Not all seizures are epilepsy also applies to the military.

Commentary The diagnosis of psychogenic nonepileptic seizures (PNES) continues to be clinically challenging despite increasing evidence that delay in diagnosis is related to increased use/cost of medical services; poor quality of life; psychiatric comor-bidities, including posttraumatic stress disorder (PTSD) and depression; medically unexplained symptoms; family dysfunc-tion; unemployment; and poor 4-year and 10-year outcomes (1–5). Even though trauma, health-related anxiety, older age, unclear episodes, and nondiagnostic video EEG (vEEG) studies are common in males with PNES, physicians are more predis-posed to diagnose PNES in women rather than men [(6–-8]). Salinsky et al. 's findings demonstrate the delay in diagnosis of PNES in U.S. veterans with NES, who were mainly male and had experienced a traumatic event, head injury, during their deployment. Between 12 and 35 percent of the military deployed to fight in Iraq, Afghanistan, and the war-on-terror sustain mild traumatic brain injury (TBI) or concussion as a result of blast injuries (9). Military who experience mild TBI and return from deployment have increased PTSD (11–43.9%) (10, 11), depression (23%), and unexplained somatic symptoms (8–32%) (10), as well as pain (43.1%) (12). Yet, these same symptoms and TBI are also risk factors for PNES. Furthermore, one-fourth to one-third of PNES cases have TBI (13, 14), and one-third of TBI patients have PNES (15). The findings by Salinsky et al. of PNES in 25% (50/203) veterans and in 26% (189/726) civilians demonstrate that PNES is undiagnosed in both U.S. veterans and civilians. But mismanagement of the 50 PNES veterans compared with the 50 civilian PNES cases is evident from the five-fold longer time to PNES diagnosis, increased percentage of patients on at least one AED, four-fold longer cumulative time on AEDs, and larger number of prescription drugs. Additional evidence for inadequate medical care and increased use of medical services by the PNES veterans includes the significantly larger number of prescription drugs at admission and the number of patients on benzodiazepines and narcotics compared with the veterans with epilepsy. The finding of TBI in 58% of the PNES and in 51% of the epilepsy veterans but only in 26% of the PNES civilians underscores the importance of including PNES in the differential diagnosis of posttrau-matic epilepsy following TBI in the military. In addition to the unequal gender distribution in the military, significantly more males in the veteran than in the civilian PNES group might reflect the previously described difficulty diagnosing PNES in males …