Epilepsy Currents, Vol. 12, No. 4 (July/August) 2012 pp. 138–139
© American Epilepsy Society
In Clinical Science
The diagnosis of psychogenic nonepileptic seizures (PNES)
continues to be clinically challenging despite increasing evi-
dence that delay in diagnosis is related to increased use/cost
of medical services; poor quality of life; psychiatric comor-
bidities, including posttraumatic stress disorder (PTSD) and
depression; medically unexplained symptoms; family dysfunc-
tion; unemployment; and poor 4-year and 10-year outcomes
(1–5). Even though trauma, health-related anxiety, older age,
unclear episodes, and nondiagnostic video EEG (vEEG) studies
are common in males with PNES, physicians are more predis-
posed to diagnose PNES in women rather than men [(6–-8] ).
Salinsky et al.’s findings demonstrate the delay in diagnosis
of PNES in U.S. veterans with NES, who were mainly male and
had experienced a traumatic event, head injury, during their
Between 12 and 35 percent of the military deployed to
fight in Iraq, Afghanistan, and the war-on-terror sustain mild
traumatic brain injury (TBI) or concussion as a result of blast
injuries (9). Military who experience mild TBI and return from
deployment have increased PTSD (11–43.9%) (10, 11), depres-
sion (23%), and unexplained somatic symptoms (8–32%) (10),
as well as pain (43.1%) (12). Yet, these same symptoms and
TBI are also risk factors for PNES. Furthermore, one-fourth to
one-third of PNES cases have TBI (13, 14), and one-third of TBI
patients have PNES (15).
The findings by Salinsky et al. of PNES in 25% (50/203)
veterans and in 26% (189/726) civilians demonstrate that PNES
is undiagnosed in both U.S. veterans and civilians. But misman-
agement of the 50 PNES veterans compared with the 50 civilian
PNES cases is evident from the five-fold longer time to PNES
diagnosis, increased percentage of patients on at least one AED,
four-fold longer cumulative time on AEDs, and larger number of
prescription drugs. Additional evidence for inadequate medical
care and increased use of medical services by the PNES veterans
includes the significantly larger number of prescription drugs at
admission and the number of patients on benzodiazepines and
narcotics compared with the veterans with epilepsy. The finding
of TBI in 58% of the PNES and in 51% of the epilepsy veterans
but only in 26% of the PNES civilians underscores the impor-
tance of including PNES in the differential diagnosis of posttrau-
matic epilepsy following TBI in the military.
In addition to the unequal gender distribution in the military,
significantly more males in the veteran than in the civilian PNES
group might reflect the previously described difficulty diagnos-
ing PNES in males even in the presence of unclear episodes (7).
The significantly older age of the veteran compared with the
civilian PNES patients is probably a correlate of the delay in diag-
nosis. It might also represent military protocol to diagnose and
treat seizures following TBI as posttraumatic epilepsy rather than
conduct diagnostic vEEG and psychiatric evaluations, particu-
larly in cases of mild TBI. Furthermore, veterans’ lack of reporting
of psychiatric symptoms related to PSTD and depression for
Psychogenic Nonepileptic Seizures in US Veterans.
Salinsky M, Spencer D, Boudreau E, Ferguson F. Neurology 2011;77(10): 945–950.
OBJECTIVES: Psychogenic nonepileptic seizures (PNES) are frequently encountered in epilepsy monitoring units (EMU)
and can result in significant long-term disability. We reviewed our experience with veterans undergoing seizure evalua-
tion in the EMU to determine the time delay to diagnosis of PNES, the frequency of PNES, and cumulative antiepileptic
drug (AED) treatment. We compared veterans with PNES to civilians with PNES studied in the same EMU. METHODS: We
reviewed records of all patients admitted to one Veterans Affairs Medical Center (VAMC) EMU over a 10-year interval.
These patients included 203 veterans and 726 civilians from the university affiliate. The percentage of patients with
PNES was calculated for the veteran and civilian groups. Fifty veterans with only PNES were identified. Each veteran
with PNES was matched to the next civilian patient with PNES. The 2 groups were compared for interval from onset of
the habitual spells to EMU diagnosis, cumulative AED treatment, and other measures. RESULTS: PNES were identified in
25% of veterans and 26% of civilians admitted to the EMU. The delay from onset of spells to EMU diagnosis averaged
60.5 months for veterans and 12.5 months for civilians (p < 0.001). Cumulative AED treatment was 4 times greater for
veterans with PNES as compared to civilians (p < 0.01). Fifty-eight percent of veterans with PNES were thought to have
seizures related to traumatic brain injury. CONCLUSIONS: The results indicate a substantial delay in the diagnosis of
PNES in veterans as compared to civilians. The delay is associated with greater cumulative AED treatment.
Not All Seizures Are Epilepsy Also Applies to the Military
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Not All Seizures Are Epilepsy
“macho” reasons and reluctance to disclose mild TBI to prevent
medical evaluations that might delay returning home and reunit-
ing with their families (16) reduce the likelihood that military
physicians will consider possible PNES in mild TBI cases.
Although this was a retrospective study, study strengths
include well-defined hypotheses and criteria for the inclusion,
exclusion, and classification of subjects into epilepsy/PNES
subgroups, as well as the use of consecutive controls (who
underwent vEEG within 34 days (range, 0–127 days) of the
veteran PNES cases. Among the study’s methodological prob-
lems, the comparison of the cumulative time on AEDs between
veteran and civilian PNES cases should have controlled for age
because civilians were significantly younger than the veterans.
In addition, only one author (who was not blind to the study’s
hypotheses) reviewed all the medical charts. In contrast to civil-
ian studies on TBI and PNES (13–15), the authors did not provide
information on the type and severity of TBI in the veteran PNES,
veteran epilepsy, and civilian PNES groups. This study also did
not report on somatic symptoms other than PNES and on psy-
chiatric diagnoses in the study’s groups. Therefore, it remains to
be determined if the larger number of prescription drugs in the
veteran compared with the civilian PNES group might reflect
more somatic symptoms associated with higher rates of PTSD,
depression, or chronic pain among the veterans (10–12). How-
ever, the authors noted that lack of information on psychiatric
diagnosis and recruitment from a tertiary center might limit
generalization of the study’s findings to other U.S. veterans.
The findings of Salinsky et al. have important clinical care
implications. In terms of diagnosis, PNES in 25% of veterans
referred for vEEG 5 to 20 years after onset of symptoms in 37%
of these veterans emphasizes the need to include PNES in the
differential diagnosis of military TBI cases with posttraumatic
epilepsy. Increasing physicians’ awareness about PNES in
military posttraumatic epilepsy cases is particularly important,
because underreporting and lack of treatment for PTSD, de-
pression, and somatic symptoms in military experiencing mild
TBI can increase both the risk for PNES and its morbidity.
Regarding treatment, these findings emphasize the
importance of revisiting prophylactic prescription of AEDs for
late onset posttraumatic epilepsy in military cases of TBI. The
guidelines of the American Academy of Neurology (17) clearly
state that, “Prophylactic use of phenytoin or valproate is not
recommended for preventing late post-traumatic seizures.” The
cognitive and behavioral adverse effects associated with AEDs
(particularly when they are not indicated) might further impair
the poor functioning, prevent employment, and decrease
the quality of life of PNES patients. Although not examined
in this study, these conditions might have contributed to the
veterans increased use of medical services as suggested by
the larger number of prescription drugs and number of pa-
tients on benzodiazepines and narcotics. Finally, the need for
prescription drugs, benzodiazepines, and narcotics indirectly
reflects the PNES veterans’ unmet mental healthcare needs.
Early diagnosis of PNES and referral for specialized psychiatric
and psychological care can prevent this downhill process.
by Rochelle Caplan, MD
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