'Pseudo-epilepsy' is actually stress

Increasing numbers of patients admitted to an epilepsy unit with intractable seizures suffer from stress rather than a true seizure disorder, mental health providers say. Physicians and psychologists say that more than one-third of patients admitted to the Johns Hopkins Hospital inpatient epilepsy monitoring unit have what they are calling “psychogenic non-epileptic seizures,” or PNES. In recent months, the number has been as many as half. The patients’ display of uncontrollable movements, far-off stares, or convulsions are not the result of the abnormal electrical discharges in the brain that characterize epilepsy, but appear to be stress-related behaviors that mimic the neurological disorder and are misdiagnosed. “These patients behave as if they have an organic brain disease, but they don’t,” says Jason Brandt, professor of psychiatry and behavioral sciences and of neurology at Johns Hopkins University School of Medicine. “And it turns out that their life stresses weren’t all that high, but they’re very sensitive to stress and they don’t deal with it well.” The team’s study suggests that people with PNES don’t necessarily experience more frequent or severe stressful events than people with epilepsy or neurologically healthy people. They seem, however, to lack effective coping mechanisms. One clue that epilepsy is not involved in what turn out to be PNES seizures is that anti-seizure medications fail to stop the symptoms, says Brandt, senior author of the study published online in the journal Seizure. That, he says, suggests that nothing is wrong with electrical activity in the patients’ brains. PNES diagnoses appear to be rising, based on what researchers have seen in recent months. In the news In the past, behaviors like PNES were called “hysteria.” Now they are often considered by psychiatrists as part of a “conversion” disorder, in which the patient unconsciously converts emotional dysfunction into physical symptoms. People at risk for pseudo-seizures are typically highly suggestible, which is why physicians often have tried not to draw attention to the condition. In recent months, headlines out of western New York have described a group of more than a dozen female high school students who experienced uncontrollable tics and other movements. Many experts now believe these were manifestations of a “contagious” psychiatric, rather than neurological, disorder. High costs The researchers undertook their study to learn why “psychogenic” symptoms so closely simulate a physical disorder and why some people are more susceptible than others. Clearly, not every overwhelmed person develops seizure symptoms, they note, nor is it known how many people experience pseudo-seizures. They evaluated 40 patients with PNES, 20 people with epilepsy and 40 healthy control volunteers; all were asked to report the frequency of various stressful life events (positive and negative) over the previous five years. Participants then appraised the distress these events induced. Each group reported roughly the same number of stressful events, but the PNES group reported much higher distress levels than the other two and were less likely to plan a course of action to counter stressful life events. Those who used denial—the failure to acknowledge stressors—experienced greater distress than those who did not, illustrating the ineffectiveness of denial as a way of warding off anxiety, Brandt says. Along with seizures, patients with PNES often have other problem behaviors and unstable relationships. Many remain occupationally disabled and have high health care expenditures, even years after the non-epileptic nature of their events is identified, the authors report. The costs of believing you have epilepsy when you don’t are high, Brandt notes. There are the psychological and social costs of disabling seizures. There are also the costs of doctor visits, medication that doesn’t work, and hospitalizations in specialty units. Gregory L. Krauss, a professor of neurology and a study co-author, says he is surprised by how many more patients are being referred to his epilepsy unit without having epilepsy at all. “There’s a lot of stress out there in our modern society, and this research highlights that many people don’t have the skills to cope with that.