Psychogenic Nonepileptic Spells Research Articles

Predictors of referral for long-term EEG monitoring for Medicare beneficiaries with drug-resistant epilepsy.

For people with drug-resistant epilepsy, the use of epilepsy surgery is low despite favorable odds of seizure freedom. To better understand surgery utilization, we explored factors associated with inpatient long-term EEG monitoring (LTM), the first step of the presurgical pathway. Using 2001-2018 Medicare files, we identified patients with incident drug-resistant epilepsy using validated criteria of ≥2 distinct antiseizure medication (ASM) prescriptions and ≥1 drug-resistant epilepsy encounter among patients with ≥2 years pre- and ≥1 year post-diagnosis Medicare enrollment. We used multilevel logistic regression to evaluate associations between LTM and patient, provider, and geographic factors. We then analyzed neurologist-diagnosed patients to further evaluate provider/environmental characteristics. Of 12 044 patients with incident drug-resistant epilepsy diagnosis identified, 2% underwent surgery. Most (68%) were diagnosed by a neurologist. In total, 19% underwent LTM near/after drug-resistant epilepsy diagnosis; another 4% only underwent LTM much prior to diagnosis. Patient factors most strongly predicting LTM were age <65 (adjusted odds ratio 1.5 [95% confidence interval 1.3-1.8]), focal epilepsy (1.6 [1.4-1.9]), psychogenic non-epileptic spells diagnosis (1.6 [1.1-2.5]) prior hospitalization (1.7, [1.5-2]), and epilepsy center proximity (1.6 [1.3-1.9]). Additional predictors included female gender, Medicare/Medicaid non-dual eligibility, certain comorbidities, physician specialties, regional neurologist density, and prior LTM. Among neurologist-diagnosed patients, neurologist <10 years from graduation, near an epilepsy center, or epilepsy-specialized increased LTM likelihood (1.5 [1.3-1.9], 2.1 [1.8-2.5], 2.6 [2.1-3.1], respectively). In this model, 37% of variation in LTM completion near/after diagnosis was explained by individual neurologist practice and/or environment rather than measurable patient factors (intraclass correlation coefficient 0.37). A small proportion of Medicare beneficiaries with drug-resistant epilepsy completed LTM, a proxy for epilepsy surgery referral. While some patient factors and access measures predicted LTM, non-patient factors explained a sizable proportion of variance in LTM completion. To increase surgery utilization, these data suggest initiatives targeting better support of neurologist referral.

Assessing Biases in the Diagnosis of Psychogenic Non-Epileptic Spells (PNES) (P14-1.009)

<h3>Objective:</h3> Assessing types of biases in diagnosing psychogenic non-epileptic spells (PNES). <h3>Background:</h3> There is an established female predominance among patients diagnosed with PNES. While there have been neurobiological differences identified for this predominance, there lies the possibility of a misdiagnosis based on gender, increasing morbidity in these patients. Another survey found that African-Americans presenting with seizures are less likely to be admitted to the hospital or to undergo urgent neuroimaging compared to Caucasians, independent of insurance status. <h3>Design/Methods:</h3> A retrospective chart review was conducted at University of Oklahoma Health Sciences Center between January 2011 and December 2020 from electronic medical records (EMR). Patients greater than 5 years of age who were admitted to Epilepsy Monitoring Unit (EMU) were included and data regarding gender, race and education level was recorded using the REDCAP database system. <h3>Results:</h3> Of the 384 patients admitted to EMU, 62%(n=239) and 38 %(n=145) were women and men, respectively. 52%(n=122) of women were suspected to have PNES on initial visit out of which 50%(n=61) were concordant with both initial and EMU diagnosis of PNES. 36% (n=51) of men were suspected to have PNES in office out of which 43%(n=22) fell into the concordant group (agreement in initially suspected and final EMU diagnosis of PNES). 49%(n=66) Caucasians, 36%(n=5) African-Americans, 38%(n=8) patients with college level education and 27%(n=3) with elementary level education were in the concordant group. These differences were statistically significant in all of the aforementioned categories (McNemar’s Exact test, all p-values &lt;0.002). <h3>Conclusions:</h3> There appears to be a small but significant difference in diagnosis of PNES depending on gender, age and race. Further large multi-center studies are needed to evaluate the differences. Once such biases and health disparities are uncovered, we can identify and address them ensuring accurate diagnosis leading to treatment and management in a timely manner reducing morbidity for our patients. <b>Disclosure:</b> Dr. Bhutta has nothing to disclose. Dr. Bailey has nothing to disclose. Mr. Wolmarans has nothing to disclose. Dr. Mallum has nothing to disclose. Mr. Grunsted has nothing to disclose. Dr. Durica has nothing to disclose. Dr. Sebasigari has nothing to disclose.

Indications for continuous electroencephalographic (cEEG) monitoring: What do they tell us?

ObjectiveWhile studies have explored clinical and EEG predictors of seizures on continuous EEG (cEEG), the role of cEEG indications as predictors of seizures has not been studied. Our study aims to fill this knowledge gap. MethodsWe used the prospective cEEG database at Cleveland Clinic for the 2016 calendar year. Patients ≥ 18 years who underwent cEEG for the indication of altered mental status (AMS) and seizure-like events (SLE: motor or patient-reported events) were included. Baseline characteristics and EEG findings were compared between the two groups. Multivariable regression was used to compare the two groups and identify seizure detection risk factors. ResultsOf 2227 patients (mean age 59.4 years) who met the inclusion criteria, 882 (50% females) underwent cEEG for AMS and 1345(51% females) for SLE. SLE patients were younger(OR: 0.988, CI: 0.98–0.99, p < 0.001), had longer monitoring(OR:1.04, CI:1.00–1.07, p = 0.033), were more likely to have epilepsy-related-breakthrough seizures(OR:25.9, CI:0.5.89–115, p < 0.001), psychogenic non-epileptic spells (OR:6.85, CI:1.60–29.3, p = 0.008), were more awake (p < 0.001) and more likely to be on anti-seizure medications(OR:1.60, CI:1.29–1.98, p < 0.001). On multivariable analysis, SLE was an independent predictor of seizure detection (OR: 2.60, CI: 1.77–3.88, p < 0.001). SignificanceOur findings highlight the differences in patients undergoing cEEG for AMS vs. SLE. SLE as a cEEG indication represents an independent predictor of seizures on cEEG and, therefore, deserves special attention. Future multicenter studies are needed to validate our findings.

Association between kinetic semiology of psychogenic nonepileptic spells and seizure type in dual disorder

PurposeEpilepsy is diagnosed in 20% of patients with psychogenic nonepileptic spells (PNES). The semiology of PNES and epileptic seizures (ES) overlaps in some patients. It is unclear whether the motor phenotype of PNES predicts the type of ES. MethodsVideo segments of EEGs in patients with PNES and ES treated in the Epilepsy Monitoring Unit at the University of Nebraska Medical Center were reviewed. Videos were categorized according to the validated motor-based classification of PNES. Ratings of kinetic PNES events were analyzed to determine if there was an association with focal or generalized ES. If available, the video segments of ES were categorized as hypokinetic or hyperkinetic based on the constellation of focal or generalized movements and other semiological features. ResultsAmong 43 patients with documented PNES–ES (median age 34, interquartile range (IQR) 26–45), 27.9% were male. The largest proportion of patients (39.5%) had focal temporal epilepsy (TE). Other diagnostic groups included focal frontal (FE, 25.6%), generalized (GE, 25.6%), or other (9.3%) epilepsies. Thirty-three PNES patients (82.5%) were rated as having a hypokinetic phenotype. On average, hypokinetic PNES patients were receiving a median of 3 (IQR 2–4) anticonvulsants, compared to a median of 2 (IQR 2–3) in hyperkinetic PNES patients (p = 0.06). While the group with coexisting FE had a higher prevalence of hyperkinetic semiology (45.4%) than either the TE (11.7%) or GE (18.1%) patients, there was no significant association between the ES type and kinetic status of PNES. Among 20 patients who had video recordings of both PNES and ES, 40% displayed the concordant hypokinetic phenotypes for PNES and seizures while 15% had hyperkinetic presentation of both event types. Among additional 16 patients with scalp EEG-negative suspected nonepileptic events and documented ES, 6 had the recordings of seizures and 3 have presented with concordant hypokinetic PNES and ES. ConclusionIn patients with PNES and ES, the hypokinetic semiology of PNES prevails over hyperkinetic semiology in TE and GE syndromes. The motor status of PNES does not predict the phenotype of coexisting ES. The concordant kinetic semiology is present in more than half of the patients with dual diagnosis and available video data.

Utilization of Brain Imaging in Evaluating Patients with Psychogenic Nonepileptic Spells

Utilization of Brain Imaging in Evaluating Patients with Psychogenic Nonepileptic Spells

Comparison of psychiatric comorbidities and impact on quality of life in patients with epilepsy or psychogenic nonepileptic spells

ObjectivesPsychiatric comorbidity is common in people with epilepsy (PWE) and psychogenic nonepileptic spells (PNES). These comorbidities can be detrimental to quality of life (QOL) and are often underdiagnosed and undertreated. Some types of epilepsy, such as focal temporal lobe epilepsy (TLE), have been associated with higher rates of psychiatric comorbidity. This study examined the impact of psychiatric comorbidity on QOL in patients admitted to two level 4 epilepsy monitoring units (EMUs). MethodsIn this prospective observational study, 200 patients admitted to two level 4 EMUs completed standardized surveys including the Quality of Life in Epilepsy (QOLIE-31-P), Generalized Anxiety Disorder 7-item (GAD-7), Patient Health Questionnaire (PHQ-9), and Beck Depression Inventory-II (BDI-II). Hierarchal multiple regression was performed to assess impact on QOL. ResultsOf the 200 participants, 113 had a diagnosis of epilepsy, 36 had a diagnosis of PNES, and 51 were excluded for nondiagnostic evaluation or dual diagnosis. Of those with epilepsy, 65 had TLE, 28 had focal extratemporal lobe epilepsy (ETLE), and 20 had nonfocal epilepsy. Patients with PNES had higher self-reported anxiety and depression levels (GAD-7: p = 0.04, PHQ-9: p < 0.01; BDI-II: p < 0.01) but similar QOL to PWE (p = 0.78). Using hierarchal multiple regression, symptoms of anxiety and depression were significant predictors of lower QOL in PWE but not in patients with PNES. There was no difference in QOL in those with ETLE and TLE. ConclusionsOur findings suggest that self-reported anxiety and depression symptoms are common in patients admitted to level 4 EMUs regardless of diagnosis and play an important role in predicting QOL in PWE. Our findings emphasize the importance of routinely screening all EMU patients for psychiatric comorbidity.

Assessing recent suicidal ideation and behavior in the adult epilepsy monitoring unit

ObjectivesThe objective of the study was to describe the prevalence of recent suicidal ideation and behavior in adult patients admitted to a tertiary epilepsy monitoring unit (EMU) and to assess the difference between patients with epileptic seizures, psychogenic nonepileptic spells (PNES), and other inpatient populations. ResultsOver the 14-month period, 316 patients were included in the study. One hundred and seventy-nine (57%) were classified as having epilepsy (ES), 116 (37%) with PNES, and 21 (7%) with comorbid ES and PNES (ES/PNES). Overall, 25 patients (8%) were screened positive for suicide risk factors (recent suicidal ideation and/or suicidal behavior). Patients admitted to the EMU had double the risk of suicide ideation and behavior when compared with other inpatient populations. There was no significant difference in the risk of suicidal ideation and behavior among patients with ES, PNES, and comorbid ES/PNES. Patients with comorbid ES/PNES had the highest risk (14%), although this did not reach statistical significance. Across all groups, patients with any comorbid psychiatric disorder had increased rates of suicidal ideation and behavior (11% vs 5%, p = 0.04). ConclusionsThe rate of suicidal ideation and behavior in this sample of EMU patients was higher compared with other inpatient populations. The presence of a psychiatric disorder was independently associated with a higher risk. There was no statistically significant difference in the risk between those with ES and PNES. Screening for suicide risk, suicidal ideation, and behavior is recommended for all patients admitted to the EMU.

Utilization of brain imaging in evaluating patients with psychogenic nonepileptic spells

BackgroundPsychogenic nonepileptic spells (PNES) are paroxysmal movements or sensory events that resemble epileptic seizures but lack corresponding ictal electrographic changes. A confirmed diagnosis of PNES is only accomplished via video electroencephalogram (vEEG) monitoring. Prior to diagnosis, patients are often assessed with neurodiagnostic imaging and their conditions treated with anticonvulsant medications, both of which are of limited clinical value and contribute to the higher cost of care. In this study, we assessed the relationship between the semiological features of PNES, medication regimen, or psychiatric comorbidities and the frequency of referrals for brain imaging tests prior to diagnosis of PNES. MethodsThis is a retrospective chart review of 224 adult patients diagnosed as having PNES at a level 4 epilepsy care center from 2012 to 2017. Patients with coexisting epilepsy were excluded. The 882 segments of vEEG records were reviewed for semiology of spells, and patients were categorized into one of seven distinct phenotypic classes according to the accepted clinical classification. The frequency of neurodiagnostic tests completed for each patient prior to vEEG was correlated with PNES phenotype and other clinical characteristics. ResultsThere were 68 (30%) males and 156 (70%) females diagnosed as having PNES with a median age of 36 years. Seventy-four percent of patients were receiving one or several anticonvulsant medications, and 67% of patients were treated with psychotropic medications other than benzodiazepines. The most prevalent PNES events were characterized by semirhythmic small amplitude movements in the extremities (class 2; 34%) followed by those resembling tonic–clonic seizures (class 4; 28%). Neurodiagnostic imaging tests including computed tomography (CT) and magnetic resonance imaging (MRI) of the brain were performed at least once in 60% of patients and 4 times or more in 11% prior to vEEG. There was a significant association between the frequency of neurodiagnostic tests and the PNES phenotype (p = 0.02). Specifically, patients with sensory changes (class 6) had more imaging tests than those with primitive gesturing and truncal posturing (classes 1 and 5, respectively). Additionally, patients diagnosed with 3 or more psychiatric disorders underwent significantly more neurodiagnostic tests relative to patients diagnosed with two or fewer psychiatric disorders (p = 0.03). Furthermore, patients whose conditions were treated with anticonvulsant medications tended to undergo more imaging scans prior to vEEG as compared with the patients whose conditions were not being treated with anticonvulsants. ConclusionsThese findings suggest that the frequency of brain imaging obtained prior to the definitive diagnosis of PNES is influenced by semiology of spells and the psychiatric health of patients. Patients who demonstrate minimal paroxysmal movements in the settings of multiple psychiatric comorbidities represent a particularly challenging patient phenotype which is linked to more frequent referrals for brain imaging. These patients should be promptly referred for vEEG to improve diagnostic accuracy and prevent treatment with anticonvulsants as well as referrals for serial neurodiagnostic tests.

Changes in antiepileptic drug-prescribing patterns in pregnant women with epilepsy

ObjectiveWe analyzed current prescribing patterns for antiepileptic drugs (AEDs) in pregnant women with epilepsy (PWWE) at 20 USA tertiary epilepsy centers. MethodsThe Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study is an NIH-funded, prospective, observational, multicenter investigation of pregnancy outcomes for both mother and child, which enrolled women from December 2012 to January 2016. Inclusion criteria for PWWE included ages 14–45 years and up to 20 weeks gestational age. Exclusion criteria included history of psychogenic nonepileptic spells, expected intelligence quotient (IQ) <70, other major medical illness, progressive cerebral disease, and switching AEDs in pregnancy prior to enrollment. ResultsThree hundred fifty-one PWWE were enrolled in the MONEAD study, which included 259 (73.8%) on monotherapy, 77 (21.9%) on polytherapy, and 15 (4.3%) on no AEDs. The most common AED monotherapy regimens were lamotrigine (42.1% of monotherapies), levetiracetam (37.5%), carbamazepine (5.4%), zonisamide (5.0%), oxcarbazepine (4.6%), and topiramate (3.1%). All other individual monotherapies were each <1%. The most common AED polytherapy combination was lamotrigine + levetiracetam (42.9% of polytherapies), followed by lacosamide + levetiracetam (6.5%), lamotrigine + zonisamide (5.2%), and all other remaining combinations (each <4%); only 5.2% of polytherapy subjects were on ≥3 AEDs (1.1% of total PWWE). Only four subjects (1.1%) were on valproate (1 monotherapy, 3 polytherapy). ConclusionsThe distribution of AED use likely reflects current prescribing patterns for PWWE cared for in USA tertiary epilepsy centers. This distribution has changed markedly since the turn of the century, but changes in the general population remain uncertain.

Using Surface Electromyography to Differentiate between Generalized Tonic-Clonic Seizures and Psychogenic Non-Epileptic Spells (P3.285)

Using Surface Electromyography to Differentiate between Generalized Tonic-Clonic Seizures and Psychogenic Non-Epileptic Spells (P3.285)

QLIF-04. BRAIN TUMORS ASSOCIATED WITH PSYCHOGENIC NON EPILEPTIC SPELLS: CASE SERIES

Epileptic seizures (ES) are considered a main focus in assessing brain tumor treatment, yet, the role of psychogenic non epileptic spells (PNES) is known to be highly prevalent and is under-reported. In the neuro-oncology literature no cases have been well described having PNES. We present a series of five patients and identify risk factors, discuss the association of PNES with brain tumors and describe their role in brain tumor treatment. Patients were identified retrospectively from our practice with diagnosis of PNES and medical history of primary or secondary brain tumors. The diagnosis of psychogenic spells was based on history, seizure observation, routine EEG, and video-EEG. The mean age of presentation was 38 years, with a female gender predominance. The initial diagnosis of brain tumor was associated with a new onset seizure prior to diagnosis in the majority of the patients. Only one patient presented PNES alone, the rest of the patients presented both ES and PNES during the course of their disease. Most of the patients in this case series presented with mixed PNES and were treated with multiple anti-epileptic drugs (AED) prior and after PNES diagnosis. The most commonly used AED was gabapentin. All of the patients received a form of combination therapy. The preferred treatment modality was chemotherapy, followed by surgical resection. The patients manifested several distressing spells that affected their overall quality of life and required multiple medical consultations. None of these patients presented clinical evidence of tumor progression at the time of PNES presentation on imaging studies. Our findings offer a new perspective in PNES diagnosis and their involvement in brain tumor treatment along with possible prognosis implications. Further studies to analyze tumor localization or tumor behavioral patterns in association with PNES are warranted.

Postdiagnosis neurological care for patients with psychogenic nonepileptic spells (PNES).

This study investigated continuity of neurological care for patients discharged from the epilepsy monitoring unit (EMU) with a diagnosis of psychogenic nonepileptic spells (PNES). Because PNES are seizure-like episodes that cannot be explained by abnormal electrical brain activity, they are challenging for patients to understand and accept. Consequently, after diagnosis, patients commonly fail to start recommended psychotherapy and instead pursue redundant medical care. As consistent relationships with healthcare providers may help, we instituted standard follow-up for patients diagnosed with PNES. We performed a retrospective observational cohort study of adults diagnosed with PNES in our EMU. In November 2013, we began routine scheduling of postdischarge follow-up neurology appointments. We compared preintervention (November 2010-October 2013) and postintervention (November 2013-May 2016) cohorts with regard to clinic attendance, understanding the diagnosis, compliance with recommendations, and event frequency. We identified 55 patients in the preintervention cohort and 123 patients in the postintervention cohort. We successfully implemented the intended practice changes; more patients had follow-up scheduled by discharge (preintervention 2% vs. postintervention 36%, p<0.001), time to follow-up decreased (46days vs. 29, p=0.001), and providers more consistently queried understanding of diagnosis (38% vs. 67%, p=0.03). Explicit planning for continued care did not produce the anticipated patient-provider relationships, as follow-up in clinic was low (38% vs. 37%). For patients who attended clinic, the intervention did not improve establishment of psychiatric care, compliance with medication recommendations, understanding of diagnosis, or event frequency. The odds of reduced event frequency were nonsignificantly increased with understanding the diagnosis (OR 3.75, p=0.14). Recommending antiepileptic drug (AED) discontinuation was associated with increased odds of event freedom (OR 6.91, p<0.01). Scheduling follow-up for patients diagnosed with PNES did not facilitate ongoing patient-provider relationships due to poor clinic attendance. As follow-up is unreliable, the inpatient visit is a critical window of opportunity for intervention.

Video-EEG results and clinical characteristics in patients with psychogenic nonepileptic spells: The effect of a coexistent epilepsy.

Epilepsy and psychogenic nonepileptic spells (PNES) can coexist, often posing diagnostic and therapeutic challenges. We sought to identify clinical and historical characteristics of two groups of patients, those with coexisting epilepsy and PNES and those with PNES alone, and determine the prevalence of coexisting epilepsy/PNES with strict diagnostic criteria in a large group of epilepsy monitoring unit (EMU) patients. We reviewed the medical records of all consecutive patients admitted to the Vanderbilt University Medical Center Adult EMU between July 1, 2007 and June 30, 2012. We identified patients with recorded PNES and classified them as having coexisting epilepsy/PNES or PNES alone and then systematically compared the clinical characteristics of these two groups. A total of 1567 patient medical records were reviewed. The prevalence rate of coexisting epilepsy/PNES was 5.2% among all EMU admissions (12.3% of all patients with epilepsy and 14.8% of all patients with PNES). These rates were lower when patients with interictal epileptiform activity (IEA) alone and no recorded ictal discharges were not included in the group with epilepsy (2.6%, 6.2%, and 7.4%, respectively). The accuracy of pre-EMU clinical suspicion was significantly higher in the group with PNES-only. Patients with epilepsy/PNES were significantly more likely to require more than one EMU admission for definitive diagnosis. The first PNES event preceded an epileptic seizure (ES) in 94.4% of patients with epilepsy/PNES. The group with PNES-only had significantly higher suggestibility, and the group with epilepsy/PNES had a significantly higher presence of epilepsy risk factors. Abnormal neurological examination and abnormal brain MRI were also significantly more common in the group with epilepsy/PNES. Our study defined the prevalence of coexisting epilepsy/PNES in a large cohort with strict diagnostic criteria and outlined specific clinical and historical characteristics differentiating the two groups of patients with coexisting epilepsy/PNES and PNES-only. These findings should help guide clinicians to reach the correct diagnosis faster and provide appropriate treatment earlier.

Factors Contributing to Diagnostic Delay in Psychogenic Non-Epileptic Spells (I14.011)

Factors Contributing to Diagnostic Delay in Psychogenic Non-Epileptic Spells (I14.011)

Factors Contributing to Diagnostic Delay in Psychogenic Non-Epileptic Spells (P4.202)

Factors Contributing to Diagnostic Delay in Psychogenic Non-Epileptic Spells (P4.202)

Thoughts, emotions, and dissociative features differentiate patients with epilepsy from patients with psychogenic nonepileptic spells (PNESs).

Psychogenic nonepileptic spells (PNESs) are often very difficult to treat, which may be, in part, related to the limited information known about what a person experiences while having PNESs. For this retrospective study, thoughts, emotions, and dissociative features during a spell were evaluated in 351 patients diagnosed with PNESs (N=223) or epilepsy (N=128). We found that a statistically higher number of thoughts, emotions, and dissociative symptoms were endorsed by patients with PNESs versus patients with epilepsy. Patients with PNESs reported significantly more anxiety and frustration, but not depression, compared with those with epilepsy. Emotions and dissociations, but not thoughts, and a history of any type of abuse were endorsed significantly more often by patients with PNESs. Patients with PNESs are prone to having poor outcomes, and interventions focusing on their actual experiences may be helpful for treatment planning.

Panic attack symptoms differentiate patients with epilepsy from those with psychogenic nonepileptic spells (PNES)

Psychogenic nonepileptic spells (PNES) are frequently challenging to differentiate from epileptic seizures. The experience of panic attack symptoms during an event may assist in distinguishing PNES from seizures secondary to epilepsy. A retrospective analysis of 354 patients diagnosed with PNES (N=224) or with epilepsy (N=130) investigated the thirteen Diagnostic and Statistical Manual—IV-Text Revision panic attack criteria endorsed by the two groups. We found a statistically higher mean number of symptoms reported by patients with PNES compared with those with epilepsy. In addition, the majority of the panic attack symptoms including heart palpitations, sweating, shortness of breath, choking feeling, chest discomfort, dizziness/unsteadiness, derealization or depersonalization, fear of dying, paresthesias, and chills or hot flashes were significantly more frequent in those with PNES. As patients with PNES frequently have poor clinical outcomes, treatment addressing the anxiety symptomatology may be beneficial.

Psychogenic nonepileptic spells in chronic epilepsy patients with moderate cognitive impairment: the need for video EEG monitoring for adequate diagnosis.

The objective of our study was to emphasize the importance of intensive video EEG monitoring in patients with a well-established diagnosis of epilepsy with moderate cognitive impairment. The idea was to diagnose new onset frequent atypical events prompting the need for frequent emergency room and clinic visits and hospital admissions. Retrospective chart reviews were conducted on patients with chronic epilepsy with moderate cognitive impairment who had an increased incidence of new onset episodes different from the baseline seizures. Data were acquired from electronic medical records. The hospital's Institutional Review Board gave approval for this retrospective analysis of patient records. We retrospectively analyzed data from three patients with an established diagnosis of epilepsy. Extensive chart reviews were performed with emphasis on type and duration of epilepsy and description of baseline seizures and description of new events. There were two men and one woman with moderate cognitive impairment. One subject had generalized epilepsy and other two had temporal lobe epilepsy. The patients were on an average of two to three antiepileptic medicines. The duration of follow-up in our neurology clinic ranged from 9 months to 5 years. The occurrence of increased frequency of these atypical events as described by the caregivers, despite therapeutic anticonvulsant levels, prompted the need for 5-day intensive video EEG monitoring. New atypical spells were documented in all three patients and the brain waves were normal during those episodes. The diagnosis of pseudoseizures was made based on the data acquired during the epilepsy monitoring unit stay. Our data analysis showed that intensive video EEG monitoring is an important tool to evaluate change in frequency and description of seizures even in cognitively impaired patients with an established diagnosis of epilepsy for adequate seizure management.

Medical comorbidities in patients with psychogenic nonepileptic spells (PNES) referred for video-EEG monitoring

Differentiating between psychogenic nonepileptic spells (PNES) and epileptic seizures without video-EEG monitoring is difficult. The presence of specific medical comorbidities may discriminate the two, helping physicians suspect PNES over epilepsy earlier. A retrospective analysis comparing the medical comorbidities of patients with PNES with those of patients with epilepsy was performed in 280 patients diagnosed with either PNES (N=158, 74.7% females) or epilepsy (N=122, 46.7% females) in the Epilepsy Monitoring Unit (EMU) of the University of Pittsburgh Medical Center over a two-year period. Patients with PNES, compared to those with epilepsy, were mostly female, significantly more likely to have a history of abuse, had more functional somatic syndromes (fibromyalgia, chronic fatigue syndrome, chronic pain syndrome, tension headaches, and irritable bowel syndrome), and had more medical illnesses that are chronic with intermittent attacks (migraines, asthma, and GERD). The presence of at least of one these disorders may lead physicians to suspect PNES over epilepsy and expedite appropriate referral for video-EEG monitoring for diagnosis.

Importance of Video-EEG Monitoring in the Diagnosis of Epilepsy in a Psychiatric Patient

Epilepsy is a chronic medical condition which is disabling to both patients and caregivers. The differential diagnosis of epilepsy includes psychogenic nonepileptic spells or “pseudoseizures.” Epilepsy is due to abnormal electrical activity in the brain, and pseudoseizure is a form of conversion disorder. The brain waves remain normal in pseudoseizures. The problem arises when a patient with significant psychiatric history presents with seizures. Pseudoseizures become high on the differential diagnosis without extensive work up. This is a case of woman with significant psychiatric issues which resulted in a delay in the diagnosis of epilepsy.