Provocative techniques should not be used for the diagnosis of psychogenic nonepileptic seizures

Abstract

Patients with psychogenic nonepileptic seizures (NES) have episodes of abnormal movements, alterations of awareness and unresponsiveness that appear similar to epileptic seizures. Unlike epileptic seizures, however, these spells occur in the absence of concurrent epileptiform activity in the brain. Such episodes are common, occurring in approximately 20% of those presenting to academic epilepsy centers for evaluation [1]. Although there is no gold standard process for diagnosis, the most common approach involves capturing the spell during electroencephalography (EEG), to demonstrate the lack of corresponding epileptiform discharges. Often patients with NES will not have spells while undergoing EEG monitoring, however, which creates difficulty in establishing a diagnosis and often leads to the use of induction procedures. Historically, the neurologists’ approach to the diagnosis of NES or other forms of conversion disorder has been controversial. In the 19th century, Charcot developed criteria for the differentiation of ‘‘hysterical attacks” from epilepsy, which included the precipitation or termination of spells by pressing on the ovaries or other ‘‘hysterogenic” areas [2]. A review of his works revealed that he was ‘‘not above slight trickery” or suggestion, as when he spoke offensively to a patient with psychogenic hearing loss to elicit a response [3]. Others in this time period were reported to use more radical methods. Gowers’ approach included applying electric shocks, covering the face with a towel to the point of asphyxiation, pouring water in the mouth, inducing vomiting with apomorphine, and pulling on pubic hair to abort spells and establish a diagnosis [4]. Perhaps the most colorful story from this era is that of Mitchell’s consultation on a puzzling case of paralysis. After examining the patient, he requested that the other doctors step into the hallway. When he joined them a moment later, they asked if the patient would ever walk again. He responded ‘‘yes, in a moment,” at which time the patient ran out of the room. When asked what happened, Dr. Mitchell replied, ‘‘I set the bedclothes on fire” [5]. In the midto late-20th century, diagnostic methods for conversion disorder may have been more ‘‘humane,” but nevertheless deceptive. Many physicians advocated the use of placebos for the diagnosis of conversion disorder in its various forms. Levy and Jankovic [6] reported a particularly striking case in which they documented a ‘‘dose dependent” reaction to a placebo injection, resulting in psychogenic nonfluent aphasia, NES, and profound