- I WOULD LIKE
	TO WELCOME EVERYONE
	
	TO OUR THIRD CALL IN OUR
	"INTRODUCTION TO EPILEPSY"
	AUDIO CALL SERIES.
	
	MY NAME IS SEAN GAMBLE,
	AND I AM WITH
	
	THE EMPLOYEE EDUCATION SERVICES
	HERE IN ST. LOUIS,
	
	AND I'M THE PROJECT MANAGER
	FOR THIS SERIES OF CALLS.
	
	THIS IS A CALL THAT
	WILL CONTINUE TO OCCUR
	EVERY OTHER MONTH
	
	ON THE FIRST WEDNESDAY
	AT 2 PM EASTERN.
	
	OUR NEXT CALL WILL
	BE ON SEPTEMBER 7th
	WITH DR. JOSE CAVAZOS.
	
	OUR LINES ARE MUTED
	AND WILL BE OPENED AT THE
	END OF THE PRESENTATION
	
	WHEN WE ARE READY FOR
	QUESTIONS AND ANSWERS.
	
	PLEASE LIMIT YOUR QUESTIONS
	TO ONE PER PERSON.
	
	PLEASE BE SURE TO COMPLETE
	YOUR EVALUATION TO GET
	CREDIT FOR THIS PROGRAM.
	
	COMPLETE DIRECTIONS
	CAN BE FOUND
	
	IN THE BROCHURE
	OR ON THE CATALOG ONLINE.
	
	YOU WILL HAVE 30 DAYS TO SUBMIT
	YOUR EVALUATION FORMS.
	
	DEADLINE DATE
	IS AUGUST 8th.
	
	NOW I'D LIKE TO WELCOME
	OUR SPEAKER FOR TODAY,
	DR. MARTIN SALINSKY.
	
	DR. SALINSKY,
	IT'S ALL YOURS.
	
	- HI. THIS IS MARTY SALINSKY
	
	FROM THE PORTLAND VA EPILEPSY
	CENTER OF EXCELLENCE.
	
	I'D LIKE TO WELCOME YOU
	ALL TO THIS CONFERENCE
	ON PSYCHOGENIC SEIZURES.
	
	WE HAVE A CROWDED
	AGENDA TODAY,
	
	SO I'M GOING TO
	START RIGHT IN.
	
	I WOULD ASK YOU ALL, IF YOU'RE
	FOLLOWING ALONG WITH THE SLIDES,
	
	TO VIEW THIS IN "NORMAL" MODE
	RATHER THAN IN "SLIDE" MODE--
	
	THAT LITTLE BUTTON AT
	THE BOTTOM OF YOUR SCREEN.
	
	THERE ARE SOME BUILDS
	THAT I INADVERTENTLY
	LEFT IN THESE SLIDES,
	
	AND IF YOU VIEW THIS
	IN NORMAL MODE, YOU WON'T
	HAVE TO DO MULTIPLE TAPS
	
	TO GET ALL OF THE ELEMENTS
	OF EACH SCREEN UP.
	
	OK. IF YOU'LL GO
	TO SLIDE NUMBER 2...
	
	"YOU'D BETTER ASK THE DOCTORS
	HERE ABOUT MY ILLNESS, SIR.
	
	ASK THEM WHETHER MY FIT
	WAS REAL OR NOT."
	
	FROM "THE BROTHERS KARAMAZOV,"
	FYODOR DOSTOEVSKY, IN 1881.
	
	AND NOW, 130 YEARS LATER,
	NEUROLOGISTS ARE STILL
	FREQUENTLY ASKED
	
	TO TELL WHETHER THE FIT
	WAS REAL OR NOT.
	
	SO OUR TOPIC TODAY IS,
	IN MY OPINION,
	
	ONE OF THE MOST FASCINATING
	TYPES OF SEIZURES
	
	AND ONE OF THE LEAST UNDERSTOOD,
	THE PSYCHOGENIC SEIZURES,
	
	AND THIS IS A SEIZURE TYPE THAT,
	I THINK, ALL VA PROVIDERS
	
	NEED TO BE FAMILIAR WITH.
	
	NEXT SLIDE IS
	SLIDE NUMBER 3.
	
	WE'LL TALK ABOUT
	3 TOPICS TODAY.
	
	FIRST, AN OVERVIEW OF
	PSYCHOGENIC SEIZURES.
	
	THEN WE'LL SPEND A FEW MINUTES
	TALKING ABOUT SOME NEW RESEARCH
	
	ON THE PROBLEM OF PSYCHOGENIC
	SEIZURES IN VETERANS.
	
	AND FINALLY, AS TIME ALLOWS,
	WE'LL SPEND A FEW MINUTES
	
	TALKING ABOUT TREATMENT
	AND PROGNOSIS.
	
	SLIDE 4.
	
	IT'S WORTH SAYING A FEW WORDS
	ABOUT EPILEPSY AS WE BEGIN.
	
	EPILEPSY IS THE
	MOST COMMON PROBLEM
	
	FACED BY NEUROLOGISTS
	IN THE WORLD.
	
	THE PREVALENCE OF
	EPILEPSY IN THE WORLD IS
	WELL OVER ONE PERCENT,
	
	MORE THAN ONE
	IN EVERY 100 PEOPLE,
	
	AND THE U.S. PREVALENCE
	IS PRETTY CLOSE TO ONE PERCENT--
	
	A LITTLE BIT HIGHER
	IN VETERANS.
	
	AND AS YOU CAN IMAGINE,
	ANY DISORDER THAT'S THIS COMMON
	
	IS GOING TO HAVE A TREMENDOUS
	IMPACT ON GLOBAL HEALTH
	
	AND IS GOING TO BE
	ENORMOUSLY EXPENSIVE,
	
	AND ANY SUBGROUP OF THIS
	POPULATION IS GOING TO BE
	
	AN IMPORTANT MEDICAL
	PROBLEM IN AND OF ITSELF.
	
	BUT OF COURSE, NOT EVERYONE
	DIAGNOSED WITH EPILEPSY
	
	IS GOING TO TURN OUT
	TO HAVE EPILEPSY,
	
	AND ON SLIDE 5, I'VE LISTED
	SEVERAL DISORDERS
	
	THAT CAN MIMIC THE APPEARANCE
	OF EPILEPTIC SEIZURES
	
	AND ARE CONFUSED
	WITH EPILEPSY IN ADULTS.
	
	SOME OF THESE ARE
	MORE COMMON THAN OTHERS.
	
	SYNCOPE, CARDIOVASCULAR
	EVENTS, ARE OBVIOUSLY
	GOING TO BE MORE COMMON
	
	THAN SLEEP DISORDERS AND
	MIGRAINE AND MOVEMENT DISORDERS
	
	AS FAR AS BEING CONFUSED
	WITH EPILEPTIC SEIZURES.
	
	BUT BY FAR,
	THE MOST COMMON DISORDERS
	
	THAT MIMIC EPILEPSY
	IN THE ADULT POPULATION
	
	ARE PSYCHOLOGICAL DISORDERS,
	
	AND PARTICULARLY WHAT WE TERM
	THE PSYCHOGENIC SEIZURES.
	
	THAT'S OUR TOPIC FOR TODAY.
	
	LET'S GO TO SLIDE 6.
	
	I HAVE A COUPLE OF
	DEFINITIONS WRITTEN OUT.
	
	A NON-EPILEPTIC SEIZURE IS
	AN ALTERATION IN BEHAVIOR
	
	THAT RESEMBLES
	AN EPILEPTIC SEIZURE
	
	BUT IT IS NOT CAUSED BY
	PAROXYSMAL NEURONAL DISCHARGES,
	
	THE ROOT CAUSE OF
	EPILEPTIC SEIZURES.
	
	AND PSYCHOGENIC SEIZURES
	ARE A SUBCATEGORY OF
	NON-EPILEPTIC SEIZURE
	
	IN WHICH THERE IS NO OTHER
	PHYSIOLOGIC ABNORMALITY
	TO EXPLAIN THE EPISODE
	
	AND IN WHICH THERE IS
	A PROBABLE PSYCHOLOGICAL
	ORIGIN TO THE EPISODE.
	
	THIS SAME IS PRESENTED
	IN CHART FORM IN SLIDE NUMBER 7.
	
	YOU CAN SEE THAT THE SEIZURES
	CAN BE BROKEN DOWN
	
	INTO EPILEPTIC SEIZURES--
	
	THAT'S A TOPIC FOR
	A DIFFERENT DAY--
	
	AND NON-EPILEPTIC SEIZURES,
	THESE SEIZURE LOOKALIKES.
	
	AND THEN WE CAN BREAK THE
	NON-EPILEPTIC SEIZURES DOWN
	
	INTO THOSE OF
	PHYSIOLOGIC ORIGIN--
	
	AND THERE'S A DIFFERENTIAL
	DIAGNOSIS THERE, SYNCOPE,
	HYPOGLYCEMIA , SO ON--
	
	AND NON-EPILEPTIC SEIZURES
	OF PSYCHOGENIC ORIGIN.
	
	AND AGAIN, THERE'S A
	DIFFERENTIAL DIAGNOSIS HERE--
	
	MALINGERING OR SOMATOFORM
	DISORDER, DISSOCIATIVE
	DISORDER, AND SO ON.
	
	IT'S OF SOME INTEREST
	TO OUR DISCUSSION TODAY
	
	THAT IN AN ADULT POPULATION
	WITH NON-EPILEPTIC SEIZURES,
	
	ROUGHLY 90% WILL BE SHOWN TO
	HAVE A PSYCHOGENIC ORIGIN,
	
	AND ONLY 10% WILL HAVE
	A PHYSIOLOGIC ORIGIN.
	
	IT'S ALSO IMPORTANT
	TO NOTE THAT MANY, IF NOT
	MOST, OF THESE PATIENTS
	
	WILL FIT INTO THE CATEGORY
	OF HAVING MEDICALLY
	REFRACTORY SEIZURES--
	
	THAT IS, SEIZURES THAT HAVE NOT
	RESPONDED TO MULTIPLE TRIALS
	
	OF CONVENTIONAL
	ANTI-EPILEPTIC DRUG THERAPY.
	
	AND I MENTION THIS BECAUSE
	THIS GROUP OF PATIENTS
	
	WITH MEDICALLY
	REFRACTORY SEIZURES
	
	IS, IN GENERAL,
	THE MOST DISABLED GROUP
	OF EPILEPSY PATIENTS,
	
	AND THEY'RE ALSO THE MOST
	EXPENSIVE GROUP TO TREAT.
	
	THE NEXT SLIDE,
	SLIDE NUMBER 8,
	
	SHOWS THE FREQUENCY
	OF PSYCHOGENIC SEIZURES
	
	FROM SEVERAL INPATIENT
	VIDEO-EEG STUDIES.
	
	I'VE LISTED THESE, I THINK,
	IN CHRONOLOGICAL ORDER,
	
	INCLUDING A SERIES
	WE DID HERE
	
	AT THE PORTLAND VA
	MEDICAL CENTER,
	
	AND WHAT YOU CAN SEE IS
	
	THAT SOMEWHERE BETWEEN
	20% AND 50% OF PATIENTS
	
	WHO COME INTO AN
	EPILEPSY MONITORING UNIT
	
	FOR A VIDEO-EEG EVALUATION
	
	WILL EXIST WITH A DIAGNOSIS
	OF PSYCHOGENIC SEIZURES.
	
	SO IT SEEMS THESE EVENTS
	ARE VERY COMMON.
	
	SLIDE NUMBER 9 SHOWS AN
	OUTPATIENT PREVALENCE ESTIMATE
	
	FOR PSYCHOGENIC SEIZURES,
	
	AND OBVIOUSLY
	THIS IS AN ESTIMATE.
	
	WE REALLY DON'T KNOW HOW MANY
	OUTPATIENTS WITH EPILEPSY
	
	HAVE PSYCHOGENIC SEIZURES,
	
	BUT AT LEAST A COUPLE
	OF THESE ESTIMATES ARE,
	I THINK, FAIRLY RELIABLE.
	
	AND IT LOOKS LIKE 4% TO 5%
	OF EPILEPSY OUTPATIENTS
	
	ACTUALLY HAVE
	PSYCHOGENIC SEIZURES.
	
	NOW, BECAUSE THESE
	PATIENTS TEND TO FALL
	
	INTO THE CATEGORY OF
	MEDICALLY REFRACTORY SEIZURES,
	
	IT TURNS OUT THAT 10% TO 20%
	OF PATIENTS WITH MEDICALLY
	REFRACTORY EPILEPSY
	
	WILL HAVE
	PSYCHOGENIC SEIZURES.
	
	THAT'S A FAIRLY
	SIZABLE GROUP.
	
	ON SLIDE 10, I HAVE LISTED
	SOME OBSERVATIONS
	
	THAT CAN BE HELPFUL
	IF YOU'RE FORTUNATE ENOUGH
	
	TO VIEW ONE
	OF THESE SEIZURES
	
	AND YOU'RE TRYING TO
	FIGURE OUT WHETHER IT'S
	PSYCHOGENIC OR NOT.
	
	AT THIS POINT IN THE
	TALK, I WOULD USUALLY
	SHOW YOU SOME VIDEOS
	
	TO HELP YOU RECOGNIZE
	THESE SEIZURES,
	
	BUT THAT'S NOT GOING
	TO BE POSSIBLE TODAY.
	
	WHEN YOU'RE DEALING WITH
	CONVULSIVE SEIZURES,
	
	THE MOST IMPORTANT
	THINGS TO LOOK FOR ARE
	THE BODY MOVEMENTS,
	
	THE WAY THE PATTERN OF
	BODY MOVEMENT PROGRESSES,
	
	AND ON SLIDE 11, I'VE GIVEN
	A COUPLE OF IMPORTANT EXAMPLES.
	
	IN EPILEPTIC SEIZURES,
	
	THE JERKING PHASE, OR THE CLONIC
	ACTIVITY, IS IN PHASE.
	
	THE ARMS AND THE
	LEGS MOVE TOGETHER,
	
	LEFT AND RIGHT
	BOTH TOGETHER.
	
	BUT IN THE NON-EPILEPTIC
	OR PSYCHOGENIC VARIETY,
	
	THE MOVEMENTS ARE
	OFTEN THRASHING
	
	AND VERY MUCH
	OUT OF PHASE,
	
	OR EVEN BICYCLING
	ON OCCASION.
	
	IN THE EPILEPTIC SEIZURE,
	
	DURING THE RIGID PHASE,
	OR THE TONIC PHASE,
	
	PATIENTS WILL SOMETIMES
	HAVE ARCHING OF THE BACK,
	
	CALLED OPISTHOTONUS,
	
	BUT YOU WILL NOT
	SEE THIS PHENOMENON
	
	CALLED PELVIC THRUSTING,
	
	A REPETITIVE THRUSTING
	ABOUT THE WAIST
	
	WHICH FOR SOME REASON
	IS PECULIAR TO THESE
	PSYCHOGENIC SEIZURES.
	
	AND IF YOU GO TO SLIDE 12,
	
	YOU'LL SEE A DRAWING
	OF A PATIENT
	
	AT THE END OF ONE OF THESE
	EPISODES OF PELVIC THRUSTING
	
	ADOPTING THIS RATHER
	EXTREME POSTURE,
	
	WHICH WE STILL SEE
	IN PATIENTS TO THIS DAY,
	
	NAMED THE ARC DE CERCLE
	BY CHARCOT AND HIS COLLEAGUES
	
	IN THE LATE 1800s.
	
	THIS IS A PLATE FROM A BOOK
	
	CALLED THE "ICONOGRAPHIE
	PHOTOGRAPHIQUE,"
	
	WHICH HAS BEEN REPRINTED
	AND I WOULD RECOMMEND TO YOU.
	
	IT'S REALLY A FASCINATING
	SERIES OF PHOTOGRAPHS
	
	AND DRAWINGS OF PATIENTS
	
	WHO WERE BEING TREATED
	FOR HYSTERIA IN FRANCE
	IN THE LATE 1800s.
	
	AND ON THE NEXT SLIDE, I HAVE
	A PICTURE OF CHARCOT HIMSELF,
	
	THE FAMOUS MASTER WHO REALLY
	PUT THIS DISORDER ON THE MAP
	
	UNDER THE NAME OF
	HYSTERO-EPILEPSY
	
	IN THE LATE 1800s.
	
	NEXT SLIDE.
	
	THIS IS A PLATE
	FROM AN ARTICLE
	
	IN "THE BRITISH MEDICAL
	JOURNAL" IN 1878
	
	BY ONE ARTHUR GAMGEE, MD,
	WHO WAS CHARGED WITH RECORDING
	
	THE DEMONSTRATIONS GIVEN
	BY PROFESSOR CHARCOT
	
	IN HIS LABORATORY IN PARIS
	
	WHERE MANY FAMOUS PHYSICIANS
	OF THE DAY CAME TO STUDY.
	
	AND IN THIS ARTICLE,
	HE SAYS,
	
	"HYSTERO-EPILEPSY IS
	A NERVOUS DISORDER OF WOMEN
	
	"OF GREAT RARITY,
	
	"AFFECTING THEM ESPECIALLY
	
	"DURING THE CHILDBEARING
	PERIOD OF LIFE...
	
	ASSOCIATED WITH HYPERAESTHESIA
	OF ONE OR BOTH OVARIAN REGIONS."
	
	AND THIS WAS THE
	THOUGHT OF THE DAY.
	
	NOW, AS IT TURNS OUT, CHARCOT
	HAD THE WHOLE THING WRONG.
	
	CHARCOT THOUGHT EPILEPSY WAS
	A PSYCHOLOGICAL DISORDER,
	
	AND HE THOUGHT HYSTERO-EPILEPSY
	WAS A COMBINATION OF
	
	THE TWO PSYCHOLOGICAL DISORDERS,
	EPILEPSY AND HYSTERIA.
	
	AND ON THE NEXT SLIDE,
	YOU'LL SEE A PICTURE
	
	OF ONE OF CHARCOT'S STUDENTS,
	JOSEPH BABINSKI,
	
	THE MAN WHO INVENTED
	THE BABINSKI TOE SIGN
	OR THE BABINSKI REFLEX,
	
	AND HIS STUDENT BABINSKI,
	SEVERAL YEARS LATER,
	
	SET CHARCOT RIGHT
	BY INFORMING HIM
	
	THAT MOST OF THE PATIENTS HE
	DIAGNOSED WITH HYSTERO-EPILEPSY
	
	HAD NO SPONTANEOUS ATTACKS.
	
	THEY WERE ONLY HAVING
	ATTACKS WHEN CHARCOT
	WOULD HYPNOTIZE THEM
	
	AND SUGGEST THAT THEY
	HAVE AN ATTACK.
	
	AND IF YOU READ THE
	ORIGINAL DESCRIPTIONS
	OF CHARCOT'S PATIENTS,
	
	THAT'S EXACTLY WHAT HE DID.
	
	NEXT SLIDE.
	
	IT WAS ANOTHER ONE
	OF CHARCOT'S STUDENTS,
	
	SIGMUND FREUD,
	
	WHO CHIMED IN ON THIS TOPIC
	A BIT LATER.
	
	YOU REMEMBER THAT
	I OPENED UP
	
	WITH A QUOTE FROM
	FYODOR DOSTOEVSKY
	
	IN "THE BROTHERS KARAMAZOV."
	
	I'VE REPRODUCED THAT QUOTE
	AT THE BOTTOM OF THE PAGE.
	
	AND IN 1928, IN A NOW
	VERY FAMOUS ARTICLE
	
	CALLED "DOSTOEVSKY
	AND PARRICIDE,"
	
	FREUD OPINED THAT
	DOSTOEVSKY HIMSELF SUFFERED
	FROM HYSTERO-EPILEPSY,
	
	AND THIS WAS CAUSED
	BY A LATENT DESIRE TO
	MURDER HIS OWN FATHER.
	
	THOSE WERE
	THE GOOD OLD DAYS.
	
	NEXT SLIDE, AND WE'RE NOW
	UP TO SLIDE 17--
	
	OTHER OBSERVATIONS
	THAT MIGHT BE HELPFUL
	
	IF YOU HAPPEN TO SEE
	ONE OF THESE SEIZURES--
	
	AND I WOULD LIKE TO POINT OUT
	ONE OF MY FAVORITES,
	
	WHICH IS THE DURATION
	OF THE ATTACK.
	
	ON SLIDE 18,
	YOU'LL SEE A CHART
	
	THAT WE MADE UP MANY YEARS AGO
	WHEN WE ACTUALLY
	
	DID THIS EXPERIMENT FOR A
	COMPLETELY DIFFERENT REASON.
	
	IT SHOWS THE LENGTH
	OF SEVERAL SEIZURES
	
	THAT WE RECORDING IN OUR
	EPILEPSY MONITORING UNIT,
	
	AND IN THE YELLOW ARE
	THE EPILEPTIC SEIZURES.
	
	YOU CAN SEE THAT
	EPILEPTIC SEIZURES
	
	GENERALLY LAST FOR A MINUTE,
	MAYBE 2 OR 3 MINUTES TOPS.
	
	OCCASIONALLY, YOU CAN
	SEE ONE A BIT LONGER.
	
	BUT THESE PSYCHOGENIC
	SEIZURES HAVE A MUCH MORE
	VARIABLE PATTERN,
	
	AND IT IS NOT UNCOMMON
	TO SEE THEM LAST 5 MINUTES,
	
	10 MINUTES, 20 MINUTES,
	OR EVEN 2 OR 3 HOURS AT A TIME.
	
	SO IF YOU HAPPEN TO SEE
	A SEIZURE OR HEAR OF A SEIZURE
	
	THAT LASTED AN
	EXTREMELY LONG TIME,
	
	THE ANTENNAS SHOULD GO UP,
	
	AND YOU SHOULD AT LEAST
	CONSIDER THE POSSIBILITY
	
	THAT THIS MIGHT NOT HAVE
	BEEN AN EPILEPTIC SEIZURE.
	
	IT MIGHT HAVE BEEN
	A PSYCHOGENIC SEIZURE.
	
	SLIDE 19.
	
	THE DIAGNOSIS OF
	PSYCHOGENIC SEIZURES RESTS
	
	ON A LABORATORY EVALUATION,
	
	AND IN THIS CASE,
	
	THE LABORATORY EVALUATION IS
	ELECTROENCEPHALOGRAPHY, OR EEG.
	
	BUT IN ORDER TO
	MAKE THE DIAGNOSIS,
	
	IT HAS TO BE AN ICTAL EEG--
	AN EEG RECORDED
	
	WHILE THE PATIENT IS
	ACTUALLY HAVING THE EVENT,
	
	NOT IN BETWEEN EVENTS.
	
	THERE ARE A COUPLE
	OF REASONS FOR THIS,
	
	AND I'VE OUTLINED THESE
	REASONS ON SLIDE 20.
	
	FIRST OF ALL, ABOUT 30% OF
	PATIENTS WHO HAVE REAL EPILEPSY
	
	WILL HAVE NO
	INTERICTAL DISCHARGES,
	
	EVEN IF YOU DO
	MULTIPLE EEGs.
	
	SO A NORMAL INTERICTAL EEG
	
	CANNOT BE USED TO
	RULE OUT EPILEPSY.
	
	SECONDLY, THERE ARE MANY PEOPLE
	WHO DO NOT HAVE EPILEPSY
	
	WHO HAVE INTERICTAL
	EPILEPTIFORM DISCHARGES
	
	IN THEIR EEG.
	
	IT'S A NONSPECIFIC FINDING.
	
	SO AN EPILEPTIFORM
	INTERICTAL EEF
	
	CANNOT BE USED TO
	DIAGNOSE EPILEPSY,
	
	AND IT CERTAINLY CANNOT
	BE USED TO RULE OUT
	
	NON-EPILEPTIC
	OR PSYCHOGENIC SEIZURES.
	
	THIRDLY--NEXT SLIDE--
	THERE ARE MANY PATIENTS
	
	WHO HAVE BOTH PSYCHOGENIC
	SEIZURES AND EPILEPTIC SEIZURES,
	
	AND THIS IS A SITUATION
	YOU CAN'T HOPE TO
	POSSIBLY TEASE APART
	
	UNLESS YOU HAVE
	AN ICTAL RECORDING
	
	OF BOTH TYPES OF SPELLS.
	
	I'VE LISTED 6 SERIES HERE
	THAT LOOKED AT THE RATE
	
	OF HAVING BOTH PSYCHOGENIC
	SEIZURES AND EPILEPTIC SEIZURES.
	
	DEPENDING ON THE STUDY,
	
	THIS RANGES ANYWHERE
	FROM 5% TO AS HIGH AS 30%.
	
	SLIDE 22.
	
	SO IT IS THE ICTAL EEG THAT
	IS THE DIAGNOSTIC MODALITY
	
	FOR PSYCHOGENIC
	NON-EPILEPTIC SEIZURES,
	
	AND IN ORDER TO DO
	AN ICTAL EEG,
	
	WE HAVE TO ADMIT PATIENTS
	TO THE HOSPITAL,
	
	TO AN EPILEPSY MONITORING UNIT,
	
	AND PERFORM CONTINUOUS INPATIENT
	VIDEO-EEG MONITORING.
	
	AND SINCE WE HAVE THE
	PATIENT IN THE HOSPITAL,
	
	WE LIKE TO DO
	A COMPREHENSIVE EVALUATION,
	
	WHICH INCLUDES NOT ONLY
	A NEUROLOGICAL EVALUATION,
	
	BUT A PSYCHIATRIC EVALUATION
	
	AND A NEUROPSYCHOLOGICAL
	EVALUATION.
	
	THIS GIVES US THE MOST
	COMPLETE PICTURE
	
	OF THESE OFTEN
	VERY COMPLEX PATIENTS.
	
	PLEASE SKIP THE NEXT TWO SLIDES
	AND GO ON TO SLIDE 25.
	
	THIS PIE CHART ON SLIDE 25
	IS A SERIES OF 58 PATIENTS
	
	THAT WE STUDIED HERE AT
	THE PORTLAND VA HOSPITAL.
	
	THEY WERE STUDIED
	BY SUSAN SMITH,
	
	A PSYCHIATRIST THAT WE WERE
	WORKING WITH AT THE TIME,
	
	AND FOR EACH PATIENT,
	SHE SELECTED
	
	ONE PRIMARY AXIS I PSYCHIATRIC
	DIAGNOSIS FROM DSM-3.
	
	THIS PIE CHART SHOWS YOU THE
	RESULT, AND AS YOU CAN SEE,
	
	A MAJORITY OF PATIENTS DIAGNOSES
	WITH PSYCHOGENIC SEIZURES
	
	WERE DIAGNOSED WITH SOMATOFORM
	OR CONVERSION DISORDERS--
	
	MORE THAN 50%.
	
	THERE IS A FAIR
	REPRESENTATION
	
	OF PATIENTS WITH
	DISSOCIATIVE DISORDERS,
	
	AND I WOULD POINT OUT THAT
	
	BOTH THE SOMATOFORM DISORDERS
	AND DISSOCIATIVE DISORDERS
	
	ASSUME THAT THE MOTIVATION
	FOR HAVING THESE SEIZURES
	
	IS SUBCONSCIOUS AND THAT
	THE PATIENTS ARE NOT AWARE
	
	THAT THESE SEIZURES
	ARE NOT REAL.
	
	MALINGERING IS REPRESENTED
	HERE, AS WELL,
	
	BUT IT'S NOT AS COMMON
	AS MOST PEOPLE THINK.
	
	IN OUR SERIES, WE ONLY
	FOUND EVIDENCE FOR THIS
	
	IN 8% OF PATIENTS,
	
	AND IN MOST SERIES,
	IT'S LESS THAN 10%.
	
	AND FACTITIOUS DISORDER,
	ANOTHER 6%.
	
	MALINGERING AND FACTITIOUS
	DISORDER ARE IMPORTANT DIAGNOSES
	
	BECAUSE IT IS ASSUMED
	IN THESE CASES
	
	THAT THE PATIENTS ARE ACTUALLY
	FAKING THE SEIZURES--
	
	THEY'RE CONSCIOUS
	OF WHAT THEY'RE DOING--
	
	FOR EITHER FINANCIAL GAIN
	OR SOME OTHER TYPE OF GAIN.
	
	ON SLIDE 26, I'VE LISTED
	SOME OF THE RESULTS
	
	FROM, I THINK, THE BEST
	PSYCHIATRIC STUDY DONE
	
	ON PATIENTS WITH
	PSYCHOGENIC SEIZURES.
	
	THIS WAS A STUDY DONE BY
	ELIZABETH BOWMAN IN 1996.
	
	AND I JUST WANT
	TO EMPHASIZE TO YOU
	
	THAT PSYCHOGENIC SEIZURES SHOULD
	BE CONSIDERED AS A SYMPTOM
	
	OF UNDERLYING
	PSYCHIATRIC DISEASE.
	
	THEY'RE REALLY NOT A DISEASE
	STATE IN AND OF THEMSELVES.
	
	THEY'RE A SYMPTOM,
	
	AND UNDERSTANDING THE UNDERLYING
	PSYCHIATRIC PROBLEMS
	
	IS ULTIMATELY THE KEY
	TO SUCCESSFUL TREATMENT.
	
	ANYWAY, IN THIS STUDY,
	
	DR. BOWMAN LOOKED
	AT 45 PATIENTS,
	
	AND I'LL POINT OUT THAT
	35 OF THE 45 WERE WOMEN,
	
	AND MUCH AS CHARCOT
	SURMISED BACK IN THE 1800s,
	
	MOST PATIENTS, ABOUT 75%,
	WHO ARE DIAGNOSED WITH
	PSYCHOGENIC SEIZURES
	
	IN THE CIVILIAN POPULATION,
	ARE WOMEN,
	
	AND IT'S A DISEASE
	LARGELY OF YOUNGER WOMEN.
	
	ALL OF THESE PATIENTS
	WERE DIAGNOSED WITH
	PSYCHOGENIC SEIZURES
	
	BY VIDEO-EEG MONITORING,
	
	AND DR. BOWMAN EXAMINED
	THESE PATIENTS USING SCID,
	
	WHICH IS A STRUCTURED CLINICAL
	INTERVIEW FOR DSM--
	
	IN THIS CASE, DSM-3--
	
	AND IS A SORT
	OF GOLD STANDARD
	
	FOR DOING OBJECTIVE
	PSYCHIATRIC EVALUATIONS.
	
	A COUPLE OF HISTORICAL
	THINGS TO POINT OUT HERE.
	
	FIRST OF ALL,
	THERE WAS A HISTORY
	
	OF PHYSICAL OR SEXUAL
	ABUSE IN CHILDHOOD
	
	IN A GREAT MAJORITY OF
	THE WOMEN IN THE STUDY,
	
	AND SEVERAL OTHER STUDIES
	HAVE REPRODUCED THIS FINDING.
	
	SECONDLY, NEARLY HAVE OF
	THE PATIENTS IN THE STUDY
	
	HAD A HISTORY
	OF SUBSTANCE ABUSE,
	
	AND THAT, AGAIN,
	IS COMMON FINDING
	
	IN PSYCHIATRIC STUDIES
	OF PSYCHOGENIC SEIZURES.
	
	SLIDE 27 LISTS THE AXIS I
	AND AXIS II DIAGNOSES
	
	MADE BY DR. BOWMAN,
	
	AND IN THIS STUDY, SHE ALLOWED
	MULTIPLE AXIS I DIAGNOSES.
	
	AND ONCE AGAIN, AS IN
	DR. SMITH'S STUDY,
	
	THE MOST COMMON DIAGNOSES
	WERE SOMATOFORM AND
	CONVERSION DISORDERS.
	
	DISSOCIATIVE DISORDERS,
	IN THIS CASE, IN 91%,
	
	BUT MANY AXIS I DIAGNOSES
	ARE REPRESENTED--
	
	AFFECTIVE DISORDERS IN
	A MAJORITY OF PATIENTS,
	
	OTHER ANXIETY DISORDERS IN
	NEARLY HALF OF THE PATIENTS--
	
	AND PERSONALITY DISORDERS,
	AXIS II,
	
	CAME IN IN MORE THAN
	60% OF PATIENTS.
	
	IN THIS STUDY, THE MEAN NUMBER
	OF CURRENT AXIS I DIAGNOSES
	
	AT THE TIME OF THE DIAGNOSIS
	OF PSYCHOGENIC SEIZURES WAS 4.4,
	
	AND I BRING THIS UP
	TO POINT OUT THAT
	
	AT THE TIME THAT THESE
	PATIENTS WERE DIAGNOSED,
	
	THEY CAME IN WITH A HEAVY LOAD
	OF PSYCHIATRIC DIAGNOSES.
	
	AND AGAIN, I THINK THIS IS
	A TIP-OFF FOR ALL OF US.
	
	WHEN YOU SEE PATIENTS
	WITH SEIZURE DISORDERS
	
	WHO ARE CARRYING A HEAVY LOAD
	OF PSYCHIATRIC DIAGNOSES,
	
	THE ANTENNAS SHOULD GO UP
	TO ALERT YOU TO THE POSSIBILITY
	
	OF PSYCHOGENIC
	NON-EPILEPTIC SEIZURES.
	
	THE FINAL POINT
	ON THIS SLIDE IS THAT
	
	NEARLY HALF OF THE PATIENTS
	IN THIS STUDY HAD PTSD--
	
	POST-TRAUMATIC STRESS DISORDER--
	
	AND THAT'S SOMETHING THAT
	WE'LL BE INTERESTED IN
	
	WHEN WE DISCUSS PSYCHOGENIC
	SEIZURES IN VETERANS
	
	HERE IN A MOMENT.
	
	AND WE CAN MOVE ON NOW
	TO SLIDE 29--
	
	THE IMPACT OF THE
	EPILEPSY DIAGNOSIS--
	
	AND I WANT TO POINT OUT
	SOMETHING WHICH I HOPE
	IS OBVIOUS TO YOU.
	
	PATIENTS WITH
	PSYCHOGENIC SEIZURES
	
	ARE JUST AS DISABLED AS
	PATIENTS WITH EPILEPSY,
	
	AND IN FACT,
	THEY'RE JUST AS DISABLED
	
	AS PATIENTS WHO HAVE
	MEDICALLY REFRACTORY EPILEPSY,
	
	THE MOST DISABLED GROUP
	IN THE EPILEPSY POPULATION.
	
	THEY SUFFER FROM
	THE SAME RESTRICTIONS
	
	ON DRIVING AND WORKING
	AND OTHER ACTIVITIES.
	
	THERE'S THE SOCIAL STIGMA
	ASSOCIATED WITH HAVING EPILEPSY
	
	AND THE PSYCHOLOGICAL PROBLEMS
	THAT COME ALONG WITH THAT,
	
	AND THERE IS
	THE CONSIDERABLE COST
	
	OF THE ASSESSMENTS
	AND TREATMENTS.
	
	IF YOU GO TO THE NEXT SLIDE,
	
	I HAVE A COST ESTIMATE
	AT THE BOTTOM.
	
	FOR 2010, IT'S ESTIMATED
	THAT PSYCHOGENIC SEIZURES
	
	WILL COST THE UNITED STATES
	
	SOMEWHERE BETWEEN 2.3
	AND 4.8 BILLION DOLLARS.
	
	EPILEPSY IS A VERY
	EXPENSIVE DISORDER,
	
	MEDICALLY REFRACTORY
	EPILEPSYEXTREMELY EXPENSIVE,
	
	AND PATIENTS WITH PSYCHOGENIC
	SEIZURES TEND TO MIMIC THE COSTS
	
	OF PATIENTS WITH MEDICALLY
	REFRACTORY EPILEPSY.
	
	NEXT SLIDE--SLIDE 31.
	
	I WOULD ALSO POINT OUT
	THAT PATIENTS WITH
	PSYCHOGENIC SEIZURES
	
	CAN SUFFER THE MEDICAL
	COMPLICATIONS OF THERAPY,
	
	AND PARTICULARLY
	ANTI-EPILEPTIC DRUG THERAPY.
	
	ON SLIDE 32,
	I'VE SHOWN THE RESULTS
	
	OF A COUPLE OF STUDIES THAT
	WE'VE DONE ON OUR PATIENTS
	
	AT THE OREGON
	HEALTH SCIENCES UNIVERSITY,
	
	OUR AFFILIATED
	UNIVERSITY HOSPITAL,
	
	ONE SERIES IN 1994
	AND ANOTHER IN 2005,
	
	IN WHICH WE SIMPLY LOOKED AT
	HOW MANY ANTI-EPILEPTIC DRUGS
	
	PATIENTS WERE TAKING AT THE TIME
	THAT THEY WERE ADMITTED
	
	TO THE EPILEPSY
	MONITORING UNIT
	
	AND DIAGNOSED WITH
	PSYCHOGENIC SEIZURES.
	
	AS YOU CAN SEE,
	IN BOTH SERIES,
	
	ABOUT 90% OF PATIENTS WERE
	TAKING ANTI-EPILEPTIC DRUGS,
	
	AND MANY OF THEM WERE
	TAKING MORE THAN ONE
	ANTI-EPILEPTIC DRUG.
	
	AND AS YOU KNOW, THESE DRUGS
	ALL HAVE SIDE EFFECTS,
	
	AND THERE ARE POTENTIAL
	COMPLICATIONS.
	
	WE'VE ALSO HAD MANY
	PATIENTS ADMITTED TO
	THE INTENSIVE CARE UNIT
	
	IN PSYCHOGENIC STATUS
	PEPILETICUS.
	
	SEVERAL OF THESE PATIENTS
	WERE INTUBATED.
	
	THEY WERE STUCK
	WITH ALL SORTS OF LINES
	
	AND GIVEN
	ALL SORTS OF DRUGS,
	
	WITH THE EXPECTED COMPLICATIONS.
	
	SO THIS DISORDER
	IS NOT BENIGN.
	
	NEXT SLIDE.
	
	I'D NOW LIKE TO TURN
	TO OUR SECOND TOPIC,
	
	WHICH IS PSYCHOGENIC SEIZURES
	IN VETERANS.
	
	WE BECAME INTERESTED IN THIS
	
	BECAUSE OF THE WIDESPREAD
	FEELING THAT SOMEHOW,
	
	PSYCHOGENIC SEIZURES ARE
	MORE COMMON IN VETERANS
	
	THAN THEY ARE IN CIVILIANS,
	
	AND THIS HAS REALLY NOT BEEN
	LOOKED AT VERY CAREFULLY.
	
	THERE'S ACTUALLY ONLY
	ONE PAPER IN THE LITERATURE
	
	ON PSYCHOGENIC SEIZURES
	IN VETERANS,
	
	AND THAT PAPER WRITTEN
	A NUMBER OF YEARS AGO,
	
	AND A RELATIVELY SMALL
	GROUP OF PATIENTS.
	
	SO WE DECIDED TO
	DO A CHART REVIEW
	
	AND LOOK AT SOME OF OUR PATIENTS
	WITH PSYCHOGENIC SEIZURES,
	
	AND BEFORE WE GET TO THAT,
	I JUST NEED TO MAKE
	ONE OR TWO QUICK POINTS
	
	ABOUT THE RELATIONSHIP
	BETWEEN TRAUMATIC BRAIN
	INJURY AND EPILEPSY.
	
	NEXT SLIDE--SLIDE 34,
	IF YOU'VE JUST JOINED US.
	
	TRAUMATIC BRAIN INJURY
	IS THE MOST COMMON CAUSE
	
	OF NEW-ONSET EPILEPSY
	IN YOUNG ADULTS.
	
	I THINK MOST OF
	YOU KNOW THAT.
	
	AND THERE'S AN
	EVEN HIGHER RISK
	
	IF IT IS A MILITARY COMBAT
	TRAUMATIC BRAIN INJURY.
	
	A RECENT REPORT FROM
	THE VIETNAM HEAD INJURY STUDY
	
	PEGS THIS AT 45%.
	
	THAT'S AN INCREDIBLY
	HIGH NUMBER.
	
	THIS MAY BE DUE TO THE
	RELATIVELY HIGH RATE
	
	OF PENETRATING
	HEAD INJURIES IN COMBAT.
	
	THESE PENETRATING HEAD INJURIES
	HAVE A VERY HIGH RISK
	
	OF DEVELOPMENT OF EPILEPSY.
	
	SLIDE 35.
	
	WHAT'S LESS WELL KNOWN
	IS THAT THERE IS ALSO
	
	THIS SORT OF
	FUNNY RELATIONSHIP
	
	BETWEEN TRAUMATIC
	BRAIN INJURY
	
	AND THE DEVELOPMENT OF
	PSYCHOGENIC SEIZURES.
	
	THERE ARE TWO
	STUDIES ON THIS
	
	THAT I HAVE QUOTED
	ON THAT SLIDE,
	
	AND IN BOTH OF THESE STUDIES,
	THE AUTHORS LOOKED
	
	AT A GROUP OF PATIENTS
	WITH PSYCHOGENIC SEIZURES
	
	AT THE TIME THAT
	THEY WERE DIAGNOSED
	
	AND ASKED THEM WHAT
	CAUSED THE SEIZURES.
	
	AND IN BOTH STUDIES,
	THE MOST COMMON SINGLE RESPONSE
	
	WAS THAT THE SEIZURES
	WERE CAUSED
	
	BY A TRAUMATIC BRAIN INJURY.
	
	AND THESE ARE
	CIVILIAN STUDIES.
	
	MOST OF THESE TRAUMATIC
	BRAIN INJURIES
	
	WERE WHAT WOULD BE CALLED
	EITHER MINOR OR MILD,
	
	AND WE NOW HAVE
	REASON TO BELIEVE
	
	THAT HEAD INJURIES OF THIS
	SEVERITY ARE NOT ASSOCIATED
	
	WITH AN INCREASED
	RISK OF SEIZURES.
	
	BUT OF COURSE,
	THE PATIENTS DON'T KNOW THAT.
	
	THEY START DEVELOPING SPELLS,
	AND THEY BLAME IT
	
	ON SOME TRAUMA
	THAT THEY'VE HAD.
	
	THE PSYCHOLOGISTS TELL ME
	THE NAME FOR THIS
	
	 IS A PERMISSIVE EVENT.
	
	THE TRAUMATIC BRAIN INJURY
	IS A PERMISSIVE EVENT,
	
	AND LATER, UNDER
	PSYCHOLOGICAL STRESS,
	
	 PATIENTS DEVELOP
	 PSYCHOGENIC SEIZURES,
	
	FEELING THAT THE TRAUMATIC
	BRAIN INJURY WAS WHAT MADE THEM
	
	MORE SUSCEPTIBLE TO
	DEVELOPING SEIZURES.
	
	SLIDE 36.
	
	THERE ARE REASONS
	TO BELIEVE THAT
	
	VETERANS ARE AT
	AN INCREASED RISK
	
	FOR THE DEVELOPMENT
	OF PSYCHOGENIC SEIZURES.
	
	FIRST IS THE RELATIVELY HIGH
	RATES OF TRAUMATIC BRAIN INJURY,
	
	AND WE'VE JUST
	DISCUSSED THAT.
	
	AND TO SOME EXTENT
	RELATED TO THIS
	
	ARE THE RELATIVELY HIGH RATES OF
	POST-TRAUMATIC STRESS DISORDER,
	
	RECENTLY ESTIMATED
	TO BE ABOUT 20%
	
	IN THE OEF/OIF VETERAN.
	
	AND AS I MENTIONED EARLIER,
	
	POST-TRAUMATIC STRESS DISORDER
	IS AN ESTABLISHED RISK FACTOR
	
	FOR THE DEVELOPMENT OF
	PSYCHOGENIC SEIZURES.
	
	THE THIRD POINT
	ON THIS SLIDE
	
	IS ONE WE DON'T USUALLY
	LIKE TO TALK ABOUT.
	
	IT'S THE ISSUE
	OF COMPENSATION,
	
	AND IT IS A FACT THAT
	IN THE VA MEDICAL SYSTEM,
	
	PATIENTS CAN EXTRACT
	SOME FINANCIAL GAIN
	
	FROM HAVING A CHRONIC ILLNESS
	
	THAT'S RELATED TO THEIR
	SERVICE IN THE MILITARY.
	
	AND EVEN THOUGH MALINGERING
	AND FACTITIOUS DISORDER
	
	ARE NOT COMMON IN
	SERIES OF PATIENTS
	
	WITH PSYCHOGENIC SEIZURES,
	
	THEY DO OCCUR, AND IT IS
	ANOTHER POTENTIAL RISK
	FACTOR FOR VETERANS.
	
	SLIDE 37.
	
	SO WE SET OUT
	TO LEARN SOMETHING
	
	ABOUT THE ISSUE OF PSYCHOGENIC
	SEIZURES IN VETERANS,
	
	AND THERE ARE 3 QUESTIONS
	WE WANTED TO ANSWER
	
	IN THE STUDY THAT
	I'LL SHOW YOU IN A MOMENT.
	
	FIRST, ARE PSYCHOGENIC SEIZURES
	MORE COMMON IN VETERANS
	
	THAN IN CIVILIANS, AT LEAST
	THOSE WHO WERE REFERRED
	
	FOR VIDEO-EEG MONITORING?
	
	SECOND, IS THERE
	A LONGER DELAY
	
	BETWEEN THE ONSET OF THE ILLNESS
	TO DIAGNOSIS IN VETERANS
	
	AS COMPARED TO
	THE CIVILIANS?
	
	AND THIRDLY, ITS BEEN
	OUR IMPRESSION
	
	THAT VETERANS WITH
	PSYCHOGENIC SEIZURES
	
	ARE ON MORE
	ANTI-EPILEPTIC DRUGS
	
	THAN CIVILIANS WHO HAVE
	PSYCHOGENIC SEIZURES,
	
	SO WE WANTED TO LOOK
	AT THAT, AS WELL.
	
	SLIDE 38.
	
	TO LOOK AT THIS PROBLEM,
	WE TOOK ADVANTAGE OF
	
	SORT OF A NATURAL
	EXPERIMENT THAT OCCURRED.
	
	BETWEEN THE YEARS
	2000 AND 2010,
	
	OUR EPILEPSY MONITORING UNIT
	UNIT AT THE PORTLAND VA
	
	WAS SHARED BY PATIENTS
	FROM THE PORTLAND VA
	
	AND BY CIVILIANS
	FROM OUR AFFILIATE,
	
	THE OREGON HEALTH SCIENCES
	UNIVERSITY.
	
	AND ALL OF THESE
	PATIENTS WERE EVALUATED
	
	IN THE SAME EPILEPSY
	MONITORING UNIT
	
	BY THE SAME DOCTORS
	AND NURSES
	
	USING THE SAME EQUIPMENT
	AND USING THE SAME
	TREATMENT PROTOCOLS.
	
	SO IT WAS FAIRLY EASY
	TO TEE UP THE COMPARISON
	
	BETWEEN THESE TWO GROUPS.
	
	ON SLIDE 39, I HAVE
	TWO PIE CHARTS SHOWING
	
	THE RESULTS OF THE STUDY,
	AND YOU'RE LOOKING NOW
	
	AT THE DISCHARGE DIAGNOSES
	IN WELL OVER 900 PATIENTS.
	
	WE START OUT ON THE LEFT.
	
	I WOULD POINT OUT THAT 25%
	OF VETERANS WERE DISCHARGED
	
	WITH A DIAGNOSIS OF PSYCHOGENIC
	NON-EPILEPTIC SEIZURES.
	
	IF WE COMPARE THAT TO DISCHARGES
	IN THE CIVILIAN PATIENTS,
	
	IT'S VIRTUALLY
	IDENTICAL--26%.
	
	SO AS A RAW NUMBER,
	THE PERCENTAGE OF VETERANS
	
	AND CIVILIANS WHO ARE
	DISCHARGED WITH A DIAGNOSIS
	
	OF PSYCHOGENIC SEIZURES
	IS VIRTUALLY IDENTICAL.
	
	HOWEVER, IT SEEMS LIKE THE
	VETERANS HAVE A HIGHER RATE
	OF PSYCHOGENIC SEIZURES
	
	BECAUSE THE RATE
	OF EPILEPTIC SEIZURES
	IS RELATIVELY LOW,
	
	AND IN FACT, THE RATE OF
	EPILEPTIC SEIZURES AS
	A DIAGNOSIS WAS ONLY 18%.
	
	IT WAS LESS THAN
	THE RATE OF DIAGNOSIS
	
	OF PSYCHOGENIC SEIZURES--
	
	MY COLLEAGUES AT OTHER
	VA EPILEPSY UNITS TELL ME
	
	THEY HAVE VERY
	SIMILAR RESULTS--
	
	WHEREAS IN THE CIVILIAN
	POPULATION, A MUCH LARGER
	GROUP OF PATIENTS, 40%,
	
	ARE DIAGNOSED WITH
	EPILEPTIC SEIZURES,
	
	AND THE GROUP WITH
	PSYCHOGENIC SEIZURES
	IS RELATIVELY SMALL.
	
	SO IF YOU SORT OF LOOK
	AT THIS AS A RATIO
	OF DIAGNOSTIC STUDIES,
	
	THE PERCENTAGE OF PATIENTS
	WHO HAVE PSYCHOGENIC SEIZURES
	
	AND ARE DIAGNOSED--
	THAT IS, REACH A DIAGNOSIS--
	
	WITHIN THE VETERAN GROUP
	IS MUCH HIGHER
	
	THAN WITHIN THE
	CIVILIAN GROUPS
	
	AND GIVES THE APPEARANCE
	
	THAT PSYCHOGENIC SEIZURES
	ARE MORE COMMON IN VETERANS.
	
	NEXT SLIDE--SLIDE 40--
	GETS TO THE COMPARISON
	
	THAT WE REALLY WANTED TO DO,
	
	AND WE WERE ABLE TO FIND
	50 VETERANS IN OUR SERIES
	
	WHO HAD
	PSYCHOGENIC SEIZURES--
	
	THAT 25% THAT I JUST
	MENTIONED TO YOU--
	
	AND WE DID A COMPARISON
	TO 50 CIVILIAN PATIENTS
	
	WHO WERE DIAGNOSED WITH
	PSYCHOGENIC SEIZURES.
	
	THESE WERE THE NEXT
	CONSECUTIVE CIVILIANS
	
	IN OUR DATABASE.
	
	ON THE SECOND LINE, YOU'LL
	SEE THAT VETERANS WERE OLDER
	
	AT THE TIME THAT THEY WERE
	ADMITTED FOR EVALUATION
	
	AND THAT MOST OF THE
	VETERANS WERE MALE,
	
	WHEREAS MOST OF THE
	CIVILIANS WERE FEMALE.
	
	THIS IS JUST AS
	YOU WOULD EXPECT.
	
	MOST OF THESE PATIENTS WERE
	USING ANTI-EPILEPTIC DRUGS
	
	AT THE TIME THEY
	WERE ADMITTED,
	
	SOMEWHERE BETWEEN ONE AND THREE
	ANTI-EPILEPTIC DRUGS--
	
	AGAIN, AS WE WOULD EXPECT.
	
	IF YOU LOOK AT
	THE BOTTOM LINE HERE,
	
	THIS IS WHERE
	IT GETS INTERESTING.
	
	WE LOOKED AT
	THE TIME INTERVAL
	
	FROM THE ONSET OF THE
	PSYCHOGENIC SEIZURES
	
	TO THE TIME THAT THE
	PATIENTS WERE ADMITTED
	
	FOR THEIR DIAGNOSTIC EPILEPSY
	MONITORING UNIT ADMISSION,
	
	AND FOR CIVILIANS,
	IT WAS ABOUT ONE YEAR,
	
	 AND FOR VETERANS,
	 IT WAS ABOUT 5 YEARS.
	
	IT WAS ABOUT
	A FIVEFOLD DIFFERENCE.
	
	SO FOR SOME REASON, VETERANS
	ARE COMING TO DIAGNOSIS
	
	AFTER A MUCH LONGER
	INTERVAL THAN CIVILIANS,
	
	AND THIS IS REFLECTED
	IN THE CUMULATIVE YEARS
	
	OF ANTI-EPILEPTIC DRUG USE,
	
	WHICH IS ONE YEAR FOR CIVILIANS
	AND 4 YEARS FOR VETERANS--
	
	AGAIN, BECAUSE OF THE
	DELAY IN DIAGNOSIS.
	
	ON SLIDE 41, WE'VE GRAPHED OUT
	THESE TIME INTERVALS
	
	FROM ONSET TO
	DIAGNOSTIC ADMISSION,
	
	AND YOU CAN SEE, TOWARD THE
	RIGHT-HAND SIDE OF THIS SLIDE,
	
	THAT THE DELAY IS
	LARGELY DUE TO VETERANS
	
	WHO HAD PSYCHOGENIC SEIZURES FOR
	5 YEARS, 10 YEARS, 20 YEARS,
	
	AND IN ONE CASE
	NEARLY 30 YEARS,
	
	BEFORE THEY
	WERE DIAGNOSED.
	
	WE REVIEWED THE CHARTS
	OF ALL OF THESE VETERANS,
	
	AND ALL OF THESE VETERANS
	
	WHO HAVE LONG-TERM
	PSYCHOGENIC SEIZURES
	
	WERE UNDER CHRONIC TREATMENT
	WITH ANTI-EPILEPTIC DRUGS
	
	FOR MEDICALLY REFRACTORY
	EPILEPSY.
	
	ON SLIDE 42--WHY THE DELAY
	IN DIAGNOSIS IN VETERANS?
	
	WELL, OF COURSE
	WE DON'T KNOW.
	
	IT MAY SIMPLY BE DUE TO
	A LACK OF AVAILABILITY
	
	OF EPILEPSY MONITORING UNITS
	IN THE VA MEDICAL SYSTEM.
	
	ABOUT HALF OF OUR PATIENTS
	CAME FROM STATES
	
	WHERE THERE WERE NO
	VA EPILEPSY MONITORING UNITS,
	
	AND THIS CREATES
	SOME DISINCENTIVE
	
	FOR SENDING PATIENTS OUT
	TO BE DIAGNOSED.
	
	HOPEFULLY, THIS HAS BEEN
	AT LEAST PARTIALLY ADDRESSED
	
	WITH THE CREATION OF THE VA
	EPILEPSY CENTERS OF EXCELLENCE.
	
	BETTER POSSIBILITY IS THAT
	THERE MAY BE SOME ACCEPTANCE
	
	OF SEIZURES WITHIN
	THE VA MEDICAL SYSTEM,
	
	PARTICULARLY AMONGST
	PRIMARY PROVIDERS,
	
	BECAUSE OF THE KNOWN
	RELATIONSHIP
	
	BETWEEN TRAUMATIC
	BRAIN INJURY AND EPILEPSY.
	
	A PATIENT WHO HAS A HISTORY
	OF TRAUMATIC BRAIN INJURY
	
	PRESENTS WITH
	SEIZURE-LIKE SPELLS,
	
	AND IT'S NOT QUESTIONED
	BECAUSE SEIZURES ARE
	
	A COMMON COMPLICATION OF
	TRAUMATIC BRAIN INJURY.
	
	WE HAVE SOME DATA
	SUPPORTING THIS.
	
	IF YOU LOOK AT
	SLIDE 43, WE ASKED,
	
	OR WE RATHER CHECKED IN THE
	CHARTS OF OUR PATIENTS--
	
	SOME WE ASKED, SOME WE
	JUST REVIEWED CHARTS FOR--
	
	TO FIND OUT WHAT THESE PATIENTS
	THOUGHT WAS THE ETIOLOGY
	
	OF WHAT TURNED OUT TO BE
	PSYCHOGENIC SEIZURES.
	
	THEY DIDN'T KNOW IT
	AT THE TIME.
	
	AND AMONG CIVILIAN PATIENTS,
	ABOUT 25%, 26% OF PATIENTS
	
	THOUGHT THAT THEIR
	SEIZURES WERE CAUSED
	
	BY A TRAUMATIC BRAIN INJURY.
	
	THIS IS VIRTUALLY IDENTICAL
	
	TO THE INFORMATION
	I SHOWED YOU A BIT EARLIER.
	
	BUT IN THE VETERAN PATIENTS,
	
	NEARLY 60% OF PATIENTS THOUGHT
	THAT THE SEIZURES WERE RELATED
	
	TO A PREVIOUS
	TRAUMATIC BRAIN INJURY.
	
	SO IT TURNS OUT THAT MANY
	OF THESE PATIENTS BELIEVED
	
	THAT TRAUMATIC BRAIN INJURY,
	
	MOSTLY TRAUMATIC BRAIN INJURIES
	IN THE MILITARY,
	
	WERE THE ROOT CAUSE
	OF THEIR SEIZURES.
	
	WE'LL MOVE ON NOW
	TO SLIDE 44,
	
	WHICH OUTLINES
	QUESTIONS REMAINING,
	
	AND OF COURSE THERE ARE
	MANY QUESTIONS REMAINING,
	
	BUT NONE ARE MORE IMPORTANT
	THAN THE FIRST ONE--
	
	WHAT ARE THE PSYCHIATRIC
	DISORDERS UNDERLYING
	
	THE DEVELOPMENT OF PSYCHOGENIC
	SEIZURES IN VETERANS?
	
	AND WE HAVE REALLY
	NO INFORMATION ON THIS,
	
	AND IT'S ABSOLUTELY CRITICAL
	THAT WE OBTAIN THIS INFORMATION,
	
	BECAUSE THAT IS THE INFORMATION
	THAT WILL EVENTUALLY DICTATE
	
	THE THERAPEUTIC APPROACHES
	THAT CAN BE USED.
	
	I'D LIKE YOU TO SKIP
	THE NEXT COUPLE OF SLIDES
	
	AND MOVE ON TO SLIDE 47,
	AND IN THE LAST 5 OR 10 MINUTES,
	
	I'D JUST LIKE TO SAY
	A FEW WORDS ABOUT
	
	THE TREATMENT OF PSYCHOGENIC
	SEIZURES AS A PROGNOSIS.
	
	SLIDE 48 OUTLINES THE
	INITIAL CONVENTIONAL THERAPY
	
	FOR PSYCHOGENIC SEIZURES.
	
	THIS IS WHAT WE DO
	IN THE MONITORING UNIT
	
	AT THE TIME THAT WE
	MAKE THE DIAGNOSIS.
	
	HONEST, SUPPORTIVE, CONCLUSIVE
	PRESENTATION OF THE DIAGNOSIS.
	
	WE LET PATIENTS KNOW
	EXACTLY WHAT'S GOING ON
	
	IN A SUPPORTIVE WAY.
	
	"WE HAVE GOOD NEWS FOR YOU.
	YOU DO NOT HAVE EPILEPSY.
	
	HERE'S WHAT'S HAPPENING."
	
	AND WE TRY AND EXPLAIN THE
	NATURE OF PSYCHOGENIC SEIZURES.
	
	THIS VARIES A BIT
	DEPENDING ON THE PATIENT
	
	AND WHAT WE BELIEVE
	
	THE UNDERLYING
	PSYCHIATRIC PROBLEMS ARE,
	
	BUT WE LIKE TO GO
	THROUGH THIS CAREFULLY.
	
	WE DISCONTINUE
	ANTI-EPILEPTIC DRUGS
	
	UNLESS THEY'RE BEING USED
	FOR ANOTHER PROBLEM,
	
	SUCH AS TREATMENT FOR PAIN
	
	OR SOME OTHER
	PSYCHIATRIC DISORDER.
	
	AND WE ALWAYS MAKE REFERRAL
	TO MENTAL HEALTH.
	
	USUALLY, THIS REFERRAL IS
	FOR SUPPORTIVE COUNSELING,
	
	BUT SOMETIMES IT'S
	FOR OTHER MODALITIES
	
	THAT WE'LL DISCUSS
	HERE IN A MOMENT.
	
	THE RESULTS OF THIS TYPE
	OF TREATMENT ARE NOT
	ENTIRELY SATISFACTORY.
	
	MANY PATIENTS CONTINUE
	TO HAVE SEIZURES,
	
	AND SO, OVER THE YEARS,
	
	VARIOUS OTHER
	TREATMENTS HAVE BEEN TRIED
	
	IN AN ATTEMPT TO MORE
	SPECIFICALLY GET AT
	
	THE ROOT CAUSE OF THESE
	PSYCHOGENIC SEIZURES,
	
	AND IF WE GO TO SLIDE 49,
	YOU'LL SEE ONE SUCH TREATMENT.
	
	THIS IS THE
	BART SIMPSON TREATMENT.
	
	I HAVE NOT PERSONALLY
	TRIED THIS TREATMENT,
	
	BUT I SUSPECT IT MAY
	WORK AS WELL
	
	AS SOME OF THE OTHER TREATMENTS
	THAT I HAVE TRIED.
	
	ON SLIDE 50, I HAVE LISTED
	THE VARIOUS TREATMENTS
	
	THAT HAVE BEEN USED IN PATIENTS
	WITH PSYCHOGENIC SEIZURES.
	
	IN THE OLD DAYS,
	PSYCHOTHERAPY WAS VERY COMMON.
	
	NOWADAYS, COGNITIVE BEHAVIORAL
	THERAPY IS MORE COMMON.
	
	MEDICATIONS HAVE BEEN USED,
	PARTICULARLY ANTIDEPRESSANTS
	
	IF THE PATIENTS WERE
	DEPRESSED, AND A VARIETY
	
	OF OTHER, SOMETIMES
	ALTERNATIVE THERAPIES--
	
	RELAXATION THERAPY, BIOFEEDBACK,
	MEDITATION, EMDR--
	
	BUT AS OF 2006, WHEN BOTH
	THE COCHRANE REVIEW
	
	AND AN NIH TREATMENT WORKSHOP
	WERE CONVENED,
	
	THERE WERE NO VALIDATED
	TREATMENTS OR CONTROLLED TRIALS.
	
	THERE'S REALLY NOTHING TO BASE
	YOUR TREATMENT DECISION ON
	
	BECAUSE THERE WERE NO GOOD
	RANDOMIZED DOUBLE-BLIND TRIALS
	
	OF ANY OF THESE THERAPIES.
	
	SLIDE 51 SHOWS A STUDY THAT WAS
	PUBLISHED JUST LAST YEAR,
	
	AND IT IS, FOR MY MONEY,
	
	THE BEST TREATMENT
	STUDY EVER DONE
	
	ON PATIENTS WITH
	PSYCHOGENIC SEIZURES.
	
	IT IS A RANDOMIZED
	BLINDED TRIAL
	
	OF COGNITIVE
	BEHAVIORAL THERAPY
	
	VERSUS STANDARD
	SUPPORTIVE COUNSELING.
	
	THE STUDY WAS DONE
	BY GOLDSTEIN ET AL.
	
	AT THE MAUDSLEY
	HOSPITAL IN LONDON.
	
	AND THIS IS A
	GOOD NEWS/BAD NEWS STUDY.
	
	THE GOOD NEWS IS THAT IT
	WAS VERY WELL CONDUCTED--
	
	I THINK REALLY IT SETS
	A NEW STANDARD--
	
	AND AT THE END OF 3 MONTHS OF
	COGNITIVE BEHAVIORAL THERAPY,
	
	YOU CAN SEE THAT THESE
	PATIENTS CLEARLY DID BETTER,
	
	WITH LOWER
	SEIZURE FREQUENCY,
	
	THAN PATIENTS WHO RECEIVED
	STANDARD MEDICAL CARE.
	
	THE BAD NEWS IS THAT IF YOU LOOK
	OUT AT THE 6-MONTH FOLLOW-UP,
	
	THE CURVES START TO MOVE
	TOGETHER, AND THE RESULTS
	
	ARE NO LONGER
	STATISTICALLY SIGNIFICANT.
	
	NEXT SLIDE.
	
	THE OTHER PIECE
	OF BAD NEWS IS
	
	THAT EVEN AT THE
	END OF TREATMENT,
	
	THERE WAS NO DIFFERENCE
	IN THE NUMBER OF PATIENTS
	
	WHO BECAME COMPLETELY
	SEIZURE FREE,
	
	THE NUMBER OF ER VISITS,
	
	THE NUMBER OF
	OUTPATIENT CLINIC VISITS,
	
	AND OTHER MEDICAL
	INDICATORS.
	
	SO THE GOOD NEWS--
	COGNITIVE BEHAVIORAL THERAPY
	
	SEEMS TO HAVE
	SOME POSITIVE EFFECT.
	
	THE BAD NEWS--
	
	THE EFFECT DOESN'T SEEM TO
	OUTLAST THE TREATMENT VERY WELL,
	
	AND BASED ON
	OTHER INDICATORS,
	
	THE EFFECT IS
	NOT PARTICULARLY STRONG.
	
	STILL, I VIEW THIS STUDY AS
	A STEP IN THE RIGHT DIRECTION.
	
	SLIDE 53 SHOWS THE RESULTS
	OF 6 STUDIES WHICH LOOKED
	
	AT THE OUTCOME OF PATIENTS
	
	WITH PSYCHOGENIC
	NON-EPILEPTIC SEIZURES.
	
	THESE STUDIES VARIED
	IN TIME INTERVAL AND IN
	THE PROTOCOLS THEY USED,
	
	BUT I JUST WANTED TO MAKE
	A COUPLE OF POINTS.
	
	THE FIRST POINT IS,
	IT'S NOT ALL BAD NEWS.
	
	JUST WITH DIAGNOSIS AND
	CONVENTIONAL THERAPY,
	
	SOMEWHERE BETWEEN 30%
	AND 50% OF THESE PATIENTS
	
	WILL STOP HAVING SEIZURES--
	
	THEY WILL BECOME
	SEIZURE FREE--
	
	WITHIN AN INTERVAL OF
	6 MONTHS TO ABOUT 4 YEARS.
	
	AND ALSO GOOD NEWS,
	A MAJORITY OF THESE PATIENTS
	
	WILL BE OFF OF
	ANTI-EPILEPTIC DRUGS
	
	OVER THE SAME INTERVAL.
	
	SEVERAL OF THESE
	STUDIES SHOWED
	
	THAT A SHORTER DURATION
	OF ILLNESS AT DIAGNOSIS
	
	CORRELATED WITH
	A BETTER OUTCOME--
	
	NOT ALL THE STUDIES,
	BUT SEVERAL.
	
	AND AGAIN, I POINT OUT
	THAT FINDING WE HAVE
	
	WITH VETERAN PATIENTS,
	
	THAT THE INTERVAL TO
	DIAGNOSIS IS MUCH LONGER
	
	THAN IT IS WITH
	CIVILIAN PATIENTS,
	
	SO WE MAY HAVE SOME
	WORK TO DO THERE
	
	IF WE WANT TO SEE
	BETTER OUTCOMES
	
	IN OUR VETERAN PATIENTS.
	
	THE LARGEST OF THESE STUDIES IS
	THE McKENZIE STUDY FROM 2010,
	
	WHICH IS SHOWN ON
	THE NEXT SLIDE, SLIDE 54.
	
	AND I JUST PUT THIS STUDY UP
	BECAUSE, AGAIN,
	
	IT HAS SOME GOOD NEWS,
	AND IT WAS FAIRLY LARGE STUDY.
	
	IF YOU LOOK TOWARD THE
	BOTTOM OF THIS CHART,
	
	THE PERCENTAGE OF PATIENTS
	USING ANTI-EPILEPTIC DRUGS
	
	WENT FROM 52% TO 13%,
	
	THE PERCENT OF PATIENTS WHO WERE
	EMPLOYED WENT FROM 10% TO 23%,
	
	AND UP AT THE TOP, AT THE 6-12
	MONTH FOLLOW-UP INTERVAL,
	
	38% OF THESE PATIENTS
	WERE FREE OF THE SEIZURES.
	
	SO JUST WITH DIAGNOSIS
	AND CONVENTIONAL THERAPY,
	
	MANY PATIENTS DO WELL--
	
	NOT AS MANY AS WE'D LIKE,
	BUT MANY PATIENTS DO WELL.
	
	THESE AUTHORS ALSO LOOKED
	AT FACTORS THAT WERE ASSOCIATED
	
	WITH A SEIZURE-FREE OUTCOME,
	AND I POINT OUT THAT PATIENTS
	
	WHO HAVE NO PRIOR HISTORY
	OF DEPRESSION OR ANXIETY
	
	TENDED TO DO BETTER.
	
	AND THIS IS AN OLD FINDING.
	
	IT'S BEEN SEEN
	IN OTHER STUDIES, AS WELL.
	
	IF YOU'LL GO TO
	THE NEXT SLIDE,
	
	AND THE KANTER STUDY FROM 1999
	IS SHOWN, AND THIS STUDY,
	
	A VERY NICELY DONE STUDY, SHOWED
	THAT THERE WAS A WORSE OUTCOME
	
	IN PATIENTS WITH A HISTORY
	OF MAJOR DEPRESSION,
	
	PERSONALITY DISORDERS,
	AND DISSOCIATIVE DISORDERS.
	
	IN OTHER WORDS, PATIENTS WHO
	HAVE A HEAVY PSYCHIATRIC BURDEN
	
	AT THE TIME OF DIAGNOSIS
	DO NOT DO AS WELL
	
	AS PATIENTS WITH A LESSER
	PSYCHIATRIC BURDEN.
	
	I THINK THAT'S A POINT THAT
	SHOULD BE FAIRLY OBVIOUS.
	
	WELL, MY TIME IS
	JUST ABOUT UP,
	
	SO I'D LIKE TO SKIP DOWN
	TO THE SUMMARY SLIDE,
	
	WHICH IS SLIDE 60, AND 3 POINTS
	I'D LIKE TO EMPHASIZE.
	
	FIRST, PSYCHOGENIC
	SEIZURES ARE COMMON.
	
	THEY PROBABLY REPRESENT
	10% TO 20% OF ALL PATIENTS
	
	WHO HAVE MEDICALLY
	REFRACTORY SEIZURES.
	
	SOME INDICATION THAT
	THEY MAY EVEN REPRESENT
	
	A HIGHER PERCENTAGE WITHIN
	THE VA MEDICAL SYSTEM.
	
	SECOND, THAT PSYCHOGENIC
	SEIZURES ARE SYMPTOMS
	
	OF PSYCHIATRIC DISORDERS.
	
	THIS IS BOTH A CLUE
	TO THE EARLY RECOGNITION
	
	OF PATIENTS WITH
	PSYCHOGENIC SEIZURES
	
	AND ULTIMATELY AN OPPORTUNITY
	FOR INTERVENTION.
	
	AND THE THIRD POINT,
	
	TREATMENT OF THIS DISORDER
	REMAINS PROBLEMATIC.
	
	I REALLY THINK THAT
	WE'RE IN OUR INFANCY
	
	WHEN IT COMES TO THE TREATMENT
	OF PSYCHOGENIC SEIZURES,
	
	BUT DIAGNOSIS ALONE,
	
	COMBINED WITH CONVENTIONAL
	SUPPORTIVE COUNSELING,
	
	WILL OFTEN LEAD
	TO IMPROVEMENT,
	
	AND EARLY DIAGNOSIS
	CAN CERTAINLY DECREASE
	THE ACCUMULATED DISABILITY
	
	ASSOCIATED WITH
	THIS DISORDER,
	
	AND IT MAY IMPROVE
	THE LONG-TERM OUTCOME.
	
	ULTIMATELY, THE TREATMENT
	WILL HAVE TO BE BASED
	
	ON THE UNDERLYING
	PSYCHIATRIC DISORDERS,
	
	AND THIS THE TOPIC THAT,
	AT LEAST FOR VETERANS,
	
	WE CURRENTLY KNOW
	VERY LITTLE ABOUT.
	
	I'D LIKE TO THANK YOU
	FOR ATTENDING
	
	THE CONFERENCE CALL TODAY,
	
	AND I WOULD BE VERY HAPPY
	TO ANSWER ANY QUESTIONS.
	
	- IS THERE ANY QUESTIONS?
	
	OR IS EVERYBODY STILL MUTED?
	
	- SOUNDS LIKE
	EVERYBODY IS STILL MUTED.
	
	- ALL RIGHT. I'M TRYING
	TO GET A HOLD
	
	OF THE OPERATOR TO GET
	EVERYBODY UNMUTED.
	
	- OK.
	
	- EVERYBODY SHOULD
	BE UNMUTED NOW.
	
	- THIS ROY KANTER.
	I'M IN CHEYENNE, WYOMING.
	
	- HEY, ROY.
	HOW ARE YOU?
	
	- FINE. HOW ARE YOU, MARTY?
	
	- I'M GOOD, THANKS.
	GOOD TO HEAR YOUR VOICE.
	
	- YEAH. SO THIS WAS
	A GREAT OVERVIEW,
	
	AND I THANK YOU FOR THAT.
	
	I THINK I SPOKE TO YOU
	OVER A YEAR AGO AND SAID
	
	I REALLY NEED TO HEAR
	A PROGRAM ON PSYCHOGENIC
	NON-EPILEPTIC SEIZURES,
	
	AND I DO APPRECIATE IT.
	
	ONE OF MY PROBLEMS IS
	TRYING TO DEAL WITH
	THE PRIMARY CARE DOCS
	
	AND THE EMERGENCY ROOM
	DOCTORS WHO,
	
	WHEN A PATIENT COMES IN
	WITH ONE OF THEIR ATTACKS,
	
	AUTOMATICALLY PUTS THESE
	FOLKS BACK ON THEIR
	ANTI-EPILEPTIC MEDICATIONS
	
	AFTER WE'VE WORKED PRETTY
	HARD TO GET THEM OFF.
	
	DO YOU HAVE AN APPROACH
	THAT YOU USE FOR THAT?
	
	- THAT'S A GREAT QUESTION.
	
	I THINK IT'S A VERY
	COMMON PROBLEM.
	
	WE HAVE IT NOT ONLY
	IN OUR VA CLINICS,
	
	BUT IN OUR CIVILIAN
	CLINICS, AS WELL.
	
	I DO NOT HAVE
	AN APPROACH TO THIS
	
	OTHER THAN FREQUENT VISITS
	TO THE EMERGENCY ROOM
	
	TO EMPHASIZE TO
	THE PHYSICIANS THERE
	
	TO PLEASE CONTACT
	THE NEUROLOGIST
	
	BEFORE THEY RESTART
	ANTI-EPILEPTIC DRUGS
	
	IN PATIENTS WHO ARE
	KNOWN TO THE SYSTEM.
	
	THAT BEING SAID, I THINK
	MY SUCCESS RATE WITH THIS
	
	IS LESS THAN 50%, AND THE
	OTHER PROBLEM, OF COURSE,
	
	IS THAT PATIENTS WITH
	PSYCHOGENIC SEIZURES ARE
	
	NOTORIOUS FOR VISITING MULTIPLE
	DIFFERENT EMERGENCY ROOMS.
	
	SO WHEREAS A PATIENT WHO
	CAME TO YOUR EMERGENCY ROOM,
	
	THE PHYSICIAN MIGHT
	LOOK UP IN CPRS
	
	AND SEE THAT THE PATIENT
	IS UNDER TREATMENT
	
	AND CALL YOU OR CALL
	ANOTHER DOCTOR WHO'S BEEN
	INVOLVED IN THEIR CARE,
	
	IF THAT PATIENT GOES CROSSTOWN
	TO ANOTHER HOSPITAL
	
	WHERE THEY DON'T HAVE
	ACCESS TO THE RECORDS,
	
	THE DOCTORS ARE MUCH MORE LIKELY
	TO SHOOT FROM THE HIP.
	
	IT'S A COMMON PROBLEM.
	
	EVERYBODY COMPLAINS ABOUT IT.
	
	I DON'T KNOW THE
	ANSWER TO THIS PROBLEM.
	
	- THANK YOU.
	
	- HI. MY NAME IS JOSIE,
	
	AND I AM FROM THE DURHAM
	VA MEDICAL CENTER.
	
	- HI, JOSIE.
	
	- WE'RE ONE OF THE EPILEPSY
	CENTERS OF EXCELLENCE,
	
	AND MY QUESTION IS, A PATIENT
	HAS BEEN GIVEN THE DIAGNOSIS
	
	OF NON-EPILEPTIC SEIZURES,
	
	WHAT TYPE OF FOLLOW-UP
	DO THESE PATIENTS HAVE
	
	ONCE THEY ARE GIVEN
	THAT DIAGNOSIS?
	
	- THAT'S A GOOD QUESTION,
	AND THE ANSWER IS, IT DEPENDS.
	
	FOR PATIENTS THAT WE SEE
	HERE AT THE PORTLAND VA,
	
	WE WILL USUALLY
	FOLLOW THEM INITIALLY
	
	IN THE EPILEPSY CLINIC,
	
	REALLY JUST TO MAKE SURE
	THAT WE'VE ESTABLISHED CARE,
	
	BUT THEN WE TURN OVER CARE
	
	TO PRIMARY CARE
	AND TO MENTAL HEALTH.
	
	THE ROLE OF NEUROLOGY IN ONGOING
	CARE IS SOMEWHAT QUESTIONABLE.
	
	MANY OF OUR PATIENTS WIND UP
	COMING FROM OTHER STATES
	
	OR OTHER PARTS OF OREGON
	
	AND FOLLOW-UP IN
	PORTLAND IS IMPRACTICAL,
	
	SO THEY GET THEIR
	FOLLOW-UP CARE THROUGH
	
	THEIR PRIMARY CARE PHYSICIANS
	OR THEIR NEUROLOGISTS
	
	IN THE LOCALE THAT THEY
	WERE REFERRED FROM.
	
	THE IMPORTANT THING,
	I THINK, IS TO MAKE SURE
	
	THAT ALL THE CARE PROVIDERS
	KNOW THE DIAGNOSIS,
	
	THAT THEY'VE RECEIVED A LETTER
	GOING OVER THE DIAGNOSIS,
	
	HOW THE DIAGNOSIS
	WAS ESTABLISHED,
	
	AND THAT THE REFERRING PROVIDERS
	HAVE A CARE PLAN IN HAND.
	
	THEY KNOW THAT THE
	PSYCHOGENIC SEIZURES
	
	SHOULD NOT BE TREATED
	WITH ANTI-EPILEPTIC DRUGS,
	
	THAT THE MAIN TREATMENT
	IS THROUGH MENTAL HEALTH,
	
	AND IF THERE ARE
	RECURRING QUESTIONS
	
	ABOUT WHETHER EPILEPTIC
	SEIZURES HAVE STARTED UP,
	
	THEY SHOULD BE
	REFERRED BACK,
	
	PROBABLY FOR FURTHER
	VIDEO-EEG MONITORING.
	
	AND I POINT OUT THAT
	IT'S NOT UNCOMMON
	
	FOR PATIENTS WHO ARE DIAGNOSED
	WITH PSYCHOGENIC SEIZURES
	
	TO END UP COMING BACK TO OUR
	CLINICS OR OUR MONITORING UNITS
	
	3 YEARS OR 5 YEARS
	OR 10 YEARS LATER
	
	BECAUSE THE PHYSICIAN
	HAS NOTICED A CHANGE
	IN THE SEIZURES,
	
	AND THEY'RE NOW WONDERING
	
	WHETHER THERE ARE EPILEPTIC
	SEIZURES, AS WELL.
	
	AND I THINK THAT'S
	A FAIR QUESTION,
	
	AND WHEN FACED
	WITH THAT QUESTION,
	
	THE BEST THING TO DO IS
	TO READMIT THE PATIENT
	
	FOR FURTHER
	VIDEO-EEG MONITORING.
	
	- OK. DO YOU HAVE, LIKE,
	
	ONCE THE PATIENT IS
	GIVEN THAT DIAGNOSIS,
	
	DURING THAT ADMISSION BEFORE
	THEY ARE DISCHARGED,
	
	DO YOU HAVE, LIKE,
	A NURSING EDUCATOR,
	
	SAY IN THE EPILEPSY CENTER,
	THAT EXPLAINS TO THE PATIENT
	
	TO HELP THEM UNDERSTAND
	OR TO KIND OF EXPLORE, MAYBE,
	
	THINGS THAT HAVE HAPPENED,
	
	TRAUMAS THAT MAY
	HAVE OCCURRED,
	
	TO HELP EXPLAIN THE DIAGNOSIS
	OF NON-EPILEPTIC SEIZURES?
	
	- WE DO THAT. I THINK
	I HAD MENTIONED THAT
	
	A LITTLE BIT EARLIER ON
	IN THE TALK,
	
	BUT THE STANDARD PROCEDURE
	AT THE TIME OF DISCHARGE
	
	IS FOR THE PHYSICIAN,
	WHETHER IT BE MYSELF
	
	OR ONE OF THE OTHER
	EPILEPTOLOGISTS
	
	WE HAVE HERE IN PORTLAND,
	
	TO HAVE A DETAILED
	DISCHARGE CONFERENCE
	
	WITH THE PATIENT AND
	ANY FAMILY MEMBERS
	THAT THEY WANT INVOLVED,
	
	EXPLAINING THE NATURE
	OF THEIR ILLNESS
	
	AND IN SOME CASES, TRYING
	TO GO INTO SOME DETAIL
	
	ABOUT THE NATURE OF,
	FOR EXAMPLE,
	
	CONVERSION DISORDER
	AND WHAT THAT MEANS.
	
	SO WE TRY AND SPEND QUITE
	A BIT OF TIME GOING OVER THIS,
	
	MAKING SURE THAT THE PATIENT...
	
	MAKING SURE THAT
	THE PATIENT UNDERSTANDS.
	
	SO WE DON'T HAVE A NURSE
	PRACTITIONER WHO DOES THIS.
	
	WE DO HAVE
	A NURSE PRACTITIONER HERE,
	
	BUT THAT DUTY FALLS
	ON THE PHYSICIAN
	
	WHO HAS DONE THE
	E.M.U. EVALUATION.
	
	I THINK IT'S
	ABSOLUTELY CRITICAL
	
	THAT THIS TYPE OF DISCHARGE
	CONFERENCE TAKES PLACE.
	
	PATIENTS WHO LEAVE THE
	EPILEPSY MONITORING UNIT
	
	AND DON'T UNDERSTAND THE
	NATURE OF THEIR DIAGNOSIS
	
	ARE, I THINK,
	DOOMED TO FAILURE.
	
	THEY'RE CERTAINLY GOING TO
	CONTINUE TO HAVE SPELLS.
	
	- THANK YOU SO MUCH.
	
	- HI. THIS IS KIRSTIN
	AT LITTLE ROCK.
	
	I JUST HAVE A QUESTION
	FOR SEAN RIGHT QUICK.
	
	ON THE BROCHURE THAT CAME
	WITH THE COURSE, IT SAYS
	
	THE DEADLINE IS JUNE 4th
	TO SUBMIT YOUR EVAL FORM.
	
	THAT'S NOT CORRECT,
	OBVIOUSLY.
	
	WHAT IS THE DEADLINE?
	
	- IT IS AUGUST 8th.
	
	- THANK YOU.
	
	- YEAH.
	
	- I HAVE ONE FURTHER QUESTION.
	
	WHAT PERCENTAGE OF PATIENTS
	WITH NON-EPILEPTIC SEIZURES
	
	ALSO TURN OUT TO HAVE
	EPILEPTIC SEIZURES?
	
	- IN...THERE...I THINK--
	
	WELL, THERE ARE AT LEAST 6
	MAJOR STUDIES OF THIS, ROY,
	
	AND THE PERCENTAGE VARIES
	DEPENDING ON WHO YOU READ.
	
	IT'S SOMEWHERE
	BETWEEN 5% AND 30%.
	
	THE LOWER ESTIMATES
	ARE PROBABLY MORE CORRECT.
	
	I WOULD SAY IT'S
	PROBABLY AROUND 10%.
	
	THE HIGHER ESTIMATES
	ARE PATIENTS
	
	WHO WERE SHOWN TO HAVE
	PSYCHOGENIC SEIZURES,
	
	 BUT ALSO HAD INTERICTAL
	 EPILEPTIFORM DISCHARGES,
	
	AND AS YOU KNOW,
	THE PRESENCE OF INTERICTAL
	EPILEPTIFORM DISCHARGES
	
	DOESN'T NECESSARILY MEAN
	THAT THE PATIENT
	
	WAS ALSO HAVING
	EPILEPTIC SEIZURES.
	
	SO IT'S PROBABLY ABOUT 10%.
	
	- ALL RIGHT.
	THANK YOU.
	
	- YEAH.
	
	- DR.SALINSKY.
	
	- YES.
	
	- THIS IS MARC TESTA
	FROM THE BALTIMORE VA.
	
	IN MY EXPERIENCE OF SEEING MEN
	WITH PSYCHOGENIC SEIZURES,
	
	THEY SEEM TO MAYBE BE
	MORE SELF-INJURIOUS
	
	OR DISPLAY
	DIFFERENT BEHAVIORS
	
	DURING THEIR EPISODES
	THAN WOMEN.
	
	HAVE YOU EXPERIENCED THAT?
	
	HAVE YOU NOTICED ANY
	DIFFERENCES IN THE SEMIOLOGY
	
	OF PSYCHOGENIC SEIZURES
	BETWEEN MEN AND WOMEN?
	
	- YES, WE HAVE. I THINK
	THEY'RE DIFFERENT,
	
	AND THERE HAVE
	ACTUALLY BEEN
	
	A COUPLE OF ARTICLES
	WRITTEN ABOUT THIS,
	
	ABOUT THE DIFFERENCES
	BETWEEN MEN AND WOMEN,
	
	AND ALSO ABOUT THE DIFFERENCES
	IN THE PSYCHIATRIC PROFILES
	
	OF MEN AND WOMEN WITH
	PSYCHOGENIC SEIZURES.
	
	FOR EXAMPLE, THE HISTORY
	OF PHYSICAL OR SEXUAL
	ABUSE IN CHILDHOOD
	
	IS MUCH MORE COMMON IN WOMEN
	WITH PSYCHOGENIC SEIZURES
	
	THAN WITH MEN.
	
	AND SOME OF THESE
	ARTICLES HAVE REMARKED
	
	THAT MEN WITH PSYCHOGENIC
	SEIZURES TEND TO HAVE
	MORE-CONVULSIVE SEIZURES,
	
	THEY TEND TO HAVE
	MORE-VIOLENT SEIZURES,
	
	AND WE HAVEN'T MADE
	A STUDY OF THIS,
	
	BUT MY IMPRESSION IS THAT
	
	AT LEAST SOME MEN
	WITH PSYCHOGENIC SEIZURES
	
	WILL TEND TO ACT OUT
	IN A MORE VIOLENT WAY
	
	THAN WE TYPICALLY
	ASSOCIATE WITH WOMEN.
	
	HOWEVER, I HAVE TO TELL YOU
	THAT IN OUR VETERAN POPULATION,
	
	WE HAVE MANY PATIENTS,
	MANY MEN,
	
	WHO HAVE, REALLY,
	PSYCHOGENIC FUGUES
	
	AS THEIR PRESENTATION
	OF PSYCHOGENIC SEIZURES,
	
	WHERE THEY GO INTO THESE
	PROLONGED FUGUE STATES
	
	WHICH CAN LAST FOR
	HOURS AT A TIME
	
	AND THEY HAVE
	NO MOVEMENTS AT ALL,
	
	SO I THINK THE PRESENTATION
	IS HIGHLY VARIABLE
	
	IN BOTH MEN AND WOMEN,
	BUT I AGREE WITH YOU,
	
	SOME MEN WITH
	PSYCHOGENIC SEIZURES
	
	HAVE A PARTICULARLY
	VIOLENT PATTERN.
	
	- ALL RIGHT. I WANT
	TO TAKE THE TIME
	
	TO THANK DR. SALINSKY
	FOR HIS TIME
	
	IN PRESENTING
	THIS POWERPOINT
	
	AND GIVING US ALL
	THE INFORMATION.
	
	WE WILL BE MEETING
	AGAIN AS A GROUP
	
	AND ALSO BE PLANNING
	OUR NEXT AUDIO CALL
	
	WITHIN THE NEXT
	COUPLE OF MONTHS.
	
	I HOPE EVERYBODY CAN
	JOIN US. THANK YOU.
	
	- THANK YOU.
	
	- THANK YOU.
	
	- THANK YOU, EVERYONE.