Can semiology predict psychogenic nonepileptic seizures? a prospective study

Approach to Patients with Seizures and Epilepsy: A Guide for Primary Care Physicians

Seizures and epilepsy are common neurologic conditions that are frequently encountered in the outpatient primary care setting. An accurate diagnosis relies on a thorough clinical history and evaluation. Understanding seizure semiology and classification is crucial in conducting the initial assessment. Knowledge of common seizure triggers and provoking factors can further guide diagnostic testing and initial management. The pharmacodynamic characteristics and side effect profiles of anti-seizure medications are important considerations when deciding treatment and counseling patients, particularly those with comorbidities and in special populations such as patient of childbearing potential.

Recent advances in understanding the neurobiology of pediatric functional neurological disorder

INTRODUCTION

Functional neurological disorder (FND) is a neuropsychiatric disorder that manifests in a broad array of functional motor, sensory, or cognitive symptoms, which arise from complex interactions between brain, mind, body, and context. Children with FND make up 10%-20% of presentations to neurology services in children's hospitals and up to 20% of adolescents admitted to hospital for the management of intractable seizures.

AREAS COVERED

The current review focuses on the neurobiology of pediatric FND. The authors present an overview of the small but growing body of research pertaining to the biological, emotion-processing, cognitive, mental health, physical health, and social system levels.

EXPERT OPINION

Emerging research suggests that pediatric FND is underpinned by aberrant changes within and between neuron-glial (brain) networks, with a variety of factors - on multiple system levels - contributing to brain network changes. In pediatric practice, adverse childhood experiences (ACEs) are commonly reported, and activation or dysregulation of stress-system components is a frequent finding. Our growing understanding of the neurobiology of pediatric FND has yielded important flow-on effects for assessing and diagnosing FND, for developing targeted treatment interventions, and for improving the treatment outcomes of children and adolescents with FND.

Experimental assessment of seizure-like behaviors in a girl with Rett syndrome

Contextual events are recognized to affect seizure-like behaviors, yet there is limited research on procedures assessing contextual control. This study aimed to examine the utilization of a brief experimental precursor functional analysis within a clinical team assessment. Furthermore, the study explored if telehealth supervision could guide a parent administered replication of the functional analysis. The participants were a young female with Rett syndrome and a history of epilepsy as well as non-epileptic seizures and her mother. The functional analysis procedures consisted of the systematic alternations of contextual conditions that were hypothesized to either prevent or evoke seizure-like behaviors. The primary outcome measure was the occurrence of behavioral precursors that were identified to consequently signal subsequent seizure-like behaviors. In addition, procedure fidelity and interobserver agreement data were obtained alongside parent rating of the procedure's social validity. The clinical functional analysis clearly suggested that the seizure-like behaviors served the function of access to attention and preferred activities. A parent administered functional analysis replicated clinical functional analysis findings. The parent's fidelity to procedures was high and scores in social validity were excellent. The results show that functional analysis procedures could provide essential information in assessment of non-epileptic seizures. Strengths and limitations are discussed.

Dissociative seizures in the emergency room: room for improvement

BACKGROUND

Dissociative seizures, also known as functional or psychogenic non-epileptic seizures, account for 11%-27% of all emergency seizure presentations. Misdiagnosis as epileptic seizures is common and leads to ineffective and potentially harmful treatment escalations. We assess the potential for diagnostic improvement at different stages of emergency workup and estimate the utility of benzodiazepines.

METHODS

A retrospective study of all emergency presentations with a discharge diagnosis of acute dissociative seizures seen at a university hospital 2010-2022 was performed to assess clinical characteristics and emergency decision-making.

RESULTS

Among 156 patients (73% female, median 29 years), 15% presented more than once for a total of 203 presentations. Half of seizures were ongoing at first medical contact; prolonged seizures and clusters were common (23% and 24%). Diagnostic accuracy differed between on-site emergency physicians and emergency department neurologists (12% vs 52%). Typical features such as eye closure, discontinuous course and asynchronous movements were common. Benzodiazepines were given in two-thirds of ongoing seizures, often in high doses and preferentially for major hyperkinetic semiology. Clinical response to benzodiazepines was mixed, with a minority of patients remaining either unaffected (16%) or becoming critically sedated (13%). A quarter of patients given benzodiazepines by emergency medical services were admitted to a monitoring unit, 9% were intubated.

CONCLUSIONS

Improved semiological assessment could reduce early misdiagnosis of dissociative seizures. Although some seizures seem to respond to benzodiazepines, critical sedation is common, and further studies are needed to assess the therapeutic ratio.

The promises and pitfalls of seizure phenomenology

The typical adult patient presenting with a first seizure has a normal clinical examination, uninformative investigations, and often has no witness to their episode. The assessing clinician, therefore, has one primary source of information to guide their assessment; the patient's experience. However, seizure phenomenology - the subjective seizure experience - has received relatively less attention by researchers than objective semiology or investigations. This essay reviews the clinical importance of seizure phenomenology, and the challenges clinicians face in eliciting accurate and clinically relevant descriptions of ictal experience. I conclude by discussing tools that clinicians may use to support the clinical application of seizure phenomenology, and exploring the subjectivity of epilepsy more broadly.

Effects of attachment styles, childhood traumas, and alexithymia in Turkish patients with epilepsy and functional seizures

INTRODUCTION

In this cross-sectional study, we used self-report scales to compare childhood traumas, attachment styles, and alexithymia among patients with functional seizures (FS) to patients with epilepsy and healthy controls. We also investigated risk factors associated with FS.

MATERIAL AND METHODS

A total of 44 patients with epilepsy, 14 patients with FS, and 25 healthy controls were included. All participants were over the age of 18 and were referred to the Baskent University Adana Epilepsy and Video-EEG Center. The patients underwent neurological examinations, brain MRIs, and video-EEG evaluations. Epileptic seizures were classified based on video EEG. The control group consisted of healthy individuals without neurological or psychiatric illness and a history of epileptic seizures or syncope. Beck Depression Inventory (BDI), Childhood Trauma Questionnaire (CTQ), Adult Attachment Scale (AAS), and Toronto Alexithymia Scale-20 (TAS-20) were applied to all participants.

RESULTS

Patients with FS had lower educational levels, higher rates of unemployment and single-marital status. The FS group had higher depression, childhood trauma, and alexithymia scores than the other groups. Furthermore, FS patients had a higher prevalence of avoidant attachment. The alexithymia and childhood trauma scores were both correlated with depression. Through the logistic regression analysis, childhood trauma scores and alexithymia were significant risk factors for FS.

CONCLUSION

The use of video-EEG for diagnosing FS can reduce the risk of misdiagnosis and inappropriate antiepileptic treatment. Psychiatric comorbidities, childhood traumas, and alexithymia are prevalent in patients with FS. Therefore, implementing a multidisciplinary treatment approach that addresses the psychological, medical, and social aspects of FS can significantly improve outcomes.

Ictal crying in epileptic seizures and psychogenic nonepileptic seizures: What are the hints to differentiate them?

OBJECTIVES

Ictal crying (IC) is a quite rare semiological manifestation of epileptic seizures (ESs) and it has been mostly reported in psychogenic nonepileptic seizures (PNESs). However, labeling IC as a pathognomonic sign of PNES can be harmful. We first aimed to investigate IC frequency in ES and PNES and highlight the differences of IC between ES and PNES. Secondly, we aimed to analyze etiology, detailed semiology, treatment options, and outcome of patients with IC in ES in more detail.

METHODS

We retrospectively screened all video-EEG monitoring unit reports from Hacettepe University Hospitals' Epilepsy Center over a 20-year period (1996-2017) for the diagnosis of IC. We included the patients with IC who had at least one documented seizure. Patients who had IC with both facial expression and vocalization compatible with crying with or without weeping and subjective feeling of sadness, were included in the study. We classified patients with IC as ES and PNES. Demographic, historical, clinical, neuroimaging, electrophysiological parameters, video-EEG data, treatment options, and prognosis of all patients were recorded. Demographic, clinical, and video-EEG data were compared between ES and PNES.

RESULTS

During the study period, 1983 patients were investigated. Six patients (all female) with ES and 37 patients (33 female) with PNES were identified. When we compared patients with PNES and ES with IC, the number of ASMs taken and duration of disease were significantly higher in patients with ES than PNES. Longer duration of seizure, longer duration of crying component, late onset of crying component in seizure, early responsiveness after seizure, not occurring during sleep, accompanied by eye closure and weeping, were found significantly higher in patients with PNES. Besides, if we analyze ES group in more detail, all had medical treatment refractory focal epilepsy and two of them whose IC was seen as an early semiological manifestation of their seizures had good outcome after nondominant anterior temporal lobectomy (ATL)+amygdalohippocampectomy (AH). However, three patients had various cortical lesions apart from temporal lobe on MRI and one patient had focal epilepsy with frontal lobe semiology with negative MRI.

CONCLUSION

Although the most common etiology for IC is PNES and it is rarely seen in ES, it can be harmful to label ictal crying as a pathognomonic sign for PNES. We proposed that there are some semiological differences in terms of IC between PNES and ES. These differences may help to distinguish IC in PNES and ES in daily practice. Moreover, it can be speculated that nondominant temporal lobe involvement may be associated with IC in ES.

Functional neurological disorder is a feminist issue

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

Why functional neurological disorder is not feigning or malingering

Functional neurological disorder (FND) is one of the commonest reasons that people seek help from a neurologist and is for many people a lifelong cause of disability and impaired quality of life. Although the evidence base regarding FND pathophysiology, treatment and service development has grown substantially in recent years, a persistent ambivalence remains amongst health professionals and others as to the veracity of symptom reporting in those with FND and whether the symptoms are not, in the end, just the same as feigned symptoms or malingering. Here, we provide our perspective on the range of evidence available, which in our view provides a clear separation between FND and feigning and malingering. We hope this will provide a further important step forward in the clinical and academic approach to people with FND, leading to improved attitudes, knowledge, treatments, care pathways and outcomes.

The Best Seizure Diagnostic Tool Is Not a Medical Device: Why Stand-Alone Video Review Needs a Current Procedural Terminology Code

The diagnosis of seizures and epilepsy is primarily based on the history, but history-taking is fraught with difficulties and has serious limitations, which is one reason for the common misdiagnosis of seizures. EEG is a very useful tool, but routine EEG has poor sensitivity, and prolonged EEG-video monitoring, the gold-standard for diagnosis, is only useful for patients with frequent events. Smartphones are ubiquitous, and their videos are increasingly used as an extension of the history and a diagnostic tool. Stand-alone videos should be considered a diagnostic tool and treated as such, including with a Current Procedural Terminology (CPT) code, the American uniform nomenclature for medical procedures, which is used for billing and reimbursement.

The clinical management of functional neurological disorder: A scoping review of the literature

OBJECTIVE

To date, there have been no reviews bringing together evidence on the clinical management of functional neurological disorder (FND) and patients', caregivers', and healthcare workers' experiences. This review provides an overview of the literature focused on the clinical management of FND.

METHODS

Four databases were searched, and a consultation exercise was conducted to retrieve relevant records dated from September 2010 to September 2020. Articles documenting diagnostic methods, treatments or interventions, or the experiences and perspectives of patients and healthcare workers in the clinical management of FND were included.

RESULTS

In total, 2756 records were retrieved, with 162 included in this review. The diagnostic methods reported predominantly included positive clinical signs, v-EEG and EEG. Psychological treatments and medication were the most reported treatments. Mixed findings of the effectiveness of CBT were found. Haloperidol, physiotherapy and scripted diagnosis were found to be effective in reducing FND symptoms. Several facilitators and barriers for patients accessing treatment for FND were reported.

CONCLUSION

The literature describing the clinical management for FND has increased considerably in recent times. A wide variety of diagnostic tools and treatments and interventions were found, with more focus being placed on tests that confirm a diagnosis than 'rule-out' tests. The main treatment type found in this review was medication. This review revealed that there is a lack of high-quality evidence and reflects the need for official clinical guidelines for FND, providing healthcare workers and patients the support needed to navigate the process to diagnose and manage FND.

The A to F of functional status in the acute setting: A scoping review

Functional status (FSt) describes the phenomenon of prolonged non-epileptic attacks that may be misidentified as Status Epilepticus (SE). The early differentiation between epileptic and functional status is crucial in order to avoid unnecessarily invasive and costly medical escalation in the latter group, including the hazards of overmedication, intubation and intensive care admission. The authors conducted a literature review of available studies describing cases of functional status to extract the common aspects of FSt seizure semiology, investigations used to differentiate from SE, and guidance for managing FSt. A search was carried out using Medline, Embase and PsychInfo databases and 3909 papers were extracted for review. 30 papers were found relevant for inclusion, describing 260 cases of FSt. FSt was found to occur more commonly in younger, female patients with a family history of epilepsy, co-morbid psychiatric diagnosis and following a recent traumatic event. Common clinical features of FSt during and after, the events were identified. While video-EEG remains the gold standard investigation for differentiating FSt from SE, many of the included studies considered the utility of other investigation modalities including serum markers and neuroimaging. One key shortcoming identified within the literature reviewed was a lack of well-defined guidance on the acute management of FSt. We offer an A-F step management plan for the immediate and longer term assessment and treatment of FSt.

Multi-centre classification of functional neurological disorders based on resting-state functional connectivity

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Using machine learning on multi-centre data, FND patients were successfully classified with an accuracy of 72%.

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The angular- and supramarginal gyri, cingular- and insular cortex, and the hippocampus were the most discriminant regions.

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To provide diagnostic utility, future studies must include patients with similar symptoms but different diagnoses.

Background

Patients suffering from functional neurological disorder (FND) experience disabling neurological symptoms not caused by an underlying classical neurological disease (such as stroke or multiple sclerosis). The diagnosis is made based on reliable positive clinical signs, but clinicians often require additional time- and cost consuming medical tests and examinations. Resting-state functional connectivity (RS FC) showed its potential as an imaging-based adjunctive biomarker to help distinguish patients from healthy controls and could represent a “rule-in” procedure to assist in the diagnostic process. However, the use of RS FC depends on its applicability in a multi-centre setting, which is particularly susceptible to inter-scanner variability. The aim of this study was to test the robustness of a classification approach based on RS FC in a multi-centre setting.

Methods

This study aimed to distinguish 86 FND patients from 86 healthy controls acquired in four different centres using a multivariate machine learning approach based on whole-brain resting-state functional connectivity. First, previously published results were replicated in each centre individually (intra-centre cross-validation) and its robustness across inter-scanner variability was assessed by pooling all the data (pooled cross-validation). Second, we evaluated the generalizability of the method by using data from each centre once as a test set, and the data from the remaining centres as a training set (inter-centre cross-validation).

Results

FND patients were successfully distinguished from healthy controls in the replication step (accuracy of 74%) as well as in each individual additional centre (accuracies of 73%, 71% and 70%). The pooled cross validation confirmed that the classifier was robust with an accuracy of 72%. The results survived post-hoc adjustment for anxiety, depression, psychotropic medication intake, and symptom severity. The most discriminant features involved the angular- and supramarginal gyri, sensorimotor cortex, cingular- and insular cortex, and hippocampal regions. The inter-centre validation step did not exceed chance level (accuracy below 50%).

Conclusions

The results demonstrate the applicability of RS FC to correctly distinguish FND patients from healthy controls in different centres and its robustness against inter-scanner variability. In order to generalize its use across different centres and aim for clinical application, future studies should work towards optimization of acquisition parameters and include neurological and psychiatric control groups presenting with similar symptoms.

Using Semiology to Classify Epileptic Seizures vs Psychogenic Nonepileptic Seizures: A Meta-analysis

Background and objectives:

Misdiagnosis of psychogenic nonepileptic seizures (PNES) and epileptic seizures (ES) is common. In the absence of the diagnostic gold standard (video EEG), clinicians rely on semiology and clinical assessment. However, questions regarding the diagnostic accuracy of different signs remain. This meta-analysis aims to evaluate the diagnostic accuracy of semiology in PNES and ES.

Methods:

We systematically searched PubMed, PsycInfo and Medline for original research publications published before 8 February 2021 with no restriction on search dates to identify studies that compared semiology in ES and PNES in epilepsy monitoring units. Non-English publications, review articles, studies reporting on only PNES or ES and studies limited to patients with developmental delay were excluded. Study characteristics and proportions of ‘event groups’ and ‘patient groups’ demonstrating signs were extracted from each article. Bivariate analysis was conducted, and data were pooled in a random effects model for meta-analysis. The I2 statistic was calculated to assess statistical heterogeneity. The QUADAS-2 tool was utilized to assess risk of bias in included studies. The positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were calculated. A PLR > 10 or an NLR < 0.1 has a large impact on the post-test probability of a diagnosis (ES or PNES) whereas a PLR between 5-10 or an NLR between 0.1- 0.2 has a moderate impact on the post-test probability of a diagnosis (ES or PNES).

Results:

The meta-analysis included 14 studies comprising of 800 patients with ES and 452 patients with PNES. For PNES, ictal eye closure (PLR 40.5 95%CI: 16.2-101.3; I2 = 0, from three studies) and asynchronous limb movements (PLR 10.2; 95%CI: 2.8-37.7; I2 = 0, from three studies) reached a PLR threshold > 5. No single sign reached a PLR threshold >5 for ES.

Conclusions:

While all signs require interpretation in the overall clinical context, the presence of ictal eye closure and asynchronous limb movements are reliable discriminative signs for PNES.

Diagnosis and management of functional neurological disorder

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.

Minimum standards for inpatient long-term video-EEG monitoring: A clinical practice guideline of the international league against epilepsy and international federation of clinical neurophysiology

The objective of this clinical practice guideline is to provide recommendations on the indications and minimum standards for inpatient long-term video-electroencephalographic monitoring (LTVEM). The Working Group of the International League Against Epilepsy and the International Federation of Clinical Neurophysiology develop guidelines aligned with the Epilepsy Guidelines Task Force. We reviewed published evidence using The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. We found limited high-level evidence aimed at specific aspects of diagnosis for LTVEM performed to evaluate patients with seizures and nonepileptic events (see Table S1). For classification of evidence, we used the Clinical Practice Guideline Process Manual of the American Academy of Neurology. We formulated recommendations for the indications, technical requirements, and essential practice elements of LTVEM to derive minimum standards used in the evaluation of patients with suspected epilepsy using GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). Further research is needed to obtain evidence about long-term outcome effects of LTVEM and establish its clinical utility.

Minimum standards for inpatient long-term video-electroencephalographic monitoring: A clinical practice guideline of the International League Against Epilepsy and International Federation of Clinical Neurophysiology

The objective of this clinical practice guideline is to provide recommendations on the indications and minimum standards for inpatient long-term video-electroencephalographic monitoring (LTVEM). The Working Group of the International League Against Epilepsy and the International Federation of Clinical Neurophysiology develop guidelines aligned with the Epilepsy Guidelines Task Force. We reviewed published evidence using the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) statement. We found limited high-level evidence aimed at specific aspects of diagnosis for LTVEM performed to evaluate patients with seizures and nonepileptic events. For classification of evidence, we used the Clinical Practice Guideline Process Manual of the American Academy of Neurology. We formulated recommendations for the indications, technical requirements, and essential practice elements of LTVEM to derive minimum standards used in the evaluation of patients with suspected epilepsy using GRADE (Grading of Recommendations Assessment, Development, and Evaluation). Further research is needed to obtain evidence about long-term outcome effects of LTVEM and to establish its clinical utility.

Misdiagnosis of prolonged psychogenic non-epileptic seizures as status epilepticus: epidemiology and associated risks

OBJECTIVE

To determine the epidemiology of prolonged psychogenic non-epileptic seizures (pPNES) misdiagnosed as status epilepticus, as well as the risks associated with non-indicated treatment.

METHODS

We performed an individual patient data analysis from the Rapid Anticonvulsant Medication Prior to Arrival Trial (RAMPART) and the Established Status Epilepticus Treatment Trial (ESETT) to assess incidence, patient characteristics and clinical course of misdiagnosed pPNES.

RESULTS

Among 980 patients aged 8 years or older diagnosed and treated for status epilepticus in RAMPART and ESETT, 79 (8.1%) were discharged with a final diagnosis of pPNES. The relative incidence was highest in adolescents and young adults (20.1%). The typical female preponderance seen in that age bracket was not evident in children and older adults. Adverse effects, including respiratory depression and intubation, were documented in 26% of patients with pPNES receiving benzodiazepines in RAMPART and 33% of patients receiving additional second-line medication in ESETT. In ESETT, patients who were treated with benzodiazepines before hospital admission had higher rates of unresponsiveness and severe adverse effects than those treated after admission, suggesting cumulative effects of accelerated treatment momentum. Across trials, one in five patients with pPNES were admitted to an intensive care unit.

CONCLUSIONS

Misdiagnosis and treatment of pPNES as status epilepticus are a common and widespread problem with deleterious consequences. Mitigating it will require training of emergency staff in semiological diagnosis. Status epilepticus response protocols should incorporate appropriate diagnostic re-evaluations at each step of treatment escalation, especially in clinical trials.

The evaluation of psychogenic non-epileptic seizures (PNES) cases with saline injection method in video-EEG monitorization unit

BACKGROUND

It has been reported that 10 to 30% of patients sent to epilepsy centers with a diagnosis of refractory epilepsy are diagnosed with psychogenic non-epileptic seizure (PNES). A wide variety of provocative methods are used to assist PNES diagnosis.

OBJECTIVE

To investigate the effect of seizure induction on the diagnosis and prognosis of PNES.

METHODS

We retrospectively examined 91 patients with PNES complaints in our video-EEG laboratory. Intravenous saline was administered to all patients for induction of seizures.

RESULTS

Saline injection was performed in 91 patients referred to our EEG lab with PNES initial diagnosis, 57 of whom were female and 34 male. Saline injection triggered an attack in 82 patients (90%).

CONCLUSIONS

In this study we have concluded that provocative methods are practical, cheap and, most of all, effective for patient diagnosis. In clinical practice, explaining the diagnosis is the first and most important step of the treatment, and careful patient-doctor communication has a positive impact on patient prognosis.

Pitfalls using smartphones videos in diagnosing functional seizures

Expert review of seizure semiology looking at video recordings independent of EEG has been found to be useful for diagnosing functional seizures. Videos recorded outside the hospital containing "spells" have similar sensitivity to EEG when quality recordings are evaluated. Recently, smartphone videos were shown to serve as an adjunct to standard history and physical examination with similar diagnostic yields when compared to diagnostic video-EEG monitoring and reviewed by experts. However, caution must be exercised when interpreting videos of paroxysmal neurological events recorded by caregivers to ensure proper video quality is maintained and recorded event is representative. In this report, we present a case of initial identification of and event falsely suggesting functional seizures in a patient with epilepsy. The smartphone video of a "seizure" was recorded by his wife using her smartphone. Despite a quality recording and a history consistent with epilepsy, the smartphone video reviewed during evaluation in the clinic suggested a functional behavior in contrast to the history that suggested epilepsy manifest as convulsions. Instead of bilateral tonic-clonic motor movements, bizarre, intermittent non-clonic wild flinging movements and vocalization were identified on the smartphone video. The discordance between the clnical history and ideo prompted inpatient video-EEG monitoring. The same nonepileptic semiology was subsequently clarified to represent a physiological nonepileptic event. The event on the smartphone was typical of his agitated post-ictal state following an electroclinical tonic-clonic seizure. With treatment the seizures became controlled with antiseizure medication in long-term follow-up. We highlight the pitfalls using patient-recorded smartphone videos in patients diagnosed with epilepsy. Understanding the utility of smartphones as an adjunct to the clinical history will help in differentiating epileptic from functional seizures.

Psychological and demographic characteristics of 368 patients with dissociative seizures: data from the CODES cohort

BACKGROUND

We examined demographic, clinical, and psychological characteristics of a large cohort (n = 368) of adults with dissociative seizures (DS) recruited to the CODES randomised controlled trial (RCT) and explored differences associated with age at onset of DS, gender, and DS semiology.

METHODS

Prior to randomisation within the CODES RCT, we collected demographic and clinical data on 368 participants. We assessed psychiatric comorbidity using the Mini-International Neuropsychiatric Interview (M.I.N.I.) and a screening measure of personality disorder and measured anxiety, depression, psychological distress, somatic symptom burden, emotional expression, functional impact of DS, avoidance behaviour, and quality of life. We undertook comparisons based on reported age at DS onset (<40 v. ⩾40), gender (male v. female), and DS semiology (predominantly hyperkinetic v. hypokinetic).

RESULTS

Our cohort was predominantly female (72%) and characterised by high levels of socio-economic deprivation. Two-thirds had predominantly hyperkinetic DS. Of the total, 69% had ⩾1 comorbid M.I.N.I. diagnosis (median number = 2), with agoraphobia being the most common concurrent diagnosis. Clinical levels of distress were reported by 86% and characteristics associated with maladaptive personality traits by 60%. Moderate-to-severe functional impairment, high levels of somatic symptoms, and impaired quality of life were also reported. Women had a younger age at DS onset than men.

CONCLUSIONS

Our study highlights the burden of psychopathology and socio-economic deprivation in a large, heterogeneous cohort of patients with DS. The lack of clear differences based on gender, DS semiology and age at onset suggests these factors do not add substantially to the heterogeneity of the cohort.

Predictive semiology of psychogenic non-epileptic seizures in an epilepsy monitoring unit

Introduction

The diagnosis of psychogenic nonepileptic seizures (PNES) is a common clinical dilemma. We sought to assess the diagnostic value of four ictal signs commonly used in differentiating PNES from epileptic seizures (ES).

Methods

We retrospectively reviewed consecutive adult video-electroencephalogram (VEM) studies conducted at a single tertiary epilepsy center between May 2009 and August 2016. Each event was assessed by a blinded rater for the presence of four signs: fluctuating course, head shaking, hip thrusting, and back arching. The final diagnosis of PNES or ES was established for each event based on clinical and VEM characteristics. All ES were pooled regardless of focal or generalized onset. We analyzed the odds ratio of each sign in PNES in comparison to ES with adjustment for repeated measures using logistic regression. Additionally, we calculated the sensitivity, specificity, predictive values, and likelihood ratios of each sign to diagnose PNES.

Results

A total of 742 events from 140 VEM studies were assessed. Fluctuating course (odds ratio (OR) 37.37, 95% confidence interval (CI) 13.56–102.96, P < 0.0001), head shaking (OR 2.95, 95% CI 1.26–6.79, P = 0.012), and hip thrusting (OR 4.28, 95% CI 1.21–15.18, P = 0.02) were each significantly predictive of PNES. Fluctuating course had the highest sensitivity (76.16%). Back arching (OR 1.06, 95% CI 0.35–3.20, P = 0.92) was not significantly associated with PNES.

Conclusion

Fluctuating course, head shaking, and hip thrusting are semiological features significantly more common in PNES than ES. Fluctuating course is the most reliable sign. Back arching does not appear to differentiate PNES from ES.

Effects of the COVID-19 pandemic on characteristics of functional (psychogenic) seizures

OBJECTIVE

We investigated whether the COVID-19 pandemic has affected the clinical characteristics of patients with functional seizure (FS) (at the time of diagnosis).

METHODS

In a retrospective study of a prospectively developed and maintained database, all patients diagnosed with FS before and during the COVID-19 pandemic were studied at the outpatient epilepsy clinic at Shiraz University of Medical Sciences, Shiraz, Iran, from December 2008 until February 2021.

RESULTS

Three hundred and eighty-eight patients were studied. Three hundred and sixty-four patients (94%) were diagnosed before and 24 persons (6%) during the pandemic. Patients diagnosed during the COVID-19 pandemic less frequently had generalized motor seizures [odds ratio (OR): 0.30, 95% confidence interval (CI): 0.12-0.77; p = 0.012] and had higher seizure frequencies (OR: 1.00, 95% CI: 1.00-1.01; p = 0.044). Functional seizures were inversely associated with the education level as a trend during the COVID-19 pandemic (OR: 0.36, 95% CI: 0.13-1.01; p = 0.052).

CONCLUSION

The COVID-19 pandemic has affected the characteristics of patients with FS (at the time of diagnosis). Larger and multi-center studies are needed to investigate the links and associations between the COVID-19 pandemic and characteristics of FS.

Diagnostic accuracy of clinical signs and symptoms for psychogenic nonepileptic attacks versus epileptic seizures: A systematic review and meta-analysis

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.

Value of smartphone videos for diagnosis of seizures: Everyone owns half an epilepsy monitoring unit

The diagnosis of epilepsy is primarily based on the history and the verbal description of the events in question. Smartphone videos are increasingly used to assist in the diagnosis. The purpose of this study is to evaluate their value for the diagnosis of seizures. We prospectively collected smartphone videos from patients who presented to our epilepsy center over two years. The video-based diagnosis was then compared to the eventual diagnosis based on video-electroencephalographic (EEG) monitoring with recorded episodes. Video-EEG studies and smartphone videos were reviewed by two separate physicians, each blinded to the other's interpretation. Fifty-four patients were included in the final analysis (mean age = 34.7 years, SD = 17 years). Data (either smartphone video or video-EEG monitoring) were inconclusive in 18 patients. Of the 36 patients with conclusive data, 34 (94%) were in agreement. Smartphone video interpretation can be a useful adjunctive tool in the diagnosis of seizure-like events.

Psychogenic non-epileptic seizures in children

Psychogenic Non-Epileptic Seizures (PNES) are a relatively common condition in children. While their clinical presentation resembles epileptic seizures, the underlying cause for PNES involves a multitude of bio-psychosocial factors. Patients may be misdiagnosed with epilepsy and subjected to unnecessary treatments, often delaying the diagnosis for years. A strong understanding of its symptomatology is essential for diagnosis of PNES. Successful management depends on effective teamwork that involves the neurologist as well as mental health professionals. This paper reviews the various aspects of PNES in children with emphasis on the clinical presentation, diagnosis as well as the underlying psychological basis and treatment.

Functional neurological disorder in the emergency department

We provide a narrative review of functional neurological disorder (FND, or conversion disorder) for the emergency department (ED). Diagnosis of FND has shifted from a "rule-out" disorder to one now based on the recognition of positive clinical signs, allowing the ED physician to make a suspected or likely diagnosis of FND. PubMed, Google Scholar, academic books, and a hand search through review article references were used to conduct a literature review. We review clinical features and diagnostic pitfalls for the most common functional neurologic presentations to the ED, including functional limb weakness, functional (nonepileptic) seizures, and functional movement disorders. We provide practical advice for discussing FND as a possible diagnosis and suggestions for initial steps in workup and management plans.

A novel scale for suspicion of psychogenic nonepileptic seizures: development and accuracy

OBJECTIVE

The differential diagnosis between epileptic and psychogenic nonepileptic seizures (PNES) is challenging, yet suspicion of PNES is crucial to rethink treatment strategies and select patients for diagnostic confirmation through video EEG (VEEG). We developed a novel scale to prospectively suspect PNES.

METHODS

First, we developed a 51-item scale in two steps, based upon literature review and panel expert opinion. A pilot study verified the applicability of the instrument, followed by a prospective evaluation of 158 patients (66.5% women, mean age 33 years) who were diagnosed for prolonged VEEG. Only epileptic seizures were recorded in 103 patients, and the other 55 had either isolated PNES or both types of seizures. Statistical procedures identified 15 items scored between 0 and 3 that best discriminated patients with and without PNES, with a high degree of consistency.

RESULTS

Internal consistency reliability of the scale for suspicion of PNES was 0.77 with Cronbach's Alpha Coefficient and 0.95 with Rasch Item Reliability Index, and performance did not differ according to the patient's gender. For a cut-off score of 20 (of 45) points, area under the curve was 0.92 (95% IC: 0.87-0.96), with an accuracy of 87%, sensitivity of 89%, specificity of 85%, positive predictive value of 77%, and negative predictive value of 94% (95% IC) for a diagnosis of PNES.

CONCLUSIONS

The scale for suspicion of PNES (SS-PNES) has high accuracy to a reliable suspicion of PNES, helping with the interpretation of apparent seizure refractoriness, reframing treatment strategies, and streamlining referral for prolonged VEEG.

Long-term Home Video EEG for Recording Clinical Events

SUMMARY

Around 50 years after the first EEG acquisition by Hans Berger, its use in ambulatory setting was demonstrated. Ever since, ambulatory EEG has been widely available and routinely used in the United States (and to a lesser extent in Europe) for diagnosis and management of patients with epilepsy. This technology alone cannot help with semiological characterization, and absence of video is one of its main drawbacks. Addition of video to ambulatory EEG potentially improves diagnostic yield and opens new aspects of utility for better characterization of patient's events, including differential diagnosis, classification, and quantification of seizure burden. Studies evaluating quality of ambulatory video EEG (aVEEG) suggest good quality recordings are feasible. In the utilization of aVEEG, to maximize yield, it is important to consider pretest probability. Having clear pretest questions and a strong index of suspicion for focal, generalized convulsive or non-epileptic seizures further increases the usefulness of aVEEG. In this article, which is part of the topical issue "Ambulatory EEG," the authors compare long-term home aVEEG to inpatient video EEG monitoring, discuss aVEEG's use in diagnosis and follow-up of patients, and present the authors' own experience of the utility of aVEEG in a teaching hospital setting.

Ambulatory EEG Monitoring, Reviewing, and Interpreting

SUMMARY

This section of this volume of the Journal of Neurophysiology's review of ambulatory EEG (aEEG) is an overview of the uses of the technique, the clinicians who most often use it, and why they use it. It looks at the use of aEEG from the perspectives of the "generalist" and the "specialist" and discusses where they have similar interests and where their interest may diverge. It compares the use of aEEG to the more classic inpatient-based epilepsy monitoring unit service and compares the advantages and disadvantages of the two approaches (aEEG vs. epilepsy monitoring unit). This section then reviews how aEEGs are clinically interpreted based on a best practices approach and how aEEGs can be modified to address recording problems that, until recently, have been approached only in an epilepsy monitoring unit environment. Finally, this section addresses the qualifications necessary for the proper interpretation and reporting of aEEG studies. At the end of this section, there are five case examples using aEEG techniques that demonstrate various aspects covered in this section. These case reports demonstrate not only the utility of aEEG but also show how aEEG recordings can be integrated into the care of complex clinical situations that are frequently encountered not only by the practicing generalists but also by epilepsy specialists who practices out of a comprehensive epilepsy program.

Validation of a predictive calculator to distinguish between patients presenting with dissociative versus epileptic seizures

Dissociative seizures (also known as psychogenic nonepileptic seizures) are a common functional neurological disorder that can be difficult to distinguish from epileptic seizures. Patients with dissociative seizures provide diagnostic challenges, leading to delays in care, inappropriate care, and significant healthcare utilization and associated costs. The dissociative seizure likelihood score (DSLS) was developed by Kerr and colleagues at UCLA to distinguish between patients with epileptic seizures and dissociative seizures based on clinical and medication history as well as features of seizure semiology. We validated this calculator at the University of Colorado, which is a Level 4 National Association of Epilepsy Center. The DSLS accurately predicted the diagnosis in 81% of patients, despite local variability in the factors associated with epileptic versus dissociative seizures between the two populations. The DSLS can be a useful tool to assist with history taking and may have important utility for clinical decision making with these difficult to distinguish patient populations.

Assessment of the Predictive Value of Outpatient Smartphone Videos for Diagnosis of Epileptic Seizures

Importance

Misdiagnosis of epilepsy is common. Video electroencephalogram provides a definitive diagnosis but is impractical for many patients referred for evaluation of epilepsy.

Objective

To evaluate the accuracy of outpatient smartphone videos in epilepsy.

Design, Setting, and Participants

This prospective, masked, diagnostic accuracy study (the OSmartViE study) took place between August 31, 2015, and August 31, 2018, at 8 academic epilepsy centers in the United States and included a convenience sample of 44 nonconsecutive outpatients who volunteered a smartphone video during evaluation and subsequently underwent video electroencephalogram monitoring. Three epileptologists uploaded videos for physicians from the 8 epilepsy centers to review.

Main Outcomes and Measures

Measures of performance (accuracy, sensitivity, specificity, positive predictive value, and negative predictive value) for smartphone video-based diagnosis by experts and trainees (the index test) were compared with those for history and physical examination and video electroencephalogram monitoring (the reference standard).

Results

Forty-four eligible epilepsy clinic outpatients (31 women [70.5%]; mean [range] age, 45.1 [20-82] years) submitted smartphone videos (530 total physician reviews). Final video electroencephalogram diagnoses included 11 epileptic seizures, 30 psychogenic nonepileptic attacks, and 3 physiologic nonepileptic events. Expert interpretation of a smartphone video was accurate in predicting a video electroencephalogram monitoring diagnosis of epileptic seizures 89.1% (95% CI, 84.2%-92.9%) of the time, with a specificity of 93.3% (95% CI, 88.3%-96.6%). Resident responses were less accurate for all metrics involving epileptic seizures and psychogenic nonepileptic attacks, despite greater confidence. Motor signs during events increased accuracy. One-fourth of the smartphone videos were correctly diagnosed by 100% of the reviewing physicians, composed solely of psychogenic attacks. When histories and physical examination results were combined with smartphone videos, correct diagnoses rose from 78.6% to 95.2%. The odds of receiving a correct diagnosis were 5.45 times greater using smartphone video alongside patient history and physical examination results than with history and physical examination alone (95% CI, 1.01-54.3; P = .02).

Conclusions and Relevance

Outpatient smartphone video review by experts has predictive and additive value for diagnosing epileptic seizures. Smartphone videos may reliably aid psychogenic nonepileptic attacks diagnosis for some people.

Video quality using outpatient smartphone videos in epilepsy: Results from the OSmartViE study

BACKGROUND AND PURPOSE

The aim of this study was to evaluate the quality of smartphone videos (SVs) of neurologic events in adult epilepsy outpatients. The use of home video recording in patients with neurological disease states is increasing. Experts interpretation of outpatient smartphone videos of seizures and neurological events has demonstrated similar diagnostic accuracy to inpatient video-electroencephalography (EEG) monitoring.

METHODS

A prospective, multicenter cohort study was conducted to evaluate SV quality in patients with paroxysmal neurologic events from August 15, 2015 through August 31, 2018. Epileptic seizures (ESs), psychogenic nonepileptic attacks (PNEAs), and physiologic nonepileptic events (PhysNEEs) were confirmed by video-EEG monitoring. Experts and senior neurology residents blindly viewed cloud-based SVs without clinical information. Quality ratings with regard to technical and operator-driven metrics were provided in responses to a survey.

RESULTS

Forty-four patients (31 women, age 45.1 years [r = 20-82]) were included and 530 SVs were viewed by a mean of seven experts and six residents; one video per patient was reviewed for a mean of 133.8 s (r = 9-543). In all, 30 patients had PNEAs, 11 had ESs, and three had PhysNEEs. Quality was suitable in 70.8% of SVs (375/530 total views), with 36/44 (81.8%) patient SVs rated as adequate by the majority of reviewers. Accuracy improved with the presence of convulsive features from 72.4% to 98.2% in ESs and from 71.1% to 95.7% in PNEAs. An accurate diagnosis was given by all reviewers (100%) in 11/44 SVs (all PNEAs). Audio was rated as good by 86.2% of reviewers for these SVs compared with 75.4% for the remaining SVs (p = 0.01). Lighting was better in SVs associated with high accuracy (p = 0.06), but clarity was not (p = 0.59). Poor video quality yielded unknown diagnoses in 24.2% of the SVs reviewed. Features hindering diagnosis were limited interactivity, restricted field of view and short video duration.

CONCLUSIONS

Smartphone video quality is adequate for clinical interpretation in the majority of patients with paroxysmal neurologic events. Quality can be optimized by encouraging interactivity with the patient, adequate duration of the SV, and enlarged field of view during videography. Quality limitations were primarily operational though accuracy remained for SV review of ESs and PNEAs.

Clinical identification of psychogenic nonepileptic events using combinations of psychological tests in a veteran sample

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.

Reliability of additional reported seizure manifestations to identify dissociative seizures

PURPOSE

Descriptions of seizure manifestations (SM), or semiology, can help localize the symptomatogenic zone and subsequently included brain regions involved in epileptic seizures, as well as identify patients with dissociative seizures (DS). Patients and witnesses are not trained observers, so these descriptions may vary from expert review of seizure video recordings of seizures. To better understand how reported factors can help identify patients with DS or epileptic seizures (ES), we evaluated the associations between more than 30 SMs and diagnosis using standardized interviews.

METHODS

Based on patient- and observer-reported data from 490 patients with diagnoses documented by video-electoencephalography, we compared the rate of each SM in five mutually exclusive groups: epileptic seizures (ES), DS, physiologic seizure-like events (PSLE), mixed DS and ES, and inconclusive testing.

RESULTS

In addition to SMs that we described in a prior manuscript, the following were associated with DS: light triggers, emotional stress trigger, pre-ictal and post-ictal headache, post-ictal muscle soreness, and ictal sensory symptoms. The following were associated with ES: triggered by missing medication, aura of déjà vu, and leftward eye deviation. There were numerous manifestations separately associated with mixed ES and DS.

CONCLUSIONS

Reported SM can help identify patients with DS, but no manifestation is pathognomonic for either ES or DS. Patients with mixed ES and DS reported factors divergent from both ES-alone and DS-alone.

DDESVSFS: A simple, rapid and comprehensive screening tool for the Differential Diagnosis of Epileptic Seizures VS Functional Seizures

OBJECTIVE

Functional seizures (FS) are often misclassified as epileptic seizures (ES). This study aimed to create an easy to use but comprehensive screening tool to guide further evaluation of patients presenting with this diagnostic dilemma.

MATERIALS AND METHODS

Demographic, clinical and diagnostic data were collected on patients admitted for video-EEG monitoring for clarification of their diagnosis. Upon discharge, patients were classified as having ES vs FS. Using the collected characteristics and video-EEG diagnosis, we created a multivariable logistic regression model to identify predictors of ES. Then, we trained an integer-coefficient model with the most frequently selected predictors, creating a pointing system coined DDESVSFS, with scores ranging from -17 to +8 points.

RESULTS

43 patients with FS and 165 patients with ES were recruited. In the final integer-coefficient model, 8 predictors were identified as significant in differentiating ES from FS: normal electroencephalogram (-3 points), predisposing factors for FS (-3 points), increased number of comorbidities (-3 points), semiology suggestive of FS (-4 points), increased seizure frequency (-4 points), longer disease duration (+3 points), antiepileptic polypharmacy (+2 points) and compliance with antiepileptic drugs (+3 points). Cumulative scores of ≤ -9 points carried <5% predictive value for ES, while cumulative scores of ≥ -1 points carried >95% predictive value. The model performed well (AUC: 0.923, sensitivity: 0.945, specificity: 0.698).

CONCLUSIONS

We propose DDESVSFS as a simple, rapid and comprehensive prediction score for the Differential Diagnosis of Epileptic Seizures VS Functional Seizures. Large prospective studies are needed to evaluate its utility in clinical practice.

Differentiating psychogenic nonepileptic seizures from epileptic seizures: An observational study of patients undergoing video-electroencephalography (VEEG) in Australia

Video-electroencephalography (VEEG) is an invaluable tool for the differentiation of psychogenic nonepileptic seizures (PNES) from epileptic seizures (ES). This paper (i) evaluates the demographics of patients undergoing VEEGs at the Princess Alexandra Hospital from July 1 2017 to July 1 2019 and identifies those subsequently diagnosed with PNES, (ii) determines the delay in PNES diagnosis and proportion of PNES patients on antiepileptic drugs (AEDs) prior to a VEEG, and (iii) determines the proportion of PNES patients who subsequently ceased their AEDs. Of the 94 patients in the study group, 51 were female and 43 were male. In total, 22 (23%) of VEEGs were consistent with epilepsy (ES), 25 (26%), with PNES, 5 (5%) mixed (PNES and ES), 5 (5%) with other types of events, and 37 were nondiagnostic. Two patients with non-diagnostic VEEGs were subsequently treated as PNES at the treating clinician's discretion. Regarding AEDs, 62 of the patients were on at least one agent at the time of VEEG recording. The mean durations of AED therapy and diagnostic delay for patients subsequently diagnosed with PNES were six years and seven years, respectively. Of these, the majority had their AEDs subsequently weaned/ceased. This study highlights the value of VEEG in diagnostic differentiation of epileptic from nonepileptic events, thereby preventing unnecessary AED therapy for patients with PNES. The results are consistent with previous studies in the literature evaluating VEEG clinical outcomes.

Objective score from initial interview identifies patients with probable dissociative seizures

OBJECTIVE

To develop a Dissociative Seizures Likelihood Score (DSLS), which is a comprehensive, evidence-based tool using information available during the first outpatient visit to identify patients with "probable" dissociative seizures (DS) to allow early triage to more extensive diagnostic assessment.

METHODS

Based on data from 1616 patients with video-electroencephalography (vEEG) confirmed diagnoses, we compared the clinical history from a single neurology interview of patients in five mutually exclusive groups: epileptic seizures (ES), DS, physiologic nonepileptic seizure-like events (PSLE), mixed DS plus ES, and inconclusive monitoring. We used data-driven methods to determine the diagnostic utility of 76 features from retrospective chart review and applied this model to prospective interviews.

RESULTS

The DSLS using recursive feature elimination (RFE) correctly identified 77% (95% confidence interval (CI), 74-80%) of prospective patients with either ES or DS, with a sensitivity of 74% and specificity of 84%. This accuracy was not significantly inferior than neurologists' impression (84%, 95% CI: 80-88%) and the kappa between neurologists' and the DSLS was 21% (95% CI: 1-41%). Only 3% of patients with DS were missed by both the fellows and our score (95% CI 0-11%).

SIGNIFICANCE

The evidence-based DSLS establishes one method to reliably identify some patients with probable DS using clinical history. The DSLS supports and does not replace clinical decision making. While not all patients with DS can be identified by clinical history alone, these methods combined with clinical judgement could be used to identify patients who warrant further diagnostic assessment at a comprehensive epilepsy center.

Epilepsy: Workup and Management in Adults

When managing epilepsy, there is a temptation to focus care with respect to the last and the next seizure. However, epilepsy is a multifaceted chronic condition and should be treated as such. Epilepsy comes with many physical risks, psychological effects, and socioeconomic ramifications, demanding a long-term commitment from the treating physician. Patients with epilepsy, compared to other chronically ill patient populations, have a worse quality of life, family function, and less social support. The majority of patients are well controlled on antiseizure drugs. However, approximately one-third will continue to have seizures despite optimized medical management. The primary aim of this article is to explore the long-term management of chronic epilepsy, and to address some of the particular needs of patients with chronic epilepsy.

Can seizure-related heart rate differentiate epileptic from psychogenic nonepileptic seizures?

OBJECTIVES

We aimed to (1) determine if seizure-related heart rate (HR) differentiates epileptic seizures (ES) from psychogenic nonepileptic seizures (PNES); (2) define the most useful point of the following HR measurements: preictal, ictal-onset, maximal-ictal, or postictal; and (3) delineate the optimal HR cutoff points (absolute HR and relative HR increase) to differentiate ES from PNES.

METHODS

All video-electroencephalography (VEEG) recorded at an Australian tertiary hospital from May 2009 to November 2015 were retrospectively reviewed. Baseline (during rest and wakefulness), 1-min preictal, ictal-onset, maximal-ictal, and 1-min postictal HR were measured for each ES and PNES event. Events lasting <10 s or with uninterpretable electrocardiogram (ECG) due to artifacts were excluded. Receiver operating characteristic curve analysis was performed to assess the diagnostic accuracy of HR reflected by the area under the curve (AUC).

RESULTS

Video-electroencephalography of 341 ES and 265 PNES from 130 patients were analyzed. The AUC for preictal, ictal-onset, maximal-ictal, and postictal HR were found to have poor differentiation between all types of ES and PNES. However, comparing bilateral tonic-clonic ES and PNES, AUC for absolute maximal-ictal HR was 0.84 (95% confidence interval [CI]: 0.73-0.95) and for absolute postictal HR was 0.90 (95% CI: 0.81-1.00) indicating good diagnostic discrimination. Using Youden's index to diagnose tonic-clonic ES, the optimal cutoff point for absolute maximal-ictal HR was 114 bpm (sensitivity: 84%, specificity: 82%) and for absolute postictal HR was 90 bpm (sensitivity: 91%, specificity: 82%).

CONCLUSION

These findings suggest that seizure-related HR is useful in differentiating bilateral tonic-clonic ES from PNES. Based on the AUC, the best diagnostic measurements are maximal-ictal and postictal HR.

Outcome Measures for Functional Neurological Disorder: A Review of the Theoretical Complexities

The development and selection of optimal outcome measures is increasingly recognized as a key component of evidence-based medicine, particularly the need for the development of a standardized set of measures for use in clinical trials. This process is particularly complex for functional neurological disorder (FND) for several reasons. FND can present with a wide range of symptoms that resemble the full spectrum of other neurological disorders. Additional physical (e.g., pain, fatigue) and psychological (e.g., depression, anxiety) symptoms are commonly associated with FND, which also can be highly disabling with implications for prognosis, and warrant concurrent assessment, despite an unclear etiological relationship with FND. Furthermore, several unique clinical aspects of FND make it likely that the usual prioritization of "objective" (or clinician-rated) over "subjective" (or patient-rated) measures might not be appropriate. Self-report measures may be more clinically meaningful in this patient population. Despite being a common and disabling disorder, there has been little research into outcome measures in FND, and to date trials have largely used measures designed for the assessment of other disorders. An international FND Core Outcome Measure group (FND-COM) has been established to develop a consensus battery of outcomes for FND: a "core outcome set." In this perspective article, the authors reviewed the process of outcome measure development and selection before considering the specific features of FND affecting the development of a core outcome set, as well as a research agenda to optimize outcome measurement in this complex neuropsychiatric disorder.

Atypical duration of epileptic and psychogenic nonepileptic events

OBJECTIVES

We aimed to estimate the frequency of epileptic seizures (ES) and psychogenic nonepileptic seizures (PNES) with atypical duration in our epilepsy monitoring unit (EMU), in order to raise awareness of atypical durations of both types of events.

MATERIALS & METHODS

We retrospectively reviewed all consecutive video-electroencephalogram (vEEG) recordings in our medical center's EMU from January 2013 to December 2017 and identified patients with seizures with atypical duration. Short PNES were defined as those lasting fewer than 2 min and long ES as those lasting for more than 5 min.

RESULTS

The files of 830 adult (age >16 years) patients were reviewed, of whom 26 patients (3.1%, mean age: 33.3 ± 9.8 years, 12 females) were diagnosed as having an unusual seizure duration. Among 432 patients with ES during monitoring, fourteen patients [3.2% (95% confidence interval (CI): 1.5%-5.0%), mean age: 33.0 ± 12.2, 5 females [had long ES durations (exceeding 5 min). In 64% of patients with long ES, the events were provoked by antiepileptic drug (AED) withdrawal during vEEG, 62% had focal lesion on brain imaging, and 64% had a frontotemporal or a temporal seizure focus. Among 223 patients diagnosed with PNES, 12 patients [5.4% (95% CI: 2.2%-8.6%), mean age: 33.6 ± 6.6, 7 females] had short PNES durations (less than 2 min) and demonstrated motor (9/12, 75%), altered responsiveness (6/12, 50%), and vocalization (5/12, 42%) as the most prominent clinical features.

CONCLUSIONS

The data from our case files highlight two main considerations in the diagnosis of paroxysmal events: prolonged event can be due to ES, while short events can be psychogenic.

Brain connectivity abnormalities in patients with functional (psychogenic nonepileptic) seizures: A systematic review

OBJECTIVES

The aim of the current endeavor was to systematically review the existing evidence on brain connectivity abnormalities in patients with functional seizures (FS).

METHODS

This systematic review was prepared according to the instructions of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. MEDLINE (accessed from PubMed) and Scopus from inception to April 4, 2020 were systematically searched. The following search strategy was implemented and these key words (in the title/abstract) were used: "connectivity" OR "network" AND "psychogenic" OR "dissociative" OR "nonepileptic".

RESULTS

Through the search strategy, we could identify eighteen articles. These studies have applied various methodologies and they could identify a variety of brain connectivity abnormalities in people with FS. However, none of these studies provided a high level of evidence. They were all small studies (none had a sample size of more than 21 patients). In addition, most of the studies did not match their cases and their controls with respect to the psychiatric comorbidities and other significant confounders.

CONCLUSION

Abnormal functional connectivity between emotion processing areas of the brain with regions involved in executive control and cognitive performance, and the functional connections of the anterior cingulate cortex are of major interest and may be involved in the pathophysiology of FS. Pursuing the concept of brain connectivity abnormalities in patients with FS and comparing the findings with well-matched controls in well-designed studies may result in a breakthrough in identifying the exact neurobiological origin of FS.

Suggestive seizure induction for inpatients with suspected psychogenic nonepileptic seizures

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.

Differential Semiology Based on Video Electroencephalography Monitoring Between Psychogenic Nonepileptic Seizures and Temporal Lobe Epileptic Seizures

BACKGROUND

Psychogenic nonepileptic seizures (PNESs) are disruptive changes in behavior without ictal correlate of epileptic activity and high prevalence of psychiatric morbidity. Differential diagnosis is difficult particularly with temporal lobe epilepsy (TLE), which is also associated with high prevalence of psychiatric comorbidity. Although video electroencephalography is the gold standard for differential diagnosis, clinical semiology analysis may help the clinician in general medical practice.

OBJECTIVE

In this study, the differential semiology, based on video electroencephalography, between PNESs and TLE seizures was analyzed.

METHODS

The video electroencephalography of patients with diagnosis of PNES and TLE were reviewed and compared between groups. Clinical semiology of all episodes recorded by video electroencephalography in each patient was analyzed and classified in accordance with the presence of behavioral arrest, motor hyperkinetic activity, impaired awareness, aura, and automatisms. Chi square test and binary logistic regression were determined.

RESULTS

Thirty-two patients with PNES (32 ± 11 y) and 34 with TLE (32 ± 12 y) were included. Female patients were predominant in the PNES group (P < 0.05). Mean time duration of episodes was 6.8 ± 10 minutes in PNES and 1.6 ± 0.8 minutes in TLE (P < 0.05). Impaired awareness (odds ratio = 24.4; 95% confidence interval = 3.79 -157.3, P < 0.01), automatisms (odds ratio = 13.9; 95% confidence interval = 2.1- 90.5, P < 0.01), and shorter duration of the events (odds ratio = 2.261, 95% confidence interval = 1.149 - 4.449, P = 0.018) were found as independent factors for detecting TLE seizures comparing PNESs.

CONCLUSION

Clinical semiology analysis may orientate the differential diagnosis in general medical practice, between PNESs and TLE seizures. Further studies comparing PNES semiology with other subtypes of epilepsies may complete these preliminary findings.