Abstracts

Rationale: Psychogenic nonepileptic spells (PNES) are a major health problem that may contribute to overly aggressive treatment, morbidity and substantial medical costs. Patients may carry a false diagnosis of epilepsy for years, receiving multiple antiepileptic medications that fail to resolve or improve spell frequency and some may be subjected to unnecessary invasive procedures (i.e. intubation). With delays in symptom characterization, patients may have difficulty accepting the clarified diagnosis, which may lead to resistance to receiving appropriate mental health treatment. For these reasons it remains critical to uncover methods to rapidly recognize when suspicion for PNES is warranted to avoid delay in diagnosis. The goal of this study was to assess for similarities in patients diagnosed with PNES in an attempt to identify the most common characteristics to ultimately aid more rapid diagnosis. Methods: A retrospective chart review of patients undergoing epilepsy monitoring at the Hunter Holmes McGuire Veterans Affairs Medical Center (VAMC) in Richmond, VA from October 2010 to December 2017 was conducted. Of patients who underwent epilepsy monitoring, 36% were found to have PNES. Extensive chart review of these patients was completed to identify commonalities in patient demographics, history, spell characteristics and time to diagnosis. Results: Of patients found to have PNES an overwhelming percentage carried a psychiatric diagnosis (80.3%) and were prescribed psychiatric medications (67.6%). Over half of patients had a history of emotional or physical trauma (Post-Traumatic Stress Disorder [PTSD] or sexual trauma). Although the majority of our observed veteran population was male, there was a significant female predominance noted in those with PNES. Fifty-eight percent of women who underwent epilepsy monitoring were found to have PNES versus only 32% of males. The most common spell semiology involved convulsions and loss or alteration of consciousness with a much smaller percentage reporting focal characteristics. Less than a third of patients had undergone prolonged EEG prior to eventual diagnosis and in over 50% of patients time to diagnosis was greater than five years. Conclusions: Psychiatric comorbidities, emotional and/or physical trauma may be closely intertwined in veterans diagnosed with PNES. Thus, care should be taken to obtain a thorough psychiatric and social history in all patients presenting with activity concerning for seizure, which may be neglected in the initial assessment. Additionally, in patients who appear refractory to initial treatment, especially female patients, epilepsy monitoring to clarify the diagnosis should not be delayed. Though this retrospective review cannot definitively correlate emotional and/or physical trauma as a direct cause for PNES in veterans, we suggest increased vigilance in identifying certain comorbidities and expediting symptom characterization. Earlier diagnosis may facilitate delivery of appropriate mental health treatment and minimize overly aggressive treatments which may be unnecessary or harmful. Funding: No external or internal funding sources were used to support this abstract.