Selim R.Benbadis, Neurologist, University of South Florida
Published January 25, 2019
I completely agree with Dr. Sethi that the diagnosis, once made, should be given unequivocally. The diagnosis of psychogenic non-epileptic seizures (PNES) can be challenging at times, but is straightforward most of the time. Similarly, and contrary to higher percentages that are often brought up, only 10–15% of patients with PNES have evidence for coexisting epilepsy. That means over 85% do not; so, systemically assuming that the patient also has epilepsy is not based on facts. Also vague terms, like non-epileptic seizures (NES), and ambiguity should be avoided. The "P" is critical. NES and PNES are not the same. Not everything that is nonepileptic is psychogenic. When in doubt, patients should not be labelled psychogenic.
Epilepsy centers always try to rule out coexisting epilepsy. But, even if we performed EEG-video monitoring for 6 months, we could not guarantee the patient will not have an epileptic seizure in the seventh month. The concern about coexisting epilepsy may be one reason psychiatrist and psychologist don't want to see those patients, but it is not the main one. I submit that even in patients with unequivocal obvious PNES and no evidence for coexisting epilepsy whatsoever, it is difficult to get them to see psychiatrists and psychologists. More than a concern about coexisting epilepsy, the issue may be that mental health professionals do not believe the diagnosis; worse, some mental health professionals may not believe in the diagnosis of somatic symptoms disorders. The issue of a prior EEG that was (mis)read as "showing epilepsy" is frustrating; we must try to obtain the record in question, but that can be difficult. Lastly, even the 10–15% of patients with PNES who do have coexisting epilepsy deserve to be treated by psychiatrist and psychologists. That should not be a reason to deny them treatment.
I completely agree with Dr. Sethi that the diagnosis, once made, should be given unequivocally. The diagnosis of psychogenic non-epileptic seizures (PNES) can be challenging at times, but is straightforward most of the time. Similarly, and contrary to higher percentages that are often brought up, only 10–15% of patients with PNES have evidence for coexisting epilepsy. That means over 85% do not; so, systemically assuming that the patient also has epilepsy is not based on facts. Also vague terms, like non-epileptic seizures (NES), and ambiguity should be avoided. The "P" is critical. NES and PNES are not the same. Not everything that is nonepileptic is psychogenic. When in doubt, patients should not be labelled psychogenic.
Epilepsy centers always try to rule out coexisting epilepsy. But, even if we performed EEG-video monitoring for 6 months, we could not guarantee the patient will not have an epileptic seizure in the seventh month. The concern about coexisting epilepsy may be one reason psychiatrist and psychologist don't want to see those patients, but it is not the main one. I submit that even in patients with unequivocal obvious PNES and no evidence for coexisting epilepsy whatsoever, it is difficult to get them to see psychiatrists and psychologists. More than a concern about coexisting epilepsy, the issue may be that mental health professionals do not believe the diagnosis; worse, some mental health professionals may not believe in the diagnosis of somatic symptoms disorders. The issue of a prior EEG that was (mis)read as "showing epilepsy" is frustrating; we must try to obtain the record in question, but that can be difficult. Lastly, even the 10–15% of patients with PNES who do have coexisting epilepsy deserve to be treated by psychiatrist and psychologists. That should not be a reason to deny them treatment.
Footnotes
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