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ABSTRACT: : Psychogenic nonepileptic seizures (PNES) are commonly encountered problem in neurological practice and usually are accompanied by other psychiatric comorbidities. Despite its prevalence and profound impact on patients and families, there have been few trials addressing treatment. Cognitive behavioral therapy may be effective but the role of pharmacologic therapy remains unclear.
: To critically evaluate evidence that PNES frequency may be reduced by treatment with selective serotonin reuptake inhibitors.
: The objective was addressed through the development of a structured, critically appraised topic. We incorporated a clinical scenario, background information, a structured question, literature search strategy, critical appraisal, results, evidence summary, commentary, and bottom line conclusions. Participants included consultant and resident neurologists, a medical librarian, epileptology, and psychiatry content experts.
: A pilot randomized control clinical trial was selected for critical appraisal. Thirty-eight PNES patients were randomized to flexible-dose sertraline (target dose, 200 mg/d) or placebo. Only 68% of patients contributed data to the primary analysis and baseline PNES frequency was notably dissimilar. Twelve-week seizure frequency rates, as compared with baseline, were 45% lower in the sertraline group (P=0.03) but unchanged in the placebo group (8% increase; P=0.78). After adjustment for baseline differences, between-treatment group comparison revealed a trend toward lower event frequency in the sertraline group (risk ratio 0.51; 95% confidence interval, 0.25-1.05; P=0.29). Psychosocial and quality of life measures did not differ between treatment groups.
: There is insufficient evidence to recommend routine treatment with sertraline to reduce PNES event frequency but these pilot data suggest a possible benefit worthy of further exploration.
The Neurologist 01/2013; 19(1):30-3. · 1.26 Impact Factor
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ABSTRACT: The Somatic Complaints scale (SOM) and Conversion subscale (SOM-C) of the Personality Assessment Inventory perform best in classifying psychogenic non-epileptic seizures (PNES) from epileptic seizures (ES); however, the impact of positive impression management (PIM) and negative impression management (NIM) scales on SOM and SOM-C classification has not been examined. We studied 187 patients from an epilepsy monitoring unit with confirmed PNES or ES. On SOM, the best cut score was 72.5T when PIM was elevated and 69.5T when there was no bias. On SOM-C, when PIM was elevated, the best cut score was 67.5T and 76.5T when there was no bias. Negative impression management elevations (n=9) were too infrequent to analyze separately. Despite similarities in classification accuracy, there were differences in sensitivity and specificity with and without PIM, impacting positive and negative predictive values. The presence of PIM bias generally increases positive predictive power of SOM and SOM-C but decreases negative predictive power.
Epilepsy & Behavior 11/2012; 25(4):534-538. · 2.34 Impact Factor
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ABSTRACT: Presurgical evaluation for refractory epilepsy typically includes assessment of cognitive and language functions. The reference standard for determination of hemispheric language dominance has been the intracarotid amobarbital test (IAT) but functional magnetic resonance imaging (fMRI) is increasingly used.
To critically assess current evidence regarding the diagnostic properties of fMRI in comparison with the IAT for determination of hemispheric language dominance.
The objective was addressed through the development of a structured critically appraised topic. This included a clinical scenario, structured question, literature search strategy, critical appraisal, results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and content experts in the fields of epilepsy and neurosurgery.
A systematic review and meta-analysis that compared the sensitivity and specificity of fMRI to IAT-determined language lateralization was selected for critical appraisal. The review included data from 23 articles (n=442); study methodology varied widely. fMRI was 83.5% sensitive and 88.1% specific for detection of hemispheric language dominance.
There are insufficient data to support routine use of fMRI for the purpose of determining hemispheric language dominance in patients with intractable epilepsy. Larger, well-designed studies of fMRI for language and other cognitive outcomes as part of the presurgical and postsurgical evaluation of epilepsy patients are necessary.
The Neurologist 09/2012; 18(5):329-31. · 1.26 Impact Factor
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ABSTRACT: Eyewitnesses frequently perceive seizures as life threatening. If an event occurs on the hospital premises, a "code blue" can be called which consumes considerable resources. The purpose of this study was to determine the frequency and characteristics of code blue calls for seizures and seizure mimickers. A retrospective review of a code blue log from 2001 through 2008 identified 50 seizure-like events, representing 5.3% of all codes. Twenty-eight (54%) occurred in inpatients; the other 22 (44%) events involved visitors or employees on the hospital premises. Eighty-six percent of the events were epileptic seizures. Seizure mimickers, particularly psychogenic nonepileptic seizures, were more common in the nonhospitalized group. Only five (17.9%) inpatients had a known diagnosis of epilepsy, compared with 17 (77.3%) of the nonhospitalized patients. This retrospective survey provides insights into how code blues are called on hospitalized versus nonhospitalized patients for seizure-like events.
Epilepsy & Behavior 06/2011; 21(2):189-90. · 2.34 Impact Factor
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ABSTRACT: Epilepsy monitoring unit (EMU) admissions during 2007-2009 at Mayo Clinic Hospital Arizona were reviewed. Of the 106 indeterminate admissions, 13 (12%) went on to have a second admission. During the second admission, 8 (62%) were diagnosed. Five patients went on to have a third or fourth admission, with none of them receiving a diagnosis. Nineteen (18%) patients had ambulatory EEG monitoring after an indeterminate admission, with only one (5%) receiving a diagnosis after ambulatory EEG monitoring. Even in patients who were initially indeterminate, medication management changed 37% of the time. Admission to the EMU was helpful for spell classification, with 80% of the patients receiving a diagnosis after the first admission. Based on this study, a second admission should be considered if no diagnosis is reached after the first admission. If no diagnosis is made after the second EMU admission, subsequent admissions are unlikely to produce a definitive diagnosis.
Epilepsy & Behavior 03/2011; 20(4):706-8. · 2.34 Impact Factor
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CONTINUUM Lifelong Learning in Neurology 06/2010; 16(3 Epilepsy):228-41.
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ABSTRACT: Olfactory and gustatory hallucinations are not often encountered in the acute care setting but may represent the subtle presenting features of a significant underlying disease process. We describe a patient whose most striking presenting symptoms were of olfactory and gustatory hallucinations and in whom the diagnosis and treatment of a new brain tumor and partial status epilepticus occurred entirely in the emergency department. The lesion was subsequently identified as glioblastoma multiforme involving the hippocampus and amygdala.
Annals of emergency medicine 03/2010; 56(4):374-7. · 4.23 Impact Factor
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ABSTRACT: Psychogenic nonepileptic seizures (PNES) are often disabling and usually associated with psychiatric disorders and reduced quality of life. Although often suspected based on historical and clinical features, the gold standard for diagnosis of PNES is video electroencephalography. Identification of clinical features that reliably distinguish PNES from ES would be valuable in acute care settings, for patients that have coexisting disorders, and those with multiple event types.
To determine the diagnostic value of putative clinical symptoms or signs of PNES against the gold standard of video electroencephalography.
We addressed the objective through development of a structured critically appraised topic that included a clinical scenario, structured question, search strategy, critical appraisal, results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and content experts in the field of epileptology.
There were wide variations in the rates of coexisting PNES and epilepsy and study methodology. Ictal stuttering and the "teddy bear" sign were associated with moderate specificity for PNES. However, the presence of pelvic thrusting or ictal eye closure did not accurately distinguish PNES from ES.
The presence of either ictal stuttering or the teddy bear sign is moderately specific but poorly sensitive for PNES. Pelvic thrusting and ictal eye closure are not reliable indicators of PNES. Future studies should establish more precise and reliable definitions of clinical signs and evaluate combinations of such signs in a broad spectrum of patients with PNES and ES spell phenotypes that may be difficult to distinguish, such as spells of unresponsiveness with motor manifestations. Because PNES and ES may coexist, analysis of diagnostic accuracy of clinical features should be performed for individual spells.
The Neurologist 08/2008; 14(4):266-70. · 1.26 Impact Factor
