MMPI indices in the identification of patients evidencing pseudoseizures

[Psychogenic non-epileptic seizures: history and critique of a concept]

This discussion of the evolution of psychiatric knowledge concerning psychogenic non-epileptic seizures (PNES) sheds light on the epistemological assumptions underlying the concept and on its practical implications as well. PNES are defined as repeated seizures or attacks which can be mistaken for epilepsy because of the similar behavioral changes displayed, but which differ in that they are not the result of abnormal electrical activity in the brain and may be psychogenic in origin. The article investigates the historical development of the concept of PNES over the past forty years. The concepts of psychiatric comorbidity, abuse, and dissociation enter the discussion owing to their roles in the checkered development of the concept of PNES.

Use of the Personality Assessment Inventory as an efficacious and cost-effective diagnostic tool for nonepileptic seizures

Video electroencephalographic monitoring (VEEG) is considered the "gold standard" for making the differential diagnosis between epileptic seizures (ES) and nonepileptic seizures (NES), but is a costly, time-consuming procedure and not readily available in all communities. Of the various diagnostic techniques and measures that have been used, the Personality Assessment Inventory (PAI) has shown promise as an effective psychological screening tool to aid in the differential diagnosis of ES/NES. Using VEEG results as the outcome measure, this study examined the diagnostic effectiveness of the PAI in a group of adults with treatment-refractory seizures. Results indicated that, on psychological screening, patients with NES endorse significantly greater functional consequences of their seizure-like episodes than participants with ES. A "NES Indicator" score, calculated from the PAI Somatization subscales, provided a sensitivity of 84% and specificity of 73% for the diagnosis of NES versus ES. The PAI appears to be a useful screening tool prior to hospital admission for VEEG.

A review of diagnostic techniques in the differential diagnosis of epileptic and nonepileptic seizures

The diagnosis of psychogenic nonepileptic seizures (PNES) is complex. Long-term electroencephalogram monitoring with video recording (video EEG) is the most common method of differential diagnosis of epilepsy and PNES. However, video EEG is complex, costly, and unavailable in some areas. Thus, alternative diagnostic techniques have been studied in the search for a diagnostic method that is as accurate as video EEG, but more cost effective, convenient, and readily available. This paper reviews the literature regarding possible diagnostic alternatives and organizes findings into 7 areas of study: demographic and medical history variables, seizure semiology, provocative testing, prolactin levels, single photon emission computed tomography, psychological testing, and neuropsychological testing. For each area, the literature is summarized, and conclusions about the accuracy of the technique as a diagnostic tool are drawn. Overall, it appears unlikely that any of the reviewed alternative techniques will replace video EEG monitoring; rather they may be more successful as complementary diagnostic tools. An important focus for further investigations involves combinations of diagnostic techniques for the differential diagnosis of epilepsy and PNES.

Clinical features and prognosis of nonepileptic seizures in a developing country

PURPOSE

To determine the predictive value of clinical features and medical history in patients with nonepileptic seizures (NESs).

METHODS

One hundred sixty-one consecutive ictal video-EEGs were reviewed, and 17 patients with 41 NESs identified. NES diagnosis was defined as paroxysmal behavioral changes suggestive of epileptic seizures recorded during video-EEC without any electrographic ictal activity. Clinical features, age, sex, coexisting epilepsy, associated psychiatric disorder, social and economic factors, delay in reaching the diagnosis of NES, previous treatment, and correlation with outcome on follow-up were examined.

RESULTS

The study population included 70% female patients with a mean age of 33 years. Mean duration of NESs before diagnosis was 9 years. Forty-one percent had coexisting epilepsy. The most frequent NES clinical features were tonic-clonic mimicking movements and fear/anxiety/hyperventilation. The most common psychiatric diagnosis was conversion disorder and dependent and borderline personality disorder. Seventy-three percent of patients with pure NESs received antiepileptic drugs (AEDs), and 63.5% of this group received new AEDs. Fifty-nine percent of the patients received psychological/psychiatric therapy. At follow-up, 23.5% were free of NESs.

CONCLUSIONS

All seizure-free patients had two good prognostic factors: having an independent lifestyle and the acceptance of the nonepileptic nature of the episodes. Video-EEG monitoring continues to be the diagnostic method to ensure accurate seizure classification. Establishing adequate health care programs to facilitate access to new technology in public hospitals as well as the implementation of continuous education programs for general practitioners and neurologists could eventually improve the diagnosis and treatment of patients with NESs.

Nonepileptic seizure outcome varies by type of spell and duration of illness

PURPOSE

To determine whether differences in clinical manifestations of psychogenic nonepileptic events are associated with differences in outcome and whether the length of illness before diagnosis correlates with outcome.

METHODS

We reviewed ictal videotapes and EEGs in 85 patients diagnosed with exclusively nonepileptic psychogenic seizures during inpatient CCTV-EEG monitoring at the University of Michigan between June 1994 and December 1996. They were classified into groups of similar ictal behaviors. Fifty-seven of these patients were available to respond to a follow-up telephone survey about their condition 2-4 years after discharge. We examined demographics, baseline EEG abnormalities, and outcome of treatment interventions. We also evaluated whether interventions were more likely to succeed if patients were diagnosed early in the course of the illness.

RESULTS

We found that the largest groups consisted of patients with motionless unresponsiveness ("catatonic," n = 19) and asynchronous motor movements with impaired responsiveness ("thrashing," n = 19). Infrequent signs included tremor, automatisms, subjective events with amnesia, and intermittent behaviors. There was a higher incidence of baseline EEG abnormalities in the thrashing group (31%) than in the catatonic group (0%). There was a higher incidence of complete remission of spells in the catatonic group (53%) than in the thrashing group (21%). Patients who had a more recent onset of seizures (most often within 1 year) were much more likely to have remission of spells after diagnosis.

CONCLUSIONS

Classification of nonepileptic seizures is useful in predicting outcome and may be valuable in further investigation of this complex set of disorders.

Behavioral, psychotic, and anxiety disorders in epilepsy: etiology, clinical features, and therapeutic implications

This chapter deals with some aspects of psychiatric disturbances in people with epilepsy. Because depression and its treatment are extensively described later in this issue, they are not discussed here. The same pertains to forced normalization.

The diagnosis of psychogenic non-epileptic seizures: a review

Diagnosing psychogenic non-epileptic seizures (PNES) is a clinical challenge. There is neither a standard in diagnosing PNES nor a comprehensive theoretical framework for this type of seizure. The diagnosis of PNES must be made by excluding epilepsy. However, epilepsy cannot always be determined and PNES and epileptic seizures may coexist. In this study, the characteristics of PNES and patients are discussed. The diagnosis of PNES and epileptic seizures was facilitated by the simultaneous recording of seizures on video tape and EEG. Seizure provoking techniques, hormonal indices, and psychological methods were also used. The benefits and limitations of these techniques are discussed and proposals are made for clinical guidelines.

Personality profiles of patients with pseudoseizures

Minnesota Multiphasic Personality Inventory profiles were analysed in 55 patients with pseudoseizures (40 patients with pseudoseizures only-pure group, and 15 patients with both pseudoseizures and epilepsy-mixed group). For each of the 10 clinical scales, there were no significant differences between the groups in mean T-score values or the incidence of pathological scores (T-score of 70 or above). In 87.3% of cases in the entire sample (groups combined), at least one clinical scale was elevated in the pathological range. For the combined groups, scales having the highest mean values as well as highest incidence of pathological scores were Schizophrenia, Hysteria and Depression. The mean profile of the entire sample (n = 55) had a two-point code of 8-3 with Schizophrenia and Hysteria as profile peaks. Application of three sets of published criteria for hysteria or conversion yielded markedly different results. This finding underscores the difficulty in evaluating the role of hysteria in pseudoseizures in the absence of a single standard. Mean values and the overall profile of this patient sample were remarkably similar to those found in two previous studies.

Psychogenic nonepileptic seizures

Psychogenic nonepileptic seizures (NES) are commonly encountered in clinical practice, and they may pose difficult diagnostic problems. For appropriate evaluation and treatment of NES, a multidisciplinary team approach is needed; typically, a neurologist with expertise in epilepsy, a psychologist or psychiatrist, and a support staff should be involved. Psychogenic NES have no single initial clinical manifestation, and various etiologic factors may contribute to their development. Of importance, psychogenic NES are "real" seizures that may be as disabling as epileptic seizures. Most often, they occur on a subconscious level, and the patient may have no control over their occurrence. Precipitation or termination of a habitual seizure during video-electroencephalographic monitoring has often been used to distinguish NES from epileptic seizures, but the results can sometimes be misleading. Numerous additional diagnostic techniques can be used to assist in making the diagnosis. Treatment is based on the type of psychiatric disorder present. Favorable prognostic factors include being female and having an independent lifestyle, normal electroencephalographic findings, higher intelligence, and no prior psychotherapy.

Epilepsy, pseudoseizures and perceived family characteristics: a controlled study

Previous research in the area of pseudoseizures has focused upon their phenomenology and the characteristics of the individual with pseudoseizures. This study set out to examine the role of pseudoseizure behaviour in fulfilling a function within the family context. Pseudoseizure patients, patients with epilepsy and healthy controls completed questionnaires measuring the following variables--anxiety and depression, locus of control, self-esteem, family characteristics and perceived seizure severity. People with pseudoseizures perceived their families as displaying less commitment and support to each other (family Cohesion scale) and less emphasis on ethical issues and values (family Moral-religious scale) than both the epilepsy and the control groups. People with pseudoseizures reported levels of family interest in political, social and recreational activities (family Intellectual-cultural scale) similar to people with epilepsy, both these group scores being lower than the control group. The two patient groups also reported higher depression scores than controls, yet only the epilepsy group had lower self-esteem than the controls. These initial findings support a role of family involvement in therapy for people with pseudoseizures and may lead to a better understanding of the aetiology of pseudoseizures, as well as clarifying characteristics which may well aid the differentiation of pseudoseizures from epilepsy.

Psychogenic seizures in old age: a case report

Psychogenic seizures are unusual after age 60 years. A 73-year-old woman had onset of psychogenic seizures at age 69 years. Five to six attacks occurred each month, usually at night, characterized by an initial subjective sensation and headache followed by generalized stiffening and shaking. Continuous EEG-closed circuit television (EEG-CCTV) monitoring clearly showed these episodes to be nonepileptic. Discontinuation of antiepileptic drugs (AEDs) did not increase the frequency or severity of attacks. Epileptiform discharges were not recorded during the awake, drowsy, or sleeping states. Psychiatric evaluation identified significant turmoil in the patient's life and a history of childhood sexual and physical abuse. Psychogenic seizures may begin in old age and should be considered in the differential diagnosis of intractable seizures in the elderly. Predominantly nocturnal occurrence should not exclude the diagnosis.

The diagnosis of pseudoseizures

Increasing experience with intensive monitoring of patients with intractable seizures has shown that a significant number of patients presents with pseudoseizures (psychogenic seizures). While in a majority of the patients differential diagnosis should be obvious, in some patients diagnostic error may occur. This is the case if the physician is unfamiliar with uncommon seizures, if the patient presents with atypical or bizarre attacks, and if interictal and/or ictal EEG are normal. Comparative studies of patients with true convulsive seizures and patients with pseudoseizures have revealed some 'typical' ictal features of pseudoseizures. Of these, longer ictal duration, less stereotypy, asynchronous extremity movements, atypical vocalization, alternating head movements and pelvic thrusting are the most characteristic. Many exceptions exist, however, since many patients with complex partial seizures (mostly of frontal origin) may present with similar ictal features. The final diagnosis of pseudoseizures is based upon integration of numerous data including careful seizure history, results of intensive video EEG monitoring and electroclinical correlation by experienced observers. Psychiatric and personality examination, different techniques of suggestion and determination of serum prolactin may provide additional diagnostic evidence.

Neuropsychological and psychiatric correlates of intractable pseudoseizures

Psychogenic seizures can mimic convulsive epilepsy and with repetitive attacks, iatrogenic complications from aggressive treatment of status epilepticus can occur. We studied neuropsychiatric features of 20 patients in whom psychogenic seizures were intractable and at times continuous. Nineteen of 20 patients seen were female, and all but one were under 40 years of age. All had convulsive attacks resistant to various medications, normal neurological examinations, and negative imaging studies and electroencephalograms (EEGs). Sixteen had previous evidence of epilepsy and the other four had epileptic relatives. Seizures were atypically prolonged, included back arching and pelvic thrusting, and persisted despite intravenous diazepam and therapeutic phenytoin and phenobarbital levels. Seizures terminated spontaneously in five, were stopped by suggestion in four, and persisted until respiratory arrest or elective intubation in 11. Ten patients had conversion disorder, six borderline or mixed personality disorder and four mental retardation. Fifteen had had some precipitating stressor and the remainder had histories of exhibiting attention-seeking behaviour. Nine of 10 patients with conversion disorder had 'conversion V' Minnesota Multiphasic Personality Inventory (MMPI) profiles, while personality disorder patients had elevation of several psychopathological scales. Patients with conversion disorder gradually improved with anticonvulsant discontinuation, while retarded individuals were helped by behaviour modification, situational change or neuroleptics. Personality disorder patients continued to have attacks and eventually discontinued follow-up. Clinical evidence of non-epileptic seizures includes clinical atypicality and long duration, exacerbation by medications and frequent attacks despite normal examination and studies.(ABSTRACT TRUNCATED AT 250 WORDS)

Further evaluation of the MMPI Pan scale in psychiatric and medical patients

The efficiency of a recently developed MMPI scale (Pan) to identify panic disorder was assessed in samples of both psychiatric and medical patients. Particular attention was paid to base rates and cutting scores. The Pan scale was found to have utility in rule-out clinical decision making. Suggestions for further validation studies are discussed.

Factors affecting the outcome of MMPI and neuropsychological assessments of psychogenic and epileptic seizure patients

The literature reveals conflicting information regarding the extent to which psychogenic seizure patients have emotional disorders and neuropsychological deficits as compared with patients with epileptic seizures. Among groups matched for numbers of subjects, age, sex, and years of education, we observed that patients who had solely psychogenic seizures with either a major component of affectual expression or relatively minor motor activity were more disturbed emotionally than epileptic patients with partial seizures. In contrast, the personality characteristics of psychogenic seizure patients whose attacks had either little affectual display or prominent motor expression could not be distinguished from those of epileptic patients with convulsive generalized seizures. Closely matched groups of patients with solely psychogenic seizures, partial seizures, or generalized seizures did not differ in neuropsychological performance. However, psychogenic seizure patients performed much better on neuropsychological measures than a less-well-educated, but otherwise matched group of patients with generalized epileptic seizures.