Epilepsy & Behavior 85 (2018) 177–182

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Epilepsy & Behavior

journal homepage: www.elsevier.com/locate/yebeh

Utilization of brain imaging in evaluating patients with psychogenic

nonepileptic spells
Danmeng Wei a, Matthew Garlinghouse a, Wenyang Li a, Nicholas Swingle a,
Kaeli K. Samson b, Olga Taraschenko a,⁎
a
Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, United States of America
b
Department of Biostatistics, University of Nebraska Medical Center, Omaha, NE, United States of America

a r t i c l e i n f o a b s t r a c t

Article history: Background: Psychogenic nonepileptic spells (PNES) are paroxysmal movements or sensory events that resemble
Received 6 April 2018 epileptic seizures but lack corresponding ictal electrographic changes. A confirmed diagnosis of PNES is only ac-
Revised 19 May 2018 complished via video electroencephalogram (vEEG) monitoring. Prior to diagnosis, patients are often assessed
Accepted 7 June 2018 with neurodiagnostic imaging and their conditions treated with anticonvulsant medications, both of which are
Available online xxxx
of limited clinical value and contribute to the higher cost of care. In this study, we assessed the relationship be-
tween the semiological features of PNES, medication regimen, or psychiatric comorbidities and the frequency of
Keywords:
Nonepileptic spells
referrals for brain imaging tests prior to diagnosis of PNES.
Magnetic resonance imaging Methods: This is a retrospective chart review of 224 adult patients diagnosed as having PNES at a level 4 epilepsy
Psychogenic seizures care center from 2012 to 2017. Patients with coexisting epilepsy were excluded. The 882 segments of vEEG re-
Computed tomography cords were reviewed for semiology of spells, and patients were categorized into one of seven distinct phenotypic
Semiological classification classes according to the accepted clinical classification. The frequency of neurodiagnostic tests completed for
each patient prior to vEEG was correlated with PNES phenotype and other clinical characteristics.
Results: There were 68 (30%) males and 156 (70%) females diagnosed as having PNES with a median age of 36
years. Seventy-four percent of patients were receiving one or several anticonvulsant medications, and 67% of pa-
tients were treated with psychotropic medications other than benzodiazepines. The most prevalent PNES events
were characterized by semirhythmic small amplitude movements in the extremities (class 2; 34%) followed by
those resembling tonic–clonic seizures (class 4; 28%). Neurodiagnostic imaging tests including computed tomog-
raphy (CT) and magnetic resonance imaging (MRI) of the brain were performed at least once in 60% of patients
and 4 times or more in 11% prior to vEEG. There was a significant association between the frequency of
neurodiagnostic tests and the PNES phenotype (p = 0.02). Specifically, patients with sensory changes (class 6)
had more imaging tests than those with primitive gesturing and truncal posturing (classes 1 and 5, respectively).
Additionally, patients diagnosed with 3 or more psychiatric disorders underwent significantly more
neurodiagnostic tests relative to patients diagnosed with two or fewer psychiatric disorders (p = 0.03). Further-
more, patients whose conditions were treated with anticonvulsant medications tended to undergo more imaging
scans prior to vEEG as compared with the patients whose conditions were not being treated with anticonvul-
sants.
Conclusions: These findings suggest that the frequency of brain imaging obtained prior to the definitive diagnosis
of PNES is influenced by semiology of spells and the psychiatric health of patients. Patients who demonstrate
minimal paroxysmal movements in the settings of multiple psychiatric comorbidities represent a particularly
challenging patient phenotype which is linked to more frequent referrals for brain imaging. These patients
should be promptly referred for vEEG to improve diagnostic accuracy and prevent treatment with anticonvul-
sants as well as referrals for serial neurodiagnostic tests.
© 2018 Elsevier Inc. All rights reserved.

1. Introduction

Psychogenic nonepileptic spells (PNES) are paroxysmal motor, sen-

⁎ Corresponding author at: Comprehensive Epilepsy Program, Department of
Neurological Sciences, University of Nebraska Medical Center, 988435 Nebraska Medical
Center, Omaha, NE 68198-8435, United States of America.
E-mail address: olha.taraschenko@unmc.edu (O. Taraschenko).
sory, or autonomic disturbances that resemble epileptic seizures. In con-
trast to epileptic seizures, PNES have no corresponding ictal changes on
videoelectroencephalogram (vEEG) and occur in the absence of

https://doi.org/10.1016/j.yebeh.2018.06.015
1525-5050/© 2018 Elsevier Inc. All rights reserved.
178 D. Wei et al. / Epilepsy & Behavior 85 (2018) 177–182
recognized neurologic or medical conditions [1–3]. Semiological fea-
tures of PNES range from pseudosyncope and paucikinetic primitive
gesturing to impressive hyperkinetic movements reminiscent of those
occurring in seizures [4]. Although several signs are considered to be
suggestive of PNES [5], none of the features are pathognomonic, and
the reliance on the clinical characteristics alone in distinguishing PNES
from seizures is discouraged. Therefore, an established standard of prac-
tice proposed by the International League Against Epilepsy is to perform
long-term EEG with accompanied video recording in all patients with
suspected PNES [6]. While vEEG is currently considered to be the most
accurate and reliable diagnostic technique for PNES [7] in healthcare fa-
cilities where access to vEEG is limited, the electrographic monitoring is
frequently replaced or complemented by other diagnostic modalities
such as computed tomography (CT), magnetic resonance imaging
(MRI), and single photon emission computed tomography (SPECT).
Globally, availability of vEEG for the diagnosis of PNES varies across
countries and has been recently reported to be particularly limited in
low-income countries [8].
In previous studies, evidence of abnormalities on brain MRI was
found in 9–10% of patients with PNES [9]. However, the presence of ce-
rebral pathology on imaging could not be relied upon to distinguish be-
tween epileptic seizures and pseudoseizures [10]. Furthermore,
redundant brain imaging in these patients contributed to the growth
of total national inpatient admission cost for PNES from 34 million
USD in 1993 to more than 2 billion USD in 2013 [11]. Given that the
emergency department (ED) is visited by these patients on average 6
times before the definitive diagnosis of PNES is established [12], it is im-
portant to understand which clinical characteristics are associated with
higher rates of referral for brain imaging by ED physicians and other
health practitioners. Using an interstate electronic medical record sys-
tem, in the present study, we assessed the patterns of referrals for
neurodiagnostic testing (e.g., head CT and brain MRI) in patients with
psychogenic spells. In addition, we examined the relationship between
the semiological features of PNES (e.g., extent of the abnormal move-
ments) and likelihood of undergoing neurodiagnostic testing prior to
vEEG. We hypothesized that PNES with prominent movements will be
more likely misdiagnosed as epileptic seizures and these patients will
be referred for imaging more often than those with more subtle move-
ments. Furthermore, we examined the association between the clinical–
demographic characteristics of patients with psychogenic spells and the
frequency of brain imaging prior to the definitive diagnosis of PNES.
2. Methods
2.1. Patient selection
The present cohort was drawn from all retrospectively identified
subjects (age: 18 years and above) who underwent vEEG monitoring
to confirm diagnosis of PNES at the University of Nebraska Medical Cen-
ter (UNMC), a level 4 comprehensive epilepsy center. The cohort was a
sample of patients who underwent vEEG monitoring between January
2012 and April 2017 (Fig. 1). The diagnosis of PNES was established in
patients presenting with new or recurrent psychogenic events that
were registered during one or multiple vEEG recordings. The paroxys-
mal events were regarded as psychogenic if patients had motor and sen-
sory disturbances or changes in affect occurred without ictal
electrographic correlates and the semiology of those events was not
consistent with EEG-negative epileptic seizures. Patients with clinical
or laboratory data supporting the evidence of acute encephalopathy, de-
lirium, syncope, or panic attacks were excluded. In addition, patients
with coexisting established diagnosis of epilepsy or those with epileptic
seizures on the assessed vEEG were excluded (Fig. 1). In patients who
underwent multiple vEEGs for PNES, only the most recent recordings
were reviewed as these studies were considered diagnostic for those
patients. The events recorded during the diagnostic vEEG were assumed
to be typical for these patients.
Charts of all paents with vEEG
monitoring 1/2012- 4/2017
2018
Epilepc seizures
Encephalopathy
No events captured
Video not available
Paents with PNES
313
PNESS alone PNES and e
epilepsy
224 89
Fig. 1. Flow diagram.
2.2. vEEG analyses
The video segments of all PNES captured during the diagnostic vEEG
recording were reviewed independently by a board-certified
epileptologist and a licensed neuropsychologist; all events were also
previously diagnosed as PNES at the time of admission by a treating
epileptologist. Every event was assigned to a category based on the pre-
viously developed classification of PNES [13] which was modified to in-
clude seven classes based on the event semiology. The events were
classified as follows: class 1 — dystonic attacks with primitive gestures;
class 2 — attacks with tremor or low range semirhythmic movements in
the extremities and various degrees of alteration of awareness; class 3 —
dialeptic (or pseudosyncope); class 4 — attacks with hyperkinetic
movements reminiscent of generalized tonic–clonic seizures; class 5 —
axial dystonic attacks characterized by sustained posturing of the
trunk and minimal movements in the extremities; class 6 — sensory
and pseudoautonomic disturbances (e.g., paresthesia, numbness, palpi-
tations, and dyspnea); and class 7 — unspecified complaints including
speech difficulties, change in affect, and perceived weakness. If overlap-
ping features of several classes were present, the category was assigned
based on the degree of abnormal movements since the latter feature
was thought to be of concern for the physicians requesting referrals
for brain imaging. All event categories accompanied by abnormal move-
ments (i.e., hyperkinetic events) were ranked according to the severity
of associated movements in the rank order of 4-5-2-1 from the most to
the least severe movements. The event categories without movements
(i.e., paucikinetic attacks) were ranked according to the presence or ab-
sence of pseudosyncope in the order of 3-6-7 from the most severe
PNES with unresponsiveness to the least severe events with poorly de-
fined semiology. Patients who presented with multiple events during
the same diagnostic vEEG were assigned an overall category; the events
with multiple semiologies were reconciled based on the rank orders noted
above. The number of different semiological categories identified during
the diagnostic vEEG was recorded for each patient. The rare (less than
3%) discrepancies in the designations of the overall categories by the two
independent reviewers were adjudicated during joint discussions. The in-
formation regarding the presence of epileptiform and nonepileptiform ab-
normalities on diagnostic vEEG (e.g., interictal epileptiform discharges,
generalized, and focal slowing) was recorded for each patient.
2.3. Extraction of the imaging data
The electronic medical charts were reviewed to collect patients' age,
gender, date of the diagnostic and preceding vEEGs, past or present
 D. Wei et al. / Epilepsy & Behavior 85 (2018) 177–182 179

psychiatric diagnoses, psychotropic medications, and anticonvulsants at
the time of admission for diagnostic vEEG. The reports of the cranial CT
and brain MRI scans performed prior to the diagnostic vEEG at UNMC af-
filiated hospitals and hospitals participating in the Nebraska Health In-
formation Initiative, a web-based health information exchange
system, were reviewed. Additionally, the reports of imaging from non-
participating hospitals manually scanned into the patients' electronic
medical charts were examined. The presence of cerebral and
extracerebral abnormalities on the imaging reports was recorded for
each patient. The assumption was made that the catalogs of imaging re-
ports within the electronic database were comprehensive for all
patients.
2.4. Statistical analyses
Descriptive statistics were calculated for variables of interest either
as medians and ranges or means and standard error (SE) of the
means. Associations between categorical variables were tested using
Fisher's exact tests. Differences in the number of scans between groups
of interest were tested using negative binomial regressions; significant
effects were followed up with Tukey–Kramer post hoc tests. For analy-
sis, SAS software version 9.4 was used (SAS Institute Inc., Cary, NC).
and fifty (67%) patients were given at least one psychotropic medication
for mood stabilization, psychosis, or treatment of posttraumatic stress
disorder (PTSD) and substance abuse (Table 1). The prescribed mood
stabilizing agents were as follows (number of patients; percent total):
citalopram (22; 9.8%), trazodone (18; 8%), sertraline (17; 7.6%), fluoxe-
tine (17; 7.6%), duloxetine (17; 7.6%), escitalopram (16; 7.1%),
venlafaxine (10; 4.4%), buspirone (8; 3.6%), bupropion (7; 3.1%), parox-
etine (6; 2.6%), lithium (3; 1.3%), amitriptyline (3; 1.3%), desvenlafaxine
(2; 0.9%), mirtazapine (2; 0.9%), vilazodone (2; 0.9%), fluvoxamine (1;
0.4%), and brexpiprazole (1; 0.4%). The antipsychotic agents prescribed
to patients with PNES were as follows (number of patients; percent
total): quetiapine (12; 5.3%), aripiprazole (6; 2.7%), risperidone (4;
1.8%), olanzapine (4; 1.8%), haloperidol (1; 0.4%), perphenazine (1;
0.4%), paliperidone (1; 0.4%), and lurasidone (1; 0.4%). Patients were
also given Adderall (4; 2%), lisdexamfetamine (1; 0.4%), clonidine (1;
0.4%), and prazosin (1; 0.4%) for the treatment of other psychiatric dis-
orders. Remarkably, 156 (70%) patients were diagnosed with at least
one psychiatric disease, and 94 (42%) patients were carrying two or
more psychiatric diagnoses at the time of admission for vEEG (Fig.
2B). These comorbidities included major depression (49.1%), anxiety
(34.8%), bipolar disorder, (13.4%), PTSD (13.4%), substance abuse (8%),
conversion disorder (4.5%), and other conditions (17.4%).

3. Results 3.2. PNES semiology and EEG findings

3.1. Demographic and clinical characteristics of patients with PNES The median number of vEEGs performed for PNES was 1 (range: 1–
4) including the most recent (i.e., diagnostic) study. Twenty patients
The studied population was selected from a 2018 consecutive series (8.9%) had at least one vEEG prior to the diagnostic study. The mean du-
of patients who underwent vEEG monitoring at UNMC between January ration of the diagnostic vEEG was 2528.5 ± 110 min. The EEG finding
2012 and April 2017 (Fig. 1). Based on the data from vEEG reports, we was normal in 155 (69%) patients and abnormal in 69 (31%) patients.
identified 313 patients who met the diagnostic criteria for PNES. This
group included 224 (72%) subjects with PNES alone and 89 (28%) sub-
jects with combined PNES and previous history of epilepsy; the latter
patients were excluded. The overall prevalence of isolated PNES in the
vEEG recordings at our center was 11.1%. The studied population was
comprised of 224 patients, 68 (30%) male and 156 (70%) female. The
median age at the time of PNES diagnosis was 36 years (range: 18–90).
On admission for the diagnostic vEEG, patients had been treated
with a median of one (range: 0–6) anticonvulsant agent and one
(range: 1–5) psychotropic medication. Specifically, benzodiazepines
were prescribed to more than one-third of patients [72 (32%)] either
for suspected epilepsy or for psychiatric indications (Table 1). In addi-
tion, 72 (32%) patients were receiving levetiracetam, and 37 (16.5%) pa-
tients were receiving gabapentin (Table 1). Overall, 57 (25.4%) patients
were not treated with anticonvulsants while 71 (31.7%) and 96 (42.9%)
were receiving one or multiple anticonvulsants (Fig. 2A). One hundred

Table 1
Outpatient pharmacotherapy in patients with PNES.

Agents Number of patients (% total)

Anticonvulsants
Benzodiazepines 72 (32)
Levetiracetam 72 (32)
Gabapentin 37 (16.4)
Phenytoin 14 (6.2)
Valproate 14 (6.2)
Lacosamide 14 (6.2)
Oxcarbazepine 10 (4.4)
Pregabaline 10 (4.4)
Carbamazepine 5 (2.2)
Barbiturates 5 (2.2)
Zonisamide 4 (1.8)
Clobazam 1 (0.4)

Psychotropic
Mood stabilizers 115 (51.3)
Fig. 2. Clinical features of patients at the time of admission for diagnostic video EEG. A.
Antipsychotics 27 (12)
Outpatient pharmacotherapy with antiseizure drugs. B. Psychiatric comorbidities of
Other 8 (3.6)
patients with PNES.
180 D. Wei et al. / Epilepsy & Behavior 85 (2018) 177–182

Among the patients with abnormal EEG findings, 65 (94.2%) had

nonepileptiform abnormalities (i.e., generalized or focal slowing, gener-
alized periodic discharges with triphasic morphology, or a combination
of these patterns). The incidental epileptiform discharges which did not
accompany the spells on the diagnostic vEEG were present in 12 (5.4%)
patients.
The video segments of 882 events were independently assessed and
events classified by two independent observers with an agreement rate
of 98% for the cumulative category. The patients had a median of 3
events per EEG recording (range: 1–31). More than two-thirds of pa-
tients (67.9%) had PNES of a single semiological class while the remain-
der demonstrated events which varied in semiology within the same
recording. Specifically, 59 (26.3%), 11 (4.9%), and 2 (0.9%) had events
consistent with two, three, and four or more classes, respectively.
Following the reconciliation of PNES into a single cumulative cate- Fig. 4. Patterns of referrals for the brain imaging scans prior to the diagnosis of PNES. (For
gory, the largest proportion of patients (34.4%) displayed the events ac- interpretation of the references to color in this figure legend, the reader is referred to the
companied by semirhythmic low amplitude movements (class 2; Fig. web version of this article.)
3). A slightly lower proportion of patients (27.7%) manifested PNES ac-
across the seven semiological categories (p = 0.007) but the number
companied by large amplitude fast movements reminiscent of those in
of CTs did not (p = 0.23). Specifically, patients from class 6 underwent
generalized tonic–clonic seizures (class 4, Fig. 3). The proportions of pa-
more MRI scans than patients presenting with events categorized as
tients with dialeptic spells (class 3) and episodes of weakness or speech
classes 2, 4, or 5 (p = 0.008, 0.03, and 0.04, respectively; post hoc
difficulties (class 7) were 11.2% and 9.8%, respectively. The events with
tests). There was no significant difference in the number of CTs, MRIs,
primitive gesturing (class 1) were present in 7.1% of patients. The dys-
or combined imaging modalities between the two sexes (p = 0.16, p
tonic arching of the back (class 5) and sensory or pseudoautonomic
= 0.90, and p = 0.19, respectively).
changes (class 6) were demonstrated by patients with equal prevalence
Taken collectively, these results suggest that patients with PNES
of 4.9% (Fig. 3). There were no significant differences in the distribution
characterized by sensory or autonomic features were subjected to
of different classes of PNES between males and females (p = 0.84). As
brain imaging more frequently than those with PNES accompanied by
shown in Fig. 3, the events were further dichotomized into the two cat-
abnormal movements. Consistent with this premise, the number of
egories based on the presence or absence of abnormal movements:
MRIs in patients with all hypokinetic PNES classes (1, 3, 6, and 7 com-
paucikinetic (classes: 1, 3, 6, 7) and hyperkinetic (classes: 2, 4, and 5).
bined) was higher than that in patients with all hyperkinetic classes
The majority of patients (67%) presented with hyperkinetic PNES.
(2, 4, and 5 combined; p = 0.004).
There was no difference in the proportions of male and female patients
Eighty-two percent of patients in the studied cohort were either free
in these two categories (p = 1.00).
of psychiatric comorbidities or carried less than three psychiatric diag-
noses while 18.3% of patients were diagnosed as having more than
3.3. Utilization of the brain imaging tests
three psychiatric diseases (Table 2). The subjects with 0–2 psychiatric
comorbidities received significantly fewer referrals for the CT scans (p
As shown in Fig. 4, 98 (43.8%) patients in the studied cohort
= 0.02) as well as combined CT and MRI tests (p = 0.03) compared
underwent at least one CT head, and 148 (66.1%) had at least one
with patients with heavier burden of psychiatric disease (Table 2).
brain MRI scan prior to being diagnosed as having PNES on vEEG. Fur-
There was no difference between the two groups in the frequency of re-
thermore, 134 (59.8%) underwent either CT or MRI at least once prior
ferrals for MRI scans (p = 0.88).
to the definitive diagnosis (Fig. 4). Remarkably, 41 (18.3%) patients
As shown in Table 3, patients whose conditions were treated with at
were referred for either tests four or more times before they received
least one anticonvulsant (including benzodiazepines) were referred for
PNES diagnosis. The frequency of referrals for both CT and MRI tests
CT scans, MRI scans, and both tests more often compared with the pa-
prior to diagnosis varied across the seven phenotypic classes (p =
tients who were not receiving anticonvulsants (p = 0.003, p = 0.03,
0.02; negative binomial regression). Specifically, patients in class 6
and p = 0.0005, respectively; binomial modeling). As shown in Table
had significantly higher volume of brain imaging than those in classes
3, the distribution of the volume of CT scans, MRI scans, or either of
1 and 5 (p = 0.03 and 0.03, respectively; Tukey–Kramer post hoc
these tests in patients whose conditions were treated with at least one
tests). Furthermore, the frequency of MRI scans alone also differed
psychotropic medication was not different from that in patients whose con-
ditions were not treated with these agents (p = 0.56, p = 0.34, and p =
0.91, respectively; binomial distribution, data not shown).
The prevalence of incidentally found abnormalities in all available CT
and MRI scans performed in these patients was 22.3% and 31%, respec-
tively. Among the patients with abnormalities on CT scans, 36 (16.1%)
patients had findings within the cerebral hemispheres, 14 (6.4%) had

Table 2
Effects of psychiatric comorbidities on patterns of referrals for brain imaging in PNES. p-Values
indicate comparisons between the groups with 0–2 and those with 3 or more diagnoses.

Number of psychiatric Number of patients Median number of scans

diagnoses (% total) (range)

CT MRI Combined

0–2 183 (81.7%) 0 (0–22) 1 (0–10) 1 (0–30)

3 or more 41 (18.3%) 1 (0–11) 1 (0–7) 2 (0–13)
Fig. 3. Semiology of paroxysmal nonepileptic events during diagnostic vEEG. Blue, p-Value 0.02* 0.88 0.02*
hyperkinetic; red, paucikinetic. n = 224. (For interpretation of the references to color in
this figure legend, the reader is referred to the web version of this article.) *, p b 0.05.
 D. Wei et al. / Epilepsy & Behavior 85 (2018) 177–182
Table 3
Effects of utilization of anticonvulsants on patterns of referrals for brain imaging in PNES.
p-Values indicate comparisons between the groups with 0 and those with 1 or more
medications.
Number of Number of patients Median number of scans
anticonvulsants (% total) (range)
CT MRI Combined
0 57 0 (0–4) 1 (0–5) 1 (0–6)
1 or more 167 0 (0–22) 1 (0–10) 1 (0–30)
p-Value 0.003* 0.03* 0.0005*
*, p b 0.05.
findings outside of the cerebral hemispheres, and 3 (1.3%) had abnor-
malities in both compartments. Among the patients with incidental ab-
normalities on MRI, 58 (25.9%) patients had abnormal findings within
the hemispheres, 12 (5.4%) patients outside of the hemispheres, and
10 (4.5%) patients in both compartments.
4. Discussion
In the present study, we demonstrated for the first time the link be-
tween the semiological features of PNES and the frequency of referrals
for brain imaging tests. Contrary to our original hypothesis, we found
that patients presenting with minimal paroxysmal movements as well
as those with sensory or pseudoautonomic changes are referred for
MRI more frequently compared with those with hyperkinetic events.
Furthermore, we determined that the presence of multiple psychiatric
comorbidities in patients with PNES is linked with a higher volume of
referrals for neurodiagnostic tests prior to the diagnostic vEEG. These
findings suggest that encounters with paroxysmal paucikinetic move-
ments and multiple psychiatric disorders may be particularly
perplexing for the providers in different healthcare settings including
ambulatory clinics, inpatient wards, and EDs. This diagnostic uncer-
tainty likely triggers excessive utilization of unjustified brain imaging
tests in these patients. We also found that patients receiving anticonvul-
sants at the time of their most recent vEEG were previously referred for
brain imaging more often than patients whose conditions were not
treated with any anticonvulsant agents. The time course of the anticon-
vulsant initiation in relation to the patterns of imaging referrals could
not be established in this retrospective study. All but one of the patients
with PNES characterized by sensory and pseudoautonomic features ei-
ther had a normal EEG or demonstrated nonepileptiform abnormalities
on their interictal EEG. Thus, it is unlikely that these patients were
misdiagnosed as having scalp-negative focal temporal seizures present-
ing with this semiology.
The demographic characteristics of the present cohort were consis-
tent with those in the other retrospective studies in patients with
PNES, suggesting that results could be generalized to similar clinical
populations elsewhere [14–17]. Specifically, in agreement with obser-
vations by other authors [14, 15], our group was represented by rela-
tively young patients (median age of 35 years), more than two-thirds
of whom were female. The prevalence of psychiatric comorbidities in
nearly two-thirds of patients was also compatible with previous reports
[14]. Likewise, the prevalence of incidental epileptiform discharges in
EEGs of patients with PNES (5.4%) was similar to that reported by others
[9]. The proportion of patients whose conditions were treated with an-
ticonvulsants in the present study (75%) was higher than the 52.3% re-
ported in the retrospective study by McKenzie et al. [18]. However, it
was not clear whether other authors included benzodiazepines in
their computations.
The utilization of the brain imaging in the present study was lower
compared with those reported by Ahmedani et al. [14]. However, the
former cohort was drawn from patients observed in an epilepsy moni-
toring unit (EMU). Nearly half of those patients entered the monitoring
with the diagnosis of “epilepsy”, and one-third of them reported a his-
tory of head trauma [14]. In contrast to that, in the present study, we
181
included patients who underwent vEEG in multiple hospital settings in-
cluding the hospital floors as well as the EMU, and their history of pre-
vious head trauma was unknown.
Brain imaging techniques previously used in the pursuit of patho-
physiological mechanisms underlying PNES failed to demonstrate any
relationship between the structural changes in the brain and the disease
phenotype [19]. Cortical thinning in the premotor and cerebellar cortex
identified in the brains of patients with nonepileptic spells was not spe-
cific for PNES as it was also found in depression [19]. In other studies,
nonspecific brain abnormalities were found in 27–30% of patients with
PNES [9, 20, 21] which was similar to the rate described in our study.
However, it is unclear if these incidental findings have any relevance
for the development of PNES. Incidental findings of anatomical brain ab-
normalities may contribute to the heightened anxiety in these patients
and further perpetuate the pursuit of urgent care and recurrent tests.
Given that the efforts to pursue imaging tests in PNES failed to offer
any additional information for the diagnosis of PNES [22], the referrals
for the brain imaging are not warranted and should not be sought. The
use of unjustified tests prior to the definitive diagnosis of PNES contrib-
utes to the immense cost of care that was estimated to approach life-
long expenditure for treatment of drug-resistant epilepsy [23–25].
There are no specific requirements by health insurance companies to
obtain neuroimaging prior to vEEG in the state of Nebraska; however,
such mandates exist in several other states. Despite that, it is unlikely
that such a mandate alone would trigger a referral for neuroimaging be-
cause the majority of patients with PNES have undergone brain scans
during their initial encounters with healthcare providers.
The average time from the onset of PNES to diagnosis is reported to
be 5.4 years [26]. While the time from the onset of spells to the defini-
tive diagnosis of PNES could not be estimated in the present study, the
recorded armamentarium of prescribed anticonvulsants in these pa-
tients is indicative of the extended course of their disease. Interestingly,
we found that patients with paucikinetic spells and those with sensory
symptoms in particular received more MRIs or both CT and MRIs prior
to diagnosis of PNES. The reason for this is not entirely clear. One expla-
nation could be that several features of paucikinetic spells (such as
numbness or acral posturing) overlap with symptoms of acute stroke
possibly leading to the increased volume of scans in these patients. Fur-
ther prospective studies will allow one to determine if the semiology of
PNES can be applied to triage the referrals for diagnostic vEEG.
Limitations of the current study stem from the assumptions made
prior to the collection of the data. Particularly, we assumed that the
most recent vEEG obtained in these patients was diagnostic of PNES,
and the recorded spells were patients' typical events. For certain pa-
tients, the spells may not have been representative of their habitual
events, and thus, the last EEG was not diagnostic for PNES encountered
at home. This could lead to overestimation of the “diagnosed” PNES and
underestimate the volume of future imaging tests. Furthermore, we as-
sumed that the catalogs of available imaging reports were comprehen-
sive for all patients. However, the records may not be complete even
within the extended electronic medical record system available in the
state of Nebraska. We also assumed that all available brain imaging
tests were obtained during the referrals related to PNES. Nevertheless,
a small percentage of patients could also be scanned for unrelated indi-
cations. This assumption could lead to overestimation of the volume of
CT and MRI scans. Given that indications for the benzodiazepines in
the present study could not be ascertained from the patients' records,
the benzodiazepines were categorized as anticonvulsants (rather than
psychotropic medications prescribed for mood and psychotic disor-
ders). The conclusions that higher utilization of anticonvulsants was as-
sociated with higher referral rates for brain imaging could be influenced
by such categorization. Finally, this study is retrospective, and a biased
sample was obtained through referrals to the level 4 epilepsy center.
Therefore, there are likely a large number of patients with PNES who
are less severely impaired and remained excluded from the present
study.
182 D. Wei et al. / Epilepsy & Behavior 85 (2018) 177–182
5. Conclusions
The present findings indicate an individualized approach based on
the event semiology, and clinical history may be used to facilitate diag-
nostic pursuit, avoid harmful delays in appropriate therapies, and pre-
vent overuse of medical resources in caring for patients with PNES. To
avoid diagnostic delays and unnecessary expenses, patients with
paucikinetic spells and those with the heavy burden of psychiatric co-
morbidities or those receiving anticonvulsants for the treatment of
spells should be triaged early for diagnostic vEEG.
Funding sources
This research was supported by the Physician Scientist Award from
the University of Nebraska Medical College to O. Taraschenko.
Acknowledgments
The authors would like to thank EEG technologists Rebecca Buch-
man, Raenelle Akers, Ryann Mycka, and Jacob Myers for their invaluable
assistance in preparation of this manuscript.
Disclosure
The authors do not have any conflicts of interest to disclose.
Ethical publication
We confirm that we have read the journal's position on issues in-
volved in ethical publication and affirm that this report is consistent
with those guidelines. The study was approved by the institutional re-
view board of the University of Nebraska Medical Center.
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