Objective:

To describe the characteristics and management of psychogenic non-epileptic seizure (PNES) presenting to an urban emergency department (ED). 

Background:

PNES is a unique diagnostic challenge with a high rate of misdiagnosis in the ED. It is imperative to study the characteristics of PNES presentations to better inform future clinical judgement and guide acute management.  

Design/Methods:

Between June and December 2018, 996 seizure-related visits at three urban EDs were reviewed and patients presenting with PNES were identified. Data was collected on patient demographics, seizure history, and hospital course; including ED treatment, ED diagnostics, and discharge information. Patients presenting with syncope or medication refills were excluded. 

Results:

We identified 32 patient encounters presenting with PNES (3.2%). The median age was 38 years and 84.3% were female. Of all encounters, 31.2% had an established history of PNES, 40.6% had a prior history of epilepsy, and 6.2% had both diagnoses. Less than half were on home anti-seizure medications (ASM) prior to the ED visit (43.8%). Overall, 40.6% received acute medication administration including benzodiazepines (25%) and/or ASM loading dose (28.1%). Acute neurodiagnostic included CT head imaging (31.2%) and EEG (9.3%). There were five inpatient admissions (15.6%), and Neurology service was consulted for 9.3% of all encounters. ASMs were prescribed upon discharge for 25% of encounters. Of these patient encounters, 37.5% had a subsequent re-presentation for PNES or seizure of unknown type. 

Conclusions:

PNES are not a commonly identified presentation to the ED. Patients identified as PNES in the ED are more likely to have a previous diagnosis of PNES/epilepsy. Despite clinical diagnosis of PNES, less than half of the patients received acute medication administration and almost one third received acute neuroimaging. Further ER studies are needed to improve identification of PNES patients to reduce the cost and burden of treatment and diagnostic studies.