Quality of life in patients with epilepsy or psychogenic nonepileptic seizures and the contribution of psychiatric comorbidities

Evaluation of quality of life's prognostic factors in people with functional seizures

AIMS

Functional non-epileptic seizures significantly impact the quality of life of patients. We aimed to identify prognostic factors associated with the quality of life in individuals with functional non-epileptic seizures.

SUBJECTS AND METHODS

Adult patients diagnosed with definite or documented functional seizures based on LaFrance's criteria (n=72) were enrolled at the time of diagnosis. Quality of life was assessed using the Quality of Life in Epilepsy Inventory-31 (QOLIE-31) at diagnosis and at a six-month follow-up. Demographic and medical information was collected, and psychiatric comorbidities were evaluated using validated scales.

RESULTS

Comparisons between diagnosis and follow-up did not reveal any factors associated with improvement in quality of life at six months after diagnosis. However, multivariable analysis, adjusted for age, sex, diagnosis delay, and frequency of functional seizures showed a significant cross-sectional relationship with a QOLIE-31 score decrease of 0.66 [95% CI -0.93;-0.39], -0.32 [-0.61; -0.03], and -0.22 [-0.42; -0.02] for an increase of 1 point of BDI-2 score, BAI score, and CTQ score respectively.

CONCLUSION

Psychiatric comorbidities, particularly depression and anxiety, are associated with worse quality of life in patients with functional seizures. This underscores the crucial importance of multidisciplinary care involving both neurological and psychiatric expertise when managing individuals with functional seizures.

Natural product-derived therapies for treating drug-resistant epilepsies: From ethnopharmacology to evidence-based medicine

ETHNOPHARMACOLOGICAL RELEVANCE

Epilepsy is one of the most prevalent neurological human diseases, affecting 1% of the population in all age groups. Despite the availability of over 25 anti-seizure medications (ASMs), which are approved in most industrialized countries, approximately 30% of epilepsy patients still experience seizures that are resistant to these drugs. Since ASMs target only limited number of neurochemical mechanisms, drug-resistant epilepsy (DRE) is not only an unmet medical need, but also a formidable challenge in drug discovery.

AIM

In this review, we examine recently approved epilepsy drugs based on natural product (NP) such as cannabidiol (CBD) and rapamycin, as well as NP-based epilepsy drug candidates still in clinical development, such as huperzine A. We also critically evaluate the therapeutic potential of botanical drugs as polytherapy or adjunct therapy specifically for DRE.

METHODS

Articles related to ethnopharmacological anti-epileptic medicines and NPs in treating all forms of epilepsy were collected from PubMed and Scopus using keywords related to epilepsy, DRE, herbal medicines, and NPs. The database clinicaltrials.gov was used to find ongoing, terminated and planned clinical trials using herbal medicines or NPs in epilepsy treatment.

RESULTS

A comprehensive review on anti-epileptic herbal drugs and natural products from the ethnomedical literature is provided. We discuss the ethnomedical context of recently approved drugs and drug candidates derived from NPs, including CBD, rapamycin, and huperzine A. Recently published studies on natural products with preclinical efficacy in animal models of DRE are summarized. Moreover, we highlight that natural products capable of pharmacologically activating the vagus nerve (VN), such as CBD, may be therapeutically useful to treat DRE.

CONCLUSIONS

The review highlights that herbal drugs utilized in traditional medicine offer a valuable source of potential anti-epileptic drug candidates with novel mechanisms of action, and with clinical promise for the treatment of drug-resistant epilepsy (DRE). Moreover, recently developed NP-based anti-seizure medications (ASMs) indicate the translational potential of metabolites of plant, microbial, fungal and animal origin.

Long-term course of psychogenic nonepileptic seizures: Who gets seizure-free, has better functional level and higher health-related quality of life?

BACKGROUND

The disease course of psychogenic nonepileptic seizures (PNES) over a prolonged period of time remains unclear. The aims of the study were: 1. to describe the course of illness with a median follow-up time of 4 years and a range of 2-15 years; and 2. to identify distinguishing features between participants regarding seizure cessation, functional level and health-related quality of life.

METHODS

Formerly, inpatients of an epileptic ward diagnosed with PNES between 2000 and 2013 were contacted via mail. They were asked by questionnaire about illness characteristics, i.e., age at onset, PNES status at onset and in the course, treatments, psychosocial situation, and quality of life status.

RESULTS

Two-thirds of the N = 63 formerly inpatients were female, their age at onset was 26.7 years. Seizure frequency decreased significantly over time, 31.7% were currently seizure-free, but still only 37% were regularly employed. Only 48% had a satisfying health-related quality of life. The remitted participants had a shorter duration of illness and higher health-related quality of life. Participants with a good level of functioning were more likely to be male, took fewer medications, and had a higher health-related quality of life. Those participants with higher quality of life were more frequently employed and had fewer seizures.

CONCLUSIONS

As participants continue to be severely limited in their functional level and quality of life over the period under review, enhanced treatment approaches that address experiential avoidance seem to be needed.

Psychiatric and psychological assessment of patients with drug-resistant epilepsy and psychogenic nonepileptic seizures (PNES) with no response to previous treatments

OBJECTIVE

Psychogenic nonepileptic seizures (PNES) are common imitators of epileptic seizures. Refractoriness to antiseizure medication hinders the differential diagnosis between ES and PNES, carrying deleterious consequences in patients with PNES. Psychiatric and psychological characteristics may assist in the differential diagnosis between drug-resistant epilepsy (DRE) and PNES. Nevertheless, current comprehensive psychiatric and psychological descriptive studies on both patient groups are scarce and with several study limitations. This study provides a comprehensive psychiatric and psychological characterization of Spanish patients with DRE and PNES.

METHOD

A cross-sectional and comparative study was completed with 104 patients with DRE and 21 with PNES. Psychiatric and psychological characteristics were assessed with the HADS, SCL-90-R, NEO-FFI-R, PDQ-4+, COPE, and QOLIE-31 tests. Parametric and non-parametric tests were used, and regression models were fit to further explore factors affecting patients' life quality.

RESULTS

Patients with PNES had greater levels of somatization and extraversion and were associated with benzodiazepine intake. Patients with DRE showed greater narcissistic personality disorder symptoms than those with PNES. In patients with DRE, difficulty in performing basic needs-related tasks and greater psychological distress severity and seizure frequency were associated with poorer life quality. In contrast, being a woman, having a psychiatric disorder history, and greater psychiatric symptoms' intensity were associated with poorer life quality in patients with PNES.

CONCLUSION

Patients with DRE and PNES share similar psychiatric and psychological characteristics, with only very few being significantly different.

Evaluation of the Antiseizure Activity of Endemic Plant Halfordia kendack Guillaumin and Its Main Constituent, Halfordin, on a Zebrafish Pentylenetetrazole (PTZ)-Induced Seizure Model

Epilepsy is a neurological disease that burdens over 50 million people worldwide. Despite the considerable number of available antiseizure medications, it is estimated that around 30% of patients still do not respond to available treatment. Herbal medicines represent a promising source of new antiseizure drugs. This study aimed to identify new drug lead candidates with antiseizure activity from endemic plants of New Caledonia. The crude methanolic leaf extract of Halfordia kendack Guillaumin (Rutaceae) significantly decreased (75 μg/mL and 100 μg/mL) seizure-like behaviour compared to sodium valproate in a zebrafish pentylenetetrazole (PTZ)-induced acute seizure model. The main coumarin compound, halfordin, was subsequently isolated by liquid-liquid chromatography and subjected to locomotor, local field potential (LFP), and gene expression assays. Halfordin (20 μM) significantly decreased convulsive-like behaviour in the locomotor and LFP analysis (by 41.4% and 60%, respectively) and significantly modulated galn, and penka gene expression.

Translocation of High Mobility Group Box 1 From the Nucleus to the Cytoplasm in Depressed Patients With Epilepsy

Depression is a common psychiatric comorbidity in patients with epilepsy, especially those with temporal lobe epilepsy (TLE). The aim of this study was to assess changes in high mobility group box protein 1 (HMGB1) expression in epileptic patients with and without comorbid depression. Sixty patients with drug-resistant TLE who underwent anterior temporal lobectomy were enrolled. Anterior hippocampal samples were collected after surgery and analyzed by immunofluorescence (n  = 7/group). We also evaluated the expression of HMGB1 in TLE patients with hippocampal sclerosis and measured the level of plasma HMGB1 by enzyme-linked immunosorbent assay. The results showed that 28.3% of the patients (17/60) had comorbid depression. HMGB1 was ubiquitously expressed in all subregions of the anterior hippocampus. The ratio of HMGB1-immunoreactive neurons and astrocytes was significantly increased in both TLE patients with hippocampal sclerosis and TLE patients with comorbid depression compared to patients with TLE only. The ratio of cytoplasmic to nuclear HMGB1-positive neurons in the hippocampus was higher in depressed patients with TLE than in nondepressed patients, which suggested that more HMGB1 translocated from the nucleus to the cytoplasm in the depressed group. There was no significant difference in the plasma level of HMGB1 among patients with TLE alone, TLE with hippocampal sclerosis, and TLE with comorbid depression. The results of the study revealed that the translocation of HMGB1 from the nucleus to the cytoplasm in hippocampal neurons may play a previously unrecognized role in the initiation and amplification of epilepsy and comorbid depression. The direct targeting of neural HMGB1 is a promising approach for anti-inflammatory therapy.

Learning from the comorbidities of epilepsy

PURPOSE OF REVIEW

Comorbidities are a common feature in epilepsy, but neither the entire spectrum nor the significance of such comorbidities has been fully explored. We review comorbidities associated with epilepsy and their associated burden, provide an overview of relationships, and discuss a new conceptualization of the comorbidities.

RECENT FINDINGS

The epidemiology of the comorbidities of epilepsy and effects on health outcomes, healthcare use, and healthcare expenditures have been partly delineated. Distinct mechanisms of the associations have been suggested but not entirely ascertained. Movement from conceptualizing epilepsy as a condition to a symptom-complex has occurred.

SUMMARY

Comorbidities are common among people with epilepsy and are associated with poorer clinical outcomes and quality of life, greater use of health resources, and increased expenditure. Becoming aware of the associated mechanisms and their uncertainty is central to understanding the relationships between epilepsy and comorbid health conditions, which have implications for diagnosis and screening, medical management, and surgical management. Conceptualizing comorbidities of epilepsy as precipitating factors and epilepsy as the symptom will improve the understanding of epilepsy and catalyze research and improvements in clinical practice.

Quality of life for patients with psychogenic nonepilepsy seizures in comparison with age- and gender-matched patients with epilepsy - Cross-sectional study

AIMS

Patients with psychogenic nonepileptic seizures (PNES), and age- and gender-matched patients with epilepsy (PWE) who utilized an out-patient service were compared regarding quality of life (QoL) and self-reported symptoms of depression. Additionally, the impact of miscellaneous clinical variables including symptoms of depression on QoL in patients with PNES and PWE in real-world settings was assessed.

SUBJECTS AND METHODS

Adult patients who had a diagnosis of definite or documented PNES based on LaFrance's criteria (PNES group, n = 62), or of epilepsy based on results of clinical and EEG procedures (Epilepsy group, n = 61) were enrolled. To assess QoL and evaluate depression, the Quality of Life in Epilepsy Inventory-10 (QOLIE-10) and Neurological Disorders Depression Inventory for Epilepsy (NDDI-E), respectively, were administered.

RESULTS

Comparisons between the groups revealed a shorter duration of illness and fewer number of attacks in patients with PNES as compared to the Epilepsy group (p < 0.0001; p = 0.0003, respectively). There was no significant difference between the groups revealed by the QOLIE-10 (p = 0.141), while the patients with PNES tended to have higher NDDI-E scores (p = 0.068). Multiple regression analysis of QOLIE-10 results in the PNES group revealed that NDDI-E score was the sole significant contributor (β = -0.425 p = 0.001). In contrast, NDDI-E score as well as attack frequency had a significant impact on QOLIE-10 results in the Epilepsy group (β = -0.283 p = 0.026; β = -0.272 p = 0.031, respectively).

CONCLUSION

In PWE and patients with PNES who utilized an out-patient service, QoL did not differ significantly between those groups. For treating PNES, psychosocial factors may be a more appropriate indicator of therapeutic goal than attack frequency.

Functional seizures are not less important than epilepsy

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People with functional seizures often suffer from psychiatric comorbidities.

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

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

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FS have increased rates of mortality compared to healthy controls.

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

Mood Disturbances, Anxiety, and Impact on Quality of Life in Patients Admitted to Epilepsy Monitoring Units

Introduction: The overall combined prevalence of anxiety and depression in patients with epilepsy has been estimated at 20.2 and 22.9%, respectively, and is considered more severe in drug-refractory epilepsy. Patients admitted to epilepsy monitoring units constitute a particular group. Also, patients with psychogenic non-epileptic seizures can reach more than 20% of all admissions. This study aims to characterize these symptoms in a large cohort of patients admitted for evaluation in a tertiary epilepsy center.

Materials and Methods: The study was conducted among 493 consecutive patients (age: 38.78 ± 12.7, 57% females) admitted for long-term video EEG from January 2013 to February 2021. Demographic, clinical, and mood disorder patients' data were collected. Anxiety and depression symptoms were assessed through the Hospital Anxiety Depression Scale (HADS-A and HADS-D), the State Trait Anxiety Inventory (STAI), and Beck Depression Inventory (BDI-II). Quality of life was determined using the QOLIE-10. Patients were divided into three groups: patients with epilepsy (n = 395), psychogenic non-epileptic seizures (PNES) (n = 56), and combined (n = 33). A univariate and multivariate regression analysis was performed for variables associated with quality of life.

Results: Of 493 patients, 45.0% had structural etiology, and considering epilepsy classification, 43.6% were of temporal lobe origin. In addition, 32.45% of patients had a previous psychiatric history, 49.9% of patients had depressive symptoms in BDI, and 30.9% according to HADS-D; 56.42 and 52.63% of patients presented pathological anxiety scores in STAI-T and STAI-S, respectively; and 44.78% according to HADS-A. PNES and combined groups revealed a higher incidence of pathologic BDI scores (64.29 and 78.79%, p < 0.001) as well as pathologic HADS-A scores (p = 0.001). Anxiety and depression pathologic results are more prevalent in females, HADS-A (females = 50.7%, males = 36.8%; p = 0.0027) and BDI > 13 (females = 56.6%, males = 41.0%; p = 0.0006). QOLIE-10 showed that 71% of the patients had their quality of life affected with significantly higher scores in the combined group than in the epilepsy and PNES groups (p = 0.0015).

Conclusions: Subjective anxiety, depression, and reduced quality of life are highly prevalent in patients with refractory epilepsy. These symptoms are more evident when PNES are associated with epilepsy and more severe among female patients. Most of the cases were not previously diagnosed. These factors should be considered in everyday clinical practice, and specific approaches might be adapted depending on the patient's profile.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Regulation of TWIK-related K+ channel 1 in the anterior hippocampus of patients with temporal lobe epilepsy with comorbid depression

Epilepsy with comorbid depression has recently attracted increasing attention. Temporal lobe epilepsy (TLE) may represent an increased risk of developing depression, especially if the seizures do not generalize. The two-pore domain potassium channel-TWIK-related K⁺ channel (TREK-1) plays important roles in both epilepsy and depression. However, the changes in its expression in patients with epilepsy with comorbid depression remain unclear. In the present study, we analyzed depressive symptoms using neuropsychiatric scales in forty-two patients with drug-resistant TLE, who also underwent EEG in waking and sleeping states, as well as 3.0 T brain MRI. We tested for TREK-1 positive neurons and microglial cells in the anterior hippocampi of patients with drug-resistant TLE with and without comorbid depression (n=5/group). Approximately 31% of patients with TLE had comorbid depression (13/42). Meanwhile, the patients who had hippocampal sclerosis had much higher scores on the depression rating scale. The results indicated the contribution of hippocampal sclerosis to the development of depression. Immunostaining of TREK-1 channels was observed in neurons and glia in the anterior hippocampus. Increased immunoreactivity of TREK-1 neurons was observed in the hippocampi of patients with TLE with comorbid depression compared with nondepressed patients with TLE. TREK-1 was expressed in almost all microglia. Curiously, more activated TREK-1-positive microglia were observed in patients with TLE with depression than in those without depression. The results suggested that a change in TREK-1 immunoreactivity was involved, at least partly, in the development of depression as a comorbidity of TLE. Imbalance of the TREK-1 channel may be a potential target for the treatment of patients with epilepsy with comorbid depression.

Psychiatric comorbidities in patients with psychogenic nonepileptic seizures

BACKGROUND

Psychogenic nonepileptic seizures (PNES) are major challenges for diagnosis and management. The heterogeneity of psychogenic seizures is attributed to diverse psychopathological comorbidities, and the causal relationship between PNES and underlying psychopathologies is still enigmatic.

OBJECTIVE

Our objective was to study psychiatric comorbidities and personality constructs in patients with PNES and compare them to a control group of patients with epilepsy.

METHOD

We randomly recruited 33 patients with PNES and 33 patients with epilepsy. All patients completed the Mini-International Neuropsychiatric Interview (MINI) to screen for psychiatric comorbidities, the Structured Clinical Interview for psychiatric disorders in Axis II (SCID II) to screen for personality disorders, and Goldberg's International Personality Item Pool (IPIP) Big Five personality questionnaire to study the psychological constructs of extroversion-introversion, agreeableness, conscientiousness, emotional stability-neuroticism, and intellect.

RESULT

Mood and anxiety disorders were highly prevalent in patients with PNES (72.7% and 54.5%, respectively); however, the prevalence of only cluster B personality disorder was higher in patients with PNES (69.7%) compared to 33.3% among patients with epilepsy (p < 0.05). Screening for personality disorders using SCID II showed that the prevalence of borderline and depressive personality disorders was significantly higher in patients with PNES (p < 0.001). Patients with psychogenic seizures were more likely to be receiving polydrug therapy (75.8%) compared to patients with epileptic seizures (45.5%); this difference was statistically significant (p < 0.05).

CONCLUSION

Psychiatric comorbidities are highly prevalent among patients with PNES.

Psychiatric symptoms are the strongest predictors of quality of life in patients with drug-resistant epilepsy or psychogenic nonepileptic seizures

OBJECTIVE

This cross-sectional study aimed to determine the effect of psychiatric comorbidity and neurocognitive deficits on the quality of life in a cohort of patients admitted for Video-EEG Monitoring (VEM) for investigation into a presumed seizure disorder.

METHODS

Patients were recruited from an inpatient VEM unit between January 2009 and December 2016. All patients had formal neuropsychiatric assessment. All patients completed questionnaires assessing psychiatric symptomatology (SCL-90-R), Anxiety and Depression (HADS), quality of life (QOLIE-89), and cognition (NUCOG).

RESULTS

A total of 451 patients were enrolled. Upon discharge, 204 patients were diagnosed to have epilepsy, 118 psychogenic nonepileptic seizures (PNES), and 29 both epilepsy and PNES, while the diagnosis was uncertain diagnosis in 100. Diagnosis (p = .002), HADS Depression score (p < .001), SCL-90-R positive symptoms total (p < .001), and NUCOG total score (p < .001) were found to be significant predictors of QOLIE-89 total scores, together explaining 65.4% of variance in quality of life. Seizure frequency was not a significant predictor of quality of life (p = .082). Patients with PNES had significantly worse quality of life, and scored higher on measures of psychiatricsymptomatology, compared to patients with epilepsy alone. The prevalence of psychiatric comorbidity was significantly higher in patients with PNES (70.3%) or both PNES and epilepsy (62.1%) compared to patients with epilepsy alone (41.2%) (p < .001).

SIGNIFICANCE

Psychiatric symptomatology, depression, and cognition were stronger determinants of quality of life than seizure frequency in this study population of patients with drug-resistant epilepsy and PNES. Patients with PNES with or without comorbid epilepsy had similar neuropsychiatric profiles.

Can Treating Patients With PNES Lower the Risk of Sudden Unexpected Death?

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.