Catherine A CarlsonMinneapolis MN, USA
Title: Psychogenic nonepileptic seizures- The empirical evidence weighs in
Seizures that do not produce an epileptiform discharge on the ictal scalp video-electroencephalogram(vEEG) will likely garner the ‘rule in’ diagnosis of PNES, or Conversion Disorder in modern nomenclature. The absence of an epileptiform discharge is interpreted as proof that the seizure is not epileptic and thus, it presumably has a psychological origin. For decades, the scalp vEEG has been hailed as the ‘gold standard’ for distinguishing PNES from epilepsy and a great deal of empirical data has been amassed on the PNES patient population. Though the PNES diagnostic entity is treated as a proven ‘fact,’ in truth, it rests on but one hypothesis that might explain a negative scalp EEG. Since not all epileptic seizures produce a scalp EEG correlate, an epileptic seizure is a recognized competing hypothesis for a negative scalp finding. Studies that gather data from both scalp and intracranial EEG recordings demonstrate that scalp-negative epileptic seizures are not uncommon, but in modern epilepsy-monitoring units, they are at high risk of being mislabeled PNES. To assess for such diagnostic error we must turn to the empirical evidence which shows that the clinical profiles of PNES and epilepsy patient populations are identical. The similarities are striking and the only data the PNES hypothesis can explain is a negative scalp EEG. Conversely, the competing epileptic hypothesis seamlessly accounts for the bulk of the findings on patients with seizures labeled PNES. The diagnostic terrain is further muddied by the ongoing conflation of conscious feigning with conversion disorder which represents a longstanding conceptual error. The data establishes that the PNES patient population consists primarily of patients with epilepsy, along with a smattering of factitious and likely psychotic disorders, thereby exposing the PNES diagnostic entity as a hypothetical construct that does not exist. Diagnostic theory and practice in epilepsy-monitoring units must be revisited.
Dr. Carlson earned her Doctor of Clinical Psychology (Psy.D.) degree from Argosy University in 1994 and has specialized in forensic psychology for over 25 years. She has been a forensic examiner in criminal and civil commitment court for the State of Minnesota since 1995. She has expertise in identifying a wide range of psychopathology including major psychiatric disorders, character pathology, substance abuse disorders, neurological co-morbidities, intellectual disabilities, intentional feigning (factitious disorders and malingering), and transient conversion symptoms. She has evaluated thousands of defendants and respondents and testified to her forensic and diagnostic opinions on many occasions. As a court-appointed examiner, she has access to clinical records not readily available to non-forensic examiners.