My apologies for using word ‘Pseudoseizures’ – but the more accepted term – Psychogenic Non Epileptic Seizure (PNES) wouldn’t fit in the title 🤷♂️. Some people mistake PNES with faked or factitious seizures aka malingering for secondary gain, hence avoiding the term ‘Pseudoseizures’ is important – it sends the wrong message. PNES is more of a conversion disorder often driven by anxiety , emotional-physical-sexual abuse or stress of a new serious medical diagnosis.
Previously, we had visited location of tongue bite as a possible diagnostic clue when there is doubt about an unwitnessed event being syncope versus epileptic seizure. Let’s talk about eyes – Eyes are powerful, they are often the first thing we notice in a person and they can say what the words cannot express, but in a psychogenic seizure, they speak by staying closed !
A study published in 2006 showed found that 50 out of 52 patients with PNES kept their eyes closed, while 152 of the 156 patients with epileptic seizures (ES) opened their eyes during seizures, confirmed with the gold standard diagnostic test for seizures – the EEG. This rings even more true if the eyes look shut forcefully and are difficult to pry open. So Eyes could be a reliable indicator – not a confirmatory diagnosis, still need to look at the entire picture and consider an EEG. My own experience has been the same, many experienced Neurology unit nurses would tell you the same. Knowing that up to 1/3rd of patients with PNES actually have a history of seizure disorders themselves, it can be useful to avoid a misdiagnosis of a ‘breakthrough’ seizures. I usually educate family members about this too. The other possible movements that tell you it’s not a true seizure include side-to-side head movements, thrashing limbs , talking during the episode. When an anxious patient told me “Doc I am having a seizure” while shaking all over with eyes tightly closed – that was an immediate diagnosis of PNES. I distinctly remember a story where the attending requesting a patient having a ‘seizure episode’ to stop so he could ask him questions, and the patient did !! – *ding ding ding* – we have PNES !
A fun poem to help remember – Imma title this ‘Seizures : Eyes wide shut edition‘
When the eyes are shut,
and head nods a ‘no’,
All limbs be thrashing BUT
It’s not a seizure yo !
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