1
|
Millman LSM, Williams IA, Jungilligens J, Pick S. Neurocognitive performance in functional neurological disorder: A systematic review and meta-analysis. Eur J Neurol 2024:e16386. [PMID: 38953473 DOI: 10.1111/ene.16386] [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: 11/08/2023] [Revised: 04/10/2024] [Accepted: 05/30/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND AND PURPOSE Cognitive complaints are common in functional neurological disorder (FND), but it is unclear whether objective neurocognitive deficits are present. This systematic review summarized validated/standardized cognitive test performance in FND samples across cognitive domains. METHODS Embase, PsycInfo and MEDLINE were searched from inception to 15 May 2023, combining terms for FND and cognitive domains (e.g., attention, memory, executive functioning). Studies included a range of FND phenotypes (seizures, motor, cognitive disorder, mixed), compared to healthy or clinical controls. Risk of bias was assessed with the modified Newcastle-Ottawa Scale and a qualitative synthesis/narrative review of cognitive performance in FND was conducted. Test performance scores were extracted, and random effects meta-analyses were run where appropriate. This review was registered on PROSPERO, CRD42023423139. RESULTS Fifty-six studies including 2260 individuals with FND were eligible. Although evidence for some impairments emerged across domains of executive functioning, attention, memory and psychomotor/processing speed, this was inconsistent across studies and FND phenotypes. Common confounds included group differences in demographics, medication and intellectual functioning. Only 24% of studies objectively assessed performance validity. Meta-analyses revealed higher scores on tests of naming (g = 0.67, 95% confidence interval [CI] 0.50, 0.84) and long-term memory (g = 0.43, 95% CI 0.13, 0.74) in functional seizures versus epilepsy, but no significant differences in working (g = -0.08, 95% CI -0.44, 0.29) or immediate (g = 0.25, 95% CI -0.02, 0.53) memory and cognitive flexibility (g = -0.01, 95% CI -0.29, 0.28). CONCLUSIONS There is mixed evidence for objective cognitive deficits in FND. Future research should control for confounds, include tests of performance validity, and assess relationships between objective and subjective neurocognitive functioning.
Collapse
Affiliation(s)
- L S Merritt Millman
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Isobel A Williams
- Psychology in Healthcare, Newcastle Upon Tyne Hospitals NHS Foundation Trust and the Translational and Clinical Research Institute, Newcastle University, Callaghan, UK
| | - Johannes Jungilligens
- Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, Bochum, Germany
| | - Susannah Pick
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| |
Collapse
|
2
|
Van Patten R, Chan L, Tocco K, Mordecai K, Altalib H, Twamley EW, Gaston TE, Grayson LP, Martin A, Fry S, Goodman A, Allendorfer JB, Correia S, Szaflarski J, LaFrance WC. Improvements in Montreal Cognitive Assessment scores after neurobehavioral therapy in adults with functional (nonepileptic) seizures and traumatic brain injury. J Psychiatr Res 2023; 165:282-289. [PMID: 37549503 DOI: 10.1016/j.jpsychires.2023.07.038] [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] [Received: 03/31/2023] [Revised: 07/18/2023] [Accepted: 07/28/2023] [Indexed: 08/09/2023]
Abstract
Cognitive functioning impacts clinical symptoms, treatment response, and quality of life in adults with functional/nonepileptic seizures (FS/NES), but no study to date examines effects of behavioral FS/NES treatment on cognition in these patients. We hypothesized that there would be a reduction in cognitive symptoms in participants with FS/NES and traumatic brain injury (TBI) following neurobehavioral therapy (NBT). We also hypothesized that select seizure-related, medication, subjective cognitive, and mental health symptoms would be negatively correlated with improvements in cognitive performance after NBT. Participants were 37 adults with TBI + FS/NES and 35 adults with TBI only, recruited from medical centers in the northeastern or southeastern U.S. TBI + FS/NES participants completed a 12 session NBT intervention, and TBI without seizures participants were not treated. All participants completed pre-post assessments of cognition (Montreal Cognitive Assessment [MoCA]) and baseline sociodemographic factors and mental health symptoms. Pre-post MoCA scores increased significantly in TBI + FS/NES participants (28/37 [75.7%] improved) but not in TBI comparisons (10/35 [28.6%] improved). Language, memory, and visuospatial/executive functions, but not attention, improved over time in the TBI + FS/NES group. Gains in cognition were concentrated in those TBI + FS/NES participants with likely baseline cognitive impairments (MoCA total score <26), and 9/17 of these participants moved from the "impaired" range at baseline (<26) to the "intact" range at endpoint (≥26). Lastly, participants taking fewer medications and reporting lower subjective cognitive difficulties at baseline showed larger pre-post MoCA total score improvements. Overall, results from this study suggest the potential for positive change in cognition in FS/NES and co-occurring TBI using evidence-based psychotherapy.
Collapse
Affiliation(s)
- Ryan Van Patten
- VA Providence Healthcare System, Providence, RI, USA; Warren Alpert Medical School of Brown University, Providence, RI, USA.
| | - Lawrence Chan
- VA Providence Healthcare System, Providence, RI, USA; Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Krista Tocco
- VA Providence Healthcare System, Providence, RI, USA; Rhode Island Hospital, Providence, RI, USA
| | | | | | - Elizabeth W Twamley
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System and UC San Diego, San Diego, CA, USA
| | - Tyler E Gaston
- University of Alabama Birmingham, Birmingham, AL, USA; Birmingham VA Medical Center, Birmingham, AL, USA
| | | | - Amber Martin
- University of Alabama Birmingham, Birmingham, AL, USA
| | - Samantha Fry
- University of Alabama Birmingham, Birmingham, AL, USA
| | - Adam Goodman
- University of Alabama Birmingham, Birmingham, AL, USA
| | | | | | | | - W Curt LaFrance
- VA Providence Healthcare System, Providence, RI, USA; Warren Alpert Medical School of Brown University, Providence, RI, USA; Rhode Island Hospital, Providence, RI, USA
| |
Collapse
|
3
|
Sullivan-Baca E, Weitzner DS, Choudhury TK, Fadipe M, Miller BI, Haneef Z. Characterizing differences in psychiatric profiles between male and female veterans with epilepsy and psychogenic non-epileptic seizures. Epilepsy Res 2022; 186:106995. [PMID: 36030730 DOI: 10.1016/j.eplepsyres.2022.106995] [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: 04/20/2022] [Revised: 07/26/2022] [Accepted: 08/04/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE While previous studies have described psychiatric profiles in patients with psychogenic non-epileptic seizures (PNES) and epileptic seizures (ES), a well-matched comparison between males and females has been lacking. To address this shortcoming, the present study sought to explore sex differences between male and female Veterans with ES and PNES in terms of psychiatric diagnoses, trauma histories, and psychiatric treatment. METHODS A male Veteran sample (PNES n = 87, ES n = 28) was identified matching age and seizure diagnosis with our previously-gathered female Veteran sample (PNES n = 90, ES n = 28). Retrospective chart review was used to obtain demographic, psychiatric, and seizure-related variables. Group differences between PNES and ES were first assessed among males followed by differences between males and females. RESULTS Males with PNES were more likely to receive psychiatric treatment (82.6 % vs. 60.7 %, p = 0.017), be prescribed more psychotropics (1.6 vs. 0.9, p = 0.003), and more likely to have childhood physical abuse (27.9 % vs. 3.6 %, p = 0.007) than those with ES. Compared to PNES, males with ES presented to the epilepsy monitoring unit (EMU) significantly later (12.8 years vs. 6.1 years, p = 0.009), and were prescribed more anti-seizure medications (ASMs) previously (2.1 vs. 0.8, p = 0.009) and currently (1.6 vs. 1.0, p = 0.001). Between males and females with PNES, females evidenced more depression (76.7 % vs. 26.3 %, p < 0.001), borderline personality disorder (18.9 % vs. 4.7 %, p = 0.004), suicidality (65.6 % vs. 33.7 %, p < 0.001), and childhood sexual abuse (37.8 % vs. 11.6 %, p < 0.001), while males had higher rates of substance use disorders (37.2 % vs. 8.9 %, p < 0.001). SIGNIFICANCE A greater psychiatric burden is seen among females compared to males with PNES, especially diagnoses of borderline personality disorder and depression. Higher rates of suicidality and inpatient psychiatric hospitalization may warrant particular consideration in screening and intervention efforts among female Veterans with PNES.
Collapse
Affiliation(s)
- Erin Sullivan-Baca
- DR Associates of North Texas (Private Researcher), Plano, TX 75093, USA.
| | - Daniel S Weitzner
- Mental Health Care Line, Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA; Psychology Department, Louisiana State University, Baton Rouge, LA 70803, USA
| | - Tabina K Choudhury
- Mental Health Care Line, Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA
| | - Melissa Fadipe
- Neurology Care Line, Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA
| | - Brian I Miller
- Neurology Care Line, Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA
| | - Zulfi Haneef
- Neurology Care Line, Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA; Department of Neurology, Baylor College of Medicine, Houston, TX 77030, USA
| |
Collapse
|
4
|
Szaflarski JP, Allendorfer JB, Goodman AM, Byington CG, Philip NS, Correia S, LaFrance WC. Diagnostic delay in functional seizures is associated with abnormal processing of facial emotions. Epilepsy Behav 2022; 131:108712. [PMID: 35526462 DOI: 10.1016/j.yebeh.2022.108712] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 04/10/2022] [Accepted: 04/16/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE In patients with functional seizures (FS), delay in diagnosis (DD) may negatively affect outcomes. Altered brain responses to emotional stimuli have been shown in adults with FS. We hypothesized that DD would be associated with differential fMRI activation in emotion processing circuits. METHODS Fifty-two adults (38 females) with video-EEG confirmed FS prospectively completed assessments related to symptoms of depression (BDI-II), anxiety (BAI), post-traumatic stress disorder (PCL-S), a measure of how their symptoms affect day-to-day life (GAF), and fMRI at 3T with emotional faces task (EFT). During fMRI, subjects indicated "male" or "female" via button press while implicitly processing happy, sad, fearful, and neutral faces. Functional magnetic resonance imaging (FMRI) response to each emotion was modeled and group analyses were performed in AFNI within pre-specified regions-of-interest involved in emotion processing. A median split (507 days) defined short- (s-DD) and long-delay diagnosis (l-DD) groups. Voxelwise regression analyses were also performed to examine linear relationship between DD and emotion processing. FMRI signal was extracted from clusters showing group differences and Spearman's correlations assessed relationships with symptom scores. RESULTS Groups did not differ in FS age of onset, sex distribution, years of education, TBI characteristics, EFT in-scanner or post-test performance, or scores on the GAF, BDI-II, BAI, and PCL-S measures. The s-DD group was younger than l-DD (mean age 32.6 vs. 40.1; p = 0.022) at the time of study participation. After correcting for age, compared to s-DD, the l-DD group showed greater fMRI activation to sad faces in the bilateral posterior cingulate cortex (PCC) and to neutral faces in the right anterior insula. Within-group linear regression revealed that with increasing DD, there was increased fMRI activation to sad faces in the PCC and to happy faces in the right anterior insula/inferior frontal gyrus (AI/IFG). There were positive correlations between PCC response to sad faces and BDI-II scores in the l-DD group (rho = 0.48, p = 0.012) and the combined sample (rho = 0.30, p = 0.029). Increased PCC activation to sad faces in those in the l-DD group was associated with worse symptoms of depression (i.e. higher BDI-II score). CONCLUSIONS Delay in FS diagnosis is associated with fMRI changes in PCC and AI/IFG. As part of the default mode network, PCC is implicated in mood control, self-referencing, and other emotion-relevant processes. In our study, PCC changes are linked to depression. Future studies should assess the effects of interventions on these abnormalities.
Collapse
Affiliation(s)
- Jerzy P Szaflarski
- Department of Neurology, University of Alabama at Birmingham (UAB), UAB Epilepsy Center, Birmingham, AL, USA.
| | - Jane B Allendorfer
- Department of Neurology, University of Alabama at Birmingham (UAB), UAB Epilepsy Center, Birmingham, AL, USA
| | - Adam M Goodman
- Department of Neurology, University of Alabama at Birmingham (UAB), UAB Epilepsy Center, Birmingham, AL, USA
| | - Caroline G Byington
- Department of Neurology, University of Alabama at Birmingham (UAB), UAB Epilepsy Center, Birmingham, AL, USA
| | - Noah S Philip
- VA RR&D Center for Neurorestoration & Neurotechnology, VA Providence Healthcare System, Providence, RI, USA; Dept of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
| | - Stephen Correia
- VA RR&D Center for Neurorestoration & Neurotechnology, VA Providence Healthcare System, Providence, RI, USA
| | - W Curt LaFrance
- VA RR&D Center for Neurorestoration & Neurotechnology, VA Providence Healthcare System, Providence, RI, USA; Dept of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
| |
Collapse
|
5
|
Goodman AM, Allendorfer JB, LaFrance WC, Szaflarski JP. Precentral gyrus and insula responses to stress vary with duration to diagnosis in functional seizures. Epilepsia 2022; 63:865-879. [PMID: 35112346 DOI: 10.1111/epi.17179] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 01/21/2022] [Accepted: 01/21/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVE This study was undertaken to determine whether undiagnosed illness duration (time between functional seizures [FS] onset and diagnosis) is linked to differences in neural response and functional connectivity during processing of stressful experiences. METHODS Forty-nine participants with traumatic brain injury preceding the onset of FS confirmed by video-electroencephalography were recruited prospectively. Participants completed psychiatric symptom assessments before undergoing functional magnetic resonance imaging (fMRI) with an acute psychosocial stress task. Linear mixed effects (LME) analyses identified significant interactions between the factors of group (early vs. delayed diagnosis) and time lag to diagnosis on neural responses to stressful math performance and auditory feedback (corrected α = .05). Functional connectivity analysis utilized clusters from initial LME analyses as seed regions to determine significant interactions between these factors on network functional connectivity. RESULTS Demographic and psychiatric symptom measures were similar between early (n = 25) and delayed (n = 24) groups. Responses to stressful math performance within the left anterior insula and functional connectivity between the anterior insula seed region and a precentral gyrus cluster were significantly negatively correlated with time lag to diagnosis for the early but not the delayed FS diagnosis group. There was no correlation between fMRI findings and psychiatric symptoms. SIGNIFICANCE This study indicates that aberrant left anterior insula activation and its functional connectivity to the precentral gyrus underlie differences in processing of stressful experiences in patients with delayed FS diagnosis. Follow-up comparisons suggest changes are associated with undiagnosed illness duration rather than psychiatric comorbidities and indicate a potential mechanistic association between neuropathophysiology, response to stressful experiences, and functional neuroanatomy in FS.
Collapse
Affiliation(s)
- Adam M Goodman
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - W Curt LaFrance
- Providence Veterans Affairs Medical Center, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | | |
Collapse
|
6
|
Asadi-Pooya AA, Brigo F, Tolchin B, Valente KD. Functional seizures are not less important than epilepsy. Epilepsy Behav Rep 2021; 16:100495. [PMID: 34805820 PMCID: PMC8585631 DOI: 10.1016/j.ebr.2021.100495] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 10/08/2021] [Accepted: 10/13/2021] [Indexed: 11/24/2022] Open
Abstract
People with functional seizures often suffer from psychiatric comorbidities. People with FS report detrimental effects on social aspects of their lives. FS are associated with a considerable direct and indirect economic burden. 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.
Collapse
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
| | - Francesco Brigo
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | - Benjamin Tolchin
- Yale Comprehensive Epilepsy Center, Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Kette D Valente
- Laboratory of Clinical Neurophysiology, Department of Psychiatry, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, Brazil
| |
Collapse
|