Epilepsy versus non-epileptic attack disorder: A diagnostic and therapeutic challenge

Epilepsy and non-epileptic attack disorder (NEAD) share a vast number of clinical features, however the aetiology and management are very different. Video-EEG is the gold standard diagnostic tool and relies on the occurrence of seizure activity during assessment to make a diagnosis. Added complexity arises from the co-existence of epilepsy and NEAD, occurring in a significant proportion of patients. Comprehensive assessment and investigation is therefore required to prevent gross mistreatment in this diagnostically difficult subgroup. We present a case of NEAD with co-existing epilepsy and the challenges that this may present in clinical practice.

Association between Epilepsy and Psychogenic Non-Epileptic Seizures: A Case Report

Epilepsy is a very complex disorder of the central nervous system. It is characterized by a sudden, disordered and excessive neuronal shock that causes different clinical evidences with specific related electroencephalogram (EEG). Psychogenic Non-Epileptic Seizures (PNES) can seriously complicate the diagnosis of epilepsy. The separoxysmal events have the same clinical evidences of epilepsy, such as an impairment of the self-control and a range of sensory, motor and mental manifestations, without the typical related electroencephalogram (EEG) because of the absence of an organic cause. The overwhelming majority of Psychogenic Non-Epileptic Seizures are related to psychological factors like dissociation. This is a defense mechanism used to cope stressful events or emotional conflicts. Psychological or psychiatric disorders, like Post Traumatic Stress Disorder (PTSD), are frequently associated to Psychogenic Non-Epileptic Seizures. In this article, we present a case report of epilepsy combined with Psychogenic Non-Epileptic Seizures. A joint intervention is of great significance in this occurrence. The subject received a psychological assessment including psychometric and projective tools. He stood MMPI-2, Wais-R, SCL-90, Rorschach test and graphic tests. A psychological disorder related to defense mechanisms was identified. The subject presents a tendency to convert his fears and emotive pains in rational and more socially acceptable problems, using his body to express his discomfort. Patient with epileptic seizures should receive a psychological assessment to exclude Psychogenic Non-Epileptic Seizures. Further studies should propose guidelines to integrate neurological, psychiatric and psychological intervention.

The first-line management of psychogenic non-epileptic seizures(PNES)in adults in the emergency:a practical approach

Distinguishing non-epileptic events,especially psychogenic non-epileptic seizures(PNES),from epileptic seizures(ES)constitutes a diagnostic challenge.Misdiagnoses are frequent,especially when video-EEG recording,the gold-standard for PNES confirmation,cannot be completed.The issue is further complicated in cases of combined PNES with ES.In emergency units,a misdiagnosis can lead to extreme antiepileptic drug escalade,unnecessary resuscitation measures(intubation,catheterization,etc.),as well as needless biologic and imaging investigations.Outside of the acute window,an incorrect diagnosis can lead to prolonged hospitalization or increase of unhelpful antiepileptic drug therapy.Early recognition is thus desirable to initiate adequate treatment and improve prognosis.Considering experience-based strategies and a thorough review of the literature,we aimed to present the main clinical clues for physicians facing PNES in non-specialized units,before management is transferred to epileptologists and neuropsychiatrists.In such conditions,patient recall or witness-report provide the first orientation for the diagnosis,recognizing that collected information may be inaccurate.Thorough analysis of an event(live or based on home-video)may lead to a clinical diagnosis of PNES with a high confidence level.Indeed,a fluctuating course,crying with gestures of frustration,pelvic thrusting,eye closure during the episode,and the absence of postictal confusion and/or amnesia are highly suggestive of PNES.Moreover,induction and/or inhibition tests of PNES have a good diagnostic value when positive.Prolactinemia may also be a useful biomarker to distinguish PNES from epileptic seizures,especially following bilateral tonic-clonic seizures.Finally,regardless the level of certainty in the diagnosis of the PNES,it is important to subsequently refer the patient for epileptological and neuropsychiatric follow-up.