thank you and thank you off
coming epilepsy is one
of diseases even the word see you
your comes from being seized by supernatural forces
the gods are the devil's depending upon which century Iran
and if epilepsy is misunderstood than the condition
psychogenic non epileptic seizures is even more misunderstood
in fact very few of my patients have ever heard of it
and probably most primary care doctors
have not heard of it as well and yet it's pretty common
at least in referral centres it's very common
and it is often misdiagnosed and it is often mistreated
so it's great to be invited to have an opportunity to
talk about this misunderstood condition
and see if we can shed some light and answer some questions
we have with us up I'm a moderator
doctor area Charice of and I will turn
over to you for questions and please feel free to direct questions
to any of us and we will feel free to
answer any other questions as best we can and thanks to the audience for being
here
well thank you doctor fisher before talking about
psychogenic non epileptic seizures 4 p.m. AEST
and how they differ from epileptic seizures could you say a word about what
are epileptic seizures sure and athletic seizure is an electrical storm in the
brain
normally the brain cells function fairly independently
with a lot of chatter if they fire
to synchronously too much together into high
a surgeon voltage then a seizure results
and the Thai procedure depends upon where in the brain that
abnormal electricity comes from if it comes from the
motor control area you may have twitching have your hand
if it comes from the visual area you may see lights
or visual hallucinations if it comes from the temporal lobes
on the side of the brain the most seizure prone part then there may be
fumbling confusion loss of memory
robot like behaviors called automatons
and if they spread to the entire brain then you have what is
often called the grand mal or more officially the tonic clonic seizure
was stiffening and shaking now a psychogenic seizures
is different in that it does not have the electrical storm
associated with that but physically
it can look rather similar to an epileptic seizure
and can take some work to diagnose which is which
let me show you and each one of each
and you can see that there's some a similarity to them
I've got permission to show the seizures
but I've rather anonymized them anyway cutting off the
the head really cut off
had just photographically so you can see this as an epileptic seizure
and it's in the tonic stiffening stage
at this point the person would be unconscious
and even though they might be making a cry if we had the audio with that
it's because at the expelled air against the clothes throat we think it's not
because a pain
and now it is in the Klondike jerking face
the seizures go on for typically a minute
for two minutes and in the person slowly wakes up
usually not remembering any other this is a non epileptic seizure
and experts might be able to tell them apart due to the
a synchronous movement of the Lambs are the type of movements
but it can be pretty hard you can see that there's
a fair amount of shaking and movements
that occurs with either up these
now in the case up the non epileptic seizure
the brain wave activity in this is ten seconds a brain waves from different
part
that they had called in each a the brainwave
activity is nice and low voltage and regular
and there's even something called what looks like a sine wave
you engineers a 10 per second alpha rhythm which is the brains healthy
idling rhythm
in the brain which you would never see during a generalized
to clinic seizure and here's a tonic clonic seizure and the amplification
here is
is turned down so that really this is twice as big
as it looks compared to this but you can see the high-voltage
rhythmical and synchronization across the head activities
so we can a tell
an epileptic from a non epileptic seizure from the EG
if we happen to record it saying in epilepsy monitoring unit
during the event and other cases we have to use
other clinical factors for the two of them is that
answer your question doctors and doctor fisher
are there some conditions that imitate epileptic seizures
but are not epileptic seizures that too was a
is a very good question and I'll
there are many of them I'll
one the most common would be a fainting
type event which is called syncope
in medical terminology they're also can be
sleep disorders people who fall asleep inappropriately perhaps they have
narcolepsy
perhaps the neuro surgery or psychiatry interns and the rebel night
and these get confused with seizures
people who have severe migraines can sometimes become confused
even without a very large headache and those are particularly hard to diagnose
if there's a fluctuation from for migraines
hypoglycemia and other metabolic conditions can cause
seizures and there's a whole checklist a
imitators have seizures on a medical basis
that aside from the medical imitators epilepsy
their other psychiatric imitators of epilepsy which you'll be hearing much
more about from my colleagues
later in the talk in turn the microphone over to doctor can
and doctor can are
what are the best psychological imitators and features so I'm on the
more frequent
the type of imitators are
panic attacks very often in the course have a panic attack in individual me
perceive that they may become somewhere
confusing they're thinking as they hyperventilate very strongly
an I these can be interpreted
by the emergence room physician as are you
probably had lots of awareness area surrounding you probably had
focal seizure on nightmares
night terrors often can be associated
diagnosis or a misdiagnosis
epilepsy when you have not infrequently
individuals who have a condition known as
intermittent explosive disorder this is a condition where
individual star a start becoming increasingly
I agitated in
in it can increase in intensity to the point where they become violent
in at the end they have no recollection of what transpired
in that lack a recollection Kate often
interpreted as a possible seizure and we often will see these
patience in the Epilepsy clinics
for
evaluation for a seizure disorders I
interestingly enough for individuals with
intermittent explosive disorder is will improve with antiplatelet medications
for
a the type
with them and tablet the crux that have mood stabilizing properties such as
cover me zipping
I in so that for their
enhances the the confusion and then you have
I individuals with artistic spectrum disorder
that have a lot of mannerisms in
as part of their manner is min and behavioral
patterns they may often be confused says epileptic seizures
in as doctor fisher mention now
the best way in in kiddies with autistic spectrum disorder
distinguishing with it these her teacher not
he's by doing VTG monitoring study very much
I'll turn the next question to doctor barry and
doctor barry why do people have PNES
arm that's another good question
the answer however i think is
is hard for us really know we we understand a lot of phenomenology
%uh these particular events the ideology of the events however is really
and clear to us we have eighty years in the out years basically come from
the on the ways in which these these
episodes actually present in the context in which the present
so if yes why it may be a manifestation
severe depression we consider this
really communications on dysfunction and we can go in and talk a little bit more
about this but the way week
consider this is my many of these people have severe anxiety disorders
as Andy which is talking about they also have episodes have fun ptsd
post-traumatic stress disorder
many of these folks have been injured as a child in a variety of different
fortunate ways
which has resulted in them developing a communication deficit
on
in 1975 Peters Sifnos actually from
Massachusetts talked about a disorder called Alexis
time in the Greek makes it basically means something for
which they have no words and many of these people suffer from the likes of
time you
have to remember that when you're all kids in years your parents
when you're growing up in your head something happen to your
parents are labeled you I'm in situations that were everywhere
the parent all situation is is non-functional
I'm people develop way of communicating
and the way they communicate is as semantically
by I'm I'm by physical manifestations
rather than being able to label emotional situations
so that's a long from answer to your question
we also are starting to look actually a at some of the
neurologically anatomic underpinnings the
diagnosis actually a farm PNES really is change in some way at least the
nomenclature in the dsm-5 now he's a call function on their logic disorder
and actually really like that terminology because that's kinda what it
is it's a functional disorder
and I like it when I presented the diagnosis to patients to
because many times these folks have been picked up by
EMT or doctors in the emergency room and you would never expect anybody to say
anything to them like you're faking it or this is not real
whatever that anybody would actually save it to an individual but
but they do and what where understanding now is that this is a function of the
anatomic physiologic process
home so I we have a lot to understand
more about this particular disorder but that's kinda cool
along the answer to your question doctor fisher and
something Jonathan
week we often treat the same patients together me from the neurological and
you from psychiatric standpoint
a lot of the ones i've seen have either suffered some form of
abuse when they were younger weather in some situation
in which they can't cope and
you know we use words here like functional and conversion disorder could
use a little bit about what those words mean
then that's a situation what absolutely
fun US question up higher conversion disorder is actually the terminology
that that is
on really tension tension the fact that it goes back to the
1800 and I was a terminology that was
was popcorn by by Freud and he basically was talking about a conversion
have an emotional conflict into a physical cinematic presentation
which resolves that particular conflict I oftentimes use the
home the analogy love for you a boy you
getting angry at his father ritter hillerman realizes that he can't do that
and developing a paralysis at that particular harm so is converting
basically the conflict into a physical manifestation invest the terminology
conversion disorder
I'm its its most of the time it's really hard to maybe
aspects that that most situations are I don't think that's necessarily true
but but as a terminology that's been used in the past I like functional
better I think that that has has more apropos to many
cases that we generally see why I just wanted to add
when I'm other perspective and for tomorrow the
thank you Jenny none epileptic seizures so very clear morphic condition to their
many causes in there there are a certain percentage of cations
who when you do an evaluation you don't identify
at the time of the evaluation any current
psychopathology in are a very often
just by telling the patient you don't have it but let's see
these are not a politically you don't need to be on medication
patient goes home in the event stop
into the serb individuals in
whom probably whenever triggered the event is not open to any more
in web maintained that persistence of these
episode was the fear of having epilepsy and then you tell them know you gonna
epilepsy and it's gotten so
I think we have to also keep that
concept in mind because very often patients will tell you
but doc I
i'd not the press and not anxious my life is going well
and we have to take aim at their faith value it's not that they're
trying to deny a sec are very often you know that can be
also going whatever triggered
without a print anymore at the time of the valley and if its accumulated stress
from a nappy stress at the moment
right the attack right my next question which is for doctor barry
I'm it current our past rest and if it is passed rest my
why would there be a delay arm
it's it's actually both so the way again I look at it
is again as a communication dysfunction I think that the thing in just mention
it also bears a little bit of
from expansion and that is when a patient goes to a unit
com like candies are ours here at stanford
home there seeing a neurologist Rogers understands sits down talks to them
they get their communication message across
there listen to their appointments are made for them for the future
not abandon no be continuously followed so when these
ragle's ago why they don't ragle's to go away take go away because
in many ways the function at this particular offense actually has been
Phil on so is it as far as past
com strasser conflicts are concerned
the has stress especially as a child can cause permanent neurological damage
and so it's important to remember that were we're learning
much more about those that particular aspect of all this
manufac- a fax brain function again
on a permanent basis these are people who have had deficits that because of
their particular backgrounds
will be with them forever doesn't mean it's insurmountable
are that you can't treated other can't learn alternate ways
developing
and and dealing with issues and problems but
that Achilles heel their remain in some particular capacity
what why does it happen now there's usually a a precipitating event
and can be a variety of different events that may remind them about previous
trauma
it may be is bob actually was talking about something that just
overruns any kinda coping strategies that they have
and mm because at that manifest in this particular fashion
the next questions you can ask Rena usurp your cum
role here for a second and and that is to his I i think these are incredibly
fascinating
I mean when you look at what I just showed you Andrew
that this is a psychological phenomena that actually took place
I think that's really a fascinating phenomenon
but the a.m is you is that some had a fun disorders is what is used to be
called
and smell a fun disorders a very common and it's not only in a row G
you we can go through every branch medicine actually
each branch as their their aspect to
psychological I'm have physical manifestations
you can do certainly with GI talk about also is a terrible pal syndrome
cardiovascular disease
dentistry in TMJ so we can go through this is not an uncommon phenomenon
it may manifest differently in different patient populations
and the next question is why does that happen and
I don't know i wish i did. but I think it's fascinating but it's really very
very common
and again that difficulty really expressing your emotions
talking communicating and having a beer
some at a communication is that the the way this actually happens frequently
oftentimes people will say on I don't know why it happens and I
because I'm totally relaxed and rested at night why should actually take place
and the way I generally understand that is as you all
remember when you were back in on biology 304 and you have to be good bc
im
ever and you got through that examine after which you thought you'd be
feeling fantastic nap its after the emergency
you get yourself through at all costs but after the emergency is when things
fall apart it went up the vision they wanted to
add to a transcending bodies that in addition to the events that you
see happening for patient headaches
are very frequent in a few have that experience but I
in in my experience vast majority of patients with psychogenic medical epic
seizures
report constant headaches in 10 times
up to a point where we have to refer them to our headaches
specialist because they don't respond to pharmacotherapy into
its it this is just too to illustrate the complexity of the problem
expand on that it's not just headaches it's also
and in general so pain disorders are extremely frequent in this population
just remember also that people with depression in many of these people have
episodes of major depression the pastor at the depression at the present time
SIMATIC complaints in pain disorders I'm sorry like that
keep
so pay pain is a very very frequent in this patient population to
so I'm it's not just had it and I think in is absolutely right that's what we
generally
it's frequently seen but pain complains a variety of different
disorders are also very frequent think about things like Byron
chronic fatigue syndrome those things across a very common this patient
population
all your comment night
we highlight the ways in which the mind and the body are intertwined in these
disorders
and in them at a farm disorders in general so thank you for that
maybe we can turn the microphone over to doctor can earn them
are these episodes in a person's control
so again I'll as I alluded before
psychogenic democratic seizures is a very clear more fake
condition in you do have
a small percentage of patients in in my opinion it is small percentage of
patients
who have what we call lingering
with wheaties a you know form
both a provisional your
movements or events that are under their control but in my experience it's
it actually very small percentage of patients in the shower
people in whom there is a being
to to be made from having the sap is a test I remember
a you know patients were suing
somebody
because of injury and they've developed this kind of
things faces this is the kind of thing but I think the majority of patients
don't have a conscious control
and I think the season X in pic very important concept
that and needs to be transmitted
to the patient and the family
members because it it is well love the big fears
that patients experience that if they can
it's going to be thought that they've been making about that they've been
faking it there
doing it to attract attention named
each one of their causes that patients me
react you know
you are you saying that been prohibited left field this year's end I'll
in I make it a point to
clarify not only to the patient but to the family that you know
this is not something that is being done relationally
whether the mechanisms
that are or print you causing these
the separate I think it varies from one patient to another gained
patients overtime
through variety of interventions in now cognitive behavior therapy
has been found to be and effective treatment helping patients
to have less a piece episodes or even stop having
Sep isn't II can
in the way the give the impression that patient under control
I'll John use here
used to and you feel do hypnosis in order to identify
triggers of these this offense
but in the majority
this is not something that patients
can can stop like that I just one second that
I'm is to run a group here with patients with phone
Nana politics measures Korea was right running one right now
and one other messages at the end of the group everybody all the events actually
both the into the group which actually is eight or nine months long by the end
of the group
all everybody had their seizures under control they didn't have anymore
have been on a political answer me they say when you go out and talk to people
ask them at the end but we want me to do
as information publisher but go talk to people
and told them these are not pseudo used because he loves
use please tell them but these are not pseudo
that has a very pretty sure quality to it that we didn't have control at these
events
with identify triggers reasons why these things happen open-air
the controller learned about it but we have no control over that
please go tell people but these were not sooner seizures that these are real
vans that happened to me and I had no control over
up
attention one that that's important for patients and their families to share
and to educate more on the population about
this disorder and doctor fisher
have a question for you how do you make a diagnosis
have not left seizures we have marvelous technology now in the neuroscience field
but the diagnosis
have seizures and epilepsy which is the condition and spontaneously recurring
seizures
still mostly made by the history that's the first point
we take the description up the events
and we use our experience to
tell us is it in alteration have sensation
motor function behavior awareness
punched out in time somewhat stereotyped if it repeats
that sounds like an epileptic seizure
or does it sound like somebody fainting when they stood up to subtly
or somebody falling asleep you can be aroused
so we take the history if
johnnie has a quote seizure every time jimmy takes is toy
it's probably not an epileptic seizure because that's not historically
consistent that some type of
behavioral episode that's occurring so most important thing
is to start with the description up the event
and we also look for
psychiatric factors it used to be said when I was in training that
a psychiatric diagnosis is a diagnosis of exclusion you have to rule out
everything else first
well that's not true anymore there are criteria there are things to look for
in a person's background that
are risk factors for psychogenic non epileptic seizures we heard some with
them
the only thing is you can assume just because they're they're that that's what
the answer is you have to look for the ring after you have to confirm it
we take a history we do an exam to see if there are any signs of neurological
damage that would go along with epileptic seizures
we run in Egypt neeg is an electroencephalogram
its brain waves it shows the
up and down voltages across a person's head because the brain is
electrochemical organism rather like a
car battery for a Tesla although a bit more complicated than that
so with epileptic discharges we have that high voltage
storm but half for the people with epilepsy will have what we call
spikes abnormal surges elf
electrical activity between seizures so somebody has a
somewhat convincing story and has those spikes
then I'm fairly convinced that's likely to be
seizures these EG is are normally thirty-minute one hour shares in the
outpatient clinic so we don't usually
capture seizure event itself
we're looking for these epileptic spikes between
seizures however if it's important to capture an event
then we can do the some type a more prolonged monitoring
we can send people home with the EG headset for 24-48 hours
that will record it on a cartridge and look at all later when they bring it
back in
they can push a button if they had what they thought was a seizure
and we can see what what are the brain waves doing at that time and then the
the gold standard test is the inpatient video
EG monitoring and what's often called in
emailed not only an Australian bird but also
standing for epilepsy monitoring unit and in that circumstance we may withdraw
medication something that would not be safe running outside
but under direct supervision it can be made safe
to provoke the events record the video
audio brainwave picture and make a determination
if those are epileptic seizures
in some cases despite our best efforts
we still can't tell and then we may do what's called the therapeutic trial
we just may try some anti-seizure medicines
if we think that's the avenue to try or we might try
anti depression medications if we think that's the avenue
or we might use medications that might address both
and see what happens so it's a process
10 the advantages of practicing medicine
and the 21st century and having smartphones
is that today we can ask family members
to take yours smart room and videotape the event
because they're offering can help us capture the actual event
in while motha time
if he needs a convulsive event you could
reach a conclusion of the 80s doesn't look like an epileptic seizure
you have to also keep in mind that certain events
King have clinker characteristic suggestive secretary Mick not a
political event in
maybe clinical seizures and %ah
the other
non-combat events where the individual
just fits their spears is unresponsive
those more difficult to to distinguish but
use the this month from today
to capture the event you you bring it to the consultation for physician
your save a lot of money to make this isn't just a little bit more complicated
on people with a political events can also have Nana politics issues as well
so on maybe ten to fifteen pass percentage a patient's
work a political so im not a political plans so this becomes
much more a complicated it's not an either/or proposition
either so you have to pay attention to that people with TB eyes for example
seizures and bother originally talked about as far as
kinda overwhelming your ability to cope I'm certainly a lotta
CNS disorders can certainly over run somebody's ability to cope in result in
on a flat tax issues
but they also may have epilepsy to so it makes it much more complicated
I just wanted to illustrate
point that that has not been emphasizing bodies that
people can our walk around with a diagnosis
non epileptic seizures for years gain
when are the very 324 patients that come to our
epilepsy monitoring unit not only ours in Miami with throughout the country and
throughout the world don't have epilepsy and many of them have been
treated as if they suffered from epilepsy for years
years to a Pats at something that
one has to always keep in mind when evaluating patients
with event had several patients referred to me for brain surgery to cure their
epilepsy
who had psychogenic not epileptic seizures we didn't to the brain surgery
Fisher maybe you could say a little bit more about those patients who have
a doctor barry brought up both epileptic and non-athletic seizures which shocked
me sound like a complex
patient group
yeah that would be our most complicated a complex patient group people who have
both um even that group is somewhat diverse
because you may have someone who had epileptic seizures
as a child it
and then they may have gone away and now other events are occurring so we assume
that they must just be the adult manifestations of those
childhood epileptic seizures but in fact
these new with answer really something different and their psychogenic non
epileptic seizures
so that that is one scenario and that's been fairly
common in my experience almost as though the
brain has somehow learned how to have epileptic seizures and
is in that kind of group so that when
says other symptoms happen in that
confer from the emotional to the physical
it takes that pathway speculate a bit on that
the the hardest patients have all are those who were having
epileptic seizures on Monday
and non epileptic seizures on Tuesday um
the the best way to get ahold of those is to do the video EG monitoring
and explore with the patient and the family what does this one look like to
you
how many of these you have at home what brings these on
how bout those what brings those on and in that circumstance where they have
both condition mixed
we clearly need to use a dual approach
both anti-seizure medications and psychiatric treatments that we
haven't talked about yet but we will um
and and take a very comprehensive approach to the
to the patient but they can be very difficult to treat I think one
one group and I'll we are you may see a higher prevalence of
both Atlantic seizures and not a political event
are individuals with cognitive developmental delay
and these are individuals who starred with epileptic seizures
and eventually they learn you know when I
have my seizures I don't have to go to
workshop right on have to do this or that game so it becomes like a problem
%um
response in the again it said that they're doing good they're faking it
don't have a
it he is just it just learned behavior
in and they're not doing it to attract attention in May
experience it's more than avoidant type of
behavior in E some studies have suggested
that among people with 9 eclectic seizures
they are cognitively paired forty percent
we'll also have epilepsy so comorbidities hi
its it's actually a good example
work will talk about treatments and just a little bit but whenever I see any
adult or child who comes in with the developmental delay
that we're concerned about the possibilities being up a lot to commence
but usually realize that you have to sit down yet to find out
about the system and what's going on the system have to do that
generally but in this particular patient population in particular
because what's happening is sometimes it's a a stress response
that there's something going on the group home that's problematic
are an individual in the grip on the having a lot of difficulty was a
romantic
break up or or whatever and I'll be manifest not words because words can't
be used
I in this particular situation it'll be manifesting behaviors
and so it's actually good example of what happens in people who do have
cognitive abilities
up a normal range and also have verbal abilities
but haven't been able to use them for one particular reason or another
it's a similar kinda on situation along that line
and thinking about stress doctor fisher can stress provoke epileptic seizures
or just PNES clearly both
surveys of people who have
ordinary epilepsy non not
psychogenic Donna politic singers
typically one asked will this stresses the
number one provoking factor
for their seizures there are many other provoking factors missing sleep missing
medicines physical
illnesses some people may be provoked by
sugars or dietary indiscretions and alcohol
and so on but stresses often listed as number one
but it isn't a one to one relationship it's not every moment they get stressed
they have an epileptic seizure if that appears to be the pattern then I'm
thinking it's probably not
epileptic and of course we've already talked about the role of stress
in PNES psychogenic non epileptic seizures
its very major but it's often
remote stress sometimes perhaps
is it fair to say with the recent reminder at some level
maybe not an obvious but a subtle reminder
have that passed distress so stress is a
here a comment faced both of those conditions
doctor kantor we know that
draft accompanies variety of psychiatric conditions
do other psychiatric conditions tend to accompany
PNES or psychogenic not athletic features and if so
what should be done for those comorbid psychiatric conditions
so sojourn already alluded to that
I'll as I said psychedelic
an epileptic events he very clear market condition
and in
many are these patients you will identify depression
and that long history of depression as among them the most frequent
comorbid conditions very often it's not only the pressure is the pressure and
anxiety disorders
and you kidding me to 3 those underlying conditions
those are the most frequent condition post-traumatic stress disorder
is peak comorbid condition
and and you can have
associated with that panic disorders that offering
the panic attacks often gets mistaken as a septic seizure
I so you have all of that spectrum
of mood and anxiety disorders personality disorders
are not unusual people with a long history of
psychogenic an epileptic seizures in the seas also
a scene in people who have been victims of very dramatic
lice throughout to or
you know being victims have severe abuse and
and neglect are very often you identify
attention deficit disorder coupled with
mood disorders in the in the combination of attention deficit disorder in the
mood disorder
I lead to these personality disorders when
this people grow up
a in the they've been victims of a
X you know address if situations in their life particularly abuse
you know it's the perfect storm in these makes
the treatment of these patients quite challenging
for psychiatrist no psychologist psychologist
are in so you have to do it very very careful and detailed
psychiatric history in order to identified
the psychiatric comorbidities is here because essentially
psychedelic not epileptic seizure is in neuropsychiatric disorder
him as john was saying are is
a condition we we are starting to identify
neurological southerner logical changes in the brain
in their chemical changes in the brain with very strong psychiatric
manifestations but the treatment is
is a Catholic treatment that your target really have to
very careful history doctor can
how do you tell someone but they don't have epilepsy
happy and yes so that bad is
a excellent question and this is
are when of what I like to call the
art of medicine when we we present
but I was his you have to be extremely extremely careful how you presented
diagnosis because
you know it it's not as easy as to saying great news you don't have
epilepsy
I you have to take all this medication II
you now have a great life it's not a simple as that
because where you're doing many of these individuals is
your basically changing their entire perception of their life you're taking
away their identity as somebody
who has lived around their seizures enormous and you tell them
no you don't have you don't have
seizures you don't have epilepsy the other replace that with yeah
so this is what I I'll tell you when I where that when I do for several
I I've learned through the years
that telling the patient the Seas
you have a psychogenic this order secretary Nick seizure
very often you think counter with their with their
you know barrier ready mean secretary reading
are you saying I'm crazy or are you saying that I'm faking it
and chill when I the first half eighth
United rep.-elect what is it doc well
these are events that mimic epileptic seizures and this is the reason
at it mimics epileptic seizures I show them the EG recording
over a person with epilepsy a shove them very GS
you sit there is no there there in the span
but what is it well these are things that happen in people who have a history
or anxiety depression we see it in individuals who've been
victims have tried Matic experiences we're seeing it now in
soldiers that are coming back from a
the war theaters pain you know any two-way of their brain
to protect them from traumatic expensive does that
sound like this maybe applying to you in aid let them
see if they can identified with
with this because that maybe the most
because the very telling me %uh no that doesn't apply to me
what that tells me is doc I'm not ready to hear
that the seaside project and I can banking in the head
all I want repelling them this is psychological
in their daughters be over speaker barry
so my approach is in those individuals
is to say okay well I don't know
what it is what's causing it we can do in our logic
no psychological and psychiatric evaluation to identify
and any better I don't meet that that gives me even
for the I'm not ready here with your trying to tell me so when I do with
those patients essay okay
the most serious complication
is view having the soviets ending up in emerging through
the docking the merchants in his party and know that the settler not a cryptic
situation because these events often mimic
recurrent seizures well be called statically platicas
you can end up in intensive care unit intubated
in doctors you know giving you a lot of medication
so you need to avoid going to the emergency room
for I also explained this event are not causing you
brain damage the electrical activity of your brain is not affected
so so the Seas in Grand River patient
I'll my experience has been however that people who've been
victims of abuse or traumatic experiences
ready able to to yeah
it was a victim of rape child
or when I was in adolescent or this happen to me
so a majority of patients if you present fitting that way
will be able to tell you and then US where do you remember what
it was like when you were being raped by transfer
very often patients with poorly I remember
my body was there but i wasnt in that allows you to connect to make the
connection so
just like your body is you know
protecting you
your mind is protecting you from experiencing the traumatic experience in
with the rape
eventually this is a mechanism the fence that
your mind users to protect you from facing certain situations that are
uncomfortable 32 to yeah
its OE you normalize it for them so then he becomes
an acceptable option you see
but I think that the peak error that we make his
going through patient a are you have secretary Nick events
I'm go to see a psychiatrist about because they're weird
building up the barriers in that result in in
more difficult referral to the to the treatment
I want to emphasize that for
any people who are listening have been doing this for 30 years and it's gotten
better
but many neurologists just have a terrible approach
psychogenic non epileptic seizures you're hearing from doctor kantor
doctor barry how it should be approached but the usual approach that we see
is what we call diagnose and at eos the neurologist
all of a sudden says this is psychiatric
it's not my business goodbye it's just another form
above abandonment in their life whereas
this is a neuropsychiatric condition and it needs a joint effort
between neurologists and psychiatrists over the long term
to take care of it
failure patients who are really suffering I also wonder
are their patients for whom there is no identifiable stressor
trauma but who have PNES older
well yes in as I was saying before we that we actually did a study
a few years ago we we actually a try to identify where
where the protectors of the course of
PNES after the diagnosis in we found that
about 20 percent above other patients we can identify at the time of the
valuation any
any psychiatric condition those patients
did well when they were discharged be
stop having the events we actually follow the patient after I
I'm a strong believer that you have to for the patient
for various reasons for speakers you don't abandon the patient number two
because you don't know that these patient may not have epileptic seizures
as well
and when you're taking the most medication from the seizure made me cum
number three because very often they have other comorbid conditions
mainly pain in hex for which you know the psychiatrist me not feel as
comfortable
in in handling are in
are servers are those are the kind
of patient in whom you don't identify the pic conditions where
they stop having the Avengers in whatever was
that quote the events in the beginning his you know
is not a print anymore right that's it nothing if area for example
one of the conditions that doctor fisher was alluding to
convulsive syncope get often misdiagnosis epilepsy
you tell somebody you have epilepsy you're messing up with life
big-time pic and write they can do
these things in so that in and of itself
came become a self-fulfilling up profit until you do the valuation and then
that's the end only should probably be a little briefer with their answer so we
leave time questions
a couple other just three more remaining question
we've talked a lot about diagnosis and I'm
giving the diagnosis and touch a little bit on the road psychotherapy in
treatment but perhaps doctor berry good faith and more about
general treatment approach for PNDs show week we're just actually finish to study
was a
3 home Institute study at Brown University Cincinnati looking at
different approaches
since the ideology many of these events or depression
we looked at the treatment of depression along with medication
we also our look at a group of patients with CBT which is cognitive behavioral
therapy
him a group that was treated with both and then a treatment as usual group is
bob alluded to
before and actually the combined approach which is always the case
with RCPT medication to pass but met there is a group that patience
who have which we took medication emancipation gets better
many it is not a political that's also get better I'm Sakana behavior therapy
is
is very useful I use a psychodynamic approach
is again as a have talked about these i think is a communication issue
and just as I'm as any was talking about
up with people who don't have a specific targeted
stressor whatever that cause these again the trying to communicate
a somatic in a systematic fashion
this can be understood these patients actually do very well the patience to do
very well those that have had the disorder
for the least amount of time so in other words patients have had them for less
than a year 6 months
is a high percentage of those patients who actually all too well
and that's one other the reasons and bob alluded to this the very beginning
is that you try and get these missions and soon as possible
before this gets to be have their personality the way that they approach
the world
because then it becomes more and more difficult actually iraq to find so
the shorter duration of time that this is actually been a problem
those patients actually do quite well money nation know that
i think is actually very critical to that this is
that this is a treatable disorder doctor fisher
as a neurologist who follows people with PNES and clinic
what is your experience with prognosis I think most to them end up doing well
when I was starting in this business it was said that the prognosis was
something between poor and dismal
but that's because their doctors weren't doing anything for them they were just
ignoring
or abandoning them so now if you
take a joint comprehensive approach and you try to address the
underlying causes for the PNAS
and you treat it you treated depression if it's there you
do cognitive behavior therapy if it applies
then the prognosis can be pretty good my experience is that people vote with
their feet
if they show up for treatment they get better if they don't show up
some reason they don't want to be treated
and they will typically go on having the offense
is a statement I think one of the things that you
when you look at the three of us here up here for a reason on a psychiatrist
activities certified both psychiatry neurology
public obviously neurologist this this is a very changing time
and that is psychiatrist neurons is the way I look at I'm very at home
working with all over me the unit mourned
in many ways I am in the country and we work together
work together all the time and Treme is patience is very difficult to think
we've tried to kinda get across the complexities patients many is the time
that I see a patient and I don't know what's going on and I'll give Bob a call
and say look at this guy sums going on here I just don't feel comfortable with
it which put him back in the unit and evaluate him again cuz I'm just not sure
about this
you have to be able to do that and these the
mind bodies
mind by cancer country urology that doesn't exist anymore there is no split
this is a
organic problem to cart it is a huge disfavor we talked on mind and body
is all one its ok it's an organism and this is a physical problem
so when we work together like this the probability of patients getting better
and getting good care
is accentuating I
I wonder if it's a were one thing the presentation of the diagnosis
is pivotal in the patient pursuing
treatment if you don't present the diagnosis is properly
you're going to make the patient
run away from your unit anyone who
has this problem know someone who has this problem and wants to get help
should go two way
comprehensive Epilepsy Center it does take a multi-disciplinary approach
takes a place that can do video EG monitoring
if you don't know how to find one outlook on epilepsy dot com
where the Epilepsy Foundation website those are now
conjoined in the same organization for find in epilepsy
center it's not something that
would typically be best handled
in your primary-care a office
unless that person has an unusual skill and experience
Sat well I think we ought to work clothes the questions down now
from are moderator area left Paris off and we ought to open it to the audience
with you moderate the audience questions as well
any other speakers my talk to any significant
cross-cultural or sociological issues related to this disorder
I live in Miami
reaches which is the city next to the United States
pic matter
but about it has the very rich
culture or diversity
we have people from the Caribbean South America
and a lot of European in Asians have also moved to
to Miami and I have to tell you that you see
these Tennessee trations very frequently in South America
use here and we've an increased frequency
because there are certain cultures in South America where insists these
actually and accept it in court
an accepted practice entered you
you you will see it I I was born and raised in Mexico
in mexico we use to see that very often when I was
during my internship in the General Hospital
Mexico in Mexico City in these
was an expression or for
from insist and in it's not only something that you see in mexico you see
it in many countries in
in South America and where these kinda practices
stop in Arizona up
work practiced for a number of years we had
I'm the Native American culture and the navajos have described the
hand trembling attacks which
are highly correlated with epileptic seizures and the
moth inflame attacks which is like a moths fluttering around the flame
which they correlate with the non epileptic seizures so they use different
words but different culture see the same phenomenon
question so what percentage of the population
has this disorder 5 percent of the world will have a seizure in their life
maybe more if especially if you count the febrile seizures in children
nobody knows really what the subset is
who have non epileptic seizures it is
a small percentage of people who have epilepsy
what number would you come up with gentleman Nana politic seizures verses
epileptic seizures in a population
studies never been done so that
that would that would be for a thousand
people with epilepsy would have not epileptic seizures up but if you go to
epilepsy centers
where there's a Richmond by referral
as doctor Cantor said some places will have
a third to a half of the people referred for Apple App see turning out to have
non-apple uptick caesar's
because the seizures have income under control with traditional medicines
10 things we haven't set that should be mentioned briefly
is that some other medicines work both for epileptic a non-apple epic seizures
so medicine like the motor gene which is a seizure medicine
is also a mood stabilizing medicine and would help
both if you're having complicated migraines with confusion
doubts and you get put on to appear a mate and
anti-epileptic medication it's also an anti headache
had a preventative medication so sometimes we can be clever and cover
both
both baths other questions
your a
in terms of PNES would
would you consider with you
be likely to see a wide variation presentation at the episodes a serial
episodes
sometimes yes and sometimes
no if we see a wide variation for me it makes the diagnosis easier
because he is yours are relatively stereotyped
one to another so if the presentation depends very much on the situation
and his varied I'm inclined to think in maybe this is not an epileptic seizure
but sometimes the the PNAS can be very stereotyped as well or they may have two
different types of PNES
each of which is stereotyped its own way okay one more question
have a question I give the impression
GP's can recognize from
I live
this I had uncontrolled seizures point here
and I got lucky one day
donating blood Welsh Road very minor seizure
doctor on the pram came
going hostile cats I handed
referred greater religious ham and then
I was medicated working after a while
and you doctor fisher take care and the hospital
video G&I head nurse seven years ago
never had another seizure that for years
twenty-two years I'm having complex partial seizures but
what's frightening as I'm driving her around with side Atherton
other people's children plus my on
any with really terrifying
my children still if I just make a sound on the phone
my I have time I for seizure in my third year was four months old
for talking and I share me mom
it's like a trauma coming back she day remember me
always pulling over the cards I would those days I had
and/or I could pull the car over and wait
for it to be over but it's really common that these people don't know why they
may just say okay
you are you having a panic attack it
to see
rapid I really wanna think
doctor Fisher doctor can earn doctor berry for joining all of us
and to think the audience for being here tonight