Generally, there are many differences between the histories of patients with nonepileptic seizures (NESs) and those of patients with epilepsy.
NESs may occur only in the presence of others or, conversely, may never have been observed. In the latter case the clinician is dependent on the patient's description, which may be fragmentary and incomplete. Indeed, only loss of consciousness may be reported. If such a patient has a history of epilepsy, the probability of misdiagnosis is high.
The interview may reveal a clear emotional trigger for NESs. This criterion is not at all definitive, however, because patients with epilepsy often ascribe seizures to "stress."
The patient's reaction to his or her seizures may offer clues to the diagnosis. The demeanor of the patient with NESs classically has been described as la belle indifference, but many authors have found such indifference to be atypical. More commonly, the patient is quite concerned about the seizures, sometimes excessively so. In fact, an exaggerated emotional response may provide a clue to NESs but should be considered in context with other information.
Treatment with AEDs, regardless of types or combinations, is rarely successful, although transient responses are not uncommon. In fact, increasing doses of AEDs may lead to a paradoxical increase in seizure frequency. Patients with NESs sometimes complain of intolerable side effects at low doses or slow dose escalation of AEDs.
A history of physical or sexual abuse is common in patients with NESs. At an appropriate time the clinician should inquire into this sensitive subject. Drawing firm conclusions from a history of abuse is perilous, however, because abuse is common in people with epilepsy and in the general population. Many people with epilepsy also have poignant histories of childhood or marital abuse.
Finally, suspicion is sometimes kindled by the patient's previous experience with other people who have epilepsy. The person may have encountered seizures in a professional capacity-for example, in a hospital setting. A family member or friend may have seizures, or the patient's own previous or current epileptic seizures may serve as templates for NESs. In addition, cultural influences may play a role in some cases.
Patients with NESs have no characteristic psychologic profile. Perhaps the most consistent results have resulted from the application of the Minnesota Multiphasic Personality Inventory (MMPI). In particular, Dodrill has reported that MMPI profiles differ between patients with epilepsy and those with NESs (Dodrill 1993). The typical findings in many NES patients are relatively high scores on the hysteria and hypochondriasis scales, with a lower score on the depression scale. These characteristics differentiated NESs from epilepsy in about 80% of cases.
Thus, the MMPI offers useful information but cannot be said to have sufficient power for diagnostic certainty. The results of psychologic testing, therefore, must be taken in concert with the results of other testing and considered supportive or nonsupportive of the diagnosis of NES.
Reviewed February 2004 by Orrin Devinsky, MD, New York University
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