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CONy 2022 | Future directions in diagnosing PNES

William Curt LaFrance Jr, MD, MPH, FAAN, FANPA, DFAPA, Brown University, Providence, RI, gives an overview of future clinical guidelines for clinicians diagnosing and treating psychogenic nonepileptic seizures (PNES). Increased education amongst doctors and patients is required to ensure any stigma associated with PNES is dispelled and to reduce dismissive diagnosis amongst clinicians. Using video EEGs (electroencephalographs) will also ensure successful detection of PNES. Dr LaFrance additionally highlights ethical approaches in diagnosis via suggestive seizure manipulation (SSM), where neurologists must have informed consent before carrying out any procedures. This interview was conducted during the 2022 World Congress on Controversies in Neurology (CONy) meeting.

Transcript (edited for clarity)

Of course, more work is needed to help educate our clinicians, our fellow physicians and clinicians, to encourage best practices. We can educate them about the importance of helping clinicians, patients, and family members to realize that psychogenic non-epileptic seizures are real seizures, they’re just not caused by abnormal brain cell discharges. So sometimes patients experience a sense of stigma, not only from society, but also from physicians, and that occurs when physicians and clinicians are dismissive of people with the diagnosis, when they might have kind of a judgmental attitude toward the individual when it’s assumed that the patient is “faking the diagnosis...

Of course, more work is needed to help educate our clinicians, our fellow physicians and clinicians, to encourage best practices. We can educate them about the importance of helping clinicians, patients, and family members to realize that psychogenic non-epileptic seizures are real seizures, they’re just not caused by abnormal brain cell discharges. So sometimes patients experience a sense of stigma, not only from society, but also from physicians, and that occurs when physicians and clinicians are dismissive of people with the diagnosis, when they might have kind of a judgmental attitude toward the individual when it’s assumed that the patient is “faking the diagnosis.”

Whereas, psychogenic non-epileptic seizures, also called functional seizures, it’s a conversion disorder so it’s an unconscious process. I think educating our fellow clinicians to let them know this is a real disorder, it’s an unconscious process, and that we can actually help our patients by making the proper diagnosis using best practices. The International League Against Epilepsy has laid out some of those tools and techniques describing the use of video EEG, or if you don’t have video EEG there are other mechanisms that can be used, so education is one area.

Another area is coming up with approaches that do not compromise ethical interactions with our patients, and so we take a pretty emphatic stance that there’s no room for deceiving our patients. The physician/patient relationship is so, so important and making sure that they have a place where they can trust the clinician is so essential to that physician/patient relationship. I would say we could find better ways to encourage that trust. We could do better with disclosure by letting people know that some procedures can induce epileptic seizures and some can actually induce psychogenic non-epileptic seizures. We might not know the mechanism for how they induce the psychogenic non-epileptic seizures but we do know that we do see that, and just being open and honest in disclosing that in the informed consent might be another way to standardize the approach.

I think it’s good that we’re having the discussion. Many of us thought, well, this debate was settled years ago. You can’t use provocative procedures, but I think that that actually came from a paper and a position that when looking at the literature… An author did a Hastings Center report in 1997 and the question there was, provoking non-epileptic seizures and the ethics of deceptive diagnostic testing. What they did is they actually conflated provocation procedures with deception, and so in this discussion what we’re doing is we’re separating out that you can still provoke a seizure even using a provoking procedure. You can still provoke non-epileptic seizures using a provoking procedure but it doesn’t have to be deceptive so those don’t have to be linked together. I think that way we can really look out for the ethics of the patient, and that includes making sure that we’re watching out for beneficence and autonomy, and that we’re looking out for justice and non-maleficence. We’re doing that for the best care of our patients.

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Disclosures

Dr. LaFrance has served on the editorial boards of Epilepsia, Epilepsy & Behavior; Journal of Neurology, Neurosurgery and Psychiatry, and Journal of Neuropsychiatry and Clinical Neurosciences; receives editor’s royalties from the publication of Gates and Rowan’s Nonepileptic Seizures, 3rd ed. (Cambridge University Press, 2010) and 4th ed. (2018); author’s royalties for Taking Control of Your Seizures: Workbook and Therapist Guide (Oxford University Press, 2015); has received research support from the Department of Defense (DoD W81XWH-17-0169), NIH (NINDS 5K23NS45902 [PI]), Providence VAMC, Center for Neurorestoration and Neurorehabilitation, Rhode Island Hospital, the American Epilepsy Society (AES), the Epilepsy Foundation (EF), Brown University and the Siravo Foundation; serves on the Epilepsy Foundation New England Professional Advisory Board, the Board of the Functional Neurological Disorder Society, and on the Council of the American Neuropsychiatric Association; has received honoraria for the American Academy of Neurology Annual Meeting Annual Course; has served as a clinic development consultant at University of Colorado Denver, Cleveland Clinic, Spectrum Health, Emory University, and Oregon Health Sciences University; and has provided medico-legal expert testimony.