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  • Review Article
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Differentiating between nonepileptic and epileptic seizures

Abstract

Psychogenic nonepileptic seizures (PNES) resemble epileptic seizures and are often misdiagnosed and mistreated as the latter. Occasionally, epileptic seizures are misdiagnosed and mistreated as PNES. 70% of PNES cases develop between the second and fourth decades of life, but this disease can also affect children and the elderly. At least 10% of patients with PNES have concurrent epileptic seizures or have had epileptic seizures before being diagnosed with PNES. Psychological stress exceeding an individual's coping capacity often precedes PNES. Clinicians can find differentiating between PNES and epileptic seizures challenging. Some clinical features can help distinguish PNES from epileptic seizures, but other features associated with PNES are nonspecific and occur during both types of seizures. Diagnostic errors often result from an overreliance on specific clinical features. Note that no single feature is pathognomonic for PNES. When typical seizures can be recorded, video-EEG is the diagnostic gold standard for PNES, and in such cases a diagnosis can be made with high accuracy. When video-EEG reveals no epileptiform activity before, during or after the ictus, thorough neurological and psychiatric histories can be used to confirm the diagnosis of PNES. In this article, we review the clinical features that can help clinicians differentiate between PNES and epileptic seizures.

Key Points

  • Psychogenic nonepileptic seizures (PNES) are often misdiagnosed and mistreated as epilepsy

  • The majority of patients with PNES have a history of developmental insults or trauma that may cause psychological stress exceeding an individual's coping capacity

  • No single clinical feature is pathognomonic for PNES; thus, diagnostic humility is essential when considering PNES as a patient's diagnosis

  • Specific clinical features can help distinguish PNES from epileptic seizures and, in most cases of PNES, a definite diagnosis can be made with video-EEG—the diagnostic gold standard

  • Consideration of a patient's neurological and psychiatric histories alongside the results of video-EEG can further improve diagnostic accuracy for PNES

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O. Devinsky, D. Gazzola and W. C. LaFrance, Jr contributed equally to researching data for the article, discussion of content, writing, and reviewing and/or editing of the manuscript before submission.

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Devinsky, O., Gazzola, D. & LaFrance, W. Differentiating between nonepileptic and epileptic seizures. Nat Rev Neurol 7, 210–220 (2011). https://doi.org/10.1038/nrneurol.2011.24

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