Psychiatric and neurologic predictors of psychogenic pseudoseizure outcome A.M. Kanner, MD; J. Parra, MD; M. Frey, RN, CGNP; G. Stebbins, PhD; S. Pierre–Louis, MD; and J. Iriarte, MD, PhD Article abstract—Objective: To investigate the patterns of occurrence of psychogenic pseudoseizures (PPS) of 45 consec- utive patients during a 6-month period after diagnosis, and to determine whether psychiatric and neurologic variables identified previously in PPS patient series can predict their recurrence after diagnosis, and whether any of these variables are associated with a particular outcome pattern. Method: Postdiagnosis PPS recurrence was assessed twice: during the first month and during a period ranging from the second to the sixth month. Outcome was categorized as follows: class I, complete cessation of PPS; class II, PPS only during one of the two observation periods; and class III, persistent PPS during the two observation periods. The authors used a logistic regression model to identify predictors of PPS recurrence (versus no PPS) among four neurologic and nine psychiatric variables, and compared their frequency among the three outcome classes. Results: Class I, n = 13 (29%); class II, n = 12 (27%); and class III, n = 20 (44%). The presence of an abnormal MR image predicted PPS recurrence during the second observation period with a 75% accuracy. The presence of all nine psychiatric variables predicted PPS recurrence during both the first and second observation periods with a 93% and an 89% accuracy respectively. Patients with a class III outcome had a markedly higher frequency of recurrent major depression, dissociative and personality disorders, and a history of chronic abuse. Patients with a class II outcome displayed a notably higher frequency of denial of stressors and psychosocial problems, refusal of treatment recommenda- tions, and new somatic symptoms after disclosure of diagnosis. Conversely, one episode of major depression was the one common diagnosis in patients with a class I outcome. Conclusions: PPS outcome after disclosure of diagnosis can be predicted by the presence of certain psychiatric characteristics. More than one psychopathogenic mechanism appears to operate in PPS. Key words: Psychogenic pseudoseizures—Pseudoseizure outcome—Sexual abuse—Intractable epilepsy. NEUROLOGY 1999;53:933–938 Pseudoseizures (PS) are nonepileptic, recurrent events that mimic epileptic seizures (ES). PS are common; an estimated 10 to 40% of patients referred to epilepsy centers with a diagnosis of intractable epilepsy have PS. 1-4 Video–EEG telemetry has gener- ated a great amount of data on the clinical manifes- tations of psychogenic pseudoseizures (PPS) 5-7 ; however, little is known about the psychopathogenic mechanisms that mediate their patterns of occur- rence and outcome. A systematic study of psychiatric disorders in PPS identified psychopathology in 89% of 45 adults, including an increased incidence of so- matoform, dissociative, affective, and personality dis- orders; and a history of abuse (sexual and physical) was reported in 84%. 8 These psychiatric disorders were not related to outcome, however. The few stud- ies that have looked at the outcome of PPS concur that some patients experience complete remission of PPS after diagnosis, even in the absence of any ther- apeutic interventions, 9,10 whereas other patients con- tinue to have PPS, even with the institution of therapy. 9-12 In the outcome studies published to date, one-third to one-half of patients had stopped experi- encing PPS at the time of follow-up, 1 to 5 years after diagnosis. 1,2,9-14 Studies that attempted to iden- tify psychiatric variables associated with outcome yielded conflicting results. For example, some stud- ies related a longer duration of PPS and the presence of a psychiatric diagnosis to poor outcome, 1,2,11,14 whereas another study 12 related poor outcome to the presence of psychosocial problems. ES (or a history of ES) coexists in 5 to 40% of patients with PPS. 5-18 Patients with mental retarda- tion have a higher comorbidity of ES and PPS. 17 There are little data, however, on the relationship between comorbidity of ES and PPS on outcome. One study 12 reported a poor outcome among patients with a history of epilepsy, whereas another 11 did not find such a relationship. The relationship between neuro- logic disorders, other than epilepsy, and PPS out- come has not been studied. We designed this prospective study to elucidate the mechanisms mediating outcome of PPS after di- agnosis. Specifically, we sought to determine 1) the patterns of occurrence of PPS during a 6-month pe- riod after diagnosis and 2) whether psychiatric and neurologic variables of patients with PPS identified previously in the literature can predict their recur- rence and whether they are associated with a partic- ular outcome pattern. From the Department of Neurological Sciences, Rush Medical College and Rush Epilepsy Center, Rush-Presbyterian-St. Luke’s Medical Center, Chicago, IL. Received October 5, 1998. Accepted in final form April 24, 1999. Address correspondence and reprint requests to Dr. Andres M. Kanner, Rush Epilepsy Center, Room 348, Murdock Building, Rush-Presbyterian-St. Luke’s Medical Center, 1653 West Congress Parkway, Chicago, IL 60612. Copyright © 1999 by the American Academy of Neurology 933