Key points
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Psychogenic non-epileptic seizures (PNES), also known as dissociative seizures/seizures/events/episodes, are defined by their superficial semiological resemblance to epileptic seizures or syncope, although the manifestations of PNES are not explained by epileptic discharges or other easily observable physiological changes.
Most PNES are believed to be non-voluntary responses to internal or external triggers that are perceived as threatening or challenging.
Although patients with PNES do not fit into a single category of current international nosologies of mental disorders, the majority of those who receive this label meet the diagnostic criteria for Functional Neurological Symptom Disorder (conversion) (DSM-5) or Dissociative Convulsive Disorder (ICD11).
The incidence of PNES has been noted to be 1.4 to 4.9/100,000/year and the prevalence is estimated to be up to 33 per 100,000 of the general population. As such, PNES are one of the three most common diagnoses made when patients present to seizure clinics. Since this condition most commonly affects young adults, questions about safe operation of a motor vehicle and PNES often arise in clinical practice.
Most patients diagnosed with PNES self-report loss of responsiveness or loss of consciousness in their events. Self-reported loss of response on PNES is significantly associated with self-reported seizure-related injuries [odds ratio (OR): 3.5; 95% confidence interval (CI): 1.4-8.7].
Drivers with neurological conditions have been found to be more likely to cause traffic accidents compared to controls (OR: 5.2, 95% CI: 2.6-10.3), as are drivers with neurological disorders. psychiatric (OR: 3.6; 95% CI: 1.9-6.9). These observations mean that it is plausible that drivers with PNES may be at increased risk of causing driving-related accidents.
However, in the absence of data demonstrating increased risk associated with PNES, mandatory driving suspension may be inappropriate, as loss of driving privileges can have a significant negative impact on patients’ quality of life. , their ability to socialize and their socioeconomic level.
The fundamental challenge lies in identifying an appropriate balance between the safety of PNES patients and the public on the one hand, and the independence, autonomy and quality of life of PNES patients on the other. Since there are currently no widely accepted practice guidelines on how to advise patients with PNES about driving.
| Goals |
Our objectives were to (a) review the literature on motor vehicle driving and PNES; b) seek the opinions of an international group of experts in the field on the issue of motor vehicle driving and PNES; and, (c) summarize the findings and propose guidance on decisions about conducting counseling for people with PNES (single or recurrent) based on the opinions of the majority of contributing experts.
| Methods |
• Phase 1 : Systematic literature review.
• Phase 2 : collection of opinions from international experts using SurveyMonkey ®. The experts included members of the ILAE PNES Working Group and people with relevant publications since 2000.
• Phase 3: Joint analysis of the findings and refinement of the conclusions by all participants via email. As an ILAE Report, the resulting text was reviewed by the Commission on Psychiatry, the ILAE Working Group on Driving Guidelines and the Executive Committee.
| Results |
Eight studies identified by the systematic review process did not provide a firm evidence base for driving regulations related to psychogenic nonepileptic seizures (PNES), but suggest that most health professionals believe the restrictions are appropriate.
Twenty-six experts responded to the survey. The majority held the view that decisions about driving privileges should consider individual patient characteristics and PNES and take into account whether private or commercial driving permits are sought.
The majority considered that people with active PNES should not be able to drive unless certain criteria were met and that PNES should be considered “active” if the last psychogenic seizure had occurred within 6 months.
| Meaning |
Recommendations on whether PwPNES can lead should be made at the individual patient level. Until future research has determined crash risk in PwPNES, a proposed algorithm can guide driving advice decisions.
| Discussion |
While it is possible that some patients with PNES are more likely than other members of the general public to be involved in traffic accidents, there is currently no compelling evidence to directly support or refute this proposition. A small study of 20 patients suggested that there was no increased risk of motor vehicle accidents among patients with PNES, but larger scale studies are clearly needed.
In a survey of healthcare professionals, more than 90% of neurologists and family medicine physicians supported the need for guidelines for making safety decisions in patients with PNES.
In the absence of high-quality evidence, an expert opinion statement providing preliminary guidance on this important social issue may be helpful. This survey and brainstorming documented variable practices across many epilepsy centers and provides the basis for future explorations of this topic.
The nature of driving restrictions in relation to medical conditions and whether they are necessary continues to be debated. To provide a sense of perspective, it may be helpful to consider the variability of risk associated with demographic characteristics. For example, it is recognized that the risk of accidents for male drivers under the age of 25 is five to seven times greater than the average risk of accidents, although this observation does not mean that members of this demographic group are prohibited from driving.
In line with previous surveys focused on PNES, the experts who contributed to the present project believed that driving restrictions should be recommended, at least for some people with this disorder.
Despite the uncertainties and lack of evidence, it seems appropriate to err on the side of caution when it comes to driving privileges, especially given that the risks associated with driving would not only affect people with PNES.
The risks to others are likely to be even greater with commercial driving than with private driving. Therefore, one could argue that drivers with PNES must demonstrate to the community that they are safe to drive.
Affected individuals may do so if they have been free of PNES for a period of time before being permitted to drive commercially. In relation to (non-commercial) driving, the expert panel contributing to this study ultimately considered a PNES-free period of six months as reasonable evidence that a PNES disorder is under control. A considerably longer period of complete control of the PNES would be appropriate before commercial driving could be permitted.
Changes in semiology represent another major challenge when exemptions from PNES-related driving restrictions have been made. Although the semiology of PNES has been shown to be relatively stable in the short term, there is evidence that, in the long term, it is more variable than the semiology of epileptic seizures. This means that the suitability of individuals with PNES for the unit should be reviewed at regular intervals .
Additionally, those with active PNES who are permitted to drive based on the proposed exception criteria should be aware that they must stop driving if the nature of their seizures changes and the criteria supporting their exception to the exemption are no longer met. driving ban.
We recognize that our project has several limitations. The most important of these is the lack of sufficient data to inform us of the risk of PNES in relation to driving. The wording of the survey questions and other questions not addressed may have influenced the results.
To achieve the goal of providing evidence-based guidelines, treating physicians must collaborate with mental health professionals, motor vehicle licensing authorities, patient groups, caregivers, and others, to fully represent the multitude of relevant perspectives on this complex topic. We particularly recognize that, regardless of medical risk, driving standards reflect social pressures and legal responsibilities.
We recognize that in response to a condition in which an individual experiences a recurrent and seemingly unpredictable loss of consciousness, there may be a public demand for regulations that are similar to those for epilepsy, even if the associated risks were minor. In the absence of relevant evidence, expert opinion can empower clinicians to make the best possible decisions about driving restrictions in relation to PNES.
The perception of PNES as a clinically heterogeneous disorder was reflected in the fact that the experts contributing to this project considered that, in certain circumstances, exceptions could be made to the general rule that patients with active PNES should not drive: the majority suggested that (non-commercial) driving should be permitted for people with PNES if there is a clearly established pattern of PNES occurring exclusively at times when the person would not be able to drive, if PNES occur exclusively after exposure to triggers very specific ones that affected people could not possibly encounter while driving, and/or whether people always experience clear warning signs of sufficient duration that would allow them to safely stop their car and stop driving before an event.
The group of people with comorbid epilepsy and PNES presents a particular diagnostic and treatment challenge. While the vast majority of patients with PNES do not experience epileptic seizures, a substantial minority (about 20%) have comorbid epilepsy. Whenever a patient with mixed epilepsy/PNES experiences epileptic seizures (or if the treating physician is unsure whether the epileptic seizures have ceased), then epilepsy-related driving restrictions should be invoked.
Similarly, patients whose seizures are of uncertain etiology and who have not received a diagnosis of PNES that is sufficiently certain that the treating physician can only recommend treatment for this disorder and discontinue any erroneously prescribed antiseizure medications. They should be encouraged to adhere to laws restricting driving with epileptic seizures.
However, if the treating physician firmly concludes that all ongoing seizures are due to PNES and that there have been no epileptic seizures for the period of time required by the relevant state law related to epilepsy, then the opinions in this document would be applicable. .
