A recent systematic review has highlighted a growing area of complexity in mild traumatic brain injury (mTBI) claims: the emergence of psychogenic nonepileptic seizures (PNES). These seizure-like episodes, which mimic epilepsy but stem from psychological causes, are increasingly reported in claimants with a history of mTBI, raising important considerations for insurers.

Key findings

• Across seven studies, up to 83% of PNES patients had experienced minor head trauma, with psychiatric comorbidities such as depression and PTSD frequently present.
• In one study, 44.6% of PNES patients had a history of TBI, and 73% of those were mild cases.
• Veterans showed a particularly strong link between mTBI, psychological trauma, and PNES.

Implications for insurers

PNES are notoriously difficult to diagnose. The gold standard - video EEG monitoring - is not always accessible, and delays are common. This diagnostic ambiguity can complicate causation arguments and impact quantum if not carefully managed.

While the review suggests there is a correlation between PNES and mTBI, it also highlights a high prevalence of pre-existing psychiatric comorbidities, including mood disorders, PTSD, and history of trauma. These factors may contribute to symptom presentation but are not caused by the index accident. This raises important causation issues.

Tactical considerations for insurers

• Scrutinise psychiatric history: Early identification of psychological risk factors will be important
• Timeline: PNES symptoms often emerge weeks or months post-injury. A clear chronology can help assess the onset and, thus, causation.
• Expert evidence is key: Neurology and psychiatry input will be essential to assess if the symptoms are, in fact, PNES.

Conclusion

As highlighted by the authors of this review, correlation is not causation and as many studies are retrospective or cross-sectional, prospective studies are needed. Nevertheless, this review reinforces the need for a nuanced, evidence-led approach to mTBI and Functional Neurological Disorder claims involving PNES. While these cases may be less common, they present unique challenges in diagnosis, causation, and quantum. Insurers should be alert to the potential for PNES in head injury claims and ensure psychiatric and neurological evidence is robustly interrogated.