Elsevier

Epilepsy & Behavior

Volume 25, Issue 3, November 2012, Pages 345-349
Epilepsy & Behavior

Psychiatric comorbidity in veterans with psychogenic seizures

https://doi.org/10.1016/j.yebeh.2012.07.013Get rights and content

Abstract

Psychogenic non-epileptic seizures (PNES) are frequently encountered in epilepsy monitoring units (EMU) at Veterans Affairs Medical Centers (VAMCs) and cause significant long-term disability. An understanding of psychiatric factors associated with PNES could aid in earlier diagnosis and treatment. We studied 50 consecutive veterans diagnosed with PNES and 37 veterans diagnosed with epileptic seizures (ES), evaluated at a VAMC EMU. We reviewed all available mental health evaluations prior to EMU evaluation. Univariate comparisons included axis I diagnoses, axis II diagnoses, and psychiatric hospitalizations. Predictive models of seizure classification were evaluated by logistic regression. A diagnosis of post-traumatic stress disorder (PTSD) preceded the diagnosis of PNES in 58% of patients and the diagnosis of ES in 13.5% (p < 0.001). On logistic regression, PTSD was the only significant psychiatric diagnosis (odds ratio 9.2). Major depression and alcohol abuse were common diagnoses but did not differentiate PNES and ES groups.

Highlights

► We reviewed psychiatric diagnosis in veterans with psychogenic seizures (PNES). ► PTSD was strongly predictive of a diagnosis of PNES in veterans. ► PTSD was the only significant predictive psychiatric diagnosis for PNES. ► Depression and substance abuse do not differentiate veterans with PNES vs. epilepsy. ► These results may aid in early recognition of PNES in veterans.

Introduction

Psychogenic non-epileptic seizures (PNES) are clinical events that resemble epileptic seizures (ES) but that are not associated with abnormal brain electrical discharges or other physiological problems. These neuropsychiatric events are common, accounting for 20–50% of epilepsy monitoring unit (EMU) discharge diagnoses [1], [2], [3], [4], [5]. Most PNES patients are mistakenly thought to have medication‐resistant epilepsy and are chronically treated with one or more antiepileptic drugs (AEDs), while the psychological nature of the disorder remains hidden [3], [6], [7], [8], [9]. Short‐ and long-term disabilities are common [7], [10].

Psychogenic non‐epileptic seizures are also common in veterans treated at Veterans Affairs Medical Centers (VAMCs). Patients diagnosed with PNES accounted for 25% of all EMU discharge diagnoses in a recent VAMC study and were more common than patients diagnosed with ES [8]. In the same study, 50 veterans with EMU‐verified PNES (without ES) were compared with 50 civilians with PNES studied in the same EMU and by the same personnel. Veterans had a considerably longer delay from onset of symptoms to the diagnosis of PNES as compared to civilians, with a median of 5 years. In one third of cases the delay exceeded a decade. The delay in diagnosis was associated with greater cumulative exposure to AEDs. Prognosis and long-term disability may also be negatively affected by the delay in diagnosis [5], [7], [11].

Psychogenic non‐epileptic seizures are generally believed to be symptoms of comorbid psychiatric disorders. These disorders have been comprehensively studied in civilians but not in veterans [12], [13], [14], [15]. An understanding of the psychiatric disorders associated with PNES is essential for designing effective treatment strategies and could aid in early recognition of PNES. Comorbid psychiatric disorders in veterans with PNES are likely to differ from those of civilians due to (a) differences in the age and sex of the populations; (b) risk of traumatic brain injury (TBI) and psychological effects of combat exposure including post-traumatic stress disorder (PTSD); and (c) potential financial motivations in the VA health care system fostering illness behavior. We studied psychiatric diagnoses preceding documentation of PNES in a carefully evaluated group of veterans with PNES and a comparison group of veterans with documented ES.

Section snippets

Patients

We reviewed records of all veterans admitted to the Portland VAMC EMU from January 2000 to July 2010. Details for this group are provided elsewhere [8]. We excluded patients who had a previously documented EMU evaluation at the Portland VAMC or elsewhere, except (a) when these evaluations were non-diagnostic or (b) when the diagnosis was modified by the repeat monitoring at the Portland VAMC. We eliminated 4 patients with missing records. There were 203 unique patients in the final group. The

Results

A median of 76 months of prior medical records was available for review of PNES patients and 116 months for review of ES patients (p = 0.01, Wilcoxon). The difference reflected the longer duration of illness for the ES group (Table 1). The mean age at admission was similar for the PNES and ES groups (47.0 vs. 50.8), and for men and women (48.7 vs. 48.0). Women were over-represented in the PNES group (p < 0.05).

Thirty-nine of 50 PNES patients (78%) had at least one qualifying mental health evaluation

Discussion

The results demonstrate that in veterans admitted for EMU evaluation, a prior diagnosis of PTSD is predictive of PNES rather than ES. Psychogenic non‐epileptic seizure patients also had a significantly greater overall burden of comorbid psychiatric illness as compared to those with ES, including a greater number of axis I diagnoses and a greater prevalence of axis II diagnoses. However, PTSD was the only diagnosis that significantly contributed to seizure type classification in the logistic

Acknowledgments

The authors thank J. Cereghino MD and D. Smith MD for review of this manuscript.

This material is the result of work supported with resources and the use of facilities at the Portland VA Medical Center.

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