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Baslet G, Bajestan SN, Aybek S, Modirrousta M, D Clin Psy JP, Cavanna A, Perez DL, Lazarow SS, Raynor G, Voon V, Ducharme S, LaFrance WC. Evidence-Based Practice for the Clinical Assessment of Psychogenic Nonepileptic Seizures: A Report From the American Neuropsychiatric Association Committee on Research. J Neuropsychiatry Clin Neurosci 2021; 33:27-42. [PMID: 32778006 DOI: 10.1176/appi.neuropsych.19120354] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The American Neuropsychiatric Association's Committee on Research assigned the task of defining the most helpful clinical factors and tests in establishing the diagnosis of psychogenic nonepileptic seizures (PNES) during a neuropsychiatric assessment. A systematic review of the literature was conducted using three search engines and specified search terms for PNES and the predetermined clinical factors and diagnostic tests, followed by a selection process with specific criteria. Data extraction results from selected articles are presented for clinical factors (semiology, psychiatric comorbidities, medical comorbidities, psychological traits) and diagnostic tests (EEG, psychometric and neuropsychological measures, prolactin level, clinical neuroimaging, autonomic testing). Semiology with video EEG (vEEG) remains the most valuable tool to determine the diagnosis of PNES. With the exception of semiology, very few studies revealed the predictive value of a clinical factor for PNES, and such findings were isolated and not replicated in most cases. Induction techniques, especially when coupled with vEEG, can lead to a captured event, which then confirms the diagnosis. In the absence of a captured event, postevent prolactin level and personality assessment can support the diagnosis but need to be carefully contextualized with other clinical factors. A comprehensive clinical assessment in patients with suspected PNES can identify several clinical factors and may include a number of tests that can support the diagnosis of PNES. This is especially relevant when the gold standard of a captured event with typical semiology on vEEG cannot be obtained.
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Affiliation(s)
- Gaston Baslet
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Sepideh N Bajestan
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Selma Aybek
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Mandana Modirrousta
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Jason Price D Clin Psy
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Andrea Cavanna
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - David L Perez
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Shelby Scott Lazarow
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Geoffrey Raynor
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Valerie Voon
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Simon Ducharme
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - W Curt LaFrance
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
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Gras A, Wardrope A, Hirsch E, Asadi Pooya AA, Duncan R, Gigineishvili D, Hingray C, Kanemoto K, Ladino L, LaFrance WC, McGonigal A, Pretorius C, Valenti Hirsch P, Vidailhet P, Zhou D, Reuber M. Use of suggestive seizure manipulation methods in the investigation of patients with possible psychogenic nonepileptic seizures-An international ILAE survey. Epilepsia Open 2021; 6:472-482. [PMID: 34288577 PMCID: PMC8408588 DOI: 10.1002/epi4.12521] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/25/2021] [Accepted: 06/27/2021] [Indexed: 02/05/2023] Open
Abstract
Video‐encephalographic (vEEG) seizure recordings make essential contributions to the differentiation of epilepsy and psychogenic nonepileptic seizures (PNES). The yield of vEEG examinations can be increased through suggestive seizure manipulation (SSM) (ie, activation/provocation/cessation procedures), but its use has raised ethical concerns. In preparation for guidelines on the investigation of patients with PNES, the ILAE PNES Task Force carried out an international survey to investigate practices of and opinions about SSM. An online questionnaire was developed by the ILAE PNES Task Force. Questions were asked at clinical unit or individual respondent level. All ILAE chapters were encouraged to send questionnaires to their members. The survey was open from July 1, 2019, to August 31, 2019. A total of 487 clinicians from 411 units across 94 countries responded. Some form of SSM was used in 296/411 units (72.0%). Over 90% reported the use of verbal suggestion, over 80% the use of activation procedures also capable of eliciting epileptic activity (hyperventilation or photic stimulation). Only 26.3% of units used techniques specifically intended to provoke PNES (eg, saline injection). Fewer than 10% of units had established protocols for SSM, only 20% of units required written patient consent, in 12.2% of units patients received explicitly false information to provoke seizures. Clinicians using SSM tended to perceive no ethical problems, whereas those not using SSM were likely to have ethical concerns about these methods. We conclude that the use of invasive nocebo techniques intended to provoke PNES in diagnostic settings has declined, but SSM is commonly combined with activation procedures also capable of eliciting epileptic activity. While research suggests that openness about the use of PNES‐specific nocebo techniques does not reduce diagnostic yield, very few units have suggestion protocols or seek patient consent. This could be addressed through establishing consensus guidance for the practice of SSM.
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Affiliation(s)
- Adrien Gras
- Liaison Psychiatry Unit, 1 Place de l'Hopital, University Hospitals Strasbourg, Strasbourg, France
| | - Alistair Wardrope
- Academic Neurology Unit, Royal Hallamshire Hospital, The University of Sheffield, Sheffield, UK.,Department of Neurosciences, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Edouard Hirsch
- Liaison Psychiatry Unit, 1 Place de l'Hopital, University Hospitals Strasbourg, Strasbourg, France.,Epilepsy Unit "Francis Rohmer", INSERM Federation de Médecine Translationelle, CHU-University Strasbourg, Strasbourg, France
| | - Ali A Asadi Pooya
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Jefferson Comprehensive Epilepsy Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Rod Duncan
- Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - David Gigineishvili
- Department of Neurology and Neurosurgery, Sarajashvili Institute of Neurology, Tbilisi State University, Tbilisi, Georgia
| | | | | | - Lady Ladino
- Neurology Section, Epilepsy Program, Hospital Pablo Tobon Uribe, Medellin, Colombia.,Universidad de Antioquia, Medellin, Colombia
| | - William Curt LaFrance
- Neuropsychiatry and Behavioral Neurology, Rhode Island Hospital, Providence, RI, USA.,Neurology and Psychiatry, Brown University, Providence, RI, USA
| | - Aileen McGonigal
- Clinical Neurophysiology and Epileptology Department, Hospital Timone, Marseille, France.,Institut de Neurosciences des Systèmes, Aix-Marseille Universite, Marseille, France
| | - Chrisma Pretorius
- Department of Psychology, Stellenbosch University, Stellenbosch, South Africa
| | | | - Pierre Vidailhet
- Liaison Psychiatry Unit, 1 Place de l'Hopital, University Hospitals Strasbourg, Strasbourg, France.,Fédèration de Medecine Translationelle, Université de Strasbourg, Strasbourg, France
| | - Dong Zhou
- Department of Neurology, West China Hospital, Sichuan University West China Hospital, Chengdu, China
| | - Markus Reuber
- Academic Neurology Unit, Royal Hallamshire Hospital, The University of Sheffield, Sheffield, UK.,Department of Neurosciences, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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