Does the primary literature provide support for clinical signs used to distinguish psychogenic nonepileptic seizures from epileptic seizures?

Abstract

Psychogenic nonepileptic seizures (PNES) represent a diagnostic challenge. When trying to distinguish between PNES and epileptic seizures (ES), clinicians rely on the presence or absence of several clinical signs. Our purpose is to establish the extent to which these signs are supported by primary data from the literature. A Medline search was used to identify primary studies that used video-EEG to define the presence or absence of different clinical signs in PNES and ES. The methodological quality of the studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool. 34 studies matched the inclusion criteria. A specific sign was considered well supported by the data from the primary literature if we were able to identify at least two controlled studies demonstrating its usefulness and if the data from other studies were supportive. There is good evidence from the literature that long duration, occurrence from apparent sleep with EEG-verified wakefulness, fluctuating course, asynchronous movements, pelvic thrusting, side-to-side head or body movement, closed eyes during the episode, ictal crying, memory recall and absence of postictal confusion are signs that distinguish PNES from ES. Post-ictal stertorous breathing proved to distinguish convulsive PNES from generalised tonic clonic seizures (GTCS) and should be added to the list of useful clinical signs. The final clinical diagnosis should encompass all available data, and should not rely on any single sign alone.

Pszichogén nem epilepsziás rosszullétek a klinikai gyakorlatban

“…A video-EEG-monitorozás a PNER diagnosztikájában elsődlegesen alkalmazandó eljárás, amely egyidejűleg rögzíti a beteg agyi elektromos aktivitását és a közben lezajló motoros és egyéb klinikai tevékenységeket [24]. Az interictalis rutin-EEG-eredmények önmagukban fél-revezetők lehetnek, mivel az epilepsziás betegek körül-belül 30%-ánál nem jelentkezik EEG-eltérés, nem specifikus EEG-eltérések viszont az egészséges populáció több mint 10%-ánál vannak jelen [24].…”

Functional neurological disorders: The neurological assessment as treatment

“…[24][25][26] Something that follows on from this is that functional disorders can also be diagnosed in the presence of existing disease such as multiple sclerosis or Parkinson's disease. [34][35][36] Sticking to this rule with patients is important in avoiding diagnostic mistakes but also therapeutic in helping patients to understand they do not have an absence of a condition (ie, nonorganic), they have a positively identifiable condition with positive criteria.…”

“…It is perhaps then worth rehearsing what the explanation of a Hoover's sign would sound like during a consultation as shown in box 2. Patient with a unilateral tremor is asked to copy a rhythmical movement with their unaffected limb: the tremor in the affected hand either 'entrains' to the rhythm of the unaffected hand, stops completely or the patient is unable to copy the simple rhythmical movement Orbicularis oculis or orbicularis oris over-contraction, especially when accompanied by jaw deviation and/ or ipsilateral functional hemiparesis Balance/gait Reduced postural sway with distraction 32 Abnormal sway that resolves during tasks such as assessing numbers written on the back or using a phone Non-epileptic attacks 26 Prolonged attack of motionless unresponsiveness Paroxysmal motionlessness and unresponsiveness lasting longer than a minute…”

Closing the Major Gap in PNES Research

“…Most of these articles address characteristics that may aid in the diagnosis of PNES. Several publications include a description of clinical features that might be useful in differentiating PNES from epileptic seizures (19)(20)(21)(22)-with the caveat that no one sign, symptom, or adjunctive test definitively differentiates PNES from epilepsy.…”