Epidemiology of psychogenic nonepileptic seizures

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.

Impact of the COVID-19 Pandemic on the Diagnostic Frequency and Medical Therapies Applied to Subjects With Functional Seizures

Background and Purposes

The coronavirus 2019 (COVID-19) pandemic was associated with catastrophic consequences and increased psychological distress. However, it is unknown if the pandemic impacted the frequency of functional seizures (FS), a well known manifestation of psychiatric disease. The study objectives are to evaluate FS diagnostic code frequency before and during the COVID-19 pandemic and the therapies applied. We hypothesized that FS frequency would be higher during the pandemic, but that the therapies applied would be similar between the two time periods.

Methods

This was a retrospective observational cohort study utilizing the TriNetX ® electronic health record (EHR) database. We included subjects aged 8 to 65 years with a diagnostic code of "conversion disorder with seizures or convulsions." After the query, the study population was divided into 2 groups [pre-COVID-19 (3/1/2018 to 2/29/2020) and COVID-19 (3/1/2020 to 2/28/2022). We analyzed subject demographics, diagnostic, procedure, and medication codes.

Results

We included 8680 subjects [5029 (57.9%) pre-COVID-19 and 3651 (42.1%) COVID-19] in this study. There was a higher odds of mental health conditions, anxiolytic prescription, emergency department services, and hospital services, but a lower odds of critical care services during COVID-19. There was no difference in antiepileptic use between the time periods.

Conclusions

During the COVID-19 pandemic, a higher odds of anxiolytic use, need for emergency department services, and hospital services was reported. In addition, there was a decreased odds of critical care services. This may reflect a change in how patients with FS were managed during the pandemic.

Brain network entropy, depression, and quality of life in people with traumatic brain injury and seizure disorders

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.

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.

"This is real", "this is hard" and "I'm not making it up": Experience of diagnosis and living with non-epileptic attack disorder

PURPOSE

To use a qualitative research approach to explore adults' experience of living with non-epileptic attack disorder.

OBJECTIVE

The objective was to explore the experience of adults (18 years+) with a confirmed diagnosis of non-epileptic attack disorder (NEAD) across the trajectory of the disorder. The topics investigated included the onset of symptoms, the experience of non-epileptic attacks, the diagnostic process and living with NEAD.

METHOD

Twelve people diagnosed with NEAD who attended a tertiary hospital neurology department took part in semi-structured interviews. The data generated were analysed using reflexive thematic analysis.

RESULTS

Eleven women and one man with median age of 25 years took part. Three themes were developed: mind-body (dis)connect, a stigmatised diagnosis and a role for containment. Adults spoke about their experience of nonepileptic attacks, the diagnostic and management process and the impact of both nonepileptic attacks and the NEAD diagnosis on their lives.

CONCLUSIONS

Adults' experience's within the healthcare system across the trajectory of NEAD influenced their own understanding and trust in their NEAD experience, how they shared this with others in their social and work lives and how they managed their NEAD symptoms on a daily basis. The research suggests the need for a consistent, timely implementation of a rule-in diagnostic approach and multi-disciplinary management of NEAD. It is recommended that lessons be taken from theoretical models including the common-sense model and a modified version of the reattribution model to support the de-stigmatisation of this diagnosis to inform psychoeducation and professionally facilitated peer-support groups.

Illness representations of people with later-onset functional seizures

PURPOSE

Although functional seizures can start at any age, little is known about the individuals for whom onset occurs after the age of 40. It has been proposed that health-related traumatic events are more relevant causal factors for people with 'later-onset functional seizures' than for those whose functional seizures begin earlier in life, however, the illness representations of people with later-onset functional seizures have not yet been investigated. This study aimed to understand the experiences and illness representations of people with later-onset functional seizures.

METHODS

This was a mixed-methods study. People with later-onset functional seizures were recruited via a neurologist's caseload and online membership-led organisations. Semi-structured interview transcripts were analysed using Template Analysis according to the Common-Sense Model (CSM). Self-report measures of demographic and clinical details were collected to characterise the sample and verify themes.

RESULTS

Eight people with later-onset functional seizures participated in the study. Illness representations relating to all domains of the CSM as well as an additional theme of 'Triggers' were identified. Functional seizures were characterised as a mysterious brain disorder analogous to a computer malfunction and involving involuntary movements associated with alterations in consciousness. Perceptions of duration were indefinite, and triggers were unknown or at the extremes of autonomic arousal. Half of the sample identified health-related events/trauma as causal. Opinions were divided on 'cumulative life stress' as a causal factor. Most perceived themselves to have limited or no control but having 'control' over seizures was conceptualised as different to reducing their likelihood, frequency, or impact. Later-onset functional seizures were viewed as being more detrimental for caring and financial responsibilities but to have advantages for acceptance.

CONCLUSIONS

This is the first study to assess the illness representations of people with later-onset functional seizures. Many themes were similar to those identified in samples including people with earlier-onset functional seizures. Health-related trauma or events were the most strongly endorsed perceived causal factor, but with the exception of 'consequences', all representations were characterised by uncertainty. Clinicians should hold in mind the interaction between life stage and the consequences of later-onset functional seizures.

Structural and functional changes associated with functional/dissociative seizures: A review of the literature

INTRODUCTION

The term 'functional/dissociative seizures (FDS)' refers to a paroxysmal, transient clinical manifestation that may include motor, sensory, vegetative, psychological and cognitive signs, similar to the manifestations observed in epileptic seizures. In recent years, there has been an increase of literature in the field of brain imaging research on functional neurological disorders and, more specifically, on FDS. However, most of the studies have been carried out on limited samples. We propose an update of this review work by performing a systematic review of studies performed since 2017 in the field of neuroimaging in patients with FDS.

METHODS

We conducted a systematic review of the literature using the PRISMA methodology and reproduced most of the methodological elements of the latest systematic literature review.

RESULTS

Our work over the last five years has identified 14 articles. It is still difficult to isolate a distinct structure or network specifically involved in the mechanism of FDS. However, certain structures are recurrently involved in imaging studies, notably the amygdala, the orbitofrontal cortex, and the anterior cingulate cortex.

CONCLUSION

The contribution of neuroimaging may allow a more precise explanation of the disorder for patients, avoiding the stigma frequently associated with this diagnosis. as with other 'conversion' phenomena which have traditionally been considered only as 'medically unexplained'. In the longer term and beyond a better understanding of the physiopathology of the disorder, the challenge of this neuroimaging work would be to identify specific imaging biomarkers for a diagnosis of FDS.

Longitudinal Comparison of PNES spell and ASM reduction in PNES Patients with and without Epilepsy Discharged from an Epilepsy Monitoring Unit

OBJECTIVE

To examine trends of Antiseizure Medication (ASM) reduction and discontinuation, as well as Psychogenic Non-Epileptic Seizure (PNES) spell reduction and resolution in patients with PNES, with and without comorbid epileptic seizures (ES).

METHODS

A retrospective analysis was conducted on data from 145 patients with PNES, including 109 with PNES alone and 36 with PNES plus comorbid epilepsy. Patients were admitted to the Epilepsy Monitoring Unit (EMU) between May 2000 and April 2008, with follow-up clinical data collected until September 2015. Clinical records were thoroughly examined, encompassing the period preceding the PNES diagnosis until either loss to follow-up or September 2015. A subsequent chart review was conducted by two neurologists, covering the period following the diagnosis of PNES until either loss to follow-up or September 2015, which ever came first.

RESULTS

Patients with PNES alone had higher rates of ASM reduction for all variables of ASM reduction measured compared to those with comorbid epilepsy (all at p < 001). Among patients with PNES alone, reductions in ASMs were observed after EMU discharge, but an uptick and plateau were seen in later follow-up years (100% of patients free of ASMs at years 2-3, 20% on at least one ASM by year 7). This pattern differs greatly in PNES + ES patients, in which the only time point at which any patient was able to discontinue all ASMs was at EMU discharge (4.5% of patients), with all patients taking at least one ASM for every other follow-up time point. Reductions in PNES spell frequency did not differ significantly between the two groups (for example PNES spells reduced at final FU 47.2% vs 42.9%, p = 0.65). In both groups, despite an initial drop in variables of PNES spell reduction and resolution in the early years post discharge, there is an eventual rebound and plateau (for example in PNES only patients, 33.9% of patients having no resolution in 1st year FU, which rises to 78% at years 4-5, and plateus around 52.8% at more than 7 years follow-up.) SIGNIFICANCE: This study contributes to the growing body of research focused on improving the current approach to management and prognostic outlook of PNES. Although PNES only patients had higher rates of ASM reduction, the uptick and plateau observed in later years highlights the challenges in managing PNES. Similarly, the continued persistence and rebound of PNES spells underline the continued poor prognostic outcomes associated with this condition.

Dual diagnosis of epilepsy and dissociative seizures: Prescription patterns, feasibility and safety of rationalising antiseizure medication

BACKGROUND

Patients with a dual-diagnosis of epilepsy and dissociative seizures (DS) have received far less attention than those with single pathology. Anti-seizure medication (ASM) prescription patterns and safety of rationalisation have not been reviewed.

METHODS

We undertook a retrospective cohort study of all patients with a dual-diagnosis admitted to the Scottish Epilepsy Centre between 2012-2020. ASM frequencies were compared across admission, discharge and follow-up and emergency hospital attendances compared a year before and after admission. Demographic data, seizure characteristics and mortality data were also reviewed.

RESULTS

Across the 139 patients included in our study, ASM frequency at follow-up was significantly lower than on admission (mean 2.51 vs 2.14, Z = -2.11 p = 0.035, r = -0.215). Total hospital attendances in the year following admission were significantly lower than in the year before (mean 1.27 vs 0.77, Z = 2.306, p = 0.021, r = -0.262). Those with inactive epilepsy had their medications reduced to a greater extent that those with active epilepsy. 44 patients had their ASM frequency reduced during admission with a similar trend of reduced hospital attendances (mean 1.29 vs 0.43 Z = -3.162 p = 0.002). There was one epilepsy related death.

CONCLUSIONS

Clinicians should consider the development of co-morbid DS in patients with epilepsy not responding to an escalation of ASM, especially if presenting with a new seizure type. Patients with a dual-diagnosis of epilepsy and DS, particularly those with well controlled epilepsy, are likely overtreated with ASM. Medication review in a tertiary epilepsy centre allows for safe rationalisation of ASM and likely contributes to the need for fewer hospital attendances.

Adolescents' qualitative expressions of functional seizure illness representation

INTRODUCTION

Adolescents with functional (nonepileptic) seizures experience challenges self-managing this mental health condition, especially at school where adolescents experience stress, bullying, accusations of faking seizures, and stigma. According to the Common Sense Model of Self-Regulation, adolescents' self-management decisions and outcomes may be shaped by their functional seizure illness representation (perceptions or mental depictions formed in response to a health threat). However, current research has only explored adults' functional seizure illness representation; little is known about adolescents. The aim of this study was to explore adolescents' expressions of illness representation characteristics (identity, cause, consequence, controllability/curability, and timeline) when describing their experience attending school with functional seizures.

METHODS

We analyzed qualitative data from 10 adolescents (age 12-19 years, 100% female) from the United States with functional seizures. Data collection occurred in 2019 via semistructured interviews about adolescents' school experiences. The theme of illness representation emerged without prompting adolescents to discuss illness representation or its characteristics. This study involved inductive analyses and magnitude coding of adolescents' unsolicited expressions of illness representation.

RESULTS

All five characteristics of illness representation were mentioned by adolescents; however, not all characteristics were mentioned by all adolescents. Adolescents' expressions of illness representation characteristics resulted in the following descriptive themes: clashing labels and mind-body façade for identity, stress for cause, gains and losses for consequence, control/lack of control for controllability/curability, and no end of seizures in sight for timeline.

CONCLUSIONS

Adolescents' expressions of illness representation reveal perceptions considered "threatening" within the Common Sense Model, especially those expressing lack of controllability/curability and condition timelines with no end in sight. The Common Sense Model offers a framework for understanding how these threatening perceptions may impact health and academic outcomes or change with intervention.

Psychogenic non-epileptic seizures with and without epilepsy: Exploring the influence of co-existing psychiatric disorders on clinical characteristics and outcomes

BACKGROUND AND OBJECTIVES

Psychogenic non-epileptic seizures (PNES) are commonly associated with co-existing psychiatric disorders. The relationship between psychiatric factors and PNES episodes with and without epilepsy remains understudied. We reviewed co-existing psychiatric disorders in PNES-only, PNES with epilepsy aiming to examine whether these co-existing disorders associated with PNES clinical presentation and long-term outcomes.

METHODS

We conducted a retrospective, longitudinal cohort study of patients with PNES diagnosed at our EMU from May 2000 to April 2008, with follow-up clinical data until September 2015. We categorized patients into three groups: PNES-only, PNES+ definite epilepsy, and PNES+ possible/probable epilepsy.

RESULTS

In total, 271 patients with PNES were identified: 194 had PNES-only, 30 had PNES+ possible or probable epilepsy, and 47 had PNES+ definite epilepsy. No significant differences were observed in the prevalence of depression, anxiety, post-traumatic stress disorder (PTSD), substance abuse, or suicidal thoughts among the three groups. Similarly, no differences in co-existing psychiatric disorders characteristics were discovered among patients grouped by various durations and frequencies of PNES episodes. At EMU admission, for PNES-only patients total of 130/194 patients (67%) were on ASMs, and 64/194 (32.9%) were not. PNES-only not on ASM were the most likely to report at least two of the three main psychiatric disorders (depression, anxiety, and PTSD; p = 0.01). At the final follow-up, 68/130 (52.3%) and 92/130 (70.8%) patients were able to discontinue or reduce their ASM intake, respectively, with no significant differences in co-existing psychiatric disorders among them (p < 0.001). Overall, 51.6% or 31.3% of patients reported reduced or resolved PNES episodes, respectively. Further, this reduction and resolution of PNES episode were not affected by any psychological variable.

CONCLUSIONS

Co-existing psychiatric disorders prevalence did not differ between patients with PNES-only and those with coexisting epilepsy. Further, co-existing psychiatric disorders characteristics did not reliably predict PNES episode duration, frequency, reduction, or resolution. For patients with PNES-only, the presence of co-existing psychiatric disorders did not predict the rate at which ASMs could be reduced or discontinued.

EEG and MRI Abnormalities in Patients With Psychogenic Nonepileptic Seizures

OBJECTIVE

To compare the rate of EEG and MRI abnormalities in psychogenic nonepileptic seizures (PNES) patients with and without suspected epilepsy. Patients were also compared in terms of their demographic and clinical profiles.

METHODS

A retrospective analysis of 271 newly diagnosed PNES patients admitted to the epilepsy monitoring unit between May 2000 and April 2008, with follow-up clinical data collected until September 2015.

RESULTS

One hundred ninety-four patients were determined to have PNES alone, 16 PNES plus possible epilepsy, 14 PNES plus probable epilepsy, and 47 PNES plus confirmed epilepsy. Fifty-seven of the 77 patients (74.0%) with possible, probable, or definite epilepsy exhibited epileptiform activity on EEG, versus only 16 of the 194 patients (8.2%) in whom epilepsy was excluded. Twenty-four of these 194 patients (12.4%) had MRI abnormalities. Three of 38 patients (7.9%) with both EEG and MRI abnormalities were confirmed not to have epilepsy. In PNES patients with EEG or MRI abnormalities compared with those without, patients with abnormalities were more likely to have epilepsy risk factors, such as central nervous system structural abnormalities, and less likely to report minor head trauma. The presence of EEG abnormalities in PNES-only patients did not influence antiseizure medication reduction, whereas those with MRI abnormalities were less likely to have their antiseizure medications reduced.

CONCLUSIONS

Psychogenic nonepileptic seizure patients without MRI or EEG abnormalities are less likely to have associated epilepsy, risk factors for epilepsy, and had different demographic profiles. There is a higher-than-expected level of EEG and MRI abnormalities in PNES patients without epilepsy.

Effects of attachment styles, childhood traumas, and alexithymia in Turkish patients with epilepsy and functional seizures

INTRODUCTION

In this cross-sectional study, we used self-report scales to compare childhood traumas, attachment styles, and alexithymia among patients with functional seizures (FS) to patients with epilepsy and healthy controls. We also investigated risk factors associated with FS.

MATERIAL AND METHODS

A total of 44 patients with epilepsy, 14 patients with FS, and 25 healthy controls were included. All participants were over the age of 18 and were referred to the Baskent University Adana Epilepsy and Video-EEG Center. The patients underwent neurological examinations, brain MRIs, and video-EEG evaluations. Epileptic seizures were classified based on video EEG. The control group consisted of healthy individuals without neurological or psychiatric illness and a history of epileptic seizures or syncope. Beck Depression Inventory (BDI), Childhood Trauma Questionnaire (CTQ), Adult Attachment Scale (AAS), and Toronto Alexithymia Scale-20 (TAS-20) were applied to all participants.

RESULTS

Patients with FS had lower educational levels, higher rates of unemployment and single-marital status. The FS group had higher depression, childhood trauma, and alexithymia scores than the other groups. Furthermore, FS patients had a higher prevalence of avoidant attachment. The alexithymia and childhood trauma scores were both correlated with depression. Through the logistic regression analysis, childhood trauma scores and alexithymia were significant risk factors for FS.

CONCLUSION

The use of video-EEG for diagnosing FS can reduce the risk of misdiagnosis and inappropriate antiepileptic treatment. Psychiatric comorbidities, childhood traumas, and alexithymia are prevalent in patients with FS. Therefore, implementing a multidisciplinary treatment approach that addresses the psychological, medical, and social aspects of FS can significantly improve outcomes.

Seizing the Connection: Exploring the Interplay Between Epilepsy and Glycemic Control in Diabetes Management

Epilepsy, a neurological disorder characterized by recurrent seizures, and diabetes, a metabolic disorder characterized by impaired regulation of glucose levels, are two distinct conditions that may appear unrelated at first glance. Nevertheless, recent scholarly investigations have revealed these entities' intricate and ever-evolving interplay. This review initially delves into the intricate interplay between epilepsy and its potential ramifications on glycemic control. Seizures, particularly those accompanied by convulsive manifestations, have the potential to induce acute perturbations in blood glucose levels via diverse mechanisms, encompassing the liberation of stress hormones, the emergence of insulin resistance, and the dysregulation of the autonomic nervous system. Comprehending these intricate mechanisms is paramount in customizing productive strategies for managing diabetes in individuals with epilepsy. On the contrary, it is worth noting that diabetes can substantially impact the trajectory and control of epilepsy. The correlation between hyperglycemia and an elevated susceptibility to seizures, as well as the potential for exacerbating the intensity of epilepsy, has been established. This narrative review offers a concise exposition of the intricate interplay between epilepsy and glycemic control within diabetes management. The objective of exploring reciprocal influences, underlying mechanisms, and common risk factors is to augment the clinical comprehension of this intricate interconnection. In essence, this acquired knowledge possesses the potential to serve as a guiding compass for healthcare professionals, enabling them to craft bespoke therapeutic approaches that enhance the holistic welfare of individuals grappling with the coexistence of epilepsy and diabetes.

Changes in the heartbeat-evoked potential are associated with functional seizures

BACKGROUND

Patients with functional seizures (FS) can experience dissociation (depersonalisation) before their seizures. Depersonalisation reflects disembodiment, which may be related to changes in interoceptive processing. The heartbeat-evoked potential (HEP) is an electroencephalogram (EEG) marker of interoceptive processing.

AIM

To assess whether alterations in interoceptive processing indexed by HEP occur prior to FS and compare this with epileptic seizures (ES).

METHODS

HEP amplitudes were calculated from EEG during video-EEG monitoring in 25 patients with FS and 19 patients with ES, and were compared between interictal and preictal states. HEP amplitude difference was calculated as preictal HEP amplitude minus interictal HEP amplitude. A receiver operating characteristic (ROC) curve analysis was used to evaluate the diagnostic performance of HEP amplitude difference in discriminating FS from ES.

RESULTS

The FS group demonstrated a significant reduction in HEP amplitude between interictal and preictal states at F8 (effect size rB=0.612, false discovery rate (FDR)-corrected q=0.030) and C4 (rB=0.600, FDR-corrected q=0.035). No differences in HEP amplitude were found between states in the ES group. Between diagnostic groups, HEP amplitude difference differed between the FS and ES groups at F8 (rB=0.423, FDR-corrected q=0.085) and C4 (rB=0.457, FDR-corrected q=0.085). Using HEP amplitude difference at frontal and central electrodes plus sex, we found that the ROC curve demonstrated an area under the curve of 0.893, with sensitivity=0.840 and specificity=0.842.

CONCLUSION

Our data support the notion that aberrant interoception occurs prior to FS. Changes in HEP amplitude may reflect a neurophysiological biomarker of FS and may have diagnostic utility in differentiating FS and ES.

[Functional neurological disorders: A clinical anthology]

Functional neurological disorders have a broad phenotypic spectrum and include different clinical syndromes, which are sometimes associated to each other or appear consecutively over the course of the disease. This clinical anthology provides details on the specific and sensitive positive signs that are to be sought in the context of a suspected functional neurological disorder. Beside these positive elements leading to the diagnosis of functional neurological disorder, we should keep in mind the possibility of an associated organic disorder as the combination of both organic and functional disorders is a relatively frequent situation in clinical practice. Here we describe the clinical characteristics of different functional neurological syndromes: motor deficits, abnormal hyperkinetic and hypokinetic movements, voice or speech disorders, sensory disorders, and functional dissociative seizures. The clinical examination and the identification of positive signs play a critical role in the diagnosis of functional neurological disorder. Knowledge of the specific signs associated with each phenotype render possible to make an early diagnosis. For that matter, it contributes to the improvement of patient care management. It allows to a better engagement in an appropriate care pathway, which influence their prognosis. Highlighting and discussing positive signs with patients can also be an interesting step in the process of explaining the disease and its management.

Dissociation in patients with epilepsy and functional seizures: A narrative review of the literature

Dissociation is a "disruption of the usually integrated functions of consciousness, memory, identity or perception of the environment" according to DSM-5.  It is commonly seen in psychiatric disorders including primary dissociative disorders, post-traumatic stress disorder, depression, and panic disorder. Dissociative phenomena are also described in the context of substance intoxication, sleep deprivation and medical illnesses including traumatic brain injury, migraines, and epilepsy. Patients with epilepsy have higher rates of dissociative experiences as measured on the Dissociative Experiences Scale compared to healthy controls. Ictal symptoms, especially in focal epilepsy of temporal lobe origin, may include dissociative-like experiences such as déjà vu/jamais vu, depersonalization, derealization and what has been described as a "dreamy state".  These descriptions are common in the setting of seizures that originate from mesial temporal lobe epilepsy and may involve the amygdala and hippocampus. Other ictal dissociative phenomena include autoscopy and out of body experiences, which are thought to be due to disruptions in networks responsible for the integration of one's own body and extra-personal space and involve the temporoparietal junction and posterior insula. In this narrative review, we will summarize the updated literature on dissociative experiences in epilepsy, as well as dissociative experiences in functional seizures. Using a case example, we will review the differential diagnosis of dissociative symptoms. We will also review neurobiological underpinnings of dissociative symptoms across different diagnostic entities and discuss how ictal symptoms may shed light on the neurobiology of complex mental processes including the subjective nature of consciousness and self-identity.

Amygdala subfield and prefrontal cortex abnormalities in patients with functional seizures

BACKGROUND

Functional seizures (FS) are paroxysmal episodes, resembling epileptic seizures, but without underlying epileptic abnormality. The aetiology and neuroanatomic associations are incompletely understood. Recent brain imaging data indicate cerebral changes, however, without clarifying possible pathophysiology. In the present study, we specifically investigated the neuroanatomic changes in subregions of the amygdala and hippocampus in FS.

METHODS

T1 MRI scans of 37 female patients with FS and 37 age-matched female seizure naïve controls (SNC) were analyzed retrospectively in FreeSurfer version 7.1. Seizure naïve controls included patients with depression and anxiety disorders. The analysis included whole-brain cortical thickness, subcortical volumes, and subfields of the amygdala and hippocampus. Group comparisons were carried out using multivariable linear models.

RESULTS

The FS and SNC groups did not differ in the whole hippocampus and amygdala volumes. However, patients had a significant reduction of the right lateral amygdala volume (p = 0.00041), an increase of the right central amygdala, (p = 0.037), and thinning of the left superior frontal gyrus (p = 0.024). Additional findings in patients were increased volumes of the right medial amygdala (p = 0.031), left anterior amygdala (p = 0.017), and left dentate gyrus of the hippocampus (p = 0.035).

CONCLUSIONS

The observations from the amygdala and hippocampus segmentation affirm that there are neuroanatomic associations of FS. The pattern of these changes aligned with some of the cerebral changes described in chronic stress conditions and depression. The pattern of detected changes further study, and may, after validation, provide biomarkers for diagnosis and treatment.

The natural history of epilepsy and nonepileptic seizures in Sturge-Weber syndrome: A retrospective case-note review

OBJECTIVE

Patients with Sturge-Weber Syndrome (SWS) experience varying degrees of neurological problems - including epilepsy, hemiparesis, learning disability (LD), and stroke-like episodes. While the range of clinical problems experienced by children with SWS is well recognized, the spectrum of clinical presentation and its treatment during adulthood has been relatively neglected in the literature to date. This study explored the natural history of epileptic and nonepileptic seizures into adulthood in patients with SWS, and their treatment, and investigated whether any clinical factors predict which symptoms a patient will experience during adulthood.

METHODS

A retrospective case-note review of a cohort of 26 adults with SWS at the National Hospital for Neurology and Neurosurgery (NHNN). Childhood data were also recorded, where available, to enable review of change/development of symptoms over time.

RESULTS

The course of epilepsy showed some improvement in adulthood - seventeen adults continued to have seizures, while six patients gained seizure freedom, and no one had adult-onset seizures. However, seizures did worsen for some patients. Although no factors reached statistical significance regarding predicting continued epilepsy in adulthood, being male, more severe LD, having required epilepsy surgery, and bilateral cortical involvement may be important. Nonepileptic seizures (NES) also began during adulthood for four patients.

SIGNIFICANCE

By adulthood, there is some degree of improvement in epilepsy overall; while NES may occur for the first time. While the majority of the results did not survive adjustments for multiple comparisons, some interesting trends appeared, which require further investigation in a multicenter national audit. Patients with more neurologically severe presentations during childhood may continue to experience seizures. Careful monitoring and screening are needed during adulthood, to detect changes and newly developing symptoms such as NES, and target treatment promptly.

Work difficulties, work restrictions, and disability benefits in people with functional seizures: A survey study

Purpose

Functional seizures (FS) cause significant long-term disability and clinicians offer differing views on proper work restrictions and qualifications for disability benefits in this population. We assess the views and perspectives of experienced disability and work limitations in people living with functional seizures.

Methods

Between (4/29/2020-1/13/2021) an open-access 21-item internet survey was conducted via FNDHope.org; allowing for people living with self-reported functional seizures to remark on topics of work difficulties, work restrictions, qualifications for disability benefits, and driving. Demographic information was collected, and univariate and multivariate logistic regressions were used to evaluate potential predictors of current employment status.

Results

One hundred eighteen (118) responses were received, of which 92 (84.4%) completed > 50% of the survey; they were predominantly (92%) female. Most respondents (88%) reported some personal difficulty at work and nearly all (99%) believed that others with FS would experience difficulties in the workplace. A majority (71%) felt that work restrictions should apply to people living with active FS, at least in certain lines of work. Most (64%) felt people with FS should qualify for disability benefits; however, 35% stated work accommodations or a new job compatible with FS was more appropriate. Of those who felt people with FS should qualify for disability, 60% thought recipients should remain eligible for disability while symptomatic and 38% felt benefits should be lifelong. In univariate and multivariate logistic regressions, older age was predictive of unemployment (univariate OR 0.95 ± 0.02, 95% CI 0.92-0.98, p-value 0.002).

Conclusion

Our results suggest that work difficulties are common in people with FS, with older age being a predictor of unemployment. A majority of people with FS support work restrictions for those with their disorder, at least in some lines of work. In comparison to a prior study of clinicians, a higher percentage of people with FS supported work restrictions. These results may help facilitate productive discussions between people with FS, providers, and policymakers regarding appropriate work and disability limitations.

Improving the treatment of functional seizures through a public specialist outpatient clinic

OBJECTIVES

We performed an audit of the first 12 months of clinical operations to assess the feasibility of a newly established public outpatient clinic for the assessment and treatment of functional (psychogenic nonepileptic) seizures (FS).

METHOD

Clinical notes for the first 12 months of the FSclinic weresystematicallyreviewed with data compiled onreferral pathways, clinic attendance, clinical features, treatments, and outcomes.

RESULTS

Of eighty-two new FS patients referred to the clinic, over 90% attended. Patients were diagnosed with FS after comprehensive epileptological and neuropsychiatric review, mostly with typical seizure-like episodes captured during video-EEG monitoring, and most accepted the diagnosis. Most had FS at least weekly, with little sense of control and significant impairment. The majority of individuals had significant psychiatric and medical comorbidity. Predisposing, precipitating, and perpetuating factors were readily identified in >90% of cases. Of 52 patients with follow-up data within12 months, 88% were either stable or improved in terms of the control of their FS.

CONCLUSION

The Alfred functional seizure clinic model, the first dedicated public outpatient clinic for FS in Australia, provides a feasible and potentially effective treatment pathway for this underserved and disabled patient group.

Potential role of FKBP5 single-nucleotide polymorphisms in functional seizures

OBJECTIVE

We investigated the associations between FKBP5 single-nucleotide polymorphisms (SNPs) and functional seizures (FS).

METHODS

Seventy patients with FS, 140 with major depressive disorder (MDD), and 140 healthy controls were studied. Their DNAs were analyzed for the rs1360780 in the 3' region and rs9470080 in the 5' region of the FKBP5. Childhood trauma questionnaire and hospital anxiety and depression scale were used.

RESULTS

Patients with FS and those with MDD had less GG and more AA genotypes in both rs9470080 and rs1360780 SNPs compared with those in healthy controls. Similar results were observed for allelic frequencies. There were no significant differences between FS and MDD groups in terms of genotype and allelic frequencies for both SNPs. The results of multinomial logistic regression analysis showed that FKBP5 polymorphisms were not associated with the diagnosis.

SIGNIFICANCE

Patients with FS and those with MDD had significantly different genotypes in both rs9470080 and rs1360780 SNPs compared with those in healthy controls. However, it seems that FKBP5 polymorphisms were not associated with FS in the absence of depression. Further genetic investigations of patients with FS may increase our understanding of the neurobiological underpinnings of this condition, but such studies should be large enough and very well designed; they should include a comparison group with depression in addition to a healthy control group.

Patients with psychogenic nonepileptic seizures and suspected epilepsy: An antiseizure medication reduction study

OBJECTIVE

To examine predictors of ASM reduction/discontinuation and PNES reduction/resolution in patients with PNES with a confirmed or strong suspicion of comorbid ES.

METHODS

A retrospective analysis of 271 newly diagnosed Patients with PNESs admitted to the EMU between May 2000 and April 2008, with follow-up clinical data collected until September 2015. Forty-seven patients met our criteria of PNES with either confirmed or probable ES.

RESULTS

Patients with PNES reduction were significantly more likely to have come off all ASMs by the time of final follow-up (21.7 vs. 0.0%, p = 0.018), while documented generalized (i.e. epileptic) seizures were much more common in patients with no reduction in PNES frequency (47.8 vs 8.7%, p = 0.003). When comparing patients that reduced their ASMs (n = 18) with those that did not (n = 27), the former were more likely to have neurological comorbid disorders (p = 0.004). When comparing patients with PNES resolution (n = 12) vs not (n = 34), those with PNES resolution were more likely to have a neurological comorbid disorder (p = 0.027), had a younger age at EMU admission (29.8 vs 37.4, p = 0.05) and a greater proportion of patients with ASMs reduced in EMU (66.7% vs 30.3%, p = 0.028). Similarly, those with ASM reduction had more unknown (non-generalized, non-focal) seizures (33.3 vs 3.7%, p = 0.029). On hierarchical regression analysis, a higher level of education and absence of generalized epilepsy remain as positive predictors of PNES reduction (p = 0.042, 0.015), while the presence of some other neurological disorder besides epilepsy (p = 0.04) and being on more ASMs at EMU admission (p = 0.03) were positive predictors of ASM reduction by final follow-up.

SIGNIFICANCE

Patients with PNES and epilepsy have distinct demographic predictors of PNES frequency and ASM reduction by final follow-up. Patients with PNES reduction and resolution had higher level education, less generalized epileptic seizures, younger age at EMU admission, more likely to have presence of a neurological disorder besides epilepsy, and a greater proportion of patients had a reduction in the number of ASMs in the EMU. Similarly, patients with ASM reduction and discontinuation were on more ASMs at initial EMU admission and also were more likely to have a neurological disorder besides epilepsy. The positive relationship between reduction in psychogenic nonepileptic seizure frequency and discontinuation of ASMs at final follow-up elucidates that tapering medication in a safe environment may reinforce psychogenic nonepileptic seizure diagnosis. This can be reassuring to both patients and clinicians, resulting in the observed improvements at the final follow-up.

Influence of comorbidity on mortality in patients with epilepsy and psychogenic nonepileptic seizures

OBJECTIVE

This study aims to determine the contribution of comorbidities to excess psychogenic nonepileptic seizures (PNES) mortality.

METHODS

A retrospective cohort study was conducted of tertiary epilepsy outpatients from St. Vincent's Hospital Melbourne, Australia with an 8:1 comparison cohort, matched by age, sex, and socioeconomic status (SES) to national administrative databases between 2007 and 2017. Privacy-preserving data linkage was undertaken with the national prescription, National Death Index, and National Coronial Information System. Forty-five comorbid disease classes were derived by applying the Australian validated RxRisk-V to all dispensed prescriptions. We fitted Cox proportional hazard models controlling for age, sex, SES, comorbidity, disease duration, and number of concomitant antiseizure medications, as a marker of disease severity. We also performed a parallel forward-selection change in estimate strategy to explore which specific comorbidities contributed to the largest changes in the hazard ratio.

RESULTS

A total of 13 488 participants were followed for a median 3.2 years (interquartile range = 2.4-4.0 years), including 1628 tertiary epilepsy outpatients, 1384 patients with epilepsy, 176 with PNES, and 59 with both. Eighty-two percent of epileptic seizures and 92% of typical PNES events were captured in an epilepsy monitoring unit. The age-/sex-/SES-adjusted hazard ratio was elevated for epilepsy (4.74, 95% confidence interval [CI] = 3.36-6.68) and PNES (3.46, 95% CI = 1.38-8.68) and remained elevated for epilepsy (3.21, 95% CI = 2.22-4.63) but not PNES (2.15, 95% CI = .77-6.04) after comorbidity adjustment. PNES had more pre-existing comorbidities (p = .0007), with a three times greater median weighted Rx-RiskV score. Psychotic illness, opioid analgesia, malignancies, and nonopioid analgesia had the greatest influence on PNES comorbid risk.

SIGNIFICANCE

Higher comorbidity appears to explain the excess PNES mortality and may represent either a wider underrecognized somatoform disorder or a psychological response to physical illness. Better understanding and management of the bidirectional relationship of these wider somatic treatments in PNES could potentially reduce the risk of death.

Frequency and economic burden of psychogenic non-epileptic seizures in patients applying for disability benefits due to epilepsy

BACKGROUND

Psychogenic non-epileptic seizures (PNES) resemble epileptic seizures and are often misdiagnosed as epilepsy.

OBJECTIVE

To investigate the frequency of PNES and to calculate the economic burden of the patients who admitted to video-electroencephalographicmonitoring (VEM) to obtain a diagnosis of epilepsy in order to apply for disability retirement.

METHODS

The present retrospective study included 134 patients who required disability reports between 2013 and 2019 and had their definite diagnoses after VEM. Following VEM, the patients were divided into three groups: epilepsy, PNES, and epilepsy + PNES.

RESULTS

In total, 22.4% (n = 30) of the patients were diagnosed with PNES, 21.6% (n = 29) with PNES and epilepsy, and 56% (n = 75), with epilepsy. The frequency of PNES among all patients was of 44% (n = 59). In patients with PNES alone, the annual cost of using anti-seizure medication was of 160.67 ± 94.04 dollars; for psychostimulant drugs, it was of 148.3 ± 72.48 dollars a year; and the mean direct cost for diagnostic procedures was of 582.9 ± 330.0 (range: 103.52-1601.3) dollars.

CONCLUSIONS

Although it is challenging to determine the qualitative and quantitative total cost in these patient groups, early diagnosis and sociopsychological support will reduce the additional financial burden on the health system and increase the quality of life of the patients.

Case report on psychogenic nonepileptic seizures: A series of unfortunate events

Psychogenic nonepileptic seizures, also called Functional Seizures, are a highly disabling form of Functional Neurological Disorder. The diagnosis of PNES could be missed in clinical scenarios where patients exhibit concurrent musculoskeletal/neurological findings. Characterization of convulsions and judicious use of diagnostics are equally valuable in establishing the diagnosis.

Functional Neurological Disorders: Clinical Spectrum, Diagnosis, and Treatment

BACKGROUND

Functional neurological disorders (FNDs) are common but often misdiagnosed.

REVIEW SUMMARY

The incidence of FNDs is between 4 and 12 per 100,000, comparable to multiple sclerosis and amyotrophic lateral sclerosis, and it is the second most common diagnosis in neurology clinics. Some clues in the history are sudden onset, intermittent time course, variability of manifestation over time, childhood trauma, and history of other somatic symptoms. Anxiety and depression are common, but not necessarily more than in the general population. Although there are no tests currently capable of demonstrating whether symptoms are willfully produced, there may not be a clear categorical difference between voluntary and involuntary symptoms. The prognosis of an FND is linked to early diagnosis and symptom duration, but unfortunately, the majority of the patients are diagnosed after considerable delays.

CONCLUSIONS

A positive diagnosis of FNDs can be made on the basis of history and neurological signs without reliance on psychological stressors. Past sensitizing events and neurobiological abnormalities contribute to the pathogenesis of FNDs. Physical rehabilitation and psychological interventions alone or in combination are helpful in the treatment.

Older patients with persistent postural-perceptual dizziness exhibit fewer emotional disorders and lower vertigo scores

The clinical characteristics of persistent postural-perceptual dizziness (PPPD) vary according to patient age and inducing factors. We aimed to analyze the differences in the clinical characteristics of PPPD with different patient age groups and different etiologies. A total of 122 PPPD patients hospitalized in the vertigo ward of Nanjing Brain Hospital from December 2018 to July 2021 were enrolled. According to whether dizziness symptoms were secondary to organic diseases, PPPD patients were divided into the primary (p-) and secondary (s-) PPPD groups; subgroups were created according to age including youth group, middle-aged group, older adults group 1 and older adults 2. We collected detailed data from each patients, including scores on the Dizziness Handicap Inventory (DHI), mental state and other clinical data. The ratio of males to females was 1:2. The prevalence of emotional disorders in the middle-aged group was the highest (67.57%) and that in the older adults groups was lower (48.08% in older adults group 1 and 8.70% in older adults group 2, P = 0.000). The proportion of p-PPPD patients with emotional disorders was significantly higher than that of s-PPPD patients (53.48% vs. 30.56%, P = 0.028). The average total DHI score in the middle-aged group was significantly higher than that in older adults group 2 (52.86 vs. 35.04, P = 0.032), and the Beck anxiety score in the middle-aged group was higher than that in older adults group 2 (38.89 vs. 27.65, P = 0.000). The middle-aged group had the highest proportion of women, the highest proportion of patients with emotional disorders and the highest vertigo score. The proportion of patients with emotional disorders and the vertigo scores were lower in the older adults groups.

Hypermobility in patients with functional seizures: Toward a pathobiological understanding of complex conditions

BACKGROUND

Functional seizures (FS), otherwise known as psychogenic nonepileptic seizures (PNES), are a common symptom presenting to neurology and epilepsy clinics. There is a pressing need for further research to understand the neurobiology of FS to develop mechanistically targeted treatments. Joint hypermobility is an expression of variation in connective tissue structure along a spectrum, and it has received increasing attention in functional neurological disorders, but there is lack of evidence of its relevance in FS.

METHODS

In the present study, forty-two patients with FS and a non-clinical comparison group of 34 age/sex-matched controls were recruited. Joint hypermobility of all participants was quantified using the Beighton scale.

RESULTS

In our sample, 24 (57%) patients with FS, and 7 (21%) of the comparison group met criteria for joint hypermobility (p = 0.002). Our statistical model revealed that patients with FS showed a significant degree of hypermobility compared to the comparison group (odds ratio = 11.1; Confidence interval: 2.1-78.0, p = 0.008), even after controlling age, sex, anxiety, and depression.

CONCLUSION

We found a significant association between FS and joint hypermobility, which was independent of anxiety and depression.

"It's hard!": Adolescents' experience attending school with psychogenic nonepileptic seizures

Adolescents with psychogenic nonepileptic seizures (PNES) face many challenges in the school setting. Researchers have identified school stressors as potential predisposing, precipitating, and perpetuating factors for PNES. However, few researchers have explored the perspectives of adolescents with PNES regarding their experiences of attending school, where they spend much of their time. Therefore, this qualitative study employed content analysis to explore the experience of attending school as an adolescent with PNES. Ten adolescents (100% female, 80% White) were interviewed. With an overwhelming response of "It's hard!" from respondents, five themes regarding the school experience emerged: stress, bullying, accusations of "faking" seizure events, feeling left out because of the condition, and school-management of PNES. Underlying these themes were expressions of the need for increased understanding from and collaboration among peers, as well as the need for increased understanding from families, healthcare providers, and school personnel including school nurses. Study findings should inform future adolescent PNES research, practice decisions made by healthcare providers in the health and education sectors, education of healthcare and school professionals, and policy development and implementation.

Treatment of Psychogenic Nonepileptic Seizures

PURPOSE OF REVIEW

Psychogenic nonepileptic seizures (PNES) are the most common Functional Neurological Disorder/Conversion Disorder subtype. Significant advances have been made related to diagnosis, neurobiology, and treatment. In this review, we summarize updates in diagnosis and management over the past 3 years.

RECENT FINDINGS

Although evidence is mixed for the treatment of PNES, psychotherapeutic modalities remain a powerful instrument to empower patients and reduce seizures. A multidisciplinary, holistic approach is beneficial. While seizure freedom in all patients may not be the achieved endpoint in this chronic, paroxysmal disorder, quality of life can be improved with treatment. Additional treatment modalities and further research are needed for patients who are refractory to current treatment. Evidence-based therapies exist for PNES, and recent findings represent an increased understanding of the clinical and neurophysiologic aspects of PNES.

Implementation of a New Clinical Testing Tool to Assess Patients During Ictal and Postictal Periods

ABSTRACT

BACKGROUND: A seizure is a sudden, uncontrolled electrical disturbance of the cortical neurons in the brain, which can cause changes in behavior, movements, feelings, and consciousness. Clinical signs and symptoms before, during, and after a seizure can help to determine the seizure onset. The use of standardized clinical testing tools has been reported as being valuable, although also challenging, by some institutions. This study investigated the effectiveness of implementing a new clinical testing tool designed with an emphasis on simplicity for use during and after seizures. METHODS: A pre-and-post evaluation study was conducted from January 2020 to November 2020 in the epilepsy monitoring unit/neurology unit at a hospital in Sydney, Australia. The primary outcome of interest was the incidence of clinical testing during seizures. The secondary outcome of interest was nurse knowledge about clinical testing during a seizure. This knowledge was measured via testing before and after clinical education sessions. The third outcome of interest was nurse confidence regarding the use of the clinical testing tool. The confidence level was measured via posteducation session follow-up surveying. RESULTS: Forty-seven nursing staff (10 neurophysiology nurse technologists and 37 neurology unit nurses) participated in the education program. Forty-four seizures were evaluated. Clinical testing during ictal and postictal periods was performed by nursing staff 82% of the time during 2020, compared with 67% during the 2018 to 2019 preeducation comparison period. This difference was not statistically significant, but it was clinically relevant (P = .07). In addition, the time from seizure alarm to clinical testing improved significantly from a median of 30.5 seconds in 2018 to 2019 to 14 seconds in 2020 (P < .001). CONCLUSION: The tool is easy and convenient for nursing staff to perform clinical examinations accurately during ictal and postictal periods.

Using Semiology to Classify Epileptic Seizures vs Psychogenic Nonepileptic Seizures: A Meta-analysis

Background and objectives:

Misdiagnosis of psychogenic nonepileptic seizures (PNES) and epileptic seizures (ES) is common. In the absence of the diagnostic gold standard (video EEG), clinicians rely on semiology and clinical assessment. However, questions regarding the diagnostic accuracy of different signs remain. This meta-analysis aims to evaluate the diagnostic accuracy of semiology in PNES and ES.

Methods:

We systematically searched PubMed, PsycInfo and Medline for original research publications published before 8 February 2021 with no restriction on search dates to identify studies that compared semiology in ES and PNES in epilepsy monitoring units. Non-English publications, review articles, studies reporting on only PNES or ES and studies limited to patients with developmental delay were excluded. Study characteristics and proportions of ‘event groups’ and ‘patient groups’ demonstrating signs were extracted from each article. Bivariate analysis was conducted, and data were pooled in a random effects model for meta-analysis. The I2 statistic was calculated to assess statistical heterogeneity. The QUADAS-2 tool was utilized to assess risk of bias in included studies. The positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were calculated. A PLR > 10 or an NLR < 0.1 has a large impact on the post-test probability of a diagnosis (ES or PNES) whereas a PLR between 5-10 or an NLR between 0.1- 0.2 has a moderate impact on the post-test probability of a diagnosis (ES or PNES).

Results:

The meta-analysis included 14 studies comprising of 800 patients with ES and 452 patients with PNES. For PNES, ictal eye closure (PLR 40.5 95%CI: 16.2-101.3; I2 = 0, from three studies) and asynchronous limb movements (PLR 10.2; 95%CI: 2.8-37.7; I2 = 0, from three studies) reached a PLR threshold > 5. No single sign reached a PLR threshold >5 for ES.

Conclusions:

While all signs require interpretation in the overall clinical context, the presence of ictal eye closure and asynchronous limb movements are reliable discriminative signs for PNES.

Case Report: Atonic PNES Capture in fMRI

Psychogenic Non-Epileptic Seizures (PNES) are a misunderstood and disabling pathology, characterized by a paroxysmal occurrence of clinical signs without the epileptic activity. Resting-state functional MRI (fMRI) studies in patients with PNES have shown abnormal functional connectivity of the resting-state networks, especially in the limbic and motor systems, and in the precuneus. However, the transient nature of PNES episodes prevents us from elucidating the underlying mechanisms of seizures. Here, we report the case of a patient who presented an atonic episode of PNES during a 3T fMRI session. The patient is a 23-year-old woman, suffering from post-traumatic stress disorder, with no neurological comorbidities. The preprocessing of the fMRI images involved realignment, co-registration, segmentation, normalization, denoising (PhysIO toolbox), and smoothing. The time boundary of the seizure was defined according to the patient's reports, and the seizure period was contrasted with the resting state period before the seizure. A whole-brain analysis showed significant activations (left inferior temporal gyrus, left temporo-occipital junction) and deactivations (right precuneus, right superior parietal lobule, right postcentral gyrus, bilateral lingual gyri, inferior occipital gyri, and cerebellar lobules; right insula in a sub-thresholded analysis). Activations and deactivations occurred in four cerebral networks: emotional processing, agency, self-perception, and dissociation. To our knowledge, this report is the first published case of functional MRI during PNES. These results could confirm the emotional and dissociative hypothesis of the physiopathology of PNES and highlight future targets for neuromodulation.

A pilot study assessing the feasibility and acceptability of Project UPLIFT adapted for patients with psychogenic nonepileptic seizures

BACKGROUND

People with psychogenic nonepileptic seizures (PNES) are at elevated risk of multiple psychiatric comorbidities. Current treatment gaps highlight the need for time-limited, distance-delivered interventions that can be cost-effectively delivered to patients with PNES. Project UPLIFT is a self-management program addressing mood problems in epilepsy that has not previously been adapted for PNES. The purpose of this study was to assess the feasibility and acceptability of UPLIFT for patients with PNES.

METHODS

Project UPLIFT was minimally adapted by a multidisciplinary research group at Dartmouth-Hitchcock Medical Center. Participants were recruited into a nonrandomized pilot study and were assessed at baseline, after completing the intervention, and at 1-month follow-up.

RESULTS

The intervention was adapted and delivered without additional modification. A total of eight participants enrolled in the trial, and six participated in the first session. All six participants who started UPLIFT completed the intervention, with a 98% attendance record across the eight sessions. At follow-up, 100% reported that UPLIFT provided useful tools for daily life. All participants continued using UPLIFT after completing the program, and 83% felt it helped with seizure management. Preliminary results provide proof-of-concept for future efficacy trials.

CONCLUSION

This study provides initial support for the feasibility and acceptability of Project UPLIFT, minimally adapted for patients with PNES. As a time-limited program that can be distance-delivered to groups of patients, UPLIFT may be well-suited for the healthcare environment brought on by the COVID-19 pandemic.

Metabolomics Provides Novel Insights into Epilepsy Diagnosis and Treatment: A Review

Epilepsy is one of the most common diseases of the central nervous system. The diagnosis of epilepsy mainly depends on electroencephalograms and symptomatology, while diagnostic biofluid markers are still lacking. In addition, approximately 30% of patients with epilepsy (PWE) show a poor response to the currently available anti-seizure medicines. An increasing number of studies have reported alterations in the blood, brain tissue, cerebrospinal fluid and urine metabolome in PWE and animal models of epilepsy. The aim of this review was to identify potential metabolic biomarkers and pathways that might facilitate diagnostic, therapeutic and prognostic determination in PWE and the understanding of the pathogenesis of the disease. The PubMed and Embase databases were searched for metabolomic studies of PWE and epileptic models published before December 2020. The study objectives, types of models and reported differentially altered metabolites were examined and compared. Pathway analyses were performed using MetaboAnalyst 5.0 online software. Thirty-five studies were included in this review. Metabolites such as glutamate, lactate and citrate were disturbed in both PWE and epileptic models, which might be potential biomarkers of epilepsy. Metabolic pathways including alanine, aspartate and glutamate metabolism; glycine, serine and threonine metabolism; glycerophospholipid metabolism; glyoxylate and dicarboxylate metabolism; and arginine and proline metabolism were involved in epilepsy. These pathways might play important roles in the pathogenesis of the disease. This review summarizes metabolites and metabolic pathways related to epilepsy and provides a novel perspective for the identification of potential biomarkers and therapeutic targets for epilepsy.

Evaluation of a new body-focused group therapy versus a guided self-help group program for adults with psychogenic non-epileptic seizures (PNES): a pilot randomized controlled feasibility study

OBJECTIVE

Psychogenic non-epileptic seizures (PNES), a common phenomenon in neurological settings, are regarded as a paroxysmal type of functional neurological disorder (FND). In a substantial proportion, PNES are disabling with poor long-term outcomes and high economic costs. Despite the clinical and financial consequences of PNES, there is still a lack of controlled clinical trials on the treatment of this challenging disorder. The study aims to evaluate the feasibility and collect first evidence of the efficacy of a group based-intervention in PNES-patients.

METHODS

A pilot randomized controlled feasibility study with a parallel-group design was performed in adult outpatients with PNES to evaluate a new body-focused group therapy (CORDIS) versus guided self-help groups. Self-assessment of dissociation (Dissociation Experience Scale-DES-20) and seizure severity (Liverpool Seizure Severity Scale-LSSS) were assessed two weeks before and two weeks after the treatment intervention and also six months after treatment as primary outcome parameters.

RESULTS

A total of 53 patients were recruited from a specialized outpatient clinic, and out of those, 29 patients completed either the body-focused group therapy program (n = 15) or a guided self-help group (SHG) therapy (n = 14). When analyzing the ITT sample (n = 22 CORDIS group, n = 20 SHG), both groups showed an effect on seizure severity and level of dissociation. In the per protocol sample (n = 13 CORDIS group, n = 12 SHG), CORDIS was superior to the self-help group for reducing seizure severity 6 months after the treatment.

SIGNIFICANCE

CORDIS is a newly developed body-focused group therapy program for adults with PNES. Further studies should include a multicentric design with a higher number of participants.

An evaluation of initial engagement with a virtual group-based psychological treatment for functional seizures

Functional seizures are a common neurological presentation but access to evidence-based treatments is sporadic and often delayed. Patient engagement is an essential prerequisite to any treatment benefits, but previous research has not investigated engagement with psychological group treatments. In this service evaluation, we compared patients who initially engaged and disengaged from an online CBT-based group treatment on demographic and clinical variables, and illness-related beliefs. A self-report survey was used to explore reasons for disengagement. Of 64 patients invited to the group treatment, 39 (60.1%) disengaged before the first session. Older age was associated with engagement with the functional seizures group. There were no other group differences between demographic, clinical, or belief-based variables. Patients who disengaged reported the timing and format as barriers to joining and had preferences for individual and in-person interventions. These findings have implications for the role of clinicians in providing regular tangible information about referral pathways, and motivating patients to engage with available treatments.

Functional Movement Disorder and Functional Seizures: What have we learned from different subtypes of functional neurological disorders?

•

Functional seizures (FS) and functional movement disorders (FMD) are the most common manifestations of functional neurological disorders.

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FMD and FS may have similarities in etiology and pathophysiology.

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FMD and FS share disabling comorbidities of chronic pain, fatigue, and cognitive symptoms.

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Neuroimaging has demonstrated structural and functional changes in emotional and motor planning pathways in FND.

•

A multidisciplinary approach and psychotherapy are the treatments for FMD and FS, respectively.

The objective of this paper is to compare and contrast FMD and FS, and highlight important differences in etiology and the clinical approach towards these two entities. While patients with FMD often experience abnormal movements on a daily basis, FS is characterized by paroxysmal events. Both patient populations share psychiatric and environmental comorbidities, but patients with FS may have increased anxiety and neuroticism and a higher percentage of childhood trauma. Functional MRI scans have demonstrated impaired executive control over motor behavior in both groups. FMD responds well to multidisciplinary rehabilitation-oriented treatment, while psychotherapy remains the mainstay of treatment for FS. For practicing clinicians, recognizing commonalities and differences in patients with FMD and FS is important to develop the most appropriate treatment plan.

Dissociation, Stressors, and Coping in Patients of Psychogenic Nonepileptic Seizures

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.

The effectiveness of psychological interventions for children and adolescents with non-epileptic seizures

BACKGROUND

This article systematically reviews the literature on the effectiveness of psychological interventions for non-epileptic seizures (NES) in children and adolescents.

METHODS

Embase, Medline and PsycINFO were searched to December 2020, for articles published in English, which used an objective measure to evaluate the outcome of a psychological intervention for NES. Further studies were identified from reference lists and experts in the field were contacted for unpublished studies.

RESULTS

Twelve studies met inclusion criteria. Of these, four were set up with the primary aim of evaluating an intervention of which two used a control group, two were prospective outcome studies and eight looked at retrospective clinical data. Two studies evaluated a single treatment modality, the others multiple treatment components. Overall, psychoeducation, and top-down psychotherapy, such as cognitive therapies, were the most frequent interventions, with recent studies describing body-oriented (bottom-up) approaches. Analysis across all studies identified a range of additional intervention components which included assessment and/or treatment for co-morbidities, liaison with school and support for parents, highlighting the importance of individualised treatment packages.

CONCLUSIONS

There is a paucity of studies specifically evaluating interventions for NES. Though a range of approaches have been described in managing this patient group, with generally positive outcomes, it is not possible to conclude from the available literature that one treatment approach is superior to another, though the information may be helpful in developing management guidelines.

Comparison of semiology in patients with psychogenic nonepileptic seizures or with epilepsy in Puerto Rico

PURPOSE

The aims of this study were to develop a descriptive profile of patients with psychogenic nonepileptic seizures (PNES) in Puerto Rico who have been evaluated using an epilepsy monitoring unit. The other aim was to establish comparisons between the clinical manifestation of PNES and events of generalized epilepsy (GE).

METHOD

A retrospective study was conducted to evaluate the information of patients who passed through the Epilepsy Unit in Caguas, Puerto Rico. In the first phase, sociodemographic information of 100 patients with PNES was collected. In the second phase, a sample of 51 cases was obtained; 37 cases with a final diagnosis of PNES and 14 cases with the diagnosis of GE. Observations were made with the objective of viewing and comparing the semiology and clinical manifestation presented through video encephalograms (vEEG) in both subsamples.

RESULTS

Patients with PNES and epilepsy demonstrated different semiological patterns. Psychogenic nonepileptic seizures is predominant in females (95%). Most patients with epilepsy presented a relatively short seizure (<2 min) compared with patients with PNES (79% vs. 46%). Patients with epilepsy showed a slow return to their baseline manifestation (100% vs. 11%). Specifically, having their eyes closed, extreme asynchronous limb movements, and rigidity were statistically significant.

CONCLUSION

These findings provide evidence that the semiology of patients with PNES is different from those displaying an epileptic seizure. This study supports the idea that the semiology of Latino patients with PNES is similar to the characteristics reported in other countries.