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Millman LSM, Williams IA, Jungilligens J, Pick S. Neurocognitive performance in functional neurological disorder: A systematic review and meta-analysis. Eur J Neurol 2024:e16386. [PMID: 38953473 DOI: 10.1111/ene.16386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 04/10/2024] [Accepted: 05/30/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND AND PURPOSE Cognitive complaints are common in functional neurological disorder (FND), but it is unclear whether objective neurocognitive deficits are present. This systematic review summarized validated/standardized cognitive test performance in FND samples across cognitive domains. METHODS Embase, PsycInfo and MEDLINE were searched from inception to 15 May 2023, combining terms for FND and cognitive domains (e.g., attention, memory, executive functioning). Studies included a range of FND phenotypes (seizures, motor, cognitive disorder, mixed), compared to healthy or clinical controls. Risk of bias was assessed with the modified Newcastle-Ottawa Scale and a qualitative synthesis/narrative review of cognitive performance in FND was conducted. Test performance scores were extracted, and random effects meta-analyses were run where appropriate. This review was registered on PROSPERO, CRD42023423139. RESULTS Fifty-six studies including 2260 individuals with FND were eligible. Although evidence for some impairments emerged across domains of executive functioning, attention, memory and psychomotor/processing speed, this was inconsistent across studies and FND phenotypes. Common confounds included group differences in demographics, medication and intellectual functioning. Only 24% of studies objectively assessed performance validity. Meta-analyses revealed higher scores on tests of naming (g = 0.67, 95% confidence interval [CI] 0.50, 0.84) and long-term memory (g = 0.43, 95% CI 0.13, 0.74) in functional seizures versus epilepsy, but no significant differences in working (g = -0.08, 95% CI -0.44, 0.29) or immediate (g = 0.25, 95% CI -0.02, 0.53) memory and cognitive flexibility (g = -0.01, 95% CI -0.29, 0.28). CONCLUSIONS There is mixed evidence for objective cognitive deficits in FND. Future research should control for confounds, include tests of performance validity, and assess relationships between objective and subjective neurocognitive functioning.
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Affiliation(s)
- L S Merritt Millman
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Isobel A Williams
- Psychology in Healthcare, Newcastle Upon Tyne Hospitals NHS Foundation Trust and the Translational and Clinical Research Institute, Newcastle University, Callaghan, UK
| | - Johannes Jungilligens
- Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, Bochum, Germany
| | - Susannah Pick
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Akhmedullin R, Kyrgyzbay G, Kimadiev D, Utebekov Z. New-onset psychogenic nonepileptic seizures after intracranial neurosurgery: A meta-analysis. Seizure 2024; 119:12-16. [PMID: 38761671 DOI: 10.1016/j.seizure.2024.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/23/2024] [Accepted: 04/24/2024] [Indexed: 05/20/2024] Open
Abstract
BACKGROUND The epidemiology of psychogenic non-epileptic seizures (PNES) is still unclear. Although approximately 14 million people need neurosurgical care annually, there is a dearth of thorough analysis on PNES occurrence following surgery. This study seeks to estimate the proportion of newly diagnosed PNES. METHODS We conducted a literature search of the PubMed, Ovid, CINAHL, and Cochrane Library databases up to December 2023. We identified studies using an observational design on the occurrence of PNES in patients who underwent intracranial surgery, and confirmed diagnosis using video-EEG. Estimates are reported as proportions using random effects models. We reported both 95 % CIs and prediction intervals (PI). We assessed the risk of bias and identified the pooled odds ratio (OR) for mutually exclusive groups. The heterogeneity was investigated using the I² statistic and significance determined using Cochran's Q-test. Post-hoc Egger's regression test, and several sensitivity analyses were performed. This study was registered in PROSPERO (CRD42023488611). RESULTS Of the 1766 unique studies identified, 86 were selected for full-text review. Eight studies (n = 3,699) were eligible for inclusion. Studies, spanning from 1995 to 2017, primarily focused on epilepsy surgeries. The pooled proportion was 3 % (95 % CI 2 %-5 %; 95 % PI 0 %-11 %). Temporal resections indicated twofold increase of PNES comparing to either resections (OR 2.05, 95 %CI 0.81-5.19). The risk of bias assessment indicated satisfactory quality for included studies, and heterogeneity in estimates was mainly explained by publication year of studies and their rounded sample size. CONCLUSIONS Given the estimations, there is expected impact of intracranial procedures on functional seizures epidemiology. Further efforts need to understand the contribution of brain resections to PNES incidence.
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Affiliation(s)
- Ruslan Akhmedullin
- Department of Medicine, Nazarbayev University School of Medicine, Kazakhstan
| | - Gaziz Kyrgyzbay
- Epileptology Centre, RSE Medical Centre Hospital of the President's Affairs Administration of the Republic of Kazakhstan, Kazakhstan.
| | - Darkhan Kimadiev
- Epileptology Centre, RSE Medical Centre Hospital of the President's Affairs Administration of the Republic of Kazakhstan, Kazakhstan
| | - Zhasulan Utebekov
- Epileptology Centre, RSE Medical Centre Hospital of the President's Affairs Administration of the Republic of Kazakhstan, Kazakhstan
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Vilyte G, Butler J, Ives-Deliperi V, Pretorius C. Medical and psychiatric comorbidities, somatic and cognitive symptoms, injuries and medical procedure history in patients with functional seizures from a public and a private hospital. Seizure 2024; 119:110-118. [PMID: 38851095 DOI: 10.1016/j.seizure.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 05/22/2024] [Accepted: 06/02/2024] [Indexed: 06/10/2024] Open
Abstract
PURPOSE Patients with functional seizures (FS), otherwise known as psychogenic non-epileptic seizures (PNES), from different socioeconomic backgrounds may differ, however, this remains a gap in current literature. Comorbidities can play both a precipitating and a perpetuating role in FS and are important in the planning of individual treatment for this condition. With this study, we aimed to describe and compare the reported medical and psychiatric comorbidities, injuries, somatic and cognitive symptoms, and medical procedures among patients with FS from a private and a public epilepsy monitoring unit (EMU) in Cape Town, South Africa. METHODS This is a retrospective case-control study. We collected data on the comorbidity and medical procedure histories, as well as symptoms and clinical signs reported by patients with video-electroencephalographically (video-EEG) confirmed FS without comorbid epilepsy. We used digital patient records starting with the earliest available digital record for each hospital until the year 2022. RESULTS A total of 305 patients from a private hospital and 67 patients from a public hospital were included in the study (N = 372). Public hospital patients had higher odds of reporting intellectual disability (aOR=15.58, 95% CI [1.80, 134.95]), circulatory system disease (aOR=2.63, 95% CI [1.02, 6.78]) and gait disturbance (aOR=8.52, 95% CI [1.96, 37.08]) compared to patients with FS attending the private hospital. They did, however, have fewer odds of reporting a history of an infectious or parasitic disease (aOR=0.31, 95% CI [0.11, 0.87]), respiratory system disease (aOR=0.23, 95% CI [0.06, 0.82]), or medical procedures in the past (aOR=0.32, 95% CI [0.16, 0.63]). CONCLUSION The study presents prevalence and comparative data on the medical profiles of patients with FS from different socioeconomic backgrounds which may inform future considerations in FS diagnosis and treatment.
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Affiliation(s)
- Gabriele Vilyte
- Department of Psychology, Faculty of Arts and Social Sciences, Stellenbosch University, Stellenbosch, South Africa.
| | - James Butler
- Division of Neurology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Victoria Ives-Deliperi
- Neuroscience Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Chrisma Pretorius
- Department of Psychology, Faculty of Arts and Social Sciences, Stellenbosch University, Stellenbosch, South Africa
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Goodman AM, Allendorfer JB, Taylor GC, Philip NS, Correia S, Blum AS, Curt LaFrance W, Szaflarski JP. Altered fronto-limbic-motor response to stress differs between functional and epileptic seizures in a TBI model. Epilepsy Behav 2024; 157:109877. [PMID: 38917672 DOI: 10.1016/j.yebeh.2024.109877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 05/30/2024] [Accepted: 06/02/2024] [Indexed: 06/27/2024]
Abstract
BACKGROUND AND OBJECTIVES Psychogenic nonepileptic (functional) seizures (FS) clinically resemble epileptic seizures (ES) with both often preceded by traumatic brain injury (TBI). FS and ES emergence and occurrence after TBI may be linked to aberrant neurobehavioral stress responses. We hypothesized that neural activity signatures in response to a psychosocial stress task would differ between TBI + FS and TBI + ES after controlling for TBI status (TBI-only). METHODS In the current multicenter study, participants were recruited prospectively from Rhode Island Hospital, Providence Rhode Island Veterans Administration Medical Center, and the University of Alabama at Birmingham Medical Center. Previous diagnoses of TBI, ES, and FS were verified based on data collected from participants, medical chart and record review, and, where indicated, results of EEG and/or video-EEG confirmatory diagnosis. TBI + ES (N = 21) and TBI + FS (N = 21) were matched for age and sex and combined into an initial group (TBI + SZ; N = 42). A TBI-only group (N = 42) was age and sex matched to the TBI with seizures (TBI + SZ) group. All participants completed an fMRI control math task (CMT) and stress math task (SMT) based on the Montreal Imaging Stress Task (MIST). RESULTS The TBI + SZ group (n = 24 female) did not differ in mood or anxiety severity compared to TBI-only group (n = 24 female). However, TBI + FS group (n = 11 female) reported greater severity of these symptoms compared to TBI + ES (n = 13 female). The linear mixed effects analysis identified neural responses that differed between TBI-only and TBI + SZ during math performance within the left premotor cortex and during auditory feedback within bilateral prefrontal cortex and hippocampus/amygdala regions. Additionally, neural responses differed between TBI + ES and TBI + FS during math performance within the right dorsolateral prefrontal cortex and bilateral amygdala during auditory feedback within the supplementary motor area. All tests comparing neural stress responses to psychiatric symptom severity failed to reach significance. DISCUSSION Controlling for TBI and seizure status, these findings implicate specific nodes within frontal, limbic, and sensorimotor networks that may maintain functional neurological symptoms and possibly distinguish FS from ES. This study provides class II evidence of differences in neural responses to psychosocial stress between ES and FS after TBI.
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Affiliation(s)
- Adam M Goodman
- Department of Neurology, University of Alabama at Birmingham (UAB), Birmingham, AL, USA; UAB Epilepsy Center, University of Alabama at Birmingham (UAB), Birmingham, AL, USA; Department of Psychology, University of Alabama at Birmingham (UAB), Birmingham, AL, USA.
| | - Jane B Allendorfer
- Department of Neurology, University of Alabama at Birmingham (UAB), Birmingham, AL, USA; UAB Epilepsy Center, University of Alabama at Birmingham (UAB), Birmingham, AL, USA; Department of Neurobiology, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Gabriella C Taylor
- Department of Neurology, University of Alabama at Birmingham (UAB), Birmingham, AL, USA; UAB Epilepsy Center, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Noah S Philip
- VA RR&D Center for Neurorestoration & Neurotechnology, VA Providence Healthcare System, Providence, RI, USA; Dept of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
| | - Stephen Correia
- VA RR&D Center for Neurorestoration & Neurotechnology, VA Providence Healthcare System, Providence, RI, USA
| | - Andrew S Blum
- Dept of Neurology, Alpert Medical School of Brown University, Providence, RI, USA
| | - W Curt LaFrance
- VA RR&D Center for Neurorestoration & Neurotechnology, VA Providence Healthcare System, Providence, RI, USA; Dept of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA; Dept of Neurology, Alpert Medical School of Brown University, Providence, RI, USA; Division of Neuropsychiatry and Behavioral Neurology, Rhode Island Hospital, Providence, RI, USA
| | - Jerzy P Szaflarski
- Department of Neurology, University of Alabama at Birmingham (UAB), Birmingham, AL, USA; UAB Epilepsy Center, University of Alabama at Birmingham (UAB), Birmingham, AL, USA; Department of Neurobiology, University of Alabama at Birmingham (UAB), Birmingham, AL, USA; Department of Neurosurgery, University of Alabama at Birmingham (UAB), Birmingham, AL, USA.
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Allendorfer JB, Nenert R, Goodman AM, Kakulamarri P, Correia S, Philip NS, LaFrance WC, Szaflarski JP. Brain network entropy, depression, and quality of life in people with traumatic brain injury and seizure disorders. Epilepsia Open 2024; 9:969-980. [PMID: 38507279 PMCID: PMC11145610 DOI: 10.1002/epi4.12926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 01/29/2024] [Accepted: 02/29/2024] [Indexed: 03/22/2024] Open
Abstract
OBJECTIVE Traumatic brain injury (TBI) often precedes the onset of epileptic (ES) or psychogenic nonepileptic seizures (PNES) with depression being a common comorbidity. The relationship between depression severity and quality of life (QOL) may be related to resting-state network complexity. We investigated these relationships in adults with TBI-only, TBI + ES, or TBI + PNES using Sample Entropy (SampEn), a measure of physiologic signals complexity. METHODS Adults with TBI-only (n = 60), TBI + ES (n = 21), or TBI + PNES (n = 56) completed the Beck Depression Inventory-II (BDI-II; depression symptom severity) and QOL in Epilepsy (QOLIE-31) assessments and underwent resting-state functional magnetic resonance imaging (rs-fMRI). SampEn values derived from six resting state functional networks were calculated per participant. Effects of group, network, and group-by-network-interactions for SampEn were investigated with a mixed-effects model. We examined relationships between BDI-II, QOL, and SampEn of each of the networks. RESULTS Groups did not differ in age, but there was a higher proportion of women with TBI + PNES (p = 0.040). TBI + ES and TBI-only groups did not differ in BDI-II or QOLIE-31 scores, while the TBI + PNES group scored worse on both measures. The fixed effects of the model revealed significant differences in SampEn values across networks (lower SampEn for the frontoparietal network compared to other networks). The likelihood ratio test for group-by-network-interactions was significant (p = 0.033). BDI-II was significantly negatively associated with Overall QOL scale scores in all groups, and significantly negatively associated with network SampEn values only in the TBI + PNES group. SIGNIFICANCE Only TBI + PNES had significant relationships between depression symptom severity and network SampEn values indicating that the resting state network complexity is related to depression severity in this group but not in TBI + ES or TBI-only. PLAIN LANGUAGE SUMMARY The brain has a complex network of internal connections. How well these connections work may be affected by TBI and seizures and may underlie mental health symptoms including depression; the worse the depression, the worse the quality of life. Our study compared brain organization in people with TBI, people with epilepsy after TBI, and people with nonepileptic seizures after TBI. Only people with nonepileptic seizures after TBI showed a relationship between how organized their brain connections were and how bad was their depression. We need to better understand these relationships to develop more impactful, effective treatments.
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Affiliation(s)
- Jane B. Allendorfer
- Department of NeurologyUniversity of Alabama at BirminghamBirminghamAlabamaUSA
- Department of NeurobiologyUniversity of Alabama at BirminghamBirminghamAlabamaUSA
- UAB Epilepsy CenterUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Rodolphe Nenert
- Department of NeurologyUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Adam M. Goodman
- Department of NeurologyUniversity of Alabama at BirminghamBirminghamAlabamaUSA
- UAB Epilepsy CenterUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Pranav Kakulamarri
- Department of NeurologyUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Stephen Correia
- VA RR&D Center for Neurorestoration and NeurotechnologyVA Providence Healthcare SystemProvidenceRhode IslandUSA
| | - Noah S. Philip
- VA RR&D Center for Neurorestoration and NeurotechnologyVA Providence Healthcare SystemProvidenceRhode IslandUSA
- Department of Psychiatry and Human BehaviorBrown UniversityProvidenceRhode IslandUSA
| | - W. Curt LaFrance
- VA RR&D Center for Neurorestoration and NeurotechnologyVA Providence Healthcare SystemProvidenceRhode IslandUSA
- Department of Psychiatry and Human BehaviorBrown UniversityProvidenceRhode IslandUSA
- Department of NeurologyBrown UniversityProvidenceRhode IslandUSA
- Division of Neuropsychiatry and Behavioral NeurologyRhode Island HospitalProvidenceRhode IslandUSA
| | - Jerzy P. Szaflarski
- Department of NeurologyUniversity of Alabama at BirminghamBirminghamAlabamaUSA
- Department of NeurobiologyUniversity of Alabama at BirminghamBirminghamAlabamaUSA
- UAB Epilepsy CenterUniversity of Alabama at BirminghamBirminghamAlabamaUSA
- Department of NeurosurgeryUniversity of Alabama at BirminghamBirminghamAlabamaUSA
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Boylan KA, Dworetzky BA, Baslet G, Polich G, Angela O’Neal M, Reinsberger C. Functional neurological disorder, physical activity and exercise: What we know and what we can learn from comorbid disorders. Epilepsy Behav Rep 2024; 27:100682. [PMID: 38953100 PMCID: PMC11215960 DOI: 10.1016/j.ebr.2024.100682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 05/29/2024] [Accepted: 05/29/2024] [Indexed: 07/03/2024] Open
Abstract
Functional neurological disorder (FND) is a common neurologic disorder associated with many comorbid symptoms including fatigue, pain, headache, and orthostasis. These concurrent symptoms lead patients to accumulate multiple diagnoses comorbid with FND, including fibromyalgia, chronic fatigue syndrome, postural orthostatic tachycardia syndrome, persistent post-concussive symptoms, and chronic pain. The role of physical activity and exercise has not been evaluated in FND populations, though has been studied in certain comorbid conditions. In this traditional narrative literature review, we highlight some existing literature on physical activity in FND, then look to comorbid disorders to highlight the therapeutic potential of physical activity. We then consider abnormalities in the autonomic nervous system (ANS) as a potential pathophysiological explanation for symptoms in FND and comorbid disorders and postulate how physical activity and exercise may provide benefit via autonomic regulation.
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Affiliation(s)
- Kelly A. Boylan
- Division of Epilepsy and Neurology, Brigham and Women’s Hospital, Boston, MA, United States
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - Barbara A. Dworetzky
- Division of Epilepsy and Neurology, Brigham and Women’s Hospital, Boston, MA, United States
| | - Gaston Baslet
- Department of Psychiatry, Brigham and Women’s Hospital, Boston, MA, United States
| | - Ginger Polich
- Department of Physical Medicine and Rehabilitation, Mass General Brigham, Boston, MA, United States
| | - M. Angela O’Neal
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, United States
| | - Claus Reinsberger
- Division of Sports Neurology and Neurosciences, Mass General Brigham Boston, MA, United States
- Institute of Sports Medicine, Paderborn University, Warburger Str. 100, 33098 Paderborn, Germany
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Polich G, Baslet G, O'Neal MA, Gupta R, Raynor LG. Functional Neurological Disorder Presenting After Concussion: A Retrospective Case Series. J Neuropsychiatry Clin Neurosci 2024:appineuropsych20230154. [PMID: 38720622 DOI: 10.1176/appi.neuropsych.20230154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Abstract
OBJECTIVE Although a majority of individuals recover from a concussion within weeks of the index injury, a substantial minority of patients report persistent postconcussion symptoms. Some of these symptoms may reflect a diagnosis of functional neurological disorder (FND). The authors evaluated the relationship between persistent postconcussion symptoms and FND symptoms. METHODS In this retrospective chart review, the authors characterized demographic and clinical information from 50 patients with a confirmed diagnosis of FND whose functional neurological symptoms started after a concussion. RESULTS Patients who developed FND after a concussion had high rates of baseline risk factors for both persistent postconcussion symptoms and FND. After the concussive event, functional neurological symptoms presented abruptly or developed insidiously over time. Functional neurological symptoms ranged widely and included gait symptoms, seizures, speech and language symptoms, weakness, sensory symptoms, tremors, and vision and oculomotor symptoms. CONCLUSIONS Functional neurological symptoms can arise after a concussion. FND should be considered in the differential diagnosis of individuals presenting with neurological symptoms beginning after a concussion. By failing to recognize functional symptoms, clinicians may inadvertently reinforce negative health-related beliefs regarding a patient's injured brain.
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Affiliation(s)
- Ginger Polich
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston (Polich); Departments of Physical Medicine and Rehabilitation (Polich), Psychiatry (Baslet, Raynor), and Neurology (O'Neal), Brigham and Women's Hospital, Boston; Department of Psychiatry, Brigham and Women's Faulkner Hospital, Boston (Gupta); Department of Psychiatry, Naval Medical Center San Diego, San Diego (Raynor)
| | - Gaston Baslet
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston (Polich); Departments of Physical Medicine and Rehabilitation (Polich), Psychiatry (Baslet, Raynor), and Neurology (O'Neal), Brigham and Women's Hospital, Boston; Department of Psychiatry, Brigham and Women's Faulkner Hospital, Boston (Gupta); Department of Psychiatry, Naval Medical Center San Diego, San Diego (Raynor)
| | - Mary Angela O'Neal
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston (Polich); Departments of Physical Medicine and Rehabilitation (Polich), Psychiatry (Baslet, Raynor), and Neurology (O'Neal), Brigham and Women's Hospital, Boston; Department of Psychiatry, Brigham and Women's Faulkner Hospital, Boston (Gupta); Department of Psychiatry, Naval Medical Center San Diego, San Diego (Raynor)
| | - Rishab Gupta
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston (Polich); Departments of Physical Medicine and Rehabilitation (Polich), Psychiatry (Baslet, Raynor), and Neurology (O'Neal), Brigham and Women's Hospital, Boston; Department of Psychiatry, Brigham and Women's Faulkner Hospital, Boston (Gupta); Department of Psychiatry, Naval Medical Center San Diego, San Diego (Raynor)
| | - Lcdr Geoffrey Raynor
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston (Polich); Departments of Physical Medicine and Rehabilitation (Polich), Psychiatry (Baslet, Raynor), and Neurology (O'Neal), Brigham and Women's Hospital, Boston; Department of Psychiatry, Brigham and Women's Faulkner Hospital, Boston (Gupta); Department of Psychiatry, Naval Medical Center San Diego, San Diego (Raynor)
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Byington CG, Goodman AM, Allendorfer JB, Correia S, LaFrance WC, Szaflarski JP. Decreased uncinate fasciculus integrity in functional seizures following traumatic brain injury. Epilepsia 2024; 65:1060-1071. [PMID: 38294068 DOI: 10.1111/epi.17896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 02/01/2024]
Abstract
OBJECTIVE The uncinate fasciculus (UF) has been implicated previously in contributing to the pathophysiology of functional (nonepileptic) seizures (FS). FS are frequently preceded by adverse life events (ALEs) and present with comorbid psychiatric symptoms, yet neurobiological correlates of these factors remain unclear. To address this gap, using advanced diffusion magnetic resonance imaging (dMRI), UF tracts in a large cohort of patients with FS and pre-existing traumatic brain injury (TBI + FS) were compared to those in patients with TBI without FS (TBI-only). We hypothesized that dMRI measures in UF structural connectivity would reveal UF differences when controlling for TBI status. Partial correlation tests assessed the potential relationships with psychiatric symptom severity measures. METHODS Participants with TBI-only (N = 46) and TBI + FS (N = 55) completed a series of symptom questionnaires and MRI scanning. Deterministic tractography via diffusion spectrum imaging (DSI) was implemented in DSI studio (https://dsi-studio.labsolver.org) with q-space diffeomorphic reconstruction (QSDR), streamline production, and manual segmentation to assess bilateral UF integrity. Fractional anisotropy (FA), radial diffusivity (RD), streamline counts, and their respective asymmetry indices (AIs) served as estimates of white matter integrity. RESULTS Compared to TBI-only, TBI + FS participants demonstrated decreased left hemisphere FA and RD asymmetry index (AI) for UF tracts (both p < .05, false discovery rate [FDR] corrected). Additionally, TBI + FS reported higher symptom severity in depression, anxiety, and PTSD measures (all p < .01). Correlation tests comparing UF white matter integrity differences to psychiatric symptom severity failed to reach criteria for significance (all p > .05, FDR corrected). SIGNIFICANCE In a large, well-characterized sample, participants with FS had decreased white matter health after controlling for the history of TBI. Planned follow-up analysis found no evidence to suggest that UF connectivity measures are a feature of group differences in mood or anxiety comorbidities for FS. These findings suggest that frontolimbic structural connectivity may play a role in FS symptomology, after accounting for prior ALEs and comorbid psychopathology severity.
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Affiliation(s)
- Caroline G Byington
- Department of Neurology, UAB Epilepsy Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Adam M Goodman
- Department of Neurology, UAB Epilepsy Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jane B Allendorfer
- Department of Neurology, UAB Epilepsy Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Neurobiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Stephen Correia
- Departments of Psychiatry and Neurology, Veterans Affairs Providence Healthcare System, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - W Curt LaFrance
- Departments of Psychiatry and Neurology, Veterans Affairs Providence Healthcare System, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Jerzy P Szaflarski
- Department of Neurology, UAB Epilepsy Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Departments of Neurobiology and Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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9
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Van Patten R, Chan L, Tocco K, Mordecai K, Altalib H, Cotton E, Correia S, Gaston TE, Grayson LP, Martin A, Fry S, Goodman A, Allendorfer JB, Szaflarski J, LaFrance WC. Reduced Subjective Cognitive Concerns With Neurobehavioral Therapy in Functional Seizures and Traumatic Brain Injury. J Neuropsychiatry Clin Neurosci 2024; 36:197-205. [PMID: 38481168 DOI: 10.1176/appi.neuropsych.20230138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
OBJECTIVE Functional seizures are common among people with traumatic brain injury (TBI). Subjective cognitive concerns refer to a person's own perception of problems with cognitive functioning in everyday life. The authors investigated the presence and correlates of subjective cognitive concerns and the response to neurobehavioral therapy among adults with TBI and functional seizures (TBI+FS group). METHODS In this observational study, participants in the TBI+FS group (N=47) completed a 12-session neurobehavioral therapy protocol for seizures, while participants in the comparison group (TBI without seizures) (N=50) received usual treatment. Subjective cognitive concerns, objective cognition, mental health, and quality of life were assessed before and after treatment. Data collection occurred from 2018 to 2022. RESULTS Baseline subjective cognitive concerns were reported for 37 (79%) participants in the TBI+FS group and 20 (40%) participants in the comparison group. In a multivariable regression model in the TBI+FS group, baseline global mental health (β=-0.97) and obsessive-compulsive symptoms (β=-1.01) were associated with subjective cognitive concerns at baseline. The TBI+FS group had fewer subjective cognitive concerns after treatment (η2=0.09), whereas the TBI comparison group showed a nonsignificant increase in subjective cognitive concerns. CONCLUSIONS Subjective cognitive concerns are common among people with TBI and functional seizures and may be related to general mental health and obsessive-compulsive symptoms. Evidence-based neurobehavioral therapy for functional seizures is a reasonable treatment option to address such concerns in this population, although additional studies in culturally diverse samples are needed. In addition, people with functional seizures would likely benefit from rehabilitation specifically targeted toward cognitive functioning.
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Affiliation(s)
- Ryan Van Patten
- Center for Neurorestoration and Neurotechnology, Veterans Affairs (VA) Providence Health Care System, and Department of Psychiatry and Human Behavior, Brown University, Providence, R.I. (Van Patten, Chan, Tocco, LaFrance); Rhode Island Hospital, Providence (Tocco, LaFrance); VA Maryland Health Care System, Baltimore (Mordecai); VA Connecticut Health Care System and Department of Neurology, Yale University, New Haven (Altalib); Department of Psychiatry and Behavioral Sciences and Department of Neurology, Northwestern University Feinberg School of Medicine, Evanston, Ill. (Cotton); College of Public Health, University of Georgia, Athens (Correia); Department of Neurology, University of Alabama at Birmingham, Birmingham (Gaston, Grayson, Martin, Fry, Goodman, Allendorfer, Szaflarski)
| | - Lawrence Chan
- Center for Neurorestoration and Neurotechnology, Veterans Affairs (VA) Providence Health Care System, and Department of Psychiatry and Human Behavior, Brown University, Providence, R.I. (Van Patten, Chan, Tocco, LaFrance); Rhode Island Hospital, Providence (Tocco, LaFrance); VA Maryland Health Care System, Baltimore (Mordecai); VA Connecticut Health Care System and Department of Neurology, Yale University, New Haven (Altalib); Department of Psychiatry and Behavioral Sciences and Department of Neurology, Northwestern University Feinberg School of Medicine, Evanston, Ill. (Cotton); College of Public Health, University of Georgia, Athens (Correia); Department of Neurology, University of Alabama at Birmingham, Birmingham (Gaston, Grayson, Martin, Fry, Goodman, Allendorfer, Szaflarski)
| | - Krista Tocco
- Center for Neurorestoration and Neurotechnology, Veterans Affairs (VA) Providence Health Care System, and Department of Psychiatry and Human Behavior, Brown University, Providence, R.I. (Van Patten, Chan, Tocco, LaFrance); Rhode Island Hospital, Providence (Tocco, LaFrance); VA Maryland Health Care System, Baltimore (Mordecai); VA Connecticut Health Care System and Department of Neurology, Yale University, New Haven (Altalib); Department of Psychiatry and Behavioral Sciences and Department of Neurology, Northwestern University Feinberg School of Medicine, Evanston, Ill. (Cotton); College of Public Health, University of Georgia, Athens (Correia); Department of Neurology, University of Alabama at Birmingham, Birmingham (Gaston, Grayson, Martin, Fry, Goodman, Allendorfer, Szaflarski)
| | - Kristen Mordecai
- Center for Neurorestoration and Neurotechnology, Veterans Affairs (VA) Providence Health Care System, and Department of Psychiatry and Human Behavior, Brown University, Providence, R.I. (Van Patten, Chan, Tocco, LaFrance); Rhode Island Hospital, Providence (Tocco, LaFrance); VA Maryland Health Care System, Baltimore (Mordecai); VA Connecticut Health Care System and Department of Neurology, Yale University, New Haven (Altalib); Department of Psychiatry and Behavioral Sciences and Department of Neurology, Northwestern University Feinberg School of Medicine, Evanston, Ill. (Cotton); College of Public Health, University of Georgia, Athens (Correia); Department of Neurology, University of Alabama at Birmingham, Birmingham (Gaston, Grayson, Martin, Fry, Goodman, Allendorfer, Szaflarski)
| | - Hamada Altalib
- Center for Neurorestoration and Neurotechnology, Veterans Affairs (VA) Providence Health Care System, and Department of Psychiatry and Human Behavior, Brown University, Providence, R.I. (Van Patten, Chan, Tocco, LaFrance); Rhode Island Hospital, Providence (Tocco, LaFrance); VA Maryland Health Care System, Baltimore (Mordecai); VA Connecticut Health Care System and Department of Neurology, Yale University, New Haven (Altalib); Department of Psychiatry and Behavioral Sciences and Department of Neurology, Northwestern University Feinberg School of Medicine, Evanston, Ill. (Cotton); College of Public Health, University of Georgia, Athens (Correia); Department of Neurology, University of Alabama at Birmingham, Birmingham (Gaston, Grayson, Martin, Fry, Goodman, Allendorfer, Szaflarski)
| | - Erica Cotton
- Center for Neurorestoration and Neurotechnology, Veterans Affairs (VA) Providence Health Care System, and Department of Psychiatry and Human Behavior, Brown University, Providence, R.I. (Van Patten, Chan, Tocco, LaFrance); Rhode Island Hospital, Providence (Tocco, LaFrance); VA Maryland Health Care System, Baltimore (Mordecai); VA Connecticut Health Care System and Department of Neurology, Yale University, New Haven (Altalib); Department of Psychiatry and Behavioral Sciences and Department of Neurology, Northwestern University Feinberg School of Medicine, Evanston, Ill. (Cotton); College of Public Health, University of Georgia, Athens (Correia); Department of Neurology, University of Alabama at Birmingham, Birmingham (Gaston, Grayson, Martin, Fry, Goodman, Allendorfer, Szaflarski)
| | - Stephen Correia
- Center for Neurorestoration and Neurotechnology, Veterans Affairs (VA) Providence Health Care System, and Department of Psychiatry and Human Behavior, Brown University, Providence, R.I. (Van Patten, Chan, Tocco, LaFrance); Rhode Island Hospital, Providence (Tocco, LaFrance); VA Maryland Health Care System, Baltimore (Mordecai); VA Connecticut Health Care System and Department of Neurology, Yale University, New Haven (Altalib); Department of Psychiatry and Behavioral Sciences and Department of Neurology, Northwestern University Feinberg School of Medicine, Evanston, Ill. (Cotton); College of Public Health, University of Georgia, Athens (Correia); Department of Neurology, University of Alabama at Birmingham, Birmingham (Gaston, Grayson, Martin, Fry, Goodman, Allendorfer, Szaflarski)
| | - Tyler E Gaston
- Center for Neurorestoration and Neurotechnology, Veterans Affairs (VA) Providence Health Care System, and Department of Psychiatry and Human Behavior, Brown University, Providence, R.I. (Van Patten, Chan, Tocco, LaFrance); Rhode Island Hospital, Providence (Tocco, LaFrance); VA Maryland Health Care System, Baltimore (Mordecai); VA Connecticut Health Care System and Department of Neurology, Yale University, New Haven (Altalib); Department of Psychiatry and Behavioral Sciences and Department of Neurology, Northwestern University Feinberg School of Medicine, Evanston, Ill. (Cotton); College of Public Health, University of Georgia, Athens (Correia); Department of Neurology, University of Alabama at Birmingham, Birmingham (Gaston, Grayson, Martin, Fry, Goodman, Allendorfer, Szaflarski)
| | - Leslie P Grayson
- Center for Neurorestoration and Neurotechnology, Veterans Affairs (VA) Providence Health Care System, and Department of Psychiatry and Human Behavior, Brown University, Providence, R.I. (Van Patten, Chan, Tocco, LaFrance); Rhode Island Hospital, Providence (Tocco, LaFrance); VA Maryland Health Care System, Baltimore (Mordecai); VA Connecticut Health Care System and Department of Neurology, Yale University, New Haven (Altalib); Department of Psychiatry and Behavioral Sciences and Department of Neurology, Northwestern University Feinberg School of Medicine, Evanston, Ill. (Cotton); College of Public Health, University of Georgia, Athens (Correia); Department of Neurology, University of Alabama at Birmingham, Birmingham (Gaston, Grayson, Martin, Fry, Goodman, Allendorfer, Szaflarski)
| | - Amber Martin
- Center for Neurorestoration and Neurotechnology, Veterans Affairs (VA) Providence Health Care System, and Department of Psychiatry and Human Behavior, Brown University, Providence, R.I. (Van Patten, Chan, Tocco, LaFrance); Rhode Island Hospital, Providence (Tocco, LaFrance); VA Maryland Health Care System, Baltimore (Mordecai); VA Connecticut Health Care System and Department of Neurology, Yale University, New Haven (Altalib); Department of Psychiatry and Behavioral Sciences and Department of Neurology, Northwestern University Feinberg School of Medicine, Evanston, Ill. (Cotton); College of Public Health, University of Georgia, Athens (Correia); Department of Neurology, University of Alabama at Birmingham, Birmingham (Gaston, Grayson, Martin, Fry, Goodman, Allendorfer, Szaflarski)
| | - Samantha Fry
- Center for Neurorestoration and Neurotechnology, Veterans Affairs (VA) Providence Health Care System, and Department of Psychiatry and Human Behavior, Brown University, Providence, R.I. (Van Patten, Chan, Tocco, LaFrance); Rhode Island Hospital, Providence (Tocco, LaFrance); VA Maryland Health Care System, Baltimore (Mordecai); VA Connecticut Health Care System and Department of Neurology, Yale University, New Haven (Altalib); Department of Psychiatry and Behavioral Sciences and Department of Neurology, Northwestern University Feinberg School of Medicine, Evanston, Ill. (Cotton); College of Public Health, University of Georgia, Athens (Correia); Department of Neurology, University of Alabama at Birmingham, Birmingham (Gaston, Grayson, Martin, Fry, Goodman, Allendorfer, Szaflarski)
| | - Adam Goodman
- Center for Neurorestoration and Neurotechnology, Veterans Affairs (VA) Providence Health Care System, and Department of Psychiatry and Human Behavior, Brown University, Providence, R.I. (Van Patten, Chan, Tocco, LaFrance); Rhode Island Hospital, Providence (Tocco, LaFrance); VA Maryland Health Care System, Baltimore (Mordecai); VA Connecticut Health Care System and Department of Neurology, Yale University, New Haven (Altalib); Department of Psychiatry and Behavioral Sciences and Department of Neurology, Northwestern University Feinberg School of Medicine, Evanston, Ill. (Cotton); College of Public Health, University of Georgia, Athens (Correia); Department of Neurology, University of Alabama at Birmingham, Birmingham (Gaston, Grayson, Martin, Fry, Goodman, Allendorfer, Szaflarski)
| | - Jane B Allendorfer
- Center for Neurorestoration and Neurotechnology, Veterans Affairs (VA) Providence Health Care System, and Department of Psychiatry and Human Behavior, Brown University, Providence, R.I. (Van Patten, Chan, Tocco, LaFrance); Rhode Island Hospital, Providence (Tocco, LaFrance); VA Maryland Health Care System, Baltimore (Mordecai); VA Connecticut Health Care System and Department of Neurology, Yale University, New Haven (Altalib); Department of Psychiatry and Behavioral Sciences and Department of Neurology, Northwestern University Feinberg School of Medicine, Evanston, Ill. (Cotton); College of Public Health, University of Georgia, Athens (Correia); Department of Neurology, University of Alabama at Birmingham, Birmingham (Gaston, Grayson, Martin, Fry, Goodman, Allendorfer, Szaflarski)
| | - Jerzy Szaflarski
- Center for Neurorestoration and Neurotechnology, Veterans Affairs (VA) Providence Health Care System, and Department of Psychiatry and Human Behavior, Brown University, Providence, R.I. (Van Patten, Chan, Tocco, LaFrance); Rhode Island Hospital, Providence (Tocco, LaFrance); VA Maryland Health Care System, Baltimore (Mordecai); VA Connecticut Health Care System and Department of Neurology, Yale University, New Haven (Altalib); Department of Psychiatry and Behavioral Sciences and Department of Neurology, Northwestern University Feinberg School of Medicine, Evanston, Ill. (Cotton); College of Public Health, University of Georgia, Athens (Correia); Department of Neurology, University of Alabama at Birmingham, Birmingham (Gaston, Grayson, Martin, Fry, Goodman, Allendorfer, Szaflarski)
| | - W Curt LaFrance
- Center for Neurorestoration and Neurotechnology, Veterans Affairs (VA) Providence Health Care System, and Department of Psychiatry and Human Behavior, Brown University, Providence, R.I. (Van Patten, Chan, Tocco, LaFrance); Rhode Island Hospital, Providence (Tocco, LaFrance); VA Maryland Health Care System, Baltimore (Mordecai); VA Connecticut Health Care System and Department of Neurology, Yale University, New Haven (Altalib); Department of Psychiatry and Behavioral Sciences and Department of Neurology, Northwestern University Feinberg School of Medicine, Evanston, Ill. (Cotton); College of Public Health, University of Georgia, Athens (Correia); Department of Neurology, University of Alabama at Birmingham, Birmingham (Gaston, Grayson, Martin, Fry, Goodman, Allendorfer, Szaflarski)
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10
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Jungilligens J, Flohr MC, Lange M, Wellmer J, Popkirov S. The relationship of action, affect, and metacognition in functional seizures. J Clin Exp Neuropsychol 2023; 45:1003-1013. [PMID: 38007609 DOI: 10.1080/13803395.2023.2287778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 11/19/2023] [Indexed: 11/27/2023]
Abstract
INTRODUCTION Metacognition provides a lens through which individuals experience, interpret, and respond to their affective states and behavior; it might thus influence complex neuropsychiatric conditions such as functional seizures - events characterized by states of heightened affective arousal and the disinhibition of prepotent behavior. In this pilot study, we aimed to establish a better understanding of the role of metacognition in functional seizures and its relationship to affective arousal and behavioral disinhibition (i.e., problems in suppressing prepared behavior). We hypothesized that affective arousal is related to higher behavioral disinhibition as well as slower reaction times, that affect and action (performing vs. not performing a movement) are related to memory and metacognition, and that metacognition is related to illness characteristics. METHODS We used a combination of an emotional go/no-go and a metacognitive recognition task with affectively valenced and neutral images in 18 patients with functional seizures. We compared markers of behavioral inhibition as well as indices for memory and metacognitive performance between affective (vs. neutral) and action/go (vs. inhibition/no-go) conditions. RESULTS Contrary to our hypothesis, behavioral disinhibition was not different between conditions. However, we found slower reaction times for affectively valenced stimuli. Memory performance and metacognition were better for affectively valenced pictures and for pictures used in go trials (i.e., associated with action/performing the movement). Illness factors (illness duration, seizure frequency, levels of self-reported anxiety) were correlated with aspects of metacognition. CONCLUSIONS This pilot study offers first insights into alterations in metacognition related to action and affect in patients with functional seizures; specifically, that affectively valenced stimuli and active engagement are related to enhanced memory and metacognition. This relationship was also found with respect to illness factors. These results provide insight into potentially underlying pathomechanisms, although the lack of a control group limits evaluating the specificity of these findings.
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Affiliation(s)
- Johannes Jungilligens
- Behavioral Neurology Research Group, Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Marie-Christin Flohr
- Behavioral Neurology Research Group, Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
- Faculty of Psychology, Ruhr University Bochum, Bochum, Germany
| | - Miriam Lange
- Behavioral Neurology Research Group, Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
- Faculty of Psychology, Ruhr University Bochum, Bochum, Germany
| | - Jörg Wellmer
- Ruhr Epileptology, Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - Stoyan Popkirov
- Department of Neurology, University Hospital Essen, Essen, Germany
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11
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Van Patten R, Chan L, Tocco K, Mordecai K, Altalib H, Twamley EW, Gaston TE, Grayson LP, Martin A, Fry S, Goodman A, Allendorfer JB, Correia S, Szaflarski J, LaFrance WC. Improvements in Montreal Cognitive Assessment scores after neurobehavioral therapy in adults with functional (nonepileptic) seizures and traumatic brain injury. J Psychiatr Res 2023; 165:282-289. [PMID: 37549503 DOI: 10.1016/j.jpsychires.2023.07.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/18/2023] [Accepted: 07/28/2023] [Indexed: 08/09/2023]
Abstract
Cognitive functioning impacts clinical symptoms, treatment response, and quality of life in adults with functional/nonepileptic seizures (FS/NES), but no study to date examines effects of behavioral FS/NES treatment on cognition in these patients. We hypothesized that there would be a reduction in cognitive symptoms in participants with FS/NES and traumatic brain injury (TBI) following neurobehavioral therapy (NBT). We also hypothesized that select seizure-related, medication, subjective cognitive, and mental health symptoms would be negatively correlated with improvements in cognitive performance after NBT. Participants were 37 adults with TBI + FS/NES and 35 adults with TBI only, recruited from medical centers in the northeastern or southeastern U.S. TBI + FS/NES participants completed a 12 session NBT intervention, and TBI without seizures participants were not treated. All participants completed pre-post assessments of cognition (Montreal Cognitive Assessment [MoCA]) and baseline sociodemographic factors and mental health symptoms. Pre-post MoCA scores increased significantly in TBI + FS/NES participants (28/37 [75.7%] improved) but not in TBI comparisons (10/35 [28.6%] improved). Language, memory, and visuospatial/executive functions, but not attention, improved over time in the TBI + FS/NES group. Gains in cognition were concentrated in those TBI + FS/NES participants with likely baseline cognitive impairments (MoCA total score <26), and 9/17 of these participants moved from the "impaired" range at baseline (<26) to the "intact" range at endpoint (≥26). Lastly, participants taking fewer medications and reporting lower subjective cognitive difficulties at baseline showed larger pre-post MoCA total score improvements. Overall, results from this study suggest the potential for positive change in cognition in FS/NES and co-occurring TBI using evidence-based psychotherapy.
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Affiliation(s)
- Ryan Van Patten
- VA Providence Healthcare System, Providence, RI, USA; Warren Alpert Medical School of Brown University, Providence, RI, USA.
| | - Lawrence Chan
- VA Providence Healthcare System, Providence, RI, USA; Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Krista Tocco
- VA Providence Healthcare System, Providence, RI, USA; Rhode Island Hospital, Providence, RI, USA
| | | | | | - Elizabeth W Twamley
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System and UC San Diego, San Diego, CA, USA
| | - Tyler E Gaston
- University of Alabama Birmingham, Birmingham, AL, USA; Birmingham VA Medical Center, Birmingham, AL, USA
| | | | - Amber Martin
- University of Alabama Birmingham, Birmingham, AL, USA
| | - Samantha Fry
- University of Alabama Birmingham, Birmingham, AL, USA
| | - Adam Goodman
- University of Alabama Birmingham, Birmingham, AL, USA
| | | | | | | | - W Curt LaFrance
- VA Providence Healthcare System, Providence, RI, USA; Warren Alpert Medical School of Brown University, Providence, RI, USA; Rhode Island Hospital, Providence, RI, USA
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12
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Carlson CA. Psychogenic Nonepileptic Seizures-High Mortality Rate Is a 'Wake-Up Call'. J Pers Med 2023; 13:892. [PMID: 37373881 DOI: 10.3390/jpm13060892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 05/18/2023] [Accepted: 05/23/2023] [Indexed: 06/29/2023] Open
Abstract
Patients with epilepsy have an elevated mortality rate compared to the general population and now studies are showing a comparable death ratio in patients diagnosed with psychogenic nonepileptic seizures. The latter is a top differential diagnosis for epilepsy and the unexpected mortality rate in these patients underscores the importance of an accurate diagnosis. Experts have called for more studies to elucidate this finding but the explanation is already available, embedded in the existing data. To illustrate, a review of the diagnostic practice in epilepsy monitoring units, of the studies examining mortality in PNES and epilepsy patients, and of the general clinical literature on the two populations was conducted. The analysis reveals that the scalp EEG test result, which distinguishes a psychogenic from an epileptic seizure, is highly fallible; that the clinical profiles of the PNES and epilepsy patient populations are virtually identical; and that both are dying of natural and non-natural causes including sudden unexpected death associated with confirmed or suspected seizure activity. The recent data showing a similar mortality rate simply constitutes more confirmatory evidence that the PNES population consists largely of patients with drug-resistant scalp EEG-negative epileptic seizures. To reduce the morbidity and mortality in these patients, they must be given access to treatments for epilepsy.
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Affiliation(s)
- Catherine A Carlson
- Minnesota Judicial Branch Psychological Services Division, Minneapolis, MN 55487, USA
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13
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Goodman AM, Kakulamarri P, Nenert R, Allendorfer JB, Philip NS, Correia S, LaFrance WC, Szaflarski JP. Relationship between intrinsic network connectivity and psychiatric symptom severity in functional seizures. J Neurol Neurosurg Psychiatry 2023; 94:136-143. [PMID: 36302640 DOI: 10.1136/jnnp-2022-329838] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 10/11/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) may precipitate the onset of functional seizures (FSs). Many patients with FS report at least one prior TBI, and these patients typically present with more severe psychiatric comorbidities. TBI and psychopathology are linked to changes in neural network connectivity, but their combined effects on these networks and relationship to the effects of FS remain unclear. We hypothesised that resting-state functional connectivity (rsFC) would differ between patients with FS and TBI (FS+TBI) compared with TBI without FS (TBI only), with variability only partially explained by the presence of psychopathology. METHODS Patients with FS+TBI (n=52) and TBI only (n=54) were matched for age and sex. All participants completed psychiatric assessments prior to resting-state functional MRI at 3 T. Independent component analysis identified five canonical rsFC networks related to emotion and motor functions. RESULTS Five linear mixed-effects analyses identified clusters of connectivity coefficients that differed between groups within the posterior cingulate of the default mode network, insula and supramarginal gyrus of the executive control network and bilateral anterior cingulate of the salience network (all α=0.05, corrected). Cluster signal extractions revealed decreased contributions to each network for FS+TBI compared to TBI only. Planned secondary analyses demonstrated correlations between signal and severity of mood, anxiety, somatisation and global functioning symptoms. CONCLUSIONS These findings indicate the presence of aberrant connectivity in FS and extend the biopsychosocial network model by demonstrating that common aetiology is linked to both FS and comorbidities, but the overlap in affected networks varies by comorbid symptoms.
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Affiliation(s)
- Adam M Goodman
- Neurology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Pranav Kakulamarri
- Neurology, The University of Alabama at Birmingham, Birmingham, Alabama, USA.,Psychology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Rodolphe Nenert
- Neurology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jane B Allendorfer
- Neurology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Noah S Philip
- RR&D Center for Neurorestoration and Neurotechnology, VA Providence Healthcare System, Providence, Rhode Island, USA.,Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Stephen Correia
- RR&D Center for Neurorestoration and Neurotechnology, VA Providence Healthcare System, Providence, Rhode Island, USA.,Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - W Curt LaFrance
- RR&D Center for Neurorestoration and Neurotechnology, VA Providence Healthcare System, Providence, Rhode Island, USA.,Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Neurology, Alpert Medical School of Brown University, Providence, RI, USA.,Division of Neuropsychiatry and Behavioral Neurology, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Jerzy P Szaflarski
- Neurology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
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14
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Rauchman SH, Zubair A, Jacob B, Rauchman D, Pinkhasov A, Placantonakis DG, Reiss AB. Traumatic brain injury: Mechanisms, manifestations, and visual sequelae. Front Neurosci 2023; 17:1090672. [PMID: 36908792 PMCID: PMC9995859 DOI: 10.3389/fnins.2023.1090672] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 02/06/2023] [Indexed: 02/25/2023] Open
Abstract
Traumatic brain injury (TBI) results when external physical forces impact the head with sufficient intensity to cause damage to the brain. TBI can be mild, moderate, or severe and may have long-term consequences including visual difficulties, cognitive deficits, headache, pain, sleep disturbances, and post-traumatic epilepsy. Disruption of the normal functioning of the brain leads to a cascade of effects with molecular and anatomical changes, persistent neuronal hyperexcitation, neuroinflammation, and neuronal loss. Destructive processes that occur at the cellular and molecular level lead to inflammation, oxidative stress, calcium dysregulation, and apoptosis. Vascular damage, ischemia and loss of blood brain barrier integrity contribute to destruction of brain tissue. This review focuses on the cellular damage incited during TBI and the frequently life-altering lasting effects of this destruction on vision, cognition, balance, and sleep. The wide range of visual complaints associated with TBI are addressed and repair processes where there is potential for intervention and neuronal preservation are highlighted.
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Affiliation(s)
| | - Aarij Zubair
- NYU Long Island School of Medicine, Mineola, NY, United States
| | - Benna Jacob
- NYU Long Island School of Medicine, Mineola, NY, United States
| | - Danielle Rauchman
- Department of Neuroscience, University of California, Santa Barbara, Santa Barbara, CA, United States
| | - Aaron Pinkhasov
- NYU Long Island School of Medicine, Mineola, NY, United States
| | | | - Allison B Reiss
- NYU Long Island School of Medicine, Mineola, NY, United States
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15
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Jungilligens J, Paredes-Echeverri S, Popkirov S, Barrett LF, Perez DL. A new science of emotion: implications for functional neurological disorder. Brain 2022; 145:2648-2663. [PMID: 35653495 PMCID: PMC9905015 DOI: 10.1093/brain/awac204] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/28/2022] [Accepted: 05/20/2022] [Indexed: 01/11/2023] Open
Abstract
Functional neurological disorder reflects impairments in brain networks leading to distressing motor, sensory and/or cognitive symptoms that demonstrate positive clinical signs on examination incongruent with other conditions. A central issue in historical and contemporary formulations of functional neurological disorder has been the mechanistic and aetiological role of emotions. However, the debate has mostly omitted fundamental questions about the nature of emotions in the first place. In this perspective article, we first outline a set of relevant working principles of the brain (e.g. allostasis, predictive processing, interoception and affect), followed by a focused review of the theory of constructed emotion to introduce a new understanding of what emotions are. Building on this theoretical framework, we formulate how altered emotion category construction can be an integral component of the pathophysiology of functional neurological disorder and related functional somatic symptoms. In doing so, we address several themes for the functional neurological disorder field including: (i) how energy regulation and the process of emotion category construction relate to symptom generation, including revisiting alexithymia, 'panic attack without panic', dissociation, insecure attachment and the influential role of life experiences; (ii) re-interpret select neurobiological research findings in functional neurological disorder cohorts through the lens of the theory of constructed emotion to illustrate its potential mechanistic relevance; and (iii) discuss therapeutic implications. While we continue to support that functional neurological disorder is mechanistically and aetiologically heterogenous, consideration of how the theory of constructed emotion relates to the generation and maintenance of functional neurological and functional somatic symptoms offers an integrated viewpoint that cuts across neurology, psychiatry, psychology and cognitive-affective neuroscience.
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Affiliation(s)
- Johannes Jungilligens
- Correspondence to: Johannes Jungilligens University Hospital Knappschaftskrankenhaus Bochum Department of Neurology In der Schornau 23-25 44892 Bochum, Germany E-mail:
| | | | - Stoyan Popkirov
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
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16
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Szaflarski JP, Allendorfer JB, Goodman AM, Byington CG, Philip NS, Correia S, LaFrance WC. Diagnostic delay in functional seizures is associated with abnormal processing of facial emotions. Epilepsy Behav 2022; 131:108712. [PMID: 35526462 DOI: 10.1016/j.yebeh.2022.108712] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 04/10/2022] [Accepted: 04/16/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE In patients with functional seizures (FS), delay in diagnosis (DD) may negatively affect outcomes. Altered brain responses to emotional stimuli have been shown in adults with FS. We hypothesized that DD would be associated with differential fMRI activation in emotion processing circuits. METHODS Fifty-two adults (38 females) with video-EEG confirmed FS prospectively completed assessments related to symptoms of depression (BDI-II), anxiety (BAI), post-traumatic stress disorder (PCL-S), a measure of how their symptoms affect day-to-day life (GAF), and fMRI at 3T with emotional faces task (EFT). During fMRI, subjects indicated "male" or "female" via button press while implicitly processing happy, sad, fearful, and neutral faces. Functional magnetic resonance imaging (FMRI) response to each emotion was modeled and group analyses were performed in AFNI within pre-specified regions-of-interest involved in emotion processing. A median split (507 days) defined short- (s-DD) and long-delay diagnosis (l-DD) groups. Voxelwise regression analyses were also performed to examine linear relationship between DD and emotion processing. FMRI signal was extracted from clusters showing group differences and Spearman's correlations assessed relationships with symptom scores. RESULTS Groups did not differ in FS age of onset, sex distribution, years of education, TBI characteristics, EFT in-scanner or post-test performance, or scores on the GAF, BDI-II, BAI, and PCL-S measures. The s-DD group was younger than l-DD (mean age 32.6 vs. 40.1; p = 0.022) at the time of study participation. After correcting for age, compared to s-DD, the l-DD group showed greater fMRI activation to sad faces in the bilateral posterior cingulate cortex (PCC) and to neutral faces in the right anterior insula. Within-group linear regression revealed that with increasing DD, there was increased fMRI activation to sad faces in the PCC and to happy faces in the right anterior insula/inferior frontal gyrus (AI/IFG). There were positive correlations between PCC response to sad faces and BDI-II scores in the l-DD group (rho = 0.48, p = 0.012) and the combined sample (rho = 0.30, p = 0.029). Increased PCC activation to sad faces in those in the l-DD group was associated with worse symptoms of depression (i.e. higher BDI-II score). CONCLUSIONS Delay in FS diagnosis is associated with fMRI changes in PCC and AI/IFG. As part of the default mode network, PCC is implicated in mood control, self-referencing, and other emotion-relevant processes. In our study, PCC changes are linked to depression. Future studies should assess the effects of interventions on these abnormalities.
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Affiliation(s)
- Jerzy P Szaflarski
- Department of Neurology, University of Alabama at Birmingham (UAB), UAB Epilepsy Center, Birmingham, AL, USA.
| | - Jane B Allendorfer
- Department of Neurology, University of Alabama at Birmingham (UAB), UAB Epilepsy Center, Birmingham, AL, USA
| | - Adam M Goodman
- Department of Neurology, University of Alabama at Birmingham (UAB), UAB Epilepsy Center, Birmingham, AL, USA
| | - Caroline G Byington
- Department of Neurology, University of Alabama at Birmingham (UAB), UAB Epilepsy Center, Birmingham, AL, USA
| | - Noah S Philip
- VA RR&D Center for Neurorestoration & Neurotechnology, VA Providence Healthcare System, Providence, RI, USA; Dept of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
| | - Stephen Correia
- VA RR&D Center for Neurorestoration & Neurotechnology, VA Providence Healthcare System, Providence, RI, USA
| | - W Curt LaFrance
- VA RR&D Center for Neurorestoration & Neurotechnology, VA Providence Healthcare System, Providence, RI, USA; Dept of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
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17
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Functional seizures are associated with cerebrovascular disease and functional stroke is more common in patients with functional seizures than epileptic seizures. Epilepsy Behav 2022; 128:108582. [PMID: 35123242 PMCID: PMC8898282 DOI: 10.1016/j.yebeh.2022.108582] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/14/2022] [Accepted: 01/17/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE To characterize the relationship between functional seizures (FSe), cerebrovascular disease (CVD), and functional stroke. METHOD A retrospective case-control study of 189 patients at a single large tertiary medical center. We performed a manual chart review of medical records of patients with FSe or epileptic seizures (ES), who also had ICD code evidence of CVD. The clinical characteristics of FSe, ES, CVD, and functional stroke were recorded. Logistic regression and Welch's t-tests were used to evaluate the differences between the FSe and ES groups. RESULTS Cerebrovascular disease was confirmed in 58.7% and 87.6% of patients with FSe or ES through manual chart review. Stroke was significantly more common in patients with ES (76.29%) than FSe (43.48%) (p = 4.07 × 10-6). However, compared to nonepileptic controls FSe was associated with both CVD (p < 0.0019) and stroke (p < 6.62 × 10-10). Functional stroke was significantly more common in patients with FSe (39.13%) than patients with ES (4.12%) (p = 4.47 × 10-9). Compared to patients with ES, patients with FSe were younger (p = 0.00022), more likely to be female (p = 0.00040), and more likely to have comorbid mental health needs including anxiety (p = 1.06 × 10-6), PTSD or history of trauma (e.g., sexual abuse) (p = 1.06 × 10-13), and bipolar disorder (p = 0.0011). CONCLUSION Our results confirm the initial observation of increased CVD in patients with FSe and further suggest that patients with FSe may be predisposed to developing another functional neurological disorder (FND) (i.e., functional stroke). We speculate that this may be due to shared risk factors and pathophysiological processes that are common to various manifestations of FND.
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Goodman AM, Allendorfer JB, LaFrance WC, Szaflarski JP. Precentral gyrus and insula responses to stress vary with duration to diagnosis in functional seizures. Epilepsia 2022; 63:865-879. [PMID: 35112346 DOI: 10.1111/epi.17179] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 01/21/2022] [Accepted: 01/21/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVE This study was undertaken to determine whether undiagnosed illness duration (time between functional seizures [FS] onset and diagnosis) is linked to differences in neural response and functional connectivity during processing of stressful experiences. METHODS Forty-nine participants with traumatic brain injury preceding the onset of FS confirmed by video-electroencephalography were recruited prospectively. Participants completed psychiatric symptom assessments before undergoing functional magnetic resonance imaging (fMRI) with an acute psychosocial stress task. Linear mixed effects (LME) analyses identified significant interactions between the factors of group (early vs. delayed diagnosis) and time lag to diagnosis on neural responses to stressful math performance and auditory feedback (corrected α = .05). Functional connectivity analysis utilized clusters from initial LME analyses as seed regions to determine significant interactions between these factors on network functional connectivity. RESULTS Demographic and psychiatric symptom measures were similar between early (n = 25) and delayed (n = 24) groups. Responses to stressful math performance within the left anterior insula and functional connectivity between the anterior insula seed region and a precentral gyrus cluster were significantly negatively correlated with time lag to diagnosis for the early but not the delayed FS diagnosis group. There was no correlation between fMRI findings and psychiatric symptoms. SIGNIFICANCE This study indicates that aberrant left anterior insula activation and its functional connectivity to the precentral gyrus underlie differences in processing of stressful experiences in patients with delayed FS diagnosis. Follow-up comparisons suggest changes are associated with undiagnosed illness duration rather than psychiatric comorbidities and indicate a potential mechanistic association between neuropathophysiology, response to stressful experiences, and functional neuroanatomy in FS.
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Affiliation(s)
- Adam M Goodman
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - W Curt LaFrance
- Providence Veterans Affairs Medical Center, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
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19
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Ertan D, Aybek S, LaFrance WC, Kanemoto K, Tarrada A, Maillard L, El-Hage W, Hingray C. Functional (psychogenic non-epileptic/dissociative) seizures: why and how? J Neurol Neurosurg Psychiatry 2022; 93:144-157. [PMID: 34824146 DOI: 10.1136/jnnp-2021-326708] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 10/18/2021] [Indexed: 11/04/2022]
Abstract
Functional seizures (FS) known also as psychogenic non-epileptic seizures or dissociative seizures, present with ictal semiological manifestations, along with various comorbid neurological and psychological disorders. Terminology inconsistencies and discrepancies in nomenclatures of FS may reflect limitations in understanding the neuropsychiatric intricacies of this disorder. Psychological and neurobiological processes of FS are incompletely understood. Nevertheless, important advances have been made on underlying neuropsychopathophysiological mechanisms of FS. These advances provide valuable information about the underlying mechanisms of mind-body interactions. From this perspective, this narrative review summarises recent studies about aetiopathogenesis of FS at two levels: possible risk factors (why) and different aetiopathogenic models of FS (how). We divided possible risk factors for FS into three categories, namely neurobiological, psychological and cognitive risk factors. We also presented different models of FS based on psychological and neuroanatomical understanding, multilevel models and integrative understanding of FS. This work should help professionals to better understand current views on the multifactorial mechanisms involved in the development of FS. Shedding light on the different FS profiles in terms of aetiopathogenesis will help guide how best to direct therapy, based on these different underlying mechanisms.
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Affiliation(s)
- Deniz Ertan
- CRAN,UMR7039, Centre de Recherche en Automatique de Nancy, Vandoeuvre les Nancy, Grand Est, France.,Unité de recherche clinique, Établissement Médical de La Teppe, Tain-l'Hermitage, France
| | - Selma Aybek
- Department of Clinical Neuroscience, Hopitaux Universitaires de Geneve, Geneva, Switzerland.,Department of Clinical Neuroscience, Inselspital Universitatsspital Bern Universitatsklinik fur Neurologie, Bern, Switzerland
| | - W Curt LaFrance
- Psychiatry and Neurology, Brown Medical School Rhode Island Hospital, Providence, Rhode Island, USA
| | - Kousuke Kanemoto
- Neuropsychiatric Department, Aichi Medical University, Nagakute, Aichi, Japan
| | - Alexis Tarrada
- Neurology Department, CHRU de Nancy, Nancy, Lorraine, France.,University Psychiatry Department, Centre Psychothérapique de Nancy, Laxou, Lorraine, France
| | - Louis Maillard
- CRAN,UMR7039, Centre de Recherche en Automatique de Nancy, Vandoeuvre les Nancy, Grand Est, France.,Neurology Department, CHRU de Nancy, Nancy, Lorraine, France
| | - Wissam El-Hage
- Department of Psychiatry, CHRU Tours, Tours, Centre, France
| | - Coraline Hingray
- Neurology Department, CHRU de Nancy, Nancy, Lorraine, France .,University Psychiatry Department, Centre Psychothérapique de Nancy, Laxou, Lorraine, France
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20
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Sharma AA, Goodman AM, Allendorfer JB, Philip NS, Correia S, LaFrance WC, Szaflarski JP. Regional brain atrophy and aberrant cortical folding relate to anxiety and depression in patients with traumatic brain injury and psychogenic nonepileptic seizures. Epilepsia 2022; 63:222-236. [PMID: 34730239 PMCID: PMC8742780 DOI: 10.1111/epi.17109] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/21/2021] [Accepted: 10/15/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Psychogenic nonepileptic seizures (PNES) are characterized by multifocal and global abnormalities in brain function and connectivity. Only a few studies have examined neuroanatomic correlates of PNES. Traumatic brain injury (TBI) is reported in 83% of patients with PNES and may be a key component of PNES pathophysiology. In this study, we included patients with TBI preceding the onset of PNES (TBI-PNES) and TBI without PNES (TBI-only) to identify neuromorphometric abnormalities associated with PNES. METHODS Adults diagnosed with TBI-PNES (n = 62) or TBI-only (n = 59) completed psychological questionnaires and underwent 3-T magnetic resonance imaging. Imaging data were analyzed by voxel- and surface-based morphometry. Voxelwise general linear models computed group differences in gray matter volume, cortical thickness, sulcal depth, fractal dimension (FDf), and gyrification. Statistical models were assessed with permutation-based testing at 5000 iterations with the Threshold-Free Cluster Enhancement toolbox. Logarithmically scaled p-values corrected for multiple comparisons using familywise error were considered significant at p < .05. Post hoc analyses determined the association between structural and psychological measures (p < .05). RESULTS TBI-PNES participants demonstrated atrophy of the left inferior frontal gyrus and the right cerebellum VIII. Relative to TBI-only, TBI-PNES participants had decreased FDf in the right superior parietal gyrus and decreased sulcal depth in the left insular cortex. Significant clusters were positively correlated with global assessment of functioning scores, and demonstrated varying negative associations with measures of anxiety, depression, somatization, and global severity of symptoms. SIGNIFICANCE The diagnosis of PNES was associated with brain atrophy and reduced cortical folding in regions implicated in emotion processing, regulation, and response inhibition. Cortical folds primarily develop during the third trimester of pregnancy and remain relatively constant throughout the remainder of one's life. Thus, the observed aberrations in FDf and sulcal depth could originate early in development. The convergence of environmental, developmental, and neurobiological factors may coalesce to reflect the neuropathophysiological substrate of PNES.
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Affiliation(s)
- Ayushe A. Sharma
- Department of Neurology, University of Alabama at Birmingham (UAB), Birmingham, AL, USA,Department of Neurobiology, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Adam M. Goodman
- Department of Neurology, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Jane B. Allendorfer
- Department of Neurology, University of Alabama at Birmingham (UAB), Birmingham, AL, USA,University of Alabama at Birmingham Epilepsy Center (UABEC), Birmingham, AL, USA
| | - Noah S. Philip
- VA RR&D Center for Neurorestoration and Neurotechnology, Providence VA & Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence RI, USA
| | - Stephen Correia
- VA RR&D Center for Neurorestoration and Neurotechnology, Providence VA & Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence RI, USA
| | - W. Curt LaFrance
- Department of Neurology, Brown University, Providence, RI, USA,VA RR&D Center for Neurorestoration and Neurotechnology, Providence VA & Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence RI, USA
| | - Jerzy P. Szaflarski
- Department of Neurology, University of Alabama at Birmingham (UAB), Birmingham, AL, USA,Department of Neurobiology, University of Alabama at Birmingham (UAB), Birmingham, AL, USA,Department of Neurosurgery, University of Alabama at Birmingham (UAB), Birmingham, AL, USA,University of Alabama at Birmingham Epilepsy Center (UABEC), Birmingham, AL, USA
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21
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Sharma AA, Szaflarski JP. Neuroinflammation as a pathophysiological factor in the development and maintenance of functional seizures: A hypothesis. Epilepsy Behav Rep 2021; 16:100496. [PMID: 34917920 PMCID: PMC8645839 DOI: 10.1016/j.ebr.2021.100496] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 10/15/2021] [Accepted: 10/21/2021] [Indexed: 12/29/2022] Open
Abstract
Early-life stress may be a priming neuroinflammatory factor for later development of FS. Secondary trauma has emerged as an important predisposing factor for FS initiation. We propose an explanatory, two-hit hypothesis for FS development. The proposed hypothesis is based on findings from neuroimaging and biomarker studies.
The neurobiological underpinnings of functional seizure (FS) development and maintenance represent an active research area. Recent work has focused on hardware (brain structure) and software (brain function and connectivity). However, understanding whether FS are an adaptive consequence of changes in brain structure, function, and/or connectivity is important for identifying a causative mechanism and for FS treatment and prevention. Further, investigation must also uncover what causes these structural and functional phenomena. Pioneering work in the field of psychoneuroimmunology has established a strong, consistent link between psychopathology, immune dysfunction, and brain structure/function. Based on this and recent FS biomarker findings, we propose a new etiologic model of FS pathophysiology. We hypothesize that early-life stressors cause neuroinflammatory and neuroendocrine changes that prime the brain for later FS development following secondary trauma (e.g., traumatic brain injury or psychological trauma). This framework coalesces existing knowledge regarding brain aberrations underlying FS and established neurobiological theories on the pathophysiology of underlying psychiatric disorders. We also propose brain temperature mapping as a way of indirectly visualizing neuroinflammation in patients with FS, particularly in emotion regulation, fear processing, and sensory-motor integration circuits. We offer a foundation on which future research can be built, with clear recommendations for future studies.
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Affiliation(s)
- Ayushe A Sharma
- Departments of Neurology, University of Alabama at Birmingham (UAB) Heersink School of Medicine, Birmingham, AL, USA.,UAB Epilepsy Center (UABEC), Birmingham, AL, USA
| | - Jerzy P Szaflarski
- Departments of Neurology, University of Alabama at Birmingham (UAB) Heersink School of Medicine, Birmingham, AL, USA.,Departments of Neurosurgery, and University of Alabama at Birmingham (UAB) Heersink School of Medicine, Birmingham, AL, USA.,Departments of Neurobiology, University of Alabama at Birmingham (UAB) Heersink School of Medicine, Birmingham, AL, USA.,UAB Epilepsy Center (UABEC), Birmingham, AL, USA
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22
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Picon EL, Perez DL, Burke MJ, Debert CT, Iverson GL, Panenka WJ, Silverberg ND. Unexpected symptoms after concussion: Potential links to functional neurological and somatic symptom disorders. J Psychosom Res 2021; 151:110661. [PMID: 34739941 DOI: 10.1016/j.jpsychores.2021.110661] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 09/24/2021] [Accepted: 10/26/2021] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Reporting of unexpected symptoms after concussion might, in some people, reflect a Functional Neurological Disorder (FND), Somatic Symptom Disorder (SSD), or exaggeration (feigning). This study aimed to determine whether reporting unexpected symptoms after concussion was associated with risk factors for FND/SSD, exaggeration, or both. METHOD Adults with persistent symptoms following concussion (N = 77; 61% women) rated the presence and severity of unexpected neurological symptoms (from the Screening for Somatoform Symptoms scale, e.g., paralysis) and somatic symptoms (from the Patient Health Questionnaire-15, e.g., stomach pain) that did not overlap with post-concussion symptom scale items. The independent variables were risk factors for exaggeration (neuropsychological performance validity test failure and personal injury litigation) and predisposing and perpetuating factors for developing FND and/or SSD (e.g., fear avoidance behavior). RESULTS When adjusting for all covariates, fear avoidance behavior was most strongly related to unexpected neurological symptoms (B = 0.11, 95% confidence interval = 0.05-0.18, p < .001), while current anxiety scores were most strongly related to unexpected somatic symptoms (B = 0.34, 95% confidence interval = 0.15-0.52, p < .001). Performance validity test failure and litigation were not significant predictors in either model. CONCLUSION Unexpected neurological and other somatic symptoms after concussion should not be dismissed as exaggeration. Psychological factors thought to perpetuate FND and SSD (e.g., fear avoidance behavior) may contribute to unexpected symptoms following concussion. More research is needed at the intersection of FND, SSD, and persistent post-concussive symptoms.
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Affiliation(s)
- Edwina L Picon
- Department of Psychology, University of British Columbia, Canada.
| | - David L Perez
- Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School; USA.
| | - Matthew J Burke
- Neuropsychiatry Program, Department of Psychiatry and Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto; Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, USA.
| | - Chantel T Debert
- Physical Medicine and Rehabilitation, Department of Clinical Neurosciences, Cumming School of Medicine, Hotchkiss Brain Institute, Alberta Children's Hospital Research Institute, University of Calgary, Canada.
| | - Grant L Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School; Spaulding Rehabilitation Hospital and Spaulding Research Institute; MassGeneral Hospital for Children Sports Concussion Program; & Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, USA.
| | - William J Panenka
- Department of Psychiatry, University of British Columbia; BC Mental Health and Substance Use Research Institute; BC Neuropsychiatry Program, Canada.
| | - Noah D Silverberg
- Department of Psychology, University of British Columbia Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Canada.
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Sawant NS, Umate MS. Dissociation, Stressors, and Coping in Patients of Psychogenic Nonepileptic Seizures. Indian J Psychol Med 2021; 43:479-484. [PMID: 35210675 PMCID: PMC8826194 DOI: 10.1177/0253717620956460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 08/17/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Psychogenic nonepileptic seizures (PNES) commonly present both to neurologists and psychiatrists and include a wide range of psychopathology. In order to understand the demographics, dissociative experiences, stressful life events, abuse, and coping in these patients, this study was undertaken. METHODS This was a cross-sectional, observational study. A total of 71 patients of PNES, referred from neurology, were assessed on Dissociative Experience Scale (DES), Scale For Trauma and Abuse, Presumptive Stressful Life Events Scale (PSLES), and Ways of Coping Questionnaire to ascertain the dissociative experiences; the prevalence of trauma, abuse, and stressful life events, and the coping mechanisms. RESULTS Females predominated, with the duration of PNES up to 2 years. The mean ± SD total DES score was 38.14 ± 14.1, indicating high dissociation. On the PSLES, for the stressful life events in the last one year, the mean score was 98.28 ± 87.1. Marital and family conflicts and death were reported more. History of childhood or adult physical and sexual abuse was less reported. History of head trauma was present in 13 patients. Emotion-focused coping was used more than problem-solving strategies. CONCLUSIONS Very few Indian studies have looked into these nuances. This study has helped in improving the understanding of the various risk factors of PNES and the coping strategies, and in sensitizing psychiatrists and neurologists to enquire into trauma and abuse of these patients.
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Affiliation(s)
- Neena S Sawant
- Dept. of Psychiatry, Seth GSMC & KEM Hospital, Mumbai, Maharashtra, India
| | - Maithili S Umate
- Dept. of Psychiatry, Grant Govt Medical College and Sir JJ Group of Hospitals, Mumbai, Maharashtra, India
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24
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Kustov GV, Zinchuk MS, Rider FK, Pashnin EV, Voinova NI, Avedisova AS, Guekht AB. [Psychogenic non-epileptic seizures]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:112-118. [PMID: 34481446 DOI: 10.17116/jnevro2021121081112] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The review provides epidemiological data and discuss the associated burden of non-epileptic seizures (PNES). Data on the prevalence, socio-demographic and clinical risk factors for the development of PNES are presented. The hypotheses of the PNES origin, including the contribution of psychological trauma, are considered. We also describe contemporary methods for differential diagnosis of epileptic seizures and PNES, including biomarkers and the use of diagnostic questionnaires. Special attention is given to the issues of the psychiatric comorbidity of PNES.
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Affiliation(s)
- G V Kustov
- Research and Clinical Center for Neuropsychiatry, Moscow, Russia
| | - M S Zinchuk
- Research and Clinical Center for Neuropsychiatry, Moscow, Russia
| | - F K Rider
- Research and Clinical Center for Neuropsychiatry, Moscow, Russia
| | - E V Pashnin
- Research and Clinical Center for Neuropsychiatry, Moscow, Russia
| | - N I Voinova
- Research and Clinical Center for Neuropsychiatry, Moscow, Russia
| | - A S Avedisova
- Research and Clinical Center for Neuropsychiatry, Moscow, Russia.,Federal Medical Research Centre for Psychiatry and Narcology, Moscow, Russia
| | - A B Guekht
- Research and Clinical Center for Neuropsychiatry, Moscow, Russia.,Pirogov Russian National Research Medical University, Moscow, Russia
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Ramamurthy S, Steven Brown L, Agostini M, Alick Lindstorm S, Dave H, Dieppa M, Ding K, Doyle A, Hays R, Harvey J, Perven G, Podkorytova I, Zepeda R, Das RR. Emergency department visits and readmissions in patients with psychogenic nonepileptic seizures (PNES) at a safety net hospital. Epilepsy Behav 2021; 122:108225. [PMID: 34352667 DOI: 10.1016/j.yebeh.2021.108225] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 07/15/2021] [Accepted: 07/16/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Readmissions and emergency department (ED) visits after an index admission have been become a quality measure due to associations with poor outcomes and increased healthcare costs. Readmissions and ED encounters have been studied in a variety of conditions including epilepsy but have not been examined exclusively in psychogenic nonepileptic seizures (PNES). In this study we examined the rate of readmissions and ED visits after a discharge from an Epilepsy Monitoring Unit (EMU) in a safety net hospital. We also determined patient phenotypes that are associated with readmissions. MATERIAL AND METHODS This was a retrospective chart review study with index admission being a discharge from an EMU between January 1 and December 31 2016 with follow-up until August 31 2020. We obtained data regarding demographics, medical and psychiatric history, and social history and treatment interventions. Our outcome variables were both all-cause and seizure-related hospital readmissions and ED visits 30 days following the index discharge and readmissions and ED visits 30 days thereafter. RESULTS Eleven of 122 patients (9%) had a non-seizure-related ED visit and/or hospitalization within 30 days of index discharge while 45 (37%) had re-contact with the health system thereafter for non-seizure-related issues. Seven of 122 patients (6%) had a seizure-related ED visit or hospital readmission within 30 days of discharge. Twenty-eight (23%) had a seizure-related readmission or ED visit after 30 days. Of these 28, 4 patients had been to an ER within 7 days of EMU discharge. The majority of subsequent encounters with the healthcare system were through the ED (n = 38) as compared to hospital (n = 10) and EMU readmissions (n = 9). On bivariate statistical analysis, charity or self-pay insurance status (p < 0.01), homelessness (p < 0.01), emergent EMU admission on index admission (p < 0.01), history of a psychiatric diagnosis (p < 0.02), and ED encounters 12 months prior to admission (p < 0.01) were significantly associated with readmission; however, on multivariate analysis only charity insurance status was a significant predictor. CONCLUSIONS In this study of readmissions and ED visits after discharge with a diagnosis of PNES at a safety net hospital, we found a seizure-related readmission rate of approximately 6% in 30 days and 23% thereafter with the majority of re-contact with the hospital being in the ED. On multi-variate analysis insurance status was a significant factor associated with readmission and ED visits. Our future research directions include examining referrals and treatment completion at the hospital's PNES clinic as well as creating a risk score to better identify patients with PNES at risk of readmission.
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Affiliation(s)
- Swetha Ramamurthy
- Department of Neurology, UT Southwestern Medical Center, 5323 Harry Hines Blvd E1.202, Dallas, TX 75390, United States.
| | - L Steven Brown
- Biostatistics, Parkland Health and Hospital System, 5200 Harry Hines Blvd, Dallas, TX 75235, United States.
| | - Mark Agostini
- Department of Neurology, UT Southwestern Medical Center, 5323 Harry Hines Blvd E1.202, Dallas, TX 75390, United States.
| | - Sasha Alick Lindstorm
- Department of Neurology, UT Southwestern Medical Center, 5323 Harry Hines Blvd E1.202, Dallas, TX 75390, United States.
| | - Hina Dave
- Department of Neurology, UT Southwestern Medical Center, 5323 Harry Hines Blvd E1.202, Dallas, TX 75390, United States.
| | - Marisara Dieppa
- Department of Neurology, UT Southwestern Medical Center, 5323 Harry Hines Blvd E1.202, Dallas, TX 75390, United States.
| | - Kan Ding
- Department of Neurology, UT Southwestern Medical Center, 5323 Harry Hines Blvd E1.202, Dallas, TX 75390, United States.
| | - Alexander Doyle
- Department of Neurology, UT Southwestern Medical Center, 5323 Harry Hines Blvd E1.202, Dallas, TX 75390, United States.
| | - Ryan Hays
- Department of Neurology, UT Southwestern Medical Center, 5323 Harry Hines Blvd E1.202, Dallas, TX 75390, United States.
| | - Jay Harvey
- Department of Neurology, UT Southwestern Medical Center, 5323 Harry Hines Blvd E1.202, Dallas, TX 75390, United States.
| | - Ghazala Perven
- Department of Neurology, UT Southwestern Medical Center, 5323 Harry Hines Blvd E1.202, Dallas, TX 75390, United States.
| | - Irina Podkorytova
- Department of Neurology, UT Southwestern Medical Center, 5323 Harry Hines Blvd E1.202, Dallas, TX 75390, United States.
| | - Rodrigo Zepeda
- Department of Neurology, UT Southwestern Medical Center, 5323 Harry Hines Blvd E1.202, Dallas, TX 75390, United States.
| | - Rohit R Das
- Department of Neurology, UT Southwestern Medical Center, 5323 Harry Hines Blvd E1.202, Dallas, TX 75390, United States.
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Asadi-Pooya AA, Farazdaghi M. Is severe head injury associated with functional (psychogenic) seizures? Seizure 2021; 89:38-40. [PMID: 33979742 DOI: 10.1016/j.seizure.2021.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/03/2021] [Accepted: 04/22/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES The aim of the current study was to compare the frequency of significant head injuries in three groups of people with seizures [idiopathic generalized epilepsies (IGE) vs. temporal lobe epilepsy (TLE) vs. functional seizures (FS)]. METHODS This was a retrospective study. All patients with a diagnosis of IGE, TLE, or FS were recruited at the outpatient epilepsy clinic at Shiraz University of Medical Sciences, Shiraz, Iran, from 2008 until 2020. RESULTS One thousand and four hundred ninety-two patients were studied (559 patients with IGE, 646 people with TLE, and 287 persons with FS). Overall, 77 (5.2%) individuals of the studied people reported experiencing severe head injuries before the onset of their seizures [9 patients (1.6%) with IGE, 56 people (8.7%) with TLE, and 12 persons (4.2%) with FS; p = 0.0001]. Compared to people with IGE, the odds ratio of having a premorbid history of severe head injury in the FS group was 2.67 [95% Confidence Interval (CI): 1.11-6.40; p = 0.0280]. Compared to people with TLE, the odds ratio of having a premorbid history of severe head injury in the FS group was 0.46 (95% CI: 0.24-0.87; p = 0.0170). CONCLUSION Severe head injury is significantly associated with FS. However, since head injury is also a significant risk factor for focal epilepsies, it may be necessary to ascertain the diagnosis of post-traumatic seizures by obtaing a detailed clinical history and also by performing video-EEG monitoring in order to adopt an appropriate treatment strategy in these patients.
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Affiliation(s)
- Ali A Asadi-Pooya
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Jefferson Comprehensive Epilepsy Center, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Mohsen Farazdaghi
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Sojka P, Paredes-Echeverri S, Perez DL. Are Functional (Psychogenic Nonepileptic) Seizures the Sole Expression of Psychological Processes? Curr Top Behav Neurosci 2021; 55:329-351. [PMID: 33768494 DOI: 10.1007/7854_2021_225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
Functional [psychogenic nonepileptic/dissociative] seizures (FND-seiz) and related functional neurological disorder subtypes were of immense interest to early founders of modern-day neurology and psychiatry. Unfortunately, the divide that occurred between the both specialties throughout the mid-twentieth century placed FND-seiz at the borderland between the two disciplines. In the process, a false Cartesian dualism emerged that labeled psychiatric conditions as impairments of the mind and neurological conditions as disturbances in structural neuroanatomy. Excitingly, modern-day neuropsychiatric perspectives now consider neurologic and psychiatric conditions as disorders of both brain and mind. In this article, we aim to integrate neurologic and psychiatric perspectives in the conceptual framing of FND-seiz. In doing so, we explore emerging relationships between symptoms, neuropsychological constructs, brain networks, and neuroendocrine/autonomic biomarkers of disease. Evidence suggests that the neuropsychological constructs of emotion processing, attention, interoception, and self-agency are important in the pathophysiology of FND-seiz. Furthermore, FND-seiz is a multi-network brain disorder, with evidence supporting roles for disturbances within and across the salience, limbic, attentional, multimodal integration, and sensorimotor networks. Risk factors, including the magnitude of previously experienced adverse life events, relate to individual differences in network architecture and neuroendocrine profiles. The time has come to use an integrated neuropsychiatric approach that embraces the closely intertwined relationship between physical health and mental health to conceptualize FND-seiz and related functional neurological disorder subtypes.
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Affiliation(s)
- Petr Sojka
- Department of Psychiatry, University Hospital Brno, Brno, Czech Republic.
| | - Sara Paredes-Echeverri
- Functional Neurological Disorder Research Program, Cognitive Behavioral Neurology Divisions, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David L Perez
- Functional Neurological Disorder Research Program, Cognitive Behavioral Neurology and Neuropsychiatry Divisions, Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Perez DL, Nicholson TR, Asadi-Pooya AA, Bègue I, Butler M, Carson AJ, David AS, Deeley Q, Diez I, Edwards MJ, Espay AJ, Gelauff JM, Hallett M, Horovitz SG, Jungilligens J, Kanaan RAA, Tijssen MAJ, Kozlowska K, LaFaver K, LaFrance WC, Lidstone SC, Marapin RS, Maurer CW, Modirrousta M, Reinders AATS, Sojka P, Staab JP, Stone J, Szaflarski JP, Aybek S. Neuroimaging in Functional Neurological Disorder: State of the Field and Research Agenda. Neuroimage Clin 2021; 30:102623. [PMID: 34215138 PMCID: PMC8111317 DOI: 10.1016/j.nicl.2021.102623] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 03/03/2021] [Indexed: 02/06/2023]
Abstract
Functional neurological disorder (FND) was of great interest to early clinical neuroscience leaders. During the 20th century, neurology and psychiatry grew apart - leaving FND a borderland condition. Fortunately, a renaissance has occurred in the last two decades, fostered by increased recognition that FND is prevalent and diagnosed using "rule-in" examination signs. The parallel use of scientific tools to bridge brain structure - function relationships has helped refine an integrated biopsychosocial framework through which to conceptualize FND. In particular, a growing number of quality neuroimaging studies using a variety of methodologies have shed light on the emerging pathophysiology of FND. This renewed scientific interest has occurred in parallel with enhanced interdisciplinary collaborations, as illustrated by new care models combining psychological and physical therapies and the creation of a new multidisciplinary FND society supporting knowledge dissemination in the field. Within this context, this article summarizes the output of the first International FND Neuroimaging Workgroup meeting, held virtually, on June 17th, 2020 to appraise the state of neuroimaging research in the field and to catalyze large-scale collaborations. We first briefly summarize neural circuit models of FND, and then detail the research approaches used to date in FND within core content areas: cohort characterization; control group considerations; task-based functional neuroimaging; resting-state networks; structural neuroimaging; biomarkers of symptom severity and risk of illness; and predictors of treatment response and prognosis. Lastly, we outline a neuroimaging-focused research agenda to elucidate the pathophysiology of FND and aid the development of novel biologically and psychologically-informed treatments.
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Affiliation(s)
- David L Perez
- Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Timothy R Nicholson
- Section of Cognitive Neuropsychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ali A Asadi-Pooya
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz Iran; Department of Neurology, Jefferson Comprehensive Epilepsy Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Indrit Bègue
- Division of Adult Psychiatry, Department of Psychiatry, University of Geneva, Geneva Switzerland; Service of Neurology Department of Clinical Neuroscience, University of Geneva, Geneva, Switzerland
| | - Matthew Butler
- Section of Cognitive Neuropsychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Alan J Carson
- Centre for Clinical Brain Sciences, The University of Edinburgh, EH16 4SB, UK
| | - Anthony S David
- Institute of Mental Health, University College London, London, UK
| | - Quinton Deeley
- South London and Maudsley NHS Foundation Trust, London UK Institute of Psychiatry Psychology and Neuroscience, King's College London, London, UK
| | - Ibai Diez
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mark J Edwards
- Neurosciences Research Centre, St George's University of London, London, UK
| | - Alberto J Espay
- James J. and Joan A. Gardner Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH, USA
| | - Jeannette M Gelauff
- Department of Neurology, Amsterdam UMC, Vrije Universiteit Amsterdam, de Boelelaan 1117, Amsterdam, Netherlands
| | - Mark Hallett
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Silvina G Horovitz
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Johannes Jungilligens
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Germany
| | - Richard A A Kanaan
- Department of Psychiatry, University of Melbourne, Austin Health Heidelberg, Australia
| | - Marina A J Tijssen
- Expertise Center Movement Disorders Groningen, University Medical Center Groningen, Groningen, University of Groningen, The Netherlands
| | - Kasia Kozlowska
- The Children's Hospital at Westmead, Westmead Institute of Medical Research, University of Sydney Medical School, Sydney, NSW, Australia
| | - Kathrin LaFaver
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - W Curt LaFrance
- Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, RI, USA
| | - Sarah C Lidstone
- Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic, University Health Network and the University of Toronto, Toronto, Ontario, Canada
| | - Ramesh S Marapin
- Expertise Center Movement Disorders Groningen, University Medical Center Groningen, Groningen, University of Groningen, The Netherlands
| | - Carine W Maurer
- Department of Neurology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA
| | - Mandana Modirrousta
- Department of Psychiatry, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3T 2N2, Canada
| | - Antje A T S Reinders
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Petr Sojka
- Department of Psychiatry, University Hospital Brno, Czech Republic
| | - Jeffrey P Staab
- Departments of Psychiatry and Psychology and Otorhinolaryngology-Head and Neck Surgery, Mayo Clinic Rochester, MN, USA
| | - Jon Stone
- Centre for Clinical Brain Sciences, The University of Edinburgh, EH16 4SB, UK
| | - Jerzy P Szaflarski
- University of Alabama at Birmingham Epilepsy Center, Department of Neurology, University of Alabama at Birmingham Birmingham, AL, USA
| | - Selma Aybek
- Neurology Department, Psychosomatic Medicine Unit, Bern University Hospital Inselspital, University of Bern, Bern, Switzerland
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Lenio S, Kerr WT, Watson M, Baker S, Bush C, Rajic A, Strom L. Validation of a predictive calculator to distinguish between patients presenting with dissociative versus epileptic seizures. Epilepsy Behav 2021; 116:107767. [PMID: 33545649 PMCID: PMC7951947 DOI: 10.1016/j.yebeh.2021.107767] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 12/29/2020] [Accepted: 12/30/2020] [Indexed: 01/30/2023]
Abstract
Dissociative seizures (also known as psychogenic nonepileptic seizures) are a common functional neurological disorder that can be difficult to distinguish from epileptic seizures. Patients with dissociative seizures provide diagnostic challenges, leading to delays in care, inappropriate care, and significant healthcare utilization and associated costs. The dissociative seizure likelihood score (DSLS) was developed by Kerr and colleagues at UCLA to distinguish between patients with epileptic seizures and dissociative seizures based on clinical and medication history as well as features of seizure semiology. We validated this calculator at the University of Colorado, which is a Level 4 National Association of Epilepsy Center. The DSLS accurately predicted the diagnosis in 81% of patients, despite local variability in the factors associated with epileptic versus dissociative seizures between the two populations. The DSLS can be a useful tool to assist with history taking and may have important utility for clinical decision making with these difficult to distinguish patient populations.
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Affiliation(s)
- Steven Lenio
- Department of Neurology, University of Colorado, Aurora, CO, USA.
| | - Wesley T Kerr
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Meagan Watson
- Department of Neurology, University of Colorado, Aurora, CO, USA
| | - Sarah Baker
- Department of Neurology, University of Colorado, Aurora, CO, USA
| | - Chad Bush
- Department of Neurology, University of Colorado, Aurora, CO, USA
| | - Alex Rajic
- Department of Neurology, University of Colorado, Aurora, CO, USA
| | - Laura Strom
- Department of Neurology, University of Colorado, Aurora, CO, USA
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Jungilligens J, Wellmer J, Kowoll A, Schlegel U, Axmacher N, Popkirov S. Microstructural integrity of affective neurocircuitry in patients with dissociative seizures is associated with emotional task performance, illness severity and trauma history. Seizure 2020; 84:91-98. [PMID: 33307466 DOI: 10.1016/j.seizure.2020.11.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/16/2020] [Accepted: 11/24/2020] [Indexed: 01/05/2023] Open
Abstract
PURPOSE To identify variations in white matter tract integrity related to behavioural control in response to emotional stimuli in patients with dissociative seizures (DS) and healthy controls (HC), and examine associations with illness characteristics and psychological trauma history. METHODS Twenty DS patients and 20 HC completed an emotional go/no-go task and questionnaires, and then underwent diffusion tensor imaging (DTI). RESULTS Patients had higher false alarm rates in response to negative emotional stimuli than HC. Task performance was correlated with self-reported difficulties in emotional awareness and regulation in everyday life. White matter analysis using tract-based spatial statistics revealed no between-group differences. In patients, fractional anisotropy (FA) in the right uncinate fasciculus, right and left fornix/stria terminalis, and corpus callosum were correlated with task performance. Similar results were found for radial diffusivity (RD), but not mean (MD) or axial diffusivity (AD). In HC, task performance was associated with AD and RD of fewer and smaller clusters in the corpus callosum and right fornix/stria terminalis, and none for FA or MD. Probabilistic tractography of thus identified tracts revealed that mean FA values were correlated with illness parameters (right fornix/stria terminalis with age at onset; posterior corpus callosum with seizure frequency), and psychological trauma history (traumatic experiences during adolescence with anterior corpus callosum). CONCLUSIONS Patients with DS show impaired behavioural control in response to emotional stimuli. Microstructural variations in task-related neurocircuitry show associations with illness parameters and psychological trauma history. Future studies using psychiatric controls should examine the specificity of these findings.
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Affiliation(s)
- Johannes Jungilligens
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany; Department of Neuropsychology, Institute of Cognitive Neuroscience, Faculty of Psychology, Ruhr University Bochum, Bochum, Germany.
| | - Jörg Wellmer
- Ruhr-Epileptology, Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - Annika Kowoll
- Institute for Diagnostic and Interventional Radiology, Neuroradiology and Nuclear Medicine, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - Uwe Schlegel
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - Nikolai Axmacher
- Department of Neuropsychology, Institute of Cognitive Neuroscience, Faculty of Psychology, Ruhr University Bochum, Bochum, Germany
| | - Stoyan Popkirov
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
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Jungilligens J, Wellmer J, Schlegel U, Kessler H, Axmacher N, Popkirov S. Impaired emotional and behavioural awareness and control in patients with dissociative seizures. Psychol Med 2020; 50:2731-2739. [PMID: 31625504 DOI: 10.1017/s0033291719002861] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Dissociative seizures (DS) are brief episodes of disrupted awareness and behavioural control that may resemble epileptic seizures. They are thought to arise in the context of impaired emotion processing and disinhibition. In a multi-perspective neuropsychological study, we aim to assess specific metacognitive traits and behavioural features involved in the affective and cognitive underpinnings of DS (emotion recognition and regulation, inhibition, interoception and sense of agency). METHODS Twenty prospectively recruited patients with video-EEG-confirmed DS and 20 healthy controls underwent comprehensive neuropsychological and psychiatric testing using validated questionnaires and structured interviews. Behavioural experimental data was obtained using a custom-made emotional go/no-go task, a digital Libet clock setup and a heartbeat counting paradigm. RESULTS Emotion recognition, as quantified in the emotional go/no-go task, was impaired in the DS group, and correlated with alexithymic traits. Behavioural inhibition, especially under conditions that would require emotion regulation, was also reduced in the emotional go/no-go task compared to controls and was correlated with neuropsychometric measures of emotion regulation. Data from the Libet clock experiment suggested impaired behavioural awareness in DS patients. No evidence of impaired interoceptive awareness was found in the heartbeat counting task. CONCLUSION These results represent comprehensive experimental evidence for alterations in emotional and behavioural awareness and control in patients with DS that yield empirical evidence for current psychopathological models. Our findings offer a more detailed understanding of key pathogenic factors in DS and provide theoretical support for recently developed cognitive-behavioural therapies for DS.
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Affiliation(s)
- Johannes Jungilligens
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
- Department of Neuropsychology, Faculty of Psychology, Institute of Cognitive Neuroscience, Ruhr University Bochum, Bochum, Germany
| | - Jörg Wellmer
- Ruhr-Epileptology, Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - Uwe Schlegel
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - Henrik Kessler
- Department of Psychosomatic Medicine and Psychotherapy, LWL-University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Nikolai Axmacher
- Department of Neuropsychology, Faculty of Psychology, Institute of Cognitive Neuroscience, Ruhr University Bochum, Bochum, Germany
| | - Stoyan Popkirov
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
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Balachandran N, Goodman AM, Allendorfer JB, Martin AN, Tocco K, Vogel V, LaFrance WC, Szaflarski JP. Relationship between neural responses to stress and mental health symptoms in psychogenic nonepileptic seizures after traumatic brain injury. Epilepsia 2020; 62:107-119. [PMID: 33238045 DOI: 10.1111/epi.16758] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 10/20/2020] [Accepted: 10/20/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To utilize traumatic brain injury (TBI) as a model for investigating functioning during acute stress experiences in psychogenic nonepileptic seizures (PNES) and to identify neural mechanisms underlying the link between changes in processing of stressful experiences and mental health symptoms in PNES. METHODS We recruited 94 participants: 50 with TBI only (TBI-only) and 44 with TBI and PNES (TBI + PNES). Participants completed mood (Beck Depression Inventory-II), anxiety (Beck Anxiety Inventory), and posttraumatic stress disorder (PTSD) symptom (PTSD Checklist-Specific Event) assessments before undergoing functional magnetic resonance imaging during an acute psychosocial stress task. Linear mixed-effects analyses identified clusters of significant interactions between group and neural responses to stressful math performance and stressful auditory feedback conditions within limbic brain regions (volume-corrected α = .05). Spearman rank correlation tests compared mean cluster signals to symptom assessments (false discovery rate-corrected α = .05). RESULTS Demographic and TBI-related measures were similar between groups; TBI + PNES demonstrated worse clinical symptom severity compared to TBI-only. Stressful math performance induced relatively greater reactivity within dorsomedial prefrontal cortex (PFC) and right hippocampal regions and relatively reduced reactivity within left hippocampal and dorsolateral PFC regions for TBI + PNES compared to TBI-only. Stressful auditory feedback induced relatively reduced reactivity within ventral PFC, cingulate, hippocampal, and amygdala regions for TBI + PNES compared to TBI-only. Changes in responses to stressful math within hippocampal and dorsal PFC regions were correlated with increased mood, anxiety, and PTSD symptom severity. SIGNIFICANCE Corticolimbic functions underlying processing of stressful experiences differ between patients with TBI + PNES and those with TBI-only. Relationships between these neural responses and symptom assessments suggest potential pathophysiologic mechanisms in PNES.
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Affiliation(s)
- Neha Balachandran
- Department of Neurology, UAB Epilepsy Center, University of Alabama at Birmingham, Birmingham, AL, USA.,Departments of Neurobiology and Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Adam M Goodman
- Department of Neurology, UAB Epilepsy Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jane B Allendorfer
- Department of Neurology, UAB Epilepsy Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Amber N Martin
- Department of Neurology, UAB Epilepsy Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Krista Tocco
- Providence Veterans Administration Medical Center, Rhode Island Hospital, Brown University, Providence, RI, USA
| | - Valerie Vogel
- Providence Veterans Administration Medical Center, Rhode Island Hospital, Brown University, Providence, RI, USA
| | - W Curt LaFrance
- Providence Veterans Administration Medical Center, Rhode Island Hospital, Brown University, Providence, RI, USA
| | - Jerzy P Szaflarski
- Department of Neurology, UAB Epilepsy Center, University of Alabama at Birmingham, Birmingham, AL, USA
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Fordington S, Manford M. A review of seizures and epilepsy following traumatic brain injury. J Neurol 2020; 267:3105-3111. [PMID: 32444981 PMCID: PMC7501105 DOI: 10.1007/s00415-020-09926-w] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 05/14/2020] [Indexed: 12/11/2022]
Abstract
Traumatic brain injury (TBI) is one of the commonest presentations to emergency departments and is associated with seizures carrying different significance at different stages following injury. We describe the epidemiology of early and late seizures following TBI, the significance of intracranial haemorrhage of different types in the risk of later epilepsy and the gaps in current understanding of risk factors contributing to the risk of post-traumatic epilepsy (PTE). The delay from injury to epilepsy presents an opportunity to understand the mechanisms underlying changes in the brain and how they may reveal potential targets for anti-epileptogenic therapy. We review existing treatments, both medical and surgical and conclude that current research is not tailored to differentiate between PTE and other forms of focal epilepsy. Finally, we review the increasing understanding of the frequency and significance of dissociative seizures following mild TBI.
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Affiliation(s)
| | - Mark Manford
- Department of Clinical Neuroscience, University of Cambridge, Cambridge, UK.
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Goodman AM, Allendorfer JB, Blum AS, Bolding MS, Correia S, Ver Hoef LW, Gaston TE, Grayson LE, Kraguljac NV, Lahti AC, Martin AN, Monroe WS, Philip NS, Tocco K, Vogel V, LaFrance WC, Szaflarski JP. White matter and neurite morphology differ in psychogenic nonepileptic seizures. Ann Clin Transl Neurol 2020; 7:1973-1984. [PMID: 32991786 PMCID: PMC7545605 DOI: 10.1002/acn3.51198] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/10/2020] [Accepted: 08/24/2020] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE To further evaluate the relationship between the clinical profiles and limbic and motor brain regions and their connecting pathways in psychogenic nonepileptic seizures (PNES). Neurite Orientation Dispersion and Density Indices (NODDI) multicompartment modeling was used to test the relationships between tissue alterations in patients with traumatic brain injury (TBI) and multiple psychiatric symptoms. METHODS The sample included participants with prior TBI (TBI; N = 37) but no PNES, and with TBI and PNES (TBI + PNES; N = 34). Participants completed 3T Siemens Prisma MRI high angular resolution imaging diffusion protocol. Statistical maps, including fractional anisotropy (FA), mean diffusivity (MD), neurite dispersion [orientation dispersion index (ODI)] and density [intracellular volume fraction (ICVF), and free water (i.e., isotropic) volume fraction (V-ISO)] signal intensity, were generated for each participant. Linear mixed-effects models identified clusters of between-group differences in indices of white matter changes. Pearson's r correlation tests assessed any relationship between signal intensity and psychiatric symptoms. RESULTS Compared to TBI, TBI + PNES revealed decreases in FA, ICVF, and V-ISO and increases in MD for clusters within cingulum bundle, uncinate fasciculus, fornix/stria terminalis, and corticospinal tract pathways (cluster threshold α = 0.05). Indices of white matter changes for these clusters correlated with depressive, anxiety, PTSD, psychoticism, and somatization symptom severity (FDR threshold α = 0.05). A follow-up within-group analysis revealed that these correlations failed to reach the criteria for significance in the TBI + PNES group alone. INTERPRETATION The results expand support for the hypothesis that alterations in pathways comprising the specific PNES network correspond to patient profiles. These findings implicate myelin-specific changes as possible contributors to PNES, thus introducing novel potential treatment targets.
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Affiliation(s)
- Adam M. Goodman
- Department of Neurology and the UAB Epilepsy CenterUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Jane B. Allendorfer
- Department of Neurology and the UAB Epilepsy CenterUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Andrew S. Blum
- Department of NeurologyRhode Island HospitalProvidenceRhode IslandUSA
- Brown UniversityProvidenceRhode IslandUSA
| | - Mark S. Bolding
- Department of RadiologyUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Stephen Correia
- Brown UniversityProvidenceRhode IslandUSA
- Department of Psychiatry and Human BehaviorAlpert Medical SchoolBrown UniversityRhode Island HospitalProvidenceRhode IslandUSA
- Center for Neurorestoration and NeurotechnologyProvidence VA Medical CenterProvidenceRhode IslandUSA
| | - Lawrence W. Ver Hoef
- Department of Neurology and the UAB Epilepsy CenterUniversity of Alabama at BirminghamBirminghamAlabamaUSA
- Birmingham VA Medical CenterBirminghamAlabamaUSA
| | - Tyler E. Gaston
- Department of Neurology and the UAB Epilepsy CenterUniversity of Alabama at BirminghamBirminghamAlabamaUSA
- Birmingham VA Medical CenterBirminghamAlabamaUSA
| | - Leslie E. Grayson
- Department of Neurology and the UAB Epilepsy CenterUniversity of Alabama at BirminghamBirminghamAlabamaUSA
- Birmingham VA Medical CenterBirminghamAlabamaUSA
- Children’s of AlabamaUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Nina V. Kraguljac
- Department of Psychiatry and Behavioral NeurobiologyUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Adrienne C. Lahti
- Department of Psychiatry and Behavioral NeurobiologyUniversity of Alabama at BirminghamBirminghamAlabamaUSA
- Departments of Neurobiology and NeurosurgeryUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Amber N. Martin
- Department of Neurology and the UAB Epilepsy CenterUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - William S. Monroe
- Department of Research ComputingUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Noah S. Philip
- Brown UniversityProvidenceRhode IslandUSA
- Center for Neurorestoration and NeurotechnologyProvidence VA Medical CenterProvidenceRhode IslandUSA
| | - Krista Tocco
- Department of NeurologyRhode Island HospitalProvidenceRhode IslandUSA
- Brown UniversityProvidenceRhode IslandUSA
- Center for Neurorestoration and NeurotechnologyProvidence VA Medical CenterProvidenceRhode IslandUSA
| | - Valerie Vogel
- Department of NeurologyRhode Island HospitalProvidenceRhode IslandUSA
- Brown UniversityProvidenceRhode IslandUSA
- Center for Neurorestoration and NeurotechnologyProvidence VA Medical CenterProvidenceRhode IslandUSA
| | - W. Curt LaFrance
- Center for Neurorestoration and NeurotechnologyProvidence VA Medical CenterProvidenceRhode IslandUSA
- Departments of Psychiatry and NeurologyRhode Island Hospital and Brown UniversityProvidenceRhode IslandUSA
| | - Jerzy P. Szaflarski
- Department of Neurology and the UAB Epilepsy CenterUniversity of Alabama at BirminghamBirminghamAlabamaUSA
- Children’s of AlabamaUniversity of Alabama at BirminghamBirminghamAlabamaUSA
- Departments of Neurobiology and NeurosurgeryUniversity of Alabama at BirminghamBirminghamAlabamaUSA
- Comprehensive Neuroscience CenterUniversity of Alabama at BirminghamBirminghamAlabamaUSA
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Cognitive Complaints in Motor Functional Neurological (Conversion) Disorders: A Focused Review and Clinical Perspective. Cogn Behav Neurol 2020; 33:77-89. [DOI: 10.1097/wnn.0000000000000218] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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36
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Ranford J, MacLean J, Alluri PR, Comeau O, Godena E, LaFrance WC, Hunt A, Stephen CD, Perez DL. Sensory Processing Difficulties in Functional Neurological Disorder: A Possible Predisposing Vulnerability? PSYCHOSOMATICS 2020; 61:343-352. [PMID: 32284249 DOI: 10.1016/j.psym.2020.02.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 02/07/2020] [Accepted: 02/10/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Functional neurological disorder (FND) is a prevalent neuropsychiatric condition characterized by sensorimotor difficulties. Patients with FND at times report that sensory experiences trigger and/or exacerbate their symptoms. Sensory processing difficulties are also commonly reported in other psychiatric disorders frequently comorbid in FND, suggesting that contextualizing sensory profiles in FND within a biopsychosocial model may be clinically relevant. OBJECTIVE To address this literature gap, we conducted a retrospective cohort study to examine sensory processing patterns and their relationship to other neuropsychiatric characteristics in patients with FND. METHODS A retrospective chart review design was used to investigate sensory processing patterns, established with the Adolescent/Adult Sensory Profile self-report questionnaire, in 44 patients with FND. Univariate analyses of cross-sectional screening tests followed by multivariate linear regression analyses were performed to identify clinical factors associated with sensory processing scores in the FND cohort. RESULTS Compared to normative data, most patients with FND reported sensory processing tendencies toward low registration, sensory sensitivity, and sensation avoiding. In multivariate regression analyses, the presence of a lifetime anxiety disorder independently predicted elevated low registration scores, while female gender and number of current medications independently predicted increased sensory sensitivity scores. In uncorrected univariate analyses only, individuals with psychogenic nonepileptic seizures were more likely to report increased sensory sensitivity and elevated low registration. CONCLUSION These preliminary findings support sensory processing difficulties in some patients with FND. Prospective and large sample size studies are needed to investigate relationships between sensory processing profiles and neuropsychiatric comorbidities, FND subtypes, and treatment outcomes.
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Affiliation(s)
- Jessica Ranford
- Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Occupational Therapy, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Julie MacLean
- Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Occupational Therapy, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Priyanka R Alluri
- Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Olivia Comeau
- Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Ellen Godena
- Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - W Curt LaFrance
- Neuropsychiatry and Behavioral Neurology Division, Departments of Psychiatry and Neurology, Rhode Island Hospital, Alpert Medical School, Brown University, Providence, RI
| | - Ann Hunt
- Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Movement Disorders Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Christopher D Stephen
- Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Movement Disorders Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - David L Perez
- Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Neuropsychiatry Unit, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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Rosales R, Dworetzky B, Baslet G. Cognitive-emotion processing in psychogenic nonepileptic seizures. Epilepsy Behav 2020; 102:106639. [PMID: 31731107 DOI: 10.1016/j.yebeh.2019.106639] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 09/22/2019] [Accepted: 09/26/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Previous literature suggests that cognitive-emotion processing contributes to the pathogenesis of psychogenic nonepileptic seizures (PNES). Characterization of alterations in cognitive-emotion processing in PNES could inform treatment. METHODS In this descriptive, cross-sectional study, 143 patients with video electroencephalogram (EEG) confirmed PNES were prospectively recruited. Patients completed self-report questionnaires on emotion perception (Trait Meta-Mood Scale (TMMS) attention and clarity subscales) and coping style (Affective Styles Questionnaire [ASQ] concealing, adjusting, and tolerating subscales) at the time of their initial evaluation for PNES. Demographic, clinical data and measures of psychopathology severity were also obtained. The TMMS and ASQ subscale scores were compared to available normative data and between PNES subgroups (based on presence of trauma-related factors). Correlation coefficients were obtained to evaluate associations between subscale scores and measures of psychopathology. RESULTS Mean scores on both TMMS subscales (attention 47.0 [SD 7.4] and clarity 37.5 [SD 8.0]) and the ASQ adjusting subscale (22.2 [SD 6.3]) were significantly lower than available normative data (p < .001). Among patients with PNES, those with a history of childhood abuse or active posttraumatic stress disorder (PTSD) were found to have significantly lower scores on emotion clarity, adjustment, and tolerance subscales than those without such histories (p < .05). Degree of clarity of emotions correlated negatively with severity of depression, anxiety, stress, and illness perception (p ≤ .001). Adjustment to and tolerance of emotional states correlated negatively with severity of depression and stress (p < .01). CONCLUSIONS Patients with PNES, especially those with active PTSD and childhood trauma, have lower clarity of their emotions and lower ability to adjust to emotional states than healthy individuals. These cognitive-emotion processing deficits are more pronounced in patients with more severe depression and reported stress. This study characterizes alterations in cognitive-emotion processing in PNES that are well-suited therapeutic targets and can therefore inform treatment interventions.
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Affiliation(s)
- Rachael Rosales
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA.
| | - Barbara Dworetzky
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA.
| | - Gaston Baslet
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA 02115, USA.
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