Diagnosis of Nonepileptic Seizures Delayed in Veterans

Allison Gandey

September 08, 2011

September 8, 2011 — Military veterans face a longer delay to diagnosis for psychogenic seizures than their civilian counterparts, warn investigators.

In a new study, it took an average of 5 years from the time symptoms started for these patients to be diagnosed with psychogenic seizures. This was in sharp contrast to the average of only 1 year for the general population.

"People with psychogenic seizures are often diagnosed with epilepsy and given drugs to treat epilepsy that do not help and can have serious side effects," lead investigator Martin Salinsky, MD, from the Portland Veterans Affairs Medical Center and Oregon Health and Sciences University, said in a news release. "The 2 types of seizures can be similar in appearance and diagnosis can be difficult."

"I completely agree with the authors, and unfortunately, this confirms what we have always known: Veterans do not get as good epilepsy care as civilians," Selim Benbadis, MD, director of the Comprehensive Epilepsy Program at the University of South Florida and Tampa General Hospital, told Medscape Medical News.

The study appears in the September 6 issue of Neurology.

Psychogenic vs Epileptic Seizures

Psychogenic nonepileptic seizures resemble epileptic seizures but are not caused by paroxysmal neuronal discharges or other physiologic problems, and are thought to be of psychological origin, the authors write.

Seizure patients evaluated at Veterans Affairs Medical Centers are at risk for both psychogenic and epileptic seizures because of relatively high rates of posttraumatic stress disorder and traumatic brain injuries in this population, the authors note. Veterans with seizures are generally older than civilians and are predominately men — factors that may influence both presentation and prognosis of psychogenic seizures, the authors explain.

In this study, researchers reviewed the medical records of 203 veterans and 726 civilians admitted to an epilepsy monitoring unit during a 10-year period. The percentage of veterans and civilians diagnosed with psychogenic seizures was about the same in both groups.

Seizure Classification

Diagnosis Veterans (%) Civilians (%)
Psychogenic 25 26
Epilepsy 18 40
Mixed 4 4
Nonepileptic 12 3
No diagnosis 41 27

Investigators then matched each veteran with psychogenic seizures to the next civilian patient with the same diagnosis and compared the 2 groups. They found the interval from onset to admission to a diagnostic epilepsy monitoring unit was 5 times longer for veterans compared with for civilians.

Comparison of Veterans and Civilians With Psychogenic Seizures

Factors Veterans (n = 50) Civilians (n = 50)
Age at admission, in years (range) 49.0 (24 - 66) 34.5 (19 - 74)
Sex, percentage male 80 26
Using antiepileptic drug (%) 72 80
Interval from onset to admission, in months (range) 60.5 (3 - 408) 12.5 (2 - 144)

Dr. Salinsky says the reasons for the delay in diagnosis are not known, but could be a result of the limited number of epilepsy monitoring units in veterans' affairs medical centers across the country.

He pointed out that 18 of the 50 veterans with nonepileptic seizures came to Oregon from states in which an epilepsy monitoring unit was not available.

This problem has recently been addressed by the creation of Veterans Affairs Epilepsy Centers of Excellence.

"A delay in diagnosis can prolong disability," Dr. Salinsky said. "Educating primary care doctors at veterans' affairs clinics about psychogenic seizures and developing an effective epilepsy center referral network should result in earlier diagnosis and appropriate treatment."

"For both veterans and civilians, the lesson is that the diagnosis of 'seizures' is not questioned enough by neurologists," Dr. Benbadis added. This is especially the case, he said, when there is a history of traumatic brain injury. "The bottom line is that when seizures do not respond to medications, electroencephalogram video monitoring should be performed."

Dr. Salinsky serves on speakers' bureaus for UCB and Pfizer and has served on scientific advisory boards for Medtronic, Cyberonics, and Lundbeck. Dr. Benbadis has served on speakers' bureaus for UCB, Cyperonics, Glaxo Smith Kline, Sleepmed, and DigiTrace. He also has worked as a consultant for Lundbeck and Pfizer.

Neurology. 2011;77:945-950. Abstract

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