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Background: Functional neurological disorders (FNDs) are neurological symptoms that cannot be explained by an underlying neurological lesion or other medical illness and that do not have clear neuropathological correlates. Psychogenic non-epileptic seizures (PNES) are a common and highly disabling form of FND, characterized by paroxysmal episodes of involuntary movements and altered consciousness that can appear clinically similar to epileptic seizures. PNES are unique among FNDs in that they are diagnosed by video electroencephalographic (VEEG), a well-established biomarker for the disorder. The course of illness and response to treatment of PNES remain controversial. This study aims to describe the epidemiology of PNES in the Department of Veterans Affairs Healthcare System (VA), evaluate outcomes of veterans offered different treatments, and compare models of care for PNES. Methods: This electronic health record (EHR) cohort study utilizes an informatics search tool and a natural language processing algorithm to identify cases of PNES nationally. We will use VA inpatient, outpatient, pharmacy, and chart abstraction data across all 170 medical centers to identify cases in fiscal years 2002-2018. Outcome measurements such as seizure frequency, emergency room visits, hospital admissions, suicide-related behavior, and the utilization of psychotherapy prior to and after PNES diagnosis will be used to assess the effectiveness of models of care. Discussion: This study will describe the risk factors and course of treatment of a large cohort of people with PNES. Since PNES are cared for by a variety of different modalities, treatment orientations, and models of care, effectiveness outcomes such as seizure outcomes and utilization of emergency visits for seizures will be assessed. Outcome measurements such as seizure frequency, emergency room visits, hospital admissions, suicide-related behavior, and psychotherapy prior to and after PNES diagnosis will be used to assess the effectiveness of models of care.

Background:The increased rate of suicide associated with epilepsy has been described, but no studies have reported the rates of suicide and suicide related behavior (SRB) associated with psychogenic non-epileptic seizures (PNES).Methods:This retrospective cohort study analyzed data from October 2002 to October 2017 within Veterans Health Administration (VHA) services. Of 801,734 veterans, 0.09% had PNES, 1.37% had epilepsy, and 98.5% had no documented seizures. Veterans coded for completed suicide, suicide attempts, and suicidal ideation were identified from electronic health records (EHR). The primary measure was the suicide-specific standardized mortality ratio (SMR) based on the number of suicide deaths and CDC national suicide mortality database. A Poisson regression was used to calculate the relative risk of suicide across groups.Results:A total of 1,870 veterans (mean age [SD] 33.76 [7.81] years) completed suicide. Veterans with PNES (RR = 1.75, 95% CI 0.84-4.24) and veterans with epilepsy (RR = 2.19, 95% CI 2.10-2.28) had higher risk for suicide compared to general veteran population. Veterans with PNES or epilepsy had higher risk of suicide and SRB if they had comorbid alcohol abuse, illicit drug abuse, major depression, post-traumatic stress disorder (PTSD), and use of psychotropic medications. Conversely, those who were married or attained higher education were at decreased risk. The SMR for completed suicide for PNES, epilepsy, and the comparison group was 2.65 (95% CI 1.95-5.52), 2.04 (95% CI 1.60 - 2.55), and 0.70 (95% CI 0.67 - 0.74), respectively.Conclusions:Veterans with seizures (both psychogenic and epileptic) are at an increased risk for death by suicide and SRB than the comparison group. These findings suggest that while the pathophysiology of PNES and epilepsy are different, the negative impact of seizures is evident in the psychosocial outcomes in both groups.