurologist, and sometimes prolonged periods of
time to figure things out
How to tell the difference between an grand mal
epileptic seizure vs PNES vs faking it?
- Seizures related to a specific stimulus (sound foods, body
- Frequency and amplitude of concussions: same frequency through
the seizure with varying amplitude.
- Maintenance of consciousness and may have some of the below
- may guard the face with passive hand drop
- resist eyelid opening
- visual fixation on a mirror
- Whit Fisher, Dr Procedurettes, squirts water in
the face of patients where there is thought of PNES. If they
grimace, probably not an epileptic seizure.
- Purposeful movement
- Avoids injury
- May use convulsions as a way of harming staff
- Intermittently awake and vocal during the episode
- Convulsive frequency decreases, amplitude increases as seizure
- No response to pain
- Allow passive eye opening
A 2010 article from the Journal of Neurology Neurosurgery and
Psychiatry broke down the evidence of what other elements can help
distinguish PNES from epileptic seizures.
- Duration over 2 minutes suggests PNES, but
we’ve all seen epileptic seizures last for a long time, status, and
some PNES can be super short
- Happens in sleep. Evidence suggests that if
the event happens in sleep, that is probably episode. PNES episodes
happen when awake
- Fluctuating course such as a pause in the
rhytmic movement, epileptic seizures usually don’t pause and then
restart, a pause favors PNES
- Flailing. You’d think the flailing patient has
PNES for sure because epilepsy doesn’t flail, but it does! Flailing
is much more common in PNES, but not so much so that it’s a clear
- Urinary incontinence, more common in epilepsy,
but does happen in PNES.
- Post-ictal recovery period. Surely, this is
the sine qua non of epilepsy. It is way way more common
following generalized epileptic seizures but happens in around 15%
- The sterterous breathing
(noisy, labored) that we see after generalized tonic clonic
epileptic seizures suggests epilepsy and is not a characteristic of
Walker’s take home points
- PNES patients aren’t ‘faking it’
- This is a real disorder, it's just not epilepsy
Chen, David K., and W. Curt LaFrance Jr. "Diagnosis and
treatment of nonepileptic seizures." CONTINUUM: Lifelong
Learning in Neurology 22.1, Epilepsy (2016):
Avbersek, Andreja, and Sanjay Sisodiya. "Does the primary
literature provide support for clinical signs used to distinguish
psychogenic nonepileptic seizures from epileptic seizures?."
Journal of Neurology, Neurosurgery & Psychiatry 81.7
Shen, Wayne, Elizabeth S. Bowman, and Omkar N. Markand.
"Presenting the diagnosis of pseudoseizure." Neurology
40.5 (1990): 756-756.
Full Text PMID:2330101