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Stroke and sexual assault trauma each were linked to psychogenic non-epileptic seizures (PNES) in a large, single-center study of electronic health records.

PNES, paroxysmal episodes that mimic epileptic seizures without the EEG pattern seen in epilepsy, are difficult to distinguish from epileptic seizures. Many PNES patients initially are misdiagnosed with epilepsy.

Of more than 2.3 million patients treated between October 1989 and October 2018 at Vanderbilt University Medical Center in Nashville, 3,341 adults had PNES (prevalence 0.14%), researchers reported at the American Epilepsy Society 2020 virtual annual meeting. Their median age was about 49 and 74% were women.

People with PNES were nearly 16 times more likely than the general hospital population to have experienced and disclosed sexual assault trauma to their healthcare providers, Vanderbilt University doctoral candidate Slavina Goleva and co-authors found.

"We saw that reports of sexual assault trauma were also increased in patients with PNES, and because females are more often victims of sexual assault, we wondered if that could partially explain why females were more likely to develop PNES," Goleva said.

"When we examined that question, we found that sexual assault trauma explained about a quarter of the increased rate of PNES among females," she told MedPage Today.

The analysis also identified novel associations between PNES and cerebrovascular disease (OR 1.08, 95% 1.06-1.09). Of 92 patients who had both PNES and stroke, 48% experienced a stroke and then were diagnosed with PNES, 29% were diagnosed with PNES before the stroke, and 23% were diagnosed with both at about the same time.

"These results identify stroke as a possible predictor for PNES and reinforce that people who are experiencing seizures and have psychiatric risk factors should be referred for video-EEG monitoring to diagnose whether they are experiencing epileptic seizures or nonepileptic seizures," said co-author Kevin Haas, MD, PhD, a neurologist at Vanderbilt University Medical Center. "Early diagnosis for patients with PNES is critical, allowing them to begin an appropriate treatment plan while avoiding misdiagnosis with epilepsy and the dangers of inappropriate treatments."

The strong association between PNES and post-traumatic stress disorder (PTSD) found in other studies also emerged in the Vanderbilt records. People with PNES were 15 times more likely to have a PTSD diagnoses than those in the general hospital population. They also were more likely to have psychiatric comorbidities in general at higher rates than other patients. About 30% of PNES patients had major depressive disorder and 27% had anxiety.

A novelty of the study was the development of an automated algorithm that incorporated ICD codes, CPT codes, and natural language processing to detect people with PNES from de-identified electronic health records, Goleva noted. "This allowed us to identify PNES patients on a much larger scale than ever before," she said.

"PNES is still very understudied," Goleva added. "We hope that publishing this algorithm will also enable other research centers with access to electronic health records to further test these findings and to pursue novel avenues of research for PNES."

"The big take-home message is that patients dealing with PNES are often managing a number of other health conditions throughout their lives and it's important for health care providers to be aware of this," co-author Lea Davis, PhD, also of Vanderbilt, told MedPage Today. "Coordinated care for patients with PNES is essential and a lot more research is needed to understand how PNES develops and how it is connected to these other health risks."

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