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Baslet G, Bajestan SN, Aybek S, Modirrousta M, D Clin Psy JP, Cavanna A, Perez DL, Lazarow SS, Raynor G, Voon V, Ducharme S, LaFrance WC. Evidence-Based Practice for the Clinical Assessment of Psychogenic Nonepileptic Seizures: A Report From the American Neuropsychiatric Association Committee on Research. J Neuropsychiatry Clin Neurosci 2021; 33:27-42. [PMID: 32778006 DOI: 10.1176/appi.neuropsych.19120354] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The American Neuropsychiatric Association's Committee on Research assigned the task of defining the most helpful clinical factors and tests in establishing the diagnosis of psychogenic nonepileptic seizures (PNES) during a neuropsychiatric assessment. A systematic review of the literature was conducted using three search engines and specified search terms for PNES and the predetermined clinical factors and diagnostic tests, followed by a selection process with specific criteria. Data extraction results from selected articles are presented for clinical factors (semiology, psychiatric comorbidities, medical comorbidities, psychological traits) and diagnostic tests (EEG, psychometric and neuropsychological measures, prolactin level, clinical neuroimaging, autonomic testing). Semiology with video EEG (vEEG) remains the most valuable tool to determine the diagnosis of PNES. With the exception of semiology, very few studies revealed the predictive value of a clinical factor for PNES, and such findings were isolated and not replicated in most cases. Induction techniques, especially when coupled with vEEG, can lead to a captured event, which then confirms the diagnosis. In the absence of a captured event, postevent prolactin level and personality assessment can support the diagnosis but need to be carefully contextualized with other clinical factors. A comprehensive clinical assessment in patients with suspected PNES can identify several clinical factors and may include a number of tests that can support the diagnosis of PNES. This is especially relevant when the gold standard of a captured event with typical semiology on vEEG cannot be obtained.
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Affiliation(s)
- Gaston Baslet
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Sepideh N Bajestan
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Selma Aybek
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Mandana Modirrousta
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Jason Price D Clin Psy
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Andrea Cavanna
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - David L Perez
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Shelby Scott Lazarow
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Geoffrey Raynor
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Valerie Voon
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Simon Ducharme
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - W Curt LaFrance
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
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Diagnostic accuracy of clinical signs and symptoms for psychogenic nonepileptic attacks versus epileptic seizures: A systematic review and meta-analysis. Epilepsy Behav 2021; 121:108030. [PMID: 34029996 DOI: 10.1016/j.yebeh.2021.108030] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 04/21/2021] [Accepted: 04/24/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Psychogenic nonepileptic attacks (PNEA) are events of altered behavior that resemble epileptic seizures (ES) but are not caused by abnormal electrical cortical activity. Understanding which clinical signs and symptoms are associated with PNEA may allow better triaging for video-electroencephalogram monitoring (VEM) and for a more accurate prediction when such testing is unavailable. METHODS We performed a systematic review searching Medline, Embase, and Cochrane Central from inception to March 29, 2019. We included original research that reported at least one clinical sign or symptom, included distinct groups of adult ES and PNEA with no overlap, and used VEM for the reference standard. Two authors independently assessed quality of the studies using the Quality Assessment of Diagnostic Accuracy Studies tool. Pooled estimates of sensitivity and specificity of studies were evaluated using a bivariate random effects model. RESULTS We identified 4028 articles, of which 33 were included. There was a female sex predominance in the PNEA population (n = 22). From our meta-analysis, pooled sensitivities (0.27-0.72) and specificities (0.51-0.89) for PNEA were modest for individual signs. History of sexual abuse had the highest pooled specificity (89%), while the most sensitive feature was female sex (72%). Individual studies (n = 4) reported high levels of accuracy for ictal eye closure (sensitivity 64-73.7% and specificity 76.9-100%) and post-traumatic stress disorder (no reported sensitivity or specificity). Assuming the pre-test probability for PNEA in a tertiary care epilepsy center is 14%, even the strongest meta-analyzed features only exert modest diagnostic value, increasing post-test probabilities to a maximum of 33%. CONCLUSIONS This review reflects the limited certainty afforded by individual clinical features to distinguish between PNEA and ES. Specific demographic and comorbid features, even despite moderately high specificities, impart minimal impact on diagnostic decision making. This emphasizes the need for the development of multisource predictive tools to optimize diagnostic likelihood ratios.
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Clinical identification of psychogenic nonepileptic events using combinations of psychological tests in a veteran sample. Epilepsy Behav 2021; 115:107631. [PMID: 33360403 DOI: 10.1016/j.yebeh.2020.107631] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 11/02/2020] [Accepted: 11/06/2020] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Patients with psychogenic nonepileptic events (PNEE) exhibit heterogenous symptoms and are best diagnosed with long-term video-electroencephalogram (vEEG) data. While extensive univariate data suggest psychological tests may confirm the etiology of PNEE, the multivariate discriminant utility of psychological tests is less clear. The current study aggregated likelihood ratios of multiple psychological tests to evaluate incremental and discriminant utility for PNEE. METHODS Veterans with vEEG-diagnosed PNEE (n = 166) or epileptic seizures (n = 92) completed self-report measures and brief neuropsychological evaluations during the 4-day vEEG hospitalization. Receiver operating characteristic (ROC) curves identified discriminating psychological tests and corresponding cut-scores (0.85 minimum specificity). Likelihood ratios from the remaining cut-scores were sequentially linked using the sample base rate of PNEE (64%) and alternative base rates (10%, 20%, 30%, 40%) to estimate posttest probabilities (PTP) of test combinations. RESULTS The Health Attitudes Survey, Health History Checklist, and Minnesota Multiphasic Personality Inventory-2-Restructured Form scales FBS-r, RC1, MLS, and NUC were identified as discriminating indicators of PNEE. Average PTPs were ≥90% when three or more indicators out of six administered were present at the sample base rate. Regardless of PNEE base rate, PTP for PNEE was ≥98% when all discriminating indicators were present and 92-99% when five of six indicators administered were present. PTPs were largely consistent with observed positive predictive values, particularly as indicators present increased. SIGNIFICANCE Aggregating psychological tests identified PNEE with a high degree of accuracy, regardless of PNEE base rate. Combining psychological tests may be useful for confirming the etiology of PNEE.
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Giussani G, Erba G, Bianchi E, Beghi E. Self-Report questionnaires for the diagnosis of psychogenic non-epileptic seizures in clinical practice. A comprehensive review of the available instruments. Seizure 2020; 79:30-43. [DOI: 10.1016/j.seizure.2020.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 03/30/2020] [Accepted: 04/16/2020] [Indexed: 02/06/2023] Open
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Wardrope A, Jamnadas-Khoda J, Broadhurst M, Grünewald RA, Heaton TJ, Howell SJ, Koepp M, Parry SW, Sisodiya S, Walker MC, Reuber M. Machine learning as a diagnostic decision aid for patients with transient loss of consciousness. Neurol Clin Pract 2019; 10:96-105. [PMID: 32309027 DOI: 10.1212/cpj.0000000000000726] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 07/25/2019] [Indexed: 11/15/2022]
Abstract
Background Transient loss of consciousness (TLOC) is a common reason for presentation to primary/emergency care; over 90% are because of epilepsy, syncope, or psychogenic non-epileptic seizures (PNES). Misdiagnoses are common, and there are currently no validated decision rules to aid diagnosis and management. We seek to explore the utility of machine-learning techniques to develop a short diagnostic instrument by extracting features with optimal discriminatory values from responses to detailed questionnaires about TLOC manifestations and comorbidities (86 questions to patients, 31 to TLOC witnesses). Methods Multi-center retrospective self- and witness-report questionnaire study in secondary care settings. Feature selection was performed by an iterative algorithm based on random forest analysis. Data were randomly divided in a 2:1 ratio into training and validation sets (163:86 for all data; 208:92 for analysis excluding witness reports). Results Three hundred patients with proven diagnoses (100 each: epilepsy, syncope and PNES) were recruited from epilepsy and syncope services. Two hundred forty-nine completed patient and witness questionnaires: 86 epilepsy (64 female), 84 PNES (61 female), and 79 syncope (59 female). Responses to 36 questions optimally predicted diagnoses. A classifier trained on these features classified 74/86 (86.0% [95% confidence interval 76.9%-92.6%]) of patients correctly in validation (100 [86.7%-100%] syncope, 85.7 [67.3%-96.0%] epilepsy, 75.0 [56.6%-88.5%] PNES). Excluding witness reports, 34 features provided optimal prediction (classifier accuracy of 72/92 [78.3 (68.4%-86.2%)] in validation, 83.8 [68.0%-93.8%] syncope, 81.5 [61.9%-93.7%] epilepsy, 67.9 [47.7%-84.1%] PNES). Conclusions A tool based on patient symptoms/comorbidities and witness reports separates well between syncope and other common causes of TLOC. It can help to differentiate epilepsy and PNES. Validated decision rules may improve diagnostic processes and reduce misdiagnosis rates. Classification of evidence This study provides Class III evidence that for patients with TLOC, patient and witness questionnaires discriminate between syncope, epilepsy and PNES.
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Affiliation(s)
- Alistair Wardrope
- Sheffield Teaching Hospitals NHS Foundation Trust (AW, RAG, SJH, MR), Royal Hallamshire Hospital; Division of Psychiatry and Applied Psychology (JJ-K), University of Nottingham, Institute of Mental Health, Innovation Park; Mental Health Liaison Team (MB), Derbyshire Healthcare NHS Foundation Trust Hartington Unit, Chesterfield; School of Mathematics and Statistics (TJH), University of Sheffield; Department of Clinical and Experimental Epilepsy (MK, SS, MCW), University College London Queen Square Institute of Neurology; NIHR Newcastle Biomedical Research Centre and Institute of Cellular Medicine (SWP), Newcastle University, Newcastle upon Tyne; and Academic Neurology Unit (MR), University of Sheffield, Royal Hallamshire Hospital, United Kingdom
| | - Jenny Jamnadas-Khoda
- Sheffield Teaching Hospitals NHS Foundation Trust (AW, RAG, SJH, MR), Royal Hallamshire Hospital; Division of Psychiatry and Applied Psychology (JJ-K), University of Nottingham, Institute of Mental Health, Innovation Park; Mental Health Liaison Team (MB), Derbyshire Healthcare NHS Foundation Trust Hartington Unit, Chesterfield; School of Mathematics and Statistics (TJH), University of Sheffield; Department of Clinical and Experimental Epilepsy (MK, SS, MCW), University College London Queen Square Institute of Neurology; NIHR Newcastle Biomedical Research Centre and Institute of Cellular Medicine (SWP), Newcastle University, Newcastle upon Tyne; and Academic Neurology Unit (MR), University of Sheffield, Royal Hallamshire Hospital, United Kingdom
| | - Mark Broadhurst
- Sheffield Teaching Hospitals NHS Foundation Trust (AW, RAG, SJH, MR), Royal Hallamshire Hospital; Division of Psychiatry and Applied Psychology (JJ-K), University of Nottingham, Institute of Mental Health, Innovation Park; Mental Health Liaison Team (MB), Derbyshire Healthcare NHS Foundation Trust Hartington Unit, Chesterfield; School of Mathematics and Statistics (TJH), University of Sheffield; Department of Clinical and Experimental Epilepsy (MK, SS, MCW), University College London Queen Square Institute of Neurology; NIHR Newcastle Biomedical Research Centre and Institute of Cellular Medicine (SWP), Newcastle University, Newcastle upon Tyne; and Academic Neurology Unit (MR), University of Sheffield, Royal Hallamshire Hospital, United Kingdom
| | - Richard A Grünewald
- Sheffield Teaching Hospitals NHS Foundation Trust (AW, RAG, SJH, MR), Royal Hallamshire Hospital; Division of Psychiatry and Applied Psychology (JJ-K), University of Nottingham, Institute of Mental Health, Innovation Park; Mental Health Liaison Team (MB), Derbyshire Healthcare NHS Foundation Trust Hartington Unit, Chesterfield; School of Mathematics and Statistics (TJH), University of Sheffield; Department of Clinical and Experimental Epilepsy (MK, SS, MCW), University College London Queen Square Institute of Neurology; NIHR Newcastle Biomedical Research Centre and Institute of Cellular Medicine (SWP), Newcastle University, Newcastle upon Tyne; and Academic Neurology Unit (MR), University of Sheffield, Royal Hallamshire Hospital, United Kingdom
| | - Timothy J Heaton
- Sheffield Teaching Hospitals NHS Foundation Trust (AW, RAG, SJH, MR), Royal Hallamshire Hospital; Division of Psychiatry and Applied Psychology (JJ-K), University of Nottingham, Institute of Mental Health, Innovation Park; Mental Health Liaison Team (MB), Derbyshire Healthcare NHS Foundation Trust Hartington Unit, Chesterfield; School of Mathematics and Statistics (TJH), University of Sheffield; Department of Clinical and Experimental Epilepsy (MK, SS, MCW), University College London Queen Square Institute of Neurology; NIHR Newcastle Biomedical Research Centre and Institute of Cellular Medicine (SWP), Newcastle University, Newcastle upon Tyne; and Academic Neurology Unit (MR), University of Sheffield, Royal Hallamshire Hospital, United Kingdom
| | - Stephen J Howell
- Sheffield Teaching Hospitals NHS Foundation Trust (AW, RAG, SJH, MR), Royal Hallamshire Hospital; Division of Psychiatry and Applied Psychology (JJ-K), University of Nottingham, Institute of Mental Health, Innovation Park; Mental Health Liaison Team (MB), Derbyshire Healthcare NHS Foundation Trust Hartington Unit, Chesterfield; School of Mathematics and Statistics (TJH), University of Sheffield; Department of Clinical and Experimental Epilepsy (MK, SS, MCW), University College London Queen Square Institute of Neurology; NIHR Newcastle Biomedical Research Centre and Institute of Cellular Medicine (SWP), Newcastle University, Newcastle upon Tyne; and Academic Neurology Unit (MR), University of Sheffield, Royal Hallamshire Hospital, United Kingdom
| | - Matthias Koepp
- Sheffield Teaching Hospitals NHS Foundation Trust (AW, RAG, SJH, MR), Royal Hallamshire Hospital; Division of Psychiatry and Applied Psychology (JJ-K), University of Nottingham, Institute of Mental Health, Innovation Park; Mental Health Liaison Team (MB), Derbyshire Healthcare NHS Foundation Trust Hartington Unit, Chesterfield; School of Mathematics and Statistics (TJH), University of Sheffield; Department of Clinical and Experimental Epilepsy (MK, SS, MCW), University College London Queen Square Institute of Neurology; NIHR Newcastle Biomedical Research Centre and Institute of Cellular Medicine (SWP), Newcastle University, Newcastle upon Tyne; and Academic Neurology Unit (MR), University of Sheffield, Royal Hallamshire Hospital, United Kingdom
| | - Steve W Parry
- Sheffield Teaching Hospitals NHS Foundation Trust (AW, RAG, SJH, MR), Royal Hallamshire Hospital; Division of Psychiatry and Applied Psychology (JJ-K), University of Nottingham, Institute of Mental Health, Innovation Park; Mental Health Liaison Team (MB), Derbyshire Healthcare NHS Foundation Trust Hartington Unit, Chesterfield; School of Mathematics and Statistics (TJH), University of Sheffield; Department of Clinical and Experimental Epilepsy (MK, SS, MCW), University College London Queen Square Institute of Neurology; NIHR Newcastle Biomedical Research Centre and Institute of Cellular Medicine (SWP), Newcastle University, Newcastle upon Tyne; and Academic Neurology Unit (MR), University of Sheffield, Royal Hallamshire Hospital, United Kingdom
| | - Sanjay Sisodiya
- Sheffield Teaching Hospitals NHS Foundation Trust (AW, RAG, SJH, MR), Royal Hallamshire Hospital; Division of Psychiatry and Applied Psychology (JJ-K), University of Nottingham, Institute of Mental Health, Innovation Park; Mental Health Liaison Team (MB), Derbyshire Healthcare NHS Foundation Trust Hartington Unit, Chesterfield; School of Mathematics and Statistics (TJH), University of Sheffield; Department of Clinical and Experimental Epilepsy (MK, SS, MCW), University College London Queen Square Institute of Neurology; NIHR Newcastle Biomedical Research Centre and Institute of Cellular Medicine (SWP), Newcastle University, Newcastle upon Tyne; and Academic Neurology Unit (MR), University of Sheffield, Royal Hallamshire Hospital, United Kingdom
| | - Matthew C Walker
- Sheffield Teaching Hospitals NHS Foundation Trust (AW, RAG, SJH, MR), Royal Hallamshire Hospital; Division of Psychiatry and Applied Psychology (JJ-K), University of Nottingham, Institute of Mental Health, Innovation Park; Mental Health Liaison Team (MB), Derbyshire Healthcare NHS Foundation Trust Hartington Unit, Chesterfield; School of Mathematics and Statistics (TJH), University of Sheffield; Department of Clinical and Experimental Epilepsy (MK, SS, MCW), University College London Queen Square Institute of Neurology; NIHR Newcastle Biomedical Research Centre and Institute of Cellular Medicine (SWP), Newcastle University, Newcastle upon Tyne; and Academic Neurology Unit (MR), University of Sheffield, Royal Hallamshire Hospital, United Kingdom
| | - Markus Reuber
- Sheffield Teaching Hospitals NHS Foundation Trust (AW, RAG, SJH, MR), Royal Hallamshire Hospital; Division of Psychiatry and Applied Psychology (JJ-K), University of Nottingham, Institute of Mental Health, Innovation Park; Mental Health Liaison Team (MB), Derbyshire Healthcare NHS Foundation Trust Hartington Unit, Chesterfield; School of Mathematics and Statistics (TJH), University of Sheffield; Department of Clinical and Experimental Epilepsy (MK, SS, MCW), University College London Queen Square Institute of Neurology; NIHR Newcastle Biomedical Research Centre and Institute of Cellular Medicine (SWP), Newcastle University, Newcastle upon Tyne; and Academic Neurology Unit (MR), University of Sheffield, Royal Hallamshire Hospital, United Kingdom
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The Fainting Assessment Inventory: A 10-Item Instrument Developed to Screen for Psychogenic Nonsyncopal Collapse Among Youth Referred for Syncope. J Nerv Ment Dis 2019; 207:255-263. [PMID: 30921250 DOI: 10.1097/nmd.0000000000000952] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The conversion disorder that appears like syncope is common but poorly recognized. The study aimed to develop and validate a brief, clinician-administered screening tool to discriminate psychogenic nonsyncopal collapse (PNSC) among young patients referred for fainting. Consecutive patients with PNSC and with syncope (15.4 ± 2.2 years) completed a 92-item inventory highlighting features typical of PNSC and neurally mediated syncope (n = 35, each cohort). Fourteen items were retained and revised and then administered to new cohorts ultimately diagnosed with PNSC or syncope (n = 40, each cohort). Further revision led to a 10-item Fainting Assessment Inventory (FAI-10). Scoring the syncope ratings positively and the PNSC ratings negatively, median scores differed between cohorts with PNSC and with syncope (-6 vs. 7; p < 0.001). Diagnostic sensitivity (0.95), specificity (0.875), positive predictive value (0.889), negative predictive value (0.93), and area under the curve (0.973) were calculated. The FAI-10 furthers clinicians' ability to distinguish various forms of transient loss of consciousness.
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Chen M, Jamnadas-Khoda J, Broadhurst M, Wall M, Grünewald R, Howell SJL, Koepp M, Parry SW, Sisodiya SM, Walker M, Hesdorffer D, Reuber M. Value of witness observations in the differential diagnosis of transient loss of consciousness. Neurology 2019; 92:e895-e904. [PMID: 30804064 DOI: 10.1212/wnl.0000000000007017] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 10/22/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE This retrospective study explores to what extent additional information from event witnesses provided using the novel 31-item Paroxysmal Event Observer (PEO) Questionnaire improves the differentiation among epilepsy, syncope, and psychogenic nonepileptic seizures (PNES) achievable with information provided by patients alone. METHODS Patients with transient loss of consciousness caused by proven epilepsy (n = 86), syncope (n = 79), or PNES (n = 84) attending specialist neurology/syncope services in the United Kingdom and event observers provided Paroxysmal Event Profile (PEP), PEO, and personal information (PI) (e.g., sex, age, medical history) data. PEO data were subjected to exploratory factor analysis (EFA) followed by confirmatory factor analysis (CFA). PEO, PEP, and PI data were used separately and in combination to differentiate diagnoses by pairwise and multinomial logistic regressions. Predicted diagnoses were compared with gold standard medical diagnoses. RESULTS EFA/CFA identified a 4-factor structure of the PEO based on 26/31 questionnaire items with loadings ≥0.4. Observer-reported factors alone differentiated better between syncope and epilepsy than patient-reported factors (accuracy: 96% vs 85%, p = 0.0004). Observer-reported data improved accuracy over differentiation based on patient-reported data alone from 90% to 100% between syncope and epilepsy (p = 0.005), 76% to 83% between epilepsy and PNES (p = 0.006), and 93% to 95% between syncope and PNES (p = 0.098). CONCLUSIONS Information from observers can make an important contribution to the differentiation of epilepsy from syncope or PNES but adds less to that of syncope from PNES.
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Affiliation(s)
- Min Chen
- From the Gertrude H. Sergievsky Center (M.C., M. Wall, D.H.), Columbia University, New York, NY; Academic Neurology Unit (J.J.-K., M.R.), Royal Hallamshire Hospital, University of Sheffield; Mental Health Liaison Team (M.B.), Derbyshire Healthcare NHS Foundation Trust Hartington Unit, Chesterfield; Department of Neurology (R.G., S.J.L.H.), Sheffield Teaching Hospitals NHS Foundation Trust; Department of Clinical and Experimental Epilepsy (M.K., S.M.S., M. Walker), Institute of Neurology, University College London; and Institute of Cellular Medicine (S.W.P.), Newcastle University, UK
| | - Jenny Jamnadas-Khoda
- From the Gertrude H. Sergievsky Center (M.C., M. Wall, D.H.), Columbia University, New York, NY; Academic Neurology Unit (J.J.-K., M.R.), Royal Hallamshire Hospital, University of Sheffield; Mental Health Liaison Team (M.B.), Derbyshire Healthcare NHS Foundation Trust Hartington Unit, Chesterfield; Department of Neurology (R.G., S.J.L.H.), Sheffield Teaching Hospitals NHS Foundation Trust; Department of Clinical and Experimental Epilepsy (M.K., S.M.S., M. Walker), Institute of Neurology, University College London; and Institute of Cellular Medicine (S.W.P.), Newcastle University, UK
| | - Mark Broadhurst
- From the Gertrude H. Sergievsky Center (M.C., M. Wall, D.H.), Columbia University, New York, NY; Academic Neurology Unit (J.J.-K., M.R.), Royal Hallamshire Hospital, University of Sheffield; Mental Health Liaison Team (M.B.), Derbyshire Healthcare NHS Foundation Trust Hartington Unit, Chesterfield; Department of Neurology (R.G., S.J.L.H.), Sheffield Teaching Hospitals NHS Foundation Trust; Department of Clinical and Experimental Epilepsy (M.K., S.M.S., M. Walker), Institute of Neurology, University College London; and Institute of Cellular Medicine (S.W.P.), Newcastle University, UK
| | - Melanie Wall
- From the Gertrude H. Sergievsky Center (M.C., M. Wall, D.H.), Columbia University, New York, NY; Academic Neurology Unit (J.J.-K., M.R.), Royal Hallamshire Hospital, University of Sheffield; Mental Health Liaison Team (M.B.), Derbyshire Healthcare NHS Foundation Trust Hartington Unit, Chesterfield; Department of Neurology (R.G., S.J.L.H.), Sheffield Teaching Hospitals NHS Foundation Trust; Department of Clinical and Experimental Epilepsy (M.K., S.M.S., M. Walker), Institute of Neurology, University College London; and Institute of Cellular Medicine (S.W.P.), Newcastle University, UK
| | - Richard Grünewald
- From the Gertrude H. Sergievsky Center (M.C., M. Wall, D.H.), Columbia University, New York, NY; Academic Neurology Unit (J.J.-K., M.R.), Royal Hallamshire Hospital, University of Sheffield; Mental Health Liaison Team (M.B.), Derbyshire Healthcare NHS Foundation Trust Hartington Unit, Chesterfield; Department of Neurology (R.G., S.J.L.H.), Sheffield Teaching Hospitals NHS Foundation Trust; Department of Clinical and Experimental Epilepsy (M.K., S.M.S., M. Walker), Institute of Neurology, University College London; and Institute of Cellular Medicine (S.W.P.), Newcastle University, UK
| | - Stephen J L Howell
- From the Gertrude H. Sergievsky Center (M.C., M. Wall, D.H.), Columbia University, New York, NY; Academic Neurology Unit (J.J.-K., M.R.), Royal Hallamshire Hospital, University of Sheffield; Mental Health Liaison Team (M.B.), Derbyshire Healthcare NHS Foundation Trust Hartington Unit, Chesterfield; Department of Neurology (R.G., S.J.L.H.), Sheffield Teaching Hospitals NHS Foundation Trust; Department of Clinical and Experimental Epilepsy (M.K., S.M.S., M. Walker), Institute of Neurology, University College London; and Institute of Cellular Medicine (S.W.P.), Newcastle University, UK
| | - Matthias Koepp
- From the Gertrude H. Sergievsky Center (M.C., M. Wall, D.H.), Columbia University, New York, NY; Academic Neurology Unit (J.J.-K., M.R.), Royal Hallamshire Hospital, University of Sheffield; Mental Health Liaison Team (M.B.), Derbyshire Healthcare NHS Foundation Trust Hartington Unit, Chesterfield; Department of Neurology (R.G., S.J.L.H.), Sheffield Teaching Hospitals NHS Foundation Trust; Department of Clinical and Experimental Epilepsy (M.K., S.M.S., M. Walker), Institute of Neurology, University College London; and Institute of Cellular Medicine (S.W.P.), Newcastle University, UK
| | - Steve W Parry
- From the Gertrude H. Sergievsky Center (M.C., M. Wall, D.H.), Columbia University, New York, NY; Academic Neurology Unit (J.J.-K., M.R.), Royal Hallamshire Hospital, University of Sheffield; Mental Health Liaison Team (M.B.), Derbyshire Healthcare NHS Foundation Trust Hartington Unit, Chesterfield; Department of Neurology (R.G., S.J.L.H.), Sheffield Teaching Hospitals NHS Foundation Trust; Department of Clinical and Experimental Epilepsy (M.K., S.M.S., M. Walker), Institute of Neurology, University College London; and Institute of Cellular Medicine (S.W.P.), Newcastle University, UK
| | - Sanjay M Sisodiya
- From the Gertrude H. Sergievsky Center (M.C., M. Wall, D.H.), Columbia University, New York, NY; Academic Neurology Unit (J.J.-K., M.R.), Royal Hallamshire Hospital, University of Sheffield; Mental Health Liaison Team (M.B.), Derbyshire Healthcare NHS Foundation Trust Hartington Unit, Chesterfield; Department of Neurology (R.G., S.J.L.H.), Sheffield Teaching Hospitals NHS Foundation Trust; Department of Clinical and Experimental Epilepsy (M.K., S.M.S., M. Walker), Institute of Neurology, University College London; and Institute of Cellular Medicine (S.W.P.), Newcastle University, UK
| | - Matthew Walker
- From the Gertrude H. Sergievsky Center (M.C., M. Wall, D.H.), Columbia University, New York, NY; Academic Neurology Unit (J.J.-K., M.R.), Royal Hallamshire Hospital, University of Sheffield; Mental Health Liaison Team (M.B.), Derbyshire Healthcare NHS Foundation Trust Hartington Unit, Chesterfield; Department of Neurology (R.G., S.J.L.H.), Sheffield Teaching Hospitals NHS Foundation Trust; Department of Clinical and Experimental Epilepsy (M.K., S.M.S., M. Walker), Institute of Neurology, University College London; and Institute of Cellular Medicine (S.W.P.), Newcastle University, UK
| | - Dale Hesdorffer
- From the Gertrude H. Sergievsky Center (M.C., M. Wall, D.H.), Columbia University, New York, NY; Academic Neurology Unit (J.J.-K., M.R.), Royal Hallamshire Hospital, University of Sheffield; Mental Health Liaison Team (M.B.), Derbyshire Healthcare NHS Foundation Trust Hartington Unit, Chesterfield; Department of Neurology (R.G., S.J.L.H.), Sheffield Teaching Hospitals NHS Foundation Trust; Department of Clinical and Experimental Epilepsy (M.K., S.M.S., M. Walker), Institute of Neurology, University College London; and Institute of Cellular Medicine (S.W.P.), Newcastle University, UK
| | - Markus Reuber
- From the Gertrude H. Sergievsky Center (M.C., M. Wall, D.H.), Columbia University, New York, NY; Academic Neurology Unit (J.J.-K., M.R.), Royal Hallamshire Hospital, University of Sheffield; Mental Health Liaison Team (M.B.), Derbyshire Healthcare NHS Foundation Trust Hartington Unit, Chesterfield; Department of Neurology (R.G., S.J.L.H.), Sheffield Teaching Hospitals NHS Foundation Trust; Department of Clinical and Experimental Epilepsy (M.K., S.M.S., M. Walker), Institute of Neurology, University College London; and Institute of Cellular Medicine (S.W.P.), Newcastle University, UK.
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Wardrope A, Newberry E, Reuber M. Diagnostic criteria to aid the differential diagnosis of patients presenting with transient loss of consciousness: A systematic review. Seizure 2018; 61:139-148. [PMID: 30145472 DOI: 10.1016/j.seizure.2018.08.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 08/08/2018] [Accepted: 08/12/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Transient loss of consciousness (TLOC) is a common presentation in primary care. Over 90% of these are due to epileptic seizures (ES), syncope, or psychogenic non-epileptic seizures (PNES). Misdiagnosis rates are as high as 30%. METHODS Systematic review of inter-ictal clinical criteria to aid differential diagnosis of TLOC. We searched Medline, EMBASE, CINAHL and PsycInfo databases, as well as relevant grey literature depositories and citations of relevant reviews and guidelines for studies giving sensitivity and specificity of inter-ictal clinical characteristics used to differentiate between causes of TLOC. Two independent reviewers selected studies for inclusion and performed critical appraisal of included articles. We performed a narrative synthesis of included studies. RESULTS Of 1023 results, 16 papers were included. Two compared syncope, ES, and PNES; all others compared ES and PNES. All were at significant risk of bias in at least one domain. 6 studied patient symptoms, 6 medical and social history, 3 witness reports and 1 examination findings. No individual criterion differentiated between diagnoses with high sensitivity and specificity. CONCLUSIONS There is a lack of validated diagnostic criteria to help clinicians assessing patients in primary or emergency care settings to discriminate between common causes of TLOC. Performance may be improved by combining sets of criteria in a clinical decision rule, but no such rule has been validated prospectively against gold-standard diagnostic criteria.
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Affiliation(s)
- Alistair Wardrope
- Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, United Kingdom; Department of Academic Neurology, University of Sheffield, Beech Hill Road, Sheffield S10 2RX, United Kingdom.
| | - Ellen Newberry
- The Rotherham NHS Foundation Trust, Rotherham Hospital, Moorgate Road, Rotherham S60 2UD, United Kingdom
| | - Markus Reuber
- Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, United Kingdom; Department of Academic Neurology, University of Sheffield, Beech Hill Road, Sheffield S10 2RX, United Kingdom
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Indranada AM, Mullen SA, Duncan R, Berlowitz DJ, Kanaan RA. The association of panic and hyperventilation with psychogenic non-epileptic seizures: A systematic review and meta-analysis. Seizure 2018; 59:108-115. [DOI: 10.1016/j.seizure.2018.05.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 05/09/2018] [Accepted: 05/11/2018] [Indexed: 10/16/2022] Open
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Hanrahan B, Ghearing G, Urban A, Plummer C, Pan J, Hendrickson R, Bagic A, Antony A. Diagnostic accuracy of paroxysmal spells: Clinical history versus observation. Epilepsy Behav 2018; 78:73-77. [PMID: 29175694 DOI: 10.1016/j.yebeh.2017.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 09/06/2017] [Accepted: 09/07/2017] [Indexed: 10/18/2022]
Abstract
Our goal was to evaluate how accurate neurologists are at differentiating between different paroxysmal events based on clinical history versus observation of the spell in question. Forty-seven neurologists reviewed 12 clinical histories and videos of recorded events of patients admitted in the Epilepsy Monitoring Unit (EMU). They were asked to diagnose events as epileptic seizures, non-epileptic behavioral spells (NEBS), or other physiologic events as well as rate their confidence in their diagnosis. The median diagnostic accuracy for all paroxysmal events was 67% for clinical history and 75% for observation (p=.001). This was largely due to the difference in accuracy within the subgroup of patients with NEBS (67% history vs. 83% observation, p<.001). There were trends for higher diagnostic accuracy and increased inter-rater agreement with higher levels of training. Physicians with higher levels of training were more confident with diagnosis based on observation. In summary, reviewing videos of paroxysmal spells may improve diagnostic accuracy and enhance the evaluation of patients. Neurologists at all levels of training should encourage the recording and review of videos of recurrent spells to aid in medical decision-making especially when there is high concern that the spells in question are NEBS.
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Affiliation(s)
| | - Gena Ghearing
- University of Iowa Carver School of Medicine, Department of Neurology, USA.
| | | | | | - Julie Pan
- UPMC Pittsburgh, Department of Neurology, USA.
| | | | - Anto Bagic
- UPMC Pittsburgh, Department of Neurology, USA.
| | - Arun Antony
- UPMC Pittsburgh, Department of Neurology, USA.
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De Paola L, Terra VC, Silvado CE, Teive HAG, Palmini A, Valente KD, Olandoski M, LaFrance WC. Improving first responders' psychogenic nonepileptic seizures diagnosis accuracy: Development and validation of a 6-item bedside diagnostic tool. Epilepsy Behav 2016; 54:40-6. [PMID: 26645799 DOI: 10.1016/j.yebeh.2015.10.025] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Revised: 10/24/2015] [Accepted: 10/26/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Epileptic seizures (ES) are often seen as a medical emergency, and their immediate and accurate recognition are pivotal in providing acute care. However, a number of clinical situations may mimic ES, potentially leading to misdiagnosis at the emergency room and to inappropriate prescription of antiepileptic drugs (AED) in the acute and chronic settings. Psychogenic nonepileptic seizures (PNES) play a major role in this scenario and often delay the correct diagnosis and increase treatment morbidity and cost. First responders often conduct the initial assessment of these patients, and their impression may be decisive in the prehospital approach to seizures. We sought to investigate and improve the accuracy of PNES diagnosis among professionals involved in the initial assistance to patients with seizures. METHODS Fifty-three registered nurses, 34 emergency physicians, 33 senior year medical students, and 12 neurology residents took a short training program consisting of an initial video-based seizure assessment test (pretest), immediately followed by a 30-minute presentation of a 6-item bedside diagnostic tool and then a video-based reassessment (posttest). Baseline status and learning curves were determined. RESULTS The distinct professional categories showed no significant differences in their ability to diagnose PNES on both pretests and posttests. All groups improved diagnostic skills after the instructional program. SIGNIFICANCE The findings helped determine the best identifiable PNES clinical signs and to provide initial validation to a novel diagnostic instrument. In addition, our results showed that educational measures might help in the identification of PNES by first responders, which may decrease the treatment gap.
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Affiliation(s)
- Luciano De Paola
- Epilepsy and EEG Service, Hospital de Clínicas, Federal University of Paraná, Brazil; EPICENTRO, Comprehensive Epilepsy Center, Hospital N S das Graças, Curitiba, Paraná, Brazil.
| | - Vera Cristina Terra
- Epilepsy and EEG Service, Hospital de Clínicas, Federal University of Paraná, Brazil; EPICENTRO, Comprehensive Epilepsy Center, Hospital N S das Graças, Curitiba, Paraná, Brazil
| | - Carlos Eduardo Silvado
- Epilepsy and EEG Service, Hospital de Clínicas, Federal University of Paraná, Brazil; EPICENTRO, Comprehensive Epilepsy Center, Hospital N S das Graças, Curitiba, Paraná, Brazil
| | | | - Andre Palmini
- Service of Neurology, Porto Alegre Epilepsy Surgery Program, The Brain Institute (InsCer), Pontificia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Kette Dualibi Valente
- Psychiatric Department, Clinic's Hospital, University of São Paulo, Brazil; Clinical Neurophysiology Laboratory, Clinic's Hospital, University of São Paulo, Brazil
| | - Márcia Olandoski
- Medical School, Pontificia Universidade Católica do Paraná, Brazil
| | - W Curt LaFrance
- Psychiatry Department, Brown Medical School, Rhode Island Hospital, Providence, RI, USA; Neurology Department, Brown Medical School, Rhode Island Hospital, Providence, RI, USA
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Current world literature. Curr Opin Psychiatry 2012; 25:251-9. [PMID: 22456191 DOI: 10.1097/yco.0b013e328352dd8d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hoppe C, Elger CE. Depression in epilepsy: a critical review from a clinical perspective. Nat Rev Neurol 2011; 7:462-72. [PMID: 21750525 DOI: 10.1038/nrneurol.2011.104] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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