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Larsen PM, Wüstenhagen S, Terney D, Gardella E, Aurlien H, Beniczky S. Seizure provocation in EEG recordings: A data-driven approach. Epileptic Disord 2024. [PMID: 38491975 DOI: 10.1002/epd2.20217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/12/2024] [Accepted: 03/06/2024] [Indexed: 03/18/2024]
Abstract
OBJECTIVE Recording seizures on video-EEG has a high diagnostic value. However, bilateral convulsive seizures constitute a risk for the patients. Our aim was to investigate the diagnostic yield and associated risks of provocation methods in short-term video-EEGs. METHODS We extracted data on seizures and provocation methods from a large database of short-term video-EEGs with standardized annotations using SCORE (Standardized Computer-based Organized reporting of EEG). RESULTS 2742 paroxysmal clinical episodes were recorded in 11 919 consecutive EEGs. Most epileptic seizures (54%) were provoked. Hyperventilation provoked most of typical absence seizures (55%), intermittent photic stimulation (IPS) provoked myoclonic seizures (25%) and most of bilateral convulsive seizures (55%), while 43% of focal seizures were precipitated by sleep. All but one of the 16 bilateral convulsive seizures were provoked by IPS or sleep. Latency between start of generalized photoparoxysmal EEG response and bilateral convulsive seizures were ≤3 s in all but one patient. SIGNIFICANCE The large, structured database provides evidence for the diagnostic utility of various provocation methods in short-term video-EEGs. The risk of bilateral convulsive seizures is relatively small, but it cannot be prevented by stopping IPS after 3 s. A priori knowledge about seizure semiology helps planning patient-tailored provocation strategy in short-term video-EEGs.
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Affiliation(s)
| | - Stephan Wüstenhagen
- Department of Clinical Neurophysiology, Danish Epilepsy Centre, Dianalund, Denmark
| | - Daniella Terney
- Department of Clinical Neurophysiology, Danish Epilepsy Centre, Dianalund, Denmark
| | - Elena Gardella
- Department of Clinical Neurophysiology, Danish Epilepsy Centre, Dianalund, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Harald Aurlien
- Department of Clinical Neurophysiology, Haukeland University Hospital and Holberg EEG AS, Bergen, Norway
| | - Sándor Beniczky
- Department of Clinical Neurophysiology, Danish Epilepsy Centre, Dianalund, Denmark
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
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Kanaan RA, Mullen SA, D'Souza W, Castro-de-Araujo LFS, Sharma A, Indranada AM. Hyperventilation in functional seizures: Evidence for subtypes. Seizure 2022; 99:8-11. [DOI: 10.1016/j.seizure.2022.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/24/2022] [Accepted: 04/25/2022] [Indexed: 11/27/2022] Open
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Fisher RS, Acharya JN, Baumer FM, French JA, Parisi P, Solodar JH, Szaflarski JP, Thio LL, Tolchin B, Wilkins AJ, Kasteleijn-Nolst Trenité D. Visually sensitive seizures: An updated review by the Epilepsy Foundation. Epilepsia 2022; 63:739-768. [PMID: 35132632 DOI: 10.1111/epi.17175] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/10/2022] [Accepted: 01/12/2022] [Indexed: 12/19/2022]
Abstract
Light flashes, patterns, or color changes can provoke seizures in up to 1 in 4000 persons. Prevalence may be higher because of selection bias. The Epilepsy Foundation reviewed light-induced seizures in 2005. Since then, images on social media, virtual reality, three-dimensional (3D) movies, and the Internet have proliferated. Hundreds of studies have explored the mechanisms and presentations of photosensitive seizures, justifying an updated review. This literature summary derives from a nonsystematic literature review via PubMed using the terms "photosensitive" and "epilepsy." The photoparoxysmal response (PPR) is an electroencephalography (EEG) phenomenon, and photosensitive seizures (PS) are seizures provoked by visual stimulation. Photosensitivity is more common in the young and in specific forms of generalized epilepsy. PS can coexist with spontaneous seizures. PS are hereditable and linked to recently identified genes. Brain imaging usually is normal, but special studies imaging white matter tracts demonstrate abnormal connectivity. Occipital cortex and connected regions are hyperexcitable in subjects with light-provoked seizures. Mechanisms remain unclear. Video games, social media clips, occasional movies, and natural stimuli can provoke PS. Virtual reality and 3D images so far appear benign unless they contain specific provocative content, for example, flashes. Images with flashes brighter than 20 candelas/m2 at 3-60 (particularly 15-20) Hz occupying at least 10 to 25% of the visual field are a risk, as are red color flashes or oscillating stripes. Equipment to assay for these characteristics is probably underutilized. Prevention of seizures includes avoiding provocative stimuli, covering one eye, wearing dark glasses, sitting at least two meters from screens, reducing contrast, and taking certain antiseizure drugs. Measurement of PPR suppression in a photosensitivity model can screen putative antiseizure drugs. Some countries regulate media to reduce risk. Visually-induced seizures remain significant public health hazards so they warrant ongoing scientific and regulatory efforts and public education.
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Affiliation(s)
- Robert S Fisher
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Jayant N Acharya
- Department of Neurology, Penn State Health, Hershey, Pennsylvania, USA
| | - Fiona Mitchell Baumer
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Jacqueline A French
- NYU Comprehensive Epilepsy Center, Epilepsy Foundation, New York, New York, USA
| | - Pasquale Parisi
- Department of Neuroscience, Mental Health, and Sensory Organs, Sapienza University, Rome, Italy
| | - Jessica H Solodar
- American Medical Writers Association-New England Chapter, Boston, Massachusetts, USA
| | - Jerzy P Szaflarski
- Department of Neurology, Neurobiology and Neurosurgery, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Liu Lin Thio
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Benjamin Tolchin
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
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4
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Abstract
Functional neurological disorder (FND), previously regarded as a diagnosis of exclusion, is now a rule-in diagnosis with available treatments. This represents a major step toward destigmatizing the disorder, which was often doubted and deemed untreatable. FND is prevalent, generally affecting young and middle aged adults, and can cause severe disability in some individuals. An early diagnosis, with subsequent access to evidence based rehabilitative and/or psychological treatments, can promote recovery-albeit not all patients respond to currently available treatments. This review presents the latest advances in the use of validated rule-in examination signs to guide diagnosis, and the range of therapeutic approaches available to care for patients with FND. The article focuses on the two most frequently identified subtypes of FND: motor (weakness and/or movement disorders) and seizure type symptoms. Twenty two studies on motor and 27 studies on seizure type symptoms report high specificities of clinical signs (64-100%), and individual signs are reviewed. Rehabilitative interventions (physical and occupational therapy) are treatments of choice for functional motor symptoms, while psychotherapy is an emerging evidence based treatment across FND subtypes. The literature to date highlights heterogeneity in responses to treatment, underscoring that more research is needed to individualize treatments and develop novel interventions.
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Affiliation(s)
- Selma Aybek
- Neurology Department, Psychosomatic Medicine Unit, Inselspital University Hospital, Bern, and Bern University, Bern, Switzerland
| | - David L Perez
- Divisions of Cognitive Behavioral Neurology and Neuropsychiatry, Functional Neurological Disorder Unit, Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Kotwas I, Arthuis M, Cermolacce M, Bartolomei F, McGonigal A. Psychogenic non-epileptic seizures: Chronology of multidisciplinary team approach to diagnosis and management. Rev Neurol (Paris) 2021; 178:692-702. [PMID: 34980511 DOI: 10.1016/j.neurol.2021.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 11/16/2021] [Accepted: 11/17/2021] [Indexed: 11/17/2022]
Abstract
While the diagnosis and management of psychogenic non-epileptic seizures (PNES) remain challenging, certain evidence-based guidelines exist, which can help to optimize patient care. A multidisciplinary team approach appears to have many benefits. Current recommendations exist for some aspects of diagnosis and management of PNES, including levels of diagnostic certainty as proposed by the International League Against Epilepsy's expert Task Force on PNES. Other aspects of clinical still care lack clear consensus, including use of suggestion techniques for recording PNES and optimal terminology, since the term "functional seizures" has recently been proposed as a possible term to replace "PNES". The present article aims to (1) review current recommendations and (2) discuss our own team's experience in managing patients with PNES. This is organized chronologically in terms of the roles of the neurologist, psychiatrist and psychologist, and discusses diagnostic issues, psychiatric assessment and treatment, and psychotherapeutic approaches.
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Affiliation(s)
- I Kotwas
- AP-HM, Timone Hospital, Clinical Neurophysiology, Marseille, France
| | - M Arthuis
- AP-HM, Timone Hospital, Clinical Neurophysiology, Marseille, France
| | - M Cermolacce
- University Department of Psychiatry, AP-HM, Sainte-Marguerite Hospital, Marseille, France
| | - F Bartolomei
- AP-HM, Timone Hospital, Clinical Neurophysiology, Marseille, France; Aix-Marseille Université, Inserm, INS, Institut de Neurosciences des Systèmes, Marseille, France
| | - A McGonigal
- AP-HM, Timone Hospital, Clinical Neurophysiology, Marseille, France; Aix-Marseille Université, Inserm, INS, Institut de Neurosciences des Systèmes, Marseille, France.
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6
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Opp J, Job B. Dissoziative Anfälle frühzeitig erkennen. Monatsschr Kinderheilkd 2021. [DOI: 10.1007/s00112-021-01355-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
ZusammenfassungWenn dissoziative Anfälle, also psychogene, nichtepileptische Anfälle als epileptische Anfälle fehlgedeutet werden, führt dies zu frustraner medikamentöser Therapie und verzögert die Einleitung der erforderlichen psychotherapeutischen Maßnahmen. Folgende Anfallssymptome sollten an dissoziative Anfälle denken lassen: unrhythmisches, wildes Hin- und Herbewegen des Kopfes oder der Extremitäten, geschlossene Augen, lange Dauer und undulierender Verlauf. Ein unauffälliges Elektroenzephalogramm (EEG) spricht für dissoziative Anfälle, aber erst ein negativer EEG-Befund während eines Anfalls ist beweisend. Im Arztgespräch ist es entscheidend, dass die Betroffenen die Möglichkeit bekommen, frei zu schildern. Betroffene mit dissoziativen Anfällen zeigen dann Besonderheiten, die als Diagnosekriterien genutzt werden sollten: Sie fokussieren auf Begleitumstände und lassen in ihren Schilderungen den Moment des Bewusstseinsverlusts aus. Sie machen eher allgemeine Angaben und unterscheiden einzelne Anfälle kaum.
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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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8
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Gras A, Wardrope A, Hirsch E, Asadi Pooya AA, Duncan R, Gigineishvili D, Hingray C, Kanemoto K, Ladino L, LaFrance WC, McGonigal A, Pretorius C, Valenti Hirsch P, Vidailhet P, Zhou D, Reuber M. Use of suggestive seizure manipulation methods in the investigation of patients with possible psychogenic nonepileptic seizures-An international ILAE survey. Epilepsia Open 2021; 6:472-482. [PMID: 34288577 PMCID: PMC8408588 DOI: 10.1002/epi4.12521] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/25/2021] [Accepted: 06/27/2021] [Indexed: 02/05/2023] Open
Abstract
Video‐encephalographic (vEEG) seizure recordings make essential contributions to the differentiation of epilepsy and psychogenic nonepileptic seizures (PNES). The yield of vEEG examinations can be increased through suggestive seizure manipulation (SSM) (ie, activation/provocation/cessation procedures), but its use has raised ethical concerns. In preparation for guidelines on the investigation of patients with PNES, the ILAE PNES Task Force carried out an international survey to investigate practices of and opinions about SSM. An online questionnaire was developed by the ILAE PNES Task Force. Questions were asked at clinical unit or individual respondent level. All ILAE chapters were encouraged to send questionnaires to their members. The survey was open from July 1, 2019, to August 31, 2019. A total of 487 clinicians from 411 units across 94 countries responded. Some form of SSM was used in 296/411 units (72.0%). Over 90% reported the use of verbal suggestion, over 80% the use of activation procedures also capable of eliciting epileptic activity (hyperventilation or photic stimulation). Only 26.3% of units used techniques specifically intended to provoke PNES (eg, saline injection). Fewer than 10% of units had established protocols for SSM, only 20% of units required written patient consent, in 12.2% of units patients received explicitly false information to provoke seizures. Clinicians using SSM tended to perceive no ethical problems, whereas those not using SSM were likely to have ethical concerns about these methods. We conclude that the use of invasive nocebo techniques intended to provoke PNES in diagnostic settings has declined, but SSM is commonly combined with activation procedures also capable of eliciting epileptic activity. While research suggests that openness about the use of PNES‐specific nocebo techniques does not reduce diagnostic yield, very few units have suggestion protocols or seek patient consent. This could be addressed through establishing consensus guidance for the practice of SSM.
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Affiliation(s)
- Adrien Gras
- Liaison Psychiatry Unit, 1 Place de l'Hopital, University Hospitals Strasbourg, Strasbourg, France
| | - Alistair Wardrope
- Academic Neurology Unit, Royal Hallamshire Hospital, The University of Sheffield, Sheffield, UK.,Department of Neurosciences, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Edouard Hirsch
- Liaison Psychiatry Unit, 1 Place de l'Hopital, University Hospitals Strasbourg, Strasbourg, France.,Epilepsy Unit "Francis Rohmer", INSERM Federation de Médecine Translationelle, CHU-University Strasbourg, Strasbourg, France
| | - Ali A Asadi Pooya
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Jefferson Comprehensive Epilepsy Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Rod Duncan
- Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - David Gigineishvili
- Department of Neurology and Neurosurgery, Sarajashvili Institute of Neurology, Tbilisi State University, Tbilisi, Georgia
| | | | | | - Lady Ladino
- Neurology Section, Epilepsy Program, Hospital Pablo Tobon Uribe, Medellin, Colombia.,Universidad de Antioquia, Medellin, Colombia
| | - William Curt LaFrance
- Neuropsychiatry and Behavioral Neurology, Rhode Island Hospital, Providence, RI, USA.,Neurology and Psychiatry, Brown University, Providence, RI, USA
| | - Aileen McGonigal
- Clinical Neurophysiology and Epileptology Department, Hospital Timone, Marseille, France.,Institut de Neurosciences des Systèmes, Aix-Marseille Universite, Marseille, France
| | - Chrisma Pretorius
- Department of Psychology, Stellenbosch University, Stellenbosch, South Africa
| | | | - Pierre Vidailhet
- Liaison Psychiatry Unit, 1 Place de l'Hopital, University Hospitals Strasbourg, Strasbourg, France.,Fédèration de Medecine Translationelle, Université de Strasbourg, Strasbourg, France
| | - Dong Zhou
- Department of Neurology, West China Hospital, Sichuan University West China Hospital, Chengdu, China
| | - Markus Reuber
- Academic Neurology Unit, Royal Hallamshire Hospital, The University of Sheffield, Sheffield, UK.,Department of Neurosciences, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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9
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Popkirov S, Grönheit W, Jungilligens J, Wehner T, Schlegel U, Wellmer J. Suggestive seizure induction for inpatients with suspected psychogenic nonepileptic seizures. Epilepsia 2020; 61:1931-1938. [PMID: 32712967 DOI: 10.1111/epi.16629] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/19/2020] [Accepted: 07/05/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the utility of suggestive seizure induction for inpatient work-up of suspected psychogenic nonepileptic seizures (PNES). METHODS Prospective study of epilepsy center inpatient admissions with suspected PNES. Patients were randomized to undergo suggestive induction first (group A) and then, if necessary, long-term video-electroencephalography (EEG) monitoring, or vice versa (group B). Diagnostic pathways were compared. Potential clinical predictors for diagnostic success were evaluated. RESULTS Length of in-hospital stay did not significantly differ between groups. Suspicion of PNES was confirmed in 43 of 77 (56%) patients, evenly distributed between group A (22 of 39) and group B (21 of 38). In nine patients, recorded habitual seizures were epileptic and in 25 cases, no diagnostic event could be recorded. Diagnosis of PNES was ascertained primarily by recording a typical seizure through suggestive induction in 24 patients and through long-term monitoring in 19 patients. In group A (induction first), monitoring was not deemed necessary in 21% of cases. In group B (monitoring first), 13% would have remained inconclusive without suggestive induction. Patients who reported triggers to their habitual seizures were not more likely to have spontaneous or provoked PNES during monitoring or suggestive inducion, respectively. Patients with subjective seizure prodromes (auras) were significantly more likely to have a PNES during suggestive induction than those without (odds ratio [OR] 3.4, 95% confidence interval [CI] 1.1-10.4). There was no significant difference in seizure frequency between patients with spontaneous PNES during long-term monitoring and those with nondiagnostic monitoring sessions. SIGNIFICANCE Our results support the notion that suggestive seizure induction can reduce the number of inconclusive inpatient workups, and can obviate resource-intensive long-term monitoring in one fifth of cases. Patients who are aware of prodromes might have a higher chance of having seizures induced through suggestion.
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Affiliation(s)
- Stoyan Popkirov
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - Wenke Grönheit
- Ruhr-Epileptology, Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - Johannes Jungilligens
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany.,Ruhr-Epileptology, Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany.,Department of Neuropsychology, Faculty of Psychology, Institute of Cognitive Neuroscience, Ruhr University Bochum, Bochum, Germany
| | - Tim Wehner
- Ruhr-Epileptology, Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - Uwe Schlegel
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - Jörg Wellmer
- Ruhr-Epileptology, Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
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10
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Gogia B, Rai PK, Matthys SA, Mong ER, Rodriguez R, Yassin A, Patel K, Patel C, Todd M. Use of noninvasive induction techniques in the diagnosis of PNES. Epilepsy Behav 2019; 99:106491. [PMID: 31654987 DOI: 10.1016/j.yebeh.2019.106491] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 08/09/2019] [Accepted: 08/09/2019] [Indexed: 10/25/2022]
Abstract
The diagnosis of psychogenic nonepileptic seizures (PNES) remains challenging. In the correct clinical setting with prolonged electroencephalography (EEG) monitoring, the specificity of provocative techniques to distinguish induced epileptic event from a nonepileptic event approaches 90%. We report our epilepsy monitoring unit (EMU) experience with the use of noninvasive verbal suggestion (VS) during hyperventilation (HV), photic stimulation (PS) as induction technique in making the diagnosis of PNES. In total, 189/423 patients were diagnosed with PNES during the EMU evaluation. Of the 189, 20 had mixed disorder and 169 patients had only PNES, 80 patients (47.3%) had a PNES with induction, and the remaining 89 of 169 patients (52.7%) had a spontaneous PNES episode that did not require induction. Verbal suggestion during HV and PS confirmed the diagnosis of PNES in 47% of the patients who otherwise did not have spontaneous events. Within the group who was diagnosed with PNES following induction, antiepileptic drugs (AEDs) were stopped in 53% of the patients. We believe that this is a large proportion of patients that would possibly remain undiagnosed if no induction were performed.
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Affiliation(s)
- Bhanu Gogia
- Department of Neurology, University of Texas Medical Branch, Galveston, TX 77555, USA.
| | - Prashant K Rai
- Department of Neurology, University of Texas Medical Branch, Galveston, TX 77555, USA.
| | - Samuel A Matthys
- University of Texas Medical Branch School of Medicine, Galveston, TX 77555, USA.
| | - Eric R Mong
- University of Texas Medical Branch School of Medicine, Galveston, TX 77555, USA.
| | - Rafael Rodriguez
- Department of Neurology, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Ahmed Yassin
- Jordan University of Science and Technology, Department of Neurosciences, Jordan.
| | - Kamakshi Patel
- Department of Neurology, University of Texas Medical Branch, Galveston, TX 77555, USA.
| | - Chilvana Patel
- Department of Neurology, University of Texas Medical Branch, Galveston, TX 77555, USA.
| | - Masel Todd
- Department of Neurology, University of Texas Medical Branch, Galveston, TX 77555, USA.
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11
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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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12
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Kandler R, Lawrence S, Pang C, Lai M, Whitehead K. Optimising the use of EEG in non-epileptic attack disorder: Results of a UK national service evaluation. Seizure 2018; 55:57-65. [PMID: 29414136 DOI: 10.1016/j.seizure.2018.01.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 01/04/2018] [Accepted: 01/05/2018] [Indexed: 10/18/2022] Open
Abstract
PURPOSE To produce an evidence base to formulate guidelines for optimal performance of EEG in patients referred with a possible diagnosis of non-epileptic attack disorder (NEAD). METHODS 51 UK EEG departments participated in the prospective study. A pro-forma was completed for all consecutive patients aged 5 years and over referred for EEG over a six month period. Information obtained included referral diagnosis, occurrence/type of attack during EEG, the use of suggestion, length of recording and who was present during the EEG. RESULTS 11,298 patients were entered into the study. 376 psychogenic non-epileptic seizures (PNES) occurred of which 337 were considered to be of the habitual type. In those patients suspected of having NEAD prior to referral, the use of verbal suggestion increased the yield of habitual attacks by a factor of three in both adults and children. Using suggestive techniques twice, improved the yield further. Non-habitual attacks occurred equally whether or not suggestion was used. At least 90% of habitual PNES occurred within the first 30 min of recording even in those patients having prolonged EEGs. In EEGs where additional professional personnel were present, PNES occurred more frequently. CONCLUSION This large multicentre study provides evidence to inform recommendations for EEG to investigate NEAD. We recommend the use of verbal suggestion at least twice and where practical the presence of additional professional staff. A thirty minute recording is sufficient to record a habitual PNES in most instances.
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Affiliation(s)
- Rosalind Kandler
- Department of Clinical Neurophysiology, Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2JF, UK.
| | - Sarah Lawrence
- Department of Clinical Neurophysiology, Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2JF, UK
| | - Catherine Pang
- Department of Clinical Neurophysiology, Queen Elizabeth Hospital, Mindelsohn Way, Birmingham, BE15 2TH, UK
| | - Ming Lai
- Department of Clinical Neurophysiology, Royal Victoria Infirmary, Queen Victoria Road, Newcastle, NE1 4LP, UK
| | - Kimberley Whitehead
- Department of Neuroscience, Physiology and Pharmacology, University College London, Gower Street, London, WC1E 6BT, UK
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13
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Popkirov S, Jungilligens J, Grönheit W, Wellmer J. Diagnosing psychogenic nonepileptic seizures: Video-EEG monitoring, suggestive seizure induction and diagnostic certainty. Epilepsy Behav 2017. [PMID: 28622545 DOI: 10.1016/j.yebeh.2017.05.027] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Psychogenic nonepileptic seizures (PNES) can remain undiagnosed for many years, leading to unnecessary medication and delayed treatment. A recent report by the International League Against Epilepsy Nonepileptic Seizures Task Force recommends a staged approach to the diagnosis of PNES (LaFrance, et al., 2013). We aimed to investigate its practical utility, and to apply the proposed classification to evaluate the role of long-term video-EEG monitoring (VEEG) and suggestive seizure induction (SSI) in PNES workup. Using electronic medical records, 122 inpatients (mean age 36.0±12.9years; 68% women) who received the diagnosis of PNES at our epilepsy center during a 4.3-year time period were included. There was an 82.8% agreement between diagnostic certainty documented at discharge and that assigned retroactively using the Task Force recommendations. In a minority of cases, having used the Task Force criteria could have encouraged the clinicians to give more certain diagnoses, exemplifying the Task Force report's utility. Both VEEG and SSI were effective at supporting high level diagnostic certainty. Interestingly, about one in four patients (26.2%) had a non-diagnostic ("negative") VEEG but a positive SSI. On average, this subgroup did not have significantly shorter mean VEEG recording times than VEEG-positive patients. However, VEEG-negative/SSI-positive patients had a significantly lower habitual seizure frequency than their counterparts. This finding emphasizes the utility of SSI in ascertaining the diagnosis of PNES in patients who do not have a spontaneous habitual event during VEEG due to, for example, low seizure frequency.
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Affiliation(s)
- Stoyan Popkirov
- Ruhr-Epileptology, Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, In der Schornau 23-25, 44892 Bochum, Germany.
| | - Johannes Jungilligens
- Ruhr-Epileptology, Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, In der Schornau 23-25, 44892 Bochum, Germany; Department of Neuropsychology, Institute of Cognitive Neuroscience, Faculty of Psychology, Ruhr University Bochum, Bochum, Germany
| | - Wenke Grönheit
- Ruhr-Epileptology, Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, In der Schornau 23-25, 44892 Bochum, Germany
| | - Jörg Wellmer
- Ruhr-Epileptology, Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, In der Schornau 23-25, 44892 Bochum, Germany
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14
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Whitehead K, Kane N, Wardrope A, Kandler R, Reuber M. Proposal for best practice in the use of video-EEG when psychogenic non-epileptic seizures are a possible diagnosis. Clin Neurophysiol Pract 2017; 2:130-139. [PMID: 30214985 PMCID: PMC6123876 DOI: 10.1016/j.cnp.2017.06.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 05/31/2017] [Accepted: 06/02/2017] [Indexed: 11/24/2022] Open
Abstract
The gold-standard for the diagnosis of psychogenic non-epileptic seizures (PNES) is capturing an attack with typical semiology and lack of epileptic ictal discharges on video-EEG. Despite the importance of this diagnostic test, lack of standardisation has resulted in a wide variety of protocols and reporting practices. The goal of this review is to provide an overview of research findings on the diagnostic video-EEG procedure, in both the adult and paediatric literature. We discuss how uncertainties about the ethical use of suggestion can be resolved, and consider what constitutes best clinical practice. We stress the importance of ictal observation and assessment and consider how diagnostically useful information is best obtained. We also discuss the optimal format of video-EEG reports; and of highlighting features with high sensitivity and specificity to reduce the risk of miscommunication. We suggest that over-interpretation of the interictal EEG, and the failure to recognise differences between typical epileptic and nonepileptic seizure manifestations are the greatest pitfalls in neurophysiological assessment of patients with PNES. Meanwhile, under-recognition of semiological pointers towards frontal lobe seizures and of the absence of epileptiform ictal EEG patterns during some epileptic seizure types (especially some seizures not associated with loss of awareness), may lead to erroneous PNES diagnoses. We propose that a standardised approach to the video-EEG examination and the subsequent written report will facilitate a clear communication of its import, improving diagnostic certainty and thereby promoting appropriate patient management.
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Affiliation(s)
- Kimberley Whitehead
- Department of Neuroscience, Physiology and Pharmacology, University College London, London, UK
| | - Nick Kane
- Grey Walter Department of Clinical Neurophysiology, North Bristol NHS Trust, Bristol, UK
| | | | - Ros Kandler
- Department of Clinical Neurophysiology, Sheffield Teaching Hospitals, Sheffield, UK
| | - Markus Reuber
- Academic Neurology Unit, University of Sheffield, Sheffield, UK
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15
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Takasaki K, Diaz Stransky A, Miller G. Psychogenic Nonepileptic Seizures: Diagnosis, Management, and Bioethics. Pediatr Neurol 2016; 62:3-8. [PMID: 27400821 DOI: 10.1016/j.pediatrneurol.2016.04.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 04/17/2016] [Accepted: 04/20/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND The diagnosis and management of psychogenic nonepileptic seizures (PNES) is often challenging and fraught with discord and disagreement between patients, parents, and physicians. Furthermore, there are ethical challenges when making the diagnosis, communicating this information, and instituting management. METHODS We reviewed the current body of knowledge regarding the characteristic differences between epileptic seizures and PNES, and the high incidence of psychiatric comorbidities. An ethical analysis was made of diagnosis and management based on ethical principles, virtue ethics, and the social contract that health professionals have with patients. RESULTS Key distinctions between PNES and epilepsy lie in both patient and seizure characteristics. Long duration, eye closure, asynchronous movements, frequent recurrence in the same context, intra-ictal awareness, and lack of post ictal state are useful in helping establish the diagnosis. Psychiatric comorbidities, history of abuse, cognitive impairment, and multiple non specific somatic complaints are some salient patient features that should increase suspicion for the diagnosis of PNES. However, definitive diagnosis rests on capturing the events on video EEG. CONCLUSION Effective diagnosis and management of PNES requires the use of video EEG and an early collaborative approach between pediatricians, neurologists, psychiatrists, nursing staff, and other professional colleagues. Ethical questions that may arise should be addressed with the virtues of competence, courage, compassion, prudence, and honesty; and the principles of respect beneficence, and the avoidance of unnecessary harm.
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Affiliation(s)
- Kaoru Takasaki
- Yale University School of Medicine, New Haven, Connecticut
| | - Andrea Diaz Stransky
- Child Study Center, Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut
| | - Geoffrey Miller
- Department of Pediatrics, Program for Biomedical Ethics, Yale University School of Medicine, New Haven, Connecticut.
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16
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Sarma AK, Khandker N, Kurczewski L, Brophy GM. Medical management of epileptic seizures: challenges and solutions. Neuropsychiatr Dis Treat 2016; 12:467-85. [PMID: 26966367 PMCID: PMC4771397 DOI: 10.2147/ndt.s80586] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Epilepsy is one of the most common neurologic illnesses. This condition afflicts 2.9 million adults and children in the US, leading to an economic impact amounting to $15.5 billion. Despite the significant burden epilepsy places on the population, it is not very well understood. As this understanding continues to evolve, it is important for clinicians to stay up to date with the latest advances to provide the best care for patients. In the last 20 years, the US Food and Drug Administration has approved 15 new antiepileptic drugs (AEDs), with many more currently in development. Other advances have been achieved in terms of diagnostic modalities like electroencephalography technology, treatment devices like vagal nerve and deep-brain stimulators, novel alternate routes of drug administration, and improvement in surgical techniques. Specific patient populations, such as the pregnant, elderly, those with HIV/AIDS, and those with psychiatric illness, present their own unique challenges, with AED side effects, drug interactions, and medical-psychiatric comorbidities adding to the conundrum. The purpose of this article is to review the latest literature guiding the management of acute epileptic seizures, focusing on the current challenges across different practice settings, and it discusses studies in various patient populations, including the pregnant, geriatric, those with HIV/AIDS, comatose, psychiatric, and "pseudoseizure" patients, and offers possible evidence-based solutions or the expert opinion of the authors. Also included is information on newer AEDs, routes of administration, and significant AED-related drug-interaction tables. This review has tried to address only some of these issues that any practitioner who deals with the acute management of seizures may encounter. The document also highlights the numerous avenues for new research that would help practitioners optimize epilepsy management.
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Affiliation(s)
- Anand K Sarma
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | - Nabil Khandker
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | - Lisa Kurczewski
- Departments of Pharmacotherapy & Outcomes Science and Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Gretchen M Brophy
- Departments of Pharmacotherapy & Outcomes Science and Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA
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17
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Popkirov S, Grönheit W, Wellmer J. A systematic review of suggestive seizure induction for the diagnosis of psychogenic nonepileptic seizures. Seizure 2015; 31:124-32. [PMID: 26362389 DOI: 10.1016/j.seizure.2015.07.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 07/03/2015] [Accepted: 07/22/2015] [Indexed: 10/23/2022] Open
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