Psychogenic nonepileptic “seizures” or “attacks”?

Psychogenic nonepileptic seizures (PNES) are paroxysmal, time-limited alterations of bodily/mental function, manifested in movement, behavior, or sensations that are of psychological etiology. The seizures in PNES can resemble epileptic seizures; however, they differ in that epileptic seizures are manifestations of abnormal synchronized cortical neuronal activity (epileptiform discharges) usually visualized on EEG. Recent literature has abandoned the use of older PNES terminology such as pseudoseizures and hysteroepilepsy, possibly because of definition ambiguity and possibly because those pejorative terms distance patients from providers.

Some clinicians have requested changing the term PNES to psychogenic nonepileptic attacks to distinguish nonepileptic seizures from “true seizures” and thus avoid misunderstanding. While there may be some controversy about PNES terminology, I submit that the terminology of PNES should stand on the grounds that the resistance of some clinicians to adopt the term PNES is based on a misinformed defense that seizures are, by definition, epileptic. As noted by the International League Against Epilepsy consensus, the word seizure derives from the Greek, meaning to take hold. A seizure, by definition, is a sudden onset of symptoms. The seizure may be descriptively modified by the preceding term “epileptic,” but that it is attributed to epileptiform activity is not inherently invested in the word “seizure.”

An analogy that illustrates the irrationality of the idea that seizure is only associated with epilepsy is found in the term “headache.” Clinicians use descriptors for various headaches to differentiate the type of headache, such as migraine headache vs tension headache (attributing functional etiology), without giving this a second thought. The analogy also is extended to the movement disorder field, where “psychogenic” is used to more clearly define dystonia, tremor, and others. Moreover, there is no controversy among the movement specialists to remove “movement” from psychogenic movement disorder. This thinking easily applies to seizure, also. In paroxysmal, time-limited, ictal presentations, there are epileptic seizures, physiologic nonepileptic seizures (e.g., convulsive syncope and seizures induced by a transient, causal agent such as electrolyte disturbance or intoxication), and psychogenic nonepileptic seizures.^1,2 The adjectives “psychogenic nonepileptic” distinguish PNES from both physiologic nonepileptic seizures and from psychologically triggered epileptic seizures (e.g., mental activity, emotion- or stress-triggered).^3–8

The 3rd edition of Gates and Rowan's Nonepileptic Seizures was recently published.⁹ Consistent with the first 2 editions and with research on terminology showing that most neurologists/epileptologists use the term PNES,¹⁰ the editors believe that PNES is the most appropriate term for this condition, moving beyond the pejorative connotation that “pseudoseizures” or “spells” carry, and the baggage that “psychogenic nonepileptic attack” has in patients with PNES (many of whom have histories of abuse, rape, or trauma), who literally have been attacked. Ultimately, a seizure is a syndrome of multiple etiologies, and just as headache and dystonia describe a syndrome, seizure does not equal epileptic “attack” with synchronous cortical activity. If there is confusion as to what type of seizure it is, we need to better explain what type it is and what treatment is indicated. Building rapport with our patients and their families improves outcomes. The term PNES provides clarity for patients, families, and providers, while not estranging them and preparing them for appropriate treatments.

DISCLOSURE

Dr. LaFrance serves on the editorial boards of Epilepsia and Epilepsy & Behavior; receives royalties from the publication of Gates and Rowan's Nonepileptic Seizures, 3^rd ed. (Cambridge University Press, 2010); receives research support from the NIH (NINDS 5K23NS45902 [PI]), Rhode Island Hospital, the American Epilepsy Society, the Epilepsy Foundation, and the Siravo Foundation; and has acted a legal expert for Healthcare Litigation Support.

Address correspondence and reprint requests to Dr. W. Curt LaFrance, Jr., Division of Neuropsychiatry and Behavioral Neurology, Rhode Island Hospital, 593 Eddy Street, Potter 3, Providence, RI 02903 William_LaFrance_Jr@Brown.edu

See page 84

Disclosure: Author disclosures are provided at the end of the article.

Received February 1, 2010. Accepted in final form April 1, 2010.