Reliability of reported peri-ictal behavior to identify psychogenic nonepileptic seizures

Abstract

A B S T R A C TPurpose: Differentiating psychogenic non-epileptic seizures (PNES) from epileptic seizures (ES) can be difficult, even when expert clinicians have video recordings of seizures. Moreover, witnesses who are not trained observers may provide descriptions that differ from the expert clinicians', which often raises concern about whether the patient has both ES and PNES. As such, quantitative, evidence-based tools to help differentiate ES from PNES based on patients' and witnesses' descriptions of seizures may assist in the early, accurate diagnosis of patients. Methods: Based on patient-and observer-reported data from 1372 patients with diagnoses documented by videoelect roencephalography (vEEG), we used logistic regression (LR) to compare specific peri-ictal behaviors and seizure triggers in five mutually exclusive groups: ES, PNES, physiologic non-epileptic seizure-like events, mixed PNES plus ES, and inconclusive monitoring. To differentiate PNES-only from ES-only, we retrospectively trained multivariate LR and a forest of decision trees (DF) to predict the documented diagnoses of 246 prospective patients. Results: The areas under the receiver operating characteristic curve (AUCs) of the DF and LR were 75% and 74%, respectively (empiric 95% CI of chance 37-62%). The overall accuracy was not significantly higher than the naïve assumption that all patients have ES (accuracy DF 71%, LR 70%, naïve 68%, p > 0.05). Conclusions: Quantitative analysis of patient-and observer-reported peri-ictal behaviors objectively changed the likelihood that a patient's seizures were psychogenic, but these reports were not reliable enough to be diagnostic in isolation. Instead, our scores may identify patients with "probable" PNES that, in the right clinical context, may warrant further diagnostic assessment.

A minority of patients with functional seizures have abnormalities on neuroimaging

“…These comparisons across patient groups would be most valuable if imaging results were viewed in the context of clinical history (e.g. DDESVSFS [114] and Functional Seizures Likelihood Score [45]) and EEG [115], which would require more discussion. While we did not compare directly the rate of neuroimaging findings in functional seizures to a similar population of patients with epilepsy at our center or re-adjudicate the radiologists' impression, the current work provides further details regarding the types of neuroimaging findings observed in patients with functional seizures in clinical practice.…”

“…Age was reported at time of imaging and was calculated at the days between their birthdate and the date of imaging. Comorbidities and confounding factors were obtained from retrospective chart review as well as, after May 2015, direct prospective interview, as described elsewhere [45].…”

Reduced left amygdala volume in patients with dissociative seizures (psychogenic nonepileptic seizures)

“…Therefore, the factors that directly cause DS have not been established. Because epileptic and dissociative seizures have similar behavioral features, more than 60 % of patients with DS are initially mistreated with anti-epileptic medications, which exposes patients to the potential side effects of antiepileptic drugs, and delays proper treatment [5,6]. Prompt treatment is associated with improved long term outcomes [7]; therefore, https://doi.org/10.1016/j.seizure.2019.12.014 Received 31 October 2019; Received in revised form 9 December 2019; Accepted 17 December 2019 Abbreviations: DS, dissociative seizures; PNES, psychogenic nonepileptic seizures; MTS, mesial temporal lobe sclerosis; NC, normal control; HS, hippocampal sclerosis; MR, magnetic resonance; EEG, electroencephalogram; FDA, Food and Drug Administration; PTSD, post-traumatic stress disorder ⁎ Corresponding author.…”

“…MR, magnetic resonance5 PTSD, post-traumatic stress disorder6 MTS, mesial temporal lobe sclerosis7 NC, normal controls8 HS, hippocampal sclerosis9 FDA, Food and Drug Administration 10 TIV, total intracranial volume H. Tatekawa, et alSeizure: European Journal of Epilepsy 75 (2020)[43][44][45][46][47][48] …”

Talking about “psychogenic nonepileptic seizure” is wrong and stigmatizing

“…For example, six articles with "PNES" in their title were identified since January 2019, i.e. in the last five months [1][2][3][4][5][6]. "PNES" is now the most common term in the neurology literature for naming a psychiatric disorder characterized by the production of clinical seizures without electroencephalographic changes.…”