Abstract
Background and Objective
The objectives of this study were to investigate health care utilization costs of patients with video-electroencephalography (VEEG)–confirmed functional seizures (FS), determine whether patients who received a satisfactory functional neurologic disorder (FND) diagnosis explanation had reduced health care utilization compared with those with a poor explanation; and to quantify the overall health care costs 2 years prediagnosis and postdiagnosis for those receiving a different explanation.
Methods
Patients with VEEG-confirmed pure FS (pFS) or mixed (functional seizure plus epileptic seizures) diagnosis between July 1, 2017, and July 1, 2019, were evaluated. Explanation of the diagnosis was determined “unsatisfactory” or “satisfactory” using self-developed criteria, and health care utilization data were collected using an itemized list. The subsequent costs 2 years post-FND diagnosis were compared with those 2 years before, and cost outcomes were compared between both groups.
Results
In patients who received a satisfactory explanation (n = 18), total health care costs were reduced from $169,803 to $117,133 USD (−31%). An increase in costs was found ($73,430 to $186,553 USD = +154%) in patients with pPNES after an unsatisfactory explanation (n = 7). On an individual level, 78% with a satisfactory explanation saw a reduction in total health care costs per year (mean $5,111 USD to $1,728 USD), and in 57%, an unsatisfactory explanation led to an increase (mean $4,425 to $20,524 USD). A similar effect was seen from explanation on patients with a dual diagnosis.
Discussion
The method of communicating an FND diagnosis has a significant impact on subsequent health care utilization. Those receiving satisfactory explanations demonstrated reduced health care utilization, whereas an unsatisfactory explanation resulted in additional expenses.
Functional neurologic disorders (FND) represent a heterogenous collection of neurologic symptoms that are inconsistent and/or incongruent with an underlying organic neurologic disorder. Features vary and may include altered speech, mobility, levels of consciousness/FS, sensory disturbance, and impairment in overall function.1 Differentiating FND from other etiologies including sleep disorders, cardiogenic syncope, and hyperekplexia among other causes can be difficult. FS (unlike other subtypes of FND) can be clearly differentiated through video-electroencephalography (VEEG) whereby a captured clinical event without an EEG correlate is indicative of an functional seizure diagnosis.2 FS are commonly encountered in the emergency department and may be undiagnosed and unrecognized, resulting in inappropriate pharmacologic and nonpharmacologic treatment strategies.3 Thus, patients with VEEG-confirmed FS are ideal for further evaluation, particularly in studies examining the efficacy of communicating an FND diagnosis.
Communicating an FND Diagnosis
There is widespread recognition that the strategy used to communicate an FND diagnosis plays a central role in a patient's treatment and affects patient outcomes.1,4 Several communication strategies are suggested in the literature. A key aspect of these is to provide an explanation that the symptoms are genuine, common, and potentially reversible.1,4,5 Furthermore, offering support regarding the positive nature of the diagnosis, provision of simple distraction techniques, information and self-help, referral to a psychologist/allied health services, and offering further outpatient reviews is an important part of delivering an FND diagnosis.1,4,6 Exploring underlying psychosocial vulnerabilities in addition to providing psychosocial support can also be beneficial in some patients.5,7
The Cost of an FND Diagnosis
Establishing an FND diagnosis can be both time consuming and expensive. The cost of health care utilization before establishing an functional seizure diagnosis in Australia has been estimated at $26,468 AUD ($19,207 USD) per person.8 While the greatest cost has been attributed to investigations, recurrent emergency presentations and admissions represent a significant burden on the publicly funded Australian health care system. Internationally, studies have similarly demonstrated significant health care utilization costs. Patients with FND presenting to the emergency department in the United States are more likely to require admission compared with those with other neurologic conditions.9 Total costs per admission are also higher for patients with FND, with total annual health care costs estimated to be greater than US$1.2 billion USD per year and rising annually in one study applicable to more than 200 million Americans.9 Patients with FND represent a significant portion of outpatient care as well, with patients presenting with symptoms that are only “somewhat” or “not at all” explained by organic disease accounting for 30% of presentations in neurology outpatient clinics.10
Application of This Study
There is mixed data about health care utilization after the diagnosis of FS within the literature. Some studies show dramatic improvements after delivering the diagnosis,11 whereas other studies show no change.12 To date, there has been limited research evaluating the communication strategy used to explain an FS diagnosis and how this affects on overall health care cost and utilization both before and after an functional seizure diagnosis. Little is also known regarding whether the method of diagnosis affects health care utilization by patients with comorbid epilepsy. This unique cohort is particularly challenging due to a significant overlap between FS and epilepsy, with as many as 22% of cases reported in the literature.13 A diagnostic VEEG consistent with FS and/or comorbid epilepsy can give the treating neurologist confidence in explaining the diagnosis.
We hypothesized therefore that the quality of communicating an functional seizure diagnosis directly affects subsequent health care utilization and costs both for the individual and greater societal health care expenditure.
Methods
We conducted a retrospective evaluation of health care utilization for patients with VEEG-proven FS, 2 years before and after their diagnosis. The study objective was to quantify public health care costs and compare patients who received a “satisfactory” explanation with those who received an “unsatisfactory” explanation of the functional origin of their attacks.
Standards Protocol Approvals, Registrations, and Patient Consents
This study was approved by the Metro South Human Research Ethics Committee with a waiver of patient consent.
Institution Description
Data were extracted from Metro South Healthcare, which is the major provider of public health services in Southeast Queensland, Australia. It is made up of 5 major hospitals in addition to several community health services, and their catchment area comprises more than 1.6 million people. Patient VEEGs were obtained from the neurophysiology service at the Princess Alexandra Hospital, a quaternary-level teaching hospital located in South Brisbane. Diagnoses to patients were given during or shortly after their admission for the VEEG and could be delivered by either the treating registrar, nurse practitioner, or general neurologist.
Patient Selection
In this study, we examined 25 patients identified in a previous study,14 with an additional patient with FS captured on hospital-based EEGs with time-locked videorecording from July 2017 to July 2019. We categorized into the following classifications according to the reporting neurologist's assessment: (1) patients with pure FS (pFS) and (2) patients with mixed FS and coexisting epileptic seizures (FS + ES), including patients with both a clinical event without VEEG correlate and/or VEEG evidence of ES activity. According to the International League Against Epilepsy Classification of Epilepsies, most patients within the mixed category likely had focal epilepsy. These diagnoses were based on the finding of interictal focal sharp waves captured on VEEG recording.15
We defined an appropriate explanation of the functional nature of the attacks based on a set of self-developed criteria. These criteria were put together by 2 neurologists with expertise in managing patients with FND (TL and AL) and were based around widespread literature evidence about the role of neurologic assessment in FND treatment.1,4 Our criteria were as follows: (1) mentioning a diagnosis of FS/FND or synonym in the record, (2) mentioning of an explanation of the diagnosis given to the patient, (3) provision of self-reading/online material about FND, (4) a referral to a psychologist (or a request to the GP to provide this), (5) a letter sent to the GP, and (6) an appropriate follow-up (<6 months). Each criterium scores 1 point with a maximum of 6. A score of 0–2 points was considered an unsatisfactory explanation and a score of 3 or higher a satisfactory explanation.
Patient characteristics including demographics, clinical features, and detailed information about health care utilization in the period 2 years prediagnosis and postdiagnosis were extracted directly from the electronic medical record. We used an itemized list to collect health care utilization data in relation to presentations with FS. This included ED presentations, hospital admissions including length of stay, outpatient clinic visits, formal mental health reviews, investigations (blood tests, imaging, EEGs), and medications with total dosages.
Outcome Measures
ED costs per presentation were estimated in accordance with billing data from the Princess Alexandra Hospital Revenue Office. Costs for other in-hospital services including admissions and mental health reviews were estimated using daily hospital fees for public compensable patients, provided by the Queensland Department of Health. For the number of hospital days, the admission date was defined as hospital day zero. Patient days were considered equivalent to the number of midnights spent in the hospital. The cost of outpatient neurology clinic visits and investigations was calculated according to the corresponding Medicare item number specified by the Department of Human Services.
To estimate the costs for medication in an individual patient, we checked the antiepileptics (brand, frequency, and total dosage) used during VEEG and calculated the costs for a “hypothetical” 2-year period of usage. Prices of different medications were established using the dispensed price for maximum quantity available for each drug on the Pharmaceutical Benefits Scheme (PBS) website provided by the Australian Government, Department of Health.
Statistical Analysis
Descriptive statistics were presented for continuous data using mean and SD or median and interquartile range (IQR) when distribution was skewed. Categorical data were presented using frequencies and percentages. Comparison of continuous data between 2 groups with skewed distribution was performed using a Mann-Whitney test and p values were reported. To determine the impact of individual elements of the explanation score on total costs, the change in costs before and after explanation was compared at the patient level for each element. A Mann-Whitney test was used to compare the change in costs between those with score = 0 and those with score = 1 for each of the 6 elements independently. Analyses were performed using the R statistical software.16
Data Availability
Owing to the potential for loss of patient confidentiality, complete individualized data cannot be made publicly available; however, anonymized data may be shared at the request of any qualified investigator.
Results
We identified 25 patients with pFS with mean age 38.2 years (SD 14.5) and 6 patients with mixed (functional and epileptic) seizures with mean age 41.4 years (SD 16.8) based on VEEG, between July 1, 2017, and July 1, 2019 (Table 1).
Table 1.
Patient Demographics Separated According to Diagnostic Classification (pFS and Mixed)
Using our self-developed criteria, we estimated that 18 patients in the purely dissociative group received a satisfactory explanation of their diagnosis (mean score of 4.9 points for this group with a maximum of 6 points reached) and 7 patients received an unsatisfactory explanation (mean of 0.7 points; with a maximum of 2 points recorded). In the mixed group, there were 3 patients with a satisfactory explanation and 3 with an unsatisfactory explanation.
Pure Functional Seizures Data Set
We compared health care utilization in the 2 years after the diagnosis with that 2 years before for 7 different categories. In the pFS group, after a satisfactory diagnosis, there was a reduction in total ED presentations; number of days spent during hospital admissions; outpatient clinic visits; pathology requests; imaging studies; and EEGs. An increase was seen in the number of mental health reviews. After an unsatisfactory explanation, there was an increase in all categories, except for the number of EEGs performed (Table 2).
Table 2.
Descriptive Statistics per Cost, Group by Explanation of the Diagnosis (Before and After) in the pFS Cohort
Initially, health care utilization was calculated in Australian dollars and then converted to USD using conversion factor 1 AUD = 0.73 USD. The total costs of health care utilization in the 18 patients with pFS who received a satisfactory explanation were $169,803 USD in the 2 years before their diagnosis compared with $117,133 USD in the 2 years after their diagnosis (a reduction of 31.0%). Hospital admissions (−$29,508 USD), ED presentations (−$9,579 USD), and outpatient clinic visits (−$7,169 USD) contributed most to this reduction. The costs of formal mental health reviews increased from $2,389 to $4,778 USD.
In the subgroup of patients who received an unsatisfactory explanation (n = 7), health care costs increased from $73,430 to $186,553 USD. Although increase in costs was seen in every category except EEGs, more than 75% of this rise was due to a higher number of hospital admission days ($143,785 USD) (Figure 1).
Figure 1. Health Care Utilization Costs by Explanation (Before and After Diagnosis) in the Pure Functional Seizure (pFS) Group.
Mixed Functional and Comorbid Epileptic Seizures Data Set
In the mixed group, patients received a diagnosis of video-proven FS in addition to an earlier diagnosis of epilepsy. In the 3 patients with mixed attacks who received a satisfactory explanation of FND, a reduction was seen in the number of ED presentations, hospital admission length of stay, mental health reviews, pathology requests, imaging studies, and EEGs. For this subgroup, there was only a slight increase in the number of outpatient clinic visits. The other 3 patients with mixed attacks, who were given an unsatisfactory diagnosis of the functional nature of their attacks on video-EEG, showed an increase in hospital utilization for every independent category.
Overall costs of health care utilization in the small cohort of 6 patients with mixed attacks could be reduced by 55.5% ($106,876–$47,593 USD) or increased by more than 700% ($14,240–$116,197 USD) depending on the explanation of the treating physician (Figure 2).
Figure 2. Health Care Utilization Costs by Explanation (Before and After Diagnosis) in the Functional Seizure Plus Epileptic Seizure (Mixed) Group.
Costs of Medication Use
During VEEG, a variety of antiepileptic medications were used in the group with purely FS, including levetiracetam, valproate, lamotrigine, topiramate, phenytoin, carbamazepine, lacosamide, gabapentin, zonisamide, and diazepam. One patient was commenced on levodopa/benserazide tablets for “focal leg seizures.” The estimated total costs of these medications over a 2-year period were $19,430 USD, which equates to $388 per person per year. One patient used medicinal cannabis for psychogenic nonepileptic attacks, and 1 patient was on a ketogenic diet during VEEG (both were discounted in total medication costs).
Costs per Individual Patient
The median total health care utilization cost per person in the 2 years before the diagnosis of FS was established was $4,768 USD (interquartile range $2,067–$14,994 USD; range $287–$47,296 USD). The total cost was calculated by adding the costs of the 7 defined categories and the mean costs for medication use. In 14 of the 18 patients with pFS (77.8%), a satisfactory explanation could reduce the mean total health care costs per person before the explanation from $5,111 USD to $1,728 USD (−66.2%) per year. Conversely, in 57.1%, an unsatisfactory explanation could increase the mean costs from $4,425 to $20,524 USD (+363.8%) on a yearly basis.
In the smaller group with mixed attacks, the median total health care cost per person before diagnosis was $10,055 USD (interquartile range $2,551–$37,747; range $1,526–$66,106 USD). A satisfactory explanation could lower these costs in 2 years from to $34,720 to $15,648 USD (−54.9%). An unsatisfactory explanation led to an increase in the mean costs from $4,923 to $38,732 USD (+686.8%). In this last group, we were unable to factor in a possible reduction of medication costs because patients were also diagnosed with ES.
Messenger of the FND Diagnosis
The explanation of the diagnosis could be given by a neurologist, registrar, or nurse practitioner (Table 1). The median rating of the neurologists was 4 (IQR 2–5) compared with 5 (IQR 4–5) by the nonspecialists. There was no significant difference in the rating of explanation satisfaction using our self-defined criteria between general neurologists and neurology registrars/nurse practitioners (Mann-Whitney test, p = 0.87). Of 9 health care professionals (5 neurologists, 3 neurology registrars, and 1 nurse practitioner), 2 of them provided 50/50% of explanations in favor of satisfactory/unsatisfactory outcomes. Otherwise, all the other ones provided satisfactory explanations in 66–100% of the cases. None of them provided less than 50% ratings for unsatisfactory outcomes. There was a poor association between a single health care professional and poor outcome (Cramer V = ϕc = 0.299).
Impact of Individual Explanation Elements
When evaluating the 6 individual elements to calculate the overall score for a satisfactory explanation, a significant impact on total costs was seen from mentioning the diagnosis of FND (p = 0.029), a letter being sent to the referring doctor (p = 0.048), and a follow-up review being provided (p = 0.021). On the contrary, no significant impact was seen from an explanation of the diagnosis being provided (p = 0.6), provision of reading material (p = 0.57), or a referral to a psychologist being made (p = 0.12).
Discussion
This study gives an important insight into the health care utilization of patients with FND within the Australian public health care system because it examines health care utilization prediagnosis and postdiagnosis and explores (and quantifies) the subsequent financial ramifications of a satisfactory vs unsatisfactory diagnosis explanation. The most significant finding to emerge from this study is the direct impact that a satisfactory or unsatisfactory explanation has on subsequent health care utilization. Not only can a satisfactory explanation of FS reduce health care utilization but an unsatisfactory explanation can dramatically increase respective health care uptake and utilization.
In this study, we demonstrated the median cost before a diagnosis of FS was $4,768 USD. Comparatively, a previous Australian study determined the median total health care utilization cost per person before an functional seizure diagnosis as $19,322 USD.8 This retrospective study was based on a 5-year period before the diagnosis, and investigations represented the highest contribution to costs. By contrast, our study identified that the major cost was attributed to hospital admission days and emergency presentations. Furthermore, their study cohort consisted of a relatively high number (18%) of patients who presented with a nonepileptic psychogenic status.
This study demonstrated that communicating an functional seizure diagnosis reduces subsequent health care utilization and overall costs. This has also been reported within the literature: a study published in 2013 examined health care costs incurred by 24 patients over a 12-month period.17 They included emergency visits and inpatient and outpatient reviews and determined that the mean cost could be reduced from $4,567 USD pre-FND diagnosis and $2,784 USD postdiagnosis. Unlike this study, they did not provide details or apply uniform criteria to assessing the method of communicating the FND diagnosis. Other studies have similarly examined costs associated with FND patient care and determined costs to be in the order of $8,156 USD to $15,000 USD per patient during publication.18,19 The costs of a diagnosis are not only limited to direct health care utilization. Other indirect economic factors that have been examined within the literature include lost income, tax, and social welfare costs. These are not inconsequential, with a study in Ireland estimating these indirect costs totalled ₠15,566 per patient.20 In this study were also examined the health care utilization in patient with mixed, FS, and comorbid ES. This cohort represents a serious challenge for clinicians. Although the numbers in our mixed group were limited (n = 6), the findings suggest similar effects on health care costs after a satisfactory or unsatisfactory explanation of the functional events.
Admissions to intensive care units (ICUs) have been recognized as a significant contributor to health care expenditure in patients with FND. Of interest, none of the examined patients within our study required an intensive care admission during the study period. ICU admissions are not only expensive but may also be a cause of unnecessary interventions including intubation, which can result in deleterious complications.8 Possible reasons for this discrepancy may be due to low sample size or limited timeframe examined.
Overall, this study highlights that providing patients with an appropriate explanation of an FND diagnosis and ensuring timely follow-up leads to subsequent reduction of health care utilization and health care costs. We also showed that in our cohort there was no difference in explanation satisfaction between a diagnosis when delivered by a neurologist and that by a registrar. This is critical information particularly in the context of identifying strategies that can reduce the financial demands of an increasingly costly public health care system and ultimately optimizing the care for patients with FND.
We acknowledge that our study needs to be interpreted in the context of its potential limitations. First, it can be difficult to differentiate the indication for an investigation and whether this was directly or indirectly associated with an underlying FND diagnosis. Therefore, objective measures including the number of ED presentations and duration of hospital admission in days was examined. Indication for admission was determined as being associated with FND (including associated pain syndromes and mental health conditions) vs those in which the FND component was “unable to determine.” eTable 1 (links.lww.com/CPJ/A385) summarizes that throughout the cohort more than 75% of the health care use in these categories was exclusively related to the functional disorder diagnosis. Second, data were skewed, meaning that some patients were frequent presenters to hospital thereby driving the number of admissions and duration of inpatient stay. Therefore, to ensure that the findings observed at the cohort level are also seen at the patient level, statistical descriptions were performed at the patient level for each group (eTable 2, A and B, links.lww.com/CPJ/A385). For most patients, there is a cost reduction after a satisfactory explanation for all parameters (between 67% and 100% of patients had a reduction in all parameters) and a rise in costs after an unsatisfactory explanation (e.g., 71% of patients with unsatisfactory explanation had an increase in ED presentations). Third, our study was performed in a single health care network in Southeast Queensland with a small sample size. Hence, this cohort may not be representative of all greater domestic or international cohorts, particularly those under differently funded health care models. Fourth, data were restricted to care received under the public health care system and thus did not include details about private specialist outpatient visits including those with a general practitioner, psychologist, physiotherapist, or other health care services. This also prevented us from assessing how many patients in this study actually accessed psychological therapy after being diagnosed with FND. Moreover, imaging and pathology performed in the private setting were not available. Gaining access to all private outpatient reviews and investigations was not logistically feasible, and thus this study focused only on those occurring in the public health system. As such, calculated health care utilization costs may be an underestimation of the true cost incurred. Classification of an explanation as satisfactory or unsatisfactory was determined based on documented data by the attending physician. Thus, poor documentation could have potentially resulted in a misclassification of a satisfactory vs unsatisfactory discussion. The same criteria were applied to the assessment of all patient records (see method section) to ensure a consistent assessment across all documented studies and assessed by 2 neurologists independently (AL and TL) to minimize any unintentional bias. Last, there are several possible confounding factors that could have affected the quality of explanation a patient received, such as time of day for patient review or if there were any communication difficulties that could have interfered with a satisfactory explanation. In addition, some patient factors such as patients with coexisting personality disorders or patients who might have been angered from previous encounters with health care professionals could have influenced the ability to deliver a satisfactory explanation.
This study provides significant insight into the health care utilization of patients with FND and the crucial role that a thorough diagnosis explanation and follow-up can have on subsequent health care engagement.
In the future, we aim to investigate prospectively whether implementing an FND diagnosis discussion incorporating the 6 criteria examined in this study can be used to reduce both health care utilization and ultimately patient satisfaction with care received. We also propose that future prospective studies include public and private data to accurately determine health care involvement beyond the public sector.
Ultimately, this research is an essential step in optimizing the care of our patients with FND and distribution of our overall health care resources
TAKE-HOME POINTS
→ The method of communicating a patient's functional diagnosis has a significant impact on subsequent health care utilization.
→ A satisfactory explanation of functional seizures can reduce health care resource utilization and overall costs.
→ By contrast, an increase in costs was found in patients with functional seizures after an unsatisfactory explanation.
→ Mentioning the diagnosis of FND, providing a letter to the general practitioner, and ensuring a follow-up review by a neurologist significantly reduced health care utilization and costs.
→ The study findings suggest similar effects on health care costs after a satisfactory or unsatisfactory explanation of functional events in patients with a dual diagnosis of epilepsy and functional seizures.
Acknowledgment
The authors acknowledge Metro South Health Centres for Health Research for facilitation of the Metro South Health Biostatistics Service provided by QCIF Facility for Advanced Bioinformatics (QCIF) and funded by Metro South Study, Education, and Research Trust Account (SERTA).
Appendix. Authors
Study Funding
T.J. Lagrand received support from the Jan Meerwaldt Foundation for an Overseas Fellowship.
Disclosure
The authors report no relevant disclosures. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.
References
- 1.Stone J, Carson A, Hallett M. Explanation as treatment for functional neurologic disorders. Handbook Clin Neurol. 2016;139:543-553. doi: 10.1016/B978-0-12-801772-2.00044-8 [DOI] [PubMed] [Google Scholar]
- 2.Cock HR, Edwards MJ. Functional neurological disorders: acute presentations and management. Clin Med. 2018;18(5):414-417. doi: 10.7861/clinmedicine.18-5-414 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Lehn A, Watson E, Ryan EG, Jones M, Cheah V, Dionisio S. Psychogenic nonepileptic seizures treated as epileptic seizures in the emergency department. Epilepsia. 2021; 62(10): 2416-2425. doi: 10.1111/epi.17038 [DOI] [PubMed] [Google Scholar]
- 4.Stone J. Functional neurological disorders: the neurological assessment as treatment. Pract Neurol. 2016;16(1):7-17. doi: 10.1136/practneurol-2015-001241 [DOI] [PubMed] [Google Scholar]
- 5.Adams C, Anderson J, Madva EN, LaFrance Jr WC, Perez DL. You've made the diagnosis of functional neurological disorder: now what? Pract Neurol. 2018;18(4):323-330. doi: 10.1136/practneurol-2017-001835 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Hallett M, Lang AnthonyE, Jankovic J, et al. Psychogenic Movement Disorders and Other Conversion Disorders. Cambridge University Press; 2011. [Google Scholar]
- 7.Lidstone SC, Nassif W, Juncos J, Factor SA, Lang AE. Diagnosing functional neurological disorder: seeing the whole picture. CNS Spectrums. 26(6) 2020:593-600. doi: 10.1017/S1092852920001996 [DOI] [PubMed] [Google Scholar]
- 8.Seneviratne U, Low ZM, Low ZX, et al. Medical health care utilization cost of patients presenting with psychogenic nonepileptic seizures. Epilepsia. 2019;60(2):349-357. doi: 10.1111/epi.14625 [DOI] [PubMed] [Google Scholar]
- 9.Stephen CD, Fung V, Lungu CI, Espay AJ. Assessment of emergency department and inpatient use and costs in adult and pediatric functional neurological disorders. JAMA Neurol. 2021;78(1):88-101. doi: 10.1001/jamaneurol.2020.3753 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Stone J, Carson A, Duncan R, et al. Symptoms 'unexplained by organic disease' in 1144 new neurology out-patients: how often does the diagnosis change at follow-up? Brain., 2009;132(10):2878-2888. doi: 10.1093/brain/awp220 [DOI] [PubMed] [Google Scholar]
- 11.McKenzie P, Oto M, Russell A, Pelosi A, Duncan R. Early outcomes and predictors in 260 patients with psychogenic nonepileptic attacks. Neurology. 2010;74(1):64-69. doi: 10.1212/WNL.0b013e3181c7da6a [DOI] [PubMed] [Google Scholar]
- 12.Salinsky M, Storzbach D, Goy E, Kellogg M, Boudreau E. Health care utilization following diagnosis of psychogenic nonepileptic seizures. Epilepsy Behav. 2016;60:107-111. doi: 10.1016/j.yebeh.2016.04.007 [DOI] [PubMed] [Google Scholar]
- 13.Kutlubaev MA, Xu Y, Hackett ML, Stone J. Dual diagnosis of epilepsy and psychogenic nonepileptic seizures: systematic review and meta-analysis of frequency, correlates, and outcomes. Epilepsy Behav. 2018;89:70-78. doi: 10.1016/j.yebeh.2018.10.010 [DOI] [PubMed] [Google Scholar]
- 14.Jones M, Gaskell J, Lehn A. Differentiating psychogenic nonepileptic seizures from epileptic seizures: an observational study of patients undergoing video-electroencephalography (VEEG) in Australia. Epilepsy Behav. 2021;114(Pt A):107542. doi: 10.1016/j.yebeh.2020.107542 [DOI] [PubMed] [Google Scholar]
- 15.Hirsch E, French J, Scheffer IE, et al. ILAE definition of the idiopathic generalized epilepsy syndromes: position statement by the ILAE task force on nosology and definitions. Epilepsia. 2022;63(6):1475-1499. doi: 10.1111/epi.17236 [DOI] [PubMed] [Google Scholar]
- 16.A Language and Environmental Statistical Computing. Foundation of Statistical Computing; 2021. [Google Scholar]
- 17.Ahmedani BK, Osborne J, Nerenz DR, et al. Diagnosis, costs, and utilization for psychogenic non-epileptic seizures in a US health care setting. Psychosomatics. 2013;54(1):28-34. doi: 10.1016/j.psym.2012.08.005 [DOI] [PubMed] [Google Scholar]
- 18.Binder LM, Salinsky MC. Psychogenic nonepileptic seizures. Neuropsychol Rev. 2007;17(4):405-412. doi: 10.1007/s11065-007-9047-5 [DOI] [PubMed] [Google Scholar]
- 19.Martin RC, Gilliam FG, Kilgore M, Faught E, Kuzniecky R. Improved health care resource utilization following video-EEG-confirmed diagnosis of nonepileptic psychogenic seizures. Seizure. 1998;7(5):385-390. doi: 10.1016/s1059-1311(05)80007-x [DOI] [PubMed] [Google Scholar]
- 20.Magee JA, Burke T, Delanty N, Pender N, Fortune GM. The economic cost of nonepileptic attack disorder in Ireland. Epilepsy Behav. 2014;33:45-48. doi: 10.1016/j.yebeh.2014.02.010 [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Owing to the potential for loss of patient confidentiality, complete individualized data cannot be made publicly available; however, anonymized data may be shared at the request of any qualified investigator.