Imperial College London



PSYCHOGENIC SYMPTOMS ARE NOT ONLY FOR THE EPILEPTOLOGIST: ALL PHYSICIANS BE AWARE!Selim R. Benbadis, MDUniversity of South Florida2 Tampa General CircleTampa, FLPhone: 813-259-8577Fax: obsolete; do not useEmail: HYPERLINK "mailto:sbenbadi@health.usf.edu" sbenbadi@health.usf.edu Richard Sutton National Heart & Lung InstituteImperial CollegeLondon, UKCharacter count for title: 82Word count: 938Search terms: seizures, syncope, psychogenicPsychogenic symptoms are pervasive in medicine and are likely under-diagnosed and under-reported for two reasons: 1) Their psychological origin, while often suspected, is usually difficult, and sometimes impossible, to prove; 2) It is safer, at least initially, for both the patient and the doctor to err on the side of organic illness.Among all psychogenic symptoms, psychogenic nonepileptic seizures events (PNEES) are by far the best studied. (We will use the term “events” in order to avoid the confusing term “seizures” here [1, 2]) Within neurology, movement disorders are also relatively well documented and studied. In cardiology, common psychogenic symptoms are non-cardiac chest pain and psychogenic pseudosyncope (PPS). The pathophysiology, or rather psychopathology, is similar for psychogenic symptoms regardless of the presenting symptoms. For patients with spells or fits, whether they are labeled PPS or PNES depends mostly on what they resemble more (shaking = seizure, limp = syncope) and to which specialist they present.In this issue of Neurology, Blad et al [31] report a sizeable group of patients with both vasovagal syncope (VVS) and psychogenic pseudosyncope (PPS). The two were coexisted more than they should by chance. Not surprisingly, the “red flags“ that suggested a psychogenic origin were similar to those that are well established for PNES [42] (see Table 1). This study is an important illustration of embellishment, or exaggeration of organic symptoms. Thus, the symptoms here can be viewed as partially psychogenic. The tilt-table procedure, like any medical procedure, acts like a provocative technique both in suggestible patients, those with PPS [42], and in those constitutionally vulnerable to vasodepression [53]. “Embellishment” is similar to subconsciously learning from VVS symptoms and signs to manifest PPS. The findings of Blad et al have important practical implications. Internists and cardiologists who evaluate syncope should consider the diagnosis of PPS more often and earlier, just like most neurologists have learned to consider the diagnosis of PNES in patients with refractory seizures. Early consideration of the diagnosis of PPS is rare among cardiologists, and only those with a special interest in syncope will currently make this diagnosis. It is likely that PPS accounts for a proportion of the group labeled “syncope of unknown origin”, although this group has decreased in numbers in recent years [64]. Because of this, the diagnostic delay for PPS is likely to be long and possibly longer than the 7-10 year diagnostic delay of PNEES [42].Another important lesson is that tilt-table tests would offer enhanced diagnostic capability by being performed routinely with EEG monitoring. “Ictal” recording easily distinguishes organic syncope (of any cause) and PPS, due to a predictable and sensitive series of changes [75]. For routine EEG monitoring during tilt to be achieved, close cooperation between neurologist and cardiologist is necessary and, unfortunately, is usually lacking. A potential limitation of the benefit of EEG monitoring is that EEG changes may not be present (“false negative”) in incomplete or “pre” syncope (e.g., dizziness, lightheadedness), but this is no different from ictal EEG being “negative” in very mild or limited “simple” partial seizures. The authors show that VVS and PPS often concur, suggesting that VVS plays an etiological role in PPS: an interesting hypothesis, but there is no proof that this is the case. Historically, the very first attack is often the most typical of VVS in a PPS patient. Those patients who come to tilt-table testing rather obviously are those where the coincidence is seen, although these persons represent a small minority of patients with syncope.If a standing provocation test were performed on all patients with syncope unexplained by history, physical and 12-lead ECG, a notable and larger proportion with PPS might be found and coincidence with VVS may be less. In parallel, most patients with PNES do not have coexisting epilepsy [86]. While psychogenic symptoms or signs exist in all specialties, PNEES are the most provable of all psychogenic symptoms, so they have been well studied. Since the advent of EEG-video monitoring, a consistent finding at epilepsy centers is that about 30% of patients with refractory seizures actually have PNEES. All specialties have their equivalent psychogenic symptoms: shortness of breath and cough in pulmonary medicine, constipation and abdominal pain in gastroenterology, blindness in ophthalmology, dysphonia or globus in otolaryngology, etc. Interestingly, pain is the least provable psychogenic symptom, so much so that the diagnosis of “psychogenic pain” is no longer accepted. Chronic pain conditions, such as fibromyalgia, continue to be controversial as to whether they are organic or psychogenic [42, 97]. Common features of psychogenic symptoms exist, whichever the specialty. They are first diagnosed as, and may coexist with, the ‘mimicked’ organic illness. In general, most patients with psychogenic symptoms are not consciously faking (factitious, malingering) but rather fall under the unconscious category (formerly somatoform disorders, now somatic symptom disorders). It then follows that if 30% of refractory seizures are psychogenic, it is likely {honestly I prefer “likely” to “possible” here } that 30% of refractory unexplained syncope is psychogenic, or partly embellished by a psychogenic component.The last, and rather sad, common feature of psychogenic symptoms across all specialties is that it is difficult to find good treatment. At least for PNES, there is recent evidence that SSRIs and CBT can be effective [108, 119]. This may not be the case for PPS, but successful treatment depends on rarely encountered mental health professionals, most of whom pay little attention and show little interest in this category of disorders [42, 1210].Table 1. Clinical features of psychogenic pseudosyncopeProlonged duration or delayed recovery, Atypical triggersHigh attack frequencyEye closure during attackLack of prodromeAttacks refractory to accepted methods in VVS (explanation, fluid, salt, and counter-pressure maneuvers) An attack occurring in office or waiting roomActive collapse in contrast to crumpling in VVSIncreased heart rate in attackREFERENCES1. Benbadis SRM. Psychogenic nonepileptic “seizures” or “attacks”? It's not just semantics: attacks. Neurology 2010; 75: 84– 86. 2. LaFrance WC Jr. Psychogenic nonepileptic “seizures” or “attacks”? It's not just semantics: seizures. Neurology 2010; 75: 87– 88.31. Blad H, Lamberts BJ, van Dijk JG, Thijs RD. Tilt-induced vasovagal syncope and psychogenic pseudosyncope: overlapping clinical entities. Neurology 2015;XX:xx-xx.42. Benbadis SR. The problem of psychogenic symptoms: is the psychiatric community in denial? Epilepsy Behav 2005;6:9-14. 53. Sutton R, Brignole M. Twenty-eight years of research permit reinterpretation of tilt-testing: hypotensive susceptibility rather than diagnosis Eur Heart J 2014; 35: 2211-2212. 64. Brignole M, Ungar A, Bartoletti A, et al. Evaluation of Guidelines in Syncope Study 2 (EGSYS-2) Group. Standardized-care pathway vs. usual management of syncope patients presenting as emergencies at general hospitals. Europace 2006; 8: 644-50.75. Benbadis SR, Chichkova R. Psychogenic pseudosyncope: An underestimated and provable diagnosis. Epilepsy Behav 2006;9:106-10.86. Benbadis SR, Agrawal V, Tatum WO IV. How many patients with psychogenic nonepileptic seizures also have epilepsy? Neurology 2001;57:915-7.97. Teive HA, Germiniani FM, Munhoz RP. Overlap between fibromyalgia tender points and Charcot’s hysterical zones: A historical curiosity. Neurology 2015;84:2096-2097.108. LaFrance WC Jr, Keitner GI, Papandonatos GD et al. Pilot pharmacologic randomized controlled trial for psychogenic nonepileptic seizures. Neurology. 2010 Sep 28;75:1166-73.119. Goldstein LH, Chalder T, Chigwedere C et al. Cognitive-behavioral therapy for psychogenic nonepileptic seizures: a pilot RCT. Neurology 2010;74:1986-94.120. Benbadis SR. Mental health organizations and the ostrich policy. Neuropsychiatry 2013;1:5–7. ................
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