Improving first responders' psychogenic nonepileptic seizures diagnosis accuracy: Development and validation of a 6-item bedside diagnostic tool

Paola, Luciano De; Terra, Vera Cristina; Silvado, Carlos Eduardo; Teive, Hélio Afonso Ghizoni; Palmini, André; Valente, Kette D.; Olandoski, Márcia; LaFrance, W. Curt

doi:10.1016/j.yebeh.2015.10.025

Cited by 39 publications

(47 citation statements)

References 41 publications

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“…We found that sudden seizure onset and postictal confusion were more common in epilepsy than PNES (OR = 0.925, 95% CI = 0.146‐0.599), associations with conflicting support in the previous literature . Our other findings were broadly consistent with older reports, and would also support the conclusion of other authors that nonexpert assessors can be supported in identifying semiological features to aid the differential diagnosis of seizures …”

Section: Discussionsupporting

confidence: 73%

Peri‐ictal responsiveness to the social environment is greater in psychogenic nonepileptic than epileptic seizures

Wardrope

Wong

McLaughlan³

et al. 2020

Epilepsia

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Objective: To look for evidence of peri-ictal social interaction in psychogenic nonepileptic seizures (PNES) and epileptic seizures exploring the notion of PNES as a form of nonverbal communication. Methods: Video recordings of typical seizures experienced by patients with epilepsy and PNES were obtained in a naturalistic social setting (residential epilepsy monitoring unit). Video analysis by three nonexpert clinicians identified 18 predefined semiological and interactional features indicative of apparent impairment of consciousness or of peri-ictal responsiveness to the social environment with assessment of interrater reliability using Fleiss κ. Features were compared between epileptic seizures and PNES. Results: One hundred eighty-nine seizures from 50 participants (24 epilepsy, 18 PNES, eight combined) were analyzed. At least fair (κ > 0.20) interrater agreement was achieved for 14 features. The PNES and epileptic seizures compared were of similar severity in terms of ictal impairment of consciousness (κ = 0.34, odds ratio [OR] = 1.11, 95% confidence interval [CI] = 0.62-1.96) and responsiveness (κ = 0.52, OR = 1.01, 95% CI = 0.55-1.86). PNES were more likely to be preceded by attempts to alert others (κ = 0.52, OR = 12.4, 95% CI = 3.2-47.7, P < .001), to show intensity affected by the presence of others (κ = 0.44, OR = 199.4, 95% CI = 12.0-3309.9, P < .001), and to display postictal behavior affected by the presence of others (κ = 0.35, OR = 91.1, 95% CI = 17.2-482.1, P < .001). Significance: Nonexpert raters can, with fair to moderate reliability, rate features characterizing ictal impairment of consciousness and responsivity in video recordings of seizures. PNES are associated with greater peri-ictal responsiveness to the social environment than epileptic seizures. These findings are consistent with a potential communicative function of PNES and could be of differential diagnostic significance. K E Y W O R D S communication, dissociative disorders, nonepileptic seizures, psychology | 759 WARDROPE Et Al. How to cite this article: Wardrope A, Wong S, McLaughlan J, Wolfe M, Oto M, Reuber M. Peri-ictal responsiveness to the social environment is greater in psychogenic nonepileptic than epileptic seizures. Epilepsia. 2020;61:758-765. https://doi.

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Section: Discussionsupporting

confidence: 73%

Peri‐ictal responsiveness to the social environment is greater in psychogenic nonepileptic than epileptic seizures

Wardrope

Wong

McLaughlan³

et al. 2020

Epilepsia

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“…Teaching medical observers specific signs to look out for may help distinguishing ES from PNES ( table 3 ). In one study, nurses, emergency physicians, medical students and neurology residents were quizzed before and after being primed on distinguishing signs of ES and PNES, and all cohorts were found to improve diagnostic skills after the instructional programme (De Paola et al ., 2016). Education on signs of PNES and ES may be helpful not only for clinicians, which may help with appropriate triage and intervention for the different seizure types, but also for office and hospital staff when events occur in the medical setting (LaFrance Jr and Wincze, 2015).…”

Section: Adults and Adolescentsmentioning

confidence: 99%

How to distinguish seizures from non‐epileptic manifestations

Leibetseder¹,

Eisermann²,

LaFrance³

et al. 2020

Epileptic Disorders

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The first and most important step in establishing diagnosis of epilepsy consists of careful history taking from patients and witnesses. The clinical evaluation of the event will lead the indication for further diagnostic tests including e.g. EEG and MRI. Hence, identifying the paroxysmal event as epileptic or non-epileptic is the very first step in the diagnostic process. Paroxysmal events pose a clinical challenge, as these are unpredictable and do not usually occur in the doctor's office. History taking, hunting for witness reports and home-video recordings are the main tools to conclude whether a paroxysmal event is a seizure or not. In this review, we describe the most common differential diagnoses of epileptic seizures, including syncope, psychogenic non-epileptic seizures, as well as a variety of paroxysmal conditions and behaviours of all age groups. Misdiagnosis of non-epileptic events as epilepsy may not only defer the correct diagnosis and treatment but also poses additional risk by prescribing antiepileptic drugs unnecessarily. Moreover, missing the diagnosis of epilepsy implies risk of additional seizures and therefore possibly injuries, sudden death in people with epilepsy, or status epilepticus. Studies have shown that patient and witness accounts are unreliable in a high percentage of cases. Therefore, the core competency of doctors and medical professionals assessing paroxysmal events is knowledge of the clinical features that help define the different aetiologies, thus empowering them to establish the most accurate appraisal of an event. [Published with video sequences].

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“…Although the studies reported in section D share the common aim to facilitate the differential diagnosis based on objective observations of the semiology of the events, the approach to the investigation varied. Three studies [36,37,39] focused on specific ictal signs whereas two others [2,38] investigated the event as a whole. One of these studies [38] used broad guidelines supplemented by vignettes illustrating characteristic features of body movements to help first responders or emergency room clinicians recognize the key signs of the syndrome while directly witnessing an attack, or ask the right questions while eliciting the description of the seizures from bystanders.…”

Section: Video-reviewmentioning

confidence: 99%

“…Three studies [36,37,39] focused on specific ictal signs whereas two others [2,38] investigated the event as a whole. One of these studies [38] used broad guidelines supplemented by vignettes illustrating characteristic features of body movements to help first responders or emergency room clinicians recognize the key signs of the syndrome while directly witnessing an attack, or ask the right questions while eliciting the description of the seizures from bystanders. On the contrary, Syed et al [2] adopted a comprehensive list of signs reported in the literature as characteristic of either syndrome to guide expert epileptologists during the review of ictal events recorded on video.…”

Section: Video-reviewmentioning

confidence: 99%

Self-Report questionnaires for the diagnosis of psychogenic non-epileptic seizures in clinical practice. A comprehensive review of the available instruments

Giussani

Erba

Bianchi

et al. 2020

Seizure

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We searched Medline from 1946 to 2019 for reports exploring differences between PNES and other comparable paroxysmal events using clinical instruments, few of which focused on the differential diagnosis using broadbased questionnaires covering multiple aspects of this condition. The majority investigated single items to highlight specific differences, either qualitative or quantitative, between groups and to elucidate some of the pathogenetic mechanisms of PNES. We selected all variables that proved to be useful for differentiating PNES from other types of paroxysmal events and classified them by category, by instrument utilized and method of investigation. This body of data will constitute the basis for assembling a new set of evidence-based questionnaires for patients and eyewitnesses to facilitate the differential diagnosis of these disorders, especially in resource-poor clinical settings. This will require a skillful translation of the content of each selected variable into clear and intuitive questions, appropriate for lay responders. Predictive variables found by more than one investigator, especially if using different approaches, have greater diagnostic weight and should be prominent in future questionnaires. However, even variables so far found to be predictive by one investigator will deserve consideration. Once the preliminary text of the questionnaires is consolidated, the instrument will need extensive testing and validation in large prospective studies before becoming available for clinical use in its definitive format.

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Improving first responders' psychogenic nonepileptic seizures diagnosis accuracy: Development and validation of a 6-item bedside diagnostic tool

Cited by 39 publications

References 41 publications

Peri‐ictal responsiveness to the social environment is greater in psychogenic nonepileptic than epileptic seizures

Peri‐ictal responsiveness to the social environment is greater in psychogenic nonepileptic than epileptic seizures

How to distinguish seizures from non‐epileptic manifestations

Self-Report questionnaires for the diagnosis of psychogenic non-epileptic seizures in clinical practice. A comprehensive review of the available instruments

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