Diagnosis Of Nonepileptic Seizures Research Articles

Testing the diagnostic accuracy of common questions for seizure diagnosis: Challenges and future directions

ObjectiveThe aim of this study was to evaluate the diagnostic accuracy of common interview questions used to distinguish a diagnosis of epilepsy from seizure mimics including non-epileptic seizures (NES), migraine, and syncope. Methods200 outpatients were recruited with an established diagnosis of focal epilepsy (n = 50), NES (n = 50), migraine (n = 50), and syncope (n = 50). Patients completed an eight-item, yes-or-no online questionnaire about symptoms related to their events. Sensitivity and specificity were calculated. Using a weighted scoring for the questions alone with baseline characteristics, the overall questionnaire was tested for diagnostic accuracy. ResultsOf individual questions, the most sensitive one asked if events are sudden in onset (98 % sensitive for epilepsy (95 % CI: 89 %, 100 %)). The least sensitive question asked if events are stereotyped (46 % sensitive for epilepsy (95 % CI: 32 %, 60 %)). Overall, three of the eight questions showed an association with epilepsy as opposed to mimics. These included questions about “sudden onset” (OR 10.76, 95 % CI: (1.66, 449.21) p = 0.0047), “duration < 5 min” (OR 3.34, 95 % CI: (1.62, 6.89), p = 0.0008), and “duration not > 30 min” (OR 4.44, 95 % CI: (1.94, 11.05), p = <0.0001). When individual seizure mimics were compared to epilepsy, differences in responses were most notable between the epilepsy and migraine patients. Syncope and NES were most similar in responses to epilepsy. The overall weighted questionnaire incorporating patient age and sex produced an area under the ROC curve of 0.80 (95 % CI: 0.74, 0.87)). ConclusionIn this study, we examined the ability of common interview questions used by physicians to distinguish between epilepsy and prevalent epilepsy mimics, specifically NES, migraines, and syncope. Using a weighted scoring system for questions, and including age and sex, produced a sensitive and specific predictive model for the diagnosis of epilepsy. In contrast to many prior studies which evaluated either a large number of questions or used methods with difficult practical application, our study is unique in that we tested a small number of easy-to-understand “yes” or “no” questions that can be implemented in most clinical settings by non-specialists.

Pediatric psychogenic non-epileptic seizures: A retrospective observational cohort study at a quaternary center

BackgroundPsychogenic non-epileptic seizures (PNES) represent a common functional disorder in the pediatric population. We aimed to characterize pediatric PNES by describing their clinical characteristics, PNES semiologies, and healthcare pathway towards and after diagnosis. Material and MethodsThis was a retrospective, observational chart review of pediatric patients aged 6 to 18 years admitted between December 2020 and December 2021 for spell classification or suspected PNES. Psychogenic non-epileptic seizure diagnosis was made by the capture of a typical event on video electroencephalogram (vEEG). We used descriptive statistics to summarize demographic and clinical characteristics. ResultsWe included 26 patients (18 females, 69.2%) with a mean age (SD) of 13.9 (2.5) years. Pre-morbid neurologic and psychiatric conditions included: epilepsy (23.1%), migraine (46.2%), mild traumatic brain injury (26.9%), anxiety (57.7%), ADHD (34.6%), and depression (30.8%). Six patients (23.1%) had a prior diagnosis of PNES. 14 patients (53.8%) presented with convulsive, and 6 (23.1%) each with non-convulsive and mixed PNES.Patients were seen by a range of providers prior to diagnosis including ED providers (50%), neurologists (53.8%), pediatricians (34.6%), and psychology/psychiatry (11.5%). Emergency department evaluation occurred for 13 patients (50%) on 15 occasions, and six (23.1%) were admitted to the hospital. The median (p25-p75) time from PNES onset to presentation and diagnosis at our institution was 3.5 (1.5–6.2) and 4.1 (3–7) months, respectively.A total of 33 events from the 26 patients were captured on vEEG. The most frequent semiologies in our cohort were rhythmic motor (27.3%) followed by equal frequency (18.2%) of complex motor and dialeptic. Eighteen patients (69.2%) were followed after the PNES diagnosis, for a median (p25-p75) of 17.3 months (6.3–21) with variable outcome. ConclusionPediatric PNES has female predominance and often presents with comorbid psychosocial stressors and psychiatric conditions. High clinical suspicion and early recognition are crucial to decrease healthcare utilization and establish timely diagnosis and treatment.

Patients with psychogenic nonepileptic seizures and suspected epilepsy: An antiseizure medication reduction study

ObjectiveTo examine predictors of ASM reduction/discontinuation and PNES reduction/resolution in patients with PNES with a confirmed or strong suspicion of comorbid ES. MethodsA retrospective analysis of 271 newly diagnosed Patients with PNESs admitted to the EMU between May 2000 and April 2008, with follow-up clinical data collected until September 2015. Forty-seven patients met our criteria of PNES with either confirmed or probable ES. ResultsPatients with PNES reduction were significantly more likely to have come off all ASMs by the time of final follow-up (21.7 vs. 0.0%, p = 0.018), while documented generalized (i.e. epileptic) seizures were much more common in patients with no reduction in PNES frequency (47.8 vs 8.7%, p = 0.003). When comparing patients that reduced their ASMs (n = 18) with those that did not (n = 27), the former were more likely to have neurological comorbid disorders (p = 0.004). When comparing patients with PNES resolution (n = 12) vs not (n = 34), those with PNES resolution were more likely to have a neurological comorbid disorder (p = 0.027), had a younger age at EMU admission (29.8 vs 37.4, p = 0.05) and a greater proportion of patients with ASMs reduced in EMU (66.7% vs 30.3%, p = 0.028). Similarly, those with ASM reduction had more unknown (non-generalized, non-focal) seizures (33.3 vs 3.7%, p = 0.029). On hierarchical regression analysis, a higher level of education and absence of generalized epilepsy remain as positive predictors of PNES reduction (p = 0.042, 0.015), while the presence of some other neurological disorder besides epilepsy (p = 0.04) and being on more ASMs at EMU admission (p = 0.03) were positive predictors of ASM reduction by final follow-up. SignificancePatients with PNES and epilepsy have distinct demographic predictors of PNES frequency and ASM reduction by final follow-up. Patients with PNES reduction and resolution had higher level education, less generalized epileptic seizures, younger age at EMU admission, more likely to have presence of a neurological disorder besides epilepsy, and a greater proportion of patients had a reduction in the number of ASMs in the EMU. Similarly, patients with ASM reduction and discontinuation were on more ASMs at initial EMU admission and also were more likely to have a neurological disorder besides epilepsy. The positive relationship between reduction in psychogenic nonepileptic seizure frequency and discontinuation of ASMs at final follow-up elucidates that tapering medication in a safe environment may reinforce psychogenic nonepileptic seizure diagnosis. This can be reassuring to both patients and clinicians, resulting in the observed improvements at the final follow-up.

A Pilot Study to Compare the Standardized Patient's Perception of Empathy Among the American Medical Graduates and International Medical Graduates Applying for Residency Training in the United States

Abstract:&#x0D; Background:&#x0D; Empathy is an essential ingredient of patient-centered care. Traditional neurology clerkship does not provide a structured way to teach, evaluate and inculcate the virtue of empathy among our medical students while dealing with various complex neurological conditions. We designed an innovative Objective Structured Clinical Evaluations (O.S.C.E.s) entitled as Empathetic Neurological Care (ENC) O.S.C.E.s as a part of clerkship evaluation to assess empathy among American Medical Graduates (A.M.G.s) and International Medical Graduates (I.M.G.s). We aim to illustrate the model of Empathetic Neurological Care (ENC) O.S.C.E. &amp; to report the comparative analysis of empathy scores among the A.M.G.s and I.M.G.s.&#x0D; Methods:&#x0D; This is a pilot study comparing empathy among A.M.G.s and I.M.G.s, measured by the Standardized Patients (SPs) using the Jefferson Scale of Patient Perceptions of Physician Empathy (5-Point Likert Type Scale) during pre-designed ENC-OSCEs. The proposed curriculum included complex neurological cases involving breaking bad news (e.g., delivering the diagnosis of A.L.S.), opioid addiction counseling, disclosing medical error (stroke), and explaining the diagnosis of non-epileptic seizures.&#x0D; Conclusion: A.M.G.s scored higher empathy as compared to I.M.G.s by the S.P.s during ENC-OSCEs. We highlight the importance of focused empathy training with assessment during neurology clerkship rotations for A.M.G.s &amp; the need of formal curricular training as a part of the orientation program at the beginning of residency training for I.M.G.s.&#x0D;

Non-epileptic paroxysmal events in paediatric patients: A single tertiary centre study in Egypt

PurposeThe misdiagnosis of non-epileptic seizures (NES) as epilepsy is one of the most common pitfalls in neuropsychiatric practice. This study aimed to describe the percentage and types of NES among children who were referred for a diagnosis of epilepsy in Upper Egypt. MethodsWe recruited a total of 876 patients who were referred to Sohag University Hospital, a tertiary referral centre in Upper Egypt, for the evaluation of suspected epilepsy. Relevant methods for the diagnosis of epilepsy, including medical history and examination, EEG, video-EEG, laboratory investigations, and brain imaging, were performed for all study participants. ResultsAmong the 876 patients who were referred for the diagnosis of suspected epilepsy during the period from June 2017 to October 2018, 171 patients (19.5 %) were diagnosed as having NES. In general, we found that NES in the paediatric age groups did not differ from that reported in various studies across several different populations. The most prevalent NES in our study was breath-holding spells (32.2 %), followed by syncope (17.5 %), psychogenic nonepileptic seizures (12.3 %), motor tics (9.9 %), and benign sleep myoclonus (7.6 %). Other less frequent NES included infantile masturbation (7 %), spasmus nutans (5.3 %), migraine (2.9 %), benign paroxysmal torticollis (2.9 %), night terrors (1.8 %), and shuddering attacks (0.6 %). ConclusionIdeally, neurologists should not misdiagnose NES as epilepsy, and whenever the diagnosis of NES is uncertain, an accurate diagnosis should be made using long-term video-EEG monitoring, especially in younger paediatric patients.

Objective Structured Clinical Exams (OSCE) are a feasible method of teaching how to discuss a nonepileptic seizure diagnosis

ObjectivePresenting the diagnosis of psychogenic nonepileptic seizures (PNES) can be a difficult task, but disclosing this information effectively is important to optimize patient outcomes. We sought to develop a standardized method to teach neurology residents how to introduce the diagnosis of PNES via an objective structured clinical examination (OSCE) with a standardized patient (SP). MethodsIn conjunction with the New York University School of Medicine Simulation Center (NYSIM), we designed an OSCE in which a resident had to inform a SP of her diagnosis of PNES and discuss a treatment plan. The SP was provided with details to gradually disclose depending on what the resident said about the history of her episodes, triggers for her episodes and her history of sexual abuse. Each encounter was observed by an attending physician who provided real-time feedback to the resident after the session. Additionally, the SP completed an objective written checklist of items the resident should have covered in the session and gave them verbal feedback. ResultsTwenty-six adult neurology (n = 22), child neurology (n = 3), and neuropsychiatry (n = 1) residents participated in this OSCE in 2018 and 2019, with full data available for 25 participants. Residents reported the OSCE was very useful (mean Likert score of 4.9/5). They felt moderately prepared (mean Likert score 3.8/5) and rated their performance as a mean of 3.3/5. On the SP's checklist, most residents were rated as Well Done in the domains of information gathering, relationship development, and education and counseling. Only in the domain of psychosocial assessment were most residents rated as Not Done (only 7/25 inquired about past trauma as a risk factor for PNES). SignificanceThe OSCEs are a feasible and useful way to teach neurology residents about discussing PNES, as they allow for provision of real-time practice and feedback in a safe environment without real patients.

Individual differences in social network size linked to nucleus accumbens and hippocampal volumes in functional neurological disorder: A pilot study

BackgroundIn the biopsychosocial formulation of functional neurological (conversion) disorder (FND), little is known about relationships between social behavior and brain anatomy. We hypothesized that social behavior would relate to brain areas implicated in affiliative behaviors and that social network size would correlate with symptom severity and predisposing vulnerabilities in FND. MethodsThis neuroimaging pilot probed how social network size, as measured by the Social Network Index, related to structural brain profiles in 23 patients with motor FND (15 woman and 8 men). FreeSurfer cortical thickness and subcortical volumetric analyses were performed correcting for multiple comparisons. Stratified analyses compared FND patients with a low social network size to matched healthy controls. Secondary exploratory analyses in an expanded sample of 38 FND patients investigated relationships between social network size, risk factors and patient-reported symptom severity. ResultsAdjusting for age and gender, neuroimaging analyses showed that social network size positively correlated with left nucleus accumbens and hippocampal volumes in patients with FND; stratified analyses did not show any group-level differences. In individuals with FND, social network size correlated with health-related quality of life, graduating college, working full-time and a non-epileptic seizure diagnosis; social network size inversely related to lifetime trauma burden, post-traumatic stress disorder severity and age. LimitationsOnly patient-reported scales were used and social network size information was not collected for healthy subjects. ConclusionsThis neuroimaging pilot adds to the literature linking affiliation network brain areas to pro-social behaviors and enhances the biopsychosocial conceptualization of FND.

The feasibility of a multidisciplinary group therapy clinic for the treatment of nonepileptic seizures

A high percentage of patients presenting to epilepsy centers have a functional neurological disorder with apparent seizures, ultimately diagnosed as nonepileptic seizures (NES). Meta-analyses suggest that psychological treatment is required, but this treatment is not reliably available, resulting in reentry of these patients to neurology clinics and urgent care settings, reducing access for these services to patients with epilepsy and resulting in inadequate psychological care for patients with NES. A sustainable, group therapy-focused treatment clinic for patients with NES was developed as a combined effort between the departments of neurology and psychiatry at the University of Colorado Hospital, consisting of a full psychiatric evaluation, a five-week psychoeducational group, a 12-week psychodynamic therapy group, individual therapy, medication management, and family assessment. One hundred and six patients were treated in this clinic between July 2016 and October 2018. Patient retention after referral for treatment was 89/136 (65.4%), and group therapy adherence was 89/106 (84.0%). Healthcare utilization, used as a proxy to demonstrate worth, decreased during and after treatment. Analysis of the 106 treated patients elucidates other clinical characteristics of this population, including psychiatric comorbidities and specific medication classes at time of NES diagnosis. We conclude that this clinic model is feasible for recruiting, retaining, and engaging patients in appropriate treatment for their NES.

Why is psychogenic nonepileptic seizure diagnosis missed? A retrospective study

PurposeThe aim of this retrospective study was to scrutinize factors that are associated with a delay in making the diagnosis of psychogenic nonepileptic seizures (PNES). MethodsIn this study, patients with PNES, who were investigated at Shiraz Comprehensive Epilepsy Center, Iran, from 2008 to 2019, were studied. We categorized the patients into the following: 1. those with a definite diagnosis of PNES in less than a year since the onset of their attacks; 2. those with a definite diagnosis of PNES later than 10 years since the onset of their attacks. ResultsDuring the study period, 330 patients were recorded. In 98 patients (30%), the diagnosis of PNES was made in less than a year since their seizure onset. In 67 patients (20%), the diagnosis of PNES was made later than 10 years since their seizure onset. Taking antiepileptic drugs (AEDs) (odds ratio (OR) = 6) and a history of ictal injury (OR = 3.6) had a positive association, and age at the onset (OR = 0.8) had an inverse association with a delay in receiving a definite diagnosis of PNES (p = 0.0001). ConclusionSome demographic variables (i.e., early age at the onset of seizures), patients' clinical variables (i.e., severe seizure manifestations such as ictal injury), and finally, some physician-related variables (i.e., prescribing AEDs) have significant associations with a delay in making a definite diagnosis of PNES.

Morbidity and mortality of nonepileptic seizures (NES): A controlled national study

Nonepileptic seizures (NES, psychogenic NES-PNES) are associated with significant morbidities. We evaluated the morbidities and mortality in a national group of children, adolescent, and adult patients before and after a first diagnosis of PNES. MethodsFrom the Danish National Patient Registry (1998–2013), we identified 1057 people of all ages with a diagnosis of NES and matched them with 2113 control individuals by age, gender, and geography. Comorbidities were calculated three years before and after diagnoses. ResultsPatients with PNES showed increased comorbidities 3 years before and after diagnosis in almost all the diagnostic domains.The strongest associations were identified with other neurological diseases (after diagnosis, Hazard Ratio (HR): 38.63; 95% Confidence Interval (CI): 21.58–69.13; P < 0.001), abnormal clinical and laboratory findings (HR: 46.59; 95 CI: 27.30–79.52; P < 0.001), other health-related factors (HR: 12.83; 95%CI: 8.45–19.46; P < 0.001), and psychiatric comorbidities (HR: 15.45; 95% CI: 9.81–24.33). Epilepsy was identified in 8% of the patients with PNES. We found especially frequent comorbidity involving overweight, depression, anxiety, dissociative somatoform condition, other convulsions, lipothymias, reports of pain and other symptoms in several organ systems, and several reports of minimal traumas to the head, trunk, and extremities. Mortality was higher in patients with NES than in controls (HR: 3.21; 95% CI: 1.92–5.34; P < 0.001). ConclusionMorbidity is more frequent in several domains, including neurological, psychiatric, and other diseases, before and after a diagnosis of NES. Mortality is significantly higher in patients with PNES as compared to controls.

Neurological Emergencies in Refugees.

Objective: Health care personnel in Europe is increasingly involved in care of displaced persons from non-European countries; we investigated the spectrum of neurological disorders and medical management in refugees presenting to the emergency room (ER) of a German university hospital.Methods: We retrospectively studied ER-patients with refugee status (R-patients) during the peak of the European refugee crisis between July 2015 and February 2016 (N = 100). Complaints on admission, medical management and diagnoses at discharge were compared to matched groups of German residents with migrational background (M-patients; N = 96) and to native Germans (N-patients; N = 95).Results: R-patients were mostly male young adults (75% male; mean age 33.2 years). Headache was the most frequent complaint in all groups (R-patients 38%; M-patients 43%; N-patients 24%). R-patients, however, presented much more often with possible or definite seizures (R-patients 27%; M-patients 9%; N-patients 15%). Initial triage, length of medical history and examination records, utilization of laboratory tests and cranial imaging did not differ between groups. However, time to diagnosis was considerably longer in R-patients (220 min; M-patients 151 min, N-patients 123 min). While strokes and other life-threatening emergencies were rare final diagnoses in R-patients, a substantial proportion was discharged with a diagnosis of non-epileptic seizures or a psychiatric disorder (20%; M-patients 6%; N-patients 7%).Conclusions: Refugee patients present with a spectrum of neurological disorders that not solely results from cultural differences but rather reflects the consequences of forced displacement. ER management of refugees requires more time, language skills and critically depends on psychosomatic/psychiatric expertise.

Preliminary Report of Psychogenic Non-Epileptic Seizure Diagnosis Among Veterans From 2004–2014 (P6.275)

Preliminary Report of Psychogenic Non-Epileptic Seizure Diagnosis Among Veterans From 2004–2014 (P6.275)

3 Non-epileptic seizures in the emergency department: an audit

Objective Non-epileptic seizures (NES) commonly present via the emergency department (ED) and may lead to inappropriate and/or costly treatment. This baseline audit aimed to determine the prevalence of NES presenting to the ED of the Royal Sussex County Hospital, a tertiary centre in Brighton, over the course of one year. It also recorded whether these patients were being flagged on the electronic patient records (EPR) system and what management they received. Method A list of all patients presenting to the ED over a 1 year period with any of the keywords ‘seizure’ ‘fit’ ‘epilepsy’ in the presenting complaint was generated using the EPR system. We classified the seizures as epilepsy, NES, mixed, secondary, or awaiting diagnosis by: searching electronic discharge summaries and electronic psychiatry patient records, cross-checking with neurology and neuropsychiatry services, and notes review. Once the NES patients were identified, we quantified the number who had been flagged on the EPR and recorded the management they received during their hospital admission. Results Out of 1242 presentations of seizures to the ED over the course of a year, 101 were NES (8.1%). This accounted for 42 of 908 patients who presented with seizures (4.6%). 13 of these patients were flagged on the EPR system. 43% of this group of NES patients attended the ED more than once over the course of the year. There were 31 admissions of NES patients over the year (45.2% with a known diagnosis of NES at admission, 54.8% without a firm diagnosis), ranging from 1 to 33 days in length. Those with a firm diagnosis of NES at the time of admission had an average length of stay of 2 days and had no emergency calls put out; those without a firm diagnosis had an average length of stay of 6 days and 3% had between 1 and 4 medical emergency calls during their admission. Conclusions Non-epileptic seizures make up an important proportion of seizure presentations to the ED, and these patients commonly re-present. It is important that such patients are flagged with a clear management plan in place if the diagnosis of NES is established, and if needed neurological and neuropsychiatric assessment is not delayed in order to minimise harmful interventions and length of stay.

Is patient acceptance of the diagnosis of psychogenic nonepileptic seizures linked to symptomatology?

ABSTRACTIntroduction: An assessment was made of general symptoms in patients with psychogenic nonepileptic seizures (PNES), comparing those who do versus those who do not accept the diagnosis. Method: A questionnaire pilot study of newly diagnosed psychogenic nonepileptic seizure patients confirmed by video electroencephalography (EEG) was carried out, using a 59-item general symptom questionnaire, with frequency (score) ranging from never (0) to every day (5). Subsequent blinded assessment of patient’s acceptance of diagnosis was made. Results: Of 13 patients studied, over a 5-month period, 8 accepted the diagnosis, and 5 did not. Acceptance of diagnosis was associated with a lower total symptom score (p < .001) and significantly lower symptom scores in 7 of the 10 symptom subscales. Conclusion: The underlying symptomatology of psychogenic nonepileptic seizure patients differs between those who do versus those who do not accept the diagnosis. The complexity of additional symptoms may contribute to poorer outcomes in those that do not accept the psychogenic nonepileptic seizure diagnosis.

The impact of conveying the diagnosis when using a biopsychosocial approach: A qualitative study among adolescents and young adults with NES (non-epileptic seizures)

PurposeThis qualitative study explored the impact of using a biopsychosocial approach to explain the diagnosis of non-epileptic seizures (NES). MethodsSemi-structured interviews of eleven adolescents and young adults who had participated in an inpatient follow–up stay of the diagnosis were used. The interviews were taped, transcribed, and analysed using systematic text condensation. ResultsThree key themes were identified:1.“Threatened self-image”: Patients initially perceived their diagnosis as being purely psychological. As they did not accept that they had mental disorders, they interpreted this as frightening and threatening, and resisted the diagnosis.2.“Being believed and belief in oneself”: Participants had many experiences of being suspected by healthcare providers of staging their seizures. Some had even begun to have doubts themselves as to whether the attacks were voluntary or not. Explaining that unconscious processes are involved in NES contributed towards increasing patients’ feelings of being believed, and thereby acceptance of the diagnosis.3.“Getting an explanation that makes sense”: Some participants identified connections between their personal histories and their seizures and became seizure-free. Others found that the explanatory models gave personal meaning, but did not become seizure-free, while a few continued to doubt whether NES was the correct diagnosis. ConclusionBeing believed was the most elemental factor for coping with the condition. Using a biopsychosocial approach to explain the diagnosis may facilitate identification with the explanatory models, and thus acceptance of the diagnosis.

Predictors for readmissions after video-EEG monitoring.

Identification of variables prognosticating 30-day readmission among adult patients admitted for video-EEG (VEEG) monitoring at a major epilepsy center. A retrospective cohort study was conducted, examining 865 consecutive admissions to the epilepsy monitoring unit (EMU) from January 2010 to June 2013. Data extracted from chart review included demographics, length of stay (LOS), seizure type(s), number of 30-day readmissions or emergency department (ED) visits and reasons for these, and patient and system/provider factors potentially contributing to the readmission. Of 865 elective admissions for VEEG monitoring, 49 patients accounted for 33 readmissions and 40 ED visits within 30 days of discharge for an overall 30-day encounter rate of 7.0% after excluding those lost to follow-up; 9 patients had more than one ED visit or readmission. Statistically significant risk factors for urgent 30-day encounters included a history of nonepileptic seizures (NES) (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.1-3.4), a dual diagnosis of both epilepsy and NES (OR 5.9, 95% CI 3.0-11.8), an urgent index admission to the EMU (OR 2.5, 95%CI 1.4-4.8), and a shorter LOS of index hospitalization (median 4.0 days vs 5.0 days, p < 0.01). The most common contributing patient factors included active psychiatric symptoms, medically refractory epilepsy, and living alone; the most common hospitalization-related factors included antiepileptic drug (AED) treatment adverse events or AED adjustment. In addition to the presence of intractable epilepsy and shorter LOS, mental health comorbidities and the presence of NES were important risk factors for 30-day readmissions and ED visits in the epilepsy population. Therefore, proactively addressing mental health comorbidities may decrease urgent health care utilization after VEEG monitoring.

Posttraumatic Epilepsy in Operation Enduring Freedom/Operation Iraqi Freedom Veterans

Penetrating traumatic brain injury (TBI) is a well-established risk factor for post-traumatic epilepsy (PTE). However, many veterans in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) who suffer from TBI do so from blast injury, and its consequences are not fully known. Two neurologists performed a chart review to describe patterns of injury and health care among all 16 OEF/OIF veterans at the VA Greater Los Angeles Healthcare System who were assigned an outpatient diagnosis of both epilepsy and TBI in 2008-2009. All Veterans were male, and the mean age was 30 years. Blast exposure was the most common mechanism of TBI (81%). Although all Veterans were assigned a diagnosis code of seizures, the diagnosis of PTE was clinically confirmed in only 3 veterans. On the other hand, the diagnosis of post-traumatic stress disorder was confirmed in 81% of the sample and a diagnosis of nonepileptic seizures was suspected in 44% of the sample. Researchers who study PTE among the OEF/OIF population using administrative data also should perform chart reviews to account for the prevalence of psychogenic nonepileptic seizures.

Comment ce que disent les patients peut nous renseigner sur leurs crises non épileptiques psychogènes

The aetiology of "psychogenic" non-epileptic seizures (NES) remains poorly understood and the differentiation of NES from epilepsy can be a difficult. In the first part of this review article we focus on recent insights into the neurobiological underpinnings of NES. We summarise a number of studies demonstrating the importance of abnormalities of emotion regulation in patients with NES. Evidence for abnormal emotion regulation comes from both self-report and experimental studies of pre-conscious cognitive processes. These studies show that NES are not the only manifestation of abnormal mental processing in these patients and that excessive social threat avoidance and emotional dysregulation are also evident between seizures and may therefore contribute to disability beyond the seizures themselves. In the second part of this review, we describe the findings of a number of studies, which have examined differences between the communication behaviour of patients with NES and those with epilepsy. We argue, that, whilst these studies initially aimed to help clinicians with the differential diagnosis of NES and epilepsy, close sociolinguistic analysis of patient's talk can also provide clues about the aetiology of NES. We conclude that the interaction of patient with NES with the doctor can be interpreted as a manifestation of avoidance and a demonstration of helplessness perhaps intended to secure active support from the doctor. In the third part of this review, we suggest that a close reading of a transcript of the interaction between a patient with NES and her doctor (and perhaps attentive listening to how patients' talk about themselves and their disorder) can yield clues to the causes of NES in individual cases.

Video-EEG for the diagnosis of non-epilepic zeizures

Objective To explore the value of video-EEG in the diagnosis of non-epileptic seizures in clinic patients.Methods The clinical and video-EEG data were retrospectively analyzed in 129 clinic patients with nonepilepsy.Results Among the 129 patients,24 were clinically diagnosed as syncope,19 as headache,15 as transient loss of consciousness,15 as neurosis,13 as dizziness,6 as transient ischemic attack,and 37 as other disorders.There were 16 patients with paroxysmal abnormal EEG,3 with epileptiform discharges,and 9 with clinical seizures during EEG detection.Conclusions Video-EEG has an important value in the diagnosis of non-epileptic seizures in clinic patients. Key words: Video-EEG; Non-epileptic seizures; Diagnosis

Recent progress in the understanding and treatment of nonepileptic seizures

There has been a steady increase in the number of publications about (psychogenic) nonepileptic seizures (NES) over the past two decades. This review focuses on work published in the past 3 years. It summarizes the most important developments in terms of diagnosis, cause, clinical manifestations and treatment of NES. Several recent studies demonstrate the scope and limitation of questionnaire-based and conversation analytic approaches to the differential diagnosis of epilepsy and NES. Experimental work has revealed that patients with NES have increased levels of physiological arousal at rest which are associated with abnormal mental processing. There is a growing understanding of the meaning and clinical significance of the heterogeneous manifestations of NES. Several studies document the therapeutic potential of an early and effective communication of the diagnosis of NES. A number of randomized controlled or uncontrolled long-term follow-up pilot studies suggest that different forms of psychotherapy are effective for NES. Recent research has improved our understanding of NES as a biopsychosocial disorder. Clear diagnostic and management pathways for patients with NES are likely to emerge in the near future.