Eye closure and other signs of psychogenic nonepileptic seizures

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By Douglas J Lanska MD MS MSPH

Article under review: Chung SS, Gerber P, Kirlin KA. Ictal eye closure is a reliable indicator for psychogenic nonepileptic seizures. Neurology 2006;66:1730-1.

Background: Unfortunately, physicians (including neurologists and psychiatrists) are often reluctant to diagnose psychogenic nonepileptic seizures, and furthermore are reluctant to try to manage patients with recognized psychogenic nonepileptic seizures without anticonvulsants (eg, to avoid the possibility of not treating seizures in patients with both epilepsy and psychogenic nonepileptic seizures) (Benbadis et al 2001). There is an average delay of 7 years between onset and the correct diagnosis of psychogenic nonepileptic seizures (Reuber et al 2002). Delay in diagnosis results in inappropriate treatment, significant risks of iatrogenic illness (eg, from adverse effects of medications, oversedation requiring intubation, vascular access, etc.), and a worse prognosis for psychogenic nonepileptic seizures (Henry and Drury 1997; Carton et al 2003; LaFrance and Benbadis 2006).

Several authors have identified helpful historical, ictal, or postictal features that should raise suspicion of psychogenic nonepileptic seizures (Benbadis et al 1995; Flugel et al 1996; Kubic et al 2004; Pappano and Bass 2004; Benbadis 2005; 2006; Chabolla and Shih 2006).

Table 1: Features That Should Raise Suspicion of Psychogenic Nonepileptic Seizures

  • History

-- Unusual seizure triggers (stress, getting upset, pain)
-- Seizures in the waiting room or office
-- Chronic pain or "fibromyalgia"
-- A "florid" review of systems
-- Psychiatric diagnoses
-- Previous mental health hospitalizations
-- Psychosocial dysfunction
-- Repeatedly normal EEGs

  • Ictal

-- Very gradual onset or termination
-- Induction or termination with placebo
-- Crying
-- Stuttering
-- Closed eyes
-- Active resistance or opposition to attempts at opening the eyelids by the examiner (including Bell phenomenon)
-- Clenched mouth during a "tonic spell"
-- Biting the lip or tip of the tongue
-- Bilateral movements with preserved awareness
-- Asynchronous movements
-- Side-to-side movements (eg, head turning)
-- Alternating movements on opposite sides (hand pounding)
-- Pelvic thrusting
-- Opisthotonus (back arching)
-- Directed aggression
-- Duration longer than 5 minutes

  • Postictal

-- Rapid recovery
-- Whispered voice
-- Partial motor responses to commands

Note that a nonspecific history of tongue biting does not discriminate between seizures and psychogenic nonepileptic seizures (Stone and Duncan 2005). Lateral tongue biting is highly specific to generalized tonic-clonic seizures (Benbadis et al 1995), but biting the lip or tip of the tongue can indicate syncope or psychogenic nonepileptic seizures (Benbadis et al 1995; DeToledo et al 1996; Stone and Duncan 2005).

Also note that complex partial seizures of frontal lobe origin can present with a bizarre constellation of symptoms leading to erroneous diagnoses of psychogenic nonepileptic seizures (Williamson et al 1985; Saygi et al 1992).

Table 2: Features of Complex Partial Seizures of Frontal Lobe Origin

  • Brief, frequent attacks
  • Vocalization
  • Complex motor automatisms

-- Side-to-side head movements
-- Kicking
-- Thrashing
-- Sexual automatisms including pelvic thrusting
-- Brief bicycling movements
-- Flipping into a prone position ("body flipping")

  • Rapid postictal recovery

Purpose: To assess whether ictal eye closure was a reliable indicator of psychogenic nonepileptic seizures.

Study design: Retrospective study.

Methods: Data from 234 consecutive patients who underwent video-EEG monitoring using standard scalp electrodes were studied. Patients ranged in age from 6 to 65 years. Antiepileptic drugs were typically reduced or discontinued to increase the likelihood of seizures for diagnostic purposes. EEGs and video clips were reviewed and classified as either epileptic seizures or psychogenic nonepileptic seizures. Video clips were subsequently reviewed (apparently not fully blinded to the classification of epileptic seizures or psychogenic nonepileptic seizures) to determine whether the patient's eyes were open or closed during the seizure.

Results: Nine hundred thirty-eight seizures were reviewed from 221 patients (median = 4 seizures per patient). One hundred fifty-six patients (71%) had epileptic seizures (129 [58%] with partial seizures and 27 [12%] with generalized seizures), 52 had psychogenic nonepileptic seizures (24%), and 13 had no events recorded (6%).

The frequency of ictal eye closure varied markedly by seizure type:

  • Partial epileptic seizures 3/129 = 2%
  • Generalized epileptic seizures 0/27 = 0%
  • All epileptic seizures 3/156 = 2%
  • Psychogenic nonepileptic seizures 50/52 = 96%

Patients with epilepsy almost always had their eyes open (and possibly deviated to 1 side) at the start of a seizure, followed by rhythmic eye blinking during tonic-clonic activity, and eye closure postictally. All 8 patients with frontal-lobe-onset partial seizures had their eyes open during their seizures.

Patients with psychogenic nonepileptic seizures typically closed their eyes for the entire duration of the seizure and some closed their eyes forcefully with facial frowning. Ictal eye closure strongly predicted psychogenic nonepileptic seizures with a sensitivity of 0.96, a specificity of 0.98, and a positive predictive value of 0.94.

Conclusions and commentary: Several authors have previously noted that eye closure during a seizure is suggestive of psychogenic nonepileptic seizures (DeToledo et al 1996; Flügel et al 1996; Reuber et al 2000; Benbadis 2006). Certainly, sustained forceful eye closure with active resistance or opposition to attempts at opening the eyes by the examiner (including demonstration of Bell phenomenon with the examiner's attempts at opening the patient's eyes) strongly supports psychogenic nonepileptic seizures. The present results suggest that observation of eye closure during a seizure is strongly predictive of psychogenic nonepileptic seizures.

Further blinded prospective studies are needed to validate these results with ascertainment of seizure type independent of eye closure, and with assessment of eye closure independent of seizure classification. As suggested by the authors, further studies are also needed to determine if these results can be applied to historical information obtained from witnesses (eg, family members, nurses, or health care professionals) outside of the video-EEG monitoring environment.