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Year : 2019  |  Volume : 41  |  Issue : 5  |  Page : 494-496  

Imaging in psychogenic nonepileptic seizures: An observational study

Department of Neurology, Jawaharlal Institute of Postgraduate Medical Education and Research, D. Nagar, Puducherry, India

Date of Web Publication5-Sep-2019

Correspondence Address:
Dr. Rajeswari Aghoram
Department of Neurology, Jawaharlal Institute of Postgraduate Medical Education and Research, D. Nagar, Pondicherry - 605 006
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJPSYM.IJPSYM_487_18

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How to cite this article:
Aghoram R, Nair PP. Imaging in psychogenic nonepileptic seizures: An observational study. Indian J Psychol Med 2019;41:494-6

How to cite this URL:
Aghoram R, Nair PP. Imaging in psychogenic nonepileptic seizures: An observational study. Indian J Psychol Med [serial online] 2019 [cited 2020 Jun 6];41:494-6. Available from:


Psychogenic nonepileptic seizures (PNES) are characterized by paroxysmal time-limited alterations in motor, sensory, autonomic, or cognitive signs and/or symptoms in the absence of excessive and hypersynchronous brain discharges.[1] It is reported that 5%–10% of outpatients in epilepsy clinics and 20%–40% of patients in epilepsy monitoring units have PNES.[2] Recently, there are reports on associations between PNES and many structural and functional brain abnormalities,[3] suggesting a neurobiological origin for PNES.

We undertook this study to look at the neuroimaging profile of our patients with PNES. This was a cross-sectional analysis of the data collected (from June 2010 to July 2013) for a study on induction techniques in PNES.[4] Demographic data including age, sex, education, occupation, religion, etc.; clinical data including duration of symptoms, use of antiepileptic drugs (AEDs), psychiatric and other comorbidities, coexisting epilepsy, frequency of events, and imaging data were collected after obtaining ethics approval. Imaging results, if available, were reviewed by a neurologist and impression recorded, if required, after discussion with a radiologist. Continuous data were compared using the t-test or Mann–Whitney U test depending upon normality. Frequencies were compared using Chi-squared tests. All data were analyzed using STATA version 14.2, StataCorp, USA.

Seventy-seven subjects with documented PNES [Video-electroencephalograph (VEEG) review by two epileptologists showing typical event in the absence of EEG changes] were included. The mean age of the participants was 22 years (SD 10.8), and 59 (76%) were women. Forty-six (60%) were on AEDs, but only ten (13%) had coexistent epilepsy. None of the participants reported sexual abuse, and two (2%) had a coexistent psychiatric illness (one psychosis and one anxiety disorder). By self-report, 14 (18%) were employed, 11 (14%) were studying, and the rest 52 (68%) described themselves as unemployed. Twenty-eight (36%) had undergone neuroimaging, of which 25 (93%) had undergone CT scans of the brain while only three had undergone MRI.

In univariate analysis, undergoing neuroimaging was associated with secondary school or higher level of education (χ2 = 3.93; P = 0.05) and lack of suspicion of PNES by referring physician (χ2 = 5.69; P = 0.02). The other factors including age, gender, duration of PNES, coexisting epilepsy, and AED intake appeared to be similar in both the groups.

Out of the 28 subjects imaged, 11 (39%; 95% CI 11%–57%) had abnormalities. The abnormalities observed are given in [Table 1]. Calcified granuloma(s) was the most common abnormality, seen in five (45%) of the 11 subjects. Both patients with psychiatric comorbidity had abnormal imaging. Only two patients with coexisting epilepsy were imaged, and one of them had abnormality (right frontal calcification). On univariate analysis, those with abnormal imaging were more likely to be men (OR = 5.6; 95% CI 0.8–45.8) and more likely to be on two or more AEDs (OR = 6.2; 95% CI 0.8–77.1) compared with those with normal imaging. Other features like age, duration of PNES, education levels, and coexisting epilepsy were not different between those with imaging abnormalities and those with normal imaging.
Table 1: Abnormalities detected on neuroimaging

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Patidar et al., in their study on demographic features of subjects with PNES from India, wanted to image all their subjects. However, they reported that only 27 of 50 patients (54%) were imaged.[5] This is, as expected, higher than 36% of subjects who were imaged in our cohort as we only collected imaging data as available at referral. So, we were able to explore the factors that may cause such patients to be more readily imaged. Higher education levels and lesser physician suspicion for PNES were found to be significantly associated with imaging. While we have no direct evidence to suggest that education will lead greater demand for imaging, there is sufficient evidence from literature in epilepsy and other fields that health-seeking behavior improves with education and lower education is associated with higher treatment gaps.[6],[7] Lower physician suspicion for PNES will also understandably lead to increased imaging. Surprisingly, we found no association between frequency of events, coexisting epilepsy, or number of AEDs used with being imaged.

Abnormal structural imaging was seen in 39% (95% CI 11%–57%) in our cohort, with the commonest abnormality being calcified granulomas. This proportion of abnormal findings in structural imaging is similar to the results presented by McSweeney et al.[8] who reported a prevalence of 25%–33% but is larger than the 18.5% reported in Indian PNES patients by Patidar et al. Possibility of incidental findings may be considered, but the prevalence of such findings on brain MRI have been reported to be around 2%[9] and on CT, 1%–19%.[10] Hence, our higher frequency of 39% cannot be accounted for by incidental findings alone.

The importance of the association between abnormalities on imaging and PNES is unclear, as these abnormal findings may be the cause of PNES, the result of unrelated trauma, a marker of associated conditions, or the result of changes secondary to PNES or therapy of PNES. In addition, in resource-poor settings like India where video EEG evaluation of PNES events is difficult, a lack of video EEG evaluation of PNES events is difficult, a lack of awareness of this relatively frequent presence of imaging abnormalities may result in inappropriate exposure of these patients to AEDs and their toxicity.

We also found that abnormalities in imaging were associated with AED polytherapy and male gender. We are unable to explain why abnormal imaging findings were more likely among men. Myers et al. studied gender difference in PNES and reported a significant difference between the genders in the frequency of events, utilization of mental health services, report of sexual trauma, levels of dissociation, and use of avoidance, but they did not comment on neuroimaging.[11] Unfortunately, most studies on PNES neuroimaging have an underrepresentation of men, and the differences between the genders remain unexplored.

The strengths of our study are that all our participants had documented PNES according to International League Against Epilepsy guidelines.[1] The number of subjects in our study is comparable to that in similar studies in the literature. Limitations of our study are that imaging was done according to the discretion of the referring physician, most underwent CT only, and no control group was present.

In conclusion, structural imaging abnormalities are not uncommon in patients with PNES. Further studies are needed to verify if these changes are specific to PNES or due to confounders like epilepsy. Gender differences in PNES also remain to be explored.

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Conflicts of interest

There are no conflicts of interest.

   References Top

LaFrance CW Jr, Baker GA, Duncan R, Goldstein LH, Reuber M. Minimum requirements for the diagnosis of psychogenic nonepileptic seizures: A staged approach: A report from the International League Against Epilepsy Nonepileptic Seizures Task Force. Epilepsia 2013;54:2005-18.  Back to cited text no. 1
Asadi-Pooya AA, Sperling MR. Epidemiology of psychogenic nonepileptic seizures. Epilepsy Behav 2015;46:60-5.  Back to cited text no. 2
Asadi-Pooya AA. Neurobiological origin of psychogenic nonepileptic seizures: A review of imaging studies. Epilepsy Behav 2015;52:256-9.  Back to cited text no. 3
Wadwekar V, Nair PP, Murgai A, Thirunavukkarasu S, Thazhath HK. Semiologic classification of psychogenic non epileptic seizures (PNES) based on video EEG analysis: Do we need new classification systems? Seizure 2014;23:222-6.  Back to cited text no. 4
Patidar Y, Gupta M, Khwaja GA, Chowdhury D, Batra A, Dasgupta A. Clinical profile of psychogenic non-epileptic seizures in adults: A study of 63 cases. Ann Indian Acad Neurol 2013;16:157-62.  Back to cited text no. 5
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Amuthan S, Gururaj G, Satishchandra P. Epilepsy in India II: Impact, burden and need for a multi-sectoral public health response. Ann Indian Acad Neurol 2015;18:369-81.  Back to cited text no. 7
Mcsweeney M, Reuber M, Levita L. Neuroimaging studies in patients with psychogenic non-epileptic seizures: A systematic meta-review. Neuroimage Clin 2017;16:210-21.  Back to cited text no. 8
Morris Z, Whiteley WN, Longstreth WT Jr, Weber F, Lee YC, Tsushima Y, et al. Incidental findings on brain magnetic resonance imaging: Systematic review and meta-analysis. BMJ 2009;339:3016-23.  Back to cited text no. 9
Ogbole GI, Adeleye AO, Owolabi MO, Olatunji RB, Yusuf BP. Incidental cranial CT findings in head injury patients in a Nigerian tertiary hospital. JEmerg Trauma Shock 2015;8:77-82.  Back to cited text no. 10
Myers L, Trobliger R, Bortnik K, Lancman M. Are there gender differences in those diagnosed with psychogenic nonepileptic seizures? Epilepsy Behav 2018;78:161-5.  Back to cited text no. 11


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