Factors associated with delay to video-EEG in dissociative seizures

Stigma in functional neurological disorder (FND) - A systematic review

OBJECTIVE

The purpose of this systematic review was to evaluate stigma and Functional Neurological Disorder (FND) regarding: 1) prevalence and associated factors, 2) the nature and context of stigma in FND, and 3) stigma-reduction interventions.

METHODS

We searched four relevant databases from inception to December 2023, using search terms relevant to FND and stigma themes. We employed the method of synthesis by "aggregation and configuration" to synthesise and analyse the data into emergent themes.

RESULTS

We found 127 studies, spanning 148 countries, involving 18,886 participants. Of these, 4889 were patients, 13,123 were healthcare professionals, and 526 were caregivers. Quantitatively, stigma has been mainly studied in patients with functional seizures, and was higher than patients with epilepsy in three studies. Stigma experienced by patients is associated with poorer quality of life and caregiver burden. We found 10 themes and 29 subthemes revealing stigma as a systemic process, with intrapersonal, interpersonal and structural aspects. Few studies examined the perspective of caregivers, the public or online community. We identified six anti-stigma interventions.

CONCLUSION

Stigma in FND is a layered process, and affects patient quality of life and provision of care. Stigma needs to be addressed from the top structures, at governmental level, so that appropriate care pathways can be created, giving patients with FND parity of esteem with other medical conditions.

Death of a loved one: A potential risk factor for onset of functional seizures

Functional seizures (FS) are a symptom of Functional Neurological Disorder (FND), the second most common neurological diagnosis made worldwide. Childhood trauma is associated with the development of FS, but more research is needed to truly understand the effects of trauma on FS onset. A sample of 256 responses by adults with FS to the Childhood Traumatic Events Scale were analyzed using a Cox proportional hazard model. When investigating each unique childhood traumatic exposure and its associated self-reported severity together, experiencing death of a loved one and experiencing violence were significantly associated with FS onset, suggesting reduced time from trauma exposure to first FS. Death of a loved one in childhood is often overlooked as an influential risk factor for future development of serious mental illnesses such as FS. In this study we show death of a loved one in childhood should be considered as an influential traumatic experience and recommend FND researchers examine its prevalence in patient histories and the potential effects on attachment-related processes and clinical treatment formulations. We recommend future studies incorporate loss of a loved one during childhood (before age 18) in both quantitative and qualitative assessments of persons with FND.

Maladaptive personality traits in patients with epilepsy and psychogenic non-epileptic seizures

OBJECTIVE

We aimed to evaluate the sociodemographic, clinical, and psychological characteristics associated with psychogenic non-epileptic seizures (PNES) in patients with epilepsy, with particular emphasis on the personality profile assessed from a dimensional perspective.

METHODS

The cohort study included 77 consecutive inpatients with active epilepsy aged 36-55 years; 52 (67.5%) were female. The presence of PNES was confirmed by video-EEG monitoring. All patients underwent the Mini-International Neuropsychiatric Interview to diagnose psychiatric disorders. All participants completed the Neurological Disorders Depression Inventory in Epilepsy, the Epilepsy Anxiety Survey Instrument - brief version, and the Personality Inventory for DSM-5 and ICD-11 Brief Form Plus Modified. Chi-square and Fisher's exact tests were used to compare categorical variables, and the Brunner-Munzel test was used for quantitative variables.

RESULTS

Twenty-four patients (31.2%) had both epilepsy and PNES. There were no significant differences in social, demographic or clinical characteristics, psychiatric diagnoses or depression severity. Compared to patients with epilepsy alone, patients with epilepsy and PNES had higher anxiety scores and more pronounced maladaptive personality traits such as disinhibition and psychoticism.

SIGNIFICANCE

The main novelty of our study is that using the recently proposed dimensional approach to personality disorders and an appropriate instrument we assessed all personality domains listed in two of the most widely used classifications of mental disorders (DSM-5 and ICD-11) in PWE with and without PNES. To our knowledge, this is the first study to demonstrate the association of the maladaptive traits of psychoticism and disinhibition with the development of PNES in PWE.

Elevated Mortality Rate in Patients With Functional Seizures After Diagnosis and Referral

Background and Objectives

To evaluate the standardized mortality ratio (SMR) of patients in the United States referred to a multidisciplinary clinic for treatment of functional seizures.

Methods

We identified patients who had or had not died based on automated retrospective review of electronic health records from a registry of patients referred to a single-center multidisciplinary functional seizures treatment clinic. We calculated an SMR by comparing the number of observed deaths with the expected number of deaths in an age-matched, sex-matched, and race-matched population within the same state, and year records were available.

Results

A total of 700 patients with functional seizures (mean age 37 years, 78% female) were followed up for 1,329 patient-years for a median of 15 months per patient (interquartile range 6-37 months). We observed 11 deaths, corresponding to a mortality rate of 8.2 per 1,000 patient-years and an SMR of 2.4 (95% confidence interval: 1.17-4.22). Five of 9 patients with identified circumstances around their death were in hospice care when they passed. None of the identified causes of death were related to seizures directly.

Discussion

These data provide further evidence of elevated mortality in functional seizures soon after diagnosis and referral to treatment. These data from the decentralized health care system of the United States build on the findings from other countries with large-scale health registries.

Using Verbally-Reported and Video-Observed Semiology to Identify Functional Seizures

Diagnosis of functional seizures, also known as psychogenic nonepileptic seizures, starts with a clinical interview and description of the seizures. A targeted approach to this evaluation can provide valuable information to gauge the likelihood of functional seizures as compared with other similar conditions including but not limited to epileptic seizures. This review focuses on the use of patient and witness descriptions and seizure videos to identify patients with probable functional seizures. Particular emphasis is given to recognizing the limitations of the available data and the influence of health-care provider expertise on diagnostic accuracy.

Ambulatory video EEG extended to 10 days: A retrospective review of a large database of ictal events

OBJECTIVE

This work aims to determine the ambulatory video electroencephalography monitoring (AVEM) duration and number of captured seizures required to resolve different clinical questions, using a retrospective review of ictal recordings.

METHODS

Patients who underwent home-based AVEM had event data analyzed retrospectively. Studies were grouped by clinical indication: differential diagnosis, seizure type classification, or treatment assessment. The proportion of studies where the conclusion was changed after the first seizure was determined, as was the AVEM duration needed for at least 99% of studies to reach a diagnostic conclusion.

RESULTS

The referring clinical question was not answered entirely by the first event in 29.6% (n = 227) of studies. Diagnostic and classification indications required a minimum of 7 days for at least 99% of studies to be answered, whilst treatment-assessment required at least 6 days.

CONCLUSIONS

At least 7 days of monitoring, and potentially multiple events, are required to adequately answer these clinical questions in at least 99% of patients. The widely applied 72 h or single event recording cut-offs may be inadequate to adequately answer these three indications in a substantial proportion of patients.

SIGNIFICANCE

Extended duration of monitoring and capturing multiple events should be considered when attempting to capture seizures on video-EEG.

Functional Seizure Clinics: A Proposed Financially Viable Solution to the Neurologist Supply and Demand Mismatch

Background and Objectives

Projections from recent studies suggest that by 2025, there will not be enough neurologists to meet the demand in 41 states. In this study, we investigate the financial impact and improved access to care for persons with epilepsy that is possible by implementing a multidisciplinary treatment clinic for persons with functional seizures (FS), previously referred to as psychogenic nonepileptic seizures, thus separating those patients out of an epilepsy clinic.

Methods

This observational retrospective study used real-time data of 156 patients referred to an FS clinic integrated into a tertiary care epilepsy center to simulate its effect on epilepsy division access and finances. Access was measured using simulations of the number of return patient visits (RPVs) and new patient visits (NPVs) of patients with FS to a dedicated epilepsy clinic, based on survey results inquiring about the standard of care without the FS clinic. Finances were simulated using the resultant access multiplied by respective wRVU and reimbursement per CPT code.

Results

Treatment of 156 patients with FS in a multidisciplinary FS clinic resulted in 343 newly opened NPVs, reimbursement of $102,000, and 1,200 wRVUs in our dedicated epilepsy clinic. There were 686 RPVs, $103,000 in reimbursement, and 1,320 wRVUs. Relative to the total number of NPVs with epilepsy clinic epileptologists, 343 NPVs represent a biennial 15.5% increase in available new patient visit slots.

Discussion

Our findings describe the financial viability of integrating a treatment clinic for persons with FS by directing them to FS-specialized treatment and thereby increasing access for patients with probable epilepsy to the dedicated epilepsy clinic. This study provides a potential solution to the national mismatch in the supply and demand of neurologists and an initial framework to use for those who wish to establish or integrate FS services in their institution.

Relationship between intrinsic network connectivity and psychiatric symptom severity in functional seizures

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.

Multidimensional psychopathological profile differences between patients with psychogenic nonepileptic seizures and epileptic seizure disorders

OBJECTIVE

Early differential diagnosis of psychogenic nonepileptic seizures (PNES) and epileptic seizures (ES) remains difficult. Self-reported psychopathology is often elevated in patients with PNES, although relatively few studies have examined multiple measures of psychopathology simultaneously. This study aimed to identify differences in multidimensional psychopathology profiles between PNES and ES patient groups.

METHOD

This was a retrospective case-control study involving patients admitted for video-EEG monitoring (VEM) over a two-year period. Clinicodemographic variables and psychometric measures of depression, anxiety, dissociation, childhood trauma, maladaptive personality traits, and cognition were recorded. Diagnosis of PNES or ES was determined by multidisciplinary assessment and consensus opinion. General linear mixed models (GLMMs) were used to investigate profile differences between diagnostic groups across psychometric measures. A general psychopathology factor was then computed using principal components analysis (PCA) and differences between groups in this 'p' factor were investigated.

RESULTS

261 patients (77 % with ES and 23 % with PNES) were included in the study. The PNES group endorsed greater symptomatology with GLMM demonstrating a significant main effect of group (η²_p = 0.05) and group by measure interaction (η²_p = 0.03). Simple effects analysis indicated that the PNES group had particularly elevated scores for childhood trauma (β = 0.78), dissociation (β = 0.70), and depression (β = 0.60). There was a high correlation between psychopathology measures, with a single p factor generated to explain 60 % variance in the psychometric scores. The p factor was elevated in the PNES group (β = 0.61). ROC curve analysis indicated that these psychometric measures had limited usefulness when considered individually (AUC range = 0.63-0.69).

CONCLUSION

Multidimensional psychopathological profile differences exist between patients with PNES and ES. Patients with PNES report more psychopathology overall, with particular elevations in childhood trauma, dissociation, and depression. Although not suitable to be used as a standalone screening tool to differentiate PNES and ES, understanding of these profiles at a construct level might help triage patients and guide further psychiatric examination and enquiry.

Clinical MRI morphological analysis of functional seizures compared to seizure-naïve and psychiatric controls

PURPOSE

Functional seizures (FS), also known as psychogenic nonepileptic seizures (PNES), are physical manifestations of acute or chronic psychological distress. Functional and structural neuroimaging have identified objective signs of this disorder. We evaluated whether magnetic resonance imaging (MRI) morphometry differed between patients with FS and clinically relevant comparison populations.

METHODS

Quality-screened clinical-grade MRIs were acquired from 666 patients from 2006 to 2020. Morphometric features were quantified with FreeSurfer v6. Mixed-effects linear regression compared the volume, thickness, and surface area within 201 regions-of-interest for 90 patients with FS, compared to seizure-naïve patients with depression (n = 243), anxiety (n = 68), and obsessive-compulsive disorder (OCD, n = 41), respectively, and to other seizure-naïve controls with similar quality MRIs, accounting for the influence of multiple confounds including depression and anxiety based on chart review. These comparison populations were obtained through review of clinical records plus research studies obtained on similar scanners.

RESULTS

After Bonferroni-Holm correction, patients with FS compared with seizure-naïve controls exhibited thinner bilateral superior temporal cortex (left 0.053 mm, p = 0.014; right 0.071 mm, p = 0.00006), thicker left lateral occipital cortex (0.052 mm, p = 0.0035), and greater left cerebellar white-matter volume (1085 mm³, p = 0.0065). These findings were not accounted for by lower MRI quality in patients with FS.

CONCLUSIONS

These results reinforce prior indications of structural neuroimaging correlates of FS and, in particular, distinguish brain morphology in FS from that in depression, anxiety, and OCD. Future work may entail comparisons with other psychiatric disorders including bipolar and schizophrenia, as well as exploration of brain structural heterogeneity within FS.

Diagnostic delay in functional seizures is associated with abnormal processing of facial emotions

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.

Precentral gyrus and insula responses to stress vary with duration to diagnosis in functional seizures

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.

Pitfalls using smartphones videos in diagnosing functional seizures

Expert review of seizure semiology looking at video recordings independent of EEG has been found to be useful for diagnosing functional seizures. Videos recorded outside the hospital containing "spells" have similar sensitivity to EEG when quality recordings are evaluated. Recently, smartphone videos were shown to serve as an adjunct to standard history and physical examination with similar diagnostic yields when compared to diagnostic video-EEG monitoring and reviewed by experts. However, caution must be exercised when interpreting videos of paroxysmal neurological events recorded by caregivers to ensure proper video quality is maintained and recorded event is representative. In this report, we present a case of initial identification of and event falsely suggesting functional seizures in a patient with epilepsy. The smartphone video of a "seizure" was recorded by his wife using her smartphone. Despite a quality recording and a history consistent with epilepsy, the smartphone video reviewed during evaluation in the clinic suggested a functional behavior in contrast to the history that suggested epilepsy manifest as convulsions. Instead of bilateral tonic-clonic motor movements, bizarre, intermittent non-clonic wild flinging movements and vocalization were identified on the smartphone video. The discordance between the clnical history and ideo prompted inpatient video-EEG monitoring. The same nonepileptic semiology was subsequently clarified to represent a physiological nonepileptic event. The event on the smartphone was typical of his agitated post-ictal state following an electroclinical tonic-clonic seizure. With treatment the seizures became controlled with antiseizure medication in long-term follow-up. We highlight the pitfalls using patient-recorded smartphone videos in patients diagnosed with epilepsy. Understanding the utility of smartphones as an adjunct to the clinical history will help in differentiating epileptic from functional seizures.

Title: Functional seizures across the adult lifespan: female sex, delay to diagnosis and disability

OBJECTIVE

The clinical characteristics of functional seizures may vary based on age-of-onset or age-of-presentation. Description of age-related differences has focused on three categories: pediatric, young-adult, and older-adult. We evaluated how factors continuously varied based on age-of-presentation across the adult lifespan.

METHODS

Based on cross-sectional data from 365 adult (18 to 88 years old) patients with documented diagnoses of functional seizures, we evaluated how the quantity and prevalence of specific ictal behaviors, historical factors, and comorbidities varied based on patient age-of-presentation using sequential weighted averages.

RESULTS

Four factors changed prominently with age-of-presentation: female predominance decreased at two inflection points - ages 35 and 62; the prevalence of work disability was higher until age-of-presentation 30 then plateaued at 80%; there was greater delay to diagnosis in older patients; and comorbidities was higher with age-of-presentation, starting from early adulthood. The proportion of patients who presented with functional seizures decreased after 50. Ictal behavior did not substantially vary with age-of-presentation.

CONCLUSION

The time from onset to diagnosis increased with age-of-presentation, which may be related to increased comorbidities and the misconception that FS do not start in older age. The female predominance decreased nonlinearly with age. By age 30, most patients' seizures already had substantial association with unemployment. These findings emphasize that patients can develop functional seizures at any age. The rapid development of disability relatively early in life, which then stays at a high prevalence rate, demonstrates the need for prompt referral for definitive diagnosis and treatment.

A minority of patients with functional seizures have abnormalities on neuroimaging

OBJECTIVE

Functional seizures often are managed incorrectly as a diagnosis of exclusion. However, a significant minority of patients with functional seizures may have abnormalities on neuroimaging that typically are associated with epilepsy, leading to diagnostic confusion. We evaluated the rate of epilepsy-associated findings on MRI, FDG-PET, and CT in patients with functional seizures.

METHODS

We studied radiologists' reports from neuroimages at our comprehensive epilepsy center from a consecutive series of patients diagnosed with functional seizures without comorbid epilepsy from 2006 to 2019. We summarized the MRI, FDG-PET, and CT results as follows: within normal limits, incidental findings, unrelated findings, non-specific abnormalities, post-operative study, epilepsy risk factors (ERF), borderline epilepsy-associated findings (EAF), and definitive EAF.

RESULTS

Of the 256 MRIs, 23% demonstrated ERF (5%), borderline EAF (8%), or definitive EAF (10%). The most common EAF was hippocampal sclerosis, with the majority of borderline EAF comprising hippocampal atrophy without T2 hyperintensity or vice versa. Of the 87 FDG-PETs, 26% demonstrated borderline EAF (17%) or definitive EAF (8%). Epilepsy-associated findings primarily included focal hypometabolism, especially of the temporal lobes, with borderline findings including subtle or questionable hypometabolism. Of the 51 CTs, only 2% had definitive EAF.

SIGNIFICANCE

This large case series provides further evidence that, while uncommon, EAF are seen in patients with functional seizures. A significant portion of these abnormal findings are borderline. The moderately high rate of these abnormalities may represent framing bias from the indication of the study being "seizures," the relative subtlety of EAF, or effects of antiseizure medications.