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Sobregrau P, Baillès E, Radua J, Carreño M, Donaire A, Setoain X, Bargalló N, Rumià J, Sánchez Vives MV, Pintor L. Design and validation of a diagnostic suspicion checklist to differentiate epileptic from psychogenic nonepileptic seizures (PNES-DSC). J Psychosom Res 2024; 180:111656. [PMID: 38615590 DOI: 10.1016/j.jpsychores.2024.111656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 03/31/2024] [Accepted: 04/01/2024] [Indexed: 04/16/2024]
Abstract
OBJECTIVE Psychogenic non-epileptic seizures (PNES) are complex clinical manifestations and misdiagnosis as status epilepticus remains high, entailing deleterious consequences for patients. Video-electroencephalography (vEEG) remains the gold-standard method for diagnosing PNES. However, time and economic constraints limit access to vEEG, and clinicians lack fast and reliable screening tools to assist in the differential diagnosis with epileptic seizures (ES). This study aimed to design and validate the PNES-DSC, a clinically based PNES diagnostic suspicion checklist with adequate sensitivity (Se) and specificity (Sp) to discriminate PNES from ES. METHODS A cross-sectional study with 125 patients (n = 104 drug-resistant epilepsy; n = 21 PNES) admitted for a vEEG protocolised study of seizures. A preliminary PNES-DSC (16-item) was designed and used by expert raters blinded to the definitive diagnosis to evaluate the seizure video recordings for each patient. Cohen's kappa coefficient, leave-one-out cross-validation (LOOCV) and balance accuracy (BAC) comprised the main validation analysis. RESULTS The final PNES-DSC is a 6-item checklist that requires only two to be present to confirm the suspicion of PNES. The LOOCV showed 71.4% BAC (Se = 45.2%; Sp = 97.6%) when the expert rater watched one seizure video recording and 83.4% BAC (Se = 69.6%; Sp = 97.2%) when the expert rater watched two seizure video recordings. CONCLUSION The PNES-DSC is a straightforward checklist with adequate psychometric properties. With an integrative approach and appropriate patient history, the PNES-DSC can assist clinicians in expediting the final diagnosis of PNES when vEEG is limited. The PNES-DSC can also be used in the absence of patients, allowing clinicians to assess seizure recordings from smartphones.
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Affiliation(s)
- Pau Sobregrau
- Psychology Faculty, University of Barcelona (UB), Barcelona 08007, Spain; Psychiatry Department, University Hospital Clinic of Barcelona (HCP), Barcelona 08036, Spain.
| | - Eva Baillès
- Psychiatry Department, Vall d'Hebron (VHIR), Barcelona 08035, Spain
| | - Joaquim Radua
- Biomedical Research Institute August Pi i Sunyer (IDIBAPS), University Hospital Clinic of Barcelona, Barcelona 08036, Spain
| | - Mar Carreño
- Clinical Institute of Neurosciences, University Hospital Clinic of Barcelona, Barcelona (HCP) 08036, Spain; Epilepsy Unit, Neurology Department, University Hospital Clinic of Barcelona (HCP), Barcelona 08036, Spain
| | - Antonio Donaire
- Clinical Institute of Neurosciences, University Hospital Clinic of Barcelona, Barcelona (HCP) 08036, Spain; Epilepsy Unit, Neurology Department, University Hospital Clinic of Barcelona (HCP), Barcelona 08036, Spain
| | - Xavier Setoain
- Diagnostic Imaging Center, University Hospital Clinic of Barcelona, Barcelona (HCP), Barcelona 08036, Spain
| | - Núria Bargalló
- Diagnostic Imaging Center, University Hospital Clinic of Barcelona, Barcelona (HCP), Barcelona 08036, Spain
| | - Jordi Rumià
- Clinical Institute of Neurosciences, University Hospital Clinic of Barcelona, Barcelona (HCP) 08036, Spain; Epilepsy Unit, Neurology Department, University Hospital Clinic of Barcelona (HCP), Barcelona 08036, Spain
| | - María V Sánchez Vives
- Biomedical Research Institute August Pi i Sunyer (IDIBAPS), University Hospital Clinic of Barcelona, Barcelona 08036, Spain; Cognition Department, Development and Educational Psychology, Faculty of Psychology, University of Barcelona (UB), Barcelona 08007, Spain
| | - Luis Pintor
- Psychiatry Department, University Hospital Clinic of Barcelona (HCP), Barcelona 08036, Spain; Biomedical Research Institute August Pi i Sunyer (IDIBAPS), University Hospital Clinic of Barcelona, Barcelona 08036, Spain; Clinical Institute of Neurosciences, University Hospital Clinic of Barcelona, Barcelona (HCP) 08036, Spain
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Amin U, Benbadis SR. The role of stand-alone videos in the diagnosis of seizures. Epilepsy Behav 2024; 153:109673. [PMID: 38430674 DOI: 10.1016/j.yebeh.2024.109673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/29/2024] [Accepted: 01/29/2024] [Indexed: 03/05/2024]
Abstract
The diagnosis of seizures and seizure mimics relies primarily on the history, but history has well-known limitations. Video recordings of events are a powerful extension of the history because they allow neurologists to view the events in question. In addition, they are readily available in situation, whereas the gold standard of EEG-video is not. That includes underserved or rural areas, and events that are too infrequent to be captured during a few days of EEG-video monitoring. Brief cellphone videos have been shown to be valuable to suggest or guide the correct diagnosis.
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Affiliation(s)
- Ushtar Amin
- Department of Neurology, University of South Florida - Tampa General Hospital, Tampa, FL 33606, USA.
| | - Selim R Benbadis
- Department of Neurology, University of South Florida - Tampa General Hospital, Tampa, FL 33606, USA.
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Karakas C, Ferreira LD, Haneef Z. Use of video alone for differentiation of epileptic seizures from non-epileptic spells: A systematic review and meta-analysis. Seizure 2023; 110:177-187. [PMID: 37406461 DOI: 10.1016/j.seizure.2023.06.022] [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: 04/03/2023] [Revised: 06/13/2023] [Accepted: 06/28/2023] [Indexed: 07/07/2023] Open
Abstract
INTRODUCTION Review of videos (without electroencephalography) to differentiate epileptic seizures (ES) from non-epileptic spells (NES) may be helpful where epilepsy monitoring is not feasible. Previous studies of video-based diagnosis have suffered from variable accuracy, sensitivity, and specificity. METHODS We systematically reviewed relevant literature in PubMed, Embase, and Web of Science from inception to September 2022, identifying articles that reported on the video-based diagnosis of ES and NES. In primary analysis, for each study, the most expert group was chosen when different groups of reviewers classified the videos (e.g., epilepsy specialists and general neurologists). In secondary analysis, we compared the diagnostic accuracy of different expertise levels (e.g., epileptologists, general neurologists, residents, medical students). Meta-analysis was performed to obtain pooled estimates of reliability measures. RESULTS From 5245 articles identified, 13 met the inclusion criteria, with cumulative data from 683 patients (696 videos) reviewed by 95 independent reviewers in primary analysis. Video alone had a strong ability to differentiate ES from NES as evidenced by the following metrics- area under the curve- 0.9 (considered "outstanding"), sensitivity- 82.2% (95% Confidence Interval [C.I], 80.2%-84.0%), specificity- 84.7% (C.I., 82.8%-86.5%), and diagnostic odds ratio- 24.7 (C.I., 11.5-52.9). The secondary analysis showed reviewer-dependent accuracy with epileptologists showing the highest accuracy (DOR 81.2, C.I., 90.0%-94.6%). CONCLUSIONS Video alone has reliable diagnostic performance for differentiating ES from NES. Meta-analysis limitations include inter-study heterogeneity including variable video quality and reviewer expertise. Combined video-EEG remains the gold standard for the diagnosis of epilepsy and NES.
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Affiliation(s)
- Cemal Karakas
- Division of Pediatric Neurology, Department of Neurology, University of Louisville, Louisville, KY, USA 40202; Norton Children's Medical Group, Louisville, KY, USA 40202.
| | - Liam D Ferreira
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA 77030
| | - Zulfi Haneef
- Department of Neurology, Baylor College of Medicine, Houston, TX, USA 77030; Neurology Care Line, VA Medical Center, Houston, TX, USA 77030
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Kanemoto K, Tadokoro Y, Motooka H, Kawasaki J, Horinouchi T, Tsuji T, Fukuchi T, Tomohiro O. Prospective multicenter cohort study of possible psychogenic nonepileptic seizure cases-Results at 1-year follow-up examinations. Epilepsia Open 2023; 8:134-145. [PMID: 36509699 PMCID: PMC9978061 DOI: 10.1002/epi4.12683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 11/30/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE The primary purpose of this prospective multicenter study was to examine clinical and demographic feature differences according to the diagnostic level of psychogenic nonepileptic seizures (PNES) and then clarify whether prognosis may also differ accordingly. METHODS Two hundred forty-two consecutive patients strongly suspected of having PNES attacks were invited to participate, of whom 52 did not consent or contact was lost. At the 1-year follow-up examination, PNES diagnosis was reconsidered in nine patients. In 96 patients, the diagnostic level remained the same (P-group), with that in 43 considered to be clinically established (CE-group) and in 42 documented (D-group). The Qolie-10 and NDDI-E questionnaires were examined at both the study entry and the follow-up examination. RESULTS Multiple regression analysis of quality of life (QoL) score (n = 173; R2 = 0.374; F = 7.349; P < 0.001) revealed NDDI-E score (t = -6.402; P < 0.001), age of PNES onset (t = -3.026; P = 0.003), and ethnic minority status (t = 3.068; P = 0.003) as significant contributors. At entry, the P-group showed the lowest PNES attack frequency (P < 0.000), the lowest rate of antiseizure, antidepressant, and antipsychotic medication (P < 0.000; P = 0.031; P = 0.013, respectively), and the lowest proportion of psychosis (P = 0.046). At follow-up, PNES attack frequency (P < 0.000), number of admittances to emergency room (P < 0.000), and scores for QoL (P < 0.000) as well as depression (P = 0.004) were found to be significantly improved together with other collateral indicators, such as rate of antiseizure medication prescription (P = 0.001) and psychiatric symptoms (P = 0.03). Multiple regression analysis of a sample limited to patients with intellectual disability (ID) (n = 44; R2 = 0.366; F = 4.493; P = 0.002) revealed continued psychotherapy at follow-up (t = 2.610, P = 0.013) and successful reduction in antiseizure medication (t = 2.868; P = 0.007) as positively related with improved QoL. SIGNIFICANCE Clinical and the socio-psychological constellation of possible, clinically established, and documented PNES were found to differ greatly. Unexpectedly, significant effects of the continuous psychotherapeutic intervention were confirmed in PNES patients with ID.
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Affiliation(s)
| | | | | | | | - Toru Horinouchi
- Department of Psychiatry & Neurology, Hokkaido University, Sapporo, Japan
| | - Tomikimi Tsuji
- Department of Neuropsychiatry, Wakayama University, Wakayama, Japan
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The utility of mobile telephone-recorded videos as adjuncts to the diagnosis of seizures and paroxysmal events in children with suspected epileptic seizures. S Afr Med J 2022; 113:42-48. [PMID: 36537547 DOI: 10.7196/samj.2023.v113i1.16661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Epilepsy is often diagnosed through clinical description, but inter-observer interpretations can be diverse and misleading. OBJECTIVE To assess the utility of smartphone videos in the diagnosis of paediatric epilepsy. METHODS The literature was reviewed for evidence to support the use of smartphone videos, inclusive of advantages, ethical practice and potential disadvantages. An existing adult-based quality of video (QOV) scoring tool was adapted for use in children. A pilot study used convenience sampling of videos from 25 patients, which were reviewed to assess the viability of the adapted QOV tool against the subsequent diagnosis for the patients with videos. The referral mechanism of the videos was reviewed for the source and consent processes followed. RESULTS A total of 14 studies were identified. Methodologies varied; only three focused on videos of children, and QOV was formally scored in three. Studies found that smartphone videos of good quality assisted the differentiation of epilepsy from non-epileptic events, especially with accompanying history and with more experienced clinicians. The ethics and risks of circulation of smartphone videos were briefly considered in a minority of the reports. The pilot study found that the adapted QOV tool correlated with videos of moderate and high quality and subsequent diagnostic closure. CONCLUSIONS Data relating to the role of smartphone video of events in children is lacking, especially from low- and middle-income settings. Guidelines for caregivers to acquire good-quality videos are not part of routine practice. The ethical implications of transfer of sensitive material have not been adequately addressed for this group. Prospective multicentre studies are needed to formally assess the viability of the adapted QOV tool for paediatric videos.
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Zheng Y, Liu X, Ju M. A case of antipsychotic-induced psychomotor seizure. Gen Psychiatr 2022; 35:e100616. [PMID: 35866001 PMCID: PMC9240898 DOI: 10.1136/gpsych-2021-100616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 06/08/2022] [Indexed: 11/03/2022] Open
Abstract
A seizure is one of the most uncommon severe adverse side effects of antipsychotics. Clinical recognition rates for it are low, especially for psychomotor seizures. The authors present a case of psychomotor seizure caused by amisulpride to treat schizophrenia. A 60-year-old male patient in our hospital experienced a recent onset of repetitive, stereotyped involuntary and unconscious movements that began with amisulpride use. All of the symptoms disappeared following amisulpride withdrawal. His Naranjo Adverse Drug Reactions Probability Scale Score was 5 points. The case sheds light on the clinical risk of seizures related to antipsychotics.
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Affiliation(s)
- Yanqun Zheng
- Department of Psychiatry, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaohua Liu
- Department of Psychiatry, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mingliang Ju
- Department of Psychiatry, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Kustov G, Zinchuk M, Rider F, Pashnin E, Voinova N, Avedisova A, Guekht A. Comorbidity of psychogenic non-epileptic seizures with mental disorders. Zh Nevrol Psikhiatr Im S S Korsakova 2022; 122:28-35. [DOI: 10.17116/jnevro202212202128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Tatum WO, Mani J, Jin K, Halford JJ, Gloss D, Fahoum F, Maillard L, Mothersill I, Beniczky S. 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. Clin Neurophysiol 2021; 134:111-128. [PMID: 34955428 DOI: 10.1016/j.clinph.2021.07.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
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.
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Affiliation(s)
- William O Tatum
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA.
| | - Jayanti Mani
- Department of Neurology, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | - Kazutaka Jin
- Department of Epileptology, Tohoku University Graduate School of Medicine, Japan
| | - Jonathan J Halford
- Department of Neurology, Medical University of South Carolina, Charleston, SC, USA.
| | - David Gloss
- Department of Neurology, Charleston Area Medical Center, Charleston, WV, USA
| | - Firas Fahoum
- Department of Neurology, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Louis Maillard
- Department of Neurology, University of Nancy, UMR7039, University of Lorraine, France.
| | - Ian Mothersill
- Department of Clinical Neurophysiology, Swiss Epilepsy Center, Zurich Switzerland.
| | - Sandor Beniczky
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark; Danish Epilepsy Center, Dianalund, Denmark.
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Tatum WO, Mani J, Jin K, Halford JJ, Gloss D, Fahoum F, Maillard L, Mothersill I, Beniczky S. 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. Epilepsia 2021; 63:290-315. [PMID: 34897662 DOI: 10.1111/epi.16977] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 06/09/2021] [Accepted: 06/09/2021] [Indexed: 01/02/2023]
Abstract
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.
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Affiliation(s)
- William O Tatum
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA
| | - Jayanti Mani
- Department of Neurology, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | - Kazutaka Jin
- Department of Epileptology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Jonathan J Halford
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - David Gloss
- Department of Neurology, Charleston Area Medical Center, Charleston, West Virginia, USA
| | - Firas Fahoum
- Department of Neurology, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Louis Maillard
- Department of Neurology, University of Nancy, UMR7039, University of Lorraine, Nancy, France
| | - Ian Mothersill
- Department of Clinical Neurophysiology, Swiss Epilepsy Center, Zurich,, Switzerland
| | - Sandor Beniczky
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark.,Danish Epilepsy Center, Dianalund, Denmark
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Zinchuk M, Beghi M, Diotti S, Pashnin E, Kustov G, Rider F, Urh L, Guekht A, Cornaggia CM. Differential diagnosis between epileptic and psychogenic nonepileptic seizures through conversational analysis: A blinded prospective study in the Russian language. Epilepsy Behav 2021; 125:108441. [PMID: 34837840 DOI: 10.1016/j.yebeh.2021.108441] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/09/2021] [Accepted: 11/09/2021] [Indexed: 10/19/2022]
Abstract
The current study examined the validity of conversational analysis (CA) in Russian patients with seizures, using a scoring table for the Simplified Linguistic Evaluation (SLE). The study sample was composed of 12 adult participants suffering either from epilepsy (ES) or psychogenic nonepileptic seizures (PNES) recruited in the Moscow Research and Clinical Center for Neuropsychiatry. Definitive diagnosis was established only after a habitual event was captured onvEEG. All participants with PNES or ES and at least one mental disorder underwent a 20-minute-long interview recorded on video. The interview then was evaluated by the external blinded physician already experienced in CA. Finally, that physician filled the SLE, consisting of 5 items analyzing the main characteristics of patient narrations. A score of ≥12 suggested a diagnosis of ES, while a score of <12 suggested a diagnosis of PNES. The blinded evaluator correctly identified 11 out of 12 cases. The concordance between the vEEG diagnosis and the CA diagnostic hypothesis was 91.67%. The sensitivity of the scoring table was 100%, while the specificity was 80%. The positive and the negative predictive values were, respectively, 87.5% and 100%. Our results suggested that the differences in seizure descriptions between patients with PNES and patients with ES are similar across Indo-European language family and are independent of psychiatric comorbidity.
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Affiliation(s)
- Mikhail Zinchuk
- Moscow Research and Clinical Center for Neuropsychiatry, Moscow, Russian Federation.
| | | | - Silvia Diotti
- University of Milano Bicocca, GSD Research, Milan, Italy
| | - Evgenii Pashnin
- Moscow Research and Clinical Center for Neuropsychiatry, Moscow, Russian Federation
| | - Georgii Kustov
- Moscow Research and Clinical Center for Neuropsychiatry, Moscow, Russian Federation
| | - Flora Rider
- Moscow Research and Clinical Center for Neuropsychiatry, Moscow, Russian Federation
| | - Lina Urh
- University of Milano Bicocca, GSD Research, Milan, Italy
| | - Alla Guekht
- Moscow Research and Clinical Center for Neuropsychiatry, Moscow, Russian Federation; Pirogov Russian National Research Medical University, Moscow, Russian Federation
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Freund B, Tatum WO. Pitfalls using smartphones videos in diagnosing functional seizures. Epilepsy Behav Rep 2021; 16:100497. [PMID: 34927041 PMCID: PMC8646964 DOI: 10.1016/j.ebr.2021.100497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/26/2021] [Accepted: 10/30/2021] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Brin Freund
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, United States
| | - William O. Tatum
- Department of Neurology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, United States
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12
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Duncan AJ, Peric I, Boston R, Seneviratne U. Predictive semiology of psychogenic non-epileptic seizures in an epilepsy monitoring unit. J Neurol 2021; 269:2172-2178. [PMID: 34550469 PMCID: PMC8456070 DOI: 10.1007/s00415-021-10805-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 09/12/2021] [Accepted: 09/13/2021] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Andrew J Duncan
- Department of Clinical Neurosciences, St. Vincent's Hospital Melbourne, Melbourne, VIC, Australia.
| | - Ivana Peric
- Department of Neurology, Monash Medical Centre, Melbourne, VIC, Australia
| | - Ray Boston
- Department of Clinical Neurosciences, St. Vincent's Hospital Melbourne, Melbourne, VIC, Australia
- Department of Clinical Studies, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, USA
| | - Udaya Seneviratne
- Department of Clinical Neurosciences, St. Vincent's Hospital Melbourne, Melbourne, VIC, Australia
- Department of Neurology, Monash Medical Centre, Melbourne, VIC, Australia
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13
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Kustov GV, Zinchuk MS, Rider FK, Pashnin EV, Voinova NI, Avedisova AS, Guekht AB. [Psychogenic non-epileptic seizures]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:112-118. [PMID: 34481446 DOI: 10.17116/jnevro2021121081112] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The review provides epidemiological data and discuss the associated burden of non-epileptic seizures (PNES). Data on the prevalence, socio-demographic and clinical risk factors for the development of PNES are presented. The hypotheses of the PNES origin, including the contribution of psychological trauma, are considered. We also describe contemporary methods for differential diagnosis of epileptic seizures and PNES, including biomarkers and the use of diagnostic questionnaires. Special attention is given to the issues of the psychiatric comorbidity of PNES.
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Affiliation(s)
- G V Kustov
- Research and Clinical Center for Neuropsychiatry, Moscow, Russia
| | - M S Zinchuk
- Research and Clinical Center for Neuropsychiatry, Moscow, Russia
| | - F K Rider
- Research and Clinical Center for Neuropsychiatry, Moscow, Russia
| | - E V Pashnin
- Research and Clinical Center for Neuropsychiatry, Moscow, Russia
| | - N I Voinova
- Research and Clinical Center for Neuropsychiatry, Moscow, Russia
| | - A S Avedisova
- Research and Clinical Center for Neuropsychiatry, Moscow, Russia.,Federal Medical Research Centre for Psychiatry and Narcology, Moscow, Russia
| | - A B Guekht
- Research and Clinical Center for Neuropsychiatry, Moscow, Russia.,Pirogov Russian National Research Medical University, Moscow, Russia
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14
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Asadi-Pooya AA, Farazdaghi M. Effects of the COVID-19 pandemic on characteristics of functional (psychogenic) seizures. J Psychosom Res 2021; 147:110514. [PMID: 34015724 PMCID: PMC9750040 DOI: 10.1016/j.jpsychores.2021.110514] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/12/2021] [Accepted: 05/13/2021] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- 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,Corresponding author at: Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohsen Farazdaghi
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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15
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Agarwal R, Gathers-Hutchins L, Stephanou H. Psychogenic non-epileptic seizures in children. Curr Probl Pediatr Adolesc Health Care 2021; 51:101036. [PMID: 34373198 DOI: 10.1016/j.cppeds.2021.101036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Rajkumar Agarwal
- Division of Neurology, Dayton Children's Hospital, Dayton, Ohio, USA; Wright State University Boonshoft School of Medicine, Dayton, Ohio, USA.
| | - Latisha Gathers-Hutchins
- Wright State University Boonshoft School of Medicine, Dayton, Ohio, USA; Division of Psychology, Dayton Children's Hospital, Dayton, Ohio, USA
| | - Hara Stephanou
- Department of School Psychology, Doctoral Student, St. John's University, New York City, New York, USA
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16
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Birca V, Keezer MR, Chamelian L, Lortie A, Nguyen DK. Recognition of Psychogenic Versus Epileptic Seizures Based on Videos. Can J Neurol Sci 2021; 49:1-9. [PMID: 34663489 DOI: 10.1017/cjn.2021.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Ictal semiology interpretation for differentiating psychogenic nonepileptic seizures (PNESs) and epileptic seizures (ESs) is important for the institution of appropriate treatment. Our objective was to assess the ability of different health care professionals (HCPs) or students to distinguish PNES from ES based on video-recorded seizure semiology. METHODS This study was designed following the Standards for Reporting of Diagnostic Accuracy Studies (STARD) guidelines. We showed in a random mix 36 videos of PNES or ES (18 each) and asked 558 participants to classify each seizure. The diagnostic accuracy of various groups of HCPs or students for PNES versus ES was assessed, as well as the effect of patient age and sex. Measures of diagnostic accuracy included sensitivity, specificity, and area under the curve (AUC). RESULTS The descending order of diagnostic accuracy (AUC) was the following (p ≤ 0.001): (1) neurologists and epileptologists; (2) neurology residents; (3) other specialists and nurses with experience in epilepsy; and (4) undergraduate medical students. Although there was a strong trend toward statistical difference, with AUC 95% confidence intervals (CIs) that were not overlapping, between epileptologists (95% CI 93, 97) compared to neurologists (95% CI 88, 91), and neurologists compared to electroencephalography technicians (95% CI 82, 87), multiple pairwise comparisons with the conservative Tukey-Kramer honest significant difference test revealed no statistical difference (p = 0.25 and 0.1, respectively). Patient age and sex did not have an effect on diagnostic accuracy in neurology specialists. CONCLUSION Visual recognition of PNES by HCPs or students varies overall proportionately with the level of expertise in the field of neurology/epilepsy.
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Affiliation(s)
- Veronica Birca
- Division of Neurology, CHUM, Université de Montréal, Montreal, Quebec, Canada
- Division of Pediatric Neurology, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Mark R Keezer
- Division of Neurology, CHUM, Université de Montréal, Montreal, Quebec, Canada
- Department of Neurosciences, Université de Montréal, Montreal, Quebec, Canada
- School of Public Health, Université de Montréal, Montreal, Quebec, Canada
| | - Laury Chamelian
- Department of Neurosciences, Université de Montréal, Montreal, Quebec, Canada
- Division of Psychiatry, CHUM, Université de Montréal, Montreal, Quebec, Canada
| | - Anne Lortie
- Department of Neurosciences, Université de Montréal, Montreal, Quebec, Canada
- Division of Pediatric Neurology, CHU Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
| | - Dang K Nguyen
- Division of Neurology, CHUM, Université de Montréal, Montreal, Quebec, Canada
- Department of Neurosciences, Université de Montréal, Montreal, Quebec, Canada
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17
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Baroni G, Martins WA, Rodrigues JC, Piccinini V, Marin C, de Lara Machado W, Bandeira DR, Paglioli E, Valente KD, Palmini A. A novel scale for suspicion of psychogenic nonepileptic seizures: development and accuracy. Seizure 2021; 89:65-72. [PMID: 34020344 DOI: 10.1016/j.seizure.2021.04.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/25/2021] [Accepted: 04/27/2021] [Indexed: 10/21/2022] Open
Abstract
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.
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Affiliation(s)
- Gislaine Baroni
- Graduate Program in Medicine and Health Sciences, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil; Epilepsy Surgery Program, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil.
| | - William Alves Martins
- Graduate Program in Medicine and Health Sciences, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil; Epilepsy Surgery Program, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil.
| | - Jaqueline C Rodrigues
- Assistant Professor, Psychology Program, Universidade do Vale dos Sinos (UNISINOS), São Leopoldo, Brazil.
| | - Vitória Piccinini
- Epilepsy Surgery Program, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil.
| | - Cássia Marin
- Epilepsy Surgery Program, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil.
| | - Wagner de Lara Machado
- Graduate Program in Psychology, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil.
| | - Denise R Bandeira
- Graduate Program in Psychology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
| | - Eliseu Paglioli
- Epilepsy Surgery Program, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil; Neurosciences and Surgical Departments, School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil.
| | - Kette D Valente
- Institute and Department of Psychiatry, Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo (HCFMUSP).
| | - André Palmini
- Graduate Program in Medicine and Health Sciences, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil; Epilepsy Surgery Program, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil; Neurosciences and Surgical Departments, School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil.
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18
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Kerr WT, Zhang X, Hill CE, Janio EA, Chau AM, Braesch CT, Le JM, Hori JM, Patel AB, Allas CH, Karimi AH, Dubey I, Sreenivasan SS, Gallardo NL, Bauirjan J, Hwang ES, Davis EC, D'Ambrosio SR, Al Banna M, Cho AY, Dewar SR, Engel J, Feusner JD, Stern JM. Epilepsy, dissociative seizures, and mixed: Associations with time to video-EEG. Seizure 2021; 86:116-122. [PMID: 33601302 PMCID: PMC7979505 DOI: 10.1016/j.seizure.2021.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/23/2021] [Accepted: 02/02/2021] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Video-electroencephalographic monitoring (VEM) is a core component to the diagnosis and evaluation of epilepsy and dissociative seizures (DS)-also known as functional or psychogenic seizures-but VEM evaluation often occurs later than recommended. To understand why delays occur, we compared how patient-reported clinical factors were associated with time from first seizure to VEM (TVEM) in patients with epilepsy, DS or mixed. METHODS We acquired data from 1245 consecutive patients with epilepsy, VEM-documented DS or mixed epilepsy and DS. We used multivariate log-normal regression with recursive feature elimination (RFE) to evaluate which of 76 clinical factors interacting with patients' diagnoses were associated with TVEM. RESULTS The mean and median TVEM were 14.6 years and 10 years, respectively (IQR 3-23 years). In the multivariate RFE model, the factors associated with longer TVEM in all patients included unemployment and not student status, more antiseizure medications (current and past), concussion, and ictal behavior suggestive of temporal lobe epilepsy. Average TVEM was shorter for DS than epilepsy, particularly for patients with depression, anxiety, migraines, and eye closure. Average TVEM was longer specifically for patients with DS taking more medications, more seizure types, non-metastatic cancer, and with other psychiatric comorbidities. CONCLUSIONS In all patients with seizures, trials of numerous antiseizure medications, unemployment and non-student status was associated with longer TVEM. These associations highlight a disconnect between International League Against Epilepsy practice parameters and observed referral patterns in epilepsy. In patients with dissociative seizures, some but not all factors classically associated with DS reduced TVEM.
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Affiliation(s)
- Wesley T Kerr
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States.
| | - Xingruo Zhang
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Chloe E Hill
- Department of Neurology, University of Michigan, Ann Arbor, MI, United States
| | - Emily A Janio
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Andrea M Chau
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Chelsea T Braesch
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Justine M Le
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Jessica M Hori
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Akash B Patel
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Corinne H Allas
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Amir H Karimi
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Ishita Dubey
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Siddhika S Sreenivasan
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Norma L Gallardo
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Janar Bauirjan
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Eric S Hwang
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Emily C Davis
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Shannon R D'Ambrosio
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Mona Al Banna
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Andrew Y Cho
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - Sandra R Dewar
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Jerome Engel
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States; Department of Neurobiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; Brain Research Institute, University of California Los Angeles, Los Angeles, CA, United States
| | - Jamie D Feusner
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, United States
| | - John M Stern
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
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19
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Lenio S, Kerr WT, Watson M, Baker S, Bush C, Rajic A, Strom L. Validation of a predictive calculator to distinguish between patients presenting with dissociative versus epileptic seizures. Epilepsy Behav 2021; 116:107767. [PMID: 33545649 PMCID: PMC7951947 DOI: 10.1016/j.yebeh.2021.107767] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 12/29/2020] [Accepted: 12/30/2020] [Indexed: 01/30/2023]
Abstract
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.
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Affiliation(s)
- Steven Lenio
- Department of Neurology, University of Colorado, Aurora, CO, USA.
| | - Wesley T Kerr
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Meagan Watson
- Department of Neurology, University of Colorado, Aurora, CO, USA
| | - Sarah Baker
- Department of Neurology, University of Colorado, Aurora, CO, USA
| | - Chad Bush
- Department of Neurology, University of Colorado, Aurora, CO, USA
| | - Alex Rajic
- Department of Neurology, University of Colorado, Aurora, CO, USA
| | - Laura Strom
- Department of Neurology, University of Colorado, Aurora, CO, USA
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20
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Tatum WO, Hirsch LJ, Gelfand MA, Acton EK, LaFrance WC, Duckrow RB, Chen DK, Blum AS, Hixson JD, Drazkowski JF, Benbadis SR, Cascino GD. Assessment of the Predictive Value of Outpatient Smartphone Videos for Diagnosis of Epileptic Seizures. JAMA Neurol 2021; 77:593-600. [PMID: 31961382 DOI: 10.1001/jamaneurol.2019.4785] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
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.
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Affiliation(s)
| | | | | | - Emily K Acton
- Department of Neurology, University of Pennsylvania, Philadelphia
| | - W Curt LaFrance
- Department of Neurology, Brown University, Providence, Rhode Island
| | - Robert B Duckrow
- Department of Neurology, Yale University, New Haven, Connecticut
| | - David K Chen
- Department of Neurology, Baylor College of Medicine, Houston, Texas
| | - Andrew S Blum
- Department of Neurology, Brown University, Providence, Rhode Island
| | - John D Hixson
- University of California, San Francisco, San Francisco
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21
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Tatum WO, Hirsch LJ, Gelfand MA, Acton EK, LaFrance WC, Duckrow RB, Chen D, Blum AS, Hixson J, Drazkowski J, Benbadis S, Cascino GD. Video quality using outpatient smartphone videos in epilepsy: Results from the OSmartViE study. Eur J Neurol 2021; 28:1453-1462. [PMID: 33465822 DOI: 10.1111/ene.14744] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/30/2020] [Accepted: 01/13/2021] [Indexed: 01/04/2023]
Abstract
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.
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Affiliation(s)
| | | | - Michael A Gelfand
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Emily K Acton
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - W Curt LaFrance
- Department of Neurology, Brown University, Providence, RI, USA
| | | | - David Chen
- Department of Neurology, Baylor University, Houston, TX, USA
| | - Andrew S Blum
- Department of Neurology, Brown University, Providence, RI, USA
| | - John Hixson
- University of California, San Francisco, CA, USA
| | | | - Selim Benbadis
- Department of Neurology, University of South Florida, Tampa, FL, USA
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22
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Viarasilpa T, Panyavachiraporn N, Osman G, Kowalski RG, Miller J, Barkley GL, Mayer SA. Differentiation of psychogenic nonepileptic attacks from status epilepticus among patients intubated for convulsive activity. Epilepsy Behav 2021; 115:107679. [PMID: 33360401 DOI: 10.1016/j.yebeh.2020.107679] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/26/2020] [Accepted: 11/26/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND OBJECTIVE Patients with psychogenic nonepileptic attacks (PNEA) sometimes receive aggressive treatment leading to intubation. This study aimed to identify patient characteristics that can help differentiate PNEA from status epilepticus (SE). METHODS We retrospectively identified patients with a final diagnosis of PNEA or SE, who were intubated for emergent convulsive symptoms and underwent continuous electroencephalography (cEEG) between 2012 and 2017. Patients who had acute brain injury or progressive brain disease as the cause of SE were excluded. We compared clinical features and laboratory values between the two groups, and identified risk factors for PNEA-related convulsive activity. RESULTS Over a six-year period, 24 of 148 consecutive patients (16%) intubated for convulsive activity had a final diagnosis of PNEA rather than SE. Compared to patients intubated for SE, intubated PNEA patients more likely were <50 years of age, female, white, had a history of a psychiatric disorder, had no history of an intracranial abnormality, and had a maximum systolic blood pressure <140 mm Hg (all P < 0.001). Patients with 0-2 of these six risk factors had a 0% (0/88) likelihood of having PNEA, those with 3-4 had a 15% (6/39) chance of having PNEA, and those with 5-6 had an 86% (18/21) chance of having PNEA. Sensitivity for PNEA among those with 5-6 risk factors was 75% (95% CI: 53-89%) and specificity was 98% (95% CI: 93-99%). CONCLUSIONS In the absence of a clear precipitating brain injury, approximately one in six patients intubated for emergent convulsive symptoms had PNEA rather than SE. Although PNEA cannot be diagnosed only by the presence of these risk factors, these simple characteristics could raise clinical suspicion for PNEA in the appropriate setting. Urgent neurological consultation may prevent unnecessary intubation of this at-risk patient population.
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Affiliation(s)
- Tanuwong Viarasilpa
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA; Division of Critical Care, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | - Nicha Panyavachiraporn
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA; Division of Critical Care, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | | | - Joseph Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, USA.
| | | | - Stephan A Mayer
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA; Departments of Neurology and Neurosurgery, Westchester Medical Center Health Network, Valhalla, NY, USA.
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Clinical utility of home videos for diagnosing epileptic seizures: a systematic review and practical recommendations for optimal and safe recording. Neurol Sci 2021; 42:1301-1309. [PMID: 33471259 PMCID: PMC7815499 DOI: 10.1007/s10072-021-05040-5] [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: 09/08/2020] [Accepted: 01/04/2021] [Indexed: 11/17/2022]
Abstract
Background The aim of the present systematic revision is to analyze existing published reports about the use of home-videos recordings (HVRs) to support physicians in the differential diagnosis of paroxysmal seizure-like episodes (PSLE). We also developed practical recommendations in order to ensure adequate quality standards and safety advice for HVRs. Material and methods A comprehensive search of PubMed, Medline, Scopus, and Google Scholar was performed, and results were included up to July 2020. All studies concerning the use of HVRs as a diagnostic tool for patients presenting PSLE were included. Results Seventeen studies satisfied all inclusion and exclusion criteria and were considered for the review. A consistent boost in diagnostic and clinical decision-making was reported across all studies in the literature. One study found that HVRs decreased the stress level in many families and improved their quality of life. Training in performing good-quality videos is necessary and increases the diagnostic value of HVRs. Conclusions HVRs can be of diagnostic value in epilepsy diagnosis and management. HVRs are low cost, widespread, and may provide great support for neurologists. It is important to train patients and caregivers in performing good quality videos to optimize this useful tool and to guarantee safety standards during the recording. Supplementary Information The online version contains supplementary material available at 10.1007/s10072-021-05040-5.
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O'Dwyer R. Epilepsy: Workup and Management in Adults. Semin Neurol 2020; 40:624-637. [PMID: 33176373 DOI: 10.1055/s-0040-1719069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Rebecca O'Dwyer
- Department of Neurological Science, Rush University Medical Center, Chicago, Illinois
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Intravooth T, Steinhoff BJ, Staack AM, Wendling AS, Stockinger J, Tanezer A, Oehl B. Visual illustration supporting patient-physician communication in epilepsy: A validation and reliability study of seizure images. Epilepsy Behav 2020; 112:107408. [PMID: 32920375 DOI: 10.1016/j.yebeh.2020.107408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 08/07/2020] [Accepted: 08/09/2020] [Indexed: 10/23/2022]
Abstract
Seizure manifestations may be difficult to describe in words alone. Thus, initially, 24 seizure images were developed to support communication and gain assistance during obtaining the patient's history. Before being used in clinical practice, these seizure images must be investigated for validity and reliability. We tested the images with untrained participants including patients with epilepsy, persons who had witnessed seizures, and participants who had neither had nor witnessed epileptic seizures. The participants filled in a questionnaire evaluating the images twice within 3 days. The participants were asked to choose one of the 2 written descriptions that best matched each seizure image. The validity was assessed using one-proportion z-test. The reliability was assessed by Gwet's AC1. The first analysis showed that the proportion of correctly identified seizure images was higher than 70%, except for 2 images representing dystonia and myoclonus. The dystonia image was modified, and the myoclonus image was removed. In the final evaluation, the seizure images were identified with an overall correctness ratio of 96%. The final AC1 of the seizure images was classified as very high. The final 23 seizure images are proved to be valid and have a high agreement that can be used in clinical practice.
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Affiliation(s)
| | - Bernhard J Steinhoff
- Kork Epilepsy Center, Kehl-Kork, Germany; University Hospital of Freiburg, Freiburg, Germany.
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Osman AH, Alsharief SM, Siddig HE. Functional neurological disorder: Characteristics and outcome in a limited-resources country (Sudan). Epilepsy Behav 2020; 111:107151. [PMID: 32698104 DOI: 10.1016/j.yebeh.2020.107151] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 04/26/2020] [Accepted: 04/26/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is a scarcity of reports from limited-resources countries on functional neurological disorder (FND). We therefore carried out this descriptive study from Sudan to highlight the clinical characteristics of patients and the cultural, diagnostic, and management outcome. METHOD Of 1000 new referrals and patients seen at a central neuropsychiatric clinic in Khartoum, Sudan, 40 fulfilled the criteria for FND. Subjects were diagnosed by excluding organic illness and confirming psychological distress through neuropsychological assessment and clinical interview. Mood was measured using the Beck Depression Inventory (BDI) and Hospital Anxiety and Depression (HAD) scales. RESULTS Young unemployed women constituted 60% of our sample. Most subjects presented with psychogenic nonepileptic seizures (82.5%), speech abnormalities (47.5%), and limb paralysis or weakness was (35%). Associated mood disorder was found in 97.5% of all subjects. However, 95% of our sample showed a remarkable clinical response to combination therapy (antidepressants and psychotherapy). SIGNIFICANCE Patients with FND showed strong evidence of comorbid affective disorders in the form of depression and anxiety disorder. Most patients (95%) responded well to combination therapy with antidepressants and psychotherapy. Sociodemographic correlates of FND in Sudan prove to be consistent with features found in Western cultures, with only minor idiosyncratic characteristics due to local culture.
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Affiliation(s)
- Abdelgadir H Osman
- Psychiatric Department, Faculty of Medicine, University of Khartoum, P.O. Box 102, Khartoum, Sudan.
| | - Sabah M Alsharief
- Psychiatric Training Scheme Khartoum, Sudan Medical Council, Estibalia Street, Khartoum, Sudan
| | - Hassab Elrasoul Siddig
- Neurology and Neuroscience Association, Alnileen Medical Centre, Alsharief Alhindi Street, Khartoum, Sudan
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Beghi M, Cornaggia I, Diotti S, Erba G, Harder G, Magaudda A, Laganà A, Vitale C, Cornaggia CM. The semantics of epileptic and psychogenic nonepileptic seizures and their differential diagnosis. Epilepsy Behav 2020; 111:107250. [PMID: 32603809 DOI: 10.1016/j.yebeh.2020.107250] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/07/2020] [Accepted: 06/08/2020] [Indexed: 11/18/2022]
Affiliation(s)
| | | | - Silvia Diotti
- School of Medicine and Surgery, University of Milano Bicocca, Milano, Italy
| | - Giuseppe Erba
- Department of Neurology, University of Rochester, USA
| | - Gaia Harder
- School of Medicine and Surgery, University of Milano Bicocca, Milano, Italy
| | - Adriana Magaudda
- Epilepsy Centre, Neurological Clinic, University of Messina, Italy
| | - Angelina Laganà
- Epilepsy Centre, Neurological Clinic, University of Messina, Italy
| | - Chiara Vitale
- Epilepsy Centre, Neurological Clinic, University of Messina, Italy
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Beghi M, Cornaggia CM, Beghi E. A brief update on psychogenic non-epileptic seizures: a challenge to overcome. JOURNAL OF EPILEPTOLOGY 2020. [DOI: 10.21307/jepil-2020-003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Semiological classification of psychogenic nonepileptic seizures: A systematic review and a new proposal. Epilepsy Behav 2019; 100:106412. [PMID: 31645005 DOI: 10.1016/j.yebeh.2019.07.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/03/2019] [Accepted: 07/04/2019] [Indexed: 11/22/2022]
Abstract
PURPOSE A semiological classification of psychogenic nonepileptic seizures (PNES) may help address proper diagnosis and management and also provide standardization for future studies. The aim of the current paper was to systematically review the literature on the proposed classification systems for the semiology of PNES and to provide a new proposal based on the best available evidence. METHODS I searched the electronic database PubMed on May 16, 2019 for articles that included the following search terms: "psychogenic" AND "semiology" or "classification" and also "nonepileptic" AND "semiology" or "classification" and also "pseudoseizure" AND "semiology" or "classification" since 1940. I applied the same methodology using the electronic database Scopus, though I limited the search to the title, abstract, and keywords. RESULTS I could identify 15 classification systems through this search strategy using the electronic database PubMed. Searching the Scopus did not yield any additional relevant papers. CONCLUSION I proposed a new semiological classification system for PNES based on this systematic review. This includes three major classes of motor seizures, nonmotor seizures, and mixed semiology. A universally accepted and appropriate semiological classification system for PNES may lead to better standardization of future studies and may also help in better understanding of the pathophysiological basis of this condition.
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Abstract
PURPOSE OF REVIEW This review addresses the scope, evaluation, treatments, and outcomes of patients with nonepileptic episodic events with a focus on psychogenic nonepileptic seizures. Differentiation of the types of events, including a review of terminology, is included, as well as a brief review of special patient populations with these disorders. RECENT FINDINGS There are continued efforts to develop tools to improve the diagnosis of these disorders. A thorough evaluation with trained personnel and physicians knowledgeable in the assessment and treatment of these disorders is important. Although inpatient video-EEG monitoring in an epilepsy monitoring unit remains the gold standard for diagnosis, the assessment of clinical and historical factors is critical and can be useful in expediting the process and improving diagnostic certainty. International efforts have recently assisted in providing guidelines for the evaluation of the psychogenic disorders and may help target educational and other resources to underserved areas. SUMMARY The prompt and accurate diagnosis of nonepileptic episodic events and psychogenic nonepileptic seizures is possible with current technology, and the appropriate and targeted use of evidence-based treatments may help improve patient quality of life and avoid unnecessary disability in patients with these disorders.
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Kerr WT, Chau AM, Janio EA, Braesch CT, Le JM, Hori JM, Patel AB, Gallardo NL, Bauirjan J, Allas CH, Karimi AH, Hwang ES, Davis EC, Buchard A, Torres-Barba D, D'Ambrosio S, Al Banna M, Cho AY, Engel J, Cohen MS, Stern JM. Reliability of reported peri-ictal behavior to identify psychogenic nonepileptic seizures. Seizure 2019; 67:45-51. [PMID: 30884437 DOI: 10.1016/j.seizure.2019.02.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 02/24/2019] [Accepted: 02/27/2019] [Indexed: 01/20/2023] Open
Abstract
PURPOSE Differentiating psychogenic non-epileptic seizures (PNES) from epileptic seizures (ES) can be difficult, even when expert clinicians have video recordings of seizures. Moreover, witnesses who are not trained observers may provide descriptions that differ from the expert clinicians', which often raises concern about whether the patient has both ES and PNES. As such, quantitative, evidence-based tools to help differentiate ES from PNES based on patients' and witnesses' descriptions of seizures may assist in the early, accurate diagnosis of patients. METHODS Based on patient- and observer-reported data from 1372 patients with diagnoses documented by video-elect roencephalography (vEEG), we used logistic regression (LR) to compare specific peri-ictal behaviors and seizure triggers in five mutually exclusive groups: ES, PNES, physiologic non-epileptic seizure-like events, mixed PNES plus ES, and inconclusive monitoring. To differentiate PNES-only from ES-only, we retrospectively trained multivariate LR and a forest of decision trees (DF) to predict the documented diagnoses of 246 prospective patients. RESULTS The areas under the receiver operating characteristic curve (AUCs) of the DF and LR were 75% and 74%, respectively (empiric 95% CI of chance 37-62%). The overall accuracy was not significantly higher than the naïve assumption that all patients have ES (accuracy DF 71%, LR 70%, naïve 68%, p > 0.05). CONCLUSIONS Quantitative analysis of patient- and observer-reported peri-ictal behaviors objectively changed the likelihood that a patient's seizures were psychogenic, but these reports were not reliable enough to be diagnostic in isolation. Instead, our scores may identify patients with "probable" PNES that, in the right clinical context, may warrant further diagnostic assessment.
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Affiliation(s)
- Wesley T Kerr
- Department of Neurology, David Geffen School of Medicine at the University of California, Los Angeles (UCLA), Los Angeles, CA, USA; Department of Internal Medicine, Eisenhower Medical Center, Rancho Mirage, CA, USA; Department of Biomathematics, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Department of Psychiatry and Biobehavioral Sciences, UCLA, Los Angeles, CA, USA.
| | - Andrea M Chau
- Department of Psychiatry and Biobehavioral Sciences, UCLA, Los Angeles, CA, USA
| | - Emily A Janio
- Department of Psychiatry and Biobehavioral Sciences, UCLA, Los Angeles, CA, USA
| | - Chelsea T Braesch
- Department of Psychiatry and Biobehavioral Sciences, UCLA, Los Angeles, CA, USA
| | - Justine M Le
- Department of Biomathematics, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jessica M Hori
- Department of Psychiatry and Biobehavioral Sciences, UCLA, Los Angeles, CA, USA
| | - Akash B Patel
- Department of Psychiatry and Biobehavioral Sciences, UCLA, Los Angeles, CA, USA
| | - Norma L Gallardo
- Department of Psychiatry and Biobehavioral Sciences, UCLA, Los Angeles, CA, USA
| | - Janar Bauirjan
- Department of Psychiatry and Biobehavioral Sciences, UCLA, Los Angeles, CA, USA
| | - Corinne H Allas
- Department of Psychiatry and Biobehavioral Sciences, UCLA, Los Angeles, CA, USA
| | - Amir H Karimi
- Department of Psychiatry and Biobehavioral Sciences, UCLA, Los Angeles, CA, USA
| | - Eric S Hwang
- Department of Psychiatry and Biobehavioral Sciences, UCLA, Los Angeles, CA, USA
| | - Emily C Davis
- Department of Psychiatry and Biobehavioral Sciences, UCLA, Los Angeles, CA, USA
| | - Albert Buchard
- Department of Psychiatry and Biobehavioral Sciences, UCLA, Los Angeles, CA, USA
| | - David Torres-Barba
- Department of Psychiatry and Biobehavioral Sciences, UCLA, Los Angeles, CA, USA
| | - Shannon D'Ambrosio
- Department of Psychiatry and Biobehavioral Sciences, UCLA, Los Angeles, CA, USA
| | - Mona Al Banna
- Department of Psychiatry and Biobehavioral Sciences, UCLA, Los Angeles, CA, USA
| | - Andrew Y Cho
- Department of Psychiatry and Biobehavioral Sciences, UCLA, Los Angeles, CA, USA
| | - Jerome Engel
- Department of Neurology, David Geffen School of Medicine at the University of California, Los Angeles (UCLA), Los Angeles, CA, USA; Department of Psychiatry and Biobehavioral Sciences, UCLA, Los Angeles, CA, USA; Department of Neurobiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Brain Research Institute, UCLA, Los Angeles, CA, USA
| | - Mark S Cohen
- Department of Neurology, David Geffen School of Medicine at the University of California, Los Angeles (UCLA), Los Angeles, CA, USA; Department of Psychiatry and Biobehavioral Sciences, UCLA, Los Angeles, CA, USA; Departments of Radiology, Psychology,Biomedical Physics, and Bioengineering, University of California Los Angeles, Los Angeles, CA, USA; California NanoSystems Institute, University of California Los Angeles, Los Angeles, CA, USA
| | - John M Stern
- Department of Neurology, David Geffen School of Medicine at the University of California, Los Angeles (UCLA), Los Angeles, CA, USA
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Semiological characteristics of patients with psychogenic nonepileptic seizures: Gender-related differences. Epilepsy Behav 2018; 89:130-134. [PMID: 30415134 DOI: 10.1016/j.yebeh.2018.10.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 10/22/2018] [Accepted: 10/22/2018] [Indexed: 10/27/2022]
Abstract
Psychogenic nonepileptic seizures (PNES) are more prevalent among women, and diagnosis may sometimes be delayed by as much as seven years. Understanding the effect of gender on the presentation of a PNES may assist with diagnosis based on semiological details in the clinical setting. Although video-EEG monitoring (VEM) is the gold standard for diagnosing PNES, determining gender-related seizure semiology through careful history may prevent diagnostic delay while waiting for VEM. The aim of this study was to investigate gender-related differences in the semiology of PNES. Patients, all aged at least 16 years, diagnosed with PNES following VEM between December 2005 and November 2016 were included in this study. All patients' medical records and video-EEG-documented PNES were reviewed, and the presence or absence of semiological signs was recorded for each documented attack. Demographic features and semiological signs of PNES were compared between female and male patients. Forty-one patients (31 females, 10 males) aged 27.2 ± 12.2 years (range: 16-65) were included in the study. Mean age at onset of PNES was higher for female patients than males, at 24.3 ± 11.5 versus 17.5 ± 3.2 years (p = 0.005). The median duration of PNES was longer for female patients than males, at 10 min (range: 5 s-120 min) versus 2 min (range: 10 s-60 min) (p = 0.016). The most common symptom was forced eye closure in both genders. No significant gender-specific differences were observed in terms of the type or semiology of PNES. Although there are no major gender-related differences in PNES semiology, our findings highlight the importance of greater caution, especially in male patients, when diagnosing PNES, remembering that onset may also occur at young ages and that a short seizure duration does not exclude PNES.
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Gasparini S, Beghi E, Ferlazzo E, Beghi M, Belcastro V, Biermann KP, Bottini G, Capovilla G, Cervellione RA, Cianci V, Coppola G, Cornaggia CM, De Fazio P, De Masi S, De Sarro G, Elia M, Erba G, Fusco L, Gambardella A, Gentile V, Giallonardo AT, Guerrini R, Ingravallo F, Iudice A, Labate A, Lucenteforte E, Magaudda A, Mumoli L, Papagno C, Pesce GB, Pucci E, Ricci P, Romeo A, Quintas R, Sueri C, Vitaliti G, Zoia R, Aguglia U. Management of psychogenic non-epileptic seizures: a multidisciplinary approach. Eur J Neurol 2018; 26:205-e15. [DOI: 10.1111/ene.13818] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 10/04/2018] [Indexed: 12/01/2022]
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Can home videos made on smartphones complement video-EEG in diagnosing psychogenic nonepileptic seizures? Seizure 2018; 62:95-98. [DOI: 10.1016/j.seizure.2018.10.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 09/29/2018] [Accepted: 10/02/2018] [Indexed: 11/18/2022] Open
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Izadyar S, Shah V, James B. Comparison of postictal semiology and behavior in psychogenic nonepileptic and epileptic seizures. Epilepsy Behav 2018; 88:123-129. [PMID: 30268021 DOI: 10.1016/j.yebeh.2018.08.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 08/16/2018] [Accepted: 08/16/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND The available information on postictal semiology and behavior in patients with psychogenic nonepileptic seizure (PNES) is limited. In this study, we explore the differences in postictal semiology and behavior between patients with epileptic seizure (ES) and PNES and focus on clinical features that may be helpful in differentiating these two conditions. METHODS In this retrospective study, video-electroencephalograph (video-EEG) of 144 seizures from 64 patients with PNES and 66 seizures from 42 patients with ES were reviewed. Three novel postictal behaviors were compared between the two groups: a) abrupt, brief, and rapid blinking or shaking of the head as if regaining sensorium or "coming out" of the ictal event; b) looking around the room with a scanning and uncertain look; c) posing a question of "what happened?" or a similar question to the others present in the room. In addition, differences in several other postictal characteristics were studied. RESULTS At least one of the three specific postictal behaviors was seen in 20.1% of patients with PNES but none of the patients with ES resulting in 100% specificity and 36% sensitivity. While mean ictal duration was significantly longer in patients with PNES (175.3 ± 168 s) compared to ES (105.4 ± 102.9 s), the interval between the end of ictal episode and first correct verbal response (74.5 ± 126.2 s versus 139.4 ± 185.4 s), or first followed command (84.1 ± 133.8 s versus 141.1 ± 192.1 s) were shorter. In the group with PNES, 59.7% of patients demonstrated a whispering or altered voice during the first correct verbal response versus 21.2% of patients in the group with ES. The first followed command was slow or erroneous in 49.3% of the patients with PNES and in 19.7% of the patients with ES. CONCLUSION In this study, we found significant differences between postictal semiology and behavior of patients with PNES and ES that can be helpful tools in distinguishing between these two conditions. Specifically, three novel postictal behaviors were studied and were found to have a high specificity, but low sensitivity, in distinguishing PNES from ES.
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Affiliation(s)
- Shahram Izadyar
- Department of Neurology, SUNY Upstate Medical University, 750 East Adams St., Syracuse, NY 13210, United States of America.
| | - Vishal Shah
- Department of Neurology, SUNY Upstate Medical University, 750 East Adams St., Syracuse, NY 13210, United States of America
| | - Brandon James
- College of Medicine, SUNY Upstate Medical University, 766 Irving Ave., Syracuse, NY 13210, United States of America
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Pataraia E, Jung R, Aull-Watschinger S, Skhirtladze-Dworschak K, Dworschak M. Seizures After Adult Cardiac Surgery and Interventional Cardiac Procedures. J Cardiothorac Vasc Anesth 2018; 32:2323-2329. [DOI: 10.1053/j.jvca.2017.12.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Indexed: 12/29/2022]
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An Overview of Psychogenic Non-Epileptic Seizures: Etiology, Diagnosis and Management. Can J Neurol Sci 2018; 45:130-136. [DOI: 10.1017/cjn.2017.283] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
AbstractThe purpose of this review is to provide an update of the research regarding the etiology, diagnosis and management of psychogenic non-epileptic seizures (PNES). A literature search using Pubmed, Ovid MEDLINE and EMBASE database was performed from 2000 up to August 2017. We have evaluated the different factors leading to PNES as well as the diagnostic approach and management of this disorder which continue to be very difficult. The coexistence of epilepsy and PNES poses special challenges and requires the coordinated efforts of the family physicians, psychiatrists, psychologists and neurologists. Although this condition has an overall poor prognosis, a multidisciplinary approach in the diagnosis and management of this disorder would likely improve the outcomes. We have proposed a diagnostic and treatment algorithm for PNES and suggested a national registry of patients suffering from this condition. The registry would contain data regarding treatment and outcomes to aid in the understanding of this entity.
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Hanrahan B, Ghearing G, Urban A, Plummer C, Pan J, Hendrickson R, Bagic A, Antony A. Diagnostic accuracy of paroxysmal spells: Clinical history versus observation. Epilepsy Behav 2018; 78:73-77. [PMID: 29175694 DOI: 10.1016/j.yebeh.2017.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 09/06/2017] [Accepted: 09/07/2017] [Indexed: 10/18/2022]
Abstract
Our goal was to evaluate how accurate neurologists are at differentiating between different paroxysmal events based on clinical history versus observation of the spell in question. Forty-seven neurologists reviewed 12 clinical histories and videos of recorded events of patients admitted in the Epilepsy Monitoring Unit (EMU). They were asked to diagnose events as epileptic seizures, non-epileptic behavioral spells (NEBS), or other physiologic events as well as rate their confidence in their diagnosis. The median diagnostic accuracy for all paroxysmal events was 67% for clinical history and 75% for observation (p=.001). This was largely due to the difference in accuracy within the subgroup of patients with NEBS (67% history vs. 83% observation, p<.001). There were trends for higher diagnostic accuracy and increased inter-rater agreement with higher levels of training. Physicians with higher levels of training were more confident with diagnosis based on observation. In summary, reviewing videos of paroxysmal spells may improve diagnostic accuracy and enhance the evaluation of patients. Neurologists at all levels of training should encourage the recording and review of videos of recurrent spells to aid in medical decision-making especially when there is high concern that the spells in question are NEBS.
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Affiliation(s)
| | - Gena Ghearing
- University of Iowa Carver School of Medicine, Department of Neurology, USA.
| | | | | | - Julie Pan
- UPMC Pittsburgh, Department of Neurology, USA.
| | | | - Anto Bagic
- UPMC Pittsburgh, Department of Neurology, USA.
| | - Arun Antony
- UPMC Pittsburgh, Department of Neurology, USA.
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Abstract
PURPOSE OF REVIEW Optimal treatment of a possible first seizure depends on the determination if the paroxysmal event was an epileptic seizure and was on an accurate assessment of the recurrence risk. This review summarizes evidence from the last 5 years addressing the following questions: Is it an epileptic seizure? Is it a first seizure? When does a first seizure indicate epilepsy? RECENT FINDINGS The acts of taking and interpreting the history from patients and witnesses continue to be the most important tools in the diagnosis of first seizures. Assessment tools based on factual questions and the observation of patients' conversational behaviour can contribute to the differentiation of patients with epileptic seizures from those who have experienced other types of transient loss of consciousness (TLOC). At present, only about 40% of patients are seen after their very first seizure. Tests have a limited role in the initial diagnosis of a seizure but help to determine the recurrence risk based on the cause. A remote symptomatic cause and detection of epileptiform discharges are associated with a recurrence risk of at least 60% and allow a diagnosis of epilepsy after a first seizure. The risk of recurrence after an acute symptomatic first seizure is well below 60%. SUMMARY Expert history-taking continues to be the most important tool in the diagnosis of a first seizure. Cause is the most important determinant of the recurrence risk. Unfortunately, there is currently no formula enabling a precise calculation of an individualized recurrence risk.
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Are the clinical classifications for psychogenic nonepileptic seizures reliable? Epilepsy Behav 2017; 77:53-57. [PMID: 29111503 DOI: 10.1016/j.yebeh.2017.09.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 09/12/2017] [Accepted: 09/16/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Psychogenic nonepileptic seizures (PNESs) are episodes that resemble epileptic seizures but are of psychological origin. A few studies have attempted to describe different types of PNES as a combination of clinical signs but their validation and robustness have not yet been reached. The aim of this study was to assess the inter-rater reliability (IRR) of five existing clinical PNES classifications. METHODS A total of 107 PNESs from 54 patients were retrospectively analyzed independently by two trained epileptologists, who were blinded to each other's findings. The recorded events were grouped according to the five chosen classifications systems. The IRR was measured using a kappa (κ) coefficient for each PNES classification. We also report category-specific κ values. RESULTS Our study demonstrated a mild to moderate IRR (κ from 0.44-0.68) for classifying PNES using the 5 proposed classification schemes. Within these classifications, the most reproducible classes are the subjective ones followed by the dialeptic group. Classes based on motor signs are the least reproducible. CONCLUSION The IRR for current clinical classifications of PNES was only moderate. The difficulty to analyze motor signs could explain this poor reliability. It is necessary to ensure the reliability of clinical classifications of PNES in order for them to be a relevant tool in clinical practice or to explore correlations in clinical research. Future research would benefit from increased precision of diagnostic criteria specific to each class.
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Erba G, Bianchi E, Giussani G, Langfitt J, Juersivich A, Beghi E. Patients' and caregivers' contributions for differentiating epileptic from psychogenic nonepileptic seizures. Value and limitations of self-reporting questionnaires: A pilot study. Seizure 2017; 53:66-71. [PMID: 29132064 DOI: 10.1016/j.seizure.2017.11.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 10/26/2017] [Accepted: 11/04/2017] [Indexed: 10/18/2022] Open
Abstract
PURPOSE Questionnaires investigating semiology and comorbidities of psychogenic non-epileptic seizures (PNES) have been used mainly to help physicians expedite referrals to epilepsy centres for confirmation of diagnosis rather than as alternative diagnostic tool when video-EEG monitoring (VEM), the current gold standard, is not available or is inconclusive. METHODS We developed one structured questionnaire for patients, exploring subjective experiences and vulnerabilities and one for eyewitnesses, focused on features observable during typical events to study prospectively 50 consecutive adult patients with PNES or epileptic seizures (ES) admitted for VEM. A list of variables representing specific signs, symptoms and risk factors was obtained from each question. Specificity (SP) and sensitivity (SE) of each variable were calculated analyzing patient's and witness' responses against the final diagnosis. Statistical significance was assessed using the Fisher's exact test. RESULTS Twenty-eight patients' questionnaires (17 PNES, 11 ES) were eligible for analysis. Seven variables with high SE and SP, of which 5 statistically significant, emerged as diagnostic predictors. They comprised three historical items: head injury, physical abuse and chronic fatigue; two warning signs: heart racing and tingling or numbness; one triggering sign: headache; one postictal symptom: physical pain. Sixteen witness questionnaires (6 PNES, 10 ES) were available. Side-to-side head movements and eyes closed were the statistically significant variables. CONCLUSION Pending further refinements, ad hoc questionnaires specifically designed for patients and eyewitnesses, may represent a practical tool for distinguishing ES from PNES in settings without sophisticated facilities or when VEM is inconclusive.
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Affiliation(s)
- Giuseppe Erba
- Department of Neurology, SEC, University of Rochester, Rochester, NY, United States
| | - Elisa Bianchi
- Laboratory of Neurological Disorders, Department of Neuroscience, IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri", Milan, Italy
| | - Giorgia Giussani
- Laboratory of Neurological Disorders, Department of Neuroscience, IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri", Milan, Italy
| | - John Langfitt
- Department of Neurology, SEC, University of Rochester, Rochester, NY, United States
| | - Adam Juersivich
- Department of Neurology, SEC, University of Rochester, Rochester, NY, United States
| | - Ettore Beghi
- Laboratory of Neurological Disorders, Department of Neuroscience, IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri", Milan, Italy.
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Papagno C, Montali L, Turner K, Frigerio A, Sirtori M, Zambrelli E, Chiesa V, Canevini MP. Differentiating PNES from epileptic seizures using conversational analysis. Epilepsy Behav 2017; 76:46-50. [PMID: 28927714 DOI: 10.1016/j.yebeh.2017.08.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 08/23/2017] [Accepted: 08/24/2017] [Indexed: 11/17/2022]
Abstract
We applied conversation analysis in an unselected continuous series of 70 patients to discriminate patients with psychogenic nonepileptic seizures (PNES) from patients with epilepsy. Two psychologists examined the patients' recorded reports. Patients were also submitted to an extensive neuropsychological battery in order to verify whether specific cognitive deficits or mental health problems are typical of patients with PNES and whether some cognitive deficits could prevent the correct diagnosis. The results showed a good percentage of correct diagnosis, with a sensitivity of 0.795 and a specificity of 0.83, while no difference in the cognitive profile was found between patients with PNES and patients with epilepsy. The results also suggest that psychologists can apply the conversation analysis as well as linguists, which is an important finding since psychologists are employed in specialized centers, while linguists in general are not part of the team.
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Affiliation(s)
- Costanza Papagno
- CIMeC and CeRiN, University of Trento, via Matteo Del Ben 5/b, 38068 Rovereto, Italy; Department of Psychology, University of Milano-Bicocca, Edificio U6, Piazza dell'Ateneo Nuovo 1, 20126 Milano, Italy.
| | - Lorenzo Montali
- Department of Psychology, University of Milano-Bicocca, Edificio U6, Piazza dell'Ateneo Nuovo 1, 20126 Milano, Italy
| | - Katherine Turner
- Epilepsy Center, San Paolo Hospital, via A. Di Rudinì 8, 20142 Milano, Italy
| | - Alessandra Frigerio
- Department of Psychology, University of Milano-Bicocca, Edificio U6, Piazza dell'Ateneo Nuovo 1, 20126 Milano, Italy
| | - Martina Sirtori
- Department of Psychology, University of Milano-Bicocca, Edificio U6, Piazza dell'Ateneo Nuovo 1, 20126 Milano, Italy
| | - Elena Zambrelli
- Epilepsy Center, San Paolo Hospital, via A. Di Rudinì 8, 20142 Milano, Italy
| | - Valentina Chiesa
- Epilepsy Center, San Paolo Hospital, via A. Di Rudinì 8, 20142 Milano, Italy
| | - Maria Paola Canevini
- Epilepsy Center, San Paolo Hospital, via A. Di Rudinì 8, 20142 Milano, Italy; Department of Health Sciences, University of Milan, 20100 Milano, Italy
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Engaging psychiatrists in the diagnosis of psychogenic nonepileptic seizures. What can they contribute? Seizure 2017; 52:182-187. [DOI: 10.1016/j.seizure.2017.10.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 10/12/2017] [Accepted: 10/13/2017] [Indexed: 11/19/2022] Open
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Ito Y, Kidokoro H, Negoro T, Tanaka M, Okai Y, Sakaguchi Y, Ogawa C, Takeuchi T, Ohno A, Yamamoto H, Nakata T, Maesawa S, Watanabe K, Takahashi Y, Natsume J. Paroxysmal nonepileptic events in children with epilepsy. Epilepsy Res 2017; 132:59-63. [PMID: 28315806 DOI: 10.1016/j.eplepsyres.2017.02.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 02/10/2017] [Accepted: 02/23/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The aim of this study was to clarify the characteristics of paroxysmal nonepileptic events (PNEs) suspected as being epileptic seizures by families of children with epilepsy. METHODS The video-EEG (vEEG) recordings of habitual paroxysmal events in children with epilepsy at Nagoya University Hospital between October 2006 and January 2016 were reviewed. Based on the doctor's suspicion before the vEEG, the PNEs were divided into two groups that included PNEs suspected as epileptic seizures and PNEs suspected as PNEs. PNEs in the former group were classified based on the suspected seizure type. RESULTS Of 886 habitual paroxysmal events, vEEG confirmed that 83 events (68 children) were PNEs. The median age of the 68 children was 3.2 years. Concurrent epilepsies included focal epilepsies (n=33), infantile spasms (n=16), and other types (n=19). The most common types of PNEs were sleep myoclonus (n=11), followed by stereotypies (n=9), awake myoclonus (n=8), paroxysmal ocular deviations (PODs, n=8), and tonic posturing (n=8). Even after direct observation or video viewing, the doctors suspected epileptic seizures in all three of the PODs and two of the tonic posturing children. Before the vEEG, however, the accurate visual information led to the speculation that the four psychogenic and two sleep myoclonus events were all PNEs. Myoclonus, stereotypies, and head drops were often misdiagnosed as epileptic spasms, while PODs and tonic posturing were often misdiagnosed as focal seizures with motor components. Additionally, staring and motion arrest during a drowsy state were often misdiagnosed as focal dyscognitive seizures. Seven of eight patients with PODs had epileptic spasms that were concurrent with epileptic seizures. A diffuse cerebral lesion or reduced visual acuity was seen in seven patients with PODs. CONCLUSION We re-emphasize that vEEG is essential for accurate diagnosis and provides evidence for listing POD in the differential diagnosis of oculomotor paroxysmal events.
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Affiliation(s)
- Yuji Ito
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Aichi, Japan; Brain & Mind Research Center, Nagoya University, Aichi, Japan
| | - Hiroyuki Kidokoro
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Aichi, Japan; Brain & Mind Research Center, Nagoya University, Aichi, Japan
| | - Tamiko Negoro
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Masaharu Tanaka
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Yu Okai
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Yoko Sakaguchi
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Chikako Ogawa
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Tomoya Takeuchi
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Atsuko Ohno
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Hiroyuki Yamamoto
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Tomohiko Nakata
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Satoshi Maesawa
- Brain & Mind Research Center, Nagoya University, Aichi, Japan
| | - Kazuyoshi Watanabe
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Yoshiyuki Takahashi
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Jun Natsume
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Aichi, Japan; Brain & Mind Research Center, Nagoya University, Aichi, Japan.
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Differential diagnosis of a paroxysmal neurological event: Do neurologists know how to clinically recognize it? Epilepsy Behav 2017; 67:77-83. [PMID: 28092837 DOI: 10.1016/j.yebeh.2016.12.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 12/15/2016] [Accepted: 12/17/2016] [Indexed: 11/21/2022]
Abstract
PURPOSE To investigate ability to recognize paroxysmal neurological events (PNE) based on video-recorded events alone in a group of physicians treating prevalent neurological conditions. METHODS Total of 12 patients' videos (6 epileptic seizures (ES), 4 psychogenic nonepileptic seizures (PNES), 2 other nonepileptic seizures (oNES)) were selected. Videos were displayed once to physicians blind to clinical data and final diagnosis. Physicians determined their clinical choice: ES, PNES, oNES, and I don't know (IDK). When ES was chosen, subjects determined type of ES: focal ES, secondary generalized tonic-clonic seizure (GTCS), primary GTCS, and IDK. RESULTS In total 145 physicians (62% female, mean age 46.2±9years) (neurologists 58.6%, neuropsychiatrists 25.5%, psychiatrists 5%, and neurology residents 10.3%) were enrolled. Physician's exposure to patients with epilepsy per week was diverse: ≤1 patient (43.7%); 1-7 patients (37.2%); >7 patients (14.5%). Reported frequency of observation of PNE was as follows: frequent (21.4%), sometimes (47.6%); rarely (26.9%); never (2.1%). Majority of subjects were not EEG readers (60.7%). Median percentage (Mdn%) of correct answers (CA) was 75% (range 25-100). Predictor of better PNE recognition was higher frequency of clinical exposure to PNE (OR 1.65; CI95% 1.11-2.45; p=0.013). Mdn% of ES CA was 83.3%, (range 33.3-100), and of PNES CA was 50% (range 0-100). Physicians were more accurate in ES than PNES identification (p<0,001). Mdn% of type of ES CA was 50%, (range 0-100). CONCLUSIONS We demonstrate the need for education about clinical features of PNE across subgroups of physicians who deliver neurological service, with emphasis on PNES and ES type classification.
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Madan N, Carvalho KS. Neurological Complications of Cardiac Disease. Semin Pediatr Neurol 2017; 24:3-13. [PMID: 28779863 DOI: 10.1016/j.spen.2017.01.001] [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
This article focuses on the complex interactions between the cardiovascular and neurologic systems. Initially, we focus on neurological complications in children with congenital heart disease both secondary to the underlying cardiac disease and complications of interventions. We later discuss diagnosis and management of common syncope syndromes with emphasis on vasovagal syncope. We also review the diagnosis, classification, and management of children and adolescents with postural orthostatic tachycardia syndrome. Lastly, we discuss long QT syndrome and sudden unexpected death in epilepsy (SUDEP), reviewing advances in genetics and current knowledge of pathophysiology of these conditions. This article attempts to provide an overview of these disorders with focus on pathophysiology, advances in molecular genetics, and current medical interventions.
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Affiliation(s)
- Nandini Madan
- From the Section of Cardiology, Department of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA.
| | - Karen S Carvalho
- Section of Neurology, Department of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA
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Seneviratne U, Minato E, Paul E. How reliable is ictal duration to differentiate psychogenic nonepileptic seizures from epileptic seizures? Epilepsy Behav 2017; 66:127-131. [PMID: 28039841 DOI: 10.1016/j.yebeh.2016.10.024] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 10/19/2016] [Accepted: 10/19/2016] [Indexed: 11/16/2022]
Abstract
We sought to investigate (1) differences in ictal duration between psychogenic nonepileptic seizures (PNES) and epileptic seizures (ES), (2) the odds of being PNES when seizures last ≥5min, and (3) the value of ictal duration as a diagnostic test to differentiate PNES from ES. We retrospectively reviewed video-EEG recordings and tabulated ictal durations of all PNES and ES. We estimated the mean ictal durations of PNES and ES using linear mixed models. The odds of being PNES when seizures last ≥5min were estimated using logistic regression. We used receiver operating characteristics (ROC) curves to study the overall diagnostic accuracy of ictal duration in differentiating PNES from ES. We studied 441 ES and 341 PNES recorded from 138 patients. The mean ictal duration of PNES (148.7s, 95% CI: 115.2-191.8) was significantly longer (p<0.001) than that of ES (47.7s, 95% CI: 37.6-60.6). The odds of being PNES was about 24 times higher (Odds ratio: 23.8, 95% CI: 7.9-71.3) when the ictal duration was ≥5min. The ROC curve yielded an area under the curve of 0.80 (95% CI 0.73-0.88). Youden's index identified 123.5s as the optimal threshold to diagnose PNES with 65% sensitivity and 93% specificity. Our results indicate that ictal duration is a useful test to raise suspicion of PNES. When a seizure lasts ≥5min, it is 24 times more likely to be PNES with the potential risk of misdiagnosis as status epilepticus.
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Affiliation(s)
- Udaya Seneviratne
- Department of Neuroscience, Monash Medical Centre, Melbourne, Australia; Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia.
| | - Erica Minato
- Department of Neuroscience, Monash Medical Centre, Melbourne, Australia.
| | - Eldho Paul
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Department of Clinical Haematology, Alfred Hospital, Melbourne, Australia.
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Wolf P, Beniczky S. Visible and invisible seizure symptoms. Epilepsia 2016; 57:1729. [DOI: 10.1111/epi.13496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Peter Wolf
- Danish Epilepsy Center; Dianalund Denmark
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Erba G, Beghi E, Magaudda A, Bianchi E, Giussani G, Di Rosa G, Laganà A, Chiesa V, Juersivich A, Langfitt J. In response: Towards a quantitative assessment of psychogenic nonepileptic seizures. Epilepsia 2016; 57:1011-2. [PMID: 27286757 DOI: 10.1111/epi.13401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Giuseppe Erba
- Department of Neurology, SEC, University of Rochester, Rochester, New York, USA
| | - Ettore Beghi
- Laboratory of Neurological Disorders, Department of Neuroscience, IRCCS-Institute for Pharmacological Research "Mario Negri", Milan, Italy.
| | - Adriana Magaudda
- Department of Neuroscience, Epilepsy Center, University of Messina, Messina, Italy
| | - Elisa Bianchi
- Laboratory of Neurological Disorders, Department of Neuroscience, IRCCS-Institute for Pharmacological Research "Mario Negri", Milan, Italy
| | - Giorgia Giussani
- Laboratory of Neurological Disorders, Department of Neuroscience, IRCCS-Institute for Pharmacological Research "Mario Negri", Milan, Italy
| | - Gabriella Di Rosa
- Department of Pediatric, Gynecological, Microbiological and Biomedical Science, Unit of Infantile Neuropsychiatry, University of Messina, Messina, Italy
| | - Angela Laganà
- Department of Neuroscience, Epilepsy Center, University of Messina, Messina, Italy
| | - Valentina Chiesa
- Neurology Unit 2, Epilepsy Center, San Paolo Hospital, Milan, Italy
| | - Adam Juersivich
- Department of Neurology, SEC, University of Rochester, Rochester, New York, USA
| | - John Langfitt
- Department of Neurology, SEC, University of Rochester, Rochester, New York, USA
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