What is 'Pseudo-Epilepsy'?

Pseudo-epilepsy, which is otherwise known as  psychogenic seizures, psychosomatic seizures, non-epileptic seizures, dissociative seizures or non-epileptic attack disorder are something that I've been seeing more frequently, but what is it?

What is Pseudo-epilespy?

This condition has attacks that may look like epileptic seizures but are not epileptic i.e. there is no electrical misfiring going on in the brain (Non-Epileptic Seizures, NES). Instead they are cause by psychological factor. Sometimes a specific traumatic event can be identified.

20% of people referred to epilepsy centres following seizures, are found to have non-epileptic seizures on video-electroencephalogram monitoring and only 5% of these patients do not have associated comorbidities e.g. other psychiatric issues. Women more commonly affected than men. 

This used to be called somatoform disorders (DSM4) and are now termed somatic symptoms disorders (DSM5) and can also be considered dissociative disorders. There are several types.

1. Organic NES - These seizures have a physical cause e.g. fainting, diabetes, alcohol related and because of this, they may be relatively easy to diagnose and the underlying cause can be found. 

2. Psychogenic NES - Caused by mental or emotional processes, rather than by a physical cause.

There are 3 types of Psychogenic NES:

1. Dissociative seizures 

These happen unconsciously, which means that the person has no control over them and they are not ‘put on’. This is the most common type of NES. 

2. Panic attacks

These can happen in frightening situations, when remembering previous frightening experiences or in a situation that the person expects to be frightening. Panic attacks can cause sweating, palpitations, trembling and difficulty breathing. The person may also lose consciousness and convulse. This can happen at the dentist!

3. Factitious seizures 

This means that the person has some level of conscious control over them. An example of this is when seizures form part of Münchausen’s Syndrome, a rare psychiatric condition where a person is driven by a need to have medical investigations and treatments.

What is the Cause?

Similar to other somatic symptom disorders, a specific traumatic event, such as physical or sexual abuse, incest, divorce, death of a loved one, or other great loss or sudden change can be identified as causation for the condition. 

'Psedudo-epilepsy' can either attributed to somatic symptom or conversion disorders:

1. Somatic symptom disorders (somatoform disorders) - suggestive of a physical disorder, but on examination cannot be accounted for by an underlying physical condition, therefore attributable to psychological factors. 

2. Conversion Disorder - physical symptoms caused by psychologic conflict, unconsciously converted to resemble those of a neurologic disorder. Develop usually during adolescence or early adulthood but may occur at any age, more common in women.

These seizures can 'look' like typical epileptic seizures, such as tonic-clonic, but also less commonly mimic absent or focal impaired epileptic seizures. 

How is it Managed?

After diagnosis (often by video EEG to rule out epilepsy), a referral to psychiatrist is made, where they can offer treatments such as:

  • Eye Movement Desensitization and Reprocessing (EMDR) 
  • Cognitive Behavioral Therapy (CBT)
  • Prolonged Exposure Psychotherapy
  • Interpersonal and Pscyhodynamic Psychotherapy
  • Mindfulness Based Psychotherapy
  • Family Therapy
  • SSRIs

Top Tips for Dental Management

  • Be non-judgemental: Many of these patients face stigma for 'faking' their illness. Their seizures are real... they just don't have an identifiable organic cause. You will lose their trust if you treat them as if their condition isn't 'real'
  • Take a full history: Ask more about their seizures, how long they last, what time of day they occur and what triggers them. Often fatigue and stress bring on their seizures, so treating them earlier in the day and giving them time can reduce the chance of them having a seizure
  • Caution with sedation: Sedation is safe for these patients, BUT from my experience, when the patient recovers they will have a higher chance of having a seizure as they become more aware of their surroundings. You may need to plan for longer recoveries, or try to discharge them as soon as possible so they do not become distressed. 
  • Oral Hygiene and their diet may not be a priority: This might mean higher incidences of caries and periodontal disease. Motivating these patients can be tricky
  • Escort for appointments: A good idea even if you are not performing sedation. Someone who can look after the patient and knows them and their seizures can be invaluable - for possible warning signs of seizures as well as aftercare

What if they have a Seizure? 

Managing any seizure, non-epileptic or not, can be very scary. In general, your management of a non-epileptic seizure will be the same as for epileptic seizures:
  1. Keep the person safe from injury or harm, and only move them if they are in danger
  2. If they have fallen, put something soft under their head to protect it
  3. Allow the seizure to happen, don’t restrain or hold them down
  4. Stay with them until they have recovered.
If you know these seizures are non-epileptic, then midazolam (normally given as rescue medication in epilepsy) will not be helpful - but if you are unsure whether it is an epileptic seizure or not, then give midazolam! I remember seeing a patient who had both non-epileptic and epileptic seizures, which is very confusing, but luckily their carer could recognise each and help manage both. 

Calling for crash team or an ambulance is often unnecessary for non-epileptic seizures, but you should always be safe and if unsure call 999 or 111 for advice depending on the urgency of the situation. 

If you want to learn more about 'pseudo-epilepsy', there's a fantastic book I've mentioned in a previous blog post by Suzanne O'Sullivan called It's All in Your Head. I'd highly recommend!

Do you have any questions about non-epileptic seizures? Please leave them in the comments below

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