566880 research-article2015

EEGXXX10.1177/1550059414566880Clinical EEG and NeuroscienceDworetzky et al

Article

A Clinically Oriented Perspective on Psychogenic Nonepileptic Seizure–Related Emergencies

Clinical EEG and Neuroscience 2015, Vol. 46(1) 26­–33 © EEG and Clinical Neuroscience Society (ECNS) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1550059414566880 eeg.sagepub.com

Barbara A. Dworetzky1, Daniel S. Weisholtz1, David L. Perez2,3,4, and Gaston Baslet4

Abstract Psychogenic nonepileptic seizures (PNES) can present emergently and are often mistaken for epileptic seizures. PNES emergencies have not been well studied, and yet there are associated serious morbidities, particularly when patients are seen in an emergency setting and are misdiagnosed. PNES may be prolonged, mimicking status epilepticus, a condition we refer to as nonepileptic psychogenic status (NEPS), and patients may receive aggressive and unnecessary medical treatments that can lead to serious iatrogenic complications, including death. NEPS is also associated with an increased risk of self-harm, including suicide attempts, and may indicate a serious comorbid psychiatric illness. In addition to iatrogenic complications of PNES, accidents and injuries are an underrecognized source of morbidity. PNES may also present during medical procedures, which may not only interfere with their completion, but may alarm practitioners who, fearing liability, may initiate further medical evaluations and treatments. When PNES occur during pregnancy, patients may be misdiagnosed with eclampsia and their offspring delivered prematurely. They also risk being placed on medications that are harmful to the fetus. Increased awareness of PNES is necessary to prevent iatrogenic harm and to identify underlying psychiatric illnesses that carry their own risks. As yet, data available to guide treatment are scant, and further study is needed. Keywords nonepileptic psychogenic status, pseudostatus, pregnancy, suicide, accidents

Introduction Seizures represent one of the leading neurological causes for visits to emergency departments (ED) and intensive care units (ICU).1 One of the primary seizure mimics, psychogenic nonepileptic seizure (PNES), creates diagnostic challenges for physicians and observers, as these patients often present emergently and dramatically. Functional neurological symptom disorder/conversion disorder is a common presentation in the ED, with PNES being the most common.2 Patients with PNES present to a variety of health care providers, including nurses, emergency physicians, surgeons, anesthesiologists, internists, pediatricians, psychiatrists, and of course, neurologists.2 While there is much written about neurologic and psychiatric emergencies, there are relatively little data on emergencies specific to PNES. A few articles limited to single case reports, or small case series, of PNES mimicking status epilepticus also known as “pseudostatus” or nonepileptic psychogenic status (NEPS) have been published. Overall, there are minimal data available to guide providers who care for these patients when they present urgently in a variety of settings and are rushed into EDs and ICUs, often recurrently.3

There has been recent focus on treatment for PNES,4-7 yet no studies have examined long-term interventions for the treatment of patients with NEPS. The absence of data is partly related to the difficulty in following these patients longitudinally and tracking their responses to treatments. One possible reason for the difficulty in capturing data on this subgroup, is that they often enter the medical system emergently through nonneurologist providers, are admitted to nonneurology services, and are discharged from the hospital or ED,8 almost immediately after it is discovered that seizures are psychogenic. In this way, there is 1

Department of Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA 2 Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA 3 Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA 4 Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA Corresponding Author: Barbara A. Dworetzky, Division of Epilepsy, Department of Neurology, Brigham & Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA. Email: [email protected]

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Dworetzky et al little time to solidify a follow-up plan; they are often lost to follow-up, only to present later to new providers who may be unaware of the previous diagnosis. Medical records may be scattered among institutions or providers, which can interfere with the acquisition of accurate and complete clinical information. In this article, we review the major PNES emergencies and discuss typical presentations, including NEPS, PNES related injuries and accidents, postprocedure events, and considerations during pregnancy. Illustrative cases will be used to facilitate discussion. Clinical insights and implications for future research in this area will be provided.

Nonepileptic Psychogenic Status: The Most Common PNES Emergency NEPS, also referred to as “pseudostatus” or “status pseudoepilepticus,” is defined, in accordance with the definition of convulsive status epilepticus, as a psychogenic nonepileptic seizure lasting 30 minutes or longer, or frequent repetitive nonepileptic seizures without a return to baseline mental state. This duration-based definition seems much less relevant for NEPS, because of the lack of risk for brain damage and the fact that the onset and termination of a PNES is often indistinct. However, the prolonged duration may lead to aggressive medical interventions, due to the known risks of under-treating convulsive status epilepticus. There have been multiple cases, and small series, reported on NEPS and the iatrogenic dangers involved, including death.9-12 In addition to iatrogenic complications,9,10,13-15 NEPS may be associated with an increased risk of substance abuse,16 self-harm and suicide attempts.3,17 A survey, done by the NES Task Force of neurologist American Epilepsy Society members, revealed that the majority of them do not track PNES duration and that events lasting 20 minutes or longer are considered markedly prolonged and a possible marker for NEPS.3 The burden and cost of PNES has not been subdivided to determine the percentage attributable to NEPS. In fact, there are relatively few studies to uncover whether it is possible to predict who is at risk of NEPS, and whether it is really a distinguishable entity, or just a more severe version of PNES.3 As a result of the lack of data, there are no guidelines on treatment for NEPS. The NES task force survey responses, regarding follow-up, revealed a trend favoring emergency psychiatric consultation, and short-term follow-up with the referring neurologist. There was no consistency in the practice of continuing EEG monitoring, or hospitalization after diagnosis, or whether to remove all antiepileptic drugs (AEDs) to disprove concomitant epilepsy.3 Asadi-Pooya et al18 compared patients with PNES-only to those with NEPS, and found no significant differences between the groups in the demographics (age at onset, age at referral, gender, education or marital status) or risk factors predisposing to PNES (history of abuse as a child, sexual abuse, physical abuse, head trauma, academic failure, confirmed epilepsy, family history of epilepsy, or medical comorbidity). Compared with PNES without prolonged attacks,

patients with NEPS were more likely to be admitted to the monitoring unit on an urgent basis, reported a higher frequency of attacks, and were diagnosed sooner into the course of their illness.8 Antecedent trauma is reported by 75% of patients with PNES, including physical, sexual, and emotional trauma,19 and a history of head trauma is reported by 30% to 45% of patients with PNES.20,21 Psychiatric risks factors for PNES include depression, anxiety,22 posttraumatic stress disorder (PTSD), chronic pain,23-25 substance abuse, borderline personality disorder,26 and dissociative disorders.27 These risk factors likely apply to NEPS as well, although this PNES subgroup is less well-studied than PNES as a whole. NEPS, in particular, has been associated with learning disabilities.19

Illustrative Case PS is a 25-year-old woman with epilepsy and a history of prior “status epilepticus” who was found actively convulsing at the scene of a motor vehicle crash. She was intubated in the field, given intravenous propofol, and brought to the ED. The trauma team evaluated her and found no evidence for any acute injury. Alcohol was found in the serum toxicology screen, and lamotrigine was requested from an outside laboratory. Convulsions continued and she was transferred to the medical ICU, where intravenous levetiracetam was loaded and neurology was consulted. Electroencephalography (EEG) was requested and revealed only electrode and movement artifact, but was otherwise normal, even when movements briefly stopped, and provided no evidence for epilepsy despite the continued convulsions. The patient awoke and demanded to leave the hospital once anticonvulsant medications were discontinued, and after she was told that her seizures did not show any correlation on the EEG. This case provides a fairly typical example of a patient presenting with NEPS to the ED with a “history of epilepsy and prior status epilepticus.” Reuber et al17 retrospectively compared 85 PNES patients with 64 with epilepsy. They found that 78% of PNES patients had experienced seizures lasting for more than 30 minutes compared with only 33% in the epilepsy group; 27% were sent to the ICU in the past compared with 22% in the epilepsy group; and 39% had recurrent hospital admissions for “status epilepticus” compared with 13% in the epilepsy group. When compared with a group of PNES patients without status, NEPS patients were, on average, younger (mean of 20 years) than those with PNES-only (mean of 30 years). This finding has also been observed in other studies.28 As in this case, neurologists often become involved after patients are already intubated or loaded with intravenous medications.17 Thus, improving the safety of this group of patients must involve education of early responders, not just neurologists. Pakalnis et al29 presented a small series of 6 children with repetitive PNES or NEPS. Interestingly, in this series, family history of epilepsy was common, and affective and anxiety disorders with acute stress seemed to be the trigger for all of the episodes. Our case was potentially triggered by the acute stress

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of the car accident. Obtaining collateral information from the primary physician or neurologist, and an urgent and definitive EEG may be essential in order to make a prompt diagnosis, to distinguish those patients with co-morbid epilepsy, and to minimize morbidity. When a patient is seen in the ED with a “history of epilepsy” and prior episodes of “status epilepticus”, there should be a pause to consider a psychogenic etiology for the event.30 This may have been helpful in the case of PS and could potentially have prevented the intubation, the ICU admission and the use of intravenous propofol and levetiracetam, all of which put her at elevated risk of iatrogenic harm. However, there are published cases of recurrent emergency visits and intubations, even when doctors are well aware of the diagnosis of PNES, likely because of how closely the episodes resemble epileptic seizures. Nguyen et al31 reported on a teenage girl who was sent to the ED for intubation and intravenous medications repeatedly despite staff awareness of the diagnosis, emphasizing the need for educating staff about the appropriate management of PNES. In such cases, treatment and close follow-up are necessary, and must include a treatment plan that the family can implement for recurrent or prolonged events that does not necessarily include a visit to the ED, and may include advice on how to keep the patient safe while minimizing iatrogenic harm.

Accidents, Injuries, and Suicide In people with epilepsy, injuries and accidents occur at 4 times the rate of the normal population, and include falls (4%), drowning (3% to 7%), and burns (2.2%).32 While these types of insults are far more common with epilepsy, they have also been described in PNES. Peguero et al33 contacted 73 of 102 consecutive patients diagnosed with PNES by video EEG (vEEG). Injuries were reported in 40% of cases, with 44% reporting tongue bites and urinary incontinence. The authors did not find a history of burns reported in the PNES patients, only in those with definite epilepsy. PNES patients with urinary incontinence are more likely to report not only injuries, most commonly minor tongue lacerations, but also more major injuries such as fractures.34 These reports occurred in nearly 31% of patients. While these statistics are substantial, self-report studies of this sort may not reflect actual rates of significant injury as they are influenced by patient perception. A recent article on functional movement disorders shows that conversion patients tend to overestimate the extent of symptoms,35 so careful distinction between self-report and objective evaluation of injuries is likely also relevant for PNES. Nevertheless, from the authors’ experience, there are definite circumstances where photos and witness reports provide significant evidence that injuries do occur. Patient reports of injuries sustained during seizures may lead practitioners to misdiagnose epilepsy, based on the common misconception that patients do not get injured during a psychogenic seizure. Objective data from the epilepsy monitoring unit (EMU) show that accidents are infrequent in PNES. Falls occurred in

approximately 2.6%, with patients who were ambulatory receiving more significant injuries.36 Authors were concerned that these falls occurred without push buttons signaling them, and without nurses responding. While accidents are infrequent, PNES patients may be seen as needing less urgent attention in the EMU. A study by Shin et al37 demonstrated that push buttons were responded to by nursing staff significantly more slowly for PNES than for epileptic seizures. Patients with PNES who report injuries or accidents are also more likely to report a past suicide attempt.33 Suicide attempts were reported by 32% of PNES patients in the study by Peguero et al.33 Rechlin et al26 reported on a series of 18 patients with NEPS, all with self-destructive behaviors, including suicide attempts. In addition, this cohort of NEPS patients had impulse control problems, substance abuse, affective dyscontrol, depression, bulimia, and borderline personality disorder (BPD). There is evidence that BPD is associated with PNES38,39 and may be present in as many as half of PNES patients.40 Depression is also quite common in PNES, and while there are several studies addressing reports of prior suicide attempts, the rate of completed suicides has not been formally addressed in PNES. A recent study, investigating cause of death in a cohort of PNES patients followed over time,41 supports a higher incidence of preexisting medical conditions in patients with late-life onset PNES, and showed no evidence that medication withdrawal, seizures, or psychiatric factors contributed to the cause of death. Kaufman and Struck42 reported a case of an attempted suicide in the EMU, highlighting this potential risk in cases of PNES. Of all the suicide risk factors mentioned, remote and recent prior suicide attempt and multiple psychiatric diagnoses seem the strongest risk factors to distinguish those at highest risk for suicide. A study, performed at a large primary care clinic, showed that 24% of patients with somatoform disorders expressed suicidal ideation.43 Anxiety disorders have also been identified as a significant risk factor for suicidality,44,45 particularly PTSD,46 which is highly comorbid in PNES. Interestingly, although suicidality and suicide attempts are relatively common in PNES patients, self-injurious behavior was actually a negative predictor of death in a mortality and PNES study.41

Illustrative Case BF is a 42-year-old woman with a history of depression, panic attacks, childhood sexual abuse, and PTSD from multiple traumatic experiences, including a skull fracture. She began experiencing staring spells, hand clenching, leg shaking, or stiffening, associated with retching and tachycardia. These episodes occurred 2 to 3 times a week, and were not improved with multiple AEDs. She presented to the ED on several occasions having fallen down the stairs, and was found by her family with a laceration on her lip, bruises on her body, and no recollection of why she fell. She had a history of several previous suicide attempts. She was admitted for vEEG, a typical event with loss of consciousness and unremarkable EEG was obtained, and a diagnosis of PNES was made.

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Dworetzky et al This case highlights the link between childhood sexual abuse, PNES with injuries, and self-harm, including suicide attempts.26 Multiple medications were not tolerated or ineffective, and repeat traumas were clear. Panic attacks, tachycardia, and dissociation are common in these cases as well. Caregivers are concerned about injury during PNES and are often not comforted by the “good news” that epilepsy has been ruled out. The balance between promoting functional reintegration and safety may be difficult for PNES patients who tend to overestimate their risk of harm. Proactively working with family and providers, and helping patients develop skills to reduce their selfdestructive tendencies are key to facilitating slow but steady functional recovery.

Ambulatory Practice and Postprocedure PNES Interestingly, a fair amount of emergency PNES occurs within the walls of the hospital, outside of the ED and ICU. A retrospective review of a log of “code blue” calls for “seizures” over 7 years47 revealed that 5.3% of all of the codes (50/948) were for seizure-like events, and among these, a small percentage (3/50) were diagnosed with PNES. All were either visitors or employees who were on hospital grounds but in non–patient care areas. Reports of NEPS and PNES following procedures are scattered in the literature.48 Medical procedures are stressful, and may serve as a trigger for patients who are already susceptible to PNES. Some of these procedures may be experienced as traumatic, and provoke PNES by evoking difficult memories or flashbacks in those who already suffer from PTSD. There have been several reports of conversion disorder in the obstetrics and anesthesiology literature following various types of procedures.49-52 This highlights a risk of invasive procedures that is often not considered.

Illustrative Case AP is a 31-year-old woman with bipolar disorder, fibromyalgia, diabetes mellitus, and renal insufficiency, who presented for a cystoscopy to evaluate symptoms of urinary retention that she had been treating with self-catheterization. She was found on the floor of the bathroom in the cystoscopy suite, face down and unresponsive, with blood in her nares. Her heart rate was 120 and a “code blue” was called for possible seizure. She remained unresponsive for 60 minutes, and was subsequently admitted to the neurology service and EEG monitoring was ordered. A second event was captured the next day on vEEG with generalized shaking of all extremities and opisthotonic posturing and absence of any epileptiform activity on the EEG. Later that morning, she told her nurse that she had passed a stone in her urine and also had blood in her sputum, but unfortunately the specimens were discarded. Previous similar presentations following invasive procedures were noted in her chart, one with sudden inability to move her legs lasting over an hour. She was sent out of the hospital to follow-up with

psychiatry and neurology, but she did not keep either of the appointments. Cystoscopy did not reveal any abnormalities to explain her urinary symptoms. This case illustrates recurrent postprocedure conversion disorder presenting as PNES. As with many such patients, PNES was only one of several functional symptoms the patient exhibited. Medicolegal concerns often loom in cases such as these where iatrogenic harm is feared, and may compel the physicians to repeat testing even though the episodes are similar to prior presentations where nothing was found. Excessive hospitalization and diagnostic testing subject patients to an increased risk of iatrogenic injury, while reinforcing their somatic attention and the notion that there remains an undiagnosed medical problem. This may enhance the patient’s anxiety, and possibly even worsen the symptoms. Providing the patient with care from a limited number of empathetic providers, rather than recurrent medical testing or assurances of cure, is one approach that might help diminish her symptoms. However, the patient did not follow-up as recommended. Engagement in treatment is a well-recognized problem in PNES, and it remains unknown if a subgroup of PNES patients who are somatically focused may present more difficulty for treatment engagement.

Pregnancy and PNES Women who are pregnant are at risk for seizures for a variety of reasons, and treatments are provided with urgency given the high stakes. While there is very little written about pregnancy and PNES, there are multiple case reports53 and several small case series regarding conversion disorder and pregnancy.54 Much of this literature is largely based on observations from the obstetric and anesthetic services. There are a few reports on patients with new-onset PNES during pregnancy, and most are single case reports55-59 with a rare small case series.60 Admitting pregnant women into the EMU and removing medication, a process often necessary in order to diagnose PNES and exclude epilepsy, carries the risk of provoking a generalized convulsion, which could be devastating to the fetus and lead to legal ramifications.61 Furthermore, the small but real risk of unexpected death in the EMU, possibly related to rapid anticonvulsant withdrawal,62 may be an unacceptable risk to take in a pregnant woman. Five cases reported in pregnancy concluded that PNES may signal serious emotional issues for the patient, and a potential concern for the unborn fetus.54 NEPS has also been reported in pregnancy in a case that led to the death of the fetus at 31 weeks after emergency C-section was undertaken.63 The patient had a history of presumed status epilepticus during a prior pregnancy while delivering a stillborn infant. For these reasons, vEEG is important to consider prior to pregnancy in any young woman with uncontrolled seizures. In women who are already pregnant, it may still be important to evaluate any concerns for PNES, preferably at the earliest recognition of pregnancy, so that unnecessary medications that may harm the fetus can be withdrawn.64

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Illustrative Case PL is a 24-year-old woman with a history of PNES who presented months after delivering a baby. She was brought to the ED again 11 weeks pregnant. Her history included 1 to 3 visits per month for syncope, asthma, and abdominal pain. In four prior admissions, vEEG for seizures were negative, and events proven to be nonepileptic on more than one occasion. Despite this, she presented to another institution, and was treated with topiramate before the pregnancy was recognized. She was brought to the ED at our institution by her boyfriend because she was having an increase in the frequency of her seizures, which were now occurring 2 to 3 times per week, associated with urinary incontinence and falling on her abdomen. Repeat vEEG again confirmed PNES, and concern for the safety of the unborn fetus was raised. The patient was evaluated by psychiatry during her vEEG admission and outpatient follow-up was arranged. This case demonstrates how difficult it can be to avoid overtreating a PNES patient with potentially harmful AEDs when she presents to different EDs with seizures, even if the episodes have been demonstrated to be nonepileptic on multiple previous occasions. Similar to the report by DeToledo et al,54 recurrent evaluations proving a diagnosis of PNES did not prevent providers from starting a potentially teratogenic medication that was not indicated. In this case, the error may have occurred because the patient’s care was fragmented between more than one hospital, as often happens when patients present to the ED via ambulance. Under ideal circumstances, the time to investigate a diagnosis of epilepsy is prior to pregnancy, so that if a diagnosis of PNES is made, AEDs can be withdrawn, and fetal exposure to them eliminated, unless proven necessary by a definitive diagnosis of epilepsy. During the pregnancy, or immediately after delivery, are times when medication withdrawal is high risk. For this patient, a multidisciplinary followup plan, involving neurology, psychiatry and social work, was created to maintain close contact with her throughout the pregnancy.

Treatment Considerations in PNES Emergencies Physicians in emergency situations have been discouraged from relying on conversion disorder as a diagnosis, in order not to miss any critical or life-threatening medical problem. Testing and aggressive treatments are frequently initiated in the ED before a full history can be confirmed and often before neurology is consulted.65 While physicians may be understandably uneasy about making a diagnosis of functional neurological symptom disorder, for fear of missing another neurologic diagnosis, the rate of misdiagnosis is relatively low at 4% in recent series.27 Reluctance to make a diagnosis may lead to overtesting, reinforcement of somatic preoccupation or attention, and a delay in initiating appropriate treatment. Additionally, overtesting may lead to erroneous diagnoses or further unnecessary tests, since positive test results may be more likely to be falsepositives than true positives if pretest probability is very low.66

On the other hand, as many as 30% of epilepsy diagnoses may be erroneous,67,68 mostly as a result of poor histories or overread EEGs,68,69 leading to unnecessary prescriptions, procedures, and adverse medication effects. This indicates that there may be a tendency to overdiagnose rather than underdiagnose epilepsy. Nevertheless, it can be difficult to withhold aggressive treatment for a patient presenting with what appears to be status epilepticus, unless a diagnosis of NEPS can be confirmed immediately. In the ED, obtaining an urgent EEG can be very useful when patients are unresponsive, especially for a prolonged period, as it may avoid admission and further testing, especially in patients who are hemodynamically stable or who have been diagnosed with comorbid epilepsy. A visit to the ED may be a “reachable moment” if the patient is conscious and talking, as the patient’s acute stress level is high and the opportunity to explore psychosocial contributions for the symptoms is most timely. Important to this process is making a definitive diagnosis on vEEG, which is especially necessary when atypical and unusual epileptic seizures, or those that are EEG negative, such as simple partial seizures, are not misdiagnosed as PNES. The vEEG allows for increased accuracy of diagnosis by expert review of clinical semiology, interictal and postictal EEG, and clinical state with time for subtle and unusual events to be verified. Once a diagnosis is made, it is important to keep patients with chronic PNES from being seen recurrently in the ED. This may require providers to become more accessible to these patients, rather than referring them elsewhere for further workup and evaluation. The patient needs to know that he or she is being heard and not dismissed. However, after a diagnosis is made and these patients are told they do not have epilepsy, they are often sent away by their neurologist without an appropriate referral, leading them to present again in another ED. As relevant as it is to “rule out epilepsy” (negative diagnosis), an explanation for the psychogenic origin of the symptoms needs to be offered (positive diagnosis). Explaining PNES as one form of an expression of distress, assimilating to panic attacks and/or depression, may eventually help patients and professionals to embrace this disorder in a less stigmatizing way. Kanner70 believes that neurologists should continue to follow these patients for at least 6 months following PNES diagnosis. This change in attitude serves 2 purposes. It sends a clear message that the neurologist is concerned about the patient, and wants to make sure that the patient successfully transitions to the new treating providers. It also helps keep the patient on the same treatment path, and not back on an AED, which is a common occurrence. This process may allow more clarity in the distinct roles of psychiatrists and neurologists.70 Removing unnecessary treatments, like AEDs, that can mislead ED physicians into treating a patient for epilepsy when they have PNES, may lessen iatrogenic harm.71,72 Oto et al73 randomized a small cohort of patients with PNES to immediate versus delayed withdrawal of AEDs and found that outcomes were improved for the group taken off the drugs immediately, with fewer seizures, less use of rescue medications, and improved locus of control. Removing unnecessary AEDs is important because of

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Dworetzky et al the tremendous financial costs of unnecessary medications and the potential for adverse effects, including cognitive and psychiatric symptoms, and even possibly suicide. There is some variability in the practice of diagnosing PNES in the EMU. The NES Task Force survey, on markedly prolonged PNES, revealed that there is no consensus on whether to keep patients in the hospital beyond diagnosis.3 Kanner70 argues to keep patients at least 24 hours after definitive diagnosis, as this can help with prognosis and guidance for further treatment. Acquiring data that shows that this approach leads to improved outcomes might offset the limits on duration of monitoring imposed by insurance companies. When treating PNES emergencies, it is critical to recognize the chronicity of the disorder, to try to understand the patient’s perspective, and to identify the emergency presentation as a possible moment to reach out to the patient and engage him or her in the necessary treatment. For patients who have frequent medical emergencies, it is important to have a single primary provider who acts as a gatekeeper and will be available and capable of redirecting the patient appropriately during these emergencies. However, this is often impractical, as it requires 24/7 coverage, excellent communication with the ED, easy access to prior testing, and sophistication in management of this difficult group of patients. In addition, this can be a very difficult group of patients to connect with for many reasons. One provider-dependent reason is the negative bias that exists in the medical profession about these patients, because they are perceived as “faking” their seizures. Patients perceive these negative feelings from staff, who do not believe that their symptoms are real, enhanced by their use of out-of-date terminology. This may contribute to the poor follow-up with psychiatry. Family members should be included in the treatment plan, as their misunderstanding of the diagnosis may lead to increased stress at home and may perpetuate the episodes. LaFrance, Baslet, Goldstein, and others have begun to forge the way for new treatments for PNES with psychotherapeutic interventions (see Baslet et al74 in this special issue). Baslet and Prensky75 demonstrated that patients are most likely to follow up if they are referred to the same institution at which they are diagnosed, if they are married, and if they have few cognitive complaints. Providing regular reviews with patients may help diminish the need for emergency visits. PNES emergencies are not uncommon, but have been largely unstudied. Maintaining vigilance to identify patients potentially at risk for harm such as suicide or accident is important, but equally important is to provide interdisciplinary care involving both neurology and psychiatry for these complex patients. Research is sorely needed to uncover preventative strategies, and to understand who may be at risk of an emergency PNES event. Are patients who present with PNES emergencies, such as NEPS and injuries, at greater risk for parasuicidal behaviors? Are they more likely to resolve with certain treatments? Capturing these data on patients who quickly enter and leave the hospital is essential for understanding PNES

emergencies. Improving the engagement of PNES patients in treatment with mental health providers needs to be a focus along with decreasing the bias and stigma against them. Author Contributions BAD, DSW, DLP, and GB substantially contributed to conception or design; BAD and GB contributed to acquisition, analysis, and interpretation; DSW and DLP contributed to interpretation; BAD and DSW drafted the manuscript; BAD, DSW, DLP, and GB critically revised the manuscript and gave final approval; BAD agrees to be accountable for all aspects of work ensuring integrity and accuracy.

Declaration of Conflicting Interests The author(s) received no financial support, and declared no conflicts of interest, with respect to the research, authorship, and/or publication of this article.

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A clinically oriented perspective on psychogenic nonepileptic seizure-related emergencies.

Psychogenic nonepileptic seizures (PNES) can present emergently and are often mistaken for epileptic seizures. PNES emergencies have not been well stu...
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