Seizure: European Journal of Epilepsy 61 (2018) 227–233

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Seizure: European Journal of Epilepsy

journal homepage: www.elsevier.com/locate/seizure

Experience of psychogenic nonepileptic seizures in the Canadian league T

against epilepsy: A survey describing current practices by neurologists and
epileptologists
Alexandra Cartera, Alyssa Dentona, Lady D. Ladinoa,b, Islam Hassanc, Tyson Sawchukd,e,
Thomas Snyderf, Mirna Vrbancicg, Markus Reuberh, Richard Huntsmani,
⁎
Jose F. Tellez-Zentenoa, , PNES Canada Group
a
Saskatchewan Epilepsy Program, College of Medicine, Division of Neurology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
b
Epilepsy Program, Neurology Section, Hospital Pablo Tobón Uribe, Universidad de Antioquia, Medellín, Colombia
c
Vancouver General Hospital Epilepsy Program and British Columbia Neuropsychiatry Program, University of British Columbia, Vancouver, British Columbia, Canada
d
Children’s Comprehensive Epilepsy Program, Pediatric Neurosciences, Alberta Children's Hospital, Calgary, Alberta, Canada
e
Alberta Children’s Hospital Research Institute, Calgary, Alberta, Canada
f
Department of Psychiatry and Comprehensive Epilepsy Program, University of Alberta Hospital, Canada
g
College of Medicine, Division of Psychiatry, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
h
Academic Neurology Unit, University of Sheffield, Sheffield, UK
i
College of Medicine, Division of Pediatric Neurology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada

A R T I C LE I N FO A B S T R A C T

Keywords: Purpose: Psychogenic nonepileptic seizures (PNES) are one of the most common differential diagnoses of epi-
Conversion disorder lepsy. Our objective is to describe current medical care in Canada and identify patterns of practice and service
Functional seizures gaps.
Nonepileptic attacks Methods: In 2015, a 36-question survey was sent via email to the 131 members of the Canadian League Against
Pseudoseizures
Epilepsy. The questions were designed after literature review and discussion with the ILAE PNES Task Force.
Psychotherapy
Questions were separated into 5 sections: 1) the role of the respondent and their exposure to PNES, 2) diagnostic
methods, 3) management of PNES, 4) etiological factors, and 5) problems accessing health care.
Results: Sixty-two questionnaires were analyzed (response rate: 47%). Most respondents were epileptologists
(76%). The majority of respondents personally diagnosed PNES and communicated the diagnosis to the patient,
but only 55% provided follow-up within their practice and only 50% recommended or arranged treatment. Many
(35%) were either unfamiliar with the diagnosis of PNES or inexperienced in arranging or offering treatment.
Most (79%) provided follow-up to patients with concomitant epilepsy, but when PNES was the sole diagnosis
follow-up rates were low. Although 84% of respondents felt that individualized psychological therapy was the
most effective treatment, 40% of patients were not referred to psychotherapy and in most cases availability such
therapy was low (30–60%).
Conclusions: Canadian health professionals’ understanding of PNES mostly reflects current international expert
opinion. Once diagnosis is made however, the majority of patients are discharged from neurological services
without appropriate psychological care.

1. Introduction distinguish from epileptic seizures: both may involve alterations in

mental status and behavior; sensory or perceptual disturbances; as well
Psychogenic nonepileptic seizures (PNES) are episodes of seizure- as simple or complex motor patterns [1]. The diagnosis of PNES may be
like symptoms that are not associated with epileptiform discharges on suggested by: (i) Failure of multiple anticonvulsants (ii) “seizures”
electroencephalogram (EEG). They can be remarkably difficult to triggered by stress and other triggers atypical for epilepsy (iii) lack of

⁎
Corresponding author at: Division of Neurology, Department of Medicine, Royal University Hospital, 103 Hospital Drive, Box 26, Room 1622, Saskatoon, SK, S7N
OW8, Canada.
E-mail address: jose.tellez@usask.ca (J.F. Tellez-Zenteno).

https://doi.org/10.1016/j.seizure.2018.08.025
Received 14 May 2018; Received in revised form 27 July 2018; Accepted 31 August 2018
1059-1311/ © 2018 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.
A. Carter et al. Seizure: European Journal of Epilepsy 61 (2018) 227–233

incontinence or injury such as tongue biting during events. PNES are a [1,11,12].
very common phenomenon, cited as the third most frequent diagnosis
in seizure clinic patients [2]. The incidence is 1.4–4.9/100,000/year, 2.2. Data and analysis
and the prevalence is estimated to be 2–33/100,000 [3]. In many cases,
PNES are associated with significant disability: while previous studies Data were collected using the online software Survey Monkey,
suggest that PNES may remit in the short term with appropriate com- which provides anonymous collection of survey responses. Responses
munication of the diagnosis (up to 30% of cases), the long-term prog- were entered directly into the Survey Monkey database and were then
nosis is poor for most patients, especially in adults, with 70% remaining collated, reformatted and imported to SPSS version 21 (SPSS Inc.,
disabled several years after initial diagnosis [4]. Pediatric patients tend Chicago, Il, USA). Questionnaires on which less than 50% of the items
to have a higher response rate to treatment possibly related to the di- had been completed were excluded from the analyses. Descriptive sta-
agnosis being made earlier. Moreover, these episodes are often mis- tistics were used to assess frequencies and distributions. Open-ended
diagnosed and patients are at risk of receiving inappropriate medica- questions were reviewed for qualitative assessment. All analyses were
tions for prolonged periods or invasive interventions such as intubation performed using SPSS version 21.
and vagal nerve stimulation [5,6].
Neurologists are best placed within the medical community to di-
2.3. Ethics
agnose and arrange treatment for PNES, given their specialist training
in the differential diagnosis of epileptic seizures and their access to the
This cross-sectional study was led by the Epilepsy Program in
diagnostic gold standard: long-term video-EEG monitoring. The ques-
Saskatchewan, Canada. The biomedical research ethics board at the
tion who should provide treatment is more difficult to answer. Most
University of Saskatchewan approved this study. Signed informed
PNES fulfill the diagnostic criteria of a psychological conversion or
consent was not required because clinicians were not providing con-
dissociative type disorder. Many patients with PNES have psychiatric
fidential health information.
comorbidities, suggesting that psychiatrists may play an important role
in further diagnostic assessment and treatment [7]. Although no evi-
dence-based management guidelines exist at present, there is evidence 3. Results
that psychological treatment is indicated and effective for many pa-
tients with this disorder [8]. Such treatments would usually be provided 3.1. General data
by psychotherapists or psychologists. However, many psychiatrists,
psychologists and psychotherapists only have limited experience with The survey response rate was 47% (62/131). All sixty-two ques-
the management of patients with PNES. tionnaires were included in the data analysis. All respondents were fully
Common practices employed by experts in Canada must be identi- trained. The majority (76%) of respondents were young male epi-
fied in order to be used as a basis for implementing guidelines for leptologists (Table 1). Fifty-eight percent of survey respondents were
physicians diagnosing and managing PNES. The International League between 31 and 50 years old. All respondents treated both hospital
Against Epilepsy (ILAE) has recently created an international PNES
Task Force to describe current treatment practices and identify service Table 1
gaps around the world [9,10]. Our objective in this paper is to focus on General information of the participants (n = 62).
responses to an ILAE survey from Canada, and to describe current Age (years)
management in this country, while identifying heterogeneity in practice 21–30 2 (3.2)
styles and service gaps, in order to provide a basis for a future stan- 31–40 16 (25.8)
41–50 20 (32.3)
dardized management approach.
51–60 11 (17.7)
61–70 8 (12.9)
2. Methods 71–80 5 (8.1)

Sex
2.1. Questionnaire Male 41 (66)
Female 21 (34)
In 2015 an internet survey was sent to all members of the Canadian Province
League Against Epilepsy (CLAE) by email. A web-based survey was Ontario 23 (37)
administered to have the broadest reach. The CLAE had 131 members Saskatchewan 9 (14.5)
Alberta 9 (14.5)
at the time of the survey. Potential recipients included adult and pe-
Quebec 7 (11.2)
diatric neurologists, epileptologists, psychiatrists, neuropsychiatrists, Nova Scotia 6 (9.6)
psychologists, neuropsychologists, nurses, neurosurgeons, social British Columbia 5 (8)
workers, and EEG technologists. Manitoba 3 (4.8)
The questions were designed after literature review and discussion Specialty
with PNES Task Force of the ILAE. This survey was designed with the Epileptologist 47 (75.8)
intent of quantifying common practices regarding PNES in Canada. General neurologist 4 (6.5)
Neuropsychologist 4 (6.5)
Questions were separated into 5 sections: 1) the role of the respondent
EEG technologist 3 (4.8)
and their exposure to PNES, 2) diagnostic methods, 3) management of Epilepsy nurses 2 (3.2)
PNES, 4) etiological factors, and 5) problems accessing health care. The Psychiatrist or Neuro-Psychiatrist 2 (3.2)
questionnaire consisted of 36 questions. Thirty-one questions offered Patients attended
predefined choices; five were open-ended questions. The response Children (aged 0–18) 27 (43.5)
format was categorical for close-ended questions (i.e. multiple-choice Adults (aged 19–74) 50 (80.6)
format) and “check the answers that apply” format for lists Elderly patients (75 and older) 39 (62.9)
Patients with intellectual disability 53 (85.5)
(Supplementary Material—Appendix A). The survey required
10–20 min to complete. A panel of experts in neurology and psychology Time to travel to the appointment (hours)
Up to 1 24 (38.7)
reviewed and tested the survey to evaluate the content, the flow, and
1–2 27 (43.5)
the format of the questions. The questions in the survey were inspired 3–4 10 (16.1)
by similar surveys carried out previously in the UK, the USA and Chile

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Fig. 1. Management of PNES patients by Canadian health professionals.

inpatients and outpatients; the majority of participants were publicly investigations for determining a diagnosis of PNES. Ninety percent of
funded (96%). Only 8% of respondents worked in community-based respondents had access to routine outpatient video-EEG monitoring and
programs. 89% had access to prolonged inpatient video-EEG (more than 8 h).
Eighty-nine percent had access to computed tomography (CT) scan and
3.2. PNES diagnosis and treatment 95% had access to brain magnetic resonance imaging (MRI).
About half (53%) of respondents reported 80–90% of their current
Seventy-seven percent (48/62) of respondents diagnosed 1–20 new patients had received the “gold standard” in PNES diagnosis (video-EEG
cases of PNES annually, while only 27% of respondents followed 1–5 recording of a typical attack), while a minority (24%) reported 100% of
cases currently in their practice. The majority of respondents (87%) patients in their practice had been diagnosed in this manner. While the
personally diagnosed PNES and communicated the diagnosis to pa- majority of PNES patients had undergone psychiatric evaluation (72%)
tients. Only 55% provided follow up within their practice and ap- or referral for psychological assessment (60%), less than half had re-
proximately 50% recommended or arranged treatment (Fig. 1). ceived psychotherapeutic assessment (49%) or neuropsychological
With regards to respondents’ confidence and familiarity with the testing (41%).
diagnosis and treatment of PNES, 65% felt confident in their ability to
diagnose PNES and did so often (90% were epileptologists). Another 3.5. Communication and follow-up
31% (19/62) felt that they were confident in their ability to distinguish
between PNES and epilepsy, but made the diagnosis only occasionally. Ninety-seven percent of respondents reported that the neurologist
Although 58% of participants answered they knew how to arrange or first communicated diagnosis of PNES to the patient. One respondent
provide treatment for patients with PNES, only 14.5% replied they were reported that neuropsychiatry initially provided the diagnosis. The di-
well informed or sufficiently familiar with psychotherapy to know how agnosis was frequently (95.2%) communicated via face-to-face ex-
this treatment might help patients with PNES. The majority of partici- planation to the patient. Eighty percent of neurologists also attempted
pants (76%) said that they knew about psychotherapy in theory but to explain the diagnosis to family members (if present), and 40% sent
could not describe what it involved or how it might work in patients letters to another healthcare practitioner when needed. The provision
with PNES. Many (35%) were either unfamiliar with the diagnosis and of leaflets (19%), referrals to websites (18%) and self-help groups (8%)
treatment of PNES or were inexperienced in arranging treatment. was not common practice. Respondents endorsed sixteen different
statements as approaches they use when explaining the diagnosis of
3.3. Etiologies of PNES PNES in their usual practice. The majority of respondents (77%) re-
ported that they explained PNES as “complex episodes with predis-
The majority (86%) of health professionals reported seeing PNES posing, triggering and perpetuating factors, stress being one of the main
more often in women than men. Respondents felt that the most relevant triggering factors (68%)”. They often clarified that the episodes are
factors in the emergence of PNES were childhood physical abuse (42%), involuntary (71%) and that anti-epileptic drugs are of no benefit (76%)
physical neglect (39%) and sexual abuse (37%), followed by co-morbid (Fig. 2). Sixty percent (37/62) of respondents offered patients at least
psychiatric conditions such as anxiety (41%), accumulated life stress one follow-up appointment after the diagnosis was initially explained.
(39%) and depression (38%). Factors such as family conflict (32%), Most (79%) provided follow-up to those patients with concomitant
epilepsy diagnosis (32%), personality disorders (30%), bullying (23%) epilepsy and about half (55%) followed up with patients undergoing
and poverty (22%) were also considered important. Other possible anti-epileptic drug withdrawal. For all other reasons, however (e.g.
factors related to PNES proposed by eight participants (13%) were in- mental health problems, awaiting treatment), follow-up rates were ra-
tellectual disability, medical background/training, witnessing seizures ther low (13–42%) (Fig. 3).
in others (family or friends), mourning, loss of financial power, post-
traumatic stress disorder and seizure freedom after having epilepsy 3.6. Treatment
surgery. Typically, the comorbid psychiatric conditions develop and
persist into adulthood after chronic childhood trauma. Eighty-four percent of respondents felt that individualized psycho-
logical therapy was the most effective treatment and that 75% of PNES
3.4. PNES services patients would receive a referral to at least one psychology appoint-
ment. However, the respondents stated that the availability of psy-
Most respondents (> 70%) had access to appropriate medical chotherapy in Canada is limited (private system 58%, public system

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Fig. 2. Diagnosis communication. We provided 16 statements

(Appendix A, question 25) and asked respondents to select all that
applied to their typical initial conversation in diagnosing their
patient with PNES. *I say that the causes of PNES are complex and
that there may be predisposing factors, factors which first started
attacks and factors, which maintain the problem.

76%). Ultimately, respondents estimated that the majority of their pa- Table 2
tients received education from the neurologist (88%) and/or anti- PNES treatment knowledge and access in Canada (n = 62).
depressants (79%), while only 60% received psychotherapy (Table 2). N (%)
The wait list for psychotherapy was reported as variable in different
areas, being around 1 to 30 months. Lack of psychological treatment The most effective treatment (according to the participants)
services (34%), lack of money for psychotherapy (30%) and lack of Cognitive Behavioural Therapy 52 (83.9%)
Antidepressant drugs 3 (4.8%)
popular awareness of PNES (35%) were perceived as the most common Group psychotherapy 2 (3.2%)
difficulties in accessing diagnostic and treatment services reported by Hypnosis 1 (1.6%)
respondents (Table 3).
Availability of psychotherapy in the area
Psychotherapy is not available in the area 1 (1.6%)
Psychotherapy is available for private patients 36 (58.1%)
4. Discussion
Psychotherapy is available for publicly insured patients 47 (75.8%)
Psychotherapy is available via telemedicine/ internet-based 11 (17.7%)
To our knowledge, this is the first Canadian study assessing health services
services and attitudes of health professionals towards PNES. We ob-
served a good geographic distribution of responses across seven pro- Access to the treatment Mean (%) ± SD Relevancea
vinces of Canada. Our response rate (47%) was significantly higher than
Education (explaining the patients ± their family 88.39 ± 24.37 High
those of similar studies in the UK (8.6%) and the USA (18%) [1,11]. A about the diagnosis)
study in Chile reported a similar response rate (45%) to ours [12]. The Support groups 33.39 ± 28.85 Moderate
majority of respondents in our study were fully trained, young epi- Individual psychological treatment (Cognitive 60.16 ± 31.54 Moderate
leptologists mostly caring for public system patients. This is consistent Behavioural Therapy)
Psychological group treatment 38.39 ± 29.09 Moderate
with results from a recent ILAE Task Force publication that found re-
Psychological family therapy 33.71 ± 29.6 Moderate
spondents across 28 high-income countries to be primarily specialized Inpatient treatment (including psychotherapy, 31.29 ± 36.59 Moderate
doctors (neurologists with special interest in epilepsy) (70%) [10]. rehabilitation)
The majority of neurologists encountered PNES on a regular basis Antidepressant drugs 78.55 ± 32.02 High
and personally made and/or communicated the diagnosis to patients Antipsychotic drugs 69.35 ± 39.78 Moderate
Anti-epileptic drugs 65.32 ± 42.6 Moderate
and their families. In contrast, only half of respondents followed pa- Beta-blockers 59.52 ± 45.85 Moderate
tients until episodes were well-controlled. This finding is similar to the Benzodiazepines 62.58 ± 42.46 Moderate
results reported in the UK (50%), in Chile (27%) and the USA (39%) Occupational therapy 40.32 ± 36.66 Moderate
[1,11,12]. The finding also reflects international trends where 20% of a
High relevance ≥ 70%, moderate relevance 31–69%, low relevance ≤
respondents from high-income countries reported not following pa- 30%.
tients beyond diagnosis [10]. Overall, it appears to be common practice
that once a neurologist has made the diagnosis, patients are often

Fig. 3. PNES follow-up by health professionals after diagnosis.

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Table 3 cases [12]. In the ILAE survey applied in 28 countries, respondents’

Access barriers to diagnosis and management (n = 62). mean estimate of the proportion of patients whose diagnosis of PNES
Mean (%) ± SD Relevancea was supported by recording a typical attack on video-EEG was 80% in
high-income, 30% in middle-income, and 2% in low-income countries,
Illiteracy 7.74 ± 12.72 Low showing a clear relationship between wealth category and the avail-
Language / communication difficulties with 12.58 ± 12.66 Low
ability of diagnostic tests [14].
professionals
Problems with geographic access to healthcare 25 ± 22.95 Low
The availability of video-EEG may shape respondents views of the
provider importance of confirming a typical PNES attack with video-EEG for the
Lack of money for tests 6.77 ± 17.9 Low diagnosis. In a survey administered to family medicine, internal medi-
Lack of money for appointments with non- 22.42 ± 28.03 Low cine and emergency medicine physicians in Ohio, most non-specialist
specialist professionals
physicians did not believe this type of investigation to be required,
Lack of money for appointment with seizure 4.19 ± 12.35 Low
expert despite its availability [17]. Additionally, this survey found differences
Lack of accessible healthcare practitioners who 25.65 ± 29.28 Low in perceptions held by health care providers about PNES, when com-
know about PNES pared to those reported by the more highly specialized respondents in
Lack of psychological treatment services 33.55 ± 30.35 Moderate
the Canadian study. For example, non-specialist respondents to Ohio
Lack of money for psychotherapy 30.48 ± 33.16 Moderate
Lack of money for drug treatment 10.97 ± 18.17 Low
survey were more likely to report thinking of the episodes as voluntary.
Stigma associated with PNES 29.52 ± 27.48 Low Furthermore, they reported inducing an event at the bedside in order to
Lack of a referral system to seizure experts 14.84 ± 18.17 Low confirm the diagnosis [17]. These findings are consistent with our
Lack of liaison between traditional healers and 18.06 ± 26.9 Low survey’s largely specialized respondents reporting a high degree of fa-
health professionals
miliarity with PNES, as well as with another study of non-experts (an
Lack of popular awareness of PNES 34.59 ± 29.69 Moderate
Lack of access to information resources about 26.29 ± 26.68 Low Irish survey of general practitioners), which revealed that most non-
PNES experts rate their understanding of PNES as low (mean of 5.7 on a scale
Lack of intellectual capacity 17.74 ± 14.07 Low of 1–10) [18].
LaFrance et al. reported that predictors of PNES cessation included
10% of participants highlighted lack of acceptance of the diagnosis by spouse or
diagnostic certainty - patients with video-EEG confirmed nonepileptic
family and long waiting lists for epilepsy monitoring unit admission as im-
events tended to do better than those diagnosed on the basis of clinical
portant causes of difficulty in accessing diagnostic or treatment services.
a
High relevance ≥70%, moderate relevance 31–69%, low relevance ≤30%. suspicion alone. Conversations around the diagnosis are already very
complex and confusing to the patient. Having the benefit of diagnostic
discharged from their service. This may lead to “bounce-back” to dif- certainty can therefore contribute to alleviating some of this confusion
ferent neurological service providers and repeated Emergency Room [8]. Clinicians’ appropriate use of language is vital when first ex-
visits, with a high potential for adverse events and perpetuation of the plaining the diagnosis of PNES, as patients can often misunderstand or
condition. Physician communication with patients about this complex be confused, leading to a potential loss of rapport with their physician
diagnosis is essential: having been associated with a marked reduction and a missed opportunity for treatment benefit [19].
in the frequency of attacks, or else enabling patients to gain control of A large proportion (84%) of our respondents endorsed psy-
attacks completely in substantial proportion of patients [8,13]. This chotherapy as the PNES treatment of choice. However, only 58% stated
initial therapeutic conversation can provide a foundation upon which to that they knew how to arrange or provide treatment for patients with
build further successful interactions and effective treatment. Un- PNES, and only 14.5% replied they were sufficiently familiar with
fortunately, there is some evidence that this initial effect is often psychotherapy to know how this treatment might help patients with
transient, with most patients relapsing if further treatment is not pro- PNES. Only 60% of patients were actually referred for at least one
vided in a timely fashion [8]. session of psychotherapy. This finding may be explained by some dif-
We observed a relatively even distribution of factors thought to ficulties related to availability of appropriately trained therapists, long
contribute to onset and maintenance of PNES. Respondent observations waiting lists (the respondents estimate was 1–30 months), and a po-
are consistent with the idea that experts consider PNES a heterogeneous tential lack of publicly funded access, according to the surveyed pro-
disorder with a multifactorial etiology, in which co-morbid psychiatric fessionals. These challenges are not limited to Canada; respondents to
conditions such as depression and anxiety are very common. These similar surveys in other high income countries such as the United
findings reflect those of previous studies exploring the etiology of PNES Kingdom also reported low referral rates for psychological treatment
[15,16]. The opinions of Canadian respondents to the survey was also (35%), low availability of the service in primary care (25%) and long
in line with those from respondents to the ILAE survey which was waiting times for psychological outpatient treatment (1–24 months)
completed by 1098 health professionals from many countries around [11]. The American study showed a strong recommendation to seek
the world. In all countries from which data was available, trauma and treatment for unresolved psychological conflicts, trauma and memories
mental health issues were most commonly recognized as etiologic fac- of abuse by referring patients to psychology (50%) or psychiatry (76%).
tors [10]. Half of American respondents arranged to have the patient meet with
Our findings suggest that hospitals in Canada are well-equipped to the psychiatrist or psychologist during inpatient monitoring to establish
make the diagnosis of PNES. Almost all health professionals reported treatment before discharge [1]. A similar trend was demonstrated in a
having access to prolonged video-EEG monitoring, magnetic resonance small PNES survey conducted in Missouri, where 60% of health care
imaging and cardiology tests required to rule out other types of non- professionals considered psychiatry as the most preferred specialty to
epileptic events, which may mimic epileptic seizures (i.e syncope). In manage this disorder [20]. Remarkably, Chile reported a high referral
this area, our findings mirror the results of surveys conducted around rate to psychiatry (84%) and respondents considered PNES as a serious
the developed world in countries such as the UK and USA [1,11]. As disorder requiring treatment from a specialist in that field [12].
well, an estimated 80% of PNES diagnoses in our survey were supported Finally, once the patient is referred to psychotherapy/psychiatry for
by the gold standard of recording a typical attack with simultaneous treatment, their engagement with the provider can be difficult. Patients
video-EEG. Comparable findings were reported in the UK (70%) and the are generally more likely to endorse a physical rather than a psycho-
USA (89%) [1,11]. By contrast, respondents to a similar survey in Chile logical basis for the condition, creating difficulties in their acceptance
reported having only limited access to these investigations. Conse- of the diagnosis, which may then lead them to seek further medical
quently video-EEG only supported diagnoses in an estimated 25% of opinions [21]. Therefore, epileptologists should continue to be involved
in their follow-up, alongside mental health specialists. Kanner et al.

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suggest continued neurological follow-up for at least six months fol- guidelines.
lowing diagnosis to ensure successful transition of patient care to a
psychiatric service [22]. Acknowledgements
An interesting finding in our cohort was the common prescription of
psychotropic drugs. Our cohort reported prescription of antidepressants Dr. Tellez-Zenteno receives grants from the University of
(79%), antipsychotic drugs (69%), benzodiazepines (62%), and beta- Saskatchewan, the Royal University Hospital Foundation in Saskatoon,
blockers (59%), despite the fact that the evidence for the use of such Saskatchewan, through the Mudjadik Thyssen Mining Professorship in
drugs in patients with PNES is very limited. This is clearly in contrast Neurosciences and UCB Canada.
with the practice in other countries. In the UK, 50% of respondents
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