Short-term outcome of psychogenic non-epileptic seizures after communication of the diagnosis

Psychoeducation interventions for people with non-epileptic seizures: A scoping review

BACKGROUND

Cognitive behavioural therapy (CBT) and other psychological approaches have a growing evidence base for treating Non-Epileptic Seizures (NES). However, communication about the diagnosis can be difficult for clinicians and is not always well received. It is thought that Psychoeducation about NES may improve engagement with treatment such as CBT and may contribute to reductions in the frequency of seizures and improvements in health related quality of life. However, psychoeducational components of treatment are often not evaluated in isolation meaning the specific benefit to patients is not currently well understood.

AIMS

The researchers aimed to examine the outcomes associated with psychoeducational interventions and the content of these programmes for NES.

METHOD

A scoping review was undertaken across four databases with seventeen eligible studies identified which were charted to analyse the data.

RESULTS

Findings revealed that components and modalities of interventions varied as did methods of evaluating the interventions. A number of different outcome measures were used and not all studies reported the significance of findings. Results across studies were inconsistent; however, there was a general trend across the studies of symptom reduction and improvement in mental health.

CONCLUSIONS

Findings illustrate that psychoeducation has potential benefits as an intervention in its own right. However, it may be best placed as a second step in a stepped care model, between initial diagnosis and further psychological treatment. The present literature needs replication and more robust studies for more certain conclusions to be drawn.

Added value of advanced workup after the first seizure: A 7-year cohort study

OBJECTIVE

This study was undertaken to establish whether advanced workup including long-term electroencephalography (LT-EEG) and brain magnetic resonance imaging (MRI) provides an additional yield for the diagnosis of new onset epilepsy (NOE) in patients presenting with a first seizure event (FSE).

METHODS

In this population-based study, all adult (≥16 years) patients presenting with FSE in the emergency department (ED) between March 1, 2010 and March 1, 2017 were assessed. Patients with obvious nonepileptic or acute symptomatic seizures were excluded. Routine EEG, LT-EEG, brain computed tomography (CT), and brain MRI were performed as part of the initial workup. These examinations' sensitivity and specificity were calculated on the basis of the final diagnosis after 2 years, along with the added value of advanced workup (MRI and LT-EEG) over routine workup (routine EEG and CT).

RESULTS

Of the 1010 patients presenting with FSE in the ED, a definite diagnosis of NOE was obtained for 501 patients (49.6%). Sensitivity of LT-EEG was higher than that of routine EEG (54.39% vs. 25.5%, p < .001). Similarly, sensitivity of MRI was higher than that of CT (67.98% vs. 54.72%, p = .009). Brain MRI showed epileptogenic lesions in an additional 32% compared to brain CT. If only MRI and LT-EEG were considered, five would have been incorrectly diagnosed as nonepileptic (5/100, 5%) compared to patients with routine EEG and MRI (25/100, 25%, p = .0001). In patients with all four examinations, advanced workup provided an overall additional yield of 50% compared to routine workup.

SIGNIFICANCE

Our results demonstrate the remarkable added value of the advanced workup launched already in the ED for the diagnosis of NOE versus nonepileptic causes of seizure mimickers. Our findings suggest the benefit of first-seizure tracks or even units with overnight EEG, similar to stroke units, activated upon admission in the ED.

Prospective multicenter cohort study of possible psychogenic nonepileptic seizure cases-Results at 1-year follow-up examinations

OBJECTIVE

The primary purpose of this prospective multicenter study was to examine clinical and demographic feature differences according to the diagnostic level of psychogenic nonepileptic seizures (PNES) and then clarify whether prognosis may also differ accordingly.

METHODS

Two hundred forty-two consecutive patients strongly suspected of having PNES attacks were invited to participate, of whom 52 did not consent or contact was lost. At the 1-year follow-up examination, PNES diagnosis was reconsidered in nine patients. In 96 patients, the diagnostic level remained the same (P-group), with that in 43 considered to be clinically established (CE-group) and in 42 documented (D-group). The Qolie-10 and NDDI-E questionnaires were examined at both the study entry and the follow-up examination.

RESULTS

Multiple regression analysis of quality of life (QoL) score (n = 173; R²  = 0.374; F = 7.349; P < 0.001) revealed NDDI-E score (t = -6.402; P < 0.001), age of PNES onset (t = -3.026; P = 0.003), and ethnic minority status (t = 3.068; P = 0.003) as significant contributors. At entry, the P-group showed the lowest PNES attack frequency (P < 0.000), the lowest rate of antiseizure, antidepressant, and antipsychotic medication (P < 0.000; P = 0.031; P = 0.013, respectively), and the lowest proportion of psychosis (P = 0.046). At follow-up, PNES attack frequency (P < 0.000), number of admittances to emergency room (P < 0.000), and scores for QoL (P < 0.000) as well as depression (P = 0.004) were found to be significantly improved together with other collateral indicators, such as rate of antiseizure medication prescription (P = 0.001) and psychiatric symptoms (P = 0.03). Multiple regression analysis of a sample limited to patients with intellectual disability (ID) (n = 44; R²  = 0.366; F = 4.493; P = 0.002) revealed continued psychotherapy at follow-up (t = 2.610, P = 0.013) and successful reduction in antiseizure medication (t = 2.868; P = 0.007) as positively related with improved QoL.

SIGNIFICANCE

Clinical and the socio-psychological constellation of possible, clinically established, and documented PNES were found to differ greatly. Unexpectedly, significant effects of the continuous psychotherapeutic intervention were confirmed in PNES patients with ID.

Improved understanding of non-epileptic seizures and reduced emergency health care usage following a single psychoeducational group for children and their parents

RATIONALE

The aim of this study was to evaluate the effectiveness of a three-hour psychoeducation group in improving understanding of non-epileptic seizures (NES), health outcomes and quality of life in young people with NES.

BACKGROUND

Multi-session psychoeducational groups for adults with NES have reported improved psychosocial functioning and reduced NES compared to those who do not receive psychoeducational interventions. To date there have been no studies in young people examining the effects of a single session of psychoeducation.

METHOD

15 young people with NES and their families attended a psychoeducation group within a specialist hospital following a multidisciplinary assessment. The group's effectiveness was evaluated in terms of perceptions of seizure controllability, seizure severity, the management of the condition and health-related quality of life measures.

RESULTS

A significant decrease in accident and emergency (A&E) visits and ambulance call outs was observed following the psychoeducation group. Young people additionally reported increased knowledge of NES and ability to cope with the condition which was maintained at 6-week follow-up. Significant reduction in NES occurrence or quality of life was not observed.

CONCLUSION

Significant reduction in A&E attendance and ambulance use was found following group psychoeducation and improvements in psychosocial functioning and knowledge about NES. Group psychoeducation has the potential to increase child and parental understanding of NES and reduce inappropriate healthcare usage.

Diagnosis and management of functional neurological disorder

Functional neurological disorder (FND), previously regarded as a diagnosis of exclusion, is now a rule-in diagnosis with available treatments. This represents a major step toward destigmatizing the disorder, which was often doubted and deemed untreatable. FND is prevalent, generally affecting young and middle aged adults, and can cause severe disability in some individuals. An early diagnosis, with subsequent access to evidence based rehabilitative and/or psychological treatments, can promote recovery-albeit not all patients respond to currently available treatments. This review presents the latest advances in the use of validated rule-in examination signs to guide diagnosis, and the range of therapeutic approaches available to care for patients with FND. The article focuses on the two most frequently identified subtypes of FND: motor (weakness and/or movement disorders) and seizure type symptoms. Twenty two studies on motor and 27 studies on seizure type symptoms report high specificities of clinical signs (64-100%), and individual signs are reviewed. Rehabilitative interventions (physical and occupational therapy) are treatments of choice for functional motor symptoms, while psychotherapy is an emerging evidence based treatment across FND subtypes. The literature to date highlights heterogeneity in responses to treatment, underscoring that more research is needed to individualize treatments and develop novel interventions.

Myths and truths about pediatric psychogenic nonepileptic seizures

Psychogenic nonepileptic seizures (PNES) is a neuropsychiatric condition that causes a transient alteration of consciousness and loss of self-control. PNES, which occur in vulnerable individuals who often have experienced trauma and are precipitated by overwhelming circumstances, are a body's expression of a distressed mind, a cry for help. PNES are misunderstood, mistreated, under-recognized, and underdiagnosed. The mindbody dichotomy, an artificial divide between physical and mental health and brain disorders into neurology and psychiatry, contributes to undue delays in the diagnosis and treatment of PNES. One of the major barriers in the effective diagnosis and treatment of PNES is the dissonance caused by different illness perceptions between patients and providers. While patients are bewildered by their experiences of disabling attacks beyond their control or comprehension, providers consider PNES trivial because they are not epileptic seizures and are caused by psychological stress. The belief that patients with PNES are feigning or controlling their symptoms leads to negative attitudes of healthcare providers, which in turn lead to a failure to provide the support and respect that patients with PNES so desperately need and deserve. A biopsychosocial perspective and better understanding of the neurobiology of PNES may help bridge this great divide between brain and behavior and improve our interaction with patients, thereby improving prognosis. Knowledge of dysregulated stress hormones, autonomic nervous system dysfunction, and altered brain connectivity in PNES will better prepare providers to communicate with patients how intangible emotional stressors could cause tangible involuntary movements and altered awareness.

Functional Neurologic Disorders: The Need for a Model of Care

Neurologists are commonly consulted for patients with a functional neurologic disorder. Best practices as to their diagnosis and treatment have been established, and multiple academic centers have programs in place for their treatment. However, given the number of patients suffering from this condition, a comprehensive model of care that can be broadly implemented needs to be developed and applied beyond specialized academic programs.

Report on a psychoeducational intervention for psychogenic non-epileptic seizures in Argentina

PURPOSE

To examine the effects of a three-session psychoeducational intervention on patients diagnosed with psychogenic non-epileptic seizures (PNES) in an Argentinian public hospital. It was hypothesized that patients would experience improvements in their understanding of PNES, illness perception and affective scores, but might not necessarily experience a significant change in post-traumatic and dissociative symptoms and in seizure frequency.

METHODS

This study included 12 patients (10 women, 2 men) who were invited to participate in a psychoeducational group after receiving a V-EEG confirmed diagnosis of PNES. The group consisted of 3 sessions lasting 2 h each. Pre and post measures included Psychoeducational Intervention Questionnaire, State-Trait Anxiety Inventory, Beck Depression Inventory-II, Brief Illness Perception Questionnaire, Posttraumatic Stress Disorder Diagnostic Scale 5, Dissociative Experiences Scale (DES-M).

RESULTS

This psychoeducational intervention produced results that were similar to interventions reported in US and European studies with regard to changes on psychological measures. Moreover, many patients also reported (on the final day of the intervention) a decrease in seizure frequency. All patients reported that participating in the intervention was a positive experience. Also, all but one patient referred that the participation in the group would have a positive impact on their quality of life.

CONCLUSIONS

Psychoeducational interventions appear to have had positive results in Argentinian patients with PNES. This is initial step in the design of empirically based psychoeducational/supportive initiatives for patients in South America.

[Pilot Data from the Evaluation of an Integrative Body Psychotherapy Program for Patients with Psychogenic Non-Epileptic Seizures]

Psychogenic non-epileptic seizures (PNES) occur in the context of various diseases. Therefore, PNES patients represent a heterogeneous group with different causative disorders. The etiology is still poorly understood. Previous concepts assume an increased rate of trauma disorders in PNES, which has been proven several times by previous studies 1 2. The clinical picture is threatening, which means that those affected often receive intensive care measures without benefiting from them 3. PNES patients accumulate especially in epilepsy centers, since a diagnostic differentiation from epileptic seizures is possible at those specialized centers. Often, the transition from making the diagnosis in epilepsy centers to follow-up treatment in psychosomatic/psychiatric settings is difficult. A reason could be that patients and practitioners are often involved in somatic disease concepts, which might be caused by the threatening clinical picture of PNES 28. Due to this difficulties, a special outpatient clinic was set up at the Charité Berlin for people with dissociative seizures, which settles in the transition from neurology to psychosomatics and works as a cooperation project 27. Out of the ambulance, a group treatment program (CORDIS) was developed, which aims at a better care of PNES patients at the interface between neurology and psychosomatic medicine. This modularized 10-week treatment program will be presented in this article and is the subject of a currently ongoing randomized, controlled evaluation study. The pilot data from the ongoing RCT study presented here showed significant effects in the effectiveness of the program, in particular the primary and secondary outcome measures.

Psychogenic nonepileptic seizures: Comparing what South African healthcare providers communicate to patients at the point of diagnosis against international guidelines

The process of communicating a diagnosis of psychogenic nonepileptic seizures (PNES) has been widely studied internationally and found to be an important factor in the reduction of symptoms as well as promoting the uptake of treatment. To date, no research has focused on diagnosis communication in the South African context. This study used applied thematic analysis to explore the content addressed by a sample of 11 South African healthcare providers (HCPs) when presenting a diagnosis of PNES to a patient. The purpose was to investigate the areas of alignment between the international guidelines and what is done in practice and to identify other elements communicated by South African HCPs that were not addressed in the guidelines. The key communication elements described in five international guidelines were grouped into nine main themes, and coding frequencies were used to identify areas of alignment. In general, the practices of the participants aligned closely to the international guidelines. There was close alignment between the guidelines and the practices of HCPs in respect of six themes, namely: that the diagnosis was not epilepsy; how the diagnosis was made; that PNES was a real, debilitating condition; an explanation of possible causes and maintaining factors; that antiepileptic drugs are not effective in treating PNES; and a description of appropriate treatment. Participants suggested four additional subthemes that may be included when presenting a diagnosis: what to do in the event of future seizures; that further investigations are not helpful; enquiry into the link between stressors and seizures; and a discussion about comorbid conditions. Participants noted the value of utilizing a guideline as a means to ensure that all HCPs involved with a patient communicate a consistent message. They emphasized that diagnosis presentation must be relevant to the South African population and discussed the need to tailor explanations for the patient's home language and level of education. Cross-cultural barriers and different cultural health beliefs may require a specially tailored communication approach grounded in a clear cultural understanding.

Natural history of patients with psychogenic nonepileptic seizures

PURPOSE

The purpose of this study was to investigate the long-term outcome of patients with psychogenic nonepileptic seizures (PNES), who never visited a psychologist and never received a proper therapy for their condition (due to lack of resources). We also aimed to investigate factors potentially associated with the outcome in these patients.

METHODS

We studied all patients with PNES, who were admitted to the epilepsy monitoring unit at the Shiraz Comprehensive Epilepsy Center, from 2008 until 2013. In a phone call interview to the patients in November and December 2018, we obtained the following information: seizure outcome, history of receiving any psychotherapy after confirming their diagnosis at referral, and finally, their current marital status, education, and employment status.

RESULTS

69 patients had the inclusion criteria. Thirty-six patients (52%) were seizure-free during the past 12 months, but 33 (48%) still suffer from seizures. The only variable (at diagnosis), which was significantly associated with their outcome, was duration of their condition before they received a definite diagnosis.

CONCLUSION

More than half of the patients with untreated PNES may become free of seizures after they receive a definite diagnosis and with the passage of time. Longer duration of PNES before the patients received a definite diagnosis may affect their long-term outcome.

Early outcomes in youth with psychogenic nonsyncopal collapse

Objective

To evaluate several early outcome measures following diagnosis of psychogenic nonsyncopal collapse (PNSC).

Methods

Over a 34-month period, a prospective cohort study was conducted of patients referred for tilt-table evaluation of fainting and orthostatic intolerance. Clinical histories were obtained and anxiety and depressive symptom questionnaires were completed prior to testing. Among 539 patients referred, 100 (18.6%) were diagnosed with PNSC. Outcome data were collected by telephone or during routine follow-up a median of 572 days postdiagnosis.

Results

Eighty-four patients (84%) provided outcome data. Following communication of the diagnosis, 32 patients (38%) had immediate PNSC resolution. Attack resolution occurred in 44% by 1 month, 51% by 6 months, 52% by 12 months, 69% after 12 months, and 31% continued to have PNSC at the time of follow-up. Patients with continued PNSC had higher anxiety scores than patients with immediate resolution (p = 0.047). Following diagnosis, emergency department visits for fainting decreased from 78.6% to 20.2% (p = 0.017), and management by psychology or psychiatry increased from 26.2% to 76.2% (p < 0.001). During the follow-up period, 8 patients (9.5%) were hospitalized for suicidal ideation, a median of 253 (range 33–470) days postdiagnosis; 12 patients (14.3%) developed new (non-PNSC) conversion disorders, a median of 86 (range 9–504) days postdiagnosis. Suicidal ideation was associated with higher anxiety (p = 0.007) but not higher depression scores.

Conclusions

The diagnostic rate of PNSC parallels that of PNES among patients referred for tertiary care evaluations. The improvements in attack frequency following PNSC diagnosis must be tempered by the potential risks of self-harm and the development of new conversion disorders.

Diagnostic and treatment practices for psychogenic nonepileptic and epileptic seizures in Namibia

PURPOSE

Information about existing healthcare resources for the management of seizures in developing countries is lacking. These countries are often poorly equipped to deal with the immense burden of costs, mortality, stigma, seizure-related disability, and comorbidities presented by seizure disorders. This study aimed to contribute to the goals of the International League Against Epilepsy (ILAE) by investigating the resources available for patients with seizure in Namibia.

METHODS

Two separate surveys on the diagnostic and treatment practices for epileptic seizures (ES) and psychogenic nonepileptic seizures (PNES) were administered to private healthcare practitioners (HCPs) in Namibia.

RESULTS

The findings are based on 50 responses from HCPs involved in the management of seizures. The responses indicate that HCPs have less confidence in their ability to manage PNES than ES. Psychological/psychiatric assessments are seldom utilized. Although HCPs engage in face-to-face communication of diagnoses, they seldom refer patients to additional sources of information. Healthcare practitioners follow up patients with ES more regularly than those with PNES. Healthcare practitioners indicated their willingness to collaborate and recognize the role of traditional health practitioners (THPs) in a supportive capacity when it comes to the management of seizures. Financial constraints, limited availability of specialized equipment, and lack of knowledge and awareness regarding seizure disorders among both HCPs and patients were mentioned as major obstacles in accessing healthcare services.

CONCLUSION

The findings of this study add to the current literature by demonstrating some of the particular characteristics of HCPs from a lower middle-income African country regarding the diagnosis and treatment of PNES and ES.

[Psychogenic non epileptic seizures : Differential diagnostic features]

Psychogenic nonepileptic seizures (PNES) are to be considered in the differential diagnosis of a transient loss of consciousness. Their discrimination from syncope, epileptic seizures or vascular events can be difficult and requires profound knowledge about the semiology and clinical presentation of PNES and their differential diagnoses. Erroneous diagnoses and the resulting therapies lead to elevated morbidity, elevated costs and a poorer outcome. The aim of the present article is to provide an overview on PNES and their delineation from the clinical pictures of epilepsy and syncope.

An Overview of Psychogenic Non-Epileptic Seizures: Etiology, Diagnosis and Management

The purpose of this review is to provide an update of the research regarding the etiology, diagnosis and management of psychogenic non-epileptic seizures (PNES). A literature search using Pubmed, Ovid MEDLINE and EMBASE database was performed from 2000 up to August 2017. We have evaluated the different factors leading to PNES as well as the diagnostic approach and management of this disorder which continue to be very difficult. The coexistence of epilepsy and PNES poses special challenges and requires the coordinated efforts of the family physicians, psychiatrists, psychologists and neurologists. Although this condition has an overall poor prognosis, a multidisciplinary approach in the diagnosis and management of this disorder would likely improve the outcomes. We have proposed a diagnostic and treatment algorithm for PNES and suggested a national registry of patients suffering from this condition. The registry would contain data regarding treatment and outcomes to aid in the understanding of this entity.

Psychogenic non-epileptic seizures: aetiology, diagnosis and management

Psychogenic non-epileptic seizures (PNES) have a significant impact on most patients in terms of distress, disability, loss of income and iatrogenic harm. Three-quarters of patients with PNES are initially misdiagnosed and treated for epilepsy. Misdiagnosis exposes patients to multiple iatrogenic harms and prevents them from accessing psychological treatment. In most cases, the patient's history (and witness accounts) should alert clinicians to the likely diagnosis of PNES. Since this diagnosis may be resisted by patients and may involve ‘un-diagnosing’ epilepsy, video-electroencephalogram recording of typical seizures is often helpful. The underlying causes of PNES are diverse: a model combining predisposing, precipitating and perpetuating factors is a useful way of conceptualising their aetiology. The initial step of treatment should be to limit iatrogenic harm. There is some evidence for the effectiveness of psychotherapy.

Access to diagnostic and therapeutic facilities for psychogenic nonepileptic seizures: An international survey by the ILAE PNES Task Force

OBJECTIVE

Studies from a small number of countries suggest that patients with psychogenic nonepileptic seizures (PNES) have limited access to diagnostic and treatment services. The PNES Task Force of the International League Against Epilepsy (ILAE) carried out 2 surveys to explore the diagnosis and treatment of PNES around the world.

METHODS

A short survey (8 questions) was sent to all 114 chapters of the ILAE. A longer survey (36 questions) was completed by healthcare professionals who see patients with seizures. Questions were separated into 5 sections: professional role, diagnostic methods, management, etiology, and access to health care.

RESULTS

Responses were received from 63 different countries. The short survey was completed by 48 ILAE chapters, and the long survey by 1098 health professionals from 28 countries. PNES were recognized as a diagnostic and therapeutic problem in all countries. Trauma and mental health issues were most commonly recognized as etiologic factors. There was a clear relationship between income and access to diagnostic tests and expertise. Psychological therapy was most commonly considered the treatment of choice. Although financial difficulties were the most commonly reported problem with service access in low-income countries, in all countries stigma, lack of popular awareness, and lack of information posed challenges.

SIGNIFICANCE

This global provider survey demonstrates that PNES are a health problem around the world. Health care for PNES could be improved with better education of healthcare professionals, the development of reliable and simple diagnostic procedures that do not rely on costly tests, and the provision of accessible information.

Postdiagnosis neurological care for patients with psychogenic nonepileptic spells (PNES)

OBJECTIVE

This study investigated continuity of neurological care for patients discharged from the epilepsy monitoring unit (EMU) with a diagnosis of psychogenic nonepileptic spells (PNES). Because PNES are seizure-like episodes that cannot be explained by abnormal electrical brain activity, they are challenging for patients to understand and accept. Consequently, after diagnosis, patients commonly fail to start recommended psychotherapy and instead pursue redundant medical care. As consistent relationships with healthcare providers may help, we instituted standard follow-up for patients diagnosed with PNES.

METHODS

We performed a retrospective observational cohort study of adults diagnosed with PNES in our EMU. In November 2013, we began routine scheduling of postdischarge follow-up neurology appointments. We compared preintervention (November 2010-October 2013) and postintervention (November 2013-May 2016) cohorts with regard to clinic attendance, understanding the diagnosis, compliance with recommendations, and event frequency.

RESULTS

We identified 55 patients in the preintervention cohort and 123 patients in the postintervention cohort. We successfully implemented the intended practice changes; more patients had follow-up scheduled by discharge (preintervention 2% vs. postintervention 36%, p<0.001), time to follow-up decreased (46days vs. 29, p=0.001), and providers more consistently queried understanding of diagnosis (38% vs. 67%, p=0.03). Explicit planning for continued care did not produce the anticipated patient-provider relationships, as follow-up in clinic was low (38% vs. 37%). For patients who attended clinic, the intervention did not improve establishment of psychiatric care, compliance with medication recommendations, understanding of diagnosis, or event frequency. The odds of reduced event frequency were nonsignificantly increased with understanding the diagnosis (OR 3.75, p=0.14). Recommending antiepileptic drug (AED) discontinuation was associated with increased odds of event freedom (OR 6.91, p<0.01).

SIGNIFICANCE

Scheduling follow-up for patients diagnosed with PNES did not facilitate ongoing patient-provider relationships due to poor clinic attendance. As follow-up is unreliable, the inpatient visit is a critical window of opportunity for intervention.

What patients think about psychogenic nonepileptic seizures in Buenos Aires, Argentina: A qualitative approach

PURPOSE

To analyse the methods of reasoning with regard to patients' experiences of living with psychogenic nonepileptic seizures (PNES) in Buenos Aires, Argentina.

METHOD

A qualitative approach using semi-structured interviews was used to gain an in-depth and contextual understanding of the perspectives of five patients with PNES. Data collection and analysis were followed by an inductive and interpretive approach informed by the principles of thematic analysis.

RESULTS

Explanatory models and prototypes were identified from the patients' narratives. Four patients related their suffering regarding psychosocial causes -family conflicts, sexual harassment, and life changes, among others-. Hereditary and organic hypotheses appeared to be unspecific. Folk explanations were common to all participants (magic, witchcraft, energetic causes). Four patients used the term epilepsy as an illness prototype, focusing on seizures and the use of antiepileptic drugs. Three of them also compared their illness to other people's "attacks" (heart attacks, panic attacks, nervous breakdown). Only one of them referred to someone who was suspected of having epilepsy.

CONCLUSION

Patients' psychosocial explanatory models are different from the results of previous studies because these studies indicate that most patients support somatic explanations. Patients also use folk explanations related to traditional medicine, which highlights the interpersonal aspects of the disease. Doctor-patient communication is essential for a correct understanding of PNES, resulting in better outcomes. It could also help to reduce the cultural distance between professionals and patients, leading to narrowing inequalities present in multicultural healthcare services.

Predictors of health-related quality of life in patients with epilepsy and psychogenic nonepileptic seizures

Epilepsy and psychogenic nonepileptic seizures (PNES) are associated with reduced health-related quality of life (HRQoL). The present study investigated the profile, relationship, and predictive power of illness perceptions, psychological distress (depression and anxiety), seizure activity, and demographic factors on HRQoL in these patient groups. Patients with epilepsy (n=62) and PNES (n=45) were recruited from a United Kingdom hospital and from membership-led organizations for individuals living with seizures. Patients completed a series of self-report questionnaires assessing: anxiety (GAD-7), depression (NDDI-E), illness perceptions (B-IPQ), HRQoL (NEWQOL-6D), and seizure frequency and severity (LSSS-3). Correlational and hierarchical multiple regression analyses were conducted. Patients with epilepsy reported higher HRQoL and scored lower on measures of depression and anxiety. Patients with PNES perceived their condition as more threatening overall. In both conditions, HRQoL was negatively correlated with more severe illness perceptions and psychological distress. In epilepsy and PNES, psychological distress (epilepsy: 27%; PNES: 24.8%) and illness perceptions (epilepsy: 23.1%; PNES: 23.3%) accounted for the largest amount of variance in HRQoL. Clinical factors were found not to be significant predictors, while demographic factors predicted HRQoL in epilepsy (12.6%), but not in PNES. Our findings support the notion that psychological factors are a stronger predictor of HRQoL in epilepsy and PNES than condition-related and demographic variables. Prior research suggests that anxiety and depression are key predictors of HRQoL; this study demonstrates that the relationship between illness perceptions and HRQoL is similarly close. These findings highlight the importance of addressing patients' beliefs about their condition.

Long-term follow-up of psychogenic pseudosyncope

OBJECTIVE

To determine the outcome of patients with psychogenic pseudosyncope (PPS) after communication of the diagnosis.

METHODS

This was a retrospective cohort study of patients with PPS referred in 2007 to 2015 to a tertiary referral center for syncope. We reviewed patient records and studied attack frequency, factors affecting attack frequency, health care use, and quality of life using a questionnaire. We explored influences on attack freedom and attack frequency in the 6 months before follow-up for age, sex, education level, duration until diagnosis, probability of diagnosis, additional syncope, and acceptance of diagnosis.

RESULTS

Forty-seven of 57 patients with PPS could be traced, of whom 35 (74%) participated. Twelve (34%) were attack-free for at least 6 months. The median time from diagnosis to follow-up was 50 months (range 6-103 months). Communicating and explaining the diagnosis resulted in immediate reduction of attack frequency (p = 0.007) from the month before diagnosis (median one attack, range 0-156) to the month after (median one attack, range 0-16). In the 6 months before follow-up, the number of admissions decreased from 19 of 35 to 0 of 35 (p = 0.002). The use of somatic and mental health care shifted toward the latter (p < 0.0001). Quality of life at follow-up (Short Form Health Survey 36) showed lower scores for 7 of 8 domains compared to matched Dutch control values; quality of life was not influenced by attack freedom.

CONCLUSIONS

After communication of the diagnosis in PPS, attack frequency decreased and health care use shifted toward mental care. Low quality of life underlines that PPS is a serious condition.

A multicenter evaluation of a brief manualized psychoeducation intervention for psychogenic nonepileptic seizures delivered by health professionals with limited experience in psychological treatment

RATIONALE

The aim of this study was to add to our understanding of the impact of psychoeducation on patients' acceptance of the diagnosis of psychogenic nonepileptic seizures (PNESs), the frequency of their seizures, and their quality of life. The study also aimed to evaluate the effectiveness of brief manualized psychoeducation interventions for PNESs, delivered by a more diverse range of clinicians and in a wider range of treatment settings.

METHOD

The final sample consisted of 25 patients diagnosed with PNESs by a neurologist specializing in the treatment of seizure disorder and referred to the psychotherapy service. The study included patients from four centers, using a manualized psychoeducation intervention delivered over 4 sessions by specialist epilepsy nurses and assistant psychologists. All patients completed self-measure questionnaires for Seizure Frequency, Impaired Functioning (WSAS), Psychological Distress (CORE-OM), Illness Perception (BIPQ), Health-Related Quality of Life: general (ED-QOL) and epilepsy-specific (NewQOL-6D), Symptom Attribution, and patient's perception of usefulness and relevance of the intervention. All measures were collected at baseline and after the completion of the fourth session.

RESULTS

All measures improved from baseline to postintervention, but this improvement was only significant for CORE-OM (p<.05) and BIPQ (p<.01). Out of the 25 patients who completed the intervention information, 6 out of 25 (24%) had been seizure-free for the past month, and an additional 6 out of 25 (24%) had achieved seizure frequency reduction. Consequently, upon completion of the intervention, 12 out of 25 patients (48%) were either seizure-free or experienced fewer seizures compared with the start of the intervention.

CONCLUSION

The evidence suggests that brief manualized psychoeducation intervention can reduce PNES frequency, improve the psychological distress, and have an effect on patients' illness perceptions that should help them engage with a more extended psychotherapy program if that was necessary. The intervention was carried out successfully by staff with relatively little training in delivering psychological interventions. Further controlled studies are required to provide proof of efficacy.

Neurophysiological investigations for the diagnosis of non-epileptic attack disorder in neuropsychiatry services: from safety standards to improved effectiveness

OBJECTIVE

The discipline of clinical neuropsychiatry currently provides specialised services for a number of conditions that cross the traditional boundaries of neurology and psychiatry, including non-epileptic attack disorder. Neurophysiological investigations have an important role within neuropsychiatry services, with video-electroencephalography (EEG) telemetry being the gold standard investigation for the differential diagnosis between epileptic seizures and non-epileptic attacks. This article reviews existing evidence on best practices for neurophysiology investigations, with focus on safety measures for video-EEG telemetry.

METHODS

We conducted a systematic literature review using the PubMed database in order to identify the scientific literature on the best practices when using neurophysiological investigations in patients with suspected epileptic seizures or non-epileptic attacks.

RESULTS

Specific measures need to be implemented for video-EEG telemetry to be safely and effectively carried out by neuropsychiatry services. A confirmed diagnosis of non-epileptic attack disorder following video-EEG telemetry carried out within neuropsychiatry units has the inherent advantage of allowing diagnosis communication and implementation of treatment strategies in a timely fashion, potentially improving clinical outcomes and cost-effectiveness significantly.

CONCLUSION

The identified recommendations set the stage for the development of standardised guidelines to enable neuropsychiatry services to implement streamlined and evidence-based care pathways.

Nonepileptic seizures: an updated review

Psychogenic nonepileptic seizures (PNES) are a functional neurological disorder/conversion disorder subtype, which are neurobehavioral conditions at the interface of neurology and psychiatry. Significant advancements over the past decade have been made in the diagnosis, management, and neurobiological understanding of PNES. This article reviews published PNES research focusing on semiologic features that distinguish PNES from epileptic seizures, consensus diagnostic criteria, the intersection of PNES and other comorbidities, neurobiological studies, evidence-based treatment interventions, and outcome studies. Epidemiology and healthcare utilization studies highlight a continued unmet medical need in the comprehensive care of PNES. Consensus guidelines for diagnostic certainty are based on clinical history, semiology of witnessed typical event(s), and EEG findings. While certain semiologic features may aid in the diagnosis of PNES, the gold standard remains capturing a typical event on video electroencephalography (EEG) showing the absence of epileptiform activity with history and semiology consistent with PNES. Medical-neurologic and psychiatric comorbidities are prevalent in PNES; these should be assessed in diagnostic evaluations and integrated into treatment interventions and prognostic considerations. Several studies, including a pilot, multicenter, randomized clinical trial, have now demonstrated that a cognitive behavioral therapy-informed psychotherapy is an efficacious treatment for PNES, and additional efforts are necessary to evaluate the utility of pharmacologic and other psychotherapy treatments. Neuroimaging studies, while requiring replication, suggest that PNES may occur in the context of alterations within and across sensorimotor, emotion regulation/processing, cognitive control, and multimodal integration brain systems. Future research could investigate similarities and differences between PNES and other somatic symptom disorders.

Psychogenic seizures: long-term outcome in patients with and without epilepsy

OBJECTIVES

Psychogenic non-epileptic seizures (PNES) may resemble epileptic events. Epileptic and non-epileptic seizures are not mutually exclusive phenomena and may coexist in the same patient. The aim of this study was to evaluate the long-term outcome of psychogenic events in patients with PNES alone and those with both PNES and epilepsy (PNES + EPI) as diagnosed by video-EEG (vEEG) monitoring.

MATERIALS AND METHODS

All adult admissions to the Tel-Aviv Medical Center's vEEG unit between 2004 and 2009 were screened for the presence of PNES. We retrospectively retrieved data from their medical files and supplemented the follow-up by a telephonic questionnaire.

RESULTS

Eligible patients (n = 51) were divided into those with PNES + EPI (n = 24) and those with PNES alone (n = 27). The follow-up period was 4.8 ± 0.3 and 4.3 ± 0.3 years, respectively. Both groups had similar female predominance and similar age at admission to the vEEG unit. Time from PNES onset to hospitalization was longer in PNES patients compared to those with PNES + EPI. The majority of subjects in each group reported a history of at least one major stressful life event. Opisthotonus was significantly more frequently observed in PNES patients, and they had more events during vEEG hospitalization. Psychogenic events ceased during the follow-up period in 22% of the PNES patients and in 58% of the PNES + EPI patients (P > 0.001).

CONCLUSION

Our results indicate that following vEEG-based diagnosis of PNES, the long-term outcome of PNES cessation may be more favorable for patients with concomitant epilepsy than for patients without epilepsy.

A standardized diagnostic approach and ongoing feedback improves outcome in psychogenic nonepileptic seizures

INTRODUCTION

Psychogenic nonepileptic seizures (PNES) are episodic alterations in behavior presumed to reflect a physical manifestation of underlying psychological distress. Standardized treatment approaches for PNES care are lacking. We evaluated common approaches to PNES management that do not require significant commitment of time and resources.

METHODOLOGY

Patients with PNES established with video-EEG monitoring were randomized to one of the following three groups: 1) PNES diagnosis delivered per the discretion of the attending physician with advice to seek mental health assistance in the community (n=12), 2) scripted PNES diagnosis provided and inpatient psychiatry consult obtained (n=10), and 3) weekly follow-up phone calls made in addition to scripted diagnosis and inpatient psychiatry consultation (n=15). Reduction in event frequency measured at 8weeks following hospital discharge represented the primary outcome variable. Secondary variables analyzed included exploration of change in self-reported mood, quality of life, and healthcare utilization.

RESULTS

No significant improvements were noted in patients simply given a PNES diagnosis and advised to seek outside care on any measure. In contrast, patients receiving a scripted diagnosis and psychiatric consultation demonstrated decreased PNES frequency accompanied by improved quality of life (QOL). Patients also receiving weekly phone calls not only demonstrated decreased PNES frequency and improvements in QOL but also exhibited improved mood.

DISCUSSION

These findings demonstrate that providing diagnostic information regarding PNES is insufficient by itself to meaningfully affect patient outcome. Structured feedback and psychiatric consultation appeared adequate to significantly reduce PNES frequency and improve aspects of quality of life, while the addition of a weekly phone contact also led to improved mood.

A Therapeutic Approach to Psychogenic Nonepileptic Seizures

OPINION STATEMENT

The diagnosis of psychogenic nonepileptic seizures (PNES) is usually made in the seizure monitoring unit (SMU; also commonly named the epilepsy monitoring unit) after PNES are recorded on video-EEG. The diagnosis should be discussed with the patient thoroughly. The discussion should focus on how the diagnosis was reached and that the diagnosis is real and treatable. When the diagnosis is communicated well, some patients may improve significantly without further interventions. Next, a psychiatric evaluation should be completed, ideally before discharge from the SMU. After discharge, the patient should undergo cognitive behavioral therapy (CBT), the only treatment for PNES that is supported by high-quality evidence. Other therapies, including psychodynamic therapy and different types of group therapy can be considered in some patients, although high-level evidence to support their use is lacking. Some patients may benefit from selective serotonin-reuptake inhibitors (SSRIs), especially when psychiatric comorbidities are present. This should be considered on a case-by-case basis.

New insights into psychogenic nonepileptic seizures 2011-2014

PURPOSE

There has been a rapid increase in the rate of publications about psychogenic nonepileptic seizures (PNES). This review summarises insights from the 50 most important original articles about PNES published since 2011 and describes the advances made in the understanding of PNES over the last 3 years.

METHOD

We carried out a systematic literature search of all English language publications about PNES published between October 2011 and October 2014 on Scopus, Ovid Medline and Web of Knowledge, and inspected all abstracts. Having excluded all review articles, case reports, conference abstracts, articles exploring PNES in children, and articles not actually focussing on PNES, we considered 150 papers for inclusion in this review. We assessed the quality of the identified studies and used expert judgement to identify the 50 most important publications from the review period and composed a narrative review based on these original papers.

RESULTS

Almost one half of the studies initially identified only provided Class 4 evidence. Recent work has provided more support for a biopsychosocial account of PNES. It has illustrated the heterogeneity of PNES, identifying varying and distinct psychological profiles of individuals with this disorder. These findings suggest that intervention needs to be flexible or adaptive if it is appropriately to target the different mechanisms which may give rise to PNES. Several educational and psychotherapeutic interventions for PNES have been described, but sufficiently powered randomised controlled trials are yet to be undertaken. Recent research using social, economic and quality of life indicators has provided further evidence of the societal and individual burden of PNES.

CONCLUSION

The research into PNES published over the last 3 years has deepened our understanding of the condition as a biopsychosocial disorder which is neither a "physical" nor a "psychological" condition. A number of small studies have demonstrated the potential of educational and psychotherapeutic treatments, but rigorous and sufficiently large trials still need to be conducted to determine the effectiveness of these interventions.

Long-term outcome of psychogenic nonepileptic seizures: the role of induction by suggestion

PURPOSE

The aims of our retrospective observational study were to evaluate the long-term outcome of PNESs after communication of the diagnosis and to define predictors of good outcome.

METHOD

Twenty-seven consecutive patients with a certain diagnosis of psychogenic nonepileptic seizures (PNESs) were included in the study. Follow-up information was obtained from each participant through a questionnaire designed for the study. Regarding seizure frequency, the patients were asked to report how many seizures they had experienced on average every month before the communication of the diagnosis and after it.

RESULTS

After the communication of the diagnosis, the median seizure frequency had dropped to 4 every month (p < 0.001). Seventeen participants (63%) were seizure-free at follow-up, and a further five (18.5%) showed a greater than 50% improvement in seizure frequency. Regarding the predictive value of clinical and sociodemographic variables for PNES global outcome, the factors gender, education, economic status, interval of time from onset, comorbidity with epilepsy, psychiatric history, mental retardation, psychological therapy, psychiatric therapy, and the presence of stressful and traumatic events were not related to prognosis; the only factor associated with a better outcome was the diagnosis made after the induction of PNESs by suggestion (p = 0.000, χ(2) = 4.654).

CONCLUSION

A substantial majority of our patients became seizure-free with communication of the diagnosis as the only intervention. The use of the induction by suggestion test was an important predictor of good outcome.

Video-electroencephalography investigation of ictal alterations of consciousness in epilepsy and nonepileptic attack disorder: practical considerations

The ictal assessment of consciousness is of central importance in the differential diagnosis of epilepsy and nonepileptic attack disorder (NEAD). Long-term video-electroencephalography (video-EEG) is currently considered the gold standard investigative technique for the evaluation of patients with recurrent attacks associated with transient alterations of arousal (responsiveness) and/or awareness (experiential states). This paper offers a concise review focusing on the practical aspects of clinical relevance in the video-EEG diagnostic workout of inpatients with suspected epilepsy or NEAD, as outlined in existing guidelines and recommendations. The reviewed literature implies that both implementation of specific procedures (e.g., activation maneuvers) and interpersonal approach (e.g., monitoring protocols) during video-EEG should be tailored to the individual patient's presentation.

Treatment of functional (psychogenic) movement disorders

Functional (psychogenic) movement disorders are a common source of disability and distress. Despite this, little systematic evidence is available to guide treatment decisions. This situation is likely to have been influenced by the "no man's land" that such patients occupy between neurologists and psychiatrists, often with neither side feeling a clear responsibility or ability to direct management. The aim of this narrative review is to provide an overview of the current state of the evidence regarding management of functional movement disorders. This reveals that there is some evidence to support the use of specific forms of cognitive behavioral therapy and physiotherapy. Such treatments may be facilitated in selected patients with the use of antidepressant medication, and may be more effective for those with severe symptoms when given as part of inpatient multidisciplinary rehabilitation. Other treatments, for example hypnosis and transcranial magnetic stimulation, are of interest, but further evidence is required regarding mechanism of effect and long-term benefit. Though prognosis is poor in general, improvement in symptoms is possible in patients with functional movement disorders, and there is a clear challenge to clinicians and therapists involved in their care to conduct and advocate for high-quality clinical trials.

Brief group psychoeducation for psychogenic nonepileptic seizures: a neurologist-initiated program in an epilepsy center

OBJECTIVE

To evaluate therapeutic efficacy upon augmenting the initial communication to patients regarding the diagnosis of psychogenic nonepileptic seizures (PNES) with a novel, brief group psychoeducation administered by the same team that provided the video-electroencephalography (VEEG) confirmed diagnosis and within 4 weeks of the diagnosis.

METHODS

Prior to discharge from the epilepsy monitoring unit (EMU), a standardized communication strategy was utilized to explain the diagnosis of PNES to all patients prior to enrollment. Enrolled patients were then randomized to either participation in three successive and monthly group psychoeducational sessions (intervention group), or routine seizure clinic follow-up visits (control group). Both groups completed questionnaires at time of enrollment, and then at approximately 3 months (follow-up 1) and 6 months (follow-up 2) after discharge, assessing for: (1) primary outcomes that include a measure of psychosocial functioning, as well as interval difference in seizure frequency/intensity; and (2) secondary outcomes that include interval seizure-related emergency room visits or hospitalizations, development of new and medically unexplained symptoms, and results of an internal measure of knowledge and perception outcomes.

RESULTS

The majority (73%) of patients from the intervention group commenced on therapy sessions within 4 weeks after learning of the diagnosis. Although we did not observe significant group difference in seizure frequency/intensity, patients from the intervention group showed significant improvement on the Work and Social Adjustment Scale (WSAS) scores at both follow-up 1 (p = 0.013) and follow-up 2 (p = 0.038) after discharge from the EMU. In addition, we observed a trend toward lesser likelihood for seizure-related emergency room visits or hospitalizations for the intervention group (p = 0.184), as well as meaningful insights from an internal measure of intervention outcomes.

SIGNIFICANCE

These findings suggest that our cost/resource effective, brief group psychoeducational program, when administered early and by the same team who confirmed and communicated the diagnosis of PNES, may contribute to significant functional improvement among participating patients.

A feasibility study of a brief psycho-educational intervention for psychogenic nonepileptic seizures

PURPOSE

We have previously reported that one in six patients stops experiencing psychogenic nonepileptic seizures (PNES) following our communication protocol. This prospective multicentre study describes a psycho-educational intervention for PNES building on the initial communication of the diagnosis and examines the feasibility of its delivery by healthcare professionals with minimal experience in psychological therapies.

METHOD

Three healthcare professionals with minimal training in psychological therapies took part in a one-day training course. 20 participants attended for a four-session manualised psycho-educational intervention delivered at three different clinical neuroscience centres. Participants completed self-report measures prior to the intervention at baseline (n=29) and seven months after diagnosis (n=13) measures included seizure frequency, health related quality of life, healthcare utilisation, activity levels, symptom attributions and levels of functioning. Therapy sessions were audiorecorded and manual adherence assessed.

RESULTS

Of 29 patients enrolled into the study, 20 started and 13 completed the intervention and provided follow-up information. At follow-up, 4/13 of patients had achieved complete seizure control and a further 3/13 reported a greater than 50% improvement in seizure frequency. After training, epilepsy nurses and assistant psychologists demonstrated sufficient adherence to the manualised psycho-educational intervention in 80% of sessions.

CONCLUSION

The delivery of our brief manualised psycho-educational intervention for PNES by health professionals with minimal training in psychological treatment was feasible. The intervention was associated with higher rates of PNES cessation than those observed in our previous studies describing the short-term outcome of the communication of the diagnosis alone. An RCT of the intervention is justified but a significant proportion of drop-outs will have to be anticipated.