Not All Seizures Are Epilepsy Also Applies to the Military
Epilepsy currents / American Epilepsy Society 07/2012; 12(4):138-9. DOI: 10.5698/1535-7511-12.4.138
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 evaluation 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.
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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
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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- [Show abstract] [Hide abstract] ABSTRACT: Since October 2001, more than 1.6 million American military service members have deployed to Iraq and Afghanistan in the Global War on Terrorism. It is estimated that between 5% and 35% of them have sustained a concussion, also called mild traumatic brain injury (mTBI), during their deployment. Up to 80% of the concussions experienced in theater are secondary to blast exposures. The unique circumstances and consequences of sustaining a concussion in combat demands a unique understanding and treatment plan. The current literature was reviewed and revealed a paucity of pathophysiological explanations on the nature of the injury and informed treatment plans. However, through observation and experience, a theoretical but scientifically plausible model for why and how blast injuries experienced in combat give rise to the symptoms that affect day-to-day function of service members who have been concussed has been developed. We also are able to offer treatment strategies based on our evaluation of the current literature and experience to help palliate postconcussive symptoms. The purpose of this review is to elucidate common physical, cognitive, emotional, and situational challenges, and possible solutions for this special population of patients who will be transitioning into the civilian sector and interfacing with health professionals. There is a need for further investigation and testing of these strategies.
- [Show abstract] [Hide abstract] ABSTRACT: A cross-sectional study of military personnel following deployment to conflicts in Iraq or Afghanistan ascertained histories of combat theater injury mechanisms and mild traumatic brain injury (TBI) and current prevalence of posttraumatic stress disorder (PTSD) and postconcussive symptoms. Associations among injuries, PTSD, and postconcussive symptoms were explored. In February 2005, a postal survey was sent to Iraq/Afghanistan veterans who had left combat theaters by September 2004 and lived in Maryland; Washington, DC; northern Virginia; and eastern West Virginia. Immediate neurologic symptoms postinjury were used to identify mild TBI. Adjusted prevalence ratios and 95% confidence intervals were computed by using Poisson regression. About 12% of 2,235 respondents reported a history consistent with mild TBI, and 11% screened positive for PTSD. Mild TBI history was common among veterans injured by bullets/shrapnel, blasts, motor vehicle crashes, air/water transport, and falls. Factors associated with PTSD included reporting multiple injury mechanisms (prevalence ratio = 3.71 for three or more mechanisms, 95% confidence interval: 2.23, 6.19) and combat mild TBI (prevalence ratio = 2.37, 95% confidence interval: 1.72, 3.28). The strongest factor associated with postconcussive symptoms was PTSD, even after overlapping symptoms were removed from the PTSD score (prevalence ratio = 3.79, 95% confidence interval: 2.57, 5.59).
- [Show abstract] [Hide abstract] ABSTRACT: The influence of gender on psychogenic nonepileptic seizures (PNES) diagnosis was examined retrospectively in 439 subjects undergoing video-EEG (vEEG) for spell classification, of whom 142 women and 42 men had confirmed PNES. The epileptologist's predicted diagnosis was correct in 72% overall. Confirmed epilepsy was correctly predicted in 94% men and 88% women. In contrast, confirmed PNES was accurately predicted in 86% women versus 61% men (p=0.003). Sex-based differences in likelihood of an indeterminate admission were not observed for predicted epilepsy or physiologic events, but were for predicted PNES (39% men, 12% women, p=0.0002). More frequent failure to record spells in men than women with predicted PNES was not explained by spell frequency, duration of monitoring, age, medication use, or personality profile. PNES are not only less common in men, but also more challenging to recognize in the clinic, and even when suspected more difficult to confirm with vEEG.
- [Show abstract] [Hide abstract] ABSTRACT: An important medical concern of the Iraq war is the potential long-term effect of mild traumatic brain injury, or concussion, particularly from blast explosions. However, the epidemiology of combat-related mild traumatic brain injury is poorly understood. We surveyed 2525 U.S. Army infantry soldiers 3 to 4 months after their return from a year-long deployment to Iraq. Validated clinical instruments were used to compare soldiers reporting mild traumatic brain injury, defined as an injury with loss of consciousness or altered mental status (e.g., dazed or confused), with soldiers who reported other injuries. Of 2525 soldiers, 124 (4.9%) reported injuries with loss of consciousness, 260 (10.3%) reported injuries with altered mental status, and 435 (17.2%) reported other injuries during deployment. Of those reporting loss of consciousness, 43.9% met criteria for post-traumatic stress disorder (PTSD), as compared with 27.3% of those reporting altered mental status, 16.2% with other injuries, and 9.1% with no injury. Soldiers with mild traumatic brain injury, primarily those who had loss of consciousness, were significantly more likely to report poor general health, missed workdays, medical visits, and a high number of somatic and postconcussive symptoms than were soldiers with other injuries. However, after adjustment for PTSD and depression, mild traumatic brain injury was no longer significantly associated with these physical health outcomes or symptoms, except for headache. Mild traumatic brain injury (i.e., concussion) occurring among soldiers deployed in Iraq is strongly associated with PTSD and physical health problems 3 to 4 months after the soldiers return home. PTSD and depression are important mediators of the relationship between mild traumatic brain injury and physical health problems.
- [Show abstract] [Hide abstract] ABSTRACT: Our knowledge of longer term outcome in psychogenic nonepileptic seizures (PNESs) patients is limited; we know less still about factors predicting prognosis. This study was intended to describe outcome in a large cohort and to identify predictive clinical and psychological factors to generate new ideas for treatment. One hundred sixty-four adult patients with PNESs (66.7%) responded to outcome, personality, and psychosymptomatology questionnaires (Dimensional Assessment of Personality Pathology-Basic Questionnaire [DAPP-BQ], Dissociative Experiences Scale, and Screening Test for Somatoform Symptoms) a mean of 11.9 years after manifestation and 4.1 years after diagnosis of PNES. Additional clinical data were retrieved from hospital records. The responses showed that 71.2% of patients continued to have seizures and 56.4% were dependent on social security. Dependence increased with follow-up. Outcome was better in patients with greater educational attainments, younger onset and diagnosis, attacks with less dramatic features, fewer additional somatoform complaints, and lower dissociation scores. Better outcome was associated with lower scores of the higher order personality dimensions "inhibitedness," "emotional dysregulation," and "compulsivity" but not "dissocial behavior" (DAPP-BQ). Outcome in PNESs is poor but variable. Clinical and personality factors can be used to provide an individualized prognosis. By generating a patient-specific profile, they show particular maladaptive traits or tendencies that can identify goals for psychological therapy.
- [Show abstract] [Hide abstract] ABSTRACT: To examine the role of head injury as a risk factor in the development of nonepileptic seizures (NES). Specifically, we will determine the relative frequency of head injury among NES patients referred to our center and will describe several pertinent clinical features and personal characteristics. Retrospective record review of patients referred to our center for evaluation of seizures over a 4-year period. All patients with NES were evaluated as in a previously described protocol, which included intensive video EEG monitoring, provocation by suggestion, and psychiatric interview. All NES patients with a history of head injury were extracted for this report. Of 102 patients with NES, nearly one-third (32%) had an antecedent head injury; 52% were male, mean age was 34 years, and 12% had coexisting epilepsy. Multiple psychiatric disorders were not uncommon (79%), and a history of abuse was found in 35%. All but four patients had documented financial gain from their injury. Follow-up at 1 year found poor long-term outcome with lasting disability; despite that, the majority (91%) of head injuries were minor. Our preliminary findings suggest that prior head injury is associated with the development of NES and may contribute to the pathogenesis of NES in vulnerable patients. Head injury and sexual or physical abuse appear to occur in comparable proportions in patients with NES. This suggests that head injury and abuse may be equally important risk factors in the development of NES.
Article: Nonepileptic Posttraumatic Seizures[Show abstract] [Hide abstract] ABSTRACT: Epileptic posttraumatic seizures (PTSs) are a well-recognized consequence of head injury (HI), but HI and nonepileptic seizures (NESs) have not been related. We describe a significant subset of patients with NESs who had their seizures attributed to HI. We reviewed the records of all patients diagnosed with NES at the University of Maryland Medical Center over a 6-year period (1989-1995) and selected patients with seizures attributed to a head injury occurring < or =3 years before the onset of their seizures. Of 157 patients with video-EEG confirmed NES, 37 (24%) had the onset of their seizures attributed to an HI. Their average age was 34 years (range, 15-56 years); 68% were women. Nonepileptic PTS usually developed within the first year after HI (89%). Convulsive symptoms were present in 54%. Whereas epileptic PTSs characteristically follow severe HI, the majority (78%) of our patients with nonepileptic PTSs sustained only mild HI. Before their HI, 76% of our patients were employed, working in the home, or students, but only 11% could continue those activities after developing nonepileptic PTSs. Nonepileptic PTSs are frequently mistaken for epileptic PTSs and result in serious disability. The misdiagnosis of nonepileptic PTSs leads to ineffective and inappropriate treatment. Patients with intractable seizures after HIs, particularly mild HIs, should be carefully evaluated for NESs.