The feasibility of a multidisciplinary group therapy clinic for the treatment of nonepileptic seizures

Referral to a Functional Seizures Clinic Reduces Inpatient and Emergency Department Health Care Utilization and Costs

Background and Objectives

People with functional seizures (FSs) experience high health care utilization and costs revolving around the emergency department (ED). Overall, appropriate treatment of FS is underused, and better care pathways are associated with lower ED reattendance. Our objective was to assess changes in total ED and inpatient visits and costs before and after referral to a specialized, comprehensive FS treatment clinic.

Methods

We collected data from 100 consecutive patients referred to the University of Colorado (CU) FS Clinic between July 2019 and December 2021. Hospital account data were obtained directly from the electronic health record. Total ED and inpatient visits, charges, and payments 1 year before and 1 year after referral were collected and analyzed using the Wilcoxon signed-rank test.

Results

Ninety-four patients were included for analysis. 79% were female, 52% were on Medicaid, and the mean age was 41 (SD 13) years. Total visits after referral (ED and inpatient) were significantly reduced compared with total visits before referral (mean = 1.44 (SD 3.52) vs 1.83 (SD 3.52), p = 0.045). The same test was performed for total charges after and before referral ($15,551 (SD $38,712) vs $30,257 (SD $81,589), p = 0.03) and for total payments after and before referral ($2,469 (SD $6,682) vs $5,199 (SD $15,084), p = 0.02).

Discussion

Referral to a specialized FS clinic is associated with reduced health care utilization and costs. This proof-of-concept study reveals that hospitals should implement policies to support efficient care pathways to comprehensive FS treatment programs with potential for cost savings.

Associations between violent and sexual childhood trauma and maladaptive coping in patients with functional seizures

OBJECTIVE

Functional seizures (FS) are a highly debilitating symptom of functional neurological disorder (FND). FS requires a multi-disciplinary approach to treatment because the patient's initial presentation is to neurology, emergency medicine, or primary care and treatment consists of psychotherapy. People with FS commonly experience severe childhood trauma, particularly sexual trauma. The authors aimed to investigate associations between reported trauma and maladaptive coping mechanisms in the FS population.

METHODS

This retrospective, observational study reports on 137 patients enrolled in the FS Clinic at the University of Colorado between March 2020 - March 2021. Multiple linear regression was used to reveal associations between self-reported childhood sexual and violent trauma and maladaptive coping mechanisms of self-blame and disengagement on the Brief COPE. A quantile regression was generated for each of these outcomes.

RESULTS

Results showed that violent and sexual trauma were experienced by 47.5% and 61.6% of the population sample, respectively. Of those exposed to violent trauma, 27.2% perceived it as extremely severe while 43.4% of those exposed to sexual trauma perceived it as extremely severe. Quantile regressions for self-blame and disengagement showed significance for the 25th percentile of those who experienced violent trauma. Self-blame was significantly associated with the 50th and 75th percentile of those exposed to sexual trauma.

CONCLUSIONS

This evidence supports the value of identifying trauma experienced by individuals with FS as it is associated with specific coping mechanisms that may affect treatment. Identifying prior trauma and resulting coping mechanisms can potentially assist in individualizing care for people with FS.

Ask the Patient: Goals for Functional seizure treatment

Treatment trials for functional seizure (FS) help improve functioning and reduce disability in affected individuals. Clinical trials have prioritized clinician-defined outcomes, but no studies have directly asked adults with FS what they hope to accomplish. This study examined patient-defined goals for treatment in a consecutive cohort of 826 adults with FS referred for outpatient treatment. Goals were reviewed and sorted into 6 categories with 32.5% of goals related to seizure management, 21.8% to abstract functional improvement, 20.3% to concrete functional improvement, 14.8% to seizure education, 10.1% to psychiatry tools, and 0.5% to Other. Although treatment trials have prioritized reduced event frequency as a primary outcome, people with FS most frequently prioritize goals for functional improvement. Data suggests that rehabilitation metrics of FS treatment outcome may be just as, or more important to adults with FS than what medical providers prioritize for outcome success. Study findings have implications for how to define FS treatment success and suggest equal prioritization of patient-centered goals to medically-defined goals in trial design.

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

BACKGROUND

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

AIMS

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

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

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

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

Background and Objectives

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

Methods

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

Results

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

Discussion

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

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

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

The Financial Burden of Functional Neurological Disorders

PURPOSE OF REVIEW

Functional neurological disorder (FND) is a common and severely debilitating condition lacking clinical ownership, existing between neurology and psychiatry. This article reports the findings of recent research investigating the economic costs of FND diagnosis and management. We define what the costs are, why they exist, and suggest actionable steps to reduce them.

RECENT FINDINGS

The financial burden of FND exists across the globe characterized by high healthcare utilization resulting in exorbitant direct and indirect costs for the patient, healthcare system, and society. Inadequate medical education and stigmatization of the disorder prolong the time to diagnosis, during which cyclical utilization of inpatient and emergency department services drive up costs. Despite being cost-effective, lack of accessible treatment compounds the issue, leaving patients without a reliable exit. Recent findings support an increased awareness and the need for a cultural shift to overcome the financial burden associated with this underserved population.

Characteristics of collaborative care networks in functional disorders: A systematic review

OBJECTIVE

Functional disorders (FD) are complex conditions, for which multidisciplinary involvement is often recommended. Collaborative care networks (CCN) may unlock the potential of the multidisciplinary team (MDT) in FD care. To understand what characteristics should be part of CCNs in FD, we studied the composition and characteristics of existing CCNs in FD.

METHODS

We performed a systematic review following PRISMA guidelines. A search of PubMed, WebofScience, PsycInfo, SocINDEX, AMED and CINAHL was undertaken to select studies describing CCNs in FD. Two reviewers extracted characteristics of the different CCNs. Characteristics were classified as relating to structure and processes of networks.

RESULTS

A total of 62 studies were identified representing 39 CCNs across 11 countries. Regarding structural characteristics, we found that most networks are outpatient, secondary-care based, with teams of between two and 19 members. Medical specialists were most commonly involved and the typical team leads as well as main patient contacts were general practitioners (GPs) or nurses. Regarding processes, collaboration was demonstrated mostly during assessment, management and patient education, less often during rehabilitation and follow-up, mostly using MDT meetings. CCNs provided a wide range of treatment modalities, reflecting a biopsychosocial approach, including psychological therapies, physiotherapy and social and occupational therapy.

CONCLUSION

CCNs for FD are heterogeneous, showing a wide variety of structures as well as processes. The heterogeneity of results provides a broad framework, demonstrating considerable variation in how this framework is applied in different contexts. Better development of network evaluation, as well as professional collaboration and education processes is needed.

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

Background and Objectives

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

Methods

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

Results

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

Discussion

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

Amygdala subfield and prefrontal cortex abnormalities in patients with functional seizures

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The neurobiology of functional neurological disorders characterised by impaired awareness

We review the neurobiology of Functional Neurological Disorders (FND), i.e., neurological disorders not explained by currently identifiable histopathological processes, in order to focus on those characterised by impaired awareness (functionally impaired awareness disorders, FIAD), and especially, on the paradigmatic case of Resignation Syndrome (RS). We thus provide an improved more integrated theory of FIAD, able to guide both research priorities and the diagnostic formulation of FIAD. We systematically address the diverse spectrum of clinical presentations of FND with impaired awareness, and offer a new framework for understanding FIAD. We find that unraveling the historical development of neurobiological theory of FIAD is of paramount importance for its current understanding. Then, we integrate contemporary clinical material in order to contextualise the neurobiology of FIAD within social, cultural, and psychological perspectives. We thus review neuro-computational insights in FND in general, to arrive at a more coherent account of FIAD. FIAD may be based on maladaptive predictive coding, shaped by stress, attention, uncertainty, and, ultimately, neurally encoded beliefs and their updates. We also critically appraise arguments in support of and against such Bayesian models. Finally, we discuss implications of our theoretical account and provide pointers towards an improved clinical diagnostic formulation of FIAD. We suggest directions for future research towards a more unified theory on which future interventions and management strategies could be based, as effective treatments and clinical trial evidence remain limited.

Multifamily Group Psychotherapy for Patients With Nonepileptic Seizures and Their Families

OBJECTIVE

Multifamily group (MFG) psychotherapy is widely used for mental and general medical conditions. MFG therapy engages family members in caring for a loved one experiencing illness and helps clarify the impact of illness on family. Use of MFG therapy for patients with nonepileptic seizures (NES) and their families to explore satisfaction with treatment and family functioning is described.

METHODS

MFG therapy for patients with NES and their participating family members was incorporated into an existing interdisciplinary group-based psychotherapy treatment program. The Family Assessment Device and a novel feedback questionnaire were used to understand the effect of MFG therapy on this population.

RESULTS

Patients with NES (N=29) and their corresponding family members (N=29) indicated on the feedback questionnaire their satisfaction with having MFG therapy as part of their treatment; satisfaction was also evidenced by a 79% (N=49 of 62) patient participation rate. Patients and family members reported enhanced understanding of the impact of illness on the family and believed MFG therapy would help them communicate about illness and reduce family conflict. Scores on the Family Assessment Device indicated that family members perceived better family functioning than did patients (average scores of 1.84 and 2.99, respectively).

CONCLUSIONS

The discrepancy in perceived family functioning supports the idea of integrating family members in treatment for patients experiencing NES. The group treatment modality was satisfactory to participants and may prove useful for other kinds of somatic symptom disorders, which are often external manifestations of internal distress. Family members can become treatment allies in psychotherapy when included in treatment.

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.

Exploring the influence of telehealth on patient engagement with a multidisciplinary Non-Epileptic Seizure (NES) Clinic during the COVID-19 pandemic

The ILAE task force has identified a gap in treatment access for patients with nonepileptic seizures (NES) [1]. Access to multidisciplinary treatment clinics for adults with NES is limited with only 18 institutions delivering care across the United States [2]. Patient engagement has been low in the University of Colorado, NES Clinic treatment program despite our clinic's status as the only clinic of its kind in the mountain west. We analyzed patient factors of those who engaged in treatment before and after COVID-19 regulations were imposed and found a 23.6% increase in treatment engagement using telehealth. Those who engaged using telehealth were more likely to be of white race, of non-Hispanic ethnicity, publicly insured, employed, have a Charlson Comorbidity Index (CCI) of zero, a daily seizure rate of 0-1, did not have suicidal ideation or attempts, and live greater than 25 miles from the NES clinic. Delivering NES treatment via telehealth reduced the logistical and psychological barriers to initiating recovery and with a severe lack of accessible treatments for patients with NES, barrier reduction is necessary. This study describes patient factors that result in higher engagement with NES treatment using telehealth and emphasizes the importance of telehealth utilization to improve access to available treatment.

Neuropsychiatric Treatment Approaches for Functional Neurological Disorder: A How to Guide

There is a growing body of knowledge regarding management of functional neurological disorder (FND). The aim of this article is to guide the clinician through FND clinical management, from delivery of the diagnosis, to creation of a biopsychosocially-informed treatment plan, to troubleshooting common issues that arise throughout longitudinal care. We review the evidence and core principles of both rehabilitative therapies (physical therapy, occupational therapy, and speech and language therapy) and psychological therapies for the treatment of FND, and discuss the benefits of engaging a multidisciplinary and interdisciplinary team. The optimal timing of specific therapeutic interventions is also discussed, emphasizing a patient-centered perspective. Resources for further reading, for both patients and clinicians, are provided throughout. Additional research is needed to further optimize the therapeutic approach to patients with FND, including the need to develop novel treatments for those that do not positively respond to currently available interventions.

Functional seizures: Cluster analysis may predict the associated risk factors

OBJECTIVES

We applied the Two-Step cluster analysis on a large cohort of patients with functional seizures (FS). We studied whether the background risk factors differed between the patient clusters.

METHODS

All patients with a diagnosis of FS were studied at the outpatient epilepsy clinic at Shiraz University of Medical Sciences, Shiraz, Iran, from 2008 until 2021. The Two-Step cluster analysis was applied considering the age at onset, sex, and seizure semiology. We also studied whether the background risk factors (e.g., a history of sexual abuse, physical abuse, etc.) differed between these patient clusters.

RESULTS

Three-hundred and fifty four patients were studied. The Two-Step cluster analysis was applied to the 230 patients who reported any associated risk factors; there were three clusters of patients. The most prominent feature of cluster 1 included akinetic seizures. The most prominent features of cluster 2 included motor seizures and no ictal injury. The most prominent features of cluster 3 included motor seizures with ictal injury. Compared with patients in cluster 3, a history of sexual abuse was more often reported by patients in cluster 1 (OR: 3.26, 95%CI: 1.12-9.47; p = 0.03). Compared with patients in cluster 3, a history of physical abuse was less often reported by patients in cluster 2 (OR: 0.45, 95%CI: 0.22-0.90; p = 0.026).

CONCLUSION

The Two-Step cluster analysis could identify three distinct clusters of patients based on their demographic and clinical characteristics. These clusters had correlations with the associated risk factors in patients with FS.

Assessing the hidden burden of psychiatric disease in patients with nonepileptic seizures

Nonepileptic seizures are commonly associated with psychiatric comorbidities, and specifically PTSD. Despite increased prevalence of psychiatric disease noted on referral of patients to our dedicated clinic for nonepileptic seizures, we found even higher rates of comorbid psychiatric disease or significant symptomatology after our initial clinic intakes, whereby patients are formally evaluated by a behavioral health provider, in addition to an epileptologist. After intake, an additional 21% of patients were identified as having PTSD or significant trauma-related symptoms, an additional 7% of patients were identified with significant anxiety or panic-related symptoms, and an additional 11% of patients were identified with significant depressive symptoms. While highly effective treatment of nonepileptic seizures remains elusive, well-developed treatment paradigms with proven efficacy exist for depression, anxiety, and PTSD. Eliciting these psychiatric comorbidities and pursuing targeted treatments, especially for those patients that do not have easy access to providers with dedicated expertise in the management of nonepileptic seizures, may be a more easily scalable and implementable treatment modality for these patients.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Validation of a predictive calculator to distinguish between patients presenting with dissociative versus epileptic seizures

Dissociative seizures (also known as psychogenic nonepileptic seizures) are a common functional neurological disorder that can be difficult to distinguish from epileptic seizures. Patients with dissociative seizures provide diagnostic challenges, leading to delays in care, inappropriate care, and significant healthcare utilization and associated costs. The dissociative seizure likelihood score (DSLS) was developed by Kerr and colleagues at UCLA to distinguish between patients with epileptic seizures and dissociative seizures based on clinical and medication history as well as features of seizure semiology. We validated this calculator at the University of Colorado, which is a Level 4 National Association of Epilepsy Center. The DSLS accurately predicted the diagnosis in 81% of patients, despite local variability in the factors associated with epileptic versus dissociative seizures between the two populations. The DSLS can be a useful tool to assist with history taking and may have important utility for clinical decision making with these difficult to distinguish patient populations.

Factors associated with delay to video-EEG in dissociative seizures

PURPOSE

While certain clinical factors suggest a diagnosis of dissociative seizures (DS), otherwise known as functional or psychogenic nonepileptic seizures (PNES), ictal video-electroencephalography monitoring (VEM) is the gold standard for diagnosis. Diagnostic delays were associated with worse quality of life and more seizures, even after treatment. To understand why diagnoses were delayed, we evaluated which factors were associated with delay to VEM.

METHODS

Using data from 341 consecutive patients with VEM-documented dissociative seizures, we used multivariate log-normal regression with recursive feature elimination (RFE) and multiple imputation of some missing data to evaluate which of 76 clinical factors were associated with time from first dissociative seizure to VEM.

RESULTS

The mean delay to VEM was 8.4 years (median 3 years, IQR 1-10 years). In the RFE multivariate model, the factors associated with longer delay to VEM included more past antiseizure medications (0.19 log-years/medication, standard error (SE) 0.05), more medications for other medical conditions (0.06 log-years/medication, SE 0.03), history of physical abuse (0.75 log-years, SE 0.27), and more seizure types (0.36 log-years/type, SE 0.11). Factors associated with shorter delay included active employment or student status (-1.05 log-years, SE 0.21) and higher seizure frequency (0.14 log-years/log[seizure/month], SE 0.06).

CONCLUSIONS

Patients with greater medical and seizure complexity had longer delays. Delays in multiple domains of healthcare can be common for victims of physical abuse. Unemployed and non-student patients may have had more barriers to access VEM. These results support earlier referral of complex cases to a comprehensive epilepsy center.

Reliability of additional reported seizure manifestations to identify dissociative seizures

PURPOSE

Descriptions of seizure manifestations (SM), or semiology, can help localize the symptomatogenic zone and subsequently included brain regions involved in epileptic seizures, as well as identify patients with dissociative seizures (DS). Patients and witnesses are not trained observers, so these descriptions may vary from expert review of seizure video recordings of seizures. To better understand how reported factors can help identify patients with DS or epileptic seizures (ES), we evaluated the associations between more than 30 SMs and diagnosis using standardized interviews.

METHODS

Based on patient- and observer-reported data from 490 patients with diagnoses documented by video-electoencephalography, we compared the rate of each SM in five mutually exclusive groups: epileptic seizures (ES), DS, physiologic seizure-like events (PSLE), mixed DS and ES, and inconclusive testing.

RESULTS

In addition to SMs that we described in a prior manuscript, the following were associated with DS: light triggers, emotional stress trigger, pre-ictal and post-ictal headache, post-ictal muscle soreness, and ictal sensory symptoms. The following were associated with ES: triggered by missing medication, aura of déjà vu, and leftward eye deviation. There were numerous manifestations separately associated with mixed ES and DS.

CONCLUSIONS

Reported SM can help identify patients with DS, but no manifestation is pathognomonic for either ES or DS. Patients with mixed ES and DS reported factors divergent from both ES-alone and DS-alone.

Sex Effects on Coping, Dissociation, and PTSD in Patients With Non-epileptic Seizures

PURPOSE OF REVIEW

Sex differences in non-epileptic seizures (NES) are of interest, as the diagnosis is more frequent in women than men (3:1 ratio). This paper reviews clinical findings regarding sex differences in NES through selective literature review and compares coping measures between women and men in our NES clinic.

RECENT FINDINGS

Some distinguishing clinical features of NES in women and men are reported in the literature. However, we found few sex differences in demographics and coping. In our population, avoidance and dissociation were strongly related to one another and significantly related to co-occurring PTSD diagnosis, which was seen in over 50% in both sexes. Our findings confirm a high prevalence of PTSD in patients with NES, suggesting that comorbid PTSD may override sex differences in accounting for use of avoidant and dissociative coping. These findings raise the possibility that NES may, at times, represent an extreme variant in dysfunctional coping in patients with PTSD.

The Educational Value of Outpatient Consultation-Liaison Rotations: A White Paper From the Academy of Consultation-Liaison Psychiatry Residency Education Subcommittee

Background

As mental health services in outpatient medical clinics expand, psychiatrists must be trained to practice in these settings.

Objectives

The Academy of Consultation-Liaison Psychiatry residency education subcommittee convened a writing group with the goal of summarizing the current evidence about outpatient consultation-liaison psychiatry (CLP) training and providing a framework for CLP educators who are interested in developing outpatient CLP rotations within their programs.

Method

MEDLINE (via PubMed), Embase, and PsycINFO (via OVID) were reviewed each from inception to December 2019, for psychiatric CLP services in ambulatory settings that involved residents or fellows. The CLP education guidelines were reviewed for recommendations relevant to outpatient CLP. We also searched MedEd portal for published curriculums relevant to CLP. The group held 2 conferences to reach consensus about recommendations in setting up outpatient CLP rotations.

Results

Seventeen articles, 3 Academy of Consultation-Liaison Psychiatry–supported guidelines, and 8 online didactic resources were identified as directly reporting on the organization and/or impact of an outpatient CLP rotation. These manuscripts indicated that residents found outpatient CLP rotations effective and relevant to their future careers. However, the literature provided few recommendations for establishing formal outpatient CLP training experiences.

Conclusions

Outpatient CLP rotations offer multiple benefits for trainees, including exposure to specific clinical scenarios and therapeutic interventions applicable only in the outpatient setting, increased continuity of care, and the unique experience of providing liaison and education to non-mental health providers. The article outlines recommendations and examples for developing outpatient CLP rotations which CLP educators can incorporate in their programs.

A Novel Integrative Psychotherapy for Psychogenic Nonepileptic Seizures Based on the Biopsychosocial Model: A Retrospective Pilot Outcome Study

BACKGROUND

Psychogenic nonepileptic seizures (PNES) represent one of the most sizable treatment challenges in neuropsychiatry. Although the underlying mechanism is far from being understood, several interventions have been suggested. However, patients with comorbid psychiatric diagnoses and epilepsy are excluded from most intervention studies.

OBJECTIVE

To To present a within-group posttreatment vs pretreatment study representing the retrospective clinical results of an integrative psychotherapy model.

METHODS

We present the clinical results of 22 patients with PNES diagnosed in an epilepsy center and treated in our neuropsychiatry clinic using an integrative rehabilitative psychotherapy. Therapy included presenting the diagnosis, psychoeducation, seizure reduction behavioral techniques, and coping with past and present stressors. Insomuch as integrative biopsychosocial psychotherapy is based on an individualized treatment protocol for each patient, treatment was individualized and case specific.

RESULTS

By the end of treatment, 36% of patients had become seizure free and a further 54% achieved a major seizure reduction (reduction of more than 70%). Seventy-two percent of patients kept at least 70% seizure reduction at follow-up. Global Assessment of Functioning scores improved from a mean of 43.09 to a mean of 72.81 at the end of treatment and 69.72 at follow-up. In addition, we present 3 case descriptions that emphasize the individualized nature of psychotherapeutic decisions.

CONCLUSIONS

Our results support the feasibility and effectiveness of biopsychosocial based integrative psychotherapy for PNES and set principles for future treatment and prospective clinical trials in the field of individualized psychotherapy.