From Mystery to Acceptance and Understanding
Psychogenic non-epileptic attacks (PNEA) are behaviors described as a sudden, violent outburst or a fit of violent action or emotion. These attacks resemble epileptic seizures, but are caused by underlying psychological factors rather than by neurological or biomedical ones. What makes PNEA different from other non-epileptic conditions, which are often mistaken for seizures, is that a thorough medical work-up has failed to reveal an organic cause.
During the attack, PNEA can include:
- convulsive movements
- blacking out
- clouded consciousness
- loss of awareness
Like epileptic seizures, they typically occur at random, but may be more likely to occur in particularly stressful situations. PNEA have also been called pseudoseizures, psychogenic seizures, non-electrical seizures, conversion or stress seizures, hysterical fits, spells, events, or episodes. Mental health and medical professionals generally prefer the term “psychogenic attacks” (meaning the attack is generated from the psyche) rather than “pseudoseizures,” as it avoids the implication that the events are being faked, or not really happening, and underscores the psychological basis of the symptom.
Management of these attacks can be very challenging. Patients may refuse to engage in psychotherapy when they believe their symptoms are caused by an underlying physical problem that their doctors are trying to pass off as “all in my head.” However, with timely and accurate diagnosis and adoption of a perspective that includes the biological, psychological, and other factors, these symptoms can become less mysterious as the individual becomes more open to treatment.
PNEA typically first occur between the ages of 20 and 30 years, although cases have been diagnosed as young as age four and as old as 70. They occur most commonly in women. Some individuals with PNEA also have had epileptic seizures which can complicate diagnosis and treatment.
Diagnosis & Assessment
Accurate and timely diagnosis of PNEA is crucial to ensure appropriate care and to avoid unnecessary and potentially dangerous treatments. Unfortunately, diagnosis is often delayed by several years. During this time, patients are typically prescribed anti-epilepsy drugs, which are ineffective with PNEA and often have significant side effects. Approximately a quarter of PNEA patients will have an unnecessary and potentially dangerous ICU admission as a result of a prolonged attack at some point during their illness. Patients often lose driving privileges, lose their jobs, and find their activities restricted—such as, no swimming, climbing, operating power tools—anything where a sudden loss of physical control or consciousness would be dangerous.
Evaluation begins with a thorough medical and neurologic examination to assess neurologic and other physical causes of the seizures. One aspect of the evaluation is obtaining a description or video of the seizures themselves.
Clinical characteristics more commonly seen in psychogenic than in epileptic events include:
- closed eyes (and resistance to others’ attempts to open them)
- limb movement
- side-to-side head movement
- pelvic thrusting
- repeated waxing and waning in the intensity of motor activity
- convulsive activity lasting more than 2 minutes
- absence of turning blue
- vocalization during convulsions
- rapid return of normal cognitive function at the end of the attack.
Injuries are rare with PNEA and typically are limited to bruises or minor lacerations.
Such observations and other information may strongly suggest PNEA, but exceptions occur frequently enough that such signs cannot be reliable to provide a definitive diagnosis. Occurrence of severe falls and injuries does not rule out PNEA, as these can occur, for example, in patients with a history of severe physical abuse in which the patient “relives” the abuse during the attack. One such patient had a childhood history of intentionally breaking her own hand and leg with a hammer or bat on multiple occasions in an effort to deal with severe family dysfunction and abuse.
The gold-standard for definitive diagnosis of PNEA is recording of events on video along with an EEG. This is accomplished through a long-term monitoring session, which consists of admission to a specialized inpatient unit where patients (on video) and their EEG are continuously recorded, 24 hours a day, for several days or up to two weeks until one or more of their typical events occur. If the patient has a normal EEG during the event, then the event can be conclusively diagnosed as non-epileptic. With the elimination of any other biomedical cause, and especially in the presence of corresponding clinical characteristics and psychogenic risk factors, the non-epileptic episode is diagnosed as psychogenic. Such risk factors include significant life events or emotional distress, including finding oneself in an unacceptable or intolerable situation with no escape. However, many patients with PNEA deny that stress is a trigger for their events, possibly due to minimization, denial, or alexithymia (literally, having no words for feelings).
Other risk factors include:
- history of trauma, abuse, or bullying in childhood or young adulthood
- difficulty controlling anger or having grown up in an anger-engendering or anger-prohibiting household (true for men especially)
- prior exposure to seizures in others or oneself
- a history of other medically unexplained symptoms or psychological diagnosis or treatment.
None of these risk factors is diagnostically definitive, and care must be taken to conclusively rule out neurological causes before reaching the diagnosis of PNEA.
Family members should be included during the evaluation whenever possible. They can provide critical details about the patient’s history and the nature, timing and precipitants of attacks that the patient may omit or not be aware of. Families typically are as anxious about the symptoms as the patient—often more so. They have often had to stand by helplessly as the patient, contending with terrifying symptoms, has been given conflicting or confusing diagnoses and ineffective treatments. Therapists trained in family systems include the family in the assessment process and provide a chance to have their observations, fears, and concerns fully heard. Responsive inclusion of the family can be critical to lowering the anxiety of the whole system and to fostering trust in the medical team.
It is important for the individual and family to remember that PNEA is considered a symptom, not a psychiatric diagnosis. PNEA can occur in the context of a number of different disorders including, most commonly, conversion disorder, as well as somatization disorder, PTSD, dissociative disorders, anxiety disorders, and others. If PNEA is present, a therapist and likely a team of professionals will decipher which disorder, or co-occurring disorders, need to be treated.
The first hurdle to be overcome in the treatment of PNEA is acceptance of the diagnosis. A trained healthcare professional, such as a family therapist, will approach discussion and treatment in terms that are positive, non-blaming, respectful, and affirming of both the psychological origin of the symptoms, as well as their involuntary nature, in terms that are common-sense and intuitive.
Patients understandably want to know how these “stress-related” symptoms can be happening to them, especially given the (sometimes apparent) lack of stress in their lives. Others conclude that to eliminate these symptoms, they need to eliminate all stress from their lives. Others worry about how abuse from long ago can be causing such huge problems in the present, especially if they’ve addressed the abuse in previous therapy.
It is not unusual for symptoms to significantly decrease or cease altogether following presentation of the diagnosis without additional treatment, though there is little evidence about the length of such remissions.
Therapy for PNEA generally focuses on understanding the emotional triggers for events, developing problem-solving skills to address the issues relating to the triggering events, encouraging verbalization for patients who may avoid or have difficulty expressing their inner world and who need to decrease anxious over-attentiveness to others and improve self-care skills.