![]() 1 Some unprovoked seizures will have history, physical, labs, imaging, and EEG that are unrevealing. Incidence of unprovoked seizures is approximately 42 to 61 per 100,000 annually, and a standardized mortality ratio (SMR) of 2.3 has been reported. A single seizure or a cluster of seizures in a 24-hour peroid with no identifiable trigger is termed unprovoked. Furthermore, the acute symptomatic seizure patients were 80% less likely to have subsequent seizures. Beyond 30 days, the 10 year mortality rate for acute symptomatic seizure was equivalent to a first unprovoked seizure. Individuals with acute symptomatic seizures from CNS infection, TBI, or stroke, however, were 8.9 times more likely to die in the first 30 days compared with patients who had a first unprovoked seizure. If reversible causes are avoided and there is no permanent brain damage, recurrence is unlikely. The most effective treatment is psychologic therapy, most commonly cognitive behavioral therapy 12 Diagnosis is made by a history consistent with PNES coupled with normal EEG findings during a typical PNES event. ![]() 11 Risk factors include female sex (80%), childhood trauma, adult trauma, posttraumatic stress disorder, history of sexual abuse, military service, and concurrent medical diagnosis (especially asthma, chronic pain, and fibromyalgia). As many as 20% to 30% of people referred to epilepsy centers for medically refractory epilepsy have PNES. 10 There is a high comorbidity of PNES and epilepsy 10% to 40% of people with epilepsy have PNES. ![]() Diagnosis of psychogenic nonepileptic seizures (PNES) can take up to 7 years from the initial event, underscoring the importance of carefully considering this diagnosis (Table 1). The American College of Cardiology and American Heart Association issue updated guidelines on managing syncope. Different types of syncope include orthostatic related, reflex (vasovagal being a common type), cardiac, and volume depletion. A nonepileptic convulsion may occur during syncope. Caused by cerebral hypoperfusion, syncope presents as an abrupt and complete loss of consciousness and postural tone followed by a rapid spontaneous recovery (Table 1). 8 Over 90% of those presenting with transient loss of consciousness are found to have syncope, psychogenic nonepileptic seizures, and epileptic seizures. The estimated lifetime incidence of transient loss of consciousness is as high as 50%. Transient loss of consciousness is one of the most common presenting complaints in people who may have had a seizure. Correct identification of epilepsy is a clinical care gap there is up to a 3-year delay in antiseizure medication (ASM) initiation in 36.7% of people with newly diagnosed epilepsy, which may be larger when the 2014 definition of epilepsy is used in future studies. 6 Determining the underlying cause of a seizure and distinguishing a seizure from epilepsy determines treatment decisions, prognosis, and counseling. The established definitions of seizures and epilepsy are listed in Box 1. 4,5 Epilepsy is the fourth most common neurologic condition. 3 Approximately 3.4 million people in the US (1.2% of the population) and 70 million people, globally, have epilepsy. 2 The lifetime incidence of seizures is approximately 10%, and 1 in 26 people in the US develop epilepsy. 1 Up to 2% of all emergency room visits or 1 in every 100 emergency room visits in the US are for seizures. In the US, approximately 150,000 adults per year will present with a first unprovoked seizure. Exploration of personal and cultural understanding of seizures is also important in order to provide responsive counseling that mitigates potential discrimination and stigma from family, educators, and employers. Empathic attentiveness to an individual’s questions is an important aspect of seizure management. Questions about the ability to work, maintaining financial stability, driving, caregiving, or childbearing suddenly cloud future plans. A first seizure is potentially the most terrifying life event a person can experience.
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