Objective: To evaluate whether treating underlying dysautonomia in patients with abnormal movements initially diagnosed with psychogenic non-epileptiform spells (PNES) leads to a reduction in motor symptoms and hospital readmissions.

Background: Patients experiencing autonomic storms related to dysautonomia may present with abnormal movements, including convulsions, tremors, and myoclonus. Due to presenting with a broad range of nonspecific symptoms, they are often misdiagnosed with functional neurological disorders (FND), such as PNES, resulting in delayed or inappropriate treatment.

Method: This cohort study included 17 adult patients who presented to St. Elizabeth’s Medical Center’s emergency department with seizure-like activity. Inclusion criteria required non-epileptiform movements, confirmed by negative routine electroencephalogram (rEEG) or continuous electroencephalogram (cEEG) testing, followed by a misdiagnosis of PNES, and referral to Neurology for further evaluation. Demographic and clinical information was collected from the electronic health record database.

Results: Among the 17 patients (male [n=6], female [n=11]), with a mean baseline age of 52 and a median baseline age of 64, the most common movement phenotypes were convulsions (64.7%, n=11), tremor (35.3%, n=6), and myoclonus (35.3%, n=6). Other frequent neurological manifestations were decreased level of consciousness (58.8%, n=10) followed by presyncope (35.3%, n=6).

All of the participants showed features of orthostatic hypotension, indicating possible dysautonomia and other autonomic nervous disorders. 82.4% of the patients (n=14) were started on at least one medication to manage their symptoms, including fludrocortisone, pyridostigmine, midodrine, and propranolol, with 47.1% (n=8) on combination therapy. 71.4% (n=10) of the patients who underwent pharmacological interventions reported improvement, including a decrease or complete resolution of abnormal movements, reduction of other dysautonomia symptoms, and fewer readmissions.

Conclusion: Patients presenting with abnormal seizure-like movements that are confirmed as non-epileptiform after further evaluation should be assessed for autonomic movement disorders (AMD). Treatment targeting orthostatic hypotension may help alleviate these abnormal movements.

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References: References
1. O’Dell JA, Walker A, Latham AJ, Parisian DJ, Branch LE, Vanderburg DD, Cox AA, Chavis S, Smith SE. The Diagnostic Journey of Dysautonomia Patients: Insights from a Patient-Reported Outcome Study. J Patient Exp. 2025 Jan 21;12:23743735251314651. doi: 10.1177/23743735251314651.
2. Safwat S, Safwat F, Sivanathan N, Daka N, Sadek M. Misdiagnosed seizure-like activity in a patient with postural orthostatic tachycardia syndrome: A case report. Cureus 2023;15(5):e39565. doi: 10.7759/cureus.39565
3. Van der Feltz-Cornelis M, Allen SF, Van Eck van der Sluijs JF. Misdiagnosis of an underlying medical condition as Conversion Disorder/Functional Neurological Disorder (CD/FND) still occurs. Gen Hos Psychiatry. 2020;65:43-46. doi: 10.1016/j.genhosppsych.2020.05.003

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MDS Abstracts - https://www.mdsabstracts.org/abstract/improved-outcomes-for-patients-with-autonomic-movement-disorders-amd-originally-evaluated-for-psychogenic-non-epileptiform-spells-pnes/