Psychogenic nonepileptic seizures treated as epileptic seizures in the emergency department

Abstract

Objectives:We aimed to estimate the rate of psychogenic nonepileptic seizures (PNES) among patients presenting to an emergency department with presumed seizures. We also wanted to identify factors that can assist health care professionals in determining whether these events are likely to be epileptic or nonepileptic. Methods:We performed two retrospective audits on patients who were treated for seizures in the department of emergency medicine at the Princess Alexandra Hospital, Brisbane, Australia. Exploratory analyses and logistic regressions were conducted to investigate the characteristics of the presentations and the relationships between our variables of interest. Results:In the group of all presentations with presumed seizures over a 3-month period (n = 157), a total of 151 presentations (96.2%) presentations were given a primary diagnosis of epileptic seizures. Of these 151 presentations, only 84 (55.6%) presented with epileptic seizures and 40 (26.5%) actually presented with PNES.In the group of patients who presented with prolonged and/or multiple events (n = 213) over a 1-year period, 196 (92.0%) were treated as epileptic seizures. Of these 196 presentations, only 85 (43.4%) presented with epileptic seizures and 97 (49.5%) actually presented with PNES. Several factors were identified to help risk stratify between epileptic seizures and PNES: Duration of events and of the postictal phase, number of events, presence of a structural brain pathology, mental health history, lactate levels and presence of tongue bite, incontinence, and/or vomiting.Significance: A large proportion of people who present to emergency departments with events resembling epileptic seizures actually have PNES rather than epilepsy-particularly those patients who present with prolonged and/or multiple events. The rate of misdiagnosis was high. Efforts need to be made to recognize patients with psychogenic nonepileptic seizures earlier and diagnose them correctly to avoid unnecessary iatrogenic harm and to provide adequate treatment.

Development and validation of a peripheral cell ratio and lactate score for differentiating status epilepticus from prolonged psychogenic nonepileptic seizures

“…Consequently, previous postictal lactate measurements were higher than in our study, ranging from 3.0 to 6.9 mmol/L compared with 2.1 mmol/L. Prolonged PNES lactate levels were similar in our cohorts at 1.25–1.4 mmol/L compared with past studies where lactate was between 1.3 and 1.7 mmol/L with the upper end of the range representing pPNES 5,22,25 …”

“…Psychogenic nonepileptic seizures (PNES) are a common source of epilepsy misdiagnosis [1][2][3][4] and the rate of misdiagnosis may be higher in those with prolonged "status epilepticus-like" events. 5,6 Conversely, incorrectly diagnosing epileptic seizures as nonictal phenomena can also occur; one study in a neurological ICU setting, demonstrated a 15.6% rate of misdiagnosis of seizures as nonictal phenomena. 3 Misdiagnosis often results in inappropriate treatment which can have serious risks for patients.…”

To the emergency room and back again: Circular healthcare pathways for acute functional neurological disorders

“…The diagnosis may be missed at acute presentation, when our cohort was identified, with some people instead diagnosed at a later stage, during hospital admission or at outpatient clinic. For example, other studies have shown that functional seizures are commonly misdiagnosed as epilepsy in acute settings [24,25]. This is a major limitation, as our approach to recording functional presentations relied on information provided by non-specialist clinicians, so it is likely than many patients presenting acutely with functional symptoms were not included in our cohort.…”

Prevalence of ictal injuries in functional (psychogenic nonepileptic) seizures: A systematic review and meta‐analysis

“…Twenty studies 15–34 reported the prevalence of injuries without specifying the type. Twenty‐two studies investigated tongue, cheek, or lip biting 4,17,19,21–23,31,33,35–48 . Eight studies reported other types of injuries, such as dental injuries, 35,36,48 fractures (e.g., leg, nose, pelvis), 35,36,44,48,49 bruises, 36,44 burns, 35,36,44,45,48 lacerations (e.g., face, scalp, limb), 35,36,42,44,48 and head injury 48,50 …”