A study, published online in the journal Seizure, reveals that over 33% of patients believed to have intractable seizures were actually presenting stress-triggered symptoms.

A team of Johns Hopkins physicians and psychologists found that more than one-third of patients admitted to The Johns Hopkins Hospital’s inpatient epilepsy monitoring unit had symptoms caused by stress, rather than a true seizure disorder.

According to the researchers, these patients, which included mothers in child-custody battles and returning war veterans, as well as over-extended professionals alike, have psychogenic non-epileptic seizures (PNES).

Signs of the condition include:

  • Convulsions

  • uncontrollable movements

  • far-off stares

The researchers note that signs of PNES appear to be stress-related behaviors that mimic and are misdiagnosed as epilepsy, but are not due to abnormal electrical discharges in the brain that characterize the neurological disorder.

Antiseizure medications fail to stop these patients’ symptoms, indicating that there is nothing physically wrong with the their brains’ electrical activity, say the researchers. In addition, the incidence of PNES is increasing, at least by what they have observed in recent months.

Previously, PNES like behaviors were referred to as “hysteria”, whereas now they are usually considered to be part of a “conversion” disorder, in which the patient unconsciously converts emotional dysfunction into physical symptoms.

They highlight that in some cases, patients have become blind or paralyzed as a result of emotional trauma. According to the researchers, physicians have tried not to publicize or bring attention to PNES, as individuals at risk for pseudo-seizures are usually highly suggestible.

In the past few months, media reports from Western New York have described more than 12 female high school students who experienced uncontrollable tics and other movements, which experts now consider to be manifestations of a “contagious” psychiatric, rather than neurological disorder.

According to neurologists and neuropsychologists at the Johns Hopkins University School of Medicine, individuals with PNES do not necessarily experience more frequent or severe stressful events than healthy individuals or those with epilepsy, although PNES patients appear to be unable to effectively deal with those stresses and as a result, feel more distressed by them.

Jason Brandt, Ph.D., senior researcher of the study, professor of psychiatry and behavioral sciences and neurology at the Johns Hopkins University School of Medicine, explained:

“These patients behave as if they have an organic brain disease, but they don’t. 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 researchers say they conducted the study in order to determine why “psychogenic” symptoms so closely simulate a physical disorder and why some individuals are more susceptible than others. They highlight that not every person who is feeling overwhelmed will develop seizure symptoms, and that they are unsure as to how many individuals experience pseudo-seizures.

The researchers enrolled 20 individuals with epilepsy, 40 patients with PNES and 40 healthy control volunteers to participate in the study. The researchers asked all participants to report the frequency of various stressful life events (both positive and negative) over the previous five years.

The participants then appraised the distress these events induced. The researchers found that the number of stressful events were roughly the same in each group, although the PNES group reported much higher distress levels than the other two groups.

In addition, they found that participants in the PNES group were not as likely to plan a course of action to counter stressful life events. Participants who used denial experienced greater distress than patients who did not, highlighting the ineffectiveness of denial as a way of keeping anxiety at bay.

Individuals with PNES not only experience seizure symptoms, but also often have unstable relationships and other problematic behaviors. Many PNES patients have high health care costs and remain occupationally disabled, even years after the non-epileptic nature of their events is identified.

PNES behavior is costly in several ways including; costs of doctor visits, medications that do now work, as well as hospitalizations in specialty units like Hopkins’ epilepsy monitoring unit (EMU).

Patients in the EMU are hooked up to a video camera to capture the onset and characteristics of a seizure, and also an electroencephalogram (EEG), which monitors electrical signals in the brain. Sensors attached to the patients scalp check for abnormal electrical discharges in the brain and check for alignment of seizure behavior. In addition, having disabling seizures that can’t be controlled results in psychological and social costs.

Gregory L. Krauss, M.D., a professor of neurology at Johns Hopkins and one of the study’s co-authors, reveals that it is surprising how many individuals without epilepsy are being referred to his epilepsy unit and that these numbers seem to be increasing. In the past few months, up to half of all patients referred to his unit have pseudo-seizures.

Using a computer analogy, the researchers say that when they discover patients who don’t have a hardware problem, but a software glitch, they get the good news. Krauss explains that often symptoms disappear rapidly. However, according to Brandt, these patients usually need cognitive behavior therapy in order to help them develop more effective ways of coping.

Krauss explained:

“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.”

Krauss, and his team, report that neurologists may be misdiagnosing PNSE patients by misreading their EEGs, and explain that individuals with PNSE can spend numerous years receiving epilepsy treatment.

In 2005, a study involving 46 patients, published in the journal Neurology, revealed patterns seen on 54% of EEG readouts with misinterpreted as epilepsy. Patients often visit Krauss after being told by a neurologist that their EEG shows they have epilepsy.

In 2007, a different study by Krauss, published in Neurology, examined the use of service dogs trained to help individuals suffering from epilepsy. The team found that 4 of the 6 patients who participated in the study actually had PNES, rather than epilepsy. According to the researchers, the dogs may have actually triggered the idea of pseudo-seizures into patients with PNES when alerting them to an oncoming seizure.

The dogs are trained to anticipate overt behavior and presumably are unable to differentiate the difference between true seizure disorders and PNES.

Krauss explained:

“We’re just seeing a large number of these patients, and we’ll probably see more of them.”

Ronald P. Lesser, M.D., and S. Marc Testa, Ph.D., both of Johns Hopkins, also worked on the newest study.

Written By: Grace Rattue