Abstracts

Rationale: Neurologists often use suggestive seizure manipulation (SSM) to induce psychogenic nonepileptic seizures (PNES) in EMU and clinic patients. In patients suspected to have PNES, successful SSM produces habitual, stereotyped episodes that helps confirm their diagnosis. The COVID-19 pandemic has shifted many encounters from the office to online; and this may complicate the diagnosis process for patients that cannot schedule EMU admissions or outpatient clinic visits. We explored two potential methods for conducting SSM in patients seen over telemedicine._x000D_
Methods: This is a retrospective case series conducted with consent waiver approved by the Johns Hopkins University Institutional Review Board. The patients were likely PNES candidates seen over telemedicine._x000D_  _x000D_ After explaining SSM to a patient and receiving their permission, an epileptologist attempted to induce PNES, using visual fixation or paced hyperventilation techniques. We attempted to terminate all induced episodes using a guided relaxation technique. These three techniques are described in Figure 1. We retrospectively reviewed clinic notes for patients that agreed to SSM over telemedicine to determine whether induction provoked habitual PNES episodes in patients, and whether these episodes were terminated using guided relaxation. After one month, we followed up with patients on their adoption of recommended therapy plans.  

Results: All of the patients in this series were female. The results of induction are described in Table 1. Seven out of eight patients had habitual PNES episodes during SSM; including five out of five induced by visual fixation on a moving finger. All PNES episodes were terminated with guided relaxation. A ninth patient experienced PNES during their visit prior to SSM, and guided relaxation also terminated this episode. 

Conclusions: In this small series, SSM conducted over telemedicine successfully induced habitual episodes in patients likely to have PNES. Both visual fixation and hyperventilation techniques effectively provoked PNES in these patients. For patients in this series, SSM induced habitual episodes with features typical for PNES such as asynchronous arm shaking. All events in this series stopped after guided relaxation – this is unlikely to occur with epileptic seizures and suggests that SSM in this series did not induce epileptic events. Despite this, some patients with likely PNES and induced episodes may still require inpatient video EEG to safely discontinue ASMs and definitively rule out epileptic seizures. Nonetheless, this series, while small, shows that SSM in telemedicine visits can successfully provoke dissociative episodes that are terminable through guided relaxation and may help confirm a diagnosis of PNES in patients.

Funding: No funding supported this abstract.