PracticeUpdate Neurology February 2019

EXPERT OPINION 21

patient undergoing one. If truly suggesting a technique that would induce an epileptic seizure, why not use it for everyone so that there is equipoise? The technique should have included the script that was used during induction to be certain that both cohorts were treated similarly even if the same person did it the same way for everyone in both groups. This would avoid the “performance art” aspect of this procedure, as some clinicians are better at suggesting that a typical seizure will occur and doing so in a non- deceptive way. In addition, the change in provocation technique over time in this study introduces another bias acknowledged by the authors, referred to as “experience.” Further, the generalizabil- ity of the results may be limited because PNES is known to more commonly affect women, and this study was conducted at the VA, with a largely male patient population. Most of the literature by now supports abandoning use of placebo injection for PNES diagnosis, citing the AMA code of ethics that prohibits the use of deceptive placebos ( www.ama- assn.org/delivering-care/use-placebo-clinical-practice ). Because hyperventilation and photic stimulation are activation procedures known to cause seizures, as long as patients consent without using deception, they are still viable techniques and can have a role in facilitating diagnosis. The focus on placebo and nocebo effects in medicine is particularly helpful for PNES and other FND,

as patients’ beliefs and expectations play a significant role in treatment and prognosis. However, before widely recommending the proper provocation techniques, there is necessary work to improve clinician attitudes and understanding of PNES and other FND so that lack of transparency or deception of any sort is abandoned in favor of the goal of helping improve patient– clinician communication and patient health and quality of life. References 1. Salinsky M, Spencer D, Boudreau E, Ferguson F. Psychogenic nonepileptic seizures in US veterans. Neurology 2011;77(10):945-950. 2. Reuber M, Fernandez G, Bauer J, Helmstaedter C, Elger CE. Diagnostic delay in psychogenic nonepileptic seizures. Neurology 2002;58(3):493-495. 3. Stagno SJ, Smith ML. The use of placebo in diagnosing psychogenic seizures: who is being deceived? Semin Neurol 1997;17(3):213-218. 4. Popkirov S, Gronheit W, Wellmer J. A systematic review of suggestive seizure induction for the diagnosis of psychogenic nonepileptic seizures. Seizure 2015;31:124-132. 5. Benbadis SR. Provocative techniques should be used for the diagnosis of psychogenic nonepileptic seizures. Epilepsy Behav 2009;15(2):106-109; discussion 115-118. 6. Chen DK, Dave H, Gadelmola K, et al. Provocative induction of psychogenic nonepileptic seizures: Noninferiority of an induction technique without versus with placebo. Epilepsia 2018 Oct 01;[EPub Ahead of Print]. www.practiceupdate.com/c/74818

VOL. 4 • NO. 1 • 2019