Hi Epi_help,

I'm noting the intrusion of the American Psychiatric Association's concepts, from the proposed "Major change #4: Modify criteria for conversion disorder," into the ILAE's concepts involving epilepsy. Major change #4, copyright 2010 APA, Draft 1/29/10, is listed on page 5, 3rd item, at: http://www.dsm5.org/Documents/Somatic/APA%20DSM%20Validity%2...
This all is under rubric of "Justification of Criteria - Somatic Symptoms," with some of the items in the body missing in the references (esp. Stone et al 2009).

My interest was originally piqued in 1983, with studies of the Minnesota Multiphasic Personality Inventory (MMPI). The MMPI is often considered to be invalidated when epilepsy is involved, esp. with temporal lobe epilepsy (TLE), I later discovered an instance of TLE being the cause of invalidating the MMPI esp. on the "Schizophrenia scale (Sc)" and the "Paranoia Scale (Pa)," and use of scales often referred to as "Fake Bad" scales and "classic conversion V pattern", as TLE is not "personality bad" nor "faking bad" in any valid and objective/reliable personality measurement scheme. Statistical elements of TLE, Somatoform Disorder, and Factitious Disorder also intersect, again introducing problems with some proposals with the new DSM-V, some issues at: http://psy.psychiatryonline.org/cgi/content/full/49/4/277

Other concerns with the use of the MMPI with "People are being hurt" concerns when great care is not practiced, which include possibly invalidating factors involving epilepsy amongst many others, is at: http://www.startribune.com/lifestyle/health/52793062.html?pa...

My favorite book about "seizures or events that are not caused by epileptiform activity" is the book "Imitators of Epilepsy" by Kaplan and Fisher (2005). This 296 page book has 21 overlapping chapters, with one chapter on PNES, 6 pages long, and one chapter on coexisting epilepsy and non-epileptic seizures, 16 pages long (the pages are bigger than of average books). Dr. John R. Gates notes "the overall rubric of NES is really quite confusing," and he cites the "crude estimates of the actual frequency of occurrence of this spectrum of disorders," but gives the percentages of 20% of epilepsy inpatients and 5% of outpatients(p. 255, first column), with 30% of the 20% of inpatients having both having both epilepsy and nonepileptic events (p. 257, first column). While NES is not kept separate of PNES, it is implied that between 25% to 87% of NES patients cease having events as per the "Minnesota Epilepsy group" (pages 259-260), hence, the seeds for the incorrect idea that between 25% to 87% of NES is "in fact" only PNES (while also trampling the fact of patients with both epilepsy and NES, which would necessarily limit "only PNES" to at the very most of 70%, with all other forms of NES then limited to 0%).

With my TLE, secondary tonic-clonics (TCs), and migraines that often imitate epileptic seizures, I don't like extreme margins of error being mistakenly used as "non-evidence" of epilepsy and/or NES and an erroneous "therefore" assumption of nearly universal PNEAs of >90% (and don't forget the hematomas and hypoglycemias).

While a nearly three-fold range for frequency error is extreme (the 25% to 87%), a sixteen-fold range for frequency error is worse than useless (2 to 33 per 100,000), even if the sub-group with epilepsy is held distinct from the general population, but Dr. Benbadis puts fourth that this can be utilized and cites others to write: "PNEAs constitute by far the most common (>90%) condition misdiagnosed as epilepsy, at least at referral epilepsy centers" (page 15 of his article). An unfornutate use of phraseology easily leading to confusion between "specific" and "non-specific" precipitators of seizures confounding the subject of PNEAs with reflex seizures and "lowered thresholds for seizures making seizures more likely to occur under non-specific factors" from the common English usage of the word "stress". The notion of "fashionable" diagnoses is on page 16. The article is as: http://www.epilepsyfoundation.org/epilepsyusa/yebeh/upload/D...

Using the label "functional symptoms" as "not at all" or only "somewhat" for physical impairments or disorders, it becomes a synonym with "PNEAs" when epilepsy is the "not at all." Then, "Non-epileptic attacks make up around 10-20% of the patients referred to specialist epilepsy clinics with intractable seizures and up to 50% of patients admitted to hospital in apparent status epilepticus." From "FUNCTIONAL SYMPTOMS AND SIGNS IN NEUROLOGY: ASSESSMENT AND DIAGNOSIS" by J Stone, A Carson, M Sharpe, J Neurol Neurosurg Psychiatry 2005;76(Supp I):i2-i12. doi: 10.1136/jnnp.2004.061655. This article is available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1765681/pdf/v076...

The dangers of overly zealous possible DSM-V founded psychiatric practices with epilepsy subjects is somewhat exemplified in the book "Psychological Masquerade: Distinguishing Psychological from Organic Disorders" by Robert L. Taylor (2007). An earlier edition is available with limited preview on books.google.com. Chapter 7 includes much on epilepsy being one of "Four Masqueraders" pp.119-150 on "LOOK INSIDE!" on amazon.com, and books.google.com with the earlier edition. The case on page 128 illustrates how dangerously stubborn psychiatric practices often are, and strangely parallels cases often cited to and by E. Fuller Torrey in his various publications involving schizophrenia and the "denying patient" who must be "voluntarily" forcibly medicated with neuroleptics to "improve" his/her non-epileptic DSM labeled conditions from schizophrenia to conversion disorders (various DSM labels are often spewed out faster than they can be put in volumes of the patient history). E. Fuller Torrey also cites patients with epilepsy being under court order to "voluntarily" take AEDs or lose the right to freedom and then be "force fed" AEDs, and he uses this as an example of what should be done with patients with mental disorders being required to imbibe neuroleptics.

Besides Taylor's examples, I remember other cases where speaking Polish in an English speaking ER was taken as a sure sign of schizophrenia, and the experiment where the "experts" couldn't tell the genuine patients from the "planted normal" patients at the Mental Treatment Centers/Hospitals. With there being "no clinical signs of non-epileptic attacks which NEVER occur in epilepsy, and apart from ictal electroencephalogram (EEG) abnormalities, there are no signs unique to epilepsy" (Stone, p. i8). Since there are many counties in the USA without EEGs, and a vast majority of clinics without EEGs, carelessness, economics, and the proposed new DSM-V bible, all assure that the number of epilepsies erroneously labeled PNEAs and associated non-particular, ethereal, statistically created constructs of DSM-V labels will prevail over the real epilepsies by ever increasing frequencies of occurrences. All the authorities on neurology have chosen to be looking the other way as this is happening.

By the philosophies of science, statistical correllations do not necessarily indicate cause-and-effect, and statistical clusters of numerical information, though they are labeled with constructed names, do not always represent causal realities. The dramatic differences in the concepts between actual phenomena with empirical classifications versus a priori criteria sets from the such as the DSM, should not be carelessly ignored. Even with great care being taken, the notion of Neuropsychiatry is overly optimistic about becoming a true science, despite the optimistic outlook of doctors in schools of thought along with CONSTANTINE G. LYKETSOS, M.D., M.H.S. as in the article at: http://neuro.psychiatryonline.org/cgi/reprint/18/4/445

Tadzio