Abstracts

Rationale: Psychogenic non-epileptic seizures (PNES) are common amongst patients evaluated at epilepsy monitoring units (EMU) within Veterans Affairs Medical Centers (VAMC). Yet there is little information regarding the underlying psychiatric problems in these patients. An understanding of these psychiatric diagnoses may be crucial to the design and implementation of therapeutic strategies. Methods: The study group consisted of 50 consecutive veterans meeting research criteria for pure PNES following evaluation at the Portland VAMC EMU. Patients were collected over a 10 year interval. The median age was 49 years, and 80% were men. Seventy-two percent of patients were receiving 1-3 antiepileptic drugs at the time of EMU admission. Extensive chart reviews for prior psychiatric diagnoses included the electronic medical record (EMR), remote EMR from other VAMCs, scanned records, and review of all paper charts. Cumulative DSM psychiatric diagnoses were abstracted up to the date of diagnostic EMU admission. Only diagnoses documented by mental health providers were included. Diagnoses by other providers, and unverified references to prior psychiatric diagnoses were not included. We also documented psychiatric hospitalizations. The comparison group consisted of 37 veterans diagnosed with only epileptic seizures during the same time interval.Results: A median of 74 months of prior medical records were available for review. Forty-one patients (82%) had mental health evaluations prior to the EMU diagnosis of PNES. These patients had a median of 3 axis I diagnoses. Post-traumatic Stress Disorder (PTSD) was the most common diagnosis, documented in 30 patients (73%). PTSD was attributed to civilian trauma in 13 patients, military combat trauma in 10, and military sexual trauma in 4. Depression was diagnosed in 29 patients (71%); 20 with major depression. Alcohol or other substance dependence was diagnosed in 24 patients (59%). PTSD, substance dependence, and depression were often seen in the same patients; 14 patients (34%) had all three diagnoses, and 28 (68%) had at least two. In addition, 15 other axis I diagnoses were represented. These included bipolar disorder, anxiety disorder, schizoaffective disorder and ADHD; each in less than 15% of patients. Personality disorders (axis II) were documented in 18 patients (44%), most often borderline or NOS. Nineteen patients had 2-12 prior psychiatric hospitalizations.Conclusions: Veterans diagnosed with PNES often have an extensive psychiatric history documented prior to EMU evaluation. While PTSD, depression, and substance abuse are most common, a broad range of psychiatric diagnoses are seen. These observations suggest that veterans with PNES may benefit from an individualized treatment approach based on underlying psychiatric diagnoses.