Driving rate in patients with seizures: Epilepsy vs. functional seizures

The clinical profile of adult-onset idiopathic generalised epilepsy

OBJECTIVE

Idiopathic generalised epilepsies (IGE) tend to begin in childhood or adolescence, whereas adult-onset presentations are less frequently observed. In this study, we describe the disease course of a cohort of patients with adult-onset IGE.

METHODS

In this retrospective observational study, we evaluated clinical features, seizure outcomes, and antiseizure medication (ASM) prescribing trends in a cohort of IGE patients with seizure onset aged 18 years or older.

RESULTS

In a cohort of 425 IGE patients, we identified 55 with adult-onset IGE (12.9 %). Forty-nine patients (89.1 %) experienced seizure onset between ages 18 and 30 years, while the remaining six patients (10.9 %) had onset after the age of 30 years. Eleven patients were initially diagnosed with focal epilepsy (20 %). Most patients (98.2 %) initially presented with generalised tonic-clonic seizures (GTCS). Epilepsy with generalised tonic-clonic seizures alone (GTCA) was the most common syndrome (65.4 %). Thirty-five patients (63.6 %) were treated with ASM monotherapy, 17 (30.9 %) with polytherapy, and three (5.4 %) were not taking any ASM. Lamotrigine, levetiracetam (38.2 %), and valproate (27.3 %) were the most prescribed ASMs. At last clinical review, 40 patients (72.7 %) were seizure-free (no seizures for ≥12 months), including those with absence seizures and myoclonic seizures, and 46 were free of GTCS for a mean duration of 6.2 years (range 1-21 years). Eight patients (14.5 %) had drug-resistant epilepsy (DRE). Eight patients attempted ASM withdrawal, with seizure recurrence occurring in six (75 %), with the period off ASM ranging from one week to 26 years.

SIGNIFICANCE

IGE should be considered as a possible diagnosis in people who first present with convulsive seizures in adulthood, particularly those aged between 18 and 30 years with normal neuroimaging. Adult-onset IGE has a good prognosis overall, with most people becoming seizure-free, although the risk of seizure recurrence appears to be high after ASM withdrawal. A minority develop DRE and require polytherapy with ≥2 ASMs.

Characteristics of patients diagnosed with psychogenic non-epileptic seizures (PNES) who request reinstatement of their driving privileges

RATIONALE

Patients who experience seizures, including PNES, are usually advised to discontinue driving, or have their driving privileges revoked until a determined period of seizure-freedom is achieved. In this retrospective study, patients with PNES who requested driving privileges or reported having resumed driving were compared to those who did not on measures of depression, anxiety, PTSD, and cognitive flexibility/motor speed.

METHODS

DiagnosisofPNESwasconfirmedwithvideo-EEG.Demographicand clinical dataand requests for reinstatement of driving privileges (requiring 6 or more months seizure freedom) and reports of decisions to resume driving were noted. Tests of motor speed and hand eye coordination and self-report questionnaires of depression, anxiety and PTSD administered as part of neuropsychological assessment were analyzed.

RESULTS

A total of 403 patients with PNES evaluated in 2010-2020 were identified. Of those, 365 patients were eligible for inclusion, and of those, 60 applied for driving privileges or reported that they resumed driving. When the two groups were compared, the group that applied for driving privileges or decided to resume driving was significantly less depressed (p = 0.001) when tested than the group that did not. Furthermore, a significant difference was seen in measures of motor performance between those who requested to resume driving and those who did not (DKEFS T1, p = 0.006, DKEFS T2, p = 0.001, DKEFS T3, p = 0.002, DKEFS T4, p = 0.001; GPT dominant, p = 0.05, GPT non-dominant, p = 0.003).

CONCLUSION

Driving a motor vehicle is a useful measure of improvement for PNES because patients with seizures are required to discontinue driving until seizure-freedom is achieved. This study revealed that lower levels of depression and better fine motor functioning were associated with reported seizure-freedom and driving resumption. Depression is commonly associated with diminished performance (slower motor response times and impaired fine motor movements) on tests of motor functioning, both of which may result in less interest in pursuing permission to resume driving. These findings suggest that mood symptoms (and associated performance on measures of motor speed and coordination) may have prognostic significance in patients diagnosed with PNES. This also suggests that timely treatment of depression in newly diagnosed patients with PNES may be indicated.

Functional Neurological Disorder and Autism Spectrum Disorder: A Complex and Potentially Significant Relationship

INTRODUCTION

Functional neurological disorder (FND) and autism spectrum disorder (ASD) are two complex neuropsychiatric conditions that have been historically classified within psychiatric domains, resulting in a lack of extensive research, insufficient clinical recognition, and persistent societal stigma. In recent years, there has been an increasing recognition among professionals and affected individuals of their possible overlap. This review explores the potential clinical and mechanistic overlap between FND and ASD, with particular attention to shared symptoms across sensory, motor, and psychiatric domains.

METHODS

We conducted a narrative analysis utilizing the PubMed, CINAHL, MEDLINE, and ScienceDirect databases from inception to June 2024. The search employed specific MeSH terms related to ASD and FND. Given the limited data availability, we included all relevant articles that explored the potential connections between FND and ASD, focusing on established findings and theoretical hypotheses areas.

RESULTS

Scientific evidence indicates that FND and ASD may co-occur more frequently than previously acknowledged and with notable overlaps in their clinical presentations and pathophysiology. Theoretical models that have been applied to FND and ASD, such as the Bayesian brain theory and the tripartite model of autism, may provide valuable insights into the intersection of these conditions. Although much of the current evidence remains speculative, it underscores the need for hypothesis-driven research to investigate these potential connections further.

CONCLUSION

ASD and FND are heterogeneous conditions that appear to co-occur in a subset of individuals, with overlapping symptomatology and possibly shared underlying mechanisms. This hypothesis-generating review emphasizes the need for further research to better understand these links, ultimately aiming to improve clinical recognition and develop targeted interventions that enhance the quality of life for affected individuals.

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.