Twenty-seven venous cutdowns to treat pseudostatus epilepticus

The A to F of functional status in the acute setting: A scoping review

Functional status (FSt) describes the phenomenon of prolonged non-epileptic attacks that may be misidentified as Status Epilepticus (SE). The early differentiation between epileptic and functional status is crucial in order to avoid unnecessarily invasive and costly medical escalation in the latter group, including the hazards of overmedication, intubation and intensive care admission. The authors conducted a literature review of available studies describing cases of functional status to extract the common aspects of FSt seizure semiology, investigations used to differentiate from SE, and guidance for managing FSt. A search was carried out using Medline, Embase and PsychInfo databases and 3909 papers were extracted for review. 30 papers were found relevant for inclusion, describing 260 cases of FSt. FSt was found to occur more commonly in younger, female patients with a family history of epilepsy, co-morbid psychiatric diagnosis and following a recent traumatic event. Common clinical features of FSt during and after, the events were identified. While video-EEG remains the gold standard investigation for differentiating FSt from SE, many of the included studies considered the utility of other investigation modalities including serum markers and neuroimaging. One key shortcoming identified within the literature reviewed was a lack of well-defined guidance on the acute management of FSt. We offer an A-F step management plan for the immediate and longer term assessment and treatment of FSt.

Psychogenic non-epileptic seizure-status in patients admitted to the intensive care unit

BACKGROUND

Psychogenic non-epileptic seizure-status (PNES-status), defined by psychogenic non-epileptic seizures (PNES) over 30 min, are often misdiagnosed as status epilepticus. We aimed to describe the features of patients who experienced PNES-status, admitted to an intensive care unit (ICU).

METHODS

We screened the patients hospitalized in our epilepsy unit during a 4-year period, with a diagnosis of PNES-status and ICU admission.

RESULTS

Among 171 patients with PNES, we identified 25 patients (15%) who presented 39 episodes of PNES-status leading to ICU admission. Some 76% of the patients were women. The median age at the time of the PNES-status episode was 35 years. Half (48%) alleged a history of epilepsy, but epilepsy was confirmed in only 12%. A history of psychiatric disease was found in 68%. PNES were present in 85% of patients before PNES-status, and semiology of PNES and PNES-status was similar for 79% of the patients, including hyperkinetic movements in 95% of the episodes and suspected loss of consciousness in 87%. Benzodiazepines were administrated in 77% of the episodes, antiepileptic drugs in 87%, and antibiotherapy for a ICU-related infection in 15% of the episodes. Oral intubation was performed in 41% of the episodes. Blood tests showed normal levels of creatine phosphokinase and leucocytes in 90% and 95% of the episodes, respectively. No epileptic activity was found during per-event electroencephalography but interictal epileptic activity was found in 10% of the episodes.

CONCLUSION

Hyperkinetic PNES-status should always be considered as a differential diagnosis of status epilepticus, with a high risk of iatrogenic consequences.

Psychogenic Non-Epileptic Status as Refractory, Generalized Hypertonic Posturing: Report of Two Adolescents

Psychogenic non-epileptic seizures (PNES) or dissociative seizures are found under the umbrella headings of functional/dissociative neurological disorders (FND) in psychiatric classifications (DSM-5; ICD-11). PNES are not characterized by any specific ictal or postictal EEG abnormalities. Patients with PNES can present with motor or non-motor symptoms, frequently associated with a change in the level of consciousness. PNES duration is variable, often longer than that of epileptic seizures. Prolonged PNES, sometimes termed PNES status, involve continuous or repetitive events that exceed 30 min. Prolonged PNES are often misdiagnosed as an epileptic event and are often inappropriately treated with high doses of antiseizure drugs. In this report, we describe two adolescent patients who presented with prolonged PNES characterized by generalized hypertonic posturing and low levels of consciousness. Despite multiple presentation to the Emergency department, and multiple normal video-EEG, the patients were misdiagnosed with epilepsy and were inappropriately treated with antiseizure medications. Both patients presented psychiatric comorbidity, consisting of a major depressive disorder, obsessive-compulsive symptoms, social withdrawal, difficulty of social interaction, and anxious-perfectionist personality traits. The episodes of prolonged PNES gradually declined within 18 months in both patients.

SUDEP in patients with epilepsy and nonepileptic seizures

We report 13 SUDEP cases in the North American SUDEP Registry with both psychogenic nonepileptic seizures (PNES) and epileptic seizures (ES) among a consecutive series of 231 cases (excluding epileptic encephalopathies). On average, cases of PNES + ES died at a younger age (23 ± 11 years) than the ES-only cohort (30 ± 14 years), and died an average of 3 years after PNES diagnosis. We found no statistically significant confounding cardiac, respiratory, or psychiatric comorbidities and equal rates of anti-seizure medication adherence, although there was a trend for higher rates of psychiatric disorders in the PNES group. Our findings confirm that patients with comorbid ES and PNES can die from SUDEP and that there may be a high-risk period after the diagnosis of PNES is made in patients with comorbid ES. Such patients should be closely monitored and provided with coordinated care of both their epilepsy and psychiatric disorder(s).

Emergency hospital care for adults with suspected seizures in the NHS in England 2007-2013: a cross-sectional study

AIMS

To quantify the frequency, characteristics, geographical variation and costs of emergency hospital care for suspected seizures.

DESIGN

Cross-sectional study using routinely collected data (Hospital Episode Statistics).

SETTING

The National Health Service in England 2007-2013.

PARTICIPANTS

Adults who attended an emergency department (ED) or were admitted to hospital.

RESULTS

In England (population 2011: 53.11 million, 41.77 million adults), suspected seizures gave rise to 50 111 unscheduled admissions per year among adults (≥18 years). This is 47.1% of unscheduled admissions for neurological conditions and 0.71% of all unscheduled admissions. Only a small proportion of admissions for suspected seizures were coded as status epilepticus (3.5%) and there were a very small number of dissociative (non-epileptic) seizures. The median length of stay for each admission was 1 day, the median cost for each admission was £1651 ($2175) and the total cost of all admissions for suspected seizures in England was £88.2 million ($116.2 million) per year. 16.8% of patients had more than one admission per year. There was significant geographical variability in the rate of admissions corrected for population age and gender differences and some areas had rates of admission which were consistently higher than the average.

CONCLUSIONS

Our data show that suspected seizures are the most common neurological cause of admissions to hospital in England, that readmissions are common and that there is significant geographical variability in admission rates. This variability has not previously been reported in the published literature. The cause of the geographical variation is unknown; important factors are likely to include prevalence, deprivation and clinical practice and these require further investigation. Dissociative seizures are not adequately diagnosed during ED attendances and hospital admissions.

A clinically oriented perspective on psychogenic nonepileptic seizure-related emergencies

Psychogenic nonepileptic seizures (PNES) can present emergently and are often mistaken for epileptic seizures. PNES emergencies have not been well studied, and yet there are associated serious morbidities, particularly when patients are seen in an emergency setting and are misdiagnosed. PNES may be prolonged, mimicking status epilepticus, a condition we refer to as nonepileptic psychogenic status (NEPS), and patients may receive aggressive and unnecessary medical treatments that can lead to serious iatrogenic complications, including death. NEPS is also associated with an increased risk of self-harm, including suicide attempts, and may indicate a serious comorbid psychiatric illness. In addition to iatrogenic complications of PNES, accidents and injuries are an underrecognized source of morbidity. PNES may also present during medical procedures, which may not only interfere with their completion, but may alarm practitioners who, fearing liability, may initiate further medical evaluations and treatments. When PNES occur during pregnancy, patients may be misdiagnosed with eclampsia and their offspring delivered prematurely. They also risk being placed on medications that are harmful to the fetus. Increased awareness of PNES is necessary to prevent iatrogenic harm and to identify underlying psychiatric illnesses that carry their own risks. As yet, data available to guide treatment are scant, and further study is needed.

Prolonged psychogenic nonepileptic seizures or pseudostatus

PURPOSE

The purpose of this study was to determine if patients with episodes of prolonged psychogenic nonepileptic seizures or pseudostatus are different from those with psychogenic nonepileptic seizures (PNESs) without prolonged attacks regarding their demographic and clinical characteristics and factors potentially predisposing to PNESs.

METHODS

In this prospective study, all patients with a clinical diagnosis of PNESs (based on ictal recordings) were recruited at the outpatient epilepsy clinic at Shiraz University of Medical Sciences from 2008 through 2013. The epileptologist interviewed all the patients. We compared the demographic and clinical characteristics of patients with PNES-status with those with PNES-only.

RESULTS

Two hundred and eleven patients were studied. Forty-nine patients (23.2%) reported episodes of PNES-status, and 162 patients (76.8%) did not report PNES-status. There were no significant differences between these two groups of patients regarding the demographic and clinical characteristics and factors potentially predisposing to PNESs.

CONCLUSION

Psychogenic nonepileptic seizure status (PNES-status) is relatively common among patients with PNESs. It seems that patients with PNES-status are not different from those with PNES-only, at least regarding the demographic and clinical characteristics and factors potentially predisposing to PNESs.

Emergency department seizure epidemiology

Although only 3% of people in the United States are diagnosed with epilepsy, 11% will have at least one seizure during their lifetime. Seizures account for about 1% of all emergency department (ED) visits, and about 2% of visits to children's hospital EDs. Seizure accounts for about 3% of prehospital transports. In adult ED patients, common causes of seizure are alcoholism, stroke, tumor, trauma, and central nervous system infection. In children, febrile seizures are most common. In infants younger than 6 months, hyponatremia and infection are important considerations. Epilepsy is an uncommon cause of seizures in the ED, accounting for a minority of seizure-related visits. Of ED patients with seizure, about 7% have status epilepticus, which has an age-dependent mortality averaging 22%.

Nonepileptic psychogenic status: markedly prolonged psychogenic nonepileptic seizures

Little is known about markedly prolonged psychogenic nonepileptic seizures (PNES) though they are reported in up to 78% of PNES. Entry to the tertiary referral epilepsy monitoring unit (EMU) is often urgent and the stay usually brief, resulting thus far in almost no data regarding outcomes. The American Epilepsy Society (AES) Nonepileptic Seizure Task Force was asked to gather evidence for consensus of practice and treatment for PNES and its spectrum. As part of the subcommittee focusing on "pseudostatus epilepticus," we sent questionnaires to AES membership inquiring about markedly prolonged events, which we call nonepileptic psychogenic status (NEPS). Ninety U.S. and international neurologists from at least 19 states in the United States responded, with approximately 45% reporting that they do not distinguish NEPS from PNES. Eighty percent of responders considered a period of 20 minutes or longer as "prolonged." Lack of consensus between responders on how to manage these patients was uncovered. The NES Task Force subcommittee on "pseudostatus" recommends that the duration of PNES is tracked and those events lasting 20 minutes or longer, with or without change in level of consciousness, are considered NEPS. Future research needs are discussed.

Diagnosing pseudoseizures: don't hold your breath

Postictal Breathing Pattern Distinguishes Epileptic from Nonepileptic Convulsive Seizures. Azar NJ, Tayah TF, Wang L, Song Y, Abou-Khalil BW. Epilepsia 2008;49(1):132–137. PURPOSE: To examine postictal breathing pattern in generalized convulsive nonepileptic seizures (GCNES) and generalized tonic–clonic seizures (GTCS) and evaluate this feature as a discriminating sign. METHODS: We reviewed the postictal breathing pattern seizures in 23 generalized tonic–clonic seizures in 15 consecutive patients with epilepsy and 24 convulsive nonepileptic seizures in 16 consecutive patients with pure psychogenic seizures. We also analyzed 21 frontal lobe hypermotor seizures (FLHS) in 9 patients with frontal lobe epilepsy. RESULTS: The breathing after GTCS was deep with prolonged inspiratory and expiratory phases, regular, and loud (except for two short seizures). The breathing after GCNES was characterized by increased respiratory rate or hyperpnea with short inspiratory and expiratory phases, as can be noted after exercise. The breathing was often irregular, with brief pauses. The altered breathing lasted longer after GTCS. The two groups differed significantly in loudness of postictal respiration, postictal snoring (only with GTCS), respiratory rate (faster for the GCNES group), and duration of altered breathing (longer after GTCS) (p < 0.00001 for all features). FLHS shared postictal breathing features of GCNES, but had other distinguishing features. CONCLUSIONS: The postictal breathing pattern can help differentiate generalized tonic–clonic seizures from nonepileptic psychogenic seizures with generalized motor activity and may be helpful to the practitioner obtaining a seizure history in the clinic setting or witnessing a seizure.

What is it like to receive a diagnosis of nonepileptic seizures?

The aim of this qualitative study was to provide insight into the experience of receiving the diagnosis of nonepileptic seizures (NES) from the patient's perspective. Semistructured interviews were conducted with eight patients who had received the diagnosis of NES over the preceding 6 months. All participants were on a waiting list for psychological treatment. Verbatim records of the interviews were analyzed using interpretative phenomenological analysis (IPA). Six main themes emerged from the data ("the experience of living with nonepileptic seizures", "label and understanding", "being left in limbo land", "doubt and certainty", "feeling like a human being again", and "emotional impact of diagnosis"). An ability to integrate the diagnosis into a personal narrative was key to participants' acceptance of the diagnosis. The communication of the diagnosis left some participants feeling distressed. The results suggest that patients need more time and resources to understand the diagnosis and more support after they have received it.

Clinical characteristics of psychogenic nonepileptic seizure status in the long-term monitoring unit

Patients with psychogenic nonepileptic seizures (PNES) mimicking status epilepticus (PNES-status) are at risk of iatrogenic complications. Our aim was to assess whether the population of patients with PNES who develop PNES-status are distinguishable. Retrospectively, we identified patients with PNES-status and compared them with patients with PNES without status and with patients with electroclinical status epilepticus (SE). Of 49 patients with PNES, 9 had PNES-status (18.2%) and 40 had PNES only. Compared with patients with PNES, subjects with PNES-status had taken fewer than three antiepileptic medications (P=0.016), had more than one event per week (P=0.026), were more likely to be admitted emergently to the monitoring unit (P=0.007), had shorter long-term monitoring (LTM) stays (P=0.003), and tended to be diagnosed sooner after initial presentation (P=0.058). Use of fewer than three antiepileptic drugs and emergent admission were independent predictors of PNES-status classification on logistic regression. Of 154 patients with epilepsy, 8 had SE during LTM (5.2%), significantly fewer than the proportion with PNES-status relative to PNES (P=0.008); the only clinical variable distinguishing these two groups was a baseline lower seizure frequency among the patients with epileptic seizures (P=0.045). Our results suggest that patients with PNES-status have features that differentiate them from patients with PNES without status and, to a lesser extent, from patients with epileptic seizures.

Measuring Outcome in Psychogenic Nonepileptic Seizures: How Relevant Is Seizure Remission?

PURPOSE

To examine whether seizure remission is a comprehensive marker of outcome in psychogenic nonepileptic seizures (PNESs).

METHODS

A postal questionnaire was returned by 147 patients with PNESs a mean of 4.2 years after diagnosis (mean age at follow-up, 38.1 years). The proportion of patients who were "unproductive" (receiving health-related state benefits) at follow-up was determined, with a comparison of markers of ongoing psychopathology (Global Severity Index, anxiety and depression scores of the Symptom Checklist 90, Somatization Index DSM of the SOMS-2) in three outcome groups: group 1, continuing seizures; group 2, seizures stopped but patients "unproductive;" and group 3, seizures stopped, patients "productive."

RESULTS

Of the patients, 71.4% continued to have seizures, and 28.6% had achieved seizure remission; 60.0% of patients with continuing seizures and 42.7% of patients in remission were "unproductive" (difference, NS). Ongoing psychopathology was related to the factor "group membership" with higher values in groups 2 and 3 than in group 1 (GSI, p < 0.001; anxiety, p = 0.01; depression, p = 0.02; Somatization Index DSM, p < 0.001). Across all patients and in the subgroup with PNESs and additional epilepsy, differences were significant only between groups 2 and 3, not between groups 1 and 2. In patients with PNESs alone, differences were significant only between groups 1 and 2.

CONCLUSIONS

Seizure remission is not a comprehensive measure of good medical or psychosocial outcome in PNESs. Nearly half the patients who become seizure free remain unproductive. Many of these patients continue to report symptoms of psychopathology. Seizure control should not be the only focus of treatment in clinical practice or outcome observation in research studies.

Update on treatments of psychological nonepileptic seizures

The literature on treatment of psychological nonepileptic seizures (NES) is limited, marked by a number of case reports and anecdotal approaches to this difficult-to-treat population. A recent review of the NES treatment literature revealed 20 reports dealing with NES treatment. The majority of the reports were class IV studies. Since the prior review, a number of pilot trials in NES treatment have been published. In this article, we summarize the etiologic conceptualizations of NES, and link these to mechanism informed treatments. We describe the recent literature on NES treatments and propose future directions for intervention research.

Functional symptoms in neurology: questions and answers

Between 10 and 30% of patients seen by neurologists have symptoms for which there is no current pathophysiological explanation. The objective of this review is to answer questions many neurologists have about disorders characterised by unexplained symptoms (functional disorders) by conducting a multidisciplinary review based on published reports and clinical experience. Current concepts explain functional symptoms as resulting from auto-suggestion, innate coping styles, disorders of volition or attention. Predisposing, precipitating, and perpetuating aetiological factors can be identified and contribute to a therapeutic formulation. The sympathetic communication of the diagnosis by the neurologist is important and all patients should be screened for psychiatric or psychological symptoms because up to two thirds have symptomatic psychiatric comorbidity. Treatment programmes are likely to be most successful if there is close collaboration between neurologists, (liaison) psychiatrists, psychologists, and general practitioners. Long term, symptoms persist in over 50% of patients and many patients remain dependent on financial help from the government. Neurologists can acquire the skills needed to engage patients in psychological treatment but would benefit from closer working relationships with liaison psychiatry or psychology.

Psychogenic nonepileptic seizures: review and update

The population incidence of psychogenic nonepileptic seizures (PNES) may be only 4% that of epilepsy, but many patients with PNES have a tendency to seek medical attention, and PNES make up a larger share of the workload of neurologists and emergency and general physicians. Although a great number of publications describe how PNES can be distinguished from epileptic seizures, it usually takes several years to arrive at this diagnosis, and three-quarters of patients (with no additional epilepsy) are treated with anticonvulsants initially. However, the management of PNES as epileptic seizures can lead to significant iatrogenic harm. Moreover, the failure to recognize the psychological cause of the disorder detracts from addressing associated psychopathology and enhances secondary somatization processes. This review provides an overview of studies of the diagnosis, etiology, treatment, and prognosis of PNES. Physicians should always consider PNES in the differential diagnosis of a seizure disorder. If a diagnosis of PNES is possible, or a diagnosis of epilepsy in doubt, a clear diagnostic categorization should be sought. This should involve the assessment of the patient by a physician versed in the diagnosis of seizure disorders and, in many cases, the documentation of a typical seizure by video-EEG. Outcome may be improved if the diagnosis is more actively sought, made earlier, and communicated more convincingly.

Pseudostatus epilepticus in childhood

Pseudostatus epilepticus in childhood has not been well reported in the literature. We describe the clinical presentation and management of a 9-year-old child with well-controlled epilepsy who presented in a prolonged period of pseudoseizures. Intensive care management over a number of weeks with multiple high-dose antiepileptic drugs, anesthesia, and ventilation at a tertiary care pediatric center was performed before the diagnosis of pseudostatus epilepticus was made. Initiation of family counseling and behavior therapy after diagnosis of the nonepileptic nature of the protracted paroxysmal events with video telemetry in our pediatric epilepsy unit was followed by remission. The patient reported herein illustrates the risks of iatrogenic morbidity that may result from a delay in the diagnosis of pseudoseizures and pseudostatus epilepticus in childhood.

Munchausen's syndrome presenting as an acute sexual assault

This report describes a female patient with Munchausen's syndrome who made a false allegation of rape, buggery and indecent assault to the Metropolitan Police. The indecent assault took the form of inserting numerous wax crayons into the vagina, necessitating her admission to hospital for their removal under a general anaesthetic. Whilst in hospital she developed a status epilepticus-like condition, requiring admission to the Intensive Therapy Unit. As a specific method of self-harm in Munchausen's syndrome, this case appears to be unique. It has not previously been reported in the literature.

Non-epileptic attack disorder: a psychological perspective

Due to the serious medical consequences in failing to recognize non-epileptic attack disorder (NEAD), and the frequency with which neurologists come into contact with such patients, clearly NEAD constitutes a major concern for clinicians in the field of epilepsy. This article presents the psychological characteristics of 185 patients with NEAD. Psychological factors that were identified as being important in the understanding of the development and maintenance of NEAD included: anxiety or stress; physical abuse; significant bereavement; family dysfunctioning; relationship problems; depression; sexual abuse. An absence of relevant psychological factors was found in only 5% of patients. From patients' descriptions of their attacks, it appears that many symptoms are related to anxiety. Our findings are largely supported by previous studies and their relevance to effective management and treatment of NEAD patients is discussed.