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Epileptic vs psychogenic nonepileptic seizures: a video-based survey
Epilepsy & Behavior 73 (2017) 42–45
Contents lists available at ScienceDirect
Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
Clinical Research
Epileptic vs psychogenic nonepileptic seizures: a video-based survey Danielle Wasserman a,⁎, Moshe Herskovitz a,b a b
Department of Neurology, Rambam Health Care Campus, Haifa, Israel Technion Faculty of Medicine, Haifa, Israel
a r t i c l e
i n f o
Article history: Received 22 February 2017 Revised 6 April 2017 Accepted 9 April 2017 Available online xxxx Keywords: Psychogenic non epileptic seizures First responders Video Video EEG Misdiagnosis Survey
a b s t r a c t Psychogenic non epileptic seizures (PNES) are present in up to 30% of patients undergoing video EEG. Delay in PNES diagnosis is an average of 7.2 years. Patients are exposed to costly, hazardous medications and other iatrogenic morbidities. Our aim was to investigate the ability to correctly diagnose ES from PNES in different groups and seniorities of medical professionals based on video alone. We showed ten video episodes' recordings (5 PNES, 5 ES) to doctors and nurses from ER, Internal Medicine ward and Neurology department, and inquired about the episodes' nature. 46 participants, 26 non-neurological and 20 neurological personnel. Seniority of responders varied. Epileptologists diagnosed correctly 87.5% of cases, General neurologists 72.8%. Neurology nurses 69.8%, ER nurses 58%, Internal Medicine physicians 54.1% and ER physicians 44.4%. Statistical significant difference between the general physicians to all neurology group professions was N 0.05. We pointed out the lack of awareness of first responders to patients presenting with seizures. Neurologist ability to recognize seizures using semiology alone is higher than other medical personnel. Take home messages is the need for video taking of episodes and education plan to first responders. © 2017 Elsevier Inc. All rights reserved.
1. Introduction Psychogenic non epileptic seizures (PNES) are paroxysmal events that may appear very similar to epileptic seizures (ES), but are not caused by epileptic activity. These events are in connotation of a psychological origin, different from other epileptic imitators as syncope, hypoglycemia, movement disorders and others [1]. It is estimated that up to 30% of patients undergoing long term video EEG monitoring suffers from PNES. Furthermore 10–30% of PNES patients have comorbidity of epilepsy, which further complicates their management [2]. Ictal semiology as eye closure, pelvic thrusting, weeping, and prolonged or stereotyped seizures is usually associated with PNES, however there is no clinical phenomenon that is 100% specific to PNES or ES [2,3]. Udaya et al. classified six types of pseudoseizures; (1) Rhythmic motor PNES characterized by rhythmic tremor or rigor-like movements. (2) Hypermotor PNES characterized by violent movements (3) Complex motor PNES characterized by complex movements such as flexion, extension, abduction, adduction, rotation, with or without clonic-like and myoclonic-like components of varying combinations and anatomic
Abbreviations: PNES, Psychogenic non epileptic seizure; ES, epileptic seizure; ER, Emergency Room. ⁎ Corresponding author at: Epilepsy Service, Dept. of Neurology, Rambam Medical Center, 1 Efron St., Haifa 31096, Israel. E-mail address: [email protected] (D. Wasserman).
http://dx.doi.org/10.1016/j.yebeh.2017.04.020 1525-5050/© 2017 Elsevier Inc. All rights reserved.
distribution. (4) Dialeptic PNES characterized by unresponsiveness without motor manifestation. (5) Nonepileptic auras characterized by subjective sensations without any external manifestations. (6) Mixed PNES where combinations of above seizure types [4]. Due to the clinical similarity, misdiagnosis is common; however may also cause under diagnosis of real epileptic seizures, Parra et al. found 57% patients misdiagnosed as PNES by their physician [5]. Studies have shown a mean PNES diagnosis delay of 7.2 years [6]. Misdiagnosis of PNES as epileptic seizures exposes patients to ineffective, costly medication with hazardous side effects. Other possible iatrogenic morbidities can be caused due to parenteral medications and even tracheal intubation. The estimated lifetime cost of PNES misdiagnosis was formerly appreciated as $100,000 per patient. With an annual cost that ranges between $650 million and $4 billion (U.S.) [7]. An earlier diagnosis of PNES will prevent inappropriate medical interventions and will psychologically prevent the “sick, disabled role” of these patients and thereby improve their prognosis and can shorten their illness [3]. To this day, there have been several studies demonstrating agreement on the semiology of epileptic seizures. Benbir et al. compared video agreement on details of the attack between two neurologists [8]. Observer agreement of seizure identification from nonconvulsive spells were appreciated in neonatal seizure identification [9] and in dogs and cats [10]. We investigated whether different groups of medical health care staff (Doctors and nurses, neurology specialists and residents and nonspecialists in different seniority levels) can correctly diagnose ES or PNES based solely on video footage.
D. Wasserman, M. Herskovitz / Epilepsy & Behavior 73 (2017) 42–45
This study aimed to highlight whether further education is required, especially to first responders, to improve consistency between them and the neurologist thereby preventing unnecessary, endangering treatments. We hypothesized that with seniority and specialty in epilepsy the percentage for correct diagnosis will be higher.
2. Methods
43
Table 1 Participants demographics.
ER doctor ER nurse Internal Medicine physician Neurology nurse General neurologist/neurology resident Neurologist: epileptologist
No of participants
Seniority range in years
9 5 12 9 7 4
2–30 2–30 0.5–20 1–29 4–32 6–31
2.1. Video recordings Ten video EEG recordings, 5 recordings of PNES and 5 ES, were chosen from a bank of video EEG monitoring in the department of neurology, Rambam Health Care Center. The videos were randomly ordered in a 13.40-minute long video sequence (with introduction and transitions). The selection of the specific cases was as follows: i. In all cases a definite diagnosis of either ES or PNES was made by a neurologist trained in Epileptology by using the clinical semiology and the concomitant EEG. ii. In all selected cases motor phenomena were observed. iii. Different types of ESs and PNESs were selected. iv. The motor phenomena were as typical as possible for each type of event. In secondary generalized the semiology included tonic clonic movements. In complex partial seizure, the semiology showed one sided automatism with contralateral dystonia and in the hypermotor seizure pronounced automatism was seen in the beginning of the seizure. The PNESs semiology contained phenomena as hyperventilation, pelvic thrusting and burst of rhythmic non variable movements, which are typically seen in PNESs [11]. v. In all selected epileptic seizures, the video showed the beginning, evolution and the end of seizure, all but one was shown in full. In the PNESs cases due to the length of seizures only part of the event was shown, with a distinct beginning and end in which the observer can appreciate the sudden burst of motor phenomena and the sudden cessation of movements. Detailed descriptions of each seizure can be seen in appendix 1. Shortly: 5 PNES videos containing generalized, hypermotor and focal seizures. 5 ES videos containing frontal hypermotor, SMA with generalization, 3 focal temporal ES; one of them with secondary generalization. The concomitant EEG recordings was not shown to the observers.
2.2. Observers and questioners
2.4. Ethics All data gathering was approved by our institutional review board.
3. Results Overall, 46 personnel participated in this study: 26 “First responders”; 9 Emergency Department physicians, 5 Emergency Department nurses, 12 Internal Medicine physicians. 20 Neurology professionals; 9 Neurology ward nurses, 7 Neurology ward physicians (specialists and residents) and 4 specialists in Epileptology. All personnel aside from three senior epileptologists are Rambam HCC medical staff. The seniority of participants varied from less than a year to 30 years' seniority, due to the structure of the hospital personnel most participants were either b10 years' seniority or more than 20. (Table 1). Overall scoring of correctly diagnosing PNES vs ES: Senior epileptologists diagnosed correctly in 87.5% of cases. General neurologists correctly diagnosed 72.8% of cases. Neurology ward nurses 69.8%, Emergency room nurses 58%, Internal Medicine physicians 54.1% and emergency room physicians 44.4%. (Fig. 1). Pairwise comparison test showed a statistical significant difference between the general physicians (ER and Internal Medicine) to all neurology group professions. Overall scoring comparison t-test between the groups p = 0.00015. Applying pairwise comparisons between the different professional groups; ER physicians had significantly lower grade compared to Neurology nurses, Neurology physicians and epileptologists, with p b 0.004, p b 0.002, p b 0.000 respectively.
Observers were briefed before viewing of the videos. Participants were informed that the purpose of the study is to determine their ability to identify ES from PNES. And that all data are anonymous. A short questionnaire following introduction included details of profession and duration of experience. Following, each video presented identical questions regarding: ES presence (yes/no), specific signs that lead them to the answer.
2.3. Statistics Statistics analysis was done using SPSS 13 for windows. For each case, a score of 10% was given for a correct diagnosis, 0 for a wrong a diagnosis. For each participant the total grade, which is the sum of all cases ranged between 0 and 100%. For each group a mean grade was calculated. One tail t Test was calculated to compare means between Internal group staff and Neurology group staff. One way ANOVA was calculated to compare means between all groups. Statistical significance was calculated as α b 0.05. Testing Reliability of the test was done by using Cronbach's test. The ability of each case to discriminate between participants who received high grades and participants who received low grades was checked by item analysis.
Fig. 1. Overall scoring: correctly diagnosing PNES or ES according to each professional group.
44
D. Wasserman, M. Herskovitz / Epilepsy & Behavior 73 (2017) 42–45
Table 2 Results divided by seniority. Seniority
Internal group
% correct
Neurology group
% correct
0–8 8–15 Above 15 years
13 4 9
46% 57% 55%
7 4 9
70% 82% 74%
Internal Medicine physicians had significantly lower grade compared to Neurology nurses, Neurology physicians and epileptologists, with p b 0.046, p b 0.030, p b 0.002 respectively. The emergency department nurses had significantly lower grades compared to epileptologists, p b 0.016 and non-significantly lower grades compared to neurology nurses and neurology physicians. Dividing the two groups to seniority there was no significant difference, of note, two young epileptologists are in the small group of young senior doctors. (Table 2). Reliability of the survey using Cronbach's analysis showed an Alpha of 0.632. The grade ranged between 20% and 100%. To make an item analysis, the participants were divided in to 3 different groups: High grade : ≥80%:Medium grade : 50%–≤70%:Low grade : b 50%: 10 ð21:7%Þ; 23 ð50%Þ and 13 ð28:3%Þ participants respectively: We found that cases 2, 7 and 9 received the lowest grades, 34%, 30% and 29% correct diagnosis respectively. All the cases including those cases made a good discrimination between the low-grade group and the high-grade group. Item analysis is shown in Fig. 2. 4. Discussion In the past years awareness has grown and some guidelines try to give tools for differentiation of PNES [12–16]. De Paola et al. published in January 2016 the percentage of improving the diagnosing ability in these first responders group with 6 item diagnostic tool, and showed that the improvement in diagnosing is similar between neurology and other caretakers [17]. There are two main findings in our study: Medical staff specialty is highly related to the chance of making a correct PNES vs ES diagnosis. Seniority in not related to the chance of making a correct diagnosis. The pairwise comparison test showed a statistical significant difference between the general physicians (ER and Internal Medicine) to all Neurology group professions. We were surprised to see that the ER
Fig. 2. Item analysis based on each case video according to the high and low grade groups.
nurses group did not show statistical significance from neurology nurses and general neurology doctors. The reasoning is that since the ER nurses come in more contact with the neurologist in the ER during the examination of these patients, their knowledge of PNES is a bit more than the general doctors that will examine these patients before or instead of the neurologist. The ability to recognize PNES from ES based on video semiology was appreciated formerly, Beniczky et al. showed in their study the ability of epileptologists to diagnose episodes correctly was 85% [18], in our research the epileptologists correctly evaluated a similar number of 87.5% of cases. Inquiring the disagreement between the first responders group to the neurology group based on individual cases, there are three cases that stand out; The first (case no. 2), a frontal, hyper-motor seizure starting from sleep with standing up in bed and stepping in place. 100% of the first responders thought this case is psychogenic. Some of the comments written: “No loss of tone or spasticity”, “No seizure characteristics”, “Moon walking”. This may point to the total lack of first responders' awareness to epileptic seizures of this type. The second most diverse case (no. 9) was a generalized rhythmic, vigorous motor PNES of a young pregnant female, head-torso-pelvis suddenly start to shake, the head stop shaking as the doctor touch her head with pelvis continuing. Correct Diagnosis in 100% among epileptologists, neurologists 57.1%, and neurology nurses 44.4%. Internal Medicine physicians, ER physicians and ER nurses' results were 33%, 11.1% and 0 respectively. Comments written by the neurology groups related to the pelvic movements as the reason of writing the episode as PNES. The third case (no. 7) is a focal PNES showing adult female with rising and movement of arm and shoulder with repetitive thrusting of the arm on the bed. Here even the general neurological groups scored below 30% however Internal Medicine physicians and ER nurses scored higher (41.6% and 60% respectively). Video EEG is still the “Gold-standard” of diagnosing PNES as “Documented diagnosis” as published by the ILEA task force, however when video-EEG is not available the clinical diagnosis is “the next best thing” [12,14,19]. Nowadays, the use of smartphone cameras is quick and accessible, enabling the video documentation of uncertain etiology episodes. Guidelines regarding the ethics of telemedicine were produced only for specific specialties such as radiology, dermatology and psychiatry or for specific clinical applications [20]. However, the WMA “Statement on the ethics in medicine” provide some basic general guidelines as; “Maintaining patient confidentiality and data integrity”; “Telemedicine should be employed primarily in situations in which a physician cannot be physically present within a safe and acceptable time period.” [21]. PNES as epilepsy is a chronic disease. When suspicion of PNES arises, proper explanation about the importance of witnessing an episode by epileptologist should be provided to the patient. Consent to family and medical personnel documentation of future episodes for diagnostic purposes can be given beforehand by the patient. This study has some limitations which needs be pointed out. The groups were not equal in their sample size. Furthermore, this applied to the selection of the video cases. As much as we tried to select classic non epileptic and epileptic semiologies as possible, one can never accurately estimate the difficulty of the survey before performing the survey. To address this issue, we took several steps; First, we checked the Reliability of the survey by using Cronbach's analysis. Our results showed the survey is reliable, meaning that every case is checking the same factor. The second step was to show the video cases to epileptologists blinded to the EEG, to see whether it is possible to differentiate clinically between the PNESs and the ESs cases. The high grade of this group assured us that it is indeed possible. The third was to check whether the hard cases differentiate between the low-grade group and the highgrade group, by using item analysis and indeed it discriminated between those groups. Hence, we believe that the survey represents a real-life situation.
D. Wasserman, M. Herskovitz / Epilepsy & Behavior 73 (2017) 42–45
In conclusion: 1. As shown here the neurologist ability to recognize epileptic seizures based upon semiology alone is higher than 70% and above 85% in experienced epileptologists. This emphasizes the need for video taking of episodes. Using telemedicine, a highly probable clinical diagnosis can be made and avoidance of unnecessary treatment can be done. 2. Education plan to first responders is needed in recognizing PNES but also in exposure to other types of episodes which are not tonicclonic as hyper motor frontal seizures or partial complex seizures. Disclosure The authors has no disclosures or conflict of interests to report. Author contribution Danielle Wasserman MD– Conceptualization of the study, Analysis and interpretation of data and revision of the manuscript. Moshe Herskovitz MD – Conceptualization of the study, Analysis and interpretation of data and revision of the manuscript. Acknowledgements To Dr. Liron Berkovitz - for video editing and Sari Eran HerskovitzFor providing statistical data analysis. Appendix A. Supplementary data Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.yebeh.2017.04.020. References [1] Benbadis S. The differential diagnosis of epilepsy: a critical review. Epilepsy Behav 2009;15:15–21. http://dx.doi.org/10.1016/j.yebeh.2009.02.024. [2] Engel J, Pedley TA. Epilepsy a comprehensive textbook; 2008. [3] Mellers JDC. Diagnosis and management of dissociative seizures. Endocrine 1997. [4] Seneviratne U, Reutens D, D'Souza W. Stereotypy of psychogenic nonepileptic seizures: insights from video-EEG monitoring. Epilepsia 2010;51:1159-68. http:// dx.doi.org/10.1111/j.1528-1167.2010.02560.x.
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[5] Parra J, Iriarte J, Kanner AM. Are we overusing the diagnosis of psychogenic nonepileptic events? Seizure 1999;8:223-7. http://dx.doi.org/10.1053/seiz.1999.0285. [6] Reuber M, Elger CE. Psychogenic nonepileptic seizures: review and update. Epilepsy Behav 2003;4:205-16. http://dx.doi.org/10.1016/S1525-5050(03)00104-5. [7] Nowack WJ. Epilepsy: a costly misdiagnosis. Clin EEG Neurosci 1997;28:225-8. http://dx.doi.org/10.1177/155005949702800407. [8] Benbir G, Demiray DY, Delil S, Yeni N. Interobserver variability of seizure semiology between two neurologist and caregivers. Seizure 2013;22:548-52. http://dx.doi.org/ 10.1016/j.seizure.2013.04.001. [9] Malone A, Anthony Ryan C, Fitzgerald A, Burgoyne L, Connolly S, Boylan GB. Interobserver agreement in neonatal seizure identification. Epilepsia 2009;50:2097-101. http://dx.doi.org/10.1111/j.1528-1167.2009.02132.x. [10] Packer RM, Berendt M, Bhatti S, Charalambous M, Cizinauskas S, De Risio L, et al. Inter-observer agreement of canine and feline paroxysmal event semiology and classification by veterinary neurology specialists and non-specialists. BMC Vet Res 2015;11:1–. http://dx.doi.org/10.1186/s12917-015-0356-2. [11] Dickinson P, Looper KJ. Psychogenic nonepileptic seizures: a current overview. Epilepsia 2012;53:1679-89. http://dx.doi.org/10.1111/j.1528-1167.2012.03606.x. [12] LaFrance WC, Baker GA, Duncan R, Goldstein LH, Reuber M. Minimum requirements for the diagnosis of psychogenic nonepileptic seizures: a staged approach: a report from the international league against epilepsy nonepileptic seizures task force. Epilepsia 2013;54:2005-18. http://dx.doi.org/10.1111/epi.12356. [13] Mostacci B, Bisulli F, Alvisi L, Licchetta L, Baruzzi A, Tinuper P. Ictal characteristics of psychogenic nonepileptic seizures: what we have learned from video/EEG recordings—a literature review. Epilepsy Behav 2011;22:144-53. http://dx.doi.org/ 10.1016/j.yebeh.2011.07.003. [14] Syed TU, LaFrance WC, Kahriman ES, Hasan SN, Rajasekaran V, Gulati D, et al. Can semiology predict psychogenic nonepileptic seizures? A prospective study. Ann Neurol 2011;69:997–1004. http://dx.doi.org/10.1002/ana.22345. [15] Russell A. The diagnosis and management of pseudoseizures or psychogenic nonepileptic events. Ann Indian Acad Neurol 2006;9:60. http://dx.doi.org/10.4103/ 0972-2327.25978. [16] Carson A, Duncan R. How do you identify and manage convulsive psychogenic nonepileptic seizures presenting acutely to casualty? Clin Dilemmas Neuropsychiatry 2012 [12number1]. [17] De Paola L, Terra VC, Silvado CE, Teive HAG, Palmini A, Valente KD, Olandoski M, LaFrance WC. Improving first responders' psychogenic nonepileptic seizures diagnosis accuracy: Development and validation of a 6-item bedside diagnostic tool. Epilepsy & Behavior 2016;54:40–6. [18] Beniczky SA, Fogarasi A, Neufeld M, Andersen NB, Wolf P, van Emde Boas W, et al. Seizure semiology inferred from clinical descriptions and from video recordings. How accurate are they? Epilepsy Behav 2012;24:213-5. http://dx.doi.org/10.1016/ j.yebeh.2012.03.036. [19] Lobello K, Morgenlander JC, Radtke RA, Bushnell CD. Video/EEG monitoring in the evaluation of paroxysmal behavioral events: duration, effectiveness, and limitations. Epilepsy Behav 2006;8:261-6. http://dx.doi.org/10.1016/j.yebeh.2005.10.010. [20] Stanberry B. Legal and ethical aspects of telemedicine. J Telemed Telecare 2006;12: 166-75. http://dx.doi.org/10.1258/135763306777488825. [21] WMA statement on the ethics of telemedicine; 2007. https://www.wma.net/policies-post/wma-statement-on-the-ethics-of-telemedicine/.
Contents lists available at ScienceDirect
Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh
Clinical Research
Epileptic vs psychogenic nonepileptic seizures: a video-based survey Danielle Wasserman a,⁎, Moshe Herskovitz a,b a b
Department of Neurology, Rambam Health Care Campus, Haifa, Israel Technion Faculty of Medicine, Haifa, Israel
a r t i c l e
i n f o
Article history: Received 22 February 2017 Revised 6 April 2017 Accepted 9 April 2017 Available online xxxx Keywords: Psychogenic non epileptic seizures First responders Video Video EEG Misdiagnosis Survey
a b s t r a c t Psychogenic non epileptic seizures (PNES) are present in up to 30% of patients undergoing video EEG. Delay in PNES diagnosis is an average of 7.2 years. Patients are exposed to costly, hazardous medications and other iatrogenic morbidities. Our aim was to investigate the ability to correctly diagnose ES from PNES in different groups and seniorities of medical professionals based on video alone. We showed ten video episodes' recordings (5 PNES, 5 ES) to doctors and nurses from ER, Internal Medicine ward and Neurology department, and inquired about the episodes' nature. 46 participants, 26 non-neurological and 20 neurological personnel. Seniority of responders varied. Epileptologists diagnosed correctly 87.5% of cases, General neurologists 72.8%. Neurology nurses 69.8%, ER nurses 58%, Internal Medicine physicians 54.1% and ER physicians 44.4%. Statistical significant difference between the general physicians to all neurology group professions was N 0.05. We pointed out the lack of awareness of first responders to patients presenting with seizures. Neurologist ability to recognize seizures using semiology alone is higher than other medical personnel. Take home messages is the need for video taking of episodes and education plan to first responders. © 2017 Elsevier Inc. All rights reserved.
1. Introduction Psychogenic non epileptic seizures (PNES) are paroxysmal events that may appear very similar to epileptic seizures (ES), but are not caused by epileptic activity. These events are in connotation of a psychological origin, different from other epileptic imitators as syncope, hypoglycemia, movement disorders and others [1]. It is estimated that up to 30% of patients undergoing long term video EEG monitoring suffers from PNES. Furthermore 10–30% of PNES patients have comorbidity of epilepsy, which further complicates their management [2]. Ictal semiology as eye closure, pelvic thrusting, weeping, and prolonged or stereotyped seizures is usually associated with PNES, however there is no clinical phenomenon that is 100% specific to PNES or ES [2,3]. Udaya et al. classified six types of pseudoseizures; (1) Rhythmic motor PNES characterized by rhythmic tremor or rigor-like movements. (2) Hypermotor PNES characterized by violent movements (3) Complex motor PNES characterized by complex movements such as flexion, extension, abduction, adduction, rotation, with or without clonic-like and myoclonic-like components of varying combinations and anatomic
Abbreviations: PNES, Psychogenic non epileptic seizure; ES, epileptic seizure; ER, Emergency Room. ⁎ Corresponding author at: Epilepsy Service, Dept. of Neurology, Rambam Medical Center, 1 Efron St., Haifa 31096, Israel. E-mail address: [email protected] (D. Wasserman).
http://dx.doi.org/10.1016/j.yebeh.2017.04.020 1525-5050/© 2017 Elsevier Inc. All rights reserved.
distribution. (4) Dialeptic PNES characterized by unresponsiveness without motor manifestation. (5) Nonepileptic auras characterized by subjective sensations without any external manifestations. (6) Mixed PNES where combinations of above seizure types [4]. Due to the clinical similarity, misdiagnosis is common; however may also cause under diagnosis of real epileptic seizures, Parra et al. found 57% patients misdiagnosed as PNES by their physician [5]. Studies have shown a mean PNES diagnosis delay of 7.2 years [6]. Misdiagnosis of PNES as epileptic seizures exposes patients to ineffective, costly medication with hazardous side effects. Other possible iatrogenic morbidities can be caused due to parenteral medications and even tracheal intubation. The estimated lifetime cost of PNES misdiagnosis was formerly appreciated as $100,000 per patient. With an annual cost that ranges between $650 million and $4 billion (U.S.) [7]. An earlier diagnosis of PNES will prevent inappropriate medical interventions and will psychologically prevent the “sick, disabled role” of these patients and thereby improve their prognosis and can shorten their illness [3]. To this day, there have been several studies demonstrating agreement on the semiology of epileptic seizures. Benbir et al. compared video agreement on details of the attack between two neurologists [8]. Observer agreement of seizure identification from nonconvulsive spells were appreciated in neonatal seizure identification [9] and in dogs and cats [10]. We investigated whether different groups of medical health care staff (Doctors and nurses, neurology specialists and residents and nonspecialists in different seniority levels) can correctly diagnose ES or PNES based solely on video footage.
D. Wasserman, M. Herskovitz / Epilepsy & Behavior 73 (2017) 42–45
This study aimed to highlight whether further education is required, especially to first responders, to improve consistency between them and the neurologist thereby preventing unnecessary, endangering treatments. We hypothesized that with seniority and specialty in epilepsy the percentage for correct diagnosis will be higher.
2. Methods
43
Table 1 Participants demographics.
ER doctor ER nurse Internal Medicine physician Neurology nurse General neurologist/neurology resident Neurologist: epileptologist
No of participants
Seniority range in years
9 5 12 9 7 4
2–30 2–30 0.5–20 1–29 4–32 6–31
2.1. Video recordings Ten video EEG recordings, 5 recordings of PNES and 5 ES, were chosen from a bank of video EEG monitoring in the department of neurology, Rambam Health Care Center. The videos were randomly ordered in a 13.40-minute long video sequence (with introduction and transitions). The selection of the specific cases was as follows: i. In all cases a definite diagnosis of either ES or PNES was made by a neurologist trained in Epileptology by using the clinical semiology and the concomitant EEG. ii. In all selected cases motor phenomena were observed. iii. Different types of ESs and PNESs were selected. iv. The motor phenomena were as typical as possible for each type of event. In secondary generalized the semiology included tonic clonic movements. In complex partial seizure, the semiology showed one sided automatism with contralateral dystonia and in the hypermotor seizure pronounced automatism was seen in the beginning of the seizure. The PNESs semiology contained phenomena as hyperventilation, pelvic thrusting and burst of rhythmic non variable movements, which are typically seen in PNESs [11]. v. In all selected epileptic seizures, the video showed the beginning, evolution and the end of seizure, all but one was shown in full. In the PNESs cases due to the length of seizures only part of the event was shown, with a distinct beginning and end in which the observer can appreciate the sudden burst of motor phenomena and the sudden cessation of movements. Detailed descriptions of each seizure can be seen in appendix 1. Shortly: 5 PNES videos containing generalized, hypermotor and focal seizures. 5 ES videos containing frontal hypermotor, SMA with generalization, 3 focal temporal ES; one of them with secondary generalization. The concomitant EEG recordings was not shown to the observers.
2.2. Observers and questioners
2.4. Ethics All data gathering was approved by our institutional review board.
3. Results Overall, 46 personnel participated in this study: 26 “First responders”; 9 Emergency Department physicians, 5 Emergency Department nurses, 12 Internal Medicine physicians. 20 Neurology professionals; 9 Neurology ward nurses, 7 Neurology ward physicians (specialists and residents) and 4 specialists in Epileptology. All personnel aside from three senior epileptologists are Rambam HCC medical staff. The seniority of participants varied from less than a year to 30 years' seniority, due to the structure of the hospital personnel most participants were either b10 years' seniority or more than 20. (Table 1). Overall scoring of correctly diagnosing PNES vs ES: Senior epileptologists diagnosed correctly in 87.5% of cases. General neurologists correctly diagnosed 72.8% of cases. Neurology ward nurses 69.8%, Emergency room nurses 58%, Internal Medicine physicians 54.1% and emergency room physicians 44.4%. (Fig. 1). Pairwise comparison test showed a statistical significant difference between the general physicians (ER and Internal Medicine) to all neurology group professions. Overall scoring comparison t-test between the groups p = 0.00015. Applying pairwise comparisons between the different professional groups; ER physicians had significantly lower grade compared to Neurology nurses, Neurology physicians and epileptologists, with p b 0.004, p b 0.002, p b 0.000 respectively.
Observers were briefed before viewing of the videos. Participants were informed that the purpose of the study is to determine their ability to identify ES from PNES. And that all data are anonymous. A short questionnaire following introduction included details of profession and duration of experience. Following, each video presented identical questions regarding: ES presence (yes/no), specific signs that lead them to the answer.
2.3. Statistics Statistics analysis was done using SPSS 13 for windows. For each case, a score of 10% was given for a correct diagnosis, 0 for a wrong a diagnosis. For each participant the total grade, which is the sum of all cases ranged between 0 and 100%. For each group a mean grade was calculated. One tail t Test was calculated to compare means between Internal group staff and Neurology group staff. One way ANOVA was calculated to compare means between all groups. Statistical significance was calculated as α b 0.05. Testing Reliability of the test was done by using Cronbach's test. The ability of each case to discriminate between participants who received high grades and participants who received low grades was checked by item analysis.
Fig. 1. Overall scoring: correctly diagnosing PNES or ES according to each professional group.
44
D. Wasserman, M. Herskovitz / Epilepsy & Behavior 73 (2017) 42–45
Table 2 Results divided by seniority. Seniority
Internal group
% correct
Neurology group
% correct
0–8 8–15 Above 15 years
13 4 9
46% 57% 55%
7 4 9
70% 82% 74%
Internal Medicine physicians had significantly lower grade compared to Neurology nurses, Neurology physicians and epileptologists, with p b 0.046, p b 0.030, p b 0.002 respectively. The emergency department nurses had significantly lower grades compared to epileptologists, p b 0.016 and non-significantly lower grades compared to neurology nurses and neurology physicians. Dividing the two groups to seniority there was no significant difference, of note, two young epileptologists are in the small group of young senior doctors. (Table 2). Reliability of the survey using Cronbach's analysis showed an Alpha of 0.632. The grade ranged between 20% and 100%. To make an item analysis, the participants were divided in to 3 different groups: High grade : ≥80%:Medium grade : 50%–≤70%:Low grade : b 50%: 10 ð21:7%Þ; 23 ð50%Þ and 13 ð28:3%Þ participants respectively: We found that cases 2, 7 and 9 received the lowest grades, 34%, 30% and 29% correct diagnosis respectively. All the cases including those cases made a good discrimination between the low-grade group and the high-grade group. Item analysis is shown in Fig. 2. 4. Discussion In the past years awareness has grown and some guidelines try to give tools for differentiation of PNES [12–16]. De Paola et al. published in January 2016 the percentage of improving the diagnosing ability in these first responders group with 6 item diagnostic tool, and showed that the improvement in diagnosing is similar between neurology and other caretakers [17]. There are two main findings in our study: Medical staff specialty is highly related to the chance of making a correct PNES vs ES diagnosis. Seniority in not related to the chance of making a correct diagnosis. The pairwise comparison test showed a statistical significant difference between the general physicians (ER and Internal Medicine) to all Neurology group professions. We were surprised to see that the ER
Fig. 2. Item analysis based on each case video according to the high and low grade groups.
nurses group did not show statistical significance from neurology nurses and general neurology doctors. The reasoning is that since the ER nurses come in more contact with the neurologist in the ER during the examination of these patients, their knowledge of PNES is a bit more than the general doctors that will examine these patients before or instead of the neurologist. The ability to recognize PNES from ES based on video semiology was appreciated formerly, Beniczky et al. showed in their study the ability of epileptologists to diagnose episodes correctly was 85% [18], in our research the epileptologists correctly evaluated a similar number of 87.5% of cases. Inquiring the disagreement between the first responders group to the neurology group based on individual cases, there are three cases that stand out; The first (case no. 2), a frontal, hyper-motor seizure starting from sleep with standing up in bed and stepping in place. 100% of the first responders thought this case is psychogenic. Some of the comments written: “No loss of tone or spasticity”, “No seizure characteristics”, “Moon walking”. This may point to the total lack of first responders' awareness to epileptic seizures of this type. The second most diverse case (no. 9) was a generalized rhythmic, vigorous motor PNES of a young pregnant female, head-torso-pelvis suddenly start to shake, the head stop shaking as the doctor touch her head with pelvis continuing. Correct Diagnosis in 100% among epileptologists, neurologists 57.1%, and neurology nurses 44.4%. Internal Medicine physicians, ER physicians and ER nurses' results were 33%, 11.1% and 0 respectively. Comments written by the neurology groups related to the pelvic movements as the reason of writing the episode as PNES. The third case (no. 7) is a focal PNES showing adult female with rising and movement of arm and shoulder with repetitive thrusting of the arm on the bed. Here even the general neurological groups scored below 30% however Internal Medicine physicians and ER nurses scored higher (41.6% and 60% respectively). Video EEG is still the “Gold-standard” of diagnosing PNES as “Documented diagnosis” as published by the ILEA task force, however when video-EEG is not available the clinical diagnosis is “the next best thing” [12,14,19]. Nowadays, the use of smartphone cameras is quick and accessible, enabling the video documentation of uncertain etiology episodes. Guidelines regarding the ethics of telemedicine were produced only for specific specialties such as radiology, dermatology and psychiatry or for specific clinical applications [20]. However, the WMA “Statement on the ethics in medicine” provide some basic general guidelines as; “Maintaining patient confidentiality and data integrity”; “Telemedicine should be employed primarily in situations in which a physician cannot be physically present within a safe and acceptable time period.” [21]. PNES as epilepsy is a chronic disease. When suspicion of PNES arises, proper explanation about the importance of witnessing an episode by epileptologist should be provided to the patient. Consent to family and medical personnel documentation of future episodes for diagnostic purposes can be given beforehand by the patient. This study has some limitations which needs be pointed out. The groups were not equal in their sample size. Furthermore, this applied to the selection of the video cases. As much as we tried to select classic non epileptic and epileptic semiologies as possible, one can never accurately estimate the difficulty of the survey before performing the survey. To address this issue, we took several steps; First, we checked the Reliability of the survey by using Cronbach's analysis. Our results showed the survey is reliable, meaning that every case is checking the same factor. The second step was to show the video cases to epileptologists blinded to the EEG, to see whether it is possible to differentiate clinically between the PNESs and the ESs cases. The high grade of this group assured us that it is indeed possible. The third was to check whether the hard cases differentiate between the low-grade group and the highgrade group, by using item analysis and indeed it discriminated between those groups. Hence, we believe that the survey represents a real-life situation.
D. Wasserman, M. Herskovitz / Epilepsy & Behavior 73 (2017) 42–45
In conclusion: 1. As shown here the neurologist ability to recognize epileptic seizures based upon semiology alone is higher than 70% and above 85% in experienced epileptologists. This emphasizes the need for video taking of episodes. Using telemedicine, a highly probable clinical diagnosis can be made and avoidance of unnecessary treatment can be done. 2. Education plan to first responders is needed in recognizing PNES but also in exposure to other types of episodes which are not tonicclonic as hyper motor frontal seizures or partial complex seizures. Disclosure The authors has no disclosures or conflict of interests to report. Author contribution Danielle Wasserman MD– Conceptualization of the study, Analysis and interpretation of data and revision of the manuscript. Moshe Herskovitz MD – Conceptualization of the study, Analysis and interpretation of data and revision of the manuscript. Acknowledgements To Dr. Liron Berkovitz - for video editing and Sari Eran HerskovitzFor providing statistical data analysis. Appendix A. Supplementary data Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.yebeh.2017.04.020. References [1] Benbadis S. The differential diagnosis of epilepsy: a critical review. Epilepsy Behav 2009;15:15–21. http://dx.doi.org/10.1016/j.yebeh.2009.02.024. [2] Engel J, Pedley TA. Epilepsy a comprehensive textbook; 2008. [3] Mellers JDC. Diagnosis and management of dissociative seizures. Endocrine 1997. [4] Seneviratne U, Reutens D, D'Souza W. Stereotypy of psychogenic nonepileptic seizures: insights from video-EEG monitoring. Epilepsia 2010;51:1159-68. http:// dx.doi.org/10.1111/j.1528-1167.2010.02560.x.
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