Imitators of Epilepsyaz9194.vo.msecnd.net/pdfs/111201/102.06.pdf · computerized method for...
Transcript of Imitators of Epilepsyaz9194.vo.msecnd.net/pdfs/111201/102.06.pdf · computerized method for...
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Imitators of Epilepsy December 2, 2011
Ronald P. Lesser, M.D.
Professor of Neurology and Neurosurgery
Department of Neurology
The Johns Hopkins Medical Institutions
Baltimore, MD
American Epilepsy Society | Annual Meeting
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Disclosure • I in the past, but no longer, have been on Speaker's Bureaus and
have given lectures supported by, or have been a consultant for the following companies, all of which have had or are developing products that could be used to treat epilepsy: Abbott Laboratories, Bertek Pharmaceuticals, Burroughs Wellcome (now GlaxoSmithKline), Cyberonics, Medtronic, Novartis, Ortho-McNeil, Wallace Laboratories, Warner-Lambert/Parke-Davis, Wyeth. I or my spouse have stock in the following companies, each of which has at least one product that can be used to treat epilepsy: Abbott, Johnson & Johnson, Pfizer. I have been a site investigator for studies funded by Lorex Pharmaceuticals, Wallace Laboratories, Warner-Lambert Company and have received funding from Medtronic; none of these have occurred for the past several years. For several years, until 2004/6, I organized a periodic dinner meeting for the Maryland Epilepsy Group. These meetings included meals purchased by Parke-Davis/Pfizer or UCB. They primarily dealt with surgical or imaging topics, but one dealt with mechanisms underlying the effects of anticonvulsants.
American Epilepsy Society | Annual Meeting
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Disclosure • Since 1999, I have been, or am, a sub-investigator for a number of
drug studies for which I receive no compensation. These have been funded by the following: Eisei (rufinamide, perampanel), Johnson & Johnson (JNJ-26489112), National Institutes of Health (progesterone), Novartis (oxcarbazepine, rufinamide, BGG492), Parke-Davis (pregabalin), Schwarz Biosciences (lacosamide), Sepracor (eslicarbazepine), SK Bio-Pharmaceuticals (YKP3089), UCB (brivaracetam, lacosamide, levetiracetam), Neuronex (intranasal diazepam), Upsher-Smith (intranasal midazolam). I have received funding from and I am entitled to sales royalty from Bio-logic Systems, Inc (now owned by Natus Medical Incorporated), which has developed products related to my research involving a computerized method for analyzing physiologic data. I also receive royalties from Persyst Development Corporation for sales of software I developed for reporting results of EEG evaluations. The terms of my arrangement with Bio-logic Systems and with Persyst have been reviewed and approved by the Johns Hopkins University in accordance with its conflict of interest policies.
American Epilepsy Society | Annual Meeting
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Learning Objectives
• understand characteristics of the most common imitator of epilepsy
• consider etiologies
• consider other disorders that can be confused with epilepsy
• consider treatment
American Epilepsy Society | Annual Meeting
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a physical way of expressing
an emotional conflict or concern
The patient may or may not
be aware of the conflict or concern
It may or not be possible
to determine the conflict or concern
Psychogenic Non-Epileptic
Seizures (PNES)
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• Iceland
35/100,000 - epilepsy1
1.4/100,000 - PNES1
• United States
29-53/100,000 - epilepsy2
1-2/100,000 - PNES3
1 Sigurdardottir and Olafsson, 1998
2 Hauser and Hesdorffer 1990
3 estimate
Incidence of PNES
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Prevalence of PNES
• point prevalence of epilepsy = 0.6%
• 1/3 of all seizures are intractable
• patients with these often go to epilepsy centers
• PNES: 10-20% of patients at epilepsy centers
• therefore 50,000-100,000 patients in U.S.?
– “sampling error”
– delayed diagnosis
-Howell et al. 1989, Hauser and Hesdorffer 1990, Gumnit, 1993
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Prevalence of PNES
- Reuber et al., 2002
Age at onset (yrs)
0 10 20 30 40 50 60 70 70 80 0
10
20
30
40
50
60
diagnostic
delay
(yrs)
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• 4-77 years old
• 734 women
250 men
- Lesser, 1996
Reported cases – 21 articles
Prevalence of PNES
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Age at onset (yrs)
0 10 20 30 40 50 60 70 70 80 0
10
20
30
40
50
60
diagnostic
delay
(yrs)
Prevalence of PNES Diagnostic delay
- Reuber et al., 2002
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• Some patients are*
dependent angry or hostile manipulative isolated resistant to psychiatric diagnosis
• This can impede diagnosis
*Groves, 1978
Diagnostic delay
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Age at onset (yrs)
0 10 20 30 40 50 60 70 70 80 0
10
20
30
40
50
60
diagnostic
delay
(yrs)
Prevalence of PNES Diagnostic delay
- Reuber et al., 2002
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# patients Mean (SD)
PNES +
Sz
AED + 260 7.8y (9.8)
AED - 53 4.9y (6.6)
PNES only AED + 161 8.4y
(10.2)
AED - 53 4.9y (6.6)
“spikes” + 17 12.5y
(15.6)
“spikes” - 195 7.1y (8.7)
- Reuber et al., 2002
Delayed Diagnosis of PNES
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• 20-60%
– Özkara and Dreifuss 1993
• 9-30%
– Lesser et al 1983, Meierkord et al 1991, Krumholz and Niedermeyer 1993 Benbadis et al. 2001
• may vary with clinical situation
• any given person may have two diagnoses
• consider each diagnosis by itself
Co-occurrence with Epilepsy
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# patients Mean (SD)
PNES +
Sz
AED + 260 7.8y (9.8)
AED - 53 4.9y (6.6)
PNES only AED + 161 8.4y
(10.2)
AED - 53 4.9y (6.6)
“spikes” + 17 12.5y
(15.6)
“spikes” - 195 7.1y (8.7)
Delayed Diagnosis of PNES
- Reuber et al., 2002
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Delayed Diagnosis of PNES wicket spike spike
See Krauss et al. 2005
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38 patients treated for somatization disorders 53% decrease in subsequent costs
Smith et al. 1995
Delayed Diagnosis → Delayed Treatment
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-King et al 1982
#
pts
0
10
20
30
40
50
60
70
80
90
wrong
right
e
e
e
p p
p
e
p
epilepsy
pnes
You’d better ask the doctors here about my illness, sir.
Ask them whether my fit was real or not.
-Smerdyakov to Ivan in The Brothers Karamazov
Accuracy of clinical diagnosis
admission hospital later
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-King et al 1982
#
pts
0
10
20
30
40
50
60
70
80
90
wrong
right
e
e
e
p p
p
e
p
epilepsy
pnes
Accuracy of clinical diagnosis
admission hospital later
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• epilepsy
• syncope
– Hyperventilation syndrome
• movement disorders, migraine,
parasomnias, g-e reflux
-Wayne 1961, Pedley 1983, Lesser 1985, Betts 1990,
Metrick et al 1991, Vossler 1995, Kapoor 2000
Pseudo-PNES
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Syncope medical student volunteers
- Dieter Schmidt
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• visual diagnoses/reports can be unreliable
• EEG often needed to verify visual impressions
• patients with frequent seizures
outpatient EEGs may record seizures
• others, admission to EMU needed
withdraw medication
wait for seizures
Accuracy of clinical diagnosis
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• Does Sandy have
epilepsy?
PNES?
both?
• Does Nicole have
epilepsy?
syncope?
PNES?
2/3?
3/3?
What about Sandy and Nicole?
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• added (10% system)
electrodes often useful
• withdraw anticonvulsants
• interictal spikes can occur
in persons with no history
of epilepsy
• epileptiform vs.
nonspecific EEG changes
• beware of normal variants
and artifacts
EMU Monitoring
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• EEG normal with PNES
• scalp EEG often normal
in persons with simple
partial seizures
EMU Monitoring
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• often gradual
onset, can be short
• apparent sleep but
actually awake
(EEG)
• symptoms at onset palpitations, malaise,
choking, numbness,
peripheral sensory
changes, pain, odors,
tastes, hallucinations
• usually short
– longer duration in some
• awake or asleep
-Lesser 1985, Thacker et al 1993,
Fakhoury et al 1993, Lancman et al 1994
• symptoms at onset altered mood, experience,
autonomic changes,
peripheral/GI sensory changes,
odors, tastes, hallucinations
Onset
PNES Epilepsy
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• behavior changes
• hyperventilation
syndrome
• may resemble
epilepsy
• emotional etiology
• behavior changes
• epigastric
• special senses
• unilateral sensory or
motor
•may have emotional etiology
Onset
PNES Epilepsy
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• may or may not
follow anatomic
pathways
• follows anatomic
pathways
Sensory
PNES Epilepsy
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•59 y/o priest
•history of alcoholism and depression
•episodes for 13 months
•bilateral weakness, numbness
affecting extremities, rectum
•notes occasional odor
•no loss of consciousness
•meds: phenytoin 300mg
•normal EEGs
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Towards the left rectal
On the side
Hip I should say…
Left hip?
Yes
Now right elbow
Right knee, very very light
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The left side is still having
a little grumble to it
All right doctor
Now my right just above the right rectal,
that part of the body
Part of the sensation
Left side is all finished
Everything is finished.
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•Second sensory area
•Glioblastoma multiforme
•Died within one year
-Penfield and
Jasper 1954
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• rigidity, pelvic thrusting*
• quasi-clonic, flailing,
thrashing, trembling
• side-to-side movements**
of head/body
• asynchronous***
• rigidity alone rare
• thrashing, kicking may
occur (frontal lobe)
• bilateral movements
– but focal motor
seizures (frontal lobe)
• usually synchronous,
may be asynchronous
(frontal lobe)
• eyes open
*4% **15% ***9% Leis et al. 1992
• eyes closed
Motor
PNES Epilepsy
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• 40 y/o woman
• episodes for 11 months
• tingling, rt scalp
• speech & movement arrest
loss of consciousness GTC sz
2 / week – 3 / 6 weeks
• chest pressure – “cat on chest” & feels “drained”
• speech/movement arrest
nausea, dizziness tired, headache
6 / 9 months
• pacemaker placed after tilt table test
continued episodes, 1 lasting 2 hours
appears distressed, eyes closed
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• crying, yelling, screaming, stuttering
• Sobbing
• complex dramatic, tragic, obscene, mystical
• cry at onset of generalized tonic or tonic-clonic seizures
• grunting during clonic movements
• various vocalizations during complex partial seizures
Vocalization
PNES Epilepsy
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• bite tongue (tip/side) / lips
• bruises, lacerations
• may not respond during
avoidance testing or to
painful stimulation
– may allow intubation
– complications of
treatment:
respiratory arrest,
septicemia,
pneumonia, urinary
tract infection, cellulitis,
foot drop -Howell et al 1989
• bite tongue (side)
• bruises/lacerations
• no response to
avoidance testing
during generalized
tonic-clonic seizure
• may respond during
complex partial
seizure or postictally
Injury
PNES Epilepsy
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• both are reported • both are reported
Urination / Defecation
PNES Epilepsy
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• salivation, hyperventilation, choking, coughing, cyanosis, pallor, flushing, headache, chest pain, laryngeal spasm, pharyngeal spasm
• hyperventilation syndrome
• similar
Autonomic Changes
PNES Epilepsy
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• usually longer
more than 2
minutes
• usually shorter
less than 2
minutes
Duration
PNES Epilepsy
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Prolactin
• 15-30 minutes after attack
• several fold increase
• most accurate:
generalized tonic-clonic
temporal lobe seizures
• less accurate:
simple partial seizures
frontal lobe seizures
• false positives and negatives can occur
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Ictal heart rate - staring spells
29
28
1
PNES
36 Total
6 HR < 130%
of baseline
30 HR ≥ 130%
of baseline
CPS
Opherk and Hirsch, 2002
Sens 30/36 = 83%
Spec 28/29 = 97%
Pos pred value 30/31 = 97%
Neg pred value 28/34 = 82%
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Seizure induction
• iv’s, moistened patches, photic
stimulation, tuning fork, suggestion
• allow vs. coerce
• 70% inducible
• be sensitive to emotional needs
and sense of dignity of the patient
-Lesser 1985, Lancman et al 1994, Walczak et al 1994,
Slater et al 1995, Devinsky and Fisher 1996, Parra et al 1998,
Benbadis et al 2000, Benbadis 2002, Gates 2002
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• often do not easily fit into
standard classifications
• Some patients found to be
psychologically normal
• some but not all studies
find relative increase
in cognitive difficulties
Diagnosis of PNES
Etiology of PNES ≠
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• External interactions
• Internal / internalized conflicts
• Psychoses, Schizophrenia
• Personality disorders
• Other
-Gumnit and Gates 1986, Gates and Erdahl 1993,
Kanner et al. 1999, Mökleby et al 2002
Diagnosis of PNES
Etiology of PNES ≠
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• External interactions
– inadequate personality, reinforced behaviors, adjustment reaction, family conflict, sexual or physical abuse, anger, hostility
• Internal / internalized conflicts
– affective disorders, panic attacks, anxiety, ocd, misinterpretation, highlighting, conversion/somatization/dissociative/ depersonalization disorders, post-traumatic stress disorders,
• Psychoses, Schizophrenia
• Personality disorders
– borderline, malingering, factitious disorder, histrionic, narcicistic, antisocial, passive-aggressive, avoidant, passive-dependent, substance abuse
• Other
– head trauma, cognitive difficulties, a.d.d., tic, genetic influences
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Initiation of treatment is an important
part of the diagnostic process
• tactfully present the diagnosis
• explore possible reasons for disorder
• recommend therapy
– some do well after this single session
but most need more
Lesser et al 1983, Meierkord et al 1991, Shen et al 1990
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• little data on usefulness
of psychiatric drugs
• useful for some etiologies
affective disorders
ocd
schizophrenia
• less useful for others
personality disorders
Initiation of treatment is an important
part of the diagnostic process
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• In most cases see the patient at least once more
– symptoms improved? exam findings?
– emotional counseling?
• If appropriate, continue following the patient.
Initiation of treatment is an important
part of the diagnostic process
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• often only rudimentary data link
seizures, personality, and treatment
• we need to evaluate effectiveness
of specific strategies
in specific types of patients
Initiation of treatment is an important
part of the diagnostic process
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The End
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References
1. Aboukasm, A. et al., "Retrospective analysis of the effects of psychotherapeutic
interventions on outcomes of psychogenic nonepileptic seizures," Epilepsia 39: 470-473
(1998).
2. Alper, K. et al., "Psychiatric classification of nonconversion nonepileptic seizures,"
Archives of Neurology 52: 199-201 (1995).
3. Benbadis, S. R., V. Agrawal, and W. O. Tatum, "How many patients with
psychogenic nonepileptic seizures also have epilepsy?," Neurology 57: 915-917 (2001).
4. Betts, T., "Pseudoseizures: seizures that are not epilepsy," Lancet 336: 163-164
(1990).
5. Birbeck, G. L. and B. G. Vickrey, "Determinants of health-related quality of life in
adults with psychogenic nonepileptic seizures: are there implications for clinical
practice?," Epilepsia 44: 141-142 (2003).
6. Bowman, E. S. and O. N. Markand, "Psychodynamics and psychiatric diagnoses of
pseudoseizure subjects," American Journal of Psychiatry 153: 57-63 (1996).
7. Bowman, E. S. and O. N. Markand, "The contribution of life events to pseudoseizure
occurrence in adults," Bull.Menninger Clin. 63: 70-88 (1999).
8. Burneo, J. G. et al., "Teddy bears: an observational finding in patients with non-
epileptic events," Neurology 61: 714-715 (2003).
9. Cervenka, M, Tran, T, Muthugovindan, D, and Lesser, R. The teddy bear sign does
not indicate the presence of psychogenic non-epileptic seizures. American Epilepsy
Society Annual Meeting, 3.280. 2010.
![Page 54: Imitators of Epilepsyaz9194.vo.msecnd.net/pdfs/111201/102.06.pdf · computerized method for analyzing physiologic data. I also receive royalties from Persyst Development Corporation](https://reader033.fdocuments.in/reader033/viewer/2022050409/5f85d3f15100a0216c690097/html5/thumbnails/54.jpg)
10. Ettinger, A. B. et al., Predictive factors for outcome of nonepileptic seizures after
diagnosis, J.Neuropsychiatry Clin.Neurosci. 11: 458-463 (1999).
11. Flügel, D. et al., "Closed Eyes During a Seizure Indicate Psychogenic Etiology: A
study with suggestive seizures provocation.," Journal of Epilepsy 9: 165-169 (1996).
12. Gates, J. R. and P. Erdahl. 1993. Classification of non-epileptic events. In Non-
epileptic seizures. Edited by A. J. Rowan and J. R. Gates. Stoneham, Massachusetts:
Butterworth-Heinemann. Ch 3, pages 21-30.
13. Groves, J. E., "Taking care of the hateful patient," N Engl J Med 298: 883-887
(1978).
14. Gumnit, R. J. 1993. Psychogenic seizures. In The treatment of epilepsy: Principles
and practice. Edited by E. Wyllie. Philadelphia: Lea & Febiger. Ch 55, pages 692-695
15. Gumnit, R. J. and J. R. Gates, "Psychogenic seizures," Epilepsia 27 Suppl 2:
S124-9 (1986).
16. Hauser, W. A. and D. C. Hesdorffer. 1990. Epilepsy: Frequency, Causes and
Consequences. New York: Demos Publications.
17. Hoerth M.T. et al., The Neurologist 14:266-270 (2008).
18. Howell, S. J., L. Owen, and D. W. Chadwick, "Pseudostatus epilepticus," Q.J.Med.
71: 507-519 (1989).
19. Kanner, A. M. et al., Psychiatric and neurologic predictors of psychogenic
pseudoseizure outcome, Neurology 53: 933-938 (1999).
20. Kapoor, W.N. Syncope. New Engl J Med. 343:1856-1862 (2000)
21. King, D. W. et al., "Pseudoseizures: diagnostic evaluation," Neurology 32: 18-23
(1982).
![Page 55: Imitators of Epilepsyaz9194.vo.msecnd.net/pdfs/111201/102.06.pdf · computerized method for analyzing physiologic data. I also receive royalties from Persyst Development Corporation](https://reader033.fdocuments.in/reader033/viewer/2022050409/5f85d3f15100a0216c690097/html5/thumbnails/55.jpg)
22. Krauss, G. L. et al., "Clinical and EEG features of patients with EEG wicket
rhythms misdiagnosed with epilepsy," Neurology 64: 1879-1883 (2005).
23. Kristensen, O. and J. Alving, "Pseudoseizures--risk factors and prognosis. A case-
control study," acta neurol.scand. 85: 177-180 (1992).
24. Krumholz, A. and E. Niedermeyer, "Psychogenic seizures: a clinical study with
follow-up data," Neurology 33: 498-502 (1983).
25. Lempert, T. and D. Schmidt, "Natural history and outcome of psychogenic
seizures: a clinical study in 50 patients," Journal of Neurology 237: 35-38 (1990).
25. Lesser, R. P. 1985. Psychogenic seizures. In Recent advances in epilepsy. Vol. 2.
Edited by T. A. Pedley and B. S. Meldrum. Edinburgh: Churchill Livingstone.
27. Lesser, R. P., "Psychogenic seizures," Neurology 46: 1499-1507 (1996).
28. Lesser, R. P. et al., "Sensory seizure mimicking a psychogenic seizure," Neurology
33: 800-802 (1983).
29. Lesser, R. P., H. Lueders, and D. S. Dinner, "Evidence for epilepsy is rare in
patients with psychogenic seizures," Neurology 33: 502-504 (1983).
30. Meierkord, H. et al., "The clinical features and prognosis of pseudoseizures
diagnosed using video-EEG telemetry," Neurology 41: 1643-1646 (1991).
31. Metrick, M. E. et al., "Nonepileptic events in childhood," Epilepsia 32: 322-328
(1991).
32. Mokleby, K. et al., "Psychiatric comorbidity and hostility in patients with
psychogenic nonepileptic seizures compared with somatoform disorders and healthy
controls," Epilepsia 43: 193-198 (2002).
33. Oliva, M. et al., "The diagnostic value of oral lacerations and incontinence during
convulsive "seizures"," Epilepsia 49: 962-967 (2008).
![Page 56: Imitators of Epilepsyaz9194.vo.msecnd.net/pdfs/111201/102.06.pdf · computerized method for analyzing physiologic data. I also receive royalties from Persyst Development Corporation](https://reader033.fdocuments.in/reader033/viewer/2022050409/5f85d3f15100a0216c690097/html5/thumbnails/56.jpg)
34. Opherk, C. and L. J. Hirsch, "Ictal heart rate differentiates epileptic from non-
epileptic seizures," Neurology 58: 636-638 (2002).
35. Pakalnis, A., M. E. Drake, Jr., and B. Phillips, "Neuropsychiatric aspects of
psychogenic status epilepticus," Neurology 41: 1104-1106 (1991).
36. Pakalnis, A., J. Paolicchi, and E. Gilles, "Psychogenic status epilepticus in
children: psychiatric and other risk factors," Neurology 54: 969-970 (2000).
37. Pedley, T. A., "Differential Diagnosis of Episodic Symptoms," Epilepsia 24: S31-
S44 (1983).
38. Reuber, M. et al., "Diagnostic delay in psychogenic nonepileptic seizures,"
Neurology 58: 493-495 (2002).
39. Selwa, L. M. et al., "Nonepileptic seizure outcome varies by type of spell and
duration of illness," Epilepsia 41(10): 1330-1334 (2000).
40. Shen, W., E. S. Bowman, and O. N. Markand, "Presenting the diagnosis of
pseudoseizure," Neurology 40: 756-759 (1990).
41. Smith, G. R., R. A. Monson, and D. C. Ray, "Psychiatric consultation in
somatization disorder," N.Engl.J.Med. 314: 1407-1413 (1995).
42. Vossler, D. G., "Nonepileptic seizures of physiologic origin," Journal of Epilepsy 8:
1-10 (1995).
43. Walczak, T. S. et al., "Outcome after diagnosis of psychogenic nonepileptic
seizures," Epilepsia 36:1131-1137 (1995).
44. Wayne, H.H. Syncope. Physiological Considerations and an Analysis of the
Clinical Characteristics in 510 Patients. American J Medicine. 30: 418-438 (1961).