Non-Epileptic Attack Disorder in the Emergency Unit

Transcription

1 Non-Epileptic Attack Disorder in the Emergency Unit Khalid Hamandi, Consultant Neurologist Malisa Pierri, Epilepsy Specialist Nurse University Hospital of Wales COI declaration none relevant to this talk no photos or videos please 1

2 What are non-epileptic attacks Size of the problem Making a diagnosis Why does it develop Cases Talk Outline What are Non-Epileptic Attacks? 2

3 a year after her father died, while Siri Hustvedt was giving a memorial speech.. I [..] launched into my first sentence, and begun to shudder violently from the neck down. My arms flapped. My knees knocked. I shook as if I were having a seizure. " Definition Attacks that may look like epileptic seizures but are not caused by altered electrical activity in the brain Rather they are caused by the bodies reaction to adverse (past) life experiences, trauma, loss or bereavement 3

4 Terminology non-epileptic attack disorder (NEAD) dissociative seizures psychogenic non epileptic seizures (PNES) functional seizures (pseudoseizures) non-epileptic attack disorder (NEAD) dissociative seizures Terminology psychogenic non epileptic seizures (PNES) functional seizures (pseudoseizures) - not genuine; sham; bogus, sham, phoney, imitation, artificial, mock, ersatz, quasi-, fake, feigned, pretended, false, faux, spurious, counterfeit, fraudulent, deceptive, misleading, assumed, contrived, affected, insincere; The prefix pseudo- (from Greek ψευδής, pseudes, "lying, false") 4

5 Size of the problem? ~ 10,000 to 15,000 people have NEAD in the UK ~ 3 in 4 people with NEAD have previously been diagnosed with epilepsy and taken anti-epileptic drugs typically takes over five years to make the diagnosis of NEAD 1 in 5 people with NEAD have been taken to intensive care units with prolonged seizures erroneously considered as "status epilepticus" Nearly 1 in 6 people stop having NEAs after the diagnosis has been explained 2 in 3 people with NEAD have less than half of the number of attacks three months after the diagnosis has been explained 1 in 2 people with NEAD become free of seizures with the right treatment From - 5

6 Making (being alert to) the diagnosis Making the diagnosis can be difficult, especially in the acute setting, and I am not able to do so or tell you how to, remote from the patient and the events they present with It is much easier in the cold light of day - in clinic, review of home video, or gold standard video-eeg There are important features that need to be recognised in the presentation - history, semiology and other observations And best management strategies can be developed 6

7 Home video generalised tonic clonic seizure Non-epileptic attack 7

8 Syncope Frontal lobe seizure with complex automatisms 8

9 What helps make a correct diagnosis A written narrative account is much more helpful than known epileptic fitting GTCS.. now post ictal Primary and witness Tell me what happened The first, the worst, the most recent Pattern Stereotypy Temporal Evolution Useful (ish) points to consider but there are no absolutes and plenty of exceptions to these 9

10 NEAD Wax and wane Asynchronous, shaking rather than clonic There is no absolute test to distinguish NEAD Resistance to eye opening Don t assess response to pain Beware post ictal confusion / behaviour disturbance. Why does it develop? 10

11 Inherent responses to traumatic or fearful situations freeze / startle / tremor / shaking / collapse / weakness / dissociation Hyperventilation, Tachycardia Elevated arousal, threat perception External triggers / reminders Learned behaviours Seizure models Media, self, friends, family, Health Care Encounters Patients are not be setting out to mimic epileptic seizures 11

12 Cases Management of NEAD the Emergency Department Malisa Pierri Lead Clinical Nurse Specialist in Epilepsy Welsh Epilepsy Centre 12

13 Delivery of diagnosis is one of the most important influences on prognosis Explanation: why not epilepsy what they do have Reassurance: not putting it on / malingering disorder very common Causes: triggering stresses Relevance of aetiological factors maintaining factors Treatment: May improve following correct diagnosis Psychological treatment Caution re AED withdrawal MELLERS 2017 Case study 1 23 year old female Initially attended EU via 999 ambulance 09/09/2017 Convulsive like episode?focal onset seizure Bloods / ECG /CT HEAD - All normal 6 further attendances in next 9 days Multiple events sometimes up to 15 per day 13

14 Description of events from pt and partner: Always happen within 2-3 minutes of dropping off to sleep Start with right hand starting to shake Eyes shut Hyperventilating, sounding as though she is choking Makes whimpering sound as event tails off Approximately 1 minute to recover, although always feel thirsty Video footage shows: Grabbing at face with right hand (as if trying to pull a mask off) Pulling and grabbing of lips Right arm back down by side, started shaking Shortly followed by 4 limbs shaking Eyes closed throughout No change in breathing Lasted 5 minutes Immediate recovery Upset afterwards 14

15 Reviewed on 18 / 09 / 17 in EU Explanation given to patient and family why NEAD, using home video NEAD booklet New information on calling for help given Long term treatment discussed Reviewed 15/02/2018 by Neurology No events since diagnosis explained Pt recognises now under immense stress at the time No f/u open access Case Study 2 21 year old female History: Refractory focal onset epilepsy since aged 15 Cerebral vascular abnormality Parry Romberg syndrome Tried and failed multiple medications 15

16 Initial presentation x3 generalised tonic clonic seizures Focal events since (some times up to 100 a day) Starts with a tingling in right hand May spread to shaking of hand and arm May spread to leg Does not lose awareness, can talk during them but may have dysphasia Feels frightened during them Last minutes Weakness in right side afterwards Surgical excision of vascular abnormalities - Oct 2009 Dec admitted to the emergency unit with frequent seizures Right arm shaking Fist clenched Irregular jerking movements Asynchronous Spread to her left leg, leg arm Reviewed by Epilepsy team in EU EEG no changes during attacks, supporting NEAD diagnosis 16

17 4/19/18 Discussed diagnosis with patient and family Urgent referral to Clinical Neuropyschologist Jan 2010 reviewed by neurology NEA still occurring but less frequent able to recognise them implemented own coping mechanisms No further EU attendances

18 Diolch yn fawr 18