We present a small case series of patients with psychogenic non-epileptic attacks (PNEA), who were misdiagnosed with “refractory epilepsy” based on the presence of epileptiform discharges (EDs), particularly generalized spike-and-wave, on their EEG. This diagnosis was reversed after admission to the epilepsy monitoring unit for spell characterization, where all stereotypical events of interest were captured and were deemed non-epileptic.

Over the past decade, there was an increased emphasis on the need to correctly diagnose patients with PNEA to avoid unnecessary treatment with anti-seizure drugs and initiate psychotherapy to attain good clinical outcome. Misdiagnosing PNEA with “refractory epilepsy” could be due to misinterpreted EEG as “abnormal with epileptiform discharges” or co-existence of PNEA with EDs in the absence of clinical seizures. Although, PNEA is seen in up to 12% of epilepsy patients, there are rare cases where PNEA only occurs without confirmed epilepsy despite the presence of EDs.

We identified seven patients with only PNEA and EDs admitted to Epilepsy Monitoring Unit for “refractory epilepsy” and retrospectively reviewed their records including their EEG.

None of the stereotypical events captured on video-EEG was associated with ictal EEG correlates. Six had generalized spike-and-wave discharges (GSW) without clinical accompaniments. Of patients who initiated psychotherapy, 60% had ≥ 50% reduction in frequency of PNEA.  

EDs can occur in “PNEA-only” patients and shouldn’t delay PNEA diagnosis or effective psychotherapeutic treatment.