Zur Ätiologie psychogener nichtepileptischer Anfälle

Zusammenfassung

Psychogene nichtepileptische Anfälle (PNEA) sind anfallsartige Ereignisse, die epileptischen Anfällen oberflächlich ähneln, jedoch durch psychopathologische Prozesse und nicht durch epileptische neuronale Störungen verursacht sind. Dieser Übersichtsartikel behandelt Fragen der Ätiologie, Nosologie, Therapie und des Verlaufs von PNEA. Vergleichende Studien und Beschreibungen von Patientenserien zeigen, dass traumatische Erlebnisse in der Kindheit (insbesondere sexueller und körperlicher Missbrauch), Traumata im Erwachsenenalter, gestörte Familienverhältnisse, psychiatrische Komorbidität, Persönlichkeitsstörungen, hirnorganische Komorbidität, niedriger sozialer Status sowie finanzieller und sozialer Krankheitsgewinn eine prädisponierende, präzipitierende oder perpetuierende Rolle spielen können. PNEA sind also kein einheitliches Syndrom mit monokausaler Pathogenese, sondern können Manifestation einer großen Zahl unterschiedlicher psychosozialer Störungen sein. Daraus ergibt sich für die Nosologie, dass PNEA im Widerspruch zu gängigen psychiatrischen Diagnosemanualen am besten als Symptom der zugrunde liegenden Störung benannt werden. Die Therapie muss auf den individuellen Patienten oder bestimmte Patientengruppen zugeschnitten werden und erfordert oft die Zusammenarbeit eines multidisziplinären Teams. Der Verlauf ist durch die PNEA verursachenden Probleme oder Störungen bestimmt. Aufgrund der komplexen Ätiologie ist die langfristig erfolgreiche Behandlung häufig schwierig.

Abstract

Psychogenic nonepileptic seizures (PNES) are paroxysmal events, which superficially resemble epileptic seizures, which are, however, not caused by epileptic neuronal discharges but by psychopathological processes. This review summarizes the etiological knowledge to address the questions of causation, nosology, therapy and prognosis of PNES. Comparative and observational studies show that traumatic childhood experiences (especially sexual and physical abuse), trauma in adulthood, poor family relationships, psychiatric comorbidity, personality disorder, organic brain pathology, low social status as well as financial and social gain can play a predisposing, precipitating or perpetuating role. This suggests that PNES are not a unitary pathological entity but an expression of a number of different psychosocial disorders. In terms of nosology this means that PNES, contrary to their current position in diagnostic manuals, are best classified as manifestations of an underlying disorder. Consequently, therapy has to be designed to suit individual patients or certain patient groups. It often requires the collaboration of a multidisciplinary team. The prognosis of PNES is determined by the underlying psychosocial problem or disorder. In view of the complex etiology of PNES, successful long-term treatment is difficult.

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