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

Cognitive behavioral therapy in adults with functional seizures: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Randomized controlled clinical trials (RCTs) investigating cognitive-behavioral therapy (CBT) among adults with functional seizures (FS) have become increasingly available, prompting the opportunity to critically appraise the efficacy and safety of CBT in this population.

METHODS

We conducted a systematic review and meta-analysis including RCTs comparing CBT in addition to standardized medical treatment (SMT) versus SMT alone for adults with FS. The primary outcome was seizure freedom at the end of treatment. Secondary outcomes included measures of quality of life, anxiety and depression assessed via standardized clinical questionnaires.

RESULTS

Three RCTs were included comprising 228 participants treated with CBT and 222 with SMT. The intervention was significantly associated with seizure freedom (Odds Ratio [OR] 1.98; 95 % confidence interval [CI] 1.14, 3.46; p = 0.02; I2 = 0 %), reductions in anxiety (standardized mean difference [SMD] -0.21; 95 % CI -0.41, -0.003; p = 0.047; I2 = 0 %) and improvements in quality of life (SMD 0.34; 95 % CI 0.12, 0.57; p = 0.003; I2 = 0 %) at the end of treatment. Conversely, no significant differences between groups were observed in depression symptoms (SMD -0.19; 95 % CI -0.39, 0.02; p = 0.08; I2 = 0 %). There was no statistically significant increase in the risk of suicidal ideation and self-harm with CBT (OR 2.11; 95 % CI 0.81, 5.48; p = 0.13; I2 = 0 %) nor were there differences in terms of discontinuation rates during follow-up (OR 0.92; 95 % CI 0.49, 1.72; p = 0.79; I2 = 7 %).

CONCLUSIONS

There is high-quality evidence supporting the efficacy and safety of CBT in treating FS. Future research should investigate whether combining CBT with other therapeutic methods could potentially enhance treatment efficacy.

A comparison of patients with epileptic seizures (ES) versus those with psychogenic non-epileptic seizures (PNES) on measures of alexithymia, mood, and anxiety

OBJECTIVE

To compare persons with epilepsy (PWE) to those with psychogenic non-epileptic seizures (PNES) on measures of depression, anxiety, and alexithymia subscales (i.e., difficulty identifying emotions, difficulty describing emotions, and external-oriented thinking).

MATERIAL AND METHODS

In this retrospective study, 235 epilepsy patients and 90 patients with PNES were evaluated between 2012 and 2020 at the Northeast Regional Epilepsy Group. These patients had completed the Toronto Alexithymia Scale (TAS-20), The Center for Epidemiologic Studies - Depression Scale (CES-D) and The State-Trait Anxiety Inventory (STAI). Background information was collected regarding work/student/disability status at the time of the evaluation history of psychiatric diagnosis; psychological trauma; and involvement in psychotherapy either at the time of the evaluation or prior.

RESULTS

Significant differences between PWEs and those with PNES were found not only in historical data (e.g., Psychiatric History, History of Trauma, and History of Therapy) (p < .001) but also on measures of Depression (p = .002) and Anxiety (p < .001). ANOVA analysis also revealed significant differences in the distribution of the TAS-Total score, TAS-Describing emotions, and TAS-Identifying emotions. Using logistic regression (stepwise model) the optimal set of predictors for a differential diagnosis of epilepsy and PNES was combination of TAS-Identifying emotions score, history of psychological trauma, and history of therapy. The accuracy of the prediction was determined to be 80.2 %.

CONCLUSIONS

Although higher alexithymia rates are present in PNES and PWEs, clinicians may find a combination of TAS-Identifying Emotion score, history of trauma, and history of psychotherapy useful in supporting a differential diagnosis. Also, a subgroup may exist among those with PNES with high levels of alexithymia, depression, and anxiety that may require a different treatment approach focused on addressing difficulties in identifying and describing their emotions and their other symptomatology.

A meta-analytic evaluation of the effectiveness and durability of psychotherapy for adults presenting with functional dissociative seizures

BACKGROUND

Psychological interventions are the most recommended treatment for functional/dissociative seizures (FDS); however, there is ongoing uncertainty about their effectiveness on seizure outcomes.

METHODS

This systematic review and meta-analysis synthesises the available data. In February 2023, we completed a systematic search of four electronic databases. We described the range of seizure-related outcomes captured, used meta-analytic methods to analyse data collected during treatment and follow-up; and explored sources of heterogeneity between outcomes.

RESULTS

Overall, 44 relevant studies were identified involving 1,300 patients. Most were categorised as being at high (39.5 %) or medium (41.9 %) risk of bias. Seizure frequency was examined in all but one study; seizure intensity, severity or bothersomeness in ten; and seizure duration and cluster in one study each. Meta-analyses could be performed on seizure freedom and seizure reduction. A pooled estimate for seizure freedom at the end of treatment was 40 %, while for follow-up it was 36 %. Pooled rates for ≥50 % improvement in seizure frequency were 66 % and 75 %. None of the included moderator variables for seizure freedom were significant. At the group level, seizure frequency improved during the treatment phase with a moderate pooled effect size (d = 0.53). FDS frequency reduced by a median of 6.5 seizures per month. There was also evidence of improvement of the other (non-frequency) seizure-related measures with psychological therapy, but data were insufficient for meta-analysis.

CONCLUSIONS

The findings of this study complement a previous meta-analysis describing psychological treatment-associated improvements in non-seizure-related outcomes. Further research on the most appropriate FDS-severity measure is needed.

Routine outcomes and evaluation of an 8-week outpatient multidisciplinary rehabilitative therapy program for functional neurological disorder

OBJECTIVES

We report routinely collected outcome data from an 8-week outpatient rehabilitative therapy program. The aims of the intervention were to (1) reduce symptom severity and (2) improve functional mobility in adults with functional neurological disorder (FND).

METHODS

The program delivered individual physiotherapy, cognitive behavioral therapy (CBT) and self-management sessions, group physiotherapy, and psychoeducation. Outcome measures included the Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI-II), Work and Social Adjustment Scale (WSAS), 10-Meter Walk Test (10MWT), Timed Up and Go (TUG), and Berg Balance Scale (BBS). Data were analyzed retrospectively in accordance with routine service evaluation. Wilcoxon signed-rank tests assessed changes in outcomes between weeks 1 and 8 for all patients completing treatment (n = 45). For patients who attended the 3-month follow-up (n = 31), Friedman's ANOVA assessed overall change in outcomes over time. Post hoc Wilcoxon signed-rank tests compared pairs of time-points (Weeks 1, 8, and 3-month follow-up).

RESULTS

Analyses of patients completing the program revealed significant improvements in scores between week 1 and week 8. Excluding the BBS, there were statistically significant improvements in all outcomes between weeks 1 and 8 and between weeks 1 and 3-month follow-up.

DISCUSSION

This outpatient therapy program provided effective treatment for FND. Patients reported reduced anxiety, depression, and functional impairment, as well as improved performance on most physiotherapy measures.

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.

Factors associated with illness representations in adults with epileptic and functional seizures: A systematic review

Illness representations refer to a person's beliefs about their health condition and are thought to influence clinical outcomes. By understanding factors related to illness representations, potentially modifiable targets for psychological intervention can be identified. The aim of this systematic review was to synthesise the literature on factors associated with illness representations in people with epilepsy and functional seizures. Three electronic databases (Psychinfo, EMBASE, and Proquest (Theses and dissertations)) were searched for studies that reported on associations between Illness Perception Questionnaire scores (or variations thereof) and biopsychosocial factors in people with epilepsy or people with functional seizures. Seventeen studies met inclusion criteria and were assessed with a bespoke quality appraisal tool. Overall, there was moderately strong evidence for an association between more threatening illness representations and poorer clinical outcomes relating to seizure characteristics, distress, coping, and quality of life; the evidence for these relationships was stronger for people with epilepsy than functional seizures. There was no clear difference between the illness representations of the two groups. The results of this review highlight the clinical importance of illness representations in people with seizure disorders, as well as opportunities for further research.

Performance of the GAD-7 in adults with dissociative seizures

PURPOSE

Little is known about the accuracy of the GAD-7, a self-report anxiety measure, in detecting generalised anxiety disorder (GAD) in people with dissociative seizures (DS). We evaluated the reliability, validity and uniformity of the GAD-7 using a diagnosis of GAD on the Mini-International Neuropsychiatric Interview as a reference.

METHODS

We assessed 368 adults with DS at the pre-randomisation phase of the CODES trial. Factor analysis for categorical data assessed GAD-7 uniformity. Diagnostic accuracy was assessed by estimating the area under the curve (AUC). We evaluated discriminant validity, reviewed data on convergent validity and calculated internal consistency. We explored correlations between GAD-7 scores and monthly DS frequency, frequency of severe seizures and measures of behavioural and emotional avoidance.

RESULTS

Internal consistency of the GAD-7 was high (α = 0.92). Factor analysis elicited one main factor and general measurement invariance. Diagnostic accuracy was fair (AUC = 0.72) but the best balance of sensitivity and specificity occurred at a cut-off of ≥12 and still had a specificity rate of only 68%. Discriminant and convergent validity were good. GAD-7 scores correlated positively with DS frequency, severe seizure frequency, behavioural and emotional avoidance (all p < 0.001).

CONCLUSION

Findings regarding internal consistency and factor structure parallel previous psychometric evaluations of the GAD-7. Correlations between GAD-7 scores and DS occurrence/severity and avoidance are evidence of the concept validity of GAD-7 and provide further support for a fear-avoidance treatment model for DS. However, the utility of the GAD-7 as a diagnostic instrument for generalised anxiety disorder is limited in patients with DS.

Psycho-socio-clinical profiles and quality of life in seizure disorders: A cross-sectional registry study

OBJECTIVE

This prospective study aimed at comparing quality of life (QoL) and psycho-socio-clinical profiles between patients with epilepsy, psychogenic nonepileptic seizures (PNES), and syncope. We also intended to identify predictors of QoL in these three seizure disorders.

METHODS

A total of 245 inpatients (epilepsy n = 182, PNES n = 50, syncope n = 13) from a tertiary epilepsy clinic were included. Information on QoL as well as on psychological, sociodemographic, and clinical profiles was retrieved using questionnaires and medical records. Group comparisons on QoL and psycho-socio-clinical profiles were performed via analyses of variance, chi-square tests, and related post hoc tests. Predictors of QoL in epilepsy and PNES were determined using general linear modeling, which was not possible for syncope due to a small sample size.

RESULTS

Patients with epilepsy, PNES, and syncope reported levels of QoL impairment that did not differ significantly between groups (p = 0.266). However, there were significant group differences regarding sex distribution (p < 0.001), seizure disorder duration (p = 0.004), seizure frequency (p = 0.019), current treatment with antiseizure medications (ASM) (p < 0.001), number of current ASM (p < 0.001), and adverse ASM events (p = 0.019). More depressive symptoms (p = 0.001), more adverse ASM events (p = 0.036), and unemployment (p = 0.046) (in this order) independently predicted a diminished QoL in epilepsy. For PNES, more depressive symptoms were the only independent predictor of lower QoL (p = 0.029).

CONCLUSIONS

Patients with epilepsy, PNES, and syncope experience similarly diminished QoL and show a general psycho-socio-clinical burden with a specific pattern for each seizure disorder diagnosis. Although clinical aspects play an undisputed role for QoL in epilepsy, the psychosocial aspects and consequences are equally, or for PNES probably even more, meaningful. A comprehensive approach to research and treatment of seizure disorders seems mandatory to increase QoL for these patients. More research on QoL in syncope is needed.

Health-related quality of life and its predictors among people living with epilepsy at Dessie Referral Hospital, Amhara, Ethiopia: A cross-sectional study

OBJECTIVES

Health-related quality of life of people living with epilepsy is significantly impaired. The disease causes a significant psychological and social impact on daily living conditions and usually has lifelong consequences for the patient and family. Therefore, this study aimed to investigate the health-related quality of life of people living with epilepsy and its predictors in Dessie Referral Hospital, Dessie, Ethiopia.

METHODS

A facility-based cross-sectional study was conducted from April to June 2020. Systematic random sampling was used to recruit a total of 385 study participants. Written informed consent was obtained for each participant, and data were collected using World Health Organization Quality of Life Brief Version and Hospital Anxiety and Depression Scale questionnaires. Descriptive statistics were used to summarize the data, while multivariate logistic regression analyses were used to examine factors affecting the quality of life. P value ⩽ 0.05 was considered statistically significant.

RESULTS

About 95.80% of the study participants had a generalized seizure, and 64.30% were on two antiepileptic drugs. Of the total, 12.20% and 37.00% suffered from depression and anxiety, respectively, based on the Hospital Anxiety and Depression Scale score. The mean total health-related quality of life score was 51.98 (standard deviation: ± 10.08; 95% confidence interval: 41.90-62.06) out of 100. Age, education level, marital status, occupation, residence, current comorbidity, family support, and recreational activities were associated with good health-related quality of life (p ⩽ 0.05).

CONCLUSION

The average overall quality of life of people living with epilepsy in the Dessie Referral Hospital was low. Therefore, concerted efforts must be made to improve the quality of life of patients over the healthcare services provided.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Perceived stress, resilience, and stress coping in patients with drug resistant epilepsy and functional dissociative seizures

PURPOSE

Depression and anxiety are psychiatric disorders related to chronic stress, commonly found in patients with drug-resistant epilepsy (DRE) and functional dissociative seizures (FDS). The present study compares the levels of perceived stress, resilience, and the styles of stress coping among patients with DRE (n=60), FDS (n=28), and controls (n=31).

METHODS

We performed a cross-sectional study. All patients underwent Video Electroencephalography to confirm the diagnosis and completed the psychiatric assessment (SCID I and II of DSM IV) supported by several instruments validated in Spanish.

RESULTS

FDS scored higher in perceived stress (p = 0.004) with lower levels of resilience compared to controls (p = 0.01). Stress coping subscales show higher scores in negative self-focus and hostility in patients with FDS compared to controls (p=0.003). Similarly, DRE patients scored higher in perceived stress (p = 0.001), and presented lower levels of resilience (p = 0.004) with higher levels of hostility compared to controls (p=0.02). However, no significant differences were found between FDS and DRE on stress coping variables. Anxiety scores and depression rates were higher in the FDS group compared to DRE (p=0.008) and higher in DRE compared to controls (p<0.05). A positive correlation between depression and perceived stress was found (r = 0.6, p=0.0001).

CONCLUSIONS

Our results delineate a more detailed picture of the psychological profile of this population, emphasizing the importance of stress factors in patients with FDS and DRE. Combined intervention strategies which enhance stress coping may be appropriate to direct treatment and psychotherapy.

Quality of Life in Psychogenic Nonepileptic Seizures: An Evolutionary Concept Analysis

Psychogenic nonepileptic seizures (PNES) pose a serious threat to quality of life (QOL) in patients who battle the disorder. As psychological treatment options have progressed, improvement in QOL has become a more common desired outcome. Despite its relevance in PNES research and treatment, QOL has not been defined in the PNES population. Rodgers' Evolutionary Method of concept analysis was used to analyze 47 articles and clarify the concept of QOL in PNES. QOL in PNES is subjective, multidimensional, associated with symptoms, and dynamic in nature. This conceptualization of QOL in PNES may be useful in future PNES research and treatment.

The association between illness perception and quality of life among Chinese adults with epilepsy: The mediating role of coping style

OBJECTIVE

To evaluate the associations between illness perception, quality of life (QOL), and coping style among patients with epilepsy (PWE), and to establish the behavior of coping style as a mediator of the interplay between illness perception and QOL.

METHODS

A cross-sectional study of 135 adult Chinese PWE was performed. All patients completed clinical and demographic questionnaires, the Chinese version of the Revised Illness Perception Questionnaire (CIPQ-R), the quality of life in epilepsy-31 inventory (QOLIE-31), and the Simplified Coping Style Questionnaire (SCSQ). Collected data were assessed through correlation analyses, structural equation modeling (SEM), and multiple stepwise linear regression assessments.

RESULTS

These patients exhibited a mean QOLIE-31 total score of 46.9 points, consistent with moderately low QOL. Under model III (F = 9.447, p < 0.01, R² = 0.486), all included variables were found to explain 48.6% of the observed variation in QOL, with illness perception and coping style, respectively, explaining 27.3% and 7% of such variation. SEM findings illustrated that the total influence value of illness perception on QOL was 77.5% (β = -0.775, p < 0.001). Moreover, the illness perception was found to have a direct impact on QOL (β = -0.620, p = 0.001), negative coping (β = 0.309, p < 0.001), and positive coping (β = -0.265, p = 0.014), with negative coping (β = -0.256, p = 0.003), and positive coping (β = 0.288, p = 0.006) also having a direct impact on such QOL. Positive and negative coping styles also served as mediators of an indirect relationship between illness perception and QOL (β = -0.27*0.29 + 0.31* - 0.26 = -0.159, p = 0.001), with coping style thus serving as a significant mediator of the association between QOL and illness perception. The mediating impact of coping style on QOL accounted for 20.5% (-0.159/-0.775) of the total influence.

CONCLUSION

Both coping style and illness perception were detected to be significantly correlated with the QOL of Chinese adult PWE, with coping style serving as a mediator of the association between QOL and illness perception in this patient population. As such, when seeking to control seizures, medical workers should assess illness perceptions and coping styles among PWE as quickly as possible in order to select the optimal interventions most likely to improve the QOL of these patients.

Meanings of quality of life among people living with epilepsy in Ghana; a qualitative exploratory study

PURPOSE

The purpose of this study was to explore the meanings of quality of life among people living with epilepsy (PLWE) in Ghana.

METHODS

An exploratory-qualitative study design was adopted. Face-to-face in-depth interviews, using a semi-structured interview guide, were conducted on 15 PLWE who were purposively selected for the study. The interviews were audio recorded and transcribed verbatim. The content analysis approach was then used to analyze the data.

RESULTS

Four themes - "acceptance", "support", "seizure control", and "self-reliance" emerged from the study as meanings of Quality of life (QoL). Quality of life meant unconditional acceptance from family, friends, acquaintances at home, school, and work, and by the public despite epilepsy. Receiving support in the form of protection from injury during a seizure, financial assistance to meet individual and family demands, emotional warmth, and spiritual support through prayers and encouragement, was QoL for PLWE. Achievement of control over seizures and being self-reliant in terms of selfcare and daily activities in addition to having some form of financial independence meant QoL.

CONCLUSION

Meanings of quality of life among PLWE is associated with being accepted and supported by family and friends as well as being in control of seizures and attaining a status of independence.

EuroQOL-5D-3L does not adequately map quality-of-life deterioration in severely affected patients with epilepsy

INTRODUCTION

The steadily increasing impact of health-related quality of life (HRQOL) on reasonable diagnostic and therapeutic decisions makes the correct mapping of HRQOL indispensable in modern epileptology. The aim of this study was to address the reliability of the often-used generic HRQOL screening questionnaire EuroQOL 5-dimension, 3-level (EQ-5D-3L) by comparing its normalized index value (calculated via the time trade-off method) and visual analog scale (VAS) to the gold standard of the extensive Quality of Life in Epilepsy Inventory (QOLIE-31). QOLIE-10 scores were compared with the extensive QOLIE-31 and EQ-5D-3L TTO.

METHODS

We conducted a retrospective analysis of a monocentric study of 184 patients with epilepsy. Bivariate Spearman correlation analysis and Fisher's r-to-z transformation were used to compare the strengths of correlations of EQ-5D-3L, QOLIE-10 and QOLIE-31 with different epilepsy-specific domains (disease severity, drug interactions, emotional well-being, stigmatization, seizure-related anxiety, cognitive impairment).

RESULTS

The different metrics of EQ-5D-3L, QOLIE-10 and QOLIE-31 showed moderate to very strong intra- and inter-metric correlations for overall HRQOL. Quality of Life in Epilepsy Inventory-31 VAS and EQ-5D-3L VAS did not show any significantly different strengths of correlations with respect to the domains studied. In contrast, the correlation strength of the normalized EQ-5D-3L index value differed significantly from the QOLIE-31 T-score for several domains, for example, for drug-related adverse events, neuropsychological deficits, symptoms of depression and seizure worry. In seizure-free patients, EQ-5D-3L VAS and EQ-5D-3L index values correlated significantly less with the domain of "cognitive impairment" than the QOLIE-31 T-score. In patients without relevant neuropsychological deficits, the strengths of correlations with the assessed domains did not differ significantly between EQ-5D-3L metrics and the QOLIE-31 T-score. The HRQOL mapping probability of QOLIE-10 was inferior to QOLIE-31 and comparable to EQ-5D-3L regarding the analyzed domains.

CONCLUSION

In contrast to the EQ-5D-3L VAS, EQ-5D-3L index values do not adequately map health-related quality of life in severely affected patients with epilepsy and therefore should not be used as screening tools. The QOLIE-31 T-score remains the gold standard for HRQOL assessment in patients with epilepsy.

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.

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.

Association between antiseizure medications and quality of life in epilepsy: A mediation analysis

OBJECTIVE

The relationship between antiseizure medications (ASMs), which improve health outcomes by controlling seizures, and health-related quality of life (HRQOL) is poorly understood and may involve intermediate variables. We evaluated the potential mediators of the association between ASMs and HRQOL.

METHODS

Data are from an outpatient registry of adult patients with epilepsy seen at the Foothills Medical Center, Calgary, Alberta, Canada. Quality of life was measured using the 10-item Quality of Life in Epilepsy, and depression was measured using the Neurological Disorders Depression Inventory for Epilepsy. Propensity score matching was used to adjust for covariate imbalance between patients who received a single ASM (monotherapy) and those who received two or more ASMs (polytherapy) due to confounding. Mediation analysis was used to estimate the mediating effects of depression and ASM side effects on the association between patients' ASM polytherapy and HRQOL.

RESULTS

Of 778 patients included in this analysis, 274 (35.2%) were on two or more ASMs. Patient-reported depression and ASM side effects jointly mediated the association between ASMs and HRQOL; these mediators accounted for 42% of the total average effect of ASM polytherapy ( β  = -13.6, 95% confidence interval = -18.2 to -8.6) on HRQOL.

SIGNIFICANCE

These findings highlight the importance of managing depression and ASM side effects for improving health outcomes of patients requiring treatment with ASMs. Intervention programs aimed at improving HRQOL of patients with epilepsy need to target these potential mediators.

Functional seizures are not less important than epilepsy

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People with functional seizures often suffer from psychiatric comorbidities.

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People with FS report detrimental effects on social aspects of their lives.

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FS are associated with a considerable direct and indirect economic burden.

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FS have increased rates of mortality compared to healthy controls.

Functional seizures (FS) are frequently encountered in neurology clinics, often affect young adults, and have significant negative impacts on many aspects of a person’s life. In the current narrative review, we searched the literature regarding some of the consequences of FS (i.e., psychiatric comorbidities, social consequences, costs that are associated with the condition, cognitive impairment in patients with FS, the quality of life of the people with FS, and the increased risk of mortality that is associated with FS). Evidence shows that FS have significant negative consequences, comparable in their magnitude to those affecting patients with epilepsy. The clinical and scientific communities should take steps to address these consequences through clinical care and research that prioritizes, facilitates, and expedites evidence-based diagnosis and treatment for FS.

Utility of mental health and sleep screening questionnaires for patients admitted to a seizure monitoring unit

RATIONALE

Patients with seizure disorders have relatively high rates of comorbid psychological and sleep disorders. Because these can profoundly affect quality of life, early recognition and treatment are of potential benefit. As a quality improvement project, we evaluated the performance and utility of a set of mental health and sleep quality screening questionnaires in patients admitted to a VA seizure monitoring unit (SMU).

METHODS

Questionnaires, including the Beck Depression Inventory-II (BDI-II), the post-traumatic stress disorder (PTSD) checklist (PCL), the Quality of Life in Epilepsy Inventory-31 (QOLIE-31), and the Pittsburgh Sleep Quality Index (PSQI), were administered to 100 patients admitted to the Portland VAMC SMU. Scored results were entered into the electronic medical record (EMR) within 72 h of hospital admission. We assessed how many patients exceeded questionnaire cutoff scores, and whether these patients had prior mental health or sleep diagnoses or evaluations within the six months preceding admission. Following hospital discharge, providers completed a survey regarding the utility of the questionnaire results. We also reviewed EMR documented mental health and sleep visits during the six months following the SMU admission.

RESULTS

Forty-seven patients (47.5%) exceeded the cutoff score for the BDI-II, including 15 without an admission diagnosis of depression, and 14 who had not seen a mental health provider in the previous six months. Similarly, 33 patients (33.3%) exceeded the cutoff score for the PCL, including nine without a diagnosis of PTSD. Scores on the BDI-II and PCL were highly correlated with the QOLIE-31 total score (r = 0.7). Seventy patients (70.7%) exceeded the cutoff score for poor sleep quality, and 37 did not have a sleep disorder diagnosis. Providers indicated that the questionnaire results were moderately or very helpful in most cases and influenced discharge recommendations to patients and referring providers in more than 50% of cases. Discharge recommendations for mental health or sleep follow-up were associated with EMR documented consultations within the six months following SMU admission.

CONCLUSIONS

The results suggest that a standard set of screening questionnaires can identify SMU patients at risk for mental health and sleep disorders, including patients not currently diagnosed or recently evaluated. Questionnaire results were perceived as helpful by providers and influenced discharge recommendations. Given that these disorders are treatable and have a major influence on health-related quality of life, the effort to collect and document this information is well justified.

Psychiatric disorders, depression and quality of life in patients with psychogenic non-epileptic seizures and drug resistant epilepsy living in Argentina

OBJECTIVES

Psychiatric disorders are frequently found in both patients with PNES and DRE, making the differential diagnosis even more complex. The aim of this study was to analyze and compare psychiatric aspects and the quality of life in patients with psychogenic non-epileptic seizures (PNES) and drug resistant epilepsy (DRE).

METHODS

Patients admitted to video-electroencephalograpy (VEEG) unit with confirmed PNES and DRE were included. Demographical characteristics, psychiatric diagnosis according to SCID I and II of DSM IV, pharmacological treatment, general functioning measured with GAF (Global assessment of functionality), quality of life (QoL) using QlesQSF (Quality of Life Enjoyment and Satisfaction Questionnaire Short Form) and depression severity using BDI II (Beck depression inventory), were compared between the groups. Non-parametric tests, chi square test, and logistic regression were used for statistical analysis.

RESULTS

148 patients consecutively admitted to VEEG were included (DRE n = 97; PNES n = 51). Somatization disorder (RR: 13.02, 95% CI: 1.23-137.39, p = 0.03) and a history of trauma (RR: 8.66, 95% CI: 3.21-23.31, p = 0.001) were associated with PNES. The QlesQ score and the GAF score were lower with a higher prevalence of suicide attempts in the PNES group (p < 0.01). A negative correlation was observed between the severity of depression and the quality of life (DRE r = - 0.28, p = 0.013; PNES r = - 0.59, p = 0.001).

CONCLUSIONS

Higher psychiatric comorbidity with poorer QoL were found in PNES patients compared to DRE. However, depression comorbidity negatively affected the QoL in both groups. Future studies based on illness perception will be orientated to complete this analysis.

What do we know about non-epileptic seizures in adults with intellectual disability: A narrative review

Psychogenic non-epileptic seizures (PNES) superficially resemble epileptic seizures, but are not associated with abnormal electrical activity in the brain. PNES are a heterogeneous entity and while there is increasing interest in the characterisation of PNES sub-groups, little is known about individuals with PNES who have an intellectual disability (ID). ID is a lifelong condition characterised by significant limitations in cognitive, social and practical skills. ID (commonly with comorbid epilepsy) has been identified as a risk factor for developing PNES. However, people with ID are often excluded from research in PNES. This has unfortunately resulted in a lack of evidence to help inform practice and policy for this population. This narrative review synthesises the currently available evidence in terms of the epidemiology, demographic and clinical profile of adults with PNES and ID. There is a particular focus on demographics, aetiological factors, PNES characteristics, diagnosis and treatment of the condition in this population. Throughout this article, we critique the existing evidence, discuss implications for clinical practice and highlight the need for further research and enquiry. What emerges from the evidence is that, even within the sub-group of those with ID, PNES are a heterogeneous condition. Individuals with ID and PNES are likely to present with diverse and complex needs requiring multidisciplinary care. This review is aimed at the broad range of healthcare professionals who may encounter this group. We hope that it will stimulate further discussion and research initiatives.

Validation of the PHQ-9 in adults with dissociative seizures

BACKGROUND

The PHQ-9 is a self-administered depression screening instrument. Little is known about its utility and accuracy in detecting depression in adults with dissociative seizures (DS).

OBJECTIVES

Using the Mini - International Neuropsychiatric Interview as a reference, we evaluated the diagnostic accuracy of the PHQ-9 in adults with DS, and examined its convergent and discriminant validity and uniformity.

METHODS

Our sample comprised 368 people with DS who completed the pre-randomisation assessment of the CODES trial. The uniformity of the PHQ-9 was determined using factor analysis for categorical data. Optimal cut-offs were determined using the area under the curve (AUC), Youden Index, and diagnostic odds ratio (DOR). Convergent and discriminant validity were assessed against pre-randomisation measures.

RESULTS

Internal consistency of the PHQ-9 was high (α = 0.87). While the diagnostic odds ratio suggested that a cut-off of ≥10 had the best predictive performance (DOR = 14.7), specificity at this cut off was only 0.49. AUC (0.74) and Youden Index (0.48) suggested a ≥ 13 cut-off would yield an optimal sensitivity (0.81) and specificity (0.67) balance. However, a cut-off score of ≥20 would be required to match specificity resulting from a cut-off of ≥13 in other medical conditions. We found good convergent and discriminant validity and one main factor for the PHQ-9.

CONCLUSIONS

In terms of internal consistency and structure, our findings were consistent with previous validation studies but indicated that a higher cut-off would be required to identify DS patients with depression with similar specificity achieved with PHQ-9 screening in different clinical and non-clinical populations.

Social aspects of life in patients with functional seizures: Closing the gap in the biopsychosocial formulation

The human, as a biological system, is an open system embedded within larger systems -including the family, culture, and socio-political environment. In this context, a patient with functional seizures (FS) is embedded in relationships, educational/professional institutions, culture, and society. Both connection to these broader systems and the quality of these connections, as well as the soundness of each system in and of itself, influence the health and well-being of patients in positive or negative ways. The social aspects of life are important determinants of health and quality of life across the lifespan. The current narrative review brings out several overarching themes in patients with FS. Sections on attachment, marriage, social networking, and stigma highlight the central roles of supportive and affirmative relationships across the lifespan. The section on education underscores the importance of keeping children and youth with FS connected within their school environments, as well as managing any barriers - learning difficulties, school response to FS events, stigma, etc.-that can diminish this connection. Finally, the sections on employment and driving highlight the value of being an active participant in one's society. In summary, FS impacts patients across most social aspects of life domains regardless of age - factors that are important when developing biopsychosocial formulations. This review concludes that the multidisciplinary management of FS requires careful assessment of social aspects of life in patients which can then be targeted for treatment, to improve their quality of life, facilitating recovery, and reducing the risk of relapse.

Neuroimaging in Functional Neurological Disorder: State of the Field and Research Agenda

Functional neurological disorder (FND) was of great interest to early clinical neuroscience leaders. During the 20th century, neurology and psychiatry grew apart - leaving FND a borderland condition. Fortunately, a renaissance has occurred in the last two decades, fostered by increased recognition that FND is prevalent and diagnosed using "rule-in" examination signs. The parallel use of scientific tools to bridge brain structure - function relationships has helped refine an integrated biopsychosocial framework through which to conceptualize FND. In particular, a growing number of quality neuroimaging studies using a variety of methodologies have shed light on the emerging pathophysiology of FND. This renewed scientific interest has occurred in parallel with enhanced interdisciplinary collaborations, as illustrated by new care models combining psychological and physical therapies and the creation of a new multidisciplinary FND society supporting knowledge dissemination in the field. Within this context, this article summarizes the output of the first International FND Neuroimaging Workgroup meeting, held virtually, on June 17th, 2020 to appraise the state of neuroimaging research in the field and to catalyze large-scale collaborations. We first briefly summarize neural circuit models of FND, and then detail the research approaches used to date in FND within core content areas: cohort characterization; control group considerations; task-based functional neuroimaging; resting-state networks; structural neuroimaging; biomarkers of symptom severity and risk of illness; and predictors of treatment response and prognosis. Lastly, we outline a neuroimaging-focused research agenda to elucidate the pathophysiology of FND and aid the development of novel biologically and psychologically-informed treatments.

Epilepsy, dissociative seizures, and mixed: Associations with time to video-EEG

PURPOSE

Video-electroencephalographic monitoring (VEM) is a core component to the diagnosis and evaluation of epilepsy and dissociative seizures (DS)-also known as functional or psychogenic seizures-but VEM evaluation often occurs later than recommended. To understand why delays occur, we compared how patient-reported clinical factors were associated with time from first seizure to VEM (TVEM) in patients with epilepsy, DS or mixed.

METHODS

We acquired data from 1245 consecutive patients with epilepsy, VEM-documented DS or mixed epilepsy and DS. We used multivariate log-normal regression with recursive feature elimination (RFE) to evaluate which of 76 clinical factors interacting with patients' diagnoses were associated with TVEM.

RESULTS

The mean and median TVEM were 14.6 years and 10 years, respectively (IQR 3-23 years). In the multivariate RFE model, the factors associated with longer TVEM in all patients included unemployment and not student status, more antiseizure medications (current and past), concussion, and ictal behavior suggestive of temporal lobe epilepsy. Average TVEM was shorter for DS than epilepsy, particularly for patients with depression, anxiety, migraines, and eye closure. Average TVEM was longer specifically for patients with DS taking more medications, more seizure types, non-metastatic cancer, and with other psychiatric comorbidities.

CONCLUSIONS

In all patients with seizures, trials of numerous antiseizure medications, unemployment and non-student status was associated with longer TVEM. These associations highlight a disconnect between International League Against Epilepsy practice parameters and observed referral patterns in epilepsy. In patients with dissociative seizures, some but not all factors classically associated with DS reduced TVEM.

Quality of Life and Associated Factors Among Patients with Epilepsy Attending Outpatient Department of Saint Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia, 2019

Background

Epilepsy is strongly associated with an impaired quality of life. Patients suffering from epilepsy have a poorer quality of life than both the general population and many other chronic disease sufferers. However, attention is not given on the quality of life of people with epilepsy other than focusing on symptom reduction. This increases the frequency of seizures, impacts on the ability to perform and increases health-related costs. The aim of this study was to assess quality of life and associated factors among patients with epilepsy attending the outpatient department of Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia.

Methods

An institution-based cross-sectional study design was conducted between May and June 2019 at Amanuel Mental Specialized Hospital. A systematic random sampling technique was used to get a total number of 447 samples. Data on quality of life was assessed through interviews using the World Health Organization Quality of Life—Brief (WHOQOL-BREF) Version. The collected data were coded, entered into EpiData 3.1, and analyzed by using SPSS version 20. Simple and multiple linear regression analysis models were fitted and the unstandardized β coefficient at 95% confidence interval was employed. The statistical significance was accepted at p-value <0.05.

Results

The mean score of quality of life was 61.1±11.6 (95%CI: 59.05, 61.23). Perceived stigma (β=−2.13, 95%CI:–2.96, −1.30), frequent seizure (β=−3.16, 95%CI: -4.27, −2.04), AED adherence (β=1.24, 95%CI: 1.10, 1.30), antiepileptic drug side effect (β=−0.32, 95%CI: -0.38, −0.26), anxiety (β-1.91, 95%CI: –2.95, −0.86), depression (β=−3.59, 95%CI: –4.67, −2.52), poor social support (β=−2.51, 95%CI: –3.62, −1.40) and moderate social support (β=−1.60, 95%CI: –2.58, −0.62) were significantly associated factors with quality of life.

Conclusion

The finding from this study indicated that quality of life of patients with epilepsy were moderate. Perceived stigma, frequent seizure, comorbid depression and anxiety, antiepileptic drug nonadherence, antiepileptic drug side effect and poor social support were the predictors of quality of life.

Functional Seizures

Functional or psychogenic seizures have proved a diagnostic and therapeutic challenge for centuries. Functional seizures can look and feel similar to epileptic seizures but are instead a common and highly disabling form of functional neurologic disorder, or conversion disorder. Consistent with the biopsychosocial model of mental illness, functional seizures are caused by biological, psychological, and social factors unrelated to epileptic discharges. People with functional seizures do not consciously fake their symptoms. Functional seizures can be differentiated from epileptic seizures through the clinical history, features of the seizures themselves, and electroencephalography findings. Psychotherapy is effective in treating functional seizures.

Explanatory factors of quality of life in psychogenic non-epileptic seizure

OBJECTIVE

Previous studies showed that patients with Psychogenic Non-Epileptic Seizures (PNES) have poor quality of life (QoL). This study explored the explicative factors of the QoL at the time of diagnosis and monitored changes over the two years of follow-up.

METHODS

We evaluated 107 participants with a diagnosis of Psychogenic Non-Epileptic Seizure (PNES), every 6 months for 24 months. Quality of life (QoL) was evaluated using the QOLIE-31 and SF-36 scales (respectively specific and generic scales of QoL). Positive evolution of QoL was defined by the increase in the score of overall QoL using QOLIE-31 sub-scale from baseline to the last interview of the patient. We also collected for each patient data on psychiatric dimensions (childhood abuse, history of traumatic events, post-traumatic stress disorder (PTSD), depression, anxiety, alexithymia, and dissociation), clinical evolution of seizures and the number of mental health consultations.

RESULTS

According to the QOLIE-31 and the SF-36, depression (p ≤ 0.001), anxiety (p < 0.001), alexithymia (p ≤ 0.001), and dissociation (p ≤ 0.004) were related to QoL at the time of the diagnosis. According to SF-36 (mental and physical), PTSD was also significantly associated with QoL (p < 0.05). The number of seizures or the co-occurrence of epilepsy did not influence QoL. Positive evolution of QoL was linked to the number of consultations for mental health issues (p = 0.02).

SIGNIFICANCE

Post-traumatic dimensions (PTSD, dissociation), alexithymia and psychiatric comorbidities (depression and anxiety disorders) seem to alter QoL in people with PNES. The current study suggests that mental health care improves QoL of patients with PNES.

Quality of life, fatigue and seizure severity in people living with epilepsy in a selected Nigerian population

BACKGROUND

Epilepsy, a chronic seizure disorder, can cause elevated fatigue and reduced quality of life (QOL) of the sufferers. Hence, improving QOL, seizure severity (SS) and fatigue are important areas of therapeutic interventions for people living with epilepsy (PLWE). Therefore, there is need to ascertain the levels and interrelationships among these constructs in PLWE.

OBJECTIVE

This study compared fatigue and QOL of PLWE with those of apparently healthy individuals (AHIs) and also determined the interrelationships between fatigue, QOL and SS in PLWE.

METHOD

This cross-sectional survey involved 91 PLWE and 101 AHIs consecutively recruited from purposively selected hospitals and hosting communities. The Short-form Health Survey (SF-36) questionnaire, the Fatigue Severity Scale, the Modified Fatigue Impact Scale and the Seizure Severity Questionnaire were used to evaluate QOL, fatigue severity (FS), fatigue impact (FI) and SS respectively. Data was analyzed using frequency count, proportions, mean and standard deviation, range, Chi-square test, Mann-Whitney U test and Spearman-rank order correlation. Alpha level was set at 0.05.

RESULTS

PLWE had significantly lower QOL compared to AHIs (U = 3057.00;p < 0.01). The two groups however experienced similar fatigue severity, but PWE suffered greater fatigue impact (U = 2798.00;p < 0.01). Significant relationships existed among FI, FS, SS and QOL in PLWE (p < 0.01).

CONCLUSION

Compared with AHIs, PLWE had poorer QOL, similar FS, and higher FI. QOL of PLWE was negatively associated with SS, FI and FS. Clinical interventions geared towards minimizing seizure, severity and impact of fatigue may improve the QOL of PLWE.

Correlates of health-related quality of life in youth with psychogenic non-epileptic seizures

BACKGROUND

Few studies have examined factors associated with health-related quality of life (HRQoL) in youth with psychogenic non-epileptic seizures (PNES). In adults, internalizing symptoms such as depression have been shown to be more closely associated with HRQoL than seizure frequency, however, this has not been studied in samples of youth. Investigations into these areas are needed in order to enhance our understanding of the impact of this condition on children and adolescents and inform future clinical intervention.

METHODS

The current study includes 37 youth and one of their parents who attended a clinic visit for treatment of PNES. Children and parents completed measures of psychological functioning, and medical data were extracted from patient charts.

RESULTS

Parent-reported anxiety (B=-0.45, p = 0.05) and depression (B=-0.60, p = 0.01) were related to parent-report of HRQoL; self-report of depression was related to self-reported HRQoL (B=-0.90, p < 0.001). Seizure frequency, somatic complaints, and social problems were not related to HRQoL in this sample.

CONCLUSIONS

Internalizing symptoms, not seizure frequency, are associated with poorer overall functioning in youth with PNES. Interventions focused on improving anxiety and depression in addition to seizure cessation may contribute to improved HRQoL in youth with PNES more so than those focused on seizure cessation alone.

Catastrophising and repetitive negative thinking tendencies in patients with psychogenic non-epileptic seizures or epilepsy

PURPOSE

Previous research suggests that catastrophisation and perseverative, or repetitive negative thinking (RNT) could play an important role in the aetiology of Psychogenic Nonepileptic Seizures (PNES). This study was designed to explore whether these cognitive tendencies are more prevalent in patients with PNES than those with epilepsy and to examine the relationship between these cognitions, depression, anxiety, seizure frequency and diagnosis.

METHODS

26 patients with PNES (PWPNES) and 29 with epilepsy (PWE) self-reported RNT (Perseverative Thinking Questionnaire), catastrophisation tendencies (modified Safety Behaviors and Catastrophizing Scale), symptoms of anxiety (Generalised Anxiety Disorder Assessment 7) and depression (Primary Health Questionnaire 9) as well as seizure frequency.

RESULTS

RNT and catastrophic thinking were highly correlated with each other and more prevalent in PWPNES than PWE. Positive correlations were also found between all other self-report measures and seizure frequency. The PNES diagnosis predicted RNT (perseverative thinking) independently of catastrophic thinking, anxiety, depression and seizure frequency.

CONCLUSION

PWPNES exhibit greater negative perseverative and catastrophising cognitive tendencies than PWE. PNES as a diagnosis independently predicted RNT. Hence, RNT and catastrophisation should be considered as possible specific targets for psychological interventions in patients with PNES.

Functional Stroke Symptoms: A Narrative Review and Conceptual Model

Stroke services have been reconfigured in recent years to facilitate early intervention. Throughout stroke settings, some patients present with functional symptoms that cannot be attributed to a structural cause. Emphasis on fast diagnosis and treatment means that a proportion of patients entering the care pathway present with functional symptoms that mimic stroke or have functional symptoms in addition to vascular stroke. There is limited understanding of mechanisms underlying functional stroke symptoms, how the treatment of such patients should be managed, and no referral pathway or treatment. Predisposing factors vary between individuals, and symptoms are heterogeneous: onset can be acute or insidious, and duration can be short-lived or chronic in the context of new or recurrent illness cognitions and behaviors. This article proposes a conceptual model of functional symptoms identified in stroke services and some hypotheses based on a narrative review of the functional neurological disorder literature. Predisposing factors may include illness experiences, stressors, and chronic autonomic nervous system arousal. Following the onset of distressing symptoms, perpetuating factors may include implicit cognitive processes, classical and operant conditioning, illness beliefs, and behavioral responses, which could form the basis of treatment targets. The proposed model will inform the development of theory-based interventions as well as a functional stroke care pathway.

Psychological inflexibility and somatization in nonepileptic attack disorder

BACKGROUND

There is no clear understanding of what causes and maintains nonepileptic attack (NEA) disorder (NEAD), or which psychological therapies may be helpful. The relationships between variables of psychological inflexibility: experiential avoidance (EA), cognitive fusion (CF), mindfulness, and key outcome variables in NEAD: somatization, impact upon life, and NEA frequency were investigated.

METHOD

Two hundred eighty-five individuals with NEAD completed validated measures online. Linear regression was used to explore which variables predicted somatization and impact upon life. Ordinal regression was used to explore variables of interest in regard to NEA frequency.

RESULTS

Mindfulness, EA, CF, somatization, and impact upon life were all significantly correlated. Mindfulness uniquely predicted somatization when considered in a model with EA and CF. Higher levels of somatization increased the odds of experiencing more NEAs. Individuals who perceived NEAD as having a more significant impact upon their lives had more NEAs, more somatic complaints, and more EA.

CONCLUSIONS

Higher levels of CF and EA appear to be related to lower levels of mindfulness. Lower levels of mindfulness predicted greater levels of somatization, and somatization predicted NEA frequency. Interventions that tackle avoidance and increase mindfulness, such as, acceptance and commitment therapy, may be beneficial for individuals with NEAD. Future directions for research are suggested as the results indicate more research is needed.

Outcome measurement in functional neurological disorder: a systematic review and recommendations

OBJECTIVES

We aimed to identify existing outcome measures for functional neurological disorder (FND), to inform the development of recommendations and to guide future research on FND outcomes.

METHODS

A systematic review was conducted to identify existing FND-specific outcome measures and the most common measurement domains and measures in previous treatment studies. Searches of Embase, MEDLINE and PsycINFO were conducted between January 1965 and June 2019. The findings were discussed during two international meetings of the FND-Core Outcome Measures group.

RESULTS

Five FND-specific measures were identified-three clinician-rated and two patient-rated-but their measurement properties have not been rigorously evaluated. No single measure was identified for use across the range of FND symptoms in adults. Across randomised controlled trials (k=40) and observational treatment studies (k=40), outcome measures most often assessed core FND symptom change. Other domains measured commonly were additional physical and psychological symptoms, life impact (ie, quality of life, disability and general functioning) and health economics/cost-utility (eg, healthcare resource use and quality-adjusted life years).

CONCLUSIONS

There are few well-validated FND-specific outcome measures. Thus, at present, we recommend that existing outcome measures, known to be reliable, valid and responsive in FND or closely related populations, are used to capture key outcome domains. Increased consistency in outcome measurement will facilitate comparison of treatment effects across FND symptom types and treatment modalities. Future work needs to more rigorously validate outcome measures used in this population.

Cognitive behavioural therapy for adults with dissociative seizures (CODES): a pragmatic, multicentre, randomised controlled trial

BACKGROUND

Dissociative seizures are paroxysmal events resembling epilepsy or syncope with characteristic features that allow them to be distinguished from other medical conditions. We aimed to compare the effectiveness of cognitive behavioural therapy (CBT) plus standardised medical care with standardised medical care alone for the reduction of dissociative seizure frequency.

METHODS

In this pragmatic, parallel-arm, multicentre randomised controlled trial, we initially recruited participants at 27 neurology or epilepsy services in England, Scotland, and Wales. Adults (≥18 years) who had dissociative seizures in the previous 8 weeks and no epileptic seizures in the previous 12 months were subsequently randomly assigned (1:1) from 17 liaison or neuropsychiatry services following psychiatric assessment, to receive standardised medical care or CBT plus standardised medical care, using a web-based system. Randomisation was stratified by neuropsychiatry or liaison psychiatry recruitment site. The trial manager, chief investigator, all treating clinicians, and patients were aware of treatment allocation, but outcome data collectors and trial statisticians were unaware of treatment allocation. Patients were followed up 6 months and 12 months after randomisation. The primary outcome was monthly dissociative seizure frequency (ie, frequency in the previous 4 weeks) assessed at 12 months. Secondary outcomes assessed at 12 months were: seizure severity (intensity) and bothersomeness; longest period of seizure freedom in the previous 6 months; complete seizure freedom in the previous 3 months; a greater than 50% reduction in seizure frequency relative to baseline; changes in dissociative seizures (rated by others); health-related quality of life; psychosocial functioning; psychiatric symptoms, psychological distress, and somatic symptom burden; and clinical impression of improvement and satisfaction. p values and statistical significance for outcomes were reported without correction for multiple comparisons as per our protocol. Primary and secondary outcomes were assessed in the intention-to-treat population with multiple imputation for missing observations. This trial is registered with the International Standard Randomised Controlled Trial registry, ISRCTN05681227, and ClinicalTrials.gov, NCT02325544.

FINDINGS

Between Jan 16, 2015, and May 31, 2017, we randomly assigned 368 patients to receive CBT plus standardised medical care (n=186) or standardised medical care alone (n=182); of whom 313 had primary outcome data at 12 months (156 [84%] of 186 patients in the CBT plus standardised medical care group and 157 [86%] of 182 patients in the standardised medical care group). At 12 months, no significant difference in monthly dissociative seizure frequency was identified between the groups (median 4 seizures [IQR 0-20] in the CBT plus standardised medical care group vs 7 seizures [1-35] in the standardised medical care group; estimated incidence rate ratio [IRR] 0·78 [95% CI 0·56-1·09]; p=0·144). Dissociative seizures were rated as less bothersome in the CBT plus standardised medical care group than the standardised medical care group (estimated mean difference -0·53 [95% CI -0·97 to -0·08]; p=0·020). The CBT plus standardised medical care group had a longer period of dissociative seizure freedom in the previous 6 months (estimated IRR 1·64 [95% CI 1·22 to 2·20]; p=0·001), reported better health-related quality of life on the EuroQoL-5 Dimensions-5 Level Health Today visual analogue scale (estimated mean difference 6·16 [95% CI 1·48 to 10·84]; p=0·010), less impairment in psychosocial functioning on the Work and Social Adjustment Scale (estimated mean difference -4·12 [95% CI -6·35 to -1·89]; p<0·001), less overall psychological distress than the standardised medical care group on the Clinical Outcomes in Routine Evaluation-10 scale (estimated mean difference -1·65 [95% CI -2·96 to -0·35]; p=0·013), and fewer somatic symptoms on the modified Patient Health Questionnaire-15 scale (estimated mean difference -1·67 [95% CI -2·90 to -0·44]; p=0·008). Clinical improvement at 12 months was greater in the CBT plus standardised medical care group than the standardised medical care alone group as reported by patients (estimated mean difference 0·66 [95% CI 0·26 to 1·04]; p=0·001) and by clinicians (estimated mean difference 0·47 [95% CI 0·21 to 0·73]; p<0·001), and the CBT plus standardised medical care group had greater satisfaction with treatment than did the standardised medical care group (estimated mean difference 0·90 [95% CI 0·48 to 1·31]; p<0·001). No significant differences in patient-reported seizure severity (estimated mean difference -0·11 [95% CI -0·50 to 0·29]; p=0·593) or seizure freedom in the last 3 months of the study (estimated odds ratio [OR] 1·77 [95% CI 0·93 to 3·37]; p=0·083) were identified between the groups. Furthermore, no significant differences were identified in the proportion of patients who had a more than 50% reduction in dissociative seizure frequency compared with baseline (OR 1·27 [95% CI 0·80 to 2·02]; p=0·313). Additionally, the 12-item Short Form survey-version 2 scores (estimated mean difference for the Physical Component Summary score 1·78 [95% CI -0·37 to 3·92]; p=0·105; estimated mean difference for the Mental Component Summary score 2·22 [95% CI -0·30 to 4·75]; p=0·084), the Generalised Anxiety Disorder-7 scale score (estimated mean difference -1·09 [95% CI -2·27 to 0·09]; p=0·069), and the Patient Health Questionnaire-9 scale depression score (estimated mean difference -1·10 [95% CI -2·41 to 0·21]; p=0·099) did not differ significantly between groups. Changes in dissociative seizures (rated by others) could not be assessed due to insufficient data. During the 12-month period, the number of adverse events was similar between the groups: 57 (31%) of 186 participants in the CBT plus standardised medical care group reported 97 adverse events and 53 (29%) of 182 participants in the standardised medical care group reported 79 adverse events.

INTERPRETATION

CBT plus standardised medical care had no statistically significant advantage compared with standardised medical care alone for the reduction of monthly seizures. However, improvements were observed in a number of clinically relevant secondary outcomes following CBT plus standardised medical care when compared with standardised medical care alone. Thus, adults with dissociative seizures might benefit from the addition of dissociative seizure-specific CBT to specialist care from neurologists and psychiatrists. Future work is needed to identify patients who would benefit most from a dissociative seizure-specific CBT approach.

FUNDING

National Institute for Health Research, Health Technology Assessment programme.

Comparison of psychiatric comorbidities and impact on quality of life in patients with epilepsy or psychogenic nonepileptic spells

OBJECTIVES

Psychiatric comorbidity is common in people with epilepsy (PWE) and psychogenic nonepileptic spells (PNES). These comorbidities can be detrimental to quality of life (QOL) and are often underdiagnosed and undertreated. Some types of epilepsy, such as focal temporal lobe epilepsy (TLE), have been associated with higher rates of psychiatric comorbidity. This study examined the impact of psychiatric comorbidity on QOL in patients admitted to two level 4 epilepsy monitoring units (EMUs).

METHODS

In this prospective observational study, 200 patients admitted to two level 4 EMUs completed standardized surveys including the Quality of Life in Epilepsy (QOLIE-31-P), Generalized Anxiety Disorder 7-item (GAD-7), Patient Health Questionnaire (PHQ-9), and Beck Depression Inventory-II (BDI-II). Hierarchal multiple regression was performed to assess impact on QOL.

RESULTS

Of the 200 participants, 113 had a diagnosis of epilepsy, 36 had a diagnosis of PNES, and 51 were excluded for nondiagnostic evaluation or dual diagnosis. Of those with epilepsy, 65 had TLE, 28 had focal extratemporal lobe epilepsy (ETLE), and 20 had nonfocal epilepsy. Patients with PNES had higher self-reported anxiety and depression levels (GAD-7: p = 0.04, PHQ-9: p < 0.01; BDI-II: p < 0.01) but similar QOL to PWE (p = 0.78). Using hierarchal multiple regression, symptoms of anxiety and depression were significant predictors of lower QOL in PWE but not in patients with PNES. There was no difference in QOL in those with ETLE and TLE.

CONCLUSIONS

Our findings suggest that self-reported anxiety and depression symptoms are common in patients admitted to level 4 EMUs regardless of diagnosis and play an important role in predicting QOL in PWE. Our findings emphasize the importance of routinely screening all EMU patients for psychiatric comorbidity.

Depression, anxiety, and clinical history in Spanish-speaking American patients with psychogenic nonepileptic seizures (PNES) compared with Spanish-speaking American patients with epilepsy

OBJECTIVE

The objective of this study was to compare Spanish-speaking American patients with epilepsy to Spanish-speaking American patients with psychogenic nonepileptic seizures (PNES) on depression, anxiety, and other clinical variables.

BACKGROUND

Research on Spanish-speaking American patients with epilepsy or PNES is relatively infrequent, with only a few studies on psychopathology in these two patient groups. Studies of English-speaking patients indicate that those with PNES present with greater depression and anxiety and report poorer quality of life (QOL) when compared with persons with epilepsy (PWEs). Similarly, although psychological trauma is observed in both groups, those with PNES appear to have more traumatic exposure compared with PWEs.

METHODS

This is a retrospective study of 74 Spanish-speaking PWEs (49 women, 31 men) and 34 Spanish-speaking patients with PNES (28 women, 4 men) (2004 to 2017). The diagnosis of epilepsy or PNES was confirmed with video-EEG. Demographic and clinical (psychological trauma, history of psychological treatment, etc.) data were collected, and Spanish versions of the Beck Depression Inventory - second edition (BDI-II) and Beck Anxiety Inventory (BAI) were completed by the patients.

RESULTS

Patients with PWEs (M = 18.19, SD = 12.89) differed significantly from those with PNES on a measure of depression (BDI-II, (M = 24.12, SD = 11.20); t (92) = -2.22, p = 0.01). In addition, PWEs (M = 15.76, SD = 14.24) also differed significantly when compared with patients with PNES on a measure of anxiety (BAI, (M = 22.46, SD = 14.02); t (93) = -2.05, p = 0.02). Significant differences in clinical and demographic data were also noted.

CONCLUSIONS

Spanish-speaking American patients with PNES were significantly more depressed and anxious and reported greater exposure to sexual trauma as compared with PWEs. Furthermore, patients with PNES tended to report more prediagnosis utilization of mental health services than PWEs. After adjusting for potential linear effects of other predictors (e.g., gender, age, seizure frequency, and psychological trauma), only a reported history of psychological trauma had a linear relationship with a depression score while higher seizure frequency and history of mental health treatment had linear relationships with an anxiety score.

Personality traits, illness behaviors, and psychiatric comorbidity in individuals with psychogenic nonepileptic seizures (PNES), epilepsy, and other nonepileptic seizures (oNES): Differentiating between the conditions

OBJECTIVES

The study aimed to investigate if South African individuals with psychogenic nonepileptic seizures (PNES) differ from individuals with epileptic seizures (ES) and other nonepileptic seizures (oNES) in terms of demographic and seizure characteristics, personality traits, illness behaviors, and depression, anxiety, and posttraumatic stress disorder (PTSD) comorbidity in statistically significant ways; and if so, to test if these differences can be utilized in raising suspicion of PNES as the differential diagnosis to epilepsy and oNES in practice.

METHODS

Data were analyzed from 29 adults with seizure complaints recruited using convenience sampling from a private and a government hospital with video-electroencephalography (vEEG) technology. A quantitative double-blind convenient sampling comparative design was used. A demographic and seizure questionnaire, the NEO Five Factor Inventory-3 (NEO-FFI-3), an abbreviated version of Illness Behavior Questionnaire (IBQ), and the Beck Anxiety Inventory - Primary Care (BAI-PC) were administered. Cronbach's alphas, analysis of variance (ANOVA), cross-tabulation, Fisher exact test, and receiver operating characteristic (ROC) analyses were performed on the dataset.

RESULTS

The total sample consisted of 29 participants, of which 5 had PNES (17%), 21 ES (73%), and 3 oNES (10%). The final sample was comprised of 24 participants from the private hospital and 5 from the government hospital. The group with PNES was found to be significantly more male, to experience significantly more monthly seizures, and chronic pain when comparing the PNES with the ES group, and the PNES with the combined ES and oNES group in both private only sample, as well as the private and government hospital combined sample. Patients with PNES also had a higher level of education compared with the group with ES in the combined private and government hospital sample, something that was not evident in the private hospital only sample. No significant differences between groups were found in either sample in terms of age, population group, language, age at first seizure, and the NEO-FFI-3 subscales. All three groups scored above the cutoff point of 5 exhibiting depression, anxiety, and PTSD symptoms on the BAI-PC in both samples. However, the group with PNES tended to score significantly higher than the group with ES and the combined ES and oNES group in the private hospital sample. A cutoff point of 12 on the BAI-PC was found to predict PNES in this seizure population with 80% sensitivity and 89% specificity. However, once the analysis was repeated on the combined private and government hospital sample, significance in BAI-PC scores between groups was lost. All scales showed good reliability in our study, with the exception of the "Openness to Experience" subscale of the NEO-FFI-3 once reliability analysis was carried out on the combined private and government hospital group.

CONCLUSIONS

This study provides an important stepping stone in the understanding of demographic and seizure factors, personality domains, abnormal illness behaviors, and psychiatric comorbidity in the South African population with PNES. The study also reported on a cutoff score of 12 on the BAI-PC predicting PNES with 80% sensitivity and 89% specificity in a private hospital sample.

Welfare consequences for people diagnosed with nonepileptic seizures: A matched nationwide study in Denmark

OBJECTIVE

We aimed to evaluate the excess direct and indirect costs associated with nonepileptic seizures.

METHODS

From the Danish National Patient Registry (2011-2016), we identified 1057 people of any age with a diagnosis of psychogenic nonepileptic seizures (PNESs) and matched them with 2113 control individuals. Additionally, 239 partners of patients with PNES aged ≥18 years were identified and compared with 471 control partners. Direct costs included frequencies and costs of hospitalizations and outpatient use weighted by diagnosis-related group, and specific outpatient costs based on data from the Danish Ministry of Health. The use and costs of drugs were based on data from the Danish Medicines Agency. The frequencies of visits and hospitalizations and costs of general practice were derived from National Health Security data. Indirect costs included labor supply-based income data, and all social transfer payments were obtained from Coherent Social Statistics.

RESULTS

A higher percentage of people with PNES and their partners compared with respective control subjects received welfare benefits (sick pay, disability pension, home care). Those with PNES had a lower employment rate than did controls for equivalent periods up to three years before the diagnosis was made. The additional direct and indirect annual costs for those aged ≥18 years, including transfers to patients with PNES, compared with controls, were €33,697 for people with PNES and €15,121 for their partners.

SIGNIFICANCE

Psychogenic nonepileptic seizures have substantial socioeconomic consequences for individual patients, their partners, and society.

Morbidity and mortality of nonepileptic seizures (NES): A controlled national study

Nonepileptic seizures (NES, psychogenic NES-PNES) are associated with significant morbidities. We evaluated the morbidities and mortality in a national group of children, adolescent, and adult patients before and after a first diagnosis of PNES.

METHODS

From the Danish National Patient Registry (1998-2013), we identified 1057 people of all ages with a diagnosis of NES and matched them with 2113 control individuals by age, gender, and geography. Comorbidities were calculated three years before and after diagnoses.

RESULTS

Patients with PNES showed increased comorbidities 3 years before and after diagnosis in almost all the diagnostic domains. The strongest associations were identified with other neurological diseases (after diagnosis, Hazard Ratio (HR): 38.63; 95% Confidence Interval (CI): 21.58-69.13; P < 0.001), abnormal clinical and laboratory findings (HR: 46.59; 95 CI: 27.30-79.52; P < 0.001), other health-related factors (HR: 12.83; 95%CI: 8.45-19.46; P < 0.001), and psychiatric comorbidities (HR: 15.45; 95% CI: 9.81-24.33). Epilepsy was identified in 8% of the patients with PNES. We found especially frequent comorbidity involving overweight, depression, anxiety, dissociative somatoform condition, other convulsions, lipothymias, reports of pain and other symptoms in several organ systems, and several reports of minimal traumas to the head, trunk, and extremities. Mortality was higher in patients with NES than in controls (HR: 3.21; 95% CI: 1.92-5.34; P < 0.001).

CONCLUSION

Morbidity is more frequent in several domains, including neurological, psychiatric, and other diseases, before and after a diagnosis of NES. Mortality is significantly higher in patients with PNES as compared to controls.

Health-related quality of life in Veterans with epileptic and psychogenic nonepileptic seizures

RATIONALE

Health-related quality of life (HRQoL) is compromised in civilians with epileptic seizures (ES) or psychogenic nonepileptic seizures (PNES). U.S. Veterans are a distinct patient group with regard to gender, age, and background. We studied HRQoL in Veterans and asked the following: (1) Is there a difference in HRQoL in Veterans with ES vs. PNES?; (2) What factors influence HRQoL in each group?; (3) What factors influenced the difference between seizure groups?

METHODS

We studied consecutive Veterans entering the epilepsy monitoring units (EMUs) of three VA Epilepsy Centers of Excellence. Patients underwent continuous video-EEG monitoring. Seizure diagnoses followed established criteria. Health-related quality of life was measured with the Quality of Life in Epilepsy Inventory-31 (QOLIE-31). Evaluations included the Structured Clinical Interview for Diagnostic and Statistical Manual-IV (DSM IV), the posttraumatic stress disorder (PTSD) Checklist (PCL), the Beck Depression Inventory II (BDI-II), and the Minnesota Multiphasic Personality Inventory-2 Restructured form (MMPI-2RF). Between-group differences were tested with Wilcoxon tests. Nested regression analysis was used to evaluate the influence of demographic, social, military, seizure-related, and psychological factors on QOLIE-31 scores.

RESULTS

The median QOLIE-31 total score was 14 points lower in Veterans with PNES vs. ES (p < 0.001; Cohen's d = 0.73). Within each seizure group, psychological factors accounted for ≥50% of the variance in QOLIE scores while combined demographic, social, and seizure-related factors accounted for 18% (group with ES) and 7% (PNES). Psychological measures, particularly PCL and the BDI-II scores, accounted for all of the difference in QOLIE-31 total scores between Veterans with ES and those with PNES.

CONCLUSIONS

Health-related quality of life as measured by the QOLIE-31 is worse in Veterans with PNES as compared with those with ES. Psychological factors account for the most of the variance in QOLIE-31 scores regardless of seizure type and also account for the difference between groups with PNES and ES. Demographic, military, social, and seizure-related factors have minimal influence on HRQoL. These results in U.S. Veterans are similar to those found in civilians despite differences in patient age, gender, and background.

The influence of attachment style and relationship quality on quality of life and psychological distress in carers of people with epileptic and nonepileptic seizures

BACKGROUND

Seizure disorders affect not only the individual living with seizures, but also those caring for them. Carer-patient relationships may be influenced by, and have an influence on, some aspects of living with seizure disorders - with potentially different interactions seen in epilepsy and psychogenic nonepileptic seizures (PNES).

OBJECTIVES

We studied the influence of patient and carer attachment style and relationship quality on carer wellbeing and psychological distress, and explored whether these associations differ between carers for people with epilepsy and for those with PNES.

METHODS

Consecutive adult patients with epilepsy (N = 66) and PNES (N = 16) and their primary informal carers completed questionnaires about relationship quality, attachment style, and psychopathological symptom burden. We used correlation analysis to identify associations between relationship quality, attachment style, and carer depression, anxiety, and wellbeing; and to explore differences in these associations between carers for people with epilepsy and for those with PNES.

RESULTS

Overall, 25.3% of carers for people with epilepsy or PNES had scores above the clinical cutoff for depression and 39.6% for anxiety; significantly more carers for people with PNES reported clinically significant depression (47.1% vs. 20.0%), but there was no difference in anxiety rates likely to be of clinical relevance. Correlations differed significantly between carers for people with epilepsy and for those with PNES in terms of patient quality of life and carer anxiety (r_E = -0.577, r_PNES = -0.025); seizure severity and carer depression (r_E = 0.248, r_PNES = -0.333) and mental wellbeing (r_E = -0.356, r_PNES = 0.264); patient depression and carer anxiety (r_E = 0.387, r_PNES = -0.266); and patient anxious attachment and carer anxiety (r_E = 0.382, r_PNES = 0.155).

SIGNIFICANCE

Clinically evident levels of psychological distress are prevalent among carers for people with epilepsy and PNES. Clinical and relationship variables affect carer quality of life differently depending on whether care is provided for individuals with epilepsy or PNES.

Quality of life and psychological dysfunction in traumatized and nontraumatized patients with psychogenic nonepileptic seizures (PNES)

OBJECTIVES

Psychogenic nonepileptic seizures (PNES) have the appearance of epileptic seizures, yet show no epileptiform discharges in the brain. The quality of life (QOL) in patients with PNES is reportedly low and trauma eems to be a relevant risk factor. The objective of this study was to examine the difference between measures of (epilepsy-specific) QOL (Quality of Life in Epilepsy Inventory; QOLIE-31p) and psychological dysfunction (trauma symptom inventory; TSI) between patients with diagnosed PNES with self-reported trauma and those without self-reported trauma.

METHODS

Patients whose PNES diagnoses were through video-electroencephalogram (EEG) monitoring at the Northeast Regional Epilepsy Group between 2008 and 2018 were included. Patients who reported to have a history of psychological trauma and those who did not were assigned to separate groups. Scores from the TSI and QOLIE-31p were compared by using multivariate analysis of covariance.

RESULTS

The total sample was comprised of 217 adult patients, 148 of which self-reported as having experienced psychological trauma in the past and 69 who did not report any psychological trauma. Traumatized patients significantly differed in terms of QOL and TSI from nontraumatized patients. Traumatized patients were demonstrated to have lower scores on the subdomain "energy" of the QOLIE-31p and the total QOLIE-31p score compared to the nontraumatized group. Similarly, the traumatized group had significantly higher scores on nearly all TSI subscales with the exception of suicidality, sexual disturbances, and somatization.

CONCLUSION

This study demonstrated significant differences between patients with PNES who have been psychologically traumatized and those who have not. In particular, patients with a history of psychological trauma present greater psychopathology and would possibly benefit from rapid identification and referral to trauma-based therapy. In turn, this may result in a reduction of disease burden, increase QOL, and a reduction in healthcare costs resulting from diagnostic delays and implementation of less targeted treatments.

Depression and quality of life in patients with epilepsy in Northwest Greece

PURPOSE

The purpose of the present study was to compare depression and QoL between patients with epilepsy and healthy controls, evaluating potentially related factors to depression and QoL in patients with epilepsy in Northwest Greece.

METHODS

A case study was conducted in adult patients with epilepsy followed up at the University Hospital of Ioannina and in healthy controls. The Patient Health Questionnaire (PHQ-9) for depression's severity evaluation, the WHOQOL-BREF questionnaire for the QoL estimation and the Adverse Event Profile (AEP) questionnaire for the Antiepileptic Drugs (AEDs) adverse effects assessment were used.

RESULTS

Seventy patients with epilepsy and 70 controls were recruited. The PHQ-9 score was higher in patients compared to controls and slightly higher than reported in patients with epilepsy. PHQ-9 was significantly associated with the AEP score. Our patients had a poorer QoL compared to controls. The level of education, the AEP and the PHQ-9 scores were associated to QoL, the last two being the most powerful predictors of QoL.

CONCLUSION

Patients with epilepsy in Northwest Greece had higher rates of depression than reported in patients with epilepsy and poorer QoL compared to controls. The adverse effects of AEDs were related to depression in our study, while the adverse effects of AEDs and depression were more powerful predictors of QoL compared to demographics and other characteristics of epilepsy.

Subjective and physiological response to emotions in temporal lobe epilepsy and psychogenic non-epileptic seizures

BACKGROUND

Temporal lobe epilepsy (TLE) and psychogenic non-epileptic seizures (PNES) are conditions frequently associated with dysfunction in emotional regulation leading to increased risk of affective disorders. This study investigates emotional processing with an objective measure of emotional reactivity in patients with TLE and patients with PNES.

METHODS

34 patients with TLE and 14 patients with PNES were evaluated on skin conductance responses (SCR) to emotions induced by short films and compared to 34 healthy controls. An attention and a suppression condition were performed while viewing the films.

RESULTS

The both groups of patients disclosed lower SCR to emotions compared to controls, mainly in suppression condition. While TLE patients had lower SCR in attention condition than controls for fear, sadness and happiness, PNES had lower SCR only for happiness. In suppression condition, both had lower SCR than controls except for peacefulness in both groups and sadness in PNES. Subjective evaluations revealed that both patient's groups scored a higher intensity for sadness than controls in attention and lower for in fear and disgust in suppression only in TLE.

LIMITATIONS

The sample size in the PNES group and the lack of a control group with similar levels of mood symptoms limited the interpretation of our results.

CONCLUSION

As no correlation were found between SCR to emotions and scores of affective disorders, this pattern of responses might be underpinned by specific pathophysiological and cognitive mechanisms related to TLE and to PNES. Thus, therapeutic approaches targeting emotional autonomic responses can be of interest in the management of these conditions.