Letter to the Editor Reply to ‘‘Psychiatric burden in psychogenic nonepileptic seizures: The tip of the iceberg?” Dear Editor, We appreciate the points that have been raised by Garg et al. as they provide a constructive critical view to our article [1] recently published in Epilepsy & Behavior. Though Garg et al. raised their concerns about overlooking the suicidal risk among the sample in our study, it was not our primary research purpose. Thereis a methodological difference between the study by Grag et al. which, in contrast to ours, included a control group of healthy individuals. In a recent article that enrolled 193 patients with epilepsy, it was concluded that suicidal risk was in- dependently correlated to the comorbid depressive disorder; on the other hand, it didnot show correlation with factors related to the epileptic seizures [2]. In another study comparing suicidal ideation and risk among three groups including patients with epi- lepsy, patients with psychogenic nonepileptic seizures (sPNES) and patients with comorbid epilepsy and PNES, authors found no sta- tistical difference relevant to suicidality among the studied groups [3]. The same study confirmed that psychiatric comorbid condi- tions independently raise the suicidal risk among the three groups [3]. We do totally agree with Garg et al. on the importance of fur- ther understanding the association between epilepsy, PNES, and suicidality. Future researches addressing this topic should enroll a large sample size, and statistical analysis should be rather carried out in a multivariate analysis model to provide valid and reliable results in the presence of a wide range of confounding factors rel- evant to psychiatric comorbidities. A particular interest should address PNES specifically, with the aim to raise awareness about the increased risk of suicide in this diagnostic category compared to normal population (rather than patients with epilepsy). Itis clin- ically pertinent to take into consideration this hidden raised risk of harm-to-self in patients presenting to emergency departments with PNES [4]. Itis worthy pointing to a newly developed psychometric tool, the Anxiety, Abuse, and Somatization Questionnaire (AASQ), which was recently published, and represents a valid,reliable, and easy to administer psychometric tool to differentiate between epileptic seizures and PNES based on underlying psychiatric attributes. This screening tool is of a significant clinical screening purpose with a high predictive value (95%) [5]. In our study [1] we didnot enroll patients with refractory epi- lepsy to avoid overlap between both diagnoses. In a recently pub- lished systemic review and meta-analysis that included 122 studies, it was concluded that duality is common in practice [6]. Though, we do recommend to conduct future studies to assess psy- chiatric comorbidities and personality attributes in a large sample of patients with refractory epilepsy as they represent a clinical challenge to daily neurological practice. Declaration of Competing Interest The authors declare that they have no known competing finan- cial interests or personal relationships that could have appeared to influence the work reported in this paper. References [1] Rady A, Elfatatry A, Molokhia T, Radwan A. Psychiatric comorbidities in patients with psychogenic nonepileptic seizures. Epilepsy Behav 2021;118:107918. https://doi.org/10.1016/j.yebeh.2021.107918 . [2] Hecimovic H, Santos JM, Carter J, Attarian HP, Fessler AJ, Vahle V, et al. Depression but not seizure factors or quality of life predicts suicidality in epilepsy. Epilepsy Behav 2012;24(4):426–9. [3] Husari KS, Blackburn KM, Ding K, Roaten K, Hays R. Assessing recent suicidal ideation and behavior in the adult epilepsy monitoring unit. Epilepsy Behav 2019;94:100–3. [4] Dworetzky BA, Weisholtz DS, Perez DL, Baslet G. A clinically oriented perspective on psychogenic nonepileptic seizure-related emergencies. Clin EEG Neurosci 2015;46(1):26–33. [5] Trainor D, Foster E, Rychkova M, Lloyd M, Leong M, Wang AD, et al. Development and validation of a screening questionnaire for psychogenic nonepileptic seizures. Epilepsy Behav 2020;112:107482. https://doi.org/ 10.1016/j.yebeh.2020.107482 . [6] Kutlubaev MA, Xu Y, Hackett ML, Stone J. Dual diagnosis of epilepsy and psychogenic nonepileptic seizures: systematic review and meta-analysis of frequency, correlates, and outcomes. Epilepsy Behav 2018;89:70–8. Ahmed Rady a,⇑ Amr Elfatatry b Tarek Molokhia a Aya Radwan a a Department of Psychiatry, Alexandria University School of Medicine, Egypt b Department of Neurology, Alexandria University School of Medicine, Egypt ⇑ Corresponding author at: Department of Psychiatry, Alexandria University School of Medicine, 29 Nabi Daniel St, Alexandria 21131, Egypt. E-mail addresses: ahmed.rady@alexmed.edu.eg, dr_ahmed_ra- dy@yahoo.fr (A. Rady) Received 10 April 2021 Accepted 10 April 2021 Available online xxxx https://doi.org/10.1016/j.yebeh.2021.107999 1525-5050/Ó 2021 Elsevier Inc. All rights reserved. Epilepsy & Behavior xxx (xxxx) xxx Contents lists available at ScienceDirect Epilepsy & Behavior journal homepage: www.elsevier.com/locate/yebeh Please cite this article as: A. Rady, A. Elfatatry, T. Molokhia et al., Reply to ‘‘Psychiatric burden in psychogenic nonepileptic seizures: The tip of the iceberg?”, Epilepsy & Behavior, https://doi.org/10.1016/j.yebeh.2021.107999