Non-epileptic Seizures

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See also: Faint/Collapse written for patients

Synonyms: non-epileptic attack disorder (NEAD); the use of the terms 'hysterical seizures' or 'pseudoseizures' is now considered to be inappropriate

Non-epileptic seizures (NES) is a descriptive term for a diverse group of disorders which refers to paroxysmal events that can be mistaken for epilepsy but are not due to an epileptic disorder. There are two subcategories of NES:[1]

  • Physiological: includes a broad spectrum of disorders - eg, syncope, paroxysms of acute neurological insults, paroxysmal toxic phenomena, non-toxic organic hallucinosis, non-epileptic myoclonus, sleep disorders, paroxysmal movement disorders, paroxysmal endocrine disturbances and transient ischaemic attacks (TIAs).
  • Psychogenic seizures include different types:[2]
    • Dissociative seizures are involuntary and happen unconsciously. This is the most common type of NES and the person has no control over the seizures.
    • Associated with psychiatric conditions that cause seizures - eg, panic attacks.
    • Factitious seizures - eg, Münchhausen's syndrome, fabricated or induced illness by carers.
  • Psychogenic non-epileptic seizures are the most common paroxysmal event misdiagnosed as epilepsy. They significantly affect the person's quality of life.[3]
  • The true prevalence is unknown. Psychogenic non-epileptic seizures are more common in females.
  • Up to one patient in five with apparently intractable epilepsy referred to specialist centres is found to have no organic cause for their seizures.[4]
  • Any psychological stress exceeding an individual's coping capacity often precedes psychogenic NES.[5]
  • It can be difficult to differentiate NES from epilepsy, especially as the two disorders may co-exist.
  • Epileptic and non-epileptic seizures can look the same and have the same features:[2]
    • They can happen suddenly and without warning.
    • They can include a loss of awareness or the person becoming unresponsive, making strange or repeated movements, or convulsing.
    • They can both cause injury and urinary incontinence.
    • They can both happen when awake and during sleep.
  • It is essential to make a thorough assessment and ensure no further harm is caused by inappropriate diagnosis and treatment.
  • Features suggesting NES include: duration over two minutes, gradual onset, fluctuating course, violent thrashing movements, side-to-side head movement, asynchronous movements, eyes closed and recall for period of unresponsiveness.
  • Features suggesting epilepsy include automatisms, incontinence and biting the tongue.

NES are one of the most common differential diagnoses of epilepsy.[6]The differentiation between epileptic and non-epileptic seizures can be difficult.[7]

Video-electroencephalogram is widely considered to be the gold standard for diagnosing NES.[7]

  • Investigations will depend on the specific presentation of each patient. Investigations include:
    • A full assessment for the presence of any underlying physical cause for epilepsy - eg, electroencephalograph (EEG), MRI brain scan.
    • EEG: provocation by suggestion may be used in the evaluation of non-epileptic attack disorder but its role is limited and may lead to false positive results in some people.[8]
    • Investigations for physical causes of NES - eg, fasting glucose, electrolytes, ECG, echocardiogram.
    • A full psychiatric assessment.
  • Serum prolactin rises in over 90% of patients after a tonic-clonic seizure and 60% of patients after a complex focal seizure (previously called a complex partial seizure). However, an increased postictal prolactin is nonspecific.

A significant number of patients have mixed epileptic and non-epileptic seizure disorders. Psychogenic non-epileptic seizures are often associated with mental health problems (eg, anxiety and depression) and also personality disorders.[9]

Where NES are suspected, suitable referral should be made to psychological or psychiatric services for further investigation and treatment.[8]

  • Management is directed at treatment of the underlying cause.
  • It is essential that patients fully understand the diagnosis of non-epileptic seizures and likely underlying causes/contributory factors. A poor reaction to the diagnosis and lack of understanding with regard to the condition and precipitating factos may lead to a poor prognosis.[10]
  • Various treatments have been tried with variable success for psychogenic NES. Treatment regimes for NES include non-psychological (eg, anti-anxiety and antidepressant medication) and psychological therapies (including cognitive behavioural therapy, hypnotherapy and paradoxical injunction therapy). With paradoxical injunction therapy, the therapist imposes a directive that places the client in a therapeutic double bind that promotes change regardless of the client's compliance with the directive.
  • There is currently no reliable evidence to support the use of any treatment, including hypnosis or paradoxical injunction therapy, in the treatment of NES.[11]
  • A review found that, after a mean follow-up of three years, about two thirds of patients continued to have dissociative seizures and more than half remained dependent on social security.
  • Receiving psychiatric treatment has been associated with a positive outcome in some studies but not in others.
  • A poor prognosis is predicted by a long delay in diagnosis and the presence of psychiatric comorbidity, including personality disorder.

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Original Author:
Dr Colin Tidy
Current Version:
Dr Colin Tidy
Peer Reviewer:
Prof Cathy Jackson
Document ID:
4162 (v4)
Last Checked:
22 February 2016
Next Review:
20 February 2021

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