Psychogenic non-epileptic seizures (PNES) have long been an area of frustration for sufferers and clinicians alike. Being that they are not caused by abnormal brain electrical discharges like their epileptic counterpart, the condition exists in the “Somatoform disorder” category that is both ‘neglected and misdiagnosed [1]’ in many a case. A recent case report and literature review published in the journal Upper Cervical Chiropractic Research has shed light on the resolution of a patients symptoms while under chiropractic care. It’s a fascinating read, on a much neglected topic.
The Epilepsy Foundation (based in America) has noted that, “Psychogenic Non-Epileptic Seizures are an uncomfortable topic, one that is difficult for both patients and healthcare professionals to discuss and treat. Yet it is estimated that PNES are diagnosed in 20 to 30% of patients seen at epilepsy centers for intractable seizures. Moreover, in the general population the prevalence rate is 2-33 per 100,000, making PNES nearly as prevalent as multiple sclerosis or trigeminal neuralgia [2].”
Dr Selim Benbadis told the Epilepsy Foundation that misdiagnosis of epilepsy in PNES patients is common, potentially occurring in up to 25% of cases. He went on to state that “Unfortunately, once the diagnosis of epilepsy is made, it is easily perpetuated without being questioned, which explains the usual diagnostic delay and cost associated with PNES. [2]”
The authors of a recent chiropractic case study appear to concur with this high level of misdiagnosis, stating that, “reliable information pertaining to the incidence or prevalence of PNES in the general population has not been reported.”
Interestingly, and perhaps disconcertingly, the authors remind us that this disorder can come with a high physical and emotional toll [1]: “PNES is a complicated disorder and somewhat vague in its clinical diagnosis and management due to its similarities with ES, and is often mistaken for generalized tonic-clonic seizure, absence seizure and simple or complex epileptic seizures. Moreover, “the failure to recognize the psychological cause of the disorder detracts physicians from addressing associated psychopathology (including suicidal ideation), and enhances secondary somatization processes,” they said (citing Reuber and Elger’s work on the condition).
The case studies authors, Friedman and Puro cited a number of predisposing or precipitating factors that may factor into the etiology of the disorder. Among the plethora of potential triggers for this complex condition are psychiatric disorders placed on axis 1 of the DSM IV system. “The commonest diagnoses are (other) somatoform or dissociative disorders, affective, anxiety, and post-traumatic stress disorder.” They also note that many patients show “abnormalities of personality development especially borderline personality disorder,” and that learning disabilities or organic brain disorders including epilepsy are common. “PNES commonly occur in the context of social or family conflict and trauma” including abuse in childhood and adolescence [1].”
It presents a complex, functional neurological, and psycho-emotional problem that can be quite life-interrupting as we see from the case study in question.
What then can chiropractic do for such a condition? It would come as no surprise that there is not a great deal of literature on chiropractic care and PNES. Hence, the resolution of PNES in a patient while under chiropractic care proves fascinating. The patient in question was 30 years old and female. She presented with a chief complaint of “full body convulsions” that began in 2013. The paper’s authors explained that prior to chiropractic care:
[She was] “diagnosed with a nonepileptic seizure disorder by an internist and two neurologists. The patient suffered from serious autonomic dysfunction, which appeared to cause symptoms of light-headedness, fainting without loss of consciousness, heavy chest compressions manifested from anxiety and loss of vision lasting 30-45 seconds. Other life threatening symptoms included complete loss of motor function in her legs, headaches, dizziness, nausea, fatigue and tremors. Progressively, these symptoms began to occur 3 times per week when she exercised or sat up too quickly, especially when getting out of bed in the morning, to lasting up to an hour each day. The patient assumed these symptoms were a result of low blood sugar, as she had a decreased appetite due to work stress.”
The patient’s primary healthcare practitioner (an internist, or doctor of internal medicine) ensured rigorous testing was done to rule out many potential underlying conditions (detailed in full in the case report referenced below [1].) Cognitive Behavioral Therapy was advised and the patient was advised to take the medication. But as care continued, the symptoms worsened. In fact, her symptoms had become 80% worse, with seizures (followed by progressively intensifying migraines) occurring 6-10 times a day and lasting 20 minutes to an hour [1]. At this point, and having exhausted all options, the internist referred her to an upper cervical chiropractor.
The QSM3 Method/Protocol
The chiropractor in question practiced the QSM3 method, which “evaluates structural misalignment based on a pre/post measurement of the patients posture [1].” It is said to be a “forward thinking, tonal based chiropractic method to measure and correct global vertebral subluxation breakdown of the entire body.” Under this method, the patient was assessed and found to have a left low hip, increased weight bearing on the left side, atlas laterality of 5°on the left with 1 and 1/5°of head tilt towards the left, and a reversed cervical curve and break in George’s line at C4. Full details of subluxation patterns and listing are provided in the case report, which goes into much greater detail on the QSM3 method)
Interestingly, the improvements were noted almost immediately (which confounded the previous pattern of worsening symptoms under previous care.)
“The patient responded well after the initial adjustment. She explained that she has never been able to stand up right without feeling compression on her spine and internal organs. The patient’s convulsion with preceding symptoms ceased for two days after the initial treatment. On the second visit, the postural analysis showed that she was slightly holding her adjustment, but her body kept trying to move into her subluxation due to prolonged trauma misalignment. After the second visit, her signs and symptoms had not been apparent for 10 days. On the tenth day after the second treatment, the patient stated that her episode did not last longer than 5 minutes.”
After 7 months of treatment under the QSM3 method she has “not experienced any episodes or symptoms related to PNES.”
What does it mean?
As this is a case study, and due to the limitation of chiropractic literature regarding this condition, it remains an issue for further research before we can generalize or even fully understand the mechanisms of such a recovery. All we know is that trauma, psychological stress and emotional distress appear to be linked, and that this patient recovered under chiropractic care when previous medical care had failed to deliver.
The conclusion reached by the authors of the case study (after a thorough and fascinating overview of QSM3 is that:
“The management that was performed utilized the QSM3 method to correct global subluxations caused by postural breakdown of the human body, which led to a reduction in symptoms pertaining to PNES.
As a result, compressional release of myofascial tension throughout the patient’s body, restoring tensegrity, demonstrated both objectively and subjectively successful.
This case study supports the ability of using tonal-based chiropractic care, as an alternative form of treatment, in reducing symptoms of a disorder that has no neurological origin.”
It is certainly an issue we will watch with curiosity as time and research progress. For now, it’s another life changed by chiropractic, and another addition to the narrative that trauma and stress can be manifested in the neurology and physiology of the patient by way of the subluxation.
Make sure you go and read the full case study to discover more about this complex condition and the protocol that appears to have been linked to a resolution of symptoms in this case.
REFERENCES:
- Friedman R and Puro S (2019), “Resolution of Psychogenic Non-epileptic Seizures Following Chiropractic Care: A Case Study & Review of the Literature,” Journal Upper Cervical Chiropractic Research, February 11,2019
- Benbadis S (2007), “The Truth about Psychogenic Non-epileptic Seizures,” Epilepsy Foundation, https://www.epilepsy.com/article/2014/3/truth-about-psychogenic-nonepileptic-seizuresretrieved 7 June 2019
- Reuber M, Elger C. Psychogenic nonepileptic seizures: review and update. Epilepsy Behav. 2003; 4(2003):205- 216.
