Evidence-Based Practice for the Clinical Assessment of Psychogenic Nonepileptic Seizures, 2020, Baslet et al

[Andy]

Full title: Evidence-Based Practice for the Clinical Assessment of Psychogenic Nonepileptic Seizures: A Report From the American Neuropsychiatric Association Committee on Research

The American Neuropsychiatric Association’s Committee on Research assigned the task of defining the most helpful clinical factors and tests in establishing the diagnosis of psychogenic nonepileptic seizures (PNES) during a neuropsychiatric assessment.

A systematic review of the literature was conducted using three search engines and specified search terms for PNES and the predetermined clinical factors and diagnostic tests, followed by a selection process with specific criteria. Data extraction results from selected articles are presented for clinical factors (semiology, psychiatric comorbidities, medical comorbidities, psychological traits) and diagnostic tests (EEG, psychometric and neuropsychological measures, prolactin level, clinical neuroimaging, autonomic testing).

Semiology with video EEG (vEEG) remains the most valuable tool to determine the diagnosis of PNES. With the exception of semiology, very few studies revealed the predictive value of a clinical factor for PNES, and such findings were isolated and not replicated in most cases. Induction techniques, especially when coupled with vEEG, can lead to a captured event, which then confirms the diagnosis. In the absence of a captured event, postevent prolactin level and personality assessment can support the diagnosis but need to be carefully contextualized with other clinical factors.

A comprehensive clinical assessment in patients with suspected PNES can identify several clinical factors and may include a number of tests that can support the diagnosis of PNES. This is especially relevant when the gold standard of a captured event with typical semiology on vEEG cannot be obtained.

Paywall, https://neuro.psychiatryonline.org/doi/10.1176/appi.neuropsych.19120354
Sci hub, https://sci-hub.tw/10.1176/appi.neuropsych.19120354

 

[Hutan]

PNESs are more frequent in women, usually start in the second or third decade of life, and can lead to chronic disability. Patients with PNES tend to have frequent health care contacts (7). Along with these estab- lished demographic characteristics, PNESs have been well described in men and in pediatric and geriatric populations.

I think they mean, 'PNEs are more frequently diagnosed in women'.

Noting that they occur in children and that semiology here is a fancy word for diagnostic signs:

Presence of a teddy bear brought into the EEG unit predicted PNES with 88% - 99% specificity and 5%-13% sensitivity (9, 10)

Yep, that's the level of sophistication the signs are at - if the patient brings a teddy bear into the EEG unit, you can be very sure that the epileptic seizures are psychogenic.

Clearly I'm not an expert; I don't know if PNEs exist or not. But I not exactly getting bowled over by the intellectual rigor here.

 

[Arnie Pye]

I think they mean, 'PNEs are more frequently diagnosed in women'.

Noting that they occur in children and that semiology here is a fancy word for diagnostic signs:

Yep, that's the level of sophistication the signs are at - if the patient brings a teddy bear into the EEG unit, you can be very sure that the epileptic seizures are psychogenic.

Clearly I'm not an expert; I don't know if PNEs exist or not. But I not exactly getting bowled over by the intellectual rigor here.

My emphasis.

That is absolutely extraordinary in a really, really sick way. It seems that the "everyone is mentally ill except me" cohort can weaponise anything and use it as a reason to dump people in the mental health dustbin.

 

[rvallee]

You know what they say about assumptions. The assumption of a psychogenic factor is just that, an assumption. A very dogmatic and logically fallacious one.

Donkey science is as good a word as any for this phenomenon and more pertinent than dismissing every disease you don't like as psychogenic. It would be great if these people just stopped making stuff up and maybe took on a profession more amenable to their, uh, "skills".

Good grief at the teddy bear thing. Something's seriously wrong with medical training that it allows people with zero judgment through.

 

[Hutan]

There's more:

This is in relation to the use of a placebo induction method (e.g. a saline injection) that the doctor says will bring on a seizure so that it can be observed:

It is argued that the deception involved in placebo techniques can be ethically questionable given the possibility of rupturing provider-patient trust, negatively affecting treatment adherence, or compromising the patient’s autonomy (30). However, the importance of a definitive and timely diagnosis of PNES is argued to be most important by those with opposing viewpoints, as it reduces harm due to misdiagnosis and lack of treatment (31).

Interictal means 'between the seizures' - so this quote is saying that cognitive and behavioural and other issues aside from the seizures aren't rare. But neither are they rare in 'real epilepsy' - after all, something is wrong with the brain

Interictal abnormalities are not rare (up to 50%), and even epileptiform discharges (up to 9%) can be seen in PNES, but should not lead to overinterpretation of a diagnosis of epilepsy. History and semiology should always contextualize clinical correlation with EEG.

See for example this from the Epilepsy Foundation:

The interictal period comprises more than 99% of most patients’ lives. Interictal cognitive and behavioral disorders profoundly impair the quality of life. These problems are continuous, unlike the seizures, which are intermittent. Encompassing a wide spectrum, these disorders often fit awkwardly into neuropsychiatric categories. Even when patients fit into Diagnostic and Statistical Manual of Mental Disorders (4) categories, they often remain untreated because some physicians believe that using medications to treat other problems might lower the seizure threshold.

Some of the most devastating neurobehavioral disorders that complicate epilepsy have neither a defined symptom- nor a syndrome-level diagnosis. For example, the ability to read social cues and respond appropriately in social settings is essential for successful social function. These skills are often lacking in patients with right hemisphere or frontal lobe seizure foci. Hence, there is a need for the development of systematic approaches to define these disorders and therapeutic interventions to reduce symptom severity.

Obesity is identified as a risk factor for psychogenic seizures.

So, it seems quite possible that an obese young woman who doesn't respond perfectly appropriately to the doctor and who has a teddy bear with her because it helps her deal with life could get labelled with psychogenic epilepsy, even if the EEG shows epileptiform discharges (i.e. brain wave patterns suggestive of epilepsy).

De novo PNES following neurosurgery has been found in 3.5%–4.6% of postsurgical patients (52, 53), with an odds ratio of 2.89 for patients with an IQ below 80 after epilepsy surgery (52).

Following neurosurgery! People have seizures after epilepsy surgery? Oh, they must be psychogenic seizures because the epilepsy has been fixed. There was that same assumption of medical infallibility with the presentation by a Pain Clinic psychiatrist that I was looking at recently - women with pelvic pain after surgery for endometriosis must have 'central sensitisation' that is fixed by CBT because their endometriosis has been 'fixed'.

 

[Hutan]

However, psychiatric comorbidities are frequent in epilepsy, and clinicians should never assume a PNES diagnosis solely based on the presence of PTSD or personality disorders.

To be fair, the authors seem to have done a pretty good job collating the evidence. It's just that they seem to have left their skepticism of the evidence at the door.

For example, traumatic brain injury:

Traumatic brain injury (TBI) has a strong association with PNES. Between 24% and 83% of PNES patients report a history of TBI, most frequently classified as mild, and many times labeled by patients as the etiological factor for PNES (54, 55). Moderate and severe TBIs are well-established risk factors for posttraumatic epilepsy. One study that specifi- cally examined the development of seizure episodes after moderate and severe TBIs found that one-third of patients had PNES versus two-thirds with epilepsy (56). Patients with moderate and severe TBI may be particularly at risk of misdiagnosis and deserve an unbiased examination of their seizure episodes, including consideration of a mixed (PNES plus ES) diagnosis.

So, if a patient has had moderate or severe brain injury, they deserve an unbiased examination of their seizure episodes. But if the patient has had only a mild brain injury, they do not deserve an unbiased examination of their seizure episodes? Who defines what a mild brain injury is, rather than a moderate one, for a particular person with their particular skull thickness and brain morphology?

I'm left feeling very grateful that I and no one in my family have seizures. It seems that there is a whole extra level of disbelief reserved for this symptom.

 

[Arnie Pye]

There was that same assumption of medical infallibility with the presentation by a Pain Clinic psychiatrist that I was looking at recently - women with pelvic pain after surgery for endometriosis must have 'central sensitisation' that is fixed by CBT because their endometriosis has been 'fixed'.

I got caught in that scenario, multiple times. I had several laparoscopies in the 90s where laser was used to burn off the top of endometriosis lesions. Nowadays it is slowly starting to dawn on some doctors and surgeons that endometriosis lesions are like icebergs. Burning off the top doesn't get rid of what's underneath. The best surgeons use excision surgery now - i.e. they cut the lesions out, but I think ordinary surgeons who aren't expert on endometriosis are still using laser despite it being almost completely useless.