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BRIEF COMMUNICATIONS: Selim R. Benbadis, Vikas Agrawal, and William O. Tatum, IV How many patients with psychogenic nonepileptic seizures also have epilepsy? Neurology 2001; 57: 915-917 [Abstract] [Full text] [PDF]

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Reply to Dr. LaFrance's letter

Selim R Benbadis   (6 November 2001)

How many patients with psychogenic nonepileptic seizures also have epilepsy?

W Curt LaFrance   (6 November 2001)

Reply to Dr. LaFrance's letter 6 November 2001
Selim R Benbadis University of South Florida College of Medicine Tampa FL Send Correspondence to journal: Re: Reply to Dr. LaFrance's letter sbenbadis{at}hsc.usf.edu Selim R Benbadis	Dr. LaFrance makes valid points, and I appreciate the opportunity to respond to his important observations on PNES. I agree that treatment is difficult and possibly not very effective. However, PNES are by definition a psychiatric disease, so that if there is failure it is in the psychiatric (not neurologic) treatments. Neurologists should make the diagnosis, refer to psychiatry, and preferably continue to follow these patients. The fact that 80% of PNES patients receive AEDs before diagnosis [1] shows that neurologists in general do not have a high enough index of suspicion for this diagnosis. Where neurologists often fail is in the delivery of the diagnosis, and I fully agree that unfortunately many patients are left without direction. This may be an important reason for the overall unsatisfactory treatment, and it should not be. There are well know caveats that warrants caution when making a diagnosis of PNES, including the fact that some “simple partial” seizures may be unassociated with surface EEG changes, and that ictal EEG may be obscured by movement artifacts. However, in the vast majority of patients, it is unequivocally clear with EEG-video monitoring that the attacks are psychogenic. Yet many reports are written in inconclusive language, simply stating facts like “an episode was recorded with no EEG changes…” When episodes are clearly psychogenic in origin, the report should so indicate, and clearly. Similarly, making the diagnosis is only the beginning, and this only helps if it is followed by clearly delivering the diagnosis to patients and their families. This must be done honestly but with confidence. A poor but common approach is to use wishy-washy conclusions (e.g., “these are seizures but not epilepsy”), while carefully avoiding the notion that these are psychogenic [2], or to give no diagnosis at all (“we can’t find the cause…”). This leaves patients and families with the impression that we cannot make a diagnosis, and that we do not know “what’s wrong.” We do know. With the understanding that patients with PNES are usually not faking, it should be possible for the clinician to present the diagnosis to patients and family without being confrontational [3], and patient education material can be useful in this regard. [4, 5] Once the diagnosis is made, clinicians need to clearly state that these are psychogenic and non-organic, using understandable layperson’s terms like psychological, emotional, or stress-related. We know it, and we should say it. With compassion, but also firmness and confidence. References 1. Benbadis SR. How many patients with pseudoseizures receive antiepileptic drugs prior to diagnosis? European Neurology 1999;41:14-115. 2. Benbadis SR. Activation by the power of suggestion. In: Burgess R, Klem G, Luders H (eds). Fundamentals of EEG technology, second edition. In press. 3. Shen W, Bowman ES, Markand ON. Presenting the diagnosis of pseudoseizure. Neurology 1990;40:756-759. 4. Benbadis SR, Friedman AL, Kosalko J et al. Psychogenic seizures: a guide for patients and families. Journal of Neuroscience Nursing 1994;6:306-308. 5. Benbadis SR, Stagno SJ. Psychogenic seizures: A guide for patients and families. ©The Cleveland Clinic Educational Foundation and Department of Scientific Publications, 1993.
How many patients with psychogenic nonepileptic seizures also have epilepsy? 6 November 2001
W Curt LaFrance Brown Medical School Providence RI Send Correspondence to journal: Re: How many patients with psychogenic nonepileptic seizures also have epilepsy? William_LaFrance_Jr{at}Brown.edu W Curt LaFrance	Benbadis et al. report the results of a review of 32 patients diagnosed with psychogenic nonepileptic seizures (PNES) in their EEG–video monitoring unit over a one-year period. [1] With the criteria of “unequivocal epileptiform discharges, focal or generalized, including sharp waves or spikes, spike-wave complexes, polyspikes or any ictal pattern,” but not “transients that met criteria for benign variants,” the study found only 10% of patients had PNES and epileptiform activity. The authors account for prior over reporting of PNES and epilepsy by the lack of tightly defined criteria for establishing the diagnosis of epilepsy. I applaud the authors for setting the bar higher for diagnosis of this difficult to assess condition. The authors’ final statement regarding PNES patients’ non-compliance “with the necessary treatment” leaves an open-ended question. What is the necessary treatment for PNES? As neurologists, we have done a fine job of classifying and describing PNES phenomenologically, [2] but we have failed in providing a treatment for these patients. At best, with the confirmed video EEG diagnosis, we inform the patients that they do not have epilepsy, recommend a tapering of their medications and that they should perhaps seek psychological counsel. Some improve with this intervention; however, many with this disorder are left without direction. Video EEG may ensure accurate seizure classification, but it does not adequately inform treatment. The difficulty with this “treatment” is that with one test, we change the status of a patient from a neurologic patient to a psychiatric patient. Whether the underlying DSM-IV diagnosis is anxiety disorder, somatization disorder, or conversion disorder is not as important as the fact that with a determination of PNES, we are taking away the patient’s “brain disorder” and turning their symptoms into a “mind issue.” Anti-epileptic therapy can cloud cognition and behavior in lone PNES. Studies, thus far, with PNES treatment have shown that psychotherapy is moderately effective in decreasing event numbers. [3] The more refractory cases are those with co-morbid psychiatric or personality disorders. At our center, we have joined the experience of the combined treatments group (pharmacotherapy and psychotherapy) with the comprehensive epilepsy center to begin assessing and developing necessary treatments for PNES. It is not yet clear what the best treatment, or combination of treatments, is for this difficult to handle problem. There is great need, however, for integrative approaches to be developed in order to manage and help these complicated patients. References: 1. Benbadis SR, Agrawal V, Tatum IV WO. How many patients with psychogenic nonepileptic seizures also have epilepsy? Neurology 2001;57:915-917. 2. Meierkord H, Will B, Fish D, Shorvon S. The clinical features and prognosis of pseudoseizures diagnosed using video-EEG telemetry. Neurology 1991;41:1643-1646. 3. Aboukasm A, Mahr G, Gahry BR, Thomas A, Barkley GL. Retrospective analysis of the effects of psychotherapeutic interventions on outcomes of psychogenic nonepileptic seizures. Epilepsia 1998;39(5):470-473.