Peri‐ictal responsiveness to the social environment is greater in psychogenic nonepileptic than epileptic seizures

Wardrope, Alistair; Wong, Siew Fan; McLaughlan, Jonathan; Wolfe, Maytal; Oto, Maria; Reuber, Markus

doi:10.1111/epi.16471

Cited by 9 publications

(5 citation statements)

References 46 publications

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“…The frequency of clinical signs such as eye closure (ES 5% vs PNES 4%), repetitive eye blinks (ES 8% vs PNES 12%), automatisms (ES 15% vs PNES 16%), and ictal vocalization (ES 5% vs PNES 12%) were not statistically significantly ( p > 0.05) different between the ES and PNES groups. A residential VEM study 49 composed 24 patients with epilepsy, 12 with PNES, and 14 with a mixed diagnosis of ES/PNES described the utility of peri-ictal responsiveness to social cues in differentiating PNES from ES. For example, PNES was more likely to be preceded by attempts to alert others (OR 12.4; 95% CI 3.2–47.7), show altered intensity in the presence of others (OR 199.4; 95% CI 12.0–3309.9), and display postictal behaviors affected by the presence of others (OR 91.1; 95% CI 17.2–482.1) (irrespective of whether the patient was diagnosed with comorbid ID).…”

Section: Resultsmentioning

confidence: 99%

“…15 This group may represent an etiologically distinct group with a greater emphasis on the environment or social interactions in its explanation and treatment. 49 The evidence for female preponderance is less clear, and there is a trend toward longer diagnostic delay (10.7 vs 6.9 years). 51 Rates of nonepileptic psychogenic status were also reported to be more common in this subgroup.…”

Section: Discussionmentioning

confidence: 99%

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Using Semiology to Classify Epileptic Seizures vs Psychogenic Nonepileptic Seizures

et al. 2022

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Background and objectives:Misdiagnosis of psychogenic nonepileptic seizures (PNES) and epileptic seizures (ES) is common. In the absence of the diagnostic gold standard (video EEG), clinicians rely on semiology and clinical assessment. However, questions regarding the diagnostic accuracy of different signs remain. This meta-analysis aims to evaluate the diagnostic accuracy of semiology in PNES and ES.Methods:We systematically searched PubMed, PsycInfo and Medline for original research publications published before 8 February 2021 with no restriction on search dates to identify studies that compared semiology in ES and PNES in epilepsy monitoring units. Non-English publications, review articles, studies reporting on only PNES or ES and studies limited to patients with developmental delay were excluded. Study characteristics and proportions of ‘event groups’ and ‘patient groups’ demonstrating signs were extracted from each article. Bivariate analysis was conducted, and data were pooled in a random effects model for meta-analysis. The I2 statistic was calculated to assess statistical heterogeneity. The QUADAS-2 tool was utilized to assess risk of bias in included studies. The positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were calculated. A PLR > 10 or an NLR < 0.1 has a large impact on the post-test probability of a diagnosis (ES or PNES) whereas a PLR between 5-10 or an NLR between 0.1- 0.2 has a moderate impact on the post-test probability of a diagnosis (ES or PNES).Results:The meta-analysis included 14 studies comprising of 800 patients with ES and 452 patients with PNES. For PNES, ictal eye closure (PLR 40.5 95%CI: 16.2-101.3; I2 = 0, from three studies) and asynchronous limb movements (PLR 10.2; 95%CI: 2.8-37.7; I2 = 0, from three studies) reached a PLR threshold > 5. No single sign reached a PLR threshold >5 for ES.Conclusions:While all signs require interpretation in the overall clinical context, the presence of ictal eye closure and asynchronous limb movements are reliable discriminative signs for PNES.

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Using Semiology to Classify Epileptic Seizures vs Psychogenic Nonepileptic Seizures

et al. 2022

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“…14 30-32 In functional (dissociative) seizures, the clinical signs of active resistance to eye opening, flutter or blinking on eyelash rub, or change in the seizure semiology in response to others during an episode have 100% specificity. [33][34][35] Physicians seem to fear giving an incorrect diagnosis. But in a review of 27 studies with FND, with a total population of 1466, the proportion of misdiagnosis was less than 4% after an average of 5 years of follow-up.…”

Section: Stigma and Misperceptions Surrounding Fndmentioning

confidence: 99%

“…Signs which have been proven to be reliable in motor FND include Hoover’s sign, hip abductor sign, drift without pronation, identification of typical FND gait, and ipsilateral weakness of the sternocleidomastoid with hemiparesis 14 30–32. In functional (dissociative) seizures, the clinical signs of active resistance to eye opening, flutter or blinking on eyelash rub, or change in the seizure semiology in response to others during an episode have 100% specificity 33–35…”

Section: Introductionmentioning

confidence: 99%

Functional neurological disorder is a feminist issue

McLoughlin

Hoeritzauer

Cabreira

et al. 2023

J Neurol Neurosurg Psychiatry

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Functional neurological disorder (FND) is a common and disabling disorder, often misunderstood by clinicians. Although viewed sceptically by some, FND is a diagnosis that can be made accurately, based on positive clinical signs, with clinical features that have remained stable for over 100 years. Despite some progress in the last decade, people with FND continue to suffer subtle and overt forms of discrimination by clinicians, researchers and the public. There is abundant evidence that disorders perceived as primarily affecting women are neglected in healthcare and medical research, and the course of FND mirrors this neglect. We outline the reasons why FND is a feminist issue, incorporating historical and contemporary clinical, research and social perspectives. We call for parity for FND in medical education, research and clinical service development so that people affected by FND can receive the care they need.

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“…They are experienced as involuntary but can be responsive to social interactions. 2 When attacks are characterised by reduced responsibility and tremulous or convulsive movements they are often misdiagnosed as epileptic seizures. In emergency care, where seizures make up 3%-5% of all emergency deployments, 11%-27% of patients initially treated for epileptic seizures are later diagnosed with dissociative seizures.…”

Section: Introductionmentioning

confidence: 99%

Dissociative seizures in the emergency room: room for improvement

Cengiz,

Jungilligens,

Michaelis

et al. 2023

J Neurol Neurosurg Psychiatry

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BackgroundDissociative seizures, also known as functional or psychogenic non-epileptic seizures, account for 11%–27% of all emergency seizure presentations. Misdiagnosis as epileptic seizures is common and leads to ineffective and potentially harmful treatment escalations. We assess the potential for diagnostic improvement at different stages of emergency workup and estimate the utility of benzodiazepines.MethodsA retrospective study of all emergency presentations with a discharge diagnosis of acute dissociative seizures seen at a university hospital 2010–2022 was performed to assess clinical characteristics and emergency decision-making.ResultsAmong 156 patients (73% female, median 29 years), 15% presented more than once for a total of 203 presentations. Half of seizures were ongoing at first medical contact; prolonged seizures and clusters were common (23% and 24%). Diagnostic accuracy differed between on-site emergency physicians and emergency department neurologists (12% vs 52%). Typical features such as eye closure, discontinuous course and asynchronous movements were common. Benzodiazepines were given in two-thirds of ongoing seizures, often in high doses and preferentially for major hyperkinetic semiology. Clinical response to benzodiazepines was mixed, with a minority of patients remaining either unaffected (16%) or becoming critically sedated (13%). A quarter of patients given benzodiazepines by emergency medical services were admitted to a monitoring unit, 9% were intubated.ConclusionsImproved semiological assessment could reduce early misdiagnosis of dissociative seizures. Although some seizures seem to respond to benzodiazepines, critical sedation is common, and further studies are needed to assess the therapeutic ratio.

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Peri‐ictal responsiveness to the social environment is greater in psychogenic nonepileptic than epileptic seizures

Cited by 9 publications

References 46 publications

Using Semiology to Classify Epileptic Seizures vs Psychogenic Nonepileptic Seizures

Using Semiology to Classify Epileptic Seizures vs Psychogenic Nonepileptic Seizures

Functional neurological disorder is a feminist issue

Dissociative seizures in the emergency room: room for improvement

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