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Epilepsy or Psychological Seizures? Eye Movements May Help Doctors Tell the Difference
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June 12, 2006 -- A surprisingly large percentage of the epilepsy patients who do not respond to medication don't really have the disorder. It often takes a decade or longer for these patients to get a correct diagnosis, but new research finds there are simple clues that can make a correct diagnosis easier.
A patient's eye movements during a seizure can help distinguish seizures caused by epilepsy from those psychological in nature.
That is the finding from one of three new studies examining the diagnosis of nonepileptic seizures published in the June issue of the journal Neurology.
Videos of Seizures
Researchers from the Barrow Neurological Institute in Phoenix, Ariz. reviewed videos of 221 people having seizures. They found that 50 of the 52 people having nonepileptic seizures closed their eyes during the event, while 152 of 156 having epileptic seizures kept their eyes open or blinked until the seizure was over.
Researcher and neurologist Steve S. Chung, MD, says that observation could potentially shorten the time to an accurate diagnosis for many patients.
"We need to confirm these results, but these findings could help guide us toward the appropriate diagnosis early on," he says. "In our experience, family members can accurately describe whether a patient's eyes were open or closed during a seizure."
Getting a Correct Diagnosis
Getting a Correct Diagnosis
Roughly one in three patients with a diagnosis of epilepsy is not helped by antiseizure drugs. It is believed that as many as a third of these patients don't have epilepsy at all.
Instead of being caused by abnormal electrical activity in the brain, as is the case with epilepsy, the nonepileptic seizures are psychological in origin.
University of South Florida neurologist Selim R. Benbadis, MD, tells WebMD that it takes an average of seven to nine years for patients with psychological nonepileptic seizures to get a correct diagnosis.
Recording Electrical Signals
This can usually be done with a video-electroencephalogram (EEG), but that test is not performed as often as it should be, Benbadis says. An EEG records electrical signals in the brain through sensors placed on the scalp. In the video-electroencephalogram, patients are videotaped while their EEG is recorded, usually over the course of several days.
"Neurologists don't tend to suspect nonepileptic seizures early on, even when the patient is not responding to drugs," Benbadis says. "They often try different drugs for years without success."
Understanding the difference between epileptic and nonepileptic seizures could help raise suspicion earlier and help a large number of patients avoid years of unnecessary drug treatment, Benbadis says.
Health Trauma May Trigger Seizures
Health Trauma May Trigger Seizures
In a second study, researchers compared 26 people whose nonepileptic seizures began when they were aged 55 or older with 241 people whose nonepileptic seizures started at a younger age.
Compared with the younger seizure patients, patients with nonepileptic, psychological seizures beginning later in life were roughly twice as likely to be male, and eight times as likely to have other severe health problems.
The older group was more likely to report health-related traumatic experiences (47% compared to 4%) and less likely to report a history of sexual abuse (4% vs. 32%).
"Our findings suggest that the development of physical ill health, especially when it has been frightening to the patient, may be an important triggering factor for nonepileptic seizures," says researcher Roderick Duncan, MD, PhD, of the West of Scotland Regional Epilepsy Service in Glasgow.
Raising Awareness
The third study involved 18 people treated in emergency rooms for seizures that did not respond to drugs. Compared to patients with epileptic seizures, those with nonepileptic seizures were more likely to be younger -- with an average age of 25 vs. 42 -- and have lower blood levels of the muscle enzyme creatine kinase, which normally rises after epileptic seizures.
Benbadis says the three studies should help raise awareness about psychologically-based nonepileptic seizures among patients and their doctors.
"When a patient has seizures but doesn't respond to treatment, it is appropriate to try different medications for a few months or even a year or two," he says. "After that, there are just two possibilities. Either it is not epilepsy, or it is epilepsy that is not responsive to drugs. In both cases, these patients need to be monitored at an epilepsy center to determine where to go from there."
SOURCES: Duncan, Chung, Holtkamp, Neurology, June 13, 2006; vol. 66: online edition. Steve S. Chung, MD, department of neurology, St. Joseph's Hospital and Medical Center, Phoenix, Ariz. Selim R. Benbadis, MD, Tampa General Hospital, University of South Florida, Tampa.
© 2006 American Academy of Neurology
Brief Communications
Ictal eye closure is a reliable indicator for psychogenic nonepileptic seizures
From the Departments of Neurology (S.S.C., P.G.) and Clinical Neuropsychology (K.A.K.), Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ.
Address correspondence and reprint requests to Dr. Steve S. Chung, Department of Neurology, 500 West Thomas Road, Suite 300, Phoenix, AZ 85013; e-mail: sschung@chw.edu
Using data from video-EEG monitoring, the authors studied whether ictal eye closure was a reliable indicator of psychogenic nonepileptic seizures (PNES). Among the 52 patients with PNES, 50 consistently closed their eyes, while 152 of the 156 patients with epileptic seizures (ES) opened their eyes during seizures. These findings suggest that ictal eye closure is a highly reliable indicator for PNES, while ictal eye opening is an indicator of ES.
Additional material related to this article can be found on the Neurology Web site. Go to www.neurology.org and scroll down the Table of Contents for the June 13 issue to find the title link for this article.
Disclosure: The authors report no conflicts of interest.
Received July 20, 2005. Accepted in final form February 27, 2006.
See also pages 1644 and 1727
Related articles in Neurology:
- June 13 Highlights
Neurology 2006 66: 1616-1617.[Full Text] - Avoiding the costs of unrecognized psychological nonepileptic seizures
- W. Curt
LaFrance, Jr and Selim R. Benbadis
Neurology 2006 66: 1620-1621.[Full Text] - Late onset psychogenic nonepileptic attacks
- Roderick
Duncan, Meritxell Oto, Emma Martin, and Anthony Pelosi
Neurology 2006 66: 1644-1647.[Abstract] [Full Text] - Diagnosis of psychogenic nonepileptic status epilepticus in the emergency setting
- Martin
Holtkamp, Jalal Othman, Katharina Buchheim, and Hartmut Meierkord
Neurology 2006 66: 1727-1729.[Abstract] [Full Text]
This article has been cited by other articles: (Search Google Scholar for Other Citing Articles)
W. C. LaFrance Jr
and S. R. Benbadis
Avoiding the costs of unrecognized psychological
nonepileptic seizures
Neurology, June 13, 2006; 66(11): 1620 - 1621.
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| Source: American Academy of Neurology (AAN) | Released: Wed 07-Jun-2006, 08:00 ET Embargo expired: Mon 12-Jun-2006, 16:00 ET |
Clues Help Identify Psychological Seizures
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Keywords AMERICAN ACADEMY OF NEUROLOGY, SEIZURES, PSYCHOLOGICAL, NEUROLOGY |
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Description Up to 30 percent of those diagnosed with epilepsy don’t actually have the disorder. They have psychological nonepileptic seizures, or psychogenic seizures, that are caused by psychological conditions, not by the abnormal electrical activity in the brain that causes epileptic seizures. |
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Newswise — Up to 30 percent of those diagnosed with epilepsy don’t actually have the disorder. They have psychological nonepileptic seizures, or psychogenic seizures, that are caused by psychological conditions, not by the abnormal electrical activity in the brain that causes epileptic seizures.
Because these nonepileptic seizures are similar to epileptic seizures, they can be difficult to diagnose. Three new studies published in the June 13, 2006, issue of Neurology, the scientific journal of the American Academy of Neurology, may help make that diagnosis easier.
“The need for an accurate diagnosis early on is crucial,” said neurologist Selim Bendadis, MD, of the University of South Florida in Tampa, who wrote an editorial accompanying the studies. “Right now there is an average of seven to nine years from the time someone first has these seizures and when they are correctly diagnosed with psychological nonepileptic seizures. During that time, they are given drugs for epilepsy that do not treat their problem and they undergo repeated testing – they pay a price physically, socially and financially.”
In the simplest of the three studies, researchers reviewed videos of 208 people whose seizures were monitored at Barrow Neurological Institute in Phoenix, AZ. They found that 50 out of 52 people with psychological nonepileptic seizures closed their eyes during seizures, while 152 out of 156 people with epileptic seizures opened their eyes during seizures.
“We need to confirm these results, but these findings could help guide us toward the appropriate diagnosis early on,” said the study author, neurologist Steve S. Chung, MD. “In our experience, family members can accurately describe whether a patient’s eyes were open or closed during a seizure.”
The second study compared 26 people whose psychological nonepileptic seizures began when they were 55 or older to 241 people whose nonepileptic seizures started when they were younger than 55. The researchers found that those with late onset nonepileptic seizures were more likely to be male (42 percent compared to 23 percent) and have severe health problems (42 percent and eight percent). The late onset group was more likely to report health-related traumatic experiences (47 percent compared to four percent) and less likely to report a history of sexual abuse (four percent and 32 percent).
“Our findings suggest that the development of physical ill health, especially when it has been frightening to the patient, may be an important triggering factor for nonepileptic seizures in a subset of patients,” said study author Rod Duncan, PhD, of the West of Scotland Regional Epilepsy Service in Glasgow.
The third study examined 18 people seen in the emergency room for continuous seizures, or status epilepticus, that did not respond to epilepsy medication. Compared to those with epileptic seizures, those with nonepileptic seizures were more likely to be less than 30 years old, were more likely to have a port system implanted for administration of IV drugs and had lower blood levels of the enzyme creatine kinase, which normally rise after epileptic seizures.
“These characteristics can help guide the emergency doctor to the correct diagnosis, which is so critical in these cases, because the drugs can result in severe complications if it is in fact not epilepsy,” said study author and neurologist Martin Holtkamp, MD, of Charité – University Medicine Berlin in Germany. “Yet an immediate diagnosis is required, even though there is often no time to access EEG recordings and the patient’s detailed history.”
Benbadis said, “The ‘red flags’ raised by these studies make a major contribution in helping raise awareness about making the diagnosis of psychological nonepileptic seizures when dealing with seizures that do not respond to medications.”
The American Academy of Neurology, an association of more than 19,000 neurologists and neuroscience professionals, is dedicated to improving patient care through education and research. A neurologist is a doctor with specialized training in diagnosing, treating, and managing disorders of the brain and nervous system such as Alzheimer’s disease, epilepsy, Parkinson disease, multiple sclerosis, and stroke. For more information about the American Academy of Neurology, visit http://www.aan.com.
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