Wednesday, February 8, 2017

Tilt-induced psychogenic nonsyncopal collapse and its mimics

Geoffrey L. Heyer,  Rebecca A. Harvey, Monica P. Islam.   Comparison of Specific Fainting Characteristics between Youth with Tilt-Induced Psychogenic Nonsyncopal Collapse versus Reflex Syncope. The American Journal of Cardiology.  In press.

Little is known about the predictive features of psychogenic nonsyncopal collapse (PNSC). The aim of the present study was to compare the self-reported fainting characteristics between young patients who were ultimately diagnosed with PNSC to those ultimately diagnosed with neurally-mediated syncope and to determine which features were predictive of either diagnosis. A prospective study was conducted of sequential patients referred for fainting. All study data were obtained prior to testing or diagnosis. Several fainting characteristics were compared between cohorts including numbers of lifetime fainting episodes, fainting frequency the week prior to evaluation, fainting duration, numbers of fainting spells in a single day, presence of presyncope, types of prodromal symptoms, tearfulness with fainting, and the numbers of emergency department visits and hospital admission for fainting. During the study period 52 patients were diagnosed with PNSC, producing a diagnostic rate of 18.9%. In univariate analyses, multiple features differed between patients with PNSC and those with syncope. After controlling for age and gender in a multivariate analysis, each of the following predicted PNSC: ≥20 lifetime fainting spells (p=.005), ≥2 fainting spells in a single day (p=.03), self-reported loss of consciousness ≥2 minutes (p=.01), and tearfulness associated with fainting (p=.022). Two or more typical prodromal symptoms (p=.004) predicted syncope. In conclusion, several characteristics related to fainting have predictive value in distinguishing PNSC from syncope, particularly among youth. Assessing these clinical features can help to inform appropriate testing and accurate diagnosis among patients who faint.

Courtesy of:

Heyer GL, Albert DV, Weber A, Gedela S, Vidaurre J. Comparison of semiologies
between tilt-induced psychogenic nonsyncopal collapse and psychogenic
nonepileptic seizures. Epilepsy Behav. 2016 Sep;62:171-5.


We sought to characterize the clinical features of tilt-induced psychogenic nonsyncopal collapse (PNSC) from a cohort of young patients and to compare the semiologies between PNSC and EEG-confirmed psychogenic nonepileptic seizures (PNES). A PNSC diagnosis was made if a clinical event occurred during tilt-table testing that the patient regarded as fainting, but neither hypotension nor EEG changes were present. A diagnosis of PNSC was made in 17.6% of all patients referred during the 15-month study period. Cohorts with psychogenic nonsyncopal collapse (n=40) and PNES (n=40) did not differ in age (15.5±2.2 versus 14.6±2.7, p=.11) or female gender (80% versus 72.5%, p=.43). Psychogenic nonsyncopal collapse events were briefer than PNES events (median: 45 versus 201.5s, p<.001). Negative motor signs (head drop, body limpness) predominated in PNSC (85% versus 20%, p<.001), while the positive motor signs of convulsion occurred more often with PNES (90% versus 30%, p<.001). Behavioral arrest (25% versus 32.5%, p=.46) and eye closure (85% versus 72.5%, p=.21) did not differ between PNSC and PNES. Patients with PNSC were more likely to be tearful before (30% versus 7.5%, p=.02) and after (62.5% versus 7.5%, p<.001) an event. In conclusion, although overlap exists, the features of PNSC generally appear similar to neurally mediated syncope, while the features of PNES generally appear similar to epileptic seizures. Psychogenic nonsyncopal collapse and PNES likely represent similar disorders that differ primarily by clinical semiologies and referral patterns.

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