ReviewPsychogenic nonepileptic seizures☆
Research highlights
► Diagnostic methods for PNES should improve to allow more rapid diagnosis. ► The optimal labeling or communication of the diagnosis remains uncertain. ► Treatment for PNES needs to take account of clinical / aetiological heterogeneity. ► Future PNES research should be hypothesis-driven (based on best current models).
Introduction
Psychogenic nonepileptic seizures (PNES) are episodes of altered movement, sensation, or experience resembling epileptic seizures, but not associated with ictal epileptiform discharges in the brain but which, instead, have a psychological origin. In the current diagnostic manuals most PNES are categorized as a manifestation of dissociative or somatoform (conversion) disorder [1], [2]. This means that they are interpreted as an involuntary response to emotional, physical, or social distress. It is appropriate to discuss PNES in this special issue because they are one of the commonest differential diagnoses of epilepsy and are typically diagnosed by physicians specializing in the treatment of seizures. They are by far the most common nonepileptic condition diagnosed in epilepsy (video/EEG) monitoring units. The fact that research interest in PNES has grown exponentially since the introduction of video/EEG monitoring is encouraging for the future. However, the impressive number of publications on this topic in the last two decades also demonstrates there still are many questions to answer. In 2 Diagnostic process, 2.1 Selim Benbadis, 2.1.1 Diagnostic challenges at the stage of clinical suspicion, 2.1.2 The issue of EEG interpretation errors, 2.1.3 Diagnostic challenges at the stage of confirmation by video/EEG monitoring, 2.1.4 Specific difficult situations, 3 Treatment issues, 3.1 W. Curt LaFrance, Jr., 3.1.1 Presentation of the diagnosis, 3.1.2 Further treatment, 4 Questions about the nature and experience of psychogenic nonepileptic seizures, three experienced clinicians who have followed the developments of PNES research closely over this period discuss some questions that future research needs to address most urgently. Selim Benbadis focuses on topics related to the diagnostic process, Curt LaFrance writes about issues related to treatment, and Markus Reuber discusses the nature and experience of PNES. In 5 Promising Areas of Research and Young Investigators, 6 Promising Areas of Research and Young Investigators, two “rising stars” describe how they got involved in research in this area and what their plans are for the future: Tanvir U. Syed focuses on his work aiming to reduce diagnostic delay, and Richard J. Brown, on his development of a psychological model for PNES.
Section snippets
Selim Benbadis
Recent studies have shown that an accurate diagnosis of PNES is delayed by a mean of more than 7 years and that most patients are initially thought to have epilepsy [3]. As long as patients are misdiagnosed as having epilepsy, they are at iatrogenic risk. The misdiagnosis of PNES is costly to patients, the health care system, and society. Repeated workups and treatments for what is mistakenly thought to be epilepsy are estimated to incur $100 to $900 million per year in medical services [4].
W. Curt LaFrance, Jr.
Given the number of people with PNES and the lack of treatment efficacy data, the NINDS has assigned developing treatments for PNES as one of its Epilepsy Benchmarks for research [29]. Treatment for PNES has a few components: confirming the diagnosis of PNES, delivering the diagnosis of PNES, discontinuing AEDs in lone PNES, and initiating psychiatric/psychological care for PNES and its comorbidities [30]. Two key areas that are unresolved for PNES treatment include what could be grouped in
Markus Reuber
The fact that nonspecialists (including general neurologists) continue to struggle with the differentiation of PNES from epileptic seizures and other causes of blackout provides a clear indication that we need to learn more about how PNES can be distinguished from other diagnoses in clinical practice. However, if we want to develop a better understanding of the nature of PNES, be in a position to prevent PNES from developing, or find the most effective treatment for a particular patient, we
5.1. Tanvir U. Syed
Reducing diagnostic delay
My first encounters with delay in diagnosis of PNES were as a neurology resident in a south Florida hospital with a three-bed inpatient epilepsy monitoring unit (EMU). One to two years into training, my fellow residents and I began to place wagers on whether we could predict, prior to the start of VEEG, if an EMU admission was going to prove epileptic or nonepileptic. Our “predictions” were made at three “well-defined” points in time: on catching a glimpse of the
6.1. Richard J. Brown
Psychological mechanisms of psychogenic nonepileptic seizures
As the overview by Dr. Benbadis, Dr. LaFrance and Dr. Reuber indicates, the majority of research in this area has focused on seizure semiology, distinguishing epileptic from nonepileptic seizures psychiatric comorbidity, and the personality correlates of PNES. Although these are crucial issues, they reveal relatively little about the pathogenesis of these events. Indeed, despite being recognized as a psychiatric phenomenon since the
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From a special issue of Epilepsy & Behavior: "The Future of Clinical Epilepsy Research" in which articles synthesize reviews from senior investigators with the contributions and research directions of promising young investigators.