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Van Patten R, Blum A, Correia S, Philip NS, Allendorfer JB, Gaston TE, Goodman A, Grayson LP, Tocco K, Vogel V, Martin A, Fry S, Bolding M, Ver Hoef L, Baird GL, Szaflarski JP, LaFrance WC. One-year follow-up of neurobehavioral therapy in functional seizures or epilepsy with traumatic brain injury: A nonrandomized controlled trial. Epilepsia 2024. [PMID: 39388338 DOI: 10.1111/epi.18137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Revised: 09/19/2024] [Accepted: 09/20/2024] [Indexed: 10/12/2024]
Abstract
OBJECTIVE Patients with traumatic brain injury (TBI) often present with seizures (functional and/or epileptic), but treatments for patients with TBI and seizures are limited. We examined treatment phase and 1-year post-enrollment outcomes following neurobehavioral therapy (NBT) for patients with TBI + functional seizures (FS) and TBI + epilepsy. METHODS In this multicenter, prospective, three-group, nonrandomized, controlled trial, with 1-year post-enrollment follow-up, three cohorts of adults were recruited: TBI + video-electroencephalography (EEG)-confirmed FS (n = 89), TBI + EEG-confirmed epilepsy (n = 29), and chart/history-confirmed TBI without seizures (n = 75). Exclusion criteria were recent psychotic or self-injurious behavior, current suicidal ideation, pending litigation or long-term disability, active substance use disorder, and inability to participate in study procedures. TBI + FS and TBI + epilepsy groups completed NBT for seizures, an evidence-based, 12-session, multimodal psychotherapy, whereas TBI without seizures participants received standard medical care. The primary outcome was change in seizure frequency; secondary outcomes were changes in mental health, TBI-related symptoms, disability, and quality of life. RESULTS Reductions in average monthly seizures occurred during treatment in TBI + FS participants (p = .002) and were significant from baseline (mean = 16.75; 95% confidence interval [CI] = 11.44-24.53) to 12 months post-enrollment (mean = 7.28, 95% CI = 4.37-12.13, p = .002, d = .38). Monthly seizures decreased during treatment in TBI + epilepsy participants (p = .002); reductions were not statistically significant from baseline (mean = 2.38, 95% CI = 1.12-5.04) to 12-month postenrollment (mean = .98, 95% CI = .40-2.42, p = .07, d = .22). Regarding treatment-phase changes in secondary outcome measures, TBI + FS participants improved significantly on 10 of 19 variables (52.6%), TBI + epilepsy participants improved on five of 19 (26.3%), and TBI-only comparisons improved on only one of 19 (5.3%). SIGNIFICANCE NBT benefited patients with TBI + FS and TBI + epilepsy. Improvements were demonstrated at 1 year post-enrollment in those with TBI + FS. NBT may be a clinically useful treatment for patients with seizures.
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Affiliation(s)
- Ryan Van Patten
- VA Providence Healthcare System, Center forNeurorestoration and Neurotechnology, and Brown University, Providence, Rhode Island, USA
| | - Andrew Blum
- Rhode Island Hospital and Brown University, Providence, Rhode Island, USA
| | - Stephen Correia
- VA Providence Healthcare System, Center forNeurorestoration and Neurotechnology, and Brown University, Providence, Rhode Island, USA
| | - Noah S Philip
- VA Providence Healthcare System, Center forNeurorestoration and Neurotechnology, and Brown University, Providence, Rhode Island, USA
| | | | - Tyler E Gaston
- University of Alabama, Birmingham, Alabama, USA
- Birmingham VA Medical Center, Birmingham, Alabama, USA
| | | | - Leslie P Grayson
- University of Alabama, Birmingham, Alabama, USA
- Birmingham VA Medical Center, Birmingham, Alabama, USA
| | - Krista Tocco
- VA Providence Healthcare System, Center forNeurorestoration and Neurotechnology, and Brown University, Providence, Rhode Island, USA
- Rhode Island Hospital and Brown University, Providence, Rhode Island, USA
| | - Valerie Vogel
- VA Providence Healthcare System, Center forNeurorestoration and Neurotechnology, and Brown University, Providence, Rhode Island, USA
- Rhode Island Hospital and Brown University, Providence, Rhode Island, USA
| | - Amber Martin
- University of Alabama, Birmingham, Alabama, USA
- Birmingham VA Medical Center, Birmingham, Alabama, USA
| | | | | | - Lawrence Ver Hoef
- University of Alabama, Birmingham, Alabama, USA
- Birmingham VA Medical Center, Birmingham, Alabama, USA
| | - Grayson L Baird
- Rhode Island Hospital and Brown University, Providence, Rhode Island, USA
| | | | - W Curt LaFrance
- VA Providence Healthcare System, Center forNeurorestoration and Neurotechnology, and Brown University, Providence, Rhode Island, USA
- Rhode Island Hospital and Brown University, Providence, Rhode Island, USA
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Steinruecke M, Mason I, Keen M, McWhirter L, Carson AJ, Stone J, Hoeritzauer I. Pain and functional neurological disorder: a systematic review and meta-analysis. J Neurol Neurosurg Psychiatry 2024; 95:874-885. [PMID: 38383157 PMCID: PMC11347250 DOI: 10.1136/jnnp-2023-332810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/24/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Functional neurological disorder (FND) is characterised by neurological symptoms, such as seizures and abnormal movements. Despite its significance to patients, the clinical features of chronic pain in people with FND, and of FND in people with chronic pain, have not been comprehensively studied. METHODS We systematically reviewed PubMed, Embase and PsycINFO for studies of chronic pain in adults with FND and FND in patients with chronic pain. We described the proportions of patients reporting pain, pain rating and timing, pain-related diagnoses and responsiveness to treatment. We performed random effects meta-analyses of the proportions of patients with FND who reported pain or were diagnosed with pain-related disorders. RESULTS Seven hundred and fifteen articles were screened and 64 were included in the analysis. Eight case-control studies of 3476 patients described pain symptoms in a higher proportion of patients with FND than controls with other neurological disorders. A random effects model of 30 cohorts found that an estimated 55% (95% CI 46% to 64%) of 4272 patients with FND reported pain. Random effects models estimated diagnoses of complex regional pain syndrome in 22% (95% CI 6% to 39%) of patients, irritable bowel syndrome in 16% (95% CI 9% to 24%) and fibromyalgia in 10% (95% CI 8% to 13%). Five studies of FND diagnoses among 361 patients with chronic pain were identified. Most interventions for FND did not ameliorate pain, even when other symptoms improved. CONCLUSIONS Pain symptoms and pain-related diagnoses are common in FND. Classification systems and treatments should routinely consider pain as a comorbidity in patients with FND.
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Affiliation(s)
| | - Isabel Mason
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Mairi Keen
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Laura McWhirter
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
- Department of Clinical Neurosciences, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Alan J Carson
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
- Department of Clinical Neurosciences, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Jon Stone
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
- Department of Clinical Neurosciences, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Ingrid Hoeritzauer
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
- Department of Clinical Neurosciences, Royal Infirmary of Edinburgh, Edinburgh, UK
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Reuber M. Cognitive function in people with functional seizures. Lancet Neurol 2024; 23:759-761. [PMID: 39030029 DOI: 10.1016/s1474-4422(24)00271-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Accepted: 06/18/2024] [Indexed: 07/21/2024]
Affiliation(s)
- Markus Reuber
- University of Sheffield, Royal Hallamshire Hospital, Sheffield S10 2JF, UK.
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Vilyte G, Butler J, Ives-Deliperi V, Pretorius C. Medical and psychiatric comorbidities, somatic and cognitive symptoms, injuries and medical procedure history in patients with functional seizures from a public and a private hospital. Seizure 2024; 119:110-118. [PMID: 38851095 DOI: 10.1016/j.seizure.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 05/22/2024] [Accepted: 06/02/2024] [Indexed: 06/10/2024] Open
Abstract
PURPOSE Patients with functional seizures (FS), otherwise known as psychogenic non-epileptic seizures (PNES), from different socioeconomic backgrounds may differ, however, this remains a gap in current literature. Comorbidities can play both a precipitating and a perpetuating role in FS and are important in the planning of individual treatment for this condition. With this study, we aimed to describe and compare the reported medical and psychiatric comorbidities, injuries, somatic and cognitive symptoms, and medical procedures among patients with FS from a private and a public epilepsy monitoring unit (EMU) in Cape Town, South Africa. METHODS This is a retrospective case-control study. We collected data on the comorbidity and medical procedure histories, as well as symptoms and clinical signs reported by patients with video-electroencephalographically (video-EEG) confirmed FS without comorbid epilepsy. We used digital patient records starting with the earliest available digital record for each hospital until the year 2022. RESULTS A total of 305 patients from a private hospital and 67 patients from a public hospital were included in the study (N = 372). Public hospital patients had higher odds of reporting intellectual disability (aOR=15.58, 95% CI [1.80, 134.95]), circulatory system disease (aOR=2.63, 95% CI [1.02, 6.78]) and gait disturbance (aOR=8.52, 95% CI [1.96, 37.08]) compared to patients with FS attending the private hospital. They did, however, have fewer odds of reporting a history of an infectious or parasitic disease (aOR=0.31, 95% CI [0.11, 0.87]), respiratory system disease (aOR=0.23, 95% CI [0.06, 0.82]), or medical procedures in the past (aOR=0.32, 95% CI [0.16, 0.63]). CONCLUSION The study presents prevalence and comparative data on the medical profiles of patients with FS from different socioeconomic backgrounds which may inform future considerations in FS diagnosis and treatment.
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Affiliation(s)
- Gabriele Vilyte
- Department of Psychology, Faculty of Arts and Social Sciences, Stellenbosch University, Stellenbosch, South Africa.
| | - James Butler
- Division of Neurology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Victoria Ives-Deliperi
- Neuroscience Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Chrisma Pretorius
- Department of Psychology, Faculty of Arts and Social Sciences, Stellenbosch University, Stellenbosch, South Africa
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Van Patten R, Mordecai K, LaFrance WC. The role of neuropsychology in the care of patients with functional neurological symptom disorder. J Int Neuropsychol Soc 2024:1-8. [PMID: 38813659 DOI: 10.1017/s1355617724000249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
OBJECTIVE Functional neurological symptom disorder (FNSD) is a neuropsychiatric condition characterized by signs/symptoms associated with brain network dysfunction. FNSDs are common and are associated with high healthcare costs. FNSDs are relevant to neuropsychologists, as they frequently present with chronic neuropsychiatric symptoms, subjective cognitive concerns, and/or low neuropsychological test scores, with associated disability and reduced quality of life. However, neuropsychologists in some settings are not involved in care of patients with FNSDs. This review summarizes relevant FNSD literature with a focus on the role of neuropsychologists. METHODS A brief review of the literature is provided with respect to epidemiology, public health impact, symptomatology, pathophysiology, and treatment. RESULTS Two primary areas of focus for this review are the following: (1) increasing neuropsychologists' training in FNSDs, and (2) increasing neuropsychologists' role in assessment and treatment of FNSD patients. CONCLUSIONS Patients with FNSD would benefit from increased involvement of neuropsychologists in their care.
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Affiliation(s)
- Ryan Van Patten
- Center for Neurorestoration and Neurotechnology, VA Providence Healthcare System, Providence, RI, USA
- Department of Psychiatry and Human Behavior, Brown University, Providence, RI, USA
| | | | - W Curt LaFrance
- Center for Neurorestoration and Neurotechnology, VA Providence Healthcare System, Providence, RI, USA
- Department of Psychiatry and Human Behavior, Brown University, Providence, RI, USA
- Rhode Island Hospital, Providence, RI, USA
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Kerr WT, Patterson EH, O'Sullivan IM, Horbatch FJ, Darpel KA, Patel PS, Robinson-Mayer N, Winder GS, Beimer NJ. Elevated Mortality Rate in Patients With Functional Seizures After Diagnosis and Referral. Neurol Clin Pract 2024; 14:e200227. [PMID: 38223352 PMCID: PMC10783975 DOI: 10.1212/cpj.0000000000200227] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 10/03/2023] [Indexed: 01/16/2024]
Abstract
Background and Objectives To evaluate the standardized mortality ratio (SMR) of patients in the United States referred to a multidisciplinary clinic for treatment of functional seizures. Methods We identified patients who had or had not died based on automated retrospective review of electronic health records from a registry of patients referred to a single-center multidisciplinary functional seizures treatment clinic. We calculated an SMR by comparing the number of observed deaths with the expected number of deaths in an age-matched, sex-matched, and race-matched population within the same state, and year records were available. Results A total of 700 patients with functional seizures (mean age 37 years, 78% female) were followed up for 1,329 patient-years for a median of 15 months per patient (interquartile range 6-37 months). We observed 11 deaths, corresponding to a mortality rate of 8.2 per 1,000 patient-years and an SMR of 2.4 (95% confidence interval: 1.17-4.22). Five of 9 patients with identified circumstances around their death were in hospice care when they passed. None of the identified causes of death were related to seizures directly. Discussion These data provide further evidence of elevated mortality in functional seizures soon after diagnosis and referral to treatment. These data from the decentralized health care system of the United States build on the findings from other countries with large-scale health registries.
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Affiliation(s)
- Wesley T Kerr
- Departments of Neurology and Biomedical Informatics (WTK), University of Pittsburgh, PA; Department of Neurology (WTK, EHP, IMO, FJH, KAD, PSP, NR-M, GSW, NJB); Department of Psychiatry (EHP, GSW, NJB), University of Michigan, Ann Arbor; Department of Neurology (KAD), St. Elizabeth Medical Center, Fort Thomas; Department of Neurology (KAD), Hazard Appalachian Regional Health, Hazard, KY; Department of Neurology (PSP), John F. Kennedy University Medical Center, Edison; Departments of Neurology and Psychiatry (PSP), Hackensack Meridian School of Medicine, Nutley, NJ; Department of Social Work (NR-M); and Department of Surgery (GSW), University of Michigan, Ann Arbor, MI
| | - Elissa H Patterson
- Departments of Neurology and Biomedical Informatics (WTK), University of Pittsburgh, PA; Department of Neurology (WTK, EHP, IMO, FJH, KAD, PSP, NR-M, GSW, NJB); Department of Psychiatry (EHP, GSW, NJB), University of Michigan, Ann Arbor; Department of Neurology (KAD), St. Elizabeth Medical Center, Fort Thomas; Department of Neurology (KAD), Hazard Appalachian Regional Health, Hazard, KY; Department of Neurology (PSP), John F. Kennedy University Medical Center, Edison; Departments of Neurology and Psychiatry (PSP), Hackensack Meridian School of Medicine, Nutley, NJ; Department of Social Work (NR-M); and Department of Surgery (GSW), University of Michigan, Ann Arbor, MI
| | - Isabel M O'Sullivan
- Departments of Neurology and Biomedical Informatics (WTK), University of Pittsburgh, PA; Department of Neurology (WTK, EHP, IMO, FJH, KAD, PSP, NR-M, GSW, NJB); Department of Psychiatry (EHP, GSW, NJB), University of Michigan, Ann Arbor; Department of Neurology (KAD), St. Elizabeth Medical Center, Fort Thomas; Department of Neurology (KAD), Hazard Appalachian Regional Health, Hazard, KY; Department of Neurology (PSP), John F. Kennedy University Medical Center, Edison; Departments of Neurology and Psychiatry (PSP), Hackensack Meridian School of Medicine, Nutley, NJ; Department of Social Work (NR-M); and Department of Surgery (GSW), University of Michigan, Ann Arbor, MI
| | - Faith J Horbatch
- Departments of Neurology and Biomedical Informatics (WTK), University of Pittsburgh, PA; Department of Neurology (WTK, EHP, IMO, FJH, KAD, PSP, NR-M, GSW, NJB); Department of Psychiatry (EHP, GSW, NJB), University of Michigan, Ann Arbor; Department of Neurology (KAD), St. Elizabeth Medical Center, Fort Thomas; Department of Neurology (KAD), Hazard Appalachian Regional Health, Hazard, KY; Department of Neurology (PSP), John F. Kennedy University Medical Center, Edison; Departments of Neurology and Psychiatry (PSP), Hackensack Meridian School of Medicine, Nutley, NJ; Department of Social Work (NR-M); and Department of Surgery (GSW), University of Michigan, Ann Arbor, MI
| | - Kyle A Darpel
- Departments of Neurology and Biomedical Informatics (WTK), University of Pittsburgh, PA; Department of Neurology (WTK, EHP, IMO, FJH, KAD, PSP, NR-M, GSW, NJB); Department of Psychiatry (EHP, GSW, NJB), University of Michigan, Ann Arbor; Department of Neurology (KAD), St. Elizabeth Medical Center, Fort Thomas; Department of Neurology (KAD), Hazard Appalachian Regional Health, Hazard, KY; Department of Neurology (PSP), John F. Kennedy University Medical Center, Edison; Departments of Neurology and Psychiatry (PSP), Hackensack Meridian School of Medicine, Nutley, NJ; Department of Social Work (NR-M); and Department of Surgery (GSW), University of Michigan, Ann Arbor, MI
| | - Palak S Patel
- Departments of Neurology and Biomedical Informatics (WTK), University of Pittsburgh, PA; Department of Neurology (WTK, EHP, IMO, FJH, KAD, PSP, NR-M, GSW, NJB); Department of Psychiatry (EHP, GSW, NJB), University of Michigan, Ann Arbor; Department of Neurology (KAD), St. Elizabeth Medical Center, Fort Thomas; Department of Neurology (KAD), Hazard Appalachian Regional Health, Hazard, KY; Department of Neurology (PSP), John F. Kennedy University Medical Center, Edison; Departments of Neurology and Psychiatry (PSP), Hackensack Meridian School of Medicine, Nutley, NJ; Department of Social Work (NR-M); and Department of Surgery (GSW), University of Michigan, Ann Arbor, MI
| | - Najda Robinson-Mayer
- Departments of Neurology and Biomedical Informatics (WTK), University of Pittsburgh, PA; Department of Neurology (WTK, EHP, IMO, FJH, KAD, PSP, NR-M, GSW, NJB); Department of Psychiatry (EHP, GSW, NJB), University of Michigan, Ann Arbor; Department of Neurology (KAD), St. Elizabeth Medical Center, Fort Thomas; Department of Neurology (KAD), Hazard Appalachian Regional Health, Hazard, KY; Department of Neurology (PSP), John F. Kennedy University Medical Center, Edison; Departments of Neurology and Psychiatry (PSP), Hackensack Meridian School of Medicine, Nutley, NJ; Department of Social Work (NR-M); and Department of Surgery (GSW), University of Michigan, Ann Arbor, MI
| | - Gerald S Winder
- Departments of Neurology and Biomedical Informatics (WTK), University of Pittsburgh, PA; Department of Neurology (WTK, EHP, IMO, FJH, KAD, PSP, NR-M, GSW, NJB); Department of Psychiatry (EHP, GSW, NJB), University of Michigan, Ann Arbor; Department of Neurology (KAD), St. Elizabeth Medical Center, Fort Thomas; Department of Neurology (KAD), Hazard Appalachian Regional Health, Hazard, KY; Department of Neurology (PSP), John F. Kennedy University Medical Center, Edison; Departments of Neurology and Psychiatry (PSP), Hackensack Meridian School of Medicine, Nutley, NJ; Department of Social Work (NR-M); and Department of Surgery (GSW), University of Michigan, Ann Arbor, MI
| | - Nicholas J Beimer
- Departments of Neurology and Biomedical Informatics (WTK), University of Pittsburgh, PA; Department of Neurology (WTK, EHP, IMO, FJH, KAD, PSP, NR-M, GSW, NJB); Department of Psychiatry (EHP, GSW, NJB), University of Michigan, Ann Arbor; Department of Neurology (KAD), St. Elizabeth Medical Center, Fort Thomas; Department of Neurology (KAD), Hazard Appalachian Regional Health, Hazard, KY; Department of Neurology (PSP), John F. Kennedy University Medical Center, Edison; Departments of Neurology and Psychiatry (PSP), Hackensack Meridian School of Medicine, Nutley, NJ; Department of Social Work (NR-M); and Department of Surgery (GSW), University of Michigan, Ann Arbor, MI
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Fox J, Mishra M. Hypertension and other vascular risk factors in patients with functional seizures. Epilepsy Behav 2024; 152:109650. [PMID: 38277850 DOI: 10.1016/j.yebeh.2024.109650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/11/2024] [Accepted: 01/15/2024] [Indexed: 01/28/2024]
Abstract
OBJECTIVE Recent literature has suggested that functional seizures are associated with an elevated risk for vascular disease and mortality. We investigated the prevalence of risk factors for vascular disease in patients who were admitted to the epilepsy monitoring unit. METHODS Patients who were admitted to the epilepsy monitoring unit and received a definitive diagnosis of either functional seizures or epilepsy were identified. Data collected included demographic, clinical characteristics, medication list, comorbidities, and scheduled blood pressure measurements that occurred every 12 h during the admission. The mean blood pressures were calculated and if they were above the American College of Cardiology and the American Heart Association guideline cutoff of 130/80 mm Hg or the patient had a documented history of hypertension the patient was counted as having the condition. A multiple logistic regression model was developed to evaluate the independent association of the patient's diagnosis (i.e., epilepsy or functional seizures) and vascular risk factors that controlled for the number of blood pressure measurements, age, sex, and if the patient was taking antihypertensive medications. RESULTS 270 patients were included in this study of which 147 patients had epilepsy and 123 had functional seizures. Among those with functional seizures, 57.72 % had either a history of hypertension or a mean blood pressure above 130/80 compared to 38.78 % of those with epilepsy (p = 0.0022). In addition, 30.89 % of functional seizures patients had hyperlipidemia and 63.41 % were obese. The logistic regression model indicated that functional seizures were independently associated with high blood pressure (OR: 2.47, 95 % CI 1.10-5.69), hyperlipidemia (OR: 3.38, 95 % CI 1.35-8.86), and obesity (OR: 4.25, 95 % CI 2.22-8.36) compared to those with epilepsy. There was no significant difference in the prevalence of diabetes (OR: 0.81, 95 % CI 0.24-2.77) or current tobacco use (OR: 1.04, 95 % CI 0.48-2.25) between the groups. SIGNIFICANCE Patients with functional seizures had an elevated prevalence of several vascular risk factors. These findings may partially account for complications associated with functional seizures and have implications related to their pathophysiology.
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Affiliation(s)
- Jonah Fox
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, United States.
| | - Murli Mishra
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, United States
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Van Patten R, Bellone JA. The neuropsychology of functional neurological disorders. J Clin Exp Neuropsychol 2023; 45:957-969. [PMID: 38441076 DOI: 10.1080/13803395.2024.2322798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Affiliation(s)
- Ryan Van Patten
- VA Providence Healthcare System, Center for Neurorestoration & Neurotechnology, Providence, RI, USA
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - John A Bellone
- Department of Behavioral Health, Kaiser Permanente, San Bernardino, CA, USA
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Peacock M, Bissell P, Ellis J, Dickson JM, Wardrope A, Grünewald R, Reuber M. 'I just need to know what they are and if you can help me': Medicalization and the search for legitimacy in people diagnosed with non-epileptic attack disorder. Epilepsy Behav 2023; 148:109485. [PMID: 37857031 DOI: 10.1016/j.yebeh.2023.109485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 09/14/2023] [Accepted: 10/07/2023] [Indexed: 10/21/2023]
Abstract
This paper focuses on the struggles for legitimacy expressed by people with non-epileptic attack disorder (NEAD), one of the most common manifestations of functional neurological disorder presenting to emergency and secondary care services. Nonepileptic attacks are episodes of altered experience, awareness, and reduced self-control that superficially resemble epileptic seizures or other paroxysmal disorders but are not associated with physiological abnormalities sufficient to explain the semiological features. "Organic" or medicalized explanations are frequently sought by patients as the only legitimate explanation for symptoms, and consequently, a diagnosis of NEAD is often contested. Drawing on narrative interviews with patients from a small exploratory study and using a sociological perspective, we propose that a psychological account of NEAD does not provide a sufficiently legitimate path into a socially sanctioned sick role. This is a reflection of the dominance of biomedicine and the associated processes of medicalization. These processes are, we argue, the sole route to achieving legitimacy. The stress-based or psychologically oriented explanations offered to patients in contemporary medical models of the etiology of NEAD engender an uncertain identity and social position and fail to provide many patients with an account of the nature or origin of their symptoms that they find satisfactory or convincing. These struggles for legitimacy (shared by others with functional or somatoform conditions) are sharpened by key features of the contemporary healthcare landscape, such as the increasing framing of health through a lens of 'responsibilization'.
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Affiliation(s)
- Marian Peacock
- Edge Hill University, Faculty of Health, Social Care & Medicine, St Helens Road, Ormskirk L39 4QP, UK.
| | | | - Julie Ellis
- Ramsden Building, University of Huddersfield, Queensgate, Huddersfield HD1 3DH, UK.
| | - Jon M Dickson
- The Medical School, The University of Sheffield, Samuel Fox House, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK.
| | - Alistair Wardrope
- Department of Neuroscience, The University of Sheffield, Sheffield, UK; Department of Clinical Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
| | - Richard Grünewald
- Academic Neurology Unit, University of Sheffield, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, UK.
| | - Markus Reuber
- Academic Neurology Unit, University of Sheffield, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, UK.
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Elkommos S, Martin-Lopez D, Koreki A, Jolliffe C, Kandasamy R, Mula M, Critchley HD, Edwards MJ, Garfinkel S, Richardson MP, Yogarajah M. Changes in the heartbeat-evoked potential are associated with functional seizures. J Neurol Neurosurg Psychiatry 2023; 94:769-775. [PMID: 37230745 DOI: 10.1136/jnnp-2022-330167] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 04/05/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Patients with functional seizures (FS) can experience dissociation (depersonalisation) before their seizures. Depersonalisation reflects disembodiment, which may be related to changes in interoceptive processing. The heartbeat-evoked potential (HEP) is an electroencephalogram (EEG) marker of interoceptive processing. AIM To assess whether alterations in interoceptive processing indexed by HEP occur prior to FS and compare this with epileptic seizures (ES). METHODS HEP amplitudes were calculated from EEG during video-EEG monitoring in 25 patients with FS and 19 patients with ES, and were compared between interictal and preictal states. HEP amplitude difference was calculated as preictal HEP amplitude minus interictal HEP amplitude. A receiver operating characteristic (ROC) curve analysis was used to evaluate the diagnostic performance of HEP amplitude difference in discriminating FS from ES. RESULTS The FS group demonstrated a significant reduction in HEP amplitude between interictal and preictal states at F8 (effect size rB=0.612, false discovery rate (FDR)-corrected q=0.030) and C4 (rB=0.600, FDR-corrected q=0.035). No differences in HEP amplitude were found between states in the ES group. Between diagnostic groups, HEP amplitude difference differed between the FS and ES groups at F8 (rB=0.423, FDR-corrected q=0.085) and C4 (rB=0.457, FDR-corrected q=0.085). Using HEP amplitude difference at frontal and central electrodes plus sex, we found that the ROC curve demonstrated an area under the curve of 0.893, with sensitivity=0.840 and specificity=0.842. CONCLUSION Our data support the notion that aberrant interoception occurs prior to FS. Changes in HEP amplitude may reflect a neurophysiological biomarker of FS and may have diagnostic utility in differentiating FS and ES.
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Affiliation(s)
- Samia Elkommos
- School of Neuroscience, King's College London Institute of Psychiatry Psychology and Neuroscience, London, UK
- Epilepsy Group, St George's Hospital Atkinson Morley Regional Neuroscience Centre, London, UK
| | - David Martin-Lopez
- Clinical Neurophysiology, St George's Hospital Atkinson Morley Regional Neuroscience Centre, London, UK
| | - Akihiro Koreki
- Psychiatry, National Hospital Organisation Shimofusa Psychiatric Medical Center, Chiba, Japan
- Neuroscience Research Centre, St George's University of London, London, UK
| | - Claire Jolliffe
- Clinical Neurophysiology, St George's Hospital Atkinson Morley Regional Neuroscience Centre, London, UK
| | - Rohan Kandasamy
- Clinical Neurophysiology, National Hospital for Neurology and Neurosurgery, London, UK
- Department of Clinical and Experimental Epilepsy, University College London, London, UK
| | - Marco Mula
- Epilepsy Group, St George's Hospital Atkinson Morley Regional Neuroscience Centre, London, UK
- Institute of Medical and Biomedical Education, St George's University of London, London, UK
| | - Hugo D Critchley
- Neuroscience, Brighton and Sussex Medical School, Brighton, UK
- Research and Development, Sussex Partnership NHS Foundation Trust, Worthing, UK
| | - Mark J Edwards
- Centre for Clinical Neuroscience, St George's University of London, London, UK
- Atkinson Morley Regional Neuroscience Centre, St George's Hospital, London, UK
| | - Sarah Garfinkel
- Institute of Cognitive Neuroscience, University College London Institute of Cognitive Neuroscience, London, UK
| | - Mark P Richardson
- School of Neuroscience, King's College London Institute of Psychiatry Psychology and Neuroscience, London, UK
- Centre for Epilepsy, King's College Hospital NHS Foundation Trust, London, UK
| | - Mahinda Yogarajah
- Department of Clinical and Experimental Epilepsy, University College London, London, UK
- Neurology, National Hospital for Neurology and Neurosurgery, London, UK
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11
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Carlson CA. Psychogenic Nonepileptic Seizures-High Mortality Rate Is a 'Wake-Up Call'. J Pers Med 2023; 13:892. [PMID: 37373881 DOI: 10.3390/jpm13060892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 05/18/2023] [Accepted: 05/23/2023] [Indexed: 06/29/2023] Open
Abstract
Patients with epilepsy have an elevated mortality rate compared to the general population and now studies are showing a comparable death ratio in patients diagnosed with psychogenic nonepileptic seizures. The latter is a top differential diagnosis for epilepsy and the unexpected mortality rate in these patients underscores the importance of an accurate diagnosis. Experts have called for more studies to elucidate this finding but the explanation is already available, embedded in the existing data. To illustrate, a review of the diagnostic practice in epilepsy monitoring units, of the studies examining mortality in PNES and epilepsy patients, and of the general clinical literature on the two populations was conducted. The analysis reveals that the scalp EEG test result, which distinguishes a psychogenic from an epileptic seizure, is highly fallible; that the clinical profiles of the PNES and epilepsy patient populations are virtually identical; and that both are dying of natural and non-natural causes including sudden unexpected death associated with confirmed or suspected seizure activity. The recent data showing a similar mortality rate simply constitutes more confirmatory evidence that the PNES population consists largely of patients with drug-resistant scalp EEG-negative epileptic seizures. To reduce the morbidity and mortality in these patients, they must be given access to treatments for epilepsy.
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Affiliation(s)
- Catherine A Carlson
- Minnesota Judicial Branch Psychological Services Division, Minneapolis, MN 55487, USA
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12
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Malekpour M, Jafari A, Kashkooli M, Salarikia SR, Negahdaripour M. A systems biology approach for discovering the cellular and molecular aspects of psychogenic non-epileptic seizure. Front Psychiatry 2023; 14:1116892. [PMID: 37252132 PMCID: PMC10213457 DOI: 10.3389/fpsyt.2023.1116892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 04/26/2023] [Indexed: 05/31/2023] Open
Abstract
Objectives Psychogenic non-epileptic seizure (PNES) is the most common non-epileptic disorder in patients referring to epilepsy centers. Contrary to common beliefs about the disease's harmlessness, the death rate of PNES patients is similar to drug-resistant epilepsy. Meanwhile, the molecular pathomechanism of PNES is unknown with very limited related research. Thus, the aim of this in silico study was to find different proteins and hormones associated with PNES via a systems biology approach. Methods Different bioinformatics databases and literature review were used to find proteins associated with PNES. The protein-hormone interaction network of PNES was constructed to discover its most influential compartments. The pathways associated with PNES pathomechanism were found by enrichment analysis of the identified proteins. Besides, the relationship between PNES-related molecules and psychiatric diseases was discovered, and the brain regions that could express altered levels of blood proteins were discovered. Results Eight genes and three hormones were found associated with PNES through the review process. Proopiomelanocortin (POMC), neuropeptide Y (NPY), cortisol, norepinephrine, and brain-derived neurotrophic factor (BDNF) were identified to have a high impact on the disease pathogenesis network. Moreover, activation of Janus kinase-signaling transducer and activator of transcription (JAK-STAT) and JAK, as well as signaling of growth hormone receptor, phosphatidylinositol 3-kinase /protein kinase B (PI3K/AKT), and neurotrophin were found associated with PNES molecular mechanism. Several psychiatric diseases such as depression, schizophrenia, and alcohol-related disorders were shown to be associated with PNES predominantly through signaling molecules. Significance This study was the first to gather the biochemicals associated with PNES. Multiple components and pathways and several psychiatric diseases associated with PNES, and some brain regions that could be altered during PNES were suggested, which should be confirmed in further studies. Altogether, these findings could be used in future molecular research on PNES patients.
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Affiliation(s)
- Mahdi Malekpour
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Aida Jafari
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Kashkooli
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Manica Negahdaripour
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Science, Shiraz, Iran
- Department of Pharmaceutical Biotechnology, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
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13
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Tan M, Pearce N, Tobias A, Cook MJ, D'Souza WJ. Influence of comorbidity on mortality in patients with epilepsy and psychogenic nonepileptic seizures. Epilepsia 2023; 64:1035-1045. [PMID: 36740578 DOI: 10.1111/epi.17532] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 02/02/2023] [Accepted: 02/02/2023] [Indexed: 02/07/2023]
Abstract
OBJECTIVE This study aims to determine the contribution of comorbidities to excess psychogenic nonepileptic seizures (PNES) mortality. METHODS A retrospective cohort study was conducted of tertiary epilepsy outpatients from St. Vincent's Hospital Melbourne, Australia with an 8:1 comparison cohort, matched by age, sex, and socioeconomic status (SES) to national administrative databases between 2007 and 2017. Privacy-preserving data linkage was undertaken with the national prescription, National Death Index, and National Coronial Information System. Forty-five comorbid disease classes were derived by applying the Australian validated RxRisk-V to all dispensed prescriptions. We fitted Cox proportional hazard models controlling for age, sex, SES, comorbidity, disease duration, and number of concomitant antiseizure medications, as a marker of disease severity. We also performed a parallel forward-selection change in estimate strategy to explore which specific comorbidities contributed to the largest changes in the hazard ratio. RESULTS A total of 13 488 participants were followed for a median 3.2 years (interquartile range = 2.4-4.0 years), including 1628 tertiary epilepsy outpatients, 1384 patients with epilepsy, 176 with PNES, and 59 with both. Eighty-two percent of epileptic seizures and 92% of typical PNES events were captured in an epilepsy monitoring unit. The age-/sex-/SES-adjusted hazard ratio was elevated for epilepsy (4.74, 95% confidence interval [CI] = 3.36-6.68) and PNES (3.46, 95% CI = 1.38-8.68) and remained elevated for epilepsy (3.21, 95% CI = 2.22-4.63) but not PNES (2.15, 95% CI = .77-6.04) after comorbidity adjustment. PNES had more pre-existing comorbidities (p = .0007), with a three times greater median weighted Rx-RiskV score. Psychotic illness, opioid analgesia, malignancies, and nonopioid analgesia had the greatest influence on PNES comorbid risk. SIGNIFICANCE Higher comorbidity appears to explain the excess PNES mortality and may represent either a wider underrecognized somatoform disorder or a psychological response to physical illness. Better understanding and management of the bidirectional relationship of these wider somatic treatments in PNES could potentially reduce the risk of death.
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Affiliation(s)
- Michael Tan
- Department of Medicine, University of Melbourne, St. Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Neil Pearce
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Aurelio Tobias
- Institute of Environmental Assessment and Water Research, Spanish Council for Scientific Research, Barcelona, Spain.,School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
| | - Mark J Cook
- Department of Medicine, University of Melbourne, St. Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Wendyl J D'Souza
- Department of Medicine, University of Melbourne, St. Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia.,Menzies Research Institute, University of Tasmania, Hobart, Tasmania, Australia
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14
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Cobb SJ, Vaughn BV, Sagherian K. Nonpharmacologic Interventions and Seizure Frequency in Patients With Psychogenic Nonepileptic Seizures: An Integrative Review. J Am Psychiatr Nurses Assoc 2022:10783903221107637. [PMID: 35801259 DOI: 10.1177/10783903221107637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Psychogenic nonepileptic seizures (PNES) pose a heavy burden on patients' lives and the health care system. The symptoms of PNES are often debilitating and cause high rates of disability and poor quality of life. Many treatment options are available, but there is no clear consensus on best practices. AIM To critique and synthesize the current literature on nonpharmacologic interventions and effects on seizure frequency in patients with PNES. METHODS An integrative review guided by the Whittemore and Knafl approach. RESULTS The review included 24 studies published from 2010 to 2020. Interventions for PNES included individualized psychotherapies, group therapies, multimodal psychotherapies, self-help therapies, and complementary and alternative medicine therapies. Individual psychotherapies such as cognitive behavioral therapy and psychoeducation were the most used treatment modalities. The most effective treatments for seizure frequency reduction were those that included multiple psychotherapy sessions with a health care provider and covered multiple domains (e.g., understanding of diagnosis, identifying triggers, and developing effective coping strategies). CONCLUSIONS Seizure frequency can be reduced in patients with PNES with multiple nonpharmacologic interventions. However, seizure frequency is not considered a comprehensive outcome measure and provides little insight into other important life domains. Further research is needed on nonpharmacologic interventions for PNES and effects on other areas of life such as sleep, employment status, global functioning, and self-efficacy.
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Affiliation(s)
- Sandra J Cobb
- Sandra J. Cobb, MSN, FNP-C, RN, REEGT, PhD in nursing candidate, University of Tennessee Knoxville, College of Nursing, Knoxville, TN, USA
| | - Bradley V Vaughn
- Bradley V. Vaughn, MD, Professor, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Knar Sagherian
- Knar Sagherian, PhD, RN, Assistant Professor, University of Tennessee Knoxville College of Nursing, Knoxville, TN, USA
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15
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Zhang L, Beghi E, Tomson T, Beghi M, Erba G, Chang Z. Mortality in patients with psychogenic non-epileptic seizures a population-based cohort study. J Neurol Neurosurg Psychiatry 2022; 93:379-385. [PMID: 35086937 DOI: 10.1136/jnnp-2021-328035] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 12/27/2021] [Indexed: 01/23/2023]
Abstract
OBJECTIVES To compare mortality, comorbidities and causes of death in people with psychogenic non-epileptic seizures (PNES), epilepsy and the general population. METHODS Using linkage of multiple Swedish national registers, we identified individuals with incident diagnosis of PNES, epilepsy and conversion disorder with motor symptoms or deficits, and 10 controls for each. Main outcome was all-cause mortality. Causes of death were categorised into non-natural (eg, suicide, injuries) and natural. Conditional Cox regression models were used to estimate HRs and 95% CIs for mortality. HRs were adjusted for socioeconomic factors and psychiatric comorbidities. RESULTS Included were 885 individuals with PNES, 50 663 with epilepsy and 1057 with conversion disorder and motor symptoms or deficits. We found 32 (3.6%) deaths among individuals with PNES, compared with 46 (0.5%) deaths in controls, giving an adjusted HR of 5.5 (95% CI 2.8 to 10.8). Patients with epilepsy had a 6.7 times higher risk of death (95% CI 6.4 to 7.0) compared with individuals without epilepsy. The association between conversion disorder with motor symptoms or deficits was non-significant after adjusting for psychiatric comorbidities. PNES carried a higher risk of natural (HR 8.1, 95% CI 4.0 to 16.4) and non-natural causes of death (HR 15.3, 95% CI 3.0 to 78.6). Suicide ranked high in patients with PNES (18.8%) and conversion disorder with motor symptoms and deficits. The association between PNES diagnosis and all-cause mortality varied with age and time since diagnosis. CONCLUSION Like epilepsy, PNES carries a higher than expected risk of both natural and non-natural causes of death. The high proportion of suicides requires further investigation.
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Affiliation(s)
- Le Zhang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Ettore Beghi
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Torbjörn Tomson
- Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | | | - Giuseppe Erba
- Department of Neurology, University of Rochester Medical Center, Rochester, New York, USA
| | - Zheng Chang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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16
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Asadi-Pooya AA. Incidence and prevalence of psychogenic nonepileptic seizures (functional seizures): a systematic review and an analytical study. Int J Neurosci 2021; 133:598-603. [PMID: 34126844 DOI: 10.1080/00207454.2021.1942870] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
AIM Psychogenic nonepileptic seizures (PNES) or functional seizures are universal phenomena. However, data on their epidemiology is limited. The aim of the current study was to review the literature on the epidemiology of PNES and to provide analytical estimates of its incidence and prevalence based on the direct data that are available from previous studies on PNES. METHODS The methods of this work had two parts: (1) MEDLINE, PsycINFO, and Scopus from inception to 19 October 2019 were systematically searched. (2) The analytical study of the incidence and prevalence of PNES was performed, based on the following data from previous studies: incidence of PNES, duration of PNES before making a diagnosis, outcome and mortality of PNES. RESULTS The search strategy yielded five articles; three were on the incidence and two on the prevalence. In the analytical part of the study, the incidence of PNES was calculated to be 3.1 (95% Confidence Interval: 1.1-5.1) per 100,000 population per year. The calculated prevalence rate of PNES in 2019 was 108.5 (95% Confidence Interval: 39.2-177.8) per 100,000 population, in the USA. CONCLUSION While, the generalizability of these calculated incidence and prevalence rates to other places in the world is limited, they give us a reasonable hint that PNES is a common condition and the prevalence is much more than that it was thought before.Supplemental data for this article is available online at https://doi.org/10.1080/00207454.2021.1942870.
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Affiliation(s)
- Ali A Asadi-Pooya
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Jefferson Comprehensive Epilepsy Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
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17
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Abstract
Mortality in Patients With Psychogenic Nonepileptic Seizures Nightscales R, McCartney L, Auvrez C, et al. Neurology. 2020;95(6):e643-e652. doi:10.1212/WNL.0000000000009855 Objective: To investigate the hypothesis that patients diagnosed with psychogenic nonepileptic seizures (PNES) on video-EEG monitoring (VEM) have increased mortality by comparison to the general population. Methods: This retrospective cohort study included patients evaluated in VEM units of 3 tertiary hospitals in Melbourne, Australia, between January 1, 1995, and December 31, 2015. Diagnosis was based on consensus opinion of experienced epileptologists and neuropsychiatrists at each hospital. Mortality was determined in patients diagnosed with PNES, epilepsy, or both conditions by linkage to the Australian National Death Index. Lifetime history of psychiatric disorders in PNES was determined from formal neuropsychiatric reports. Results: A total of 5508 patients underwent VEM. A total of 674 (12.2%) were diagnosed with PNES, 3064 (55.6%) with epilepsy, 175 (3.2%) with both conditions, and 1595 (29.0%) received other diagnoses or had no diagnosis made. The standardized mortality ratio (SMR) of patients diagnosed with PNES was 2.5 (95% CI: 2.0-3.3). Those younger than 30 had an 8-fold higher risk of death (95% CI: 3.4-19.8). Direct comparison revealed no significant difference in mortality rate between diagnostic groups. Among deaths in patients diagnosed with PNES (n = 55), external causes contributed 18%, with 20% of deaths in those younger than 50 years attributed to suicide, and “epilepsy” was recorded as the cause of death in 24%. Conclusions: Patients diagnosed with PNES have a SMR 2.5 times above the general population, dying at a rate comparable to those with drug-resistant epilepsy. This emphasizes the importance of prompt diagnosis, identification of risk factors, and implementation of appropriate strategies to prevent potential avoidable deaths.
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18
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Bruzzone Giraldez MJ, LaFrance WC. Mortality in patients with psychogenic nonepileptic seizures. Neurology 2020; 95:237-238. [DOI: 10.1212/wnl.0000000000009861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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19
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Romigi A, Ricciardo Rizzo G, Izzi F, Guerrisi M, Caccamo M, Testa F, Centonze D, Mercuri NB, Toschi N. Heart Rate Variability Parameters During Psychogenic Non-epileptic Seizures: Comparison Between Patients With Pure PNES and Comorbid Epilepsy. Front Neurol 2020; 11:713. [PMID: 32849194 PMCID: PMC7426492 DOI: 10.3389/fneur.2020.00713] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 06/10/2020] [Indexed: 11/24/2022] Open
Abstract
Introduction: Psychogenic non-epileptic seizures (PNES) may resemble epileptic seizures. There are few data about ictal ANS activity alterations induced by PNES in patients with pure PNES (pPNES) compared to PNES with comorbid epilepsy (PNES/ES). We aimed to compare heart rate variability (HRV) parameters and hence autonomic regulation in PNES in epileptic and non-epileptic patients. Methods: We obtained HRV data from video-electroencephalography recordings in 22 patients presenting PNES (11 pPNES and 11 PNES/ES) in awake, and supine states. We calculated HRV parameters in both time and frequency domains including low frequency (LF) power, high frequency power (HF), LF/HF ratio, square root of the mean of the sum of the squares of differences between adjacent R wave intervals (RMSSD) and the standard deviation of all consecutive R wave intervals (SDNN). We also evaluated approximate entropy (ApEn), cardiosympathetic index (CSI), and cardiovagal index (CVI). Four conditions were considered: basal condition (BAS), before PNES (PRE), during PNES (ICT) and after PNES (POST). Results: HRV analysis showed significantly higher ICT LF and LF/HF ratio vs. each condition. We also found higher POST HF vs. PRE and BAS, lower RRI in ICT vs. each condition and PRE vs. BAS. POST RMSSD was significantly higher compared to all other states. ICT CSI was significantly higher compared to all other states, whereas CSI was significantly lower in POST vs. PRE and PRE CVI lower than ICT and higher in POST vs. BAS and PRE. Also, ICT ApEn was lower than in all other states. Higher LF in pPNES vs. PNES/ES was also evident when compared across groups. Significance: A few studies examined HRV alterations in PNES, reporting high sympathetic tone (although less evident than in epileptic seizures). Our data suggest a sympathetic overdrive before and during PNES followed by a post-PNES increase in vagal tone. A sympathovagal imbalance was more evident in pPNES as compared to PNES/ES.
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Affiliation(s)
- Andrea Romigi
- IRCCS Neuromed Sleep Medicine Centre, Pozzilli, Italy
| | | | - Francesca Izzi
- Neurophysiopathology Unit, Department of Systems Medicine, Sleep Medicine Centre, Tor Vergata University and Hospital, Rome, Italy
| | - Maria Guerrisi
- Medical Physics Section, Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy
| | - Marco Caccamo
- IRCCS Neuromed Sleep Medicine Centre, Pozzilli, Italy
| | | | | | - Nicola B Mercuri
- Department of Neuroscience, "Tor Vergata" University, Rome, Italy
| | - Nicola Toschi
- Medical Physics Section, Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy.,Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
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20
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Nightscales R, McCartney L, Auvrez C, Tao G, Barnard S, Malpas CB, Perucca P, McIntosh A, Chen Z, Sivathamboo S, Ignatiadis S, Jones S, Adams S, Cook MJ, Kwan P, Velakoulis D, D'Souza W, Berkovic SF, O'Brien TJ. Mortality in patients with psychogenic nonepileptic seizures. Neurology 2020; 95:e643-e652. [DOI: 10.1212/wnl.0000000000009855] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 02/06/2020] [Indexed: 02/07/2023] Open
Abstract
ObjectiveTo investigate the hypothesis that patients diagnosed with psychogenic nonepileptic seizures (PNES) on video-EEG monitoring (VEM) have increased mortality by comparison to the general population.MethodsThis retrospective cohort study included patients evaluated in VEM units of 3 tertiary hospitals in Melbourne, Australia, between January 1, 1995, and December 31, 2015. Diagnosis was based on consensus opinion of experienced epileptologists and neuropsychiatrists at each hospital. Mortality was determined in patients diagnosed with PNES, epilepsy, or both conditions by linkage to the Australian National Death Index. Lifetime history of psychiatric disorders in PNES was determined from formal neuropsychiatric reports.ResultsA total of 5,508 patients underwent VEM. A total of 674 (12.2%) were diagnosed with PNES, 3064 (55.6%) with epilepsy, 175 (3.2%) with both conditions, and 1,595 (29.0%) received other diagnoses or had no diagnosis made. The standardized mortality ratio (SMR) of patients diagnosed with PNES was 2.5 (95% confidence interval [CI] 2.0–3.3). Those younger than 30 had an 8-fold higher risk of death (95% CI 3.4–19.8). Direct comparison revealed no significant difference in mortality rate between diagnostic groups. Among deaths in patients diagnosed with PNES (n = 55), external causes contributed 18%, with 20% of deaths in those younger than 50 years attributed to suicide, and “epilepsy” was recorded as the cause of death in 24%.ConclusionsPatients diagnosed with PNES have a SMR 2.5 times above the general population, dying at a rate comparable to those with drug-resistant epilepsy. This emphasizes the importance of prompt diagnosis, identification of risk factors, and implementation of appropriate strategies to prevent potential avoidable deaths.
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21
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Koreki A, Garfkinel SN, Mula M, Agrawal N, Cope S, Eilon T, Gould Van Praag C, Critchley HD, Edwards M, Yogarajah M. Trait and state interoceptive abnormalities are associated with dissociation and seizure frequency in patients with functional seizures. Epilepsia 2020; 61:1156-1165. [PMID: 32501547 PMCID: PMC7737228 DOI: 10.1111/epi.16532] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 04/20/2020] [Accepted: 04/21/2020] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Dissociative traits represent a disturbance in selfhood that may predispose to, and trigger, functional seizures (FSs). The predictive representation and control of the internal physiological state of the body (interoception) are proposed to underpin the integrity of the sense of self ("minimal selfhood"). Therefore, discrepancies between objective and subjective aspects of interoception may relate to symptom expression in patients with FSs. Here, we tested whether individual differences in trait measures of interoception relate to dissociative symptoms, and whether state interoceptive deficits predict FS occurrence. METHODS Forty-one participants with FSs and 30 controls completed questionnaire ratings of dissociation, and measures of (1) interoceptive accuracy (IA)-objective performance on heartbeat detection tasks; (2) trait interoceptive sensibility-subjective sensitivity to internal sensations (using the Porges Body Perception Questionnaire); and (3) state interoceptive sensibility-subjective trial-by-trial measures of confidence in heartbeat detection. Interoceptive trait prediction error (ITPE) was calculated from the discrepancy between IA and trait sensibility, and interoceptive state prediction error (ISPE) from the discrepancy between IA and state sensibility. RESULTS Patients with FSs had significantly lower IA and greater trait interoceptive sensibility than healthy controls. ITPE was the strongest predictor of dissociation after controlling for trait anxiety and depression in a regression model. ISPE correlated significantly with FS frequency after controlling for state anxiety. SIGNIFICANCE Patients with FSs have disturbances in interoceptive processing that predict both dissociative traits reflecting the disrupted integrity of self-representation, and the expression of FSs. These findings provide insight into the pathophysiology of functional neurological disorder, and could lead to novel diagnostic and therapeutic approaches.
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Affiliation(s)
- Akihiro Koreki
- Neurosciences Research CentreSt George's University of LondonLondonUK
- Department of NeuropsychiatryNational Hospital Organization Shimofusa Psychiatric Medical CenterChibaJapan
| | - Sarah N. Garfkinel
- Brighton and Sussex Medical School and The Sackler Centre for Consciousness ScienceUniversity of SussexSussexUK
| | - Marco Mula
- Atkinson Morley Regional Neuroscience CentreSt George's HospitalLondonUK
| | - Niruj Agrawal
- Atkinson Morley Regional Neuroscience CentreSt George's HospitalLondonUK
- Department of NeuropsychiatrySouth West London and St George's Mental Health TrustLondonUK
| | - Sarah Cope
- Department of NeuropsychiatrySouth West London and St George's Mental Health TrustLondonUK
| | - Talia Eilon
- Department of NeuropsychiatrySouth West London and St George's Mental Health TrustLondonUK
| | - Cassandra Gould Van Praag
- Brighton and Sussex Medical School and The Sackler Centre for Consciousness ScienceUniversity of SussexSussexUK
- Department of PsychiatryUniversity of OxfordOxfordUK
| | - Hugo D. Critchley
- Brighton and Sussex Medical School and The Sackler Centre for Consciousness ScienceUniversity of SussexSussexUK
| | - Mark Edwards
- Neurosciences Research CentreSt George's University of LondonLondonUK
- Atkinson Morley Regional Neuroscience CentreSt George's HospitalLondonUK
| | - Mahinda Yogarajah
- Neurosciences Research CentreSt George's University of LondonLondonUK
- Atkinson Morley Regional Neuroscience CentreSt George's HospitalLondonUK
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22
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Campbell J, Walker E, No L, Sundram F. Nonepileptic seizures in individuals attending neurological services in New Zealand. Epilepsy Behav 2019; 101:106568. [PMID: 31675600 DOI: 10.1016/j.yebeh.2019.106568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 09/08/2019] [Accepted: 09/13/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVES This study examined the demographic, social, and clinical (neurological and psychiatric) characteristics of people with psychogenic nonepileptic seizures (PNES) presenting to tertiary neurological services at Auckland District Health Board, New Zealand. METHODS Electronic notes and video-electroencephalography (video-EEG) data gathered from the telemetry unit based on synchronized acquisition (motor activity and brain electrophysiology) over a five-year period (2011 to 2015 inclusive) were retrospectively examined. Two groups were compared: people with PNES only or people with combined PNES and epileptic seizures (ES) (the group with PNES) and a control group with ES only, matched 1:1 by age and gender. RESULTS Sixty-six people in the group with PNES were matched with an equivalent number of ES controls. As a cohort, there was high psychiatric and medical comorbidity in both groups, but overall, those with PNES experienced higher rates than their ES counterparts. An older age of onset, female gender, and history of abuse were more frequently seen in those with PNES. Compared with controls, people with PNES more commonly had daily seizures (rather than monthly) but presented less frequently to neurology services. A high proportion of people with PNES experienced historical traumas, ongoing stressors, and disability. Almost half of the people with PNES were on antiepileptic drugs (AEDs) and received limited psychiatric or psychological input. In contrast, people with ES were more likely to be on psychotropic medication. CONCLUSION Both PNES and ES are associated with high levels of psychiatric and medical comorbidity. Additionally, PNES were found to be associated with iatrogenic harm and disability. Though people with PNES and ES often have a range of associated needs, there is, however, limited access to appropriate services. The needs of these populations should be better met through enhanced integration across psychiatry, neurology, and multidisciplinary services.
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Affiliation(s)
- Jill Campbell
- Department of Psychological Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1142, New Zealand.
| | - Elizabeth Walker
- Department of Neurology, Auckland City Hospital, 2 Park Road, Grafton, Auckland, 1023, New Zealand.
| | - Liz No
- Middlemore Hospital, Hospital Road, Otahuhu, Auckland 1640, New Zealand.
| | - Frederick Sundram
- Department of Psychological Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1142, New Zealand.
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