Author response to Dr. Sethi: Psychogenic seizures and comorbid epilepsy
BenjaminTolchin, Neurologist, Yale Comprehensive Epilepsy Center
Barbara A.Dworetzky, Neurologist, Brigham and Women's Hospital
SteveMartino, Psychologist, Yale University School of Medicine
HalBlumenfeld, Neurologist, Yale Comprehensive Epilepsy Center
Lawrence J.Hirsch, Neurologist, Yale Comprehensive Epilepsy Center
GastonBaslet, Psychiatrist, Brigham and Women's Hospital
Published January 24, 2019
We appreciate Dr. Sethi's important reminder that it is the responsibility of neurologists to diagnose both psychogenic nonepileptic seizures (PNES) and epilepsy, and—in cases of PNES—to rule out or rule in comorbid epilepsy. Making as definite a diagnosis is possible, and communicating the diagnosis clearly to the patient and to the treating behavioral specialists is essential to the treatment of PNES. An ambiguous diagnosis can undermine the confidence of the patient and behavioral health specialists in the psychotherapeutic process, leading to nonadherence.
This is why it is important, whenever possible, to capture all typical spells on video electroencephalogram (EEG) during spell characterization, as recommended by the International League Against Epilepsy Nonepileptic Seizures Task Force.1,2 Additionally in situations like those described by Dr. Sethi, in which a prior EEG was read as abnormal, we recommend that the current neurologist obtain and review the original EEG, as normal EEG activity is frequently overread as epileptiform abnormalities.3 While comorbid PNES plus epilepsy does exist in a small minority of cases, it is not the common occurrence that older research suggested.4 It is important that a prior overread EEG not be allowed to confuse an otherwise clear diagnosis of PNES and thereby undermine treatment.
References
Tolchin B, Dworetzky BA, Martino S, Blumenfeld H, Hirsch LJ, Baslet G. Adherence with psychotherapy and treatment outcomes with psychogenic nonepileptic seizures. Neurology Epub 2019 Jan 4.
LaFrance WC Jr, Baker GA, Duncan R, Goldstein LH, Reuber M. Minimum requirements for the diagnosis of psychogenic nonepileptic seizures: a staged approach: a report from the International League Against Epilepsy Nonepileptic Seizures Task Force. Epilepsia 2013;54:2005–2018.
Benbadis SR. "Just like EKGs!" Should EEGs undergo a confirmatory interpretation by a clinical neurophysiologist? Neurology 2013;80:S47–S51.
Kutlubaev MA, Xu Y, Hackett ML, Stone J. Dual diagnosis of epilepsy and psychogenic nonepileptic seizures: Systematic review and meta-analysis of frequency, correlates, and outcomes. Epilepsy Behav 2018;89:70–78.
We appreciate Dr. Sethi's important reminder that it is the responsibility of neurologists to diagnose both psychogenic nonepileptic seizures (PNES) and epilepsy, and—in cases of PNES—to rule out or rule in comorbid epilepsy. Making as definite a diagnosis is possible, and communicating the diagnosis clearly to the patient and to the treating behavioral specialists is essential to the treatment of PNES. An ambiguous diagnosis can undermine the confidence of the patient and behavioral health specialists in the psychotherapeutic process, leading to nonadherence.
This is why it is important, whenever possible, to capture all typical spells on video electroencephalogram (EEG) during spell characterization, as recommended by the International League Against Epilepsy Nonepileptic Seizures Task Force.1,2 Additionally in situations like those described by Dr. Sethi, in which a prior EEG was read as abnormal, we recommend that the current neurologist obtain and review the original EEG, as normal EEG activity is frequently overread as epileptiform abnormalities.3 While comorbid PNES plus epilepsy does exist in a small minority of cases, it is not the common occurrence that older research suggested.4 It is important that a prior overread EEG not be allowed to confuse an otherwise clear diagnosis of PNES and thereby undermine treatment.
References
Footnotes
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