An Overview of Psychogenic Non-Epileptic Seizures: Etiology, Diagnosis and Management

Psychogenic Non-epileptic Seizure in a Laboring Female: A Case Report

Psychogenic non-epileptic seizures (PNES) are seizure-like activities characterized by motor and sensory impairments that are mild and mimic other medical conditions. They are commonly associated with psychiatric conditions and are typically a diagnosis of exclusion. These episodes are generally uncommon and rarely seen in pregnancy or labor. The treatment consists of managing the underlying cause as well as cognitive behavioral therapy. They may mimic absence seizures, which are diagnosed when there are episodes of staring present. This report presents the case of a 26-year-old laboring female who experienced multiple psychogenic seizures. The purpose of this case report is to illustrate how psychogenic non-epileptic seizures (PNES) can imitate epileptic or absence seizures and, thus, should be a diagnosis considered in females in labor.

The role of neuropsychology in the care of patients with functional neurological symptom disorder

OBJECTIVE

Functional neurological symptom disorder (FNSD) is a neuropsychiatric condition characterized by signs/symptoms associated with brain network dysfunction. FNSDs are common and are associated with high healthcare costs. FNSDs are relevant to neuropsychologists, as they frequently present with chronic neuropsychiatric symptoms, subjective cognitive concerns, and/or low neuropsychological test scores, with associated disability and reduced quality of life. However, neuropsychologists in some settings are not involved in care of patients with FNSDs. This review summarizes relevant FNSD literature with a focus on the role of neuropsychologists.

METHODS

A brief review of the literature is provided with respect to epidemiology, public health impact, symptomatology, pathophysiology, and treatment.

RESULTS

Two primary areas of focus for this review are the following: (1) increasing neuropsychologists' training in FNSDs, and (2) increasing neuropsychologists' role in assessment and treatment of FNSD patients.

CONCLUSIONS

Patients with FNSD would benefit from increased involvement of neuropsychologists in their care.

"This is real", "this is hard" and "I'm not making it up": Experience of diagnosis and living with non-epileptic attack disorder

PURPOSE

To use a qualitative research approach to explore adults' experience of living with non-epileptic attack disorder.

OBJECTIVE

The objective was to explore the experience of adults (18 years+) with a confirmed diagnosis of non-epileptic attack disorder (NEAD) across the trajectory of the disorder. The topics investigated included the onset of symptoms, the experience of non-epileptic attacks, the diagnostic process and living with NEAD.

METHOD

Twelve people diagnosed with NEAD who attended a tertiary hospital neurology department took part in semi-structured interviews. The data generated were analysed using reflexive thematic analysis.

RESULTS

Eleven women and one man with median age of 25 years took part. Three themes were developed: mind-body (dis)connect, a stigmatised diagnosis and a role for containment. Adults spoke about their experience of nonepileptic attacks, the diagnostic and management process and the impact of both nonepileptic attacks and the NEAD diagnosis on their lives.

CONCLUSIONS

Adults' experience's within the healthcare system across the trajectory of NEAD influenced their own understanding and trust in their NEAD experience, how they shared this with others in their social and work lives and how they managed their NEAD symptoms on a daily basis. The research suggests the need for a consistent, timely implementation of a rule-in diagnostic approach and multi-disciplinary management of NEAD. It is recommended that lessons be taken from theoretical models including the common-sense model and a modified version of the reattribution model to support the de-stigmatisation of this diagnosis to inform psychoeducation and professionally facilitated peer-support groups.

Characteristics and outcomes of youth with functional seizures attending intensive interdisciplinary pain treatment

Functional seizures (FS) can be debilitating and negatively impact quality of life. Yet intervention research for FS is limited, especially for youth. This study examined clinical characteristics and outcomes of youth with FS (13-23 years) presenting to a pediatric intensive interdisciplinary pain treatment (IIPT) program in the midwestern United States. Sixty youth (mean age = 16.5 years; 83.3 % female) met inclusion criteria. At intake, comorbid chronic pain, somatic symptoms, autonomic dysfunction, eating and weight disturbances, and mental health concerns were common. Despite this high symptom burden, youth with FS reported significant improvements in functioning measured with the Functional Disability Inventory, t(53) = 9.80, p <.001, d = 1.32; depression measured with the Center for Epidemiological Studies - Depression Scale for Children, t(53) = 6.76, p <.001, d = 0.91; anxiety measured with the Spence Children's Anxiety Scale, t(53) = 3.97, p < .001, d = 0.53; and catastrophizing measured with the Pain Catastrophizing Scale for Children, t(53) = 6.44, p <.001, d = 0.86, following completion of the program, suggesting that IIPT may be an effective treatment option for highly disabled and emotionally distressed youth with FS. Future research is needed to continue to refine best practices for youth with FS to reduce suffering and improve outcomes.

Multidisciplinary Care for Pediatric Patients With Psychogenic Nonepileptic Seizures May Be Associated With Decreased Health Care Utilization

Background and Objectives

Psychogenic nonepileptic seizures (PNES) are paroxysmal events that resemble epileptic seizures but have psychological underpinnings. Patients with PNES have high health care utilization. We hypothesize that appropriate care would lead to decreases in utilization. The aim of this study was to measure the impact of a multidisciplinary PNES clinic in reducing health care utilization (HCU) in youth with PNES referred to the clinic.

Methods

We reviewed the frequency of visits to the emergency department (ED), urgent care (UC), planned and unplanned hospitalizations, neurodiagnostic studies, and total charges associated with these encounters 12 months before and 12 months after initial referral to the clinic. Manual chart review of all patients referred from November 2017 to March 2020 was performed.

Results

Two hundred and twelve unique patients were included in this retrospective study. Patient sex was identified as 71% female, 28% male, and 1% other, with an average age of 14 years at diagnosis. These patients visited the ED a total of 410 times before being seen in the PNES clinic, which decreased to 187 visits after (75% reduction). All measures of HCU decreased in the 12 months after the visit, and statistically significant differences were observed in all measures of HCU except for head MRIs, leading to an estimated potential cost savings of $7,978,447.

Discussion

Patients with PNES were found to have decreased health care utilization in the 12 months after referral to the Nationwide Children's Hospital multidisciplinary clinic, including significant decreases in emergency services and unnecessary diagnostic testing, in the 12 months after the referral.

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.

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.

Predicting outcome of patients with psychogenic nonepileptic seizures after diagnosis in an epilepsy monitoring unit

OBJECTIVE

To identify predictors of Psychogenic NonEpileptic Seizure (PNES) improvement and anti-seizure medication (ASM) discontinuation in patients with PNES only.

METHODS

This is a retrospective study of a consecutively enrolled cohort of 271 patients diagnosed with PNES by video-EEG (vEEG) telemetry in our Epilepsy Monitoring Unit (EMU) between May 2000 and February 2010. Patients with any possibility of past or present comorbid epilepsy based on clinical, EEG, and neuroimaging, or less than one year of follow-up after discharge were excluded.

RESULTS

A total of 109 subjects were included. The mean age at PNES onset was 33 (range 6-89), mean age at EMU admission was 38.3 (16-89.8), 70.6% were female mean video-EEG length was 6.1 days, and the median time of final follow-up 3.3 (CI 1.6-6.4) years. 51/108 patients (47.2%) reported a PNES decrease and 29 (26.8%) experienced PNES resolution. 59/73 (81.9%) subjects on ASM at the time of EMU admission were able to discontinue them by the final visit. On univariate analysis, patients whose PNES frequency improved were significantly younger at time of admission, more likely married or cohabiting, less likely unemployed, less likely to have migraine, and had a higher frequency of PNES. On hierarchical regression analysis, younger age and employment remained significant predictors of PNES improvement and resolution. Patients who achieved ASM discontinuation had significantly more children and subsequent EMU visits, were less likely to have history of minor head trauma immediately preceding PNES onset and structural brain lesions, experienced a greater reduction of ASMs during the EMU admission, and had a greater improvement of their PNES frequency at the final visit (p ≤ 0.05). On hierarchical regression analysis, higher number of children, absence of structural brain lesions, fewer ASMs at EMU discharge, and improvement of PNES frequency remained significant predictors of ASM discontinuation.

CONCLUSION

The outcome of PNES is positively correlated with earlier age of diagnosis in an EMU, especially in patients with better social resources. Furthermore, discontinuation of ASM is more likely if the process is initiated during the EMU stay and in the absence of structural brain lesions.

Non-epileptic paroxysmal events in paediatric patients: A single tertiary centre study in Egypt

PURPOSE

The misdiagnosis of non-epileptic seizures (NES) as epilepsy is one of the most common pitfalls in neuropsychiatric practice. This study aimed to describe the percentage and types of NES among children who were referred for a diagnosis of epilepsy in Upper Egypt.

METHODS

We recruited a total of 876 patients who were referred to Sohag University Hospital, a tertiary referral centre in Upper Egypt, for the evaluation of suspected epilepsy. Relevant methods for the diagnosis of epilepsy, including medical history and examination, EEG, video-EEG, laboratory investigations, and brain imaging, were performed for all study participants.

RESULTS

Among the 876 patients who were referred for the diagnosis of suspected epilepsy during the period from June 2017 to October 2018, 171 patients (19.5 %) were diagnosed as having NES. In general, we found that NES in the paediatric age groups did not differ from that reported in various studies across several different populations. The most prevalent NES in our study was breath-holding spells (32.2 %), followed by syncope (17.5 %), psychogenic nonepileptic seizures (12.3 %), motor tics (9.9 %), and benign sleep myoclonus (7.6 %). Other less frequent NES included infantile masturbation (7 %), spasmus nutans (5.3 %), migraine (2.9 %), benign paroxysmal torticollis (2.9 %), night terrors (1.8 %), and shuddering attacks (0.6 %).

CONCLUSION

Ideally, neurologists should not misdiagnose NES as epilepsy, and whenever the diagnosis of NES is uncertain, an accurate diagnosis should be made using long-term video-EEG monitoring, especially in younger paediatric patients.

EEG Biofeedback for Treatment of Psychogenic Non-Epileptic Seizures (PNES) in Multiple Sclerosis: A Case Report

The objective of the present study was to evaluate the effectiveness of EEG biofeedback for treatment of psychogenic non-epileptic seizures (PNES) in a patient with multiple sclerosis. The patient was a 47-year-old female who has been experiencing several PNES types after being diagnosed with multiple sclerosis. She underwent 16 sessions of the EEG biofeedback over a period of two months. Following EEG biofeedback, the patient reported that her PNES attacks had stopped and the treatment resulted in significant abatement in her clinical seizure symptoms. The analysis of sensorimotor rhythm (SMR) values revealed reduction of psychogenic non-epileptic seizure. The Beck Anxiety Inventory (BAI) and Word Health Organization Quality of Life Questionnaire (WHOQOL) were used before and after treatment. Decreased anxiety as well as increased quality of life was observed after treatment. Generally, the results indicated that EEG biofeedback was a useful procedure in treating PNES, promoting quality of life and reducing anxiety in our patient with multiple sclerosis.

Art and psychogenic nonepileptic seizures

Psychogenic nonepileptic seizures (PNES) are episodes of seizure-like symptoms that are not associated with epileptiform discharges on electroencephalogram (EEG). They can be remarkably difficult to distinguish from epileptic seizures: both may involve alterations in mental status and behavior, sensory or perceptual disturbances, as well as simple or complex motor patterns. Pictorial expressions of PNES have always attracted attention from the lay public and medical practitioners alike, by showing the rich variety of semiologies seen in the condition and its differences with epileptic seizures. In this article, we present two new contemporary artistic descriptions by the Canadian artist Iris Hauser about PNES. The depictions highlight key signs seen in PNES such as "eyes closed during events", "the hyperextension of the back and limbs", and the "claw-like finger posturing". We believe that the drawings can provide a valuable educational component in the initial assessment of patients suspected of having PNES as a training tool to identify and refer patients for more advanced testing.

Psychogenic nonepileptic seizures in children-Prospective validation of a clinical care pathway & risk factors for treatment outcome

PURPOSE

The purpose of this study was to prospectively validate a care pathway for psychogenic nonepileptic seizures (PNES) in a pediatric setting. The pathway was developed based on a previous study of patients at our center, which demonstrated positive treatment outcomes of 80% full or partial remission. Sequentially referred patients with PNES in the validation cohort received care prospectively according to the pathway algorithm. It was hypothesized that the validation cohort would achieve outcomes similar to that of the development cohort as a result of standardized care.

METHOD

We performed a retrospective chart review of 43 children sequentially referred, assessed, and treated within a specialized neurology psychology service for suspected PNES over a 5-year period. The majority of patients (n = 41, 95%) met diagnostic criteria for probable, clinically established, or documented PNES, according to the International League Against Epilepsy (ILAE) criteria.

RESULTS

Ages ranged from 6 to 18 years of age at time of diagnosis, with the majority of patients being female (n = 29, 67%) and adolescent (n = 31, 72%). There was a high level of adherence to the care algorithm (n = 34, 84%). The development and validation cohorts were similar across demographic, clinical, and psychological characteristics. Standardized care resulted in high rates of full (n = 27, 63%) and partial (n = 12, 28%) remission, as self-reported at discharge. A 96% decrease in mean monthly frequency of total PNES events was also observed at discharge, as was a significant reduction in healthcare utilization related to PNES (74% fewer ambulance calls and 85% fewer emergency department (ED) visits). Post hoc analyses demonstrated that duration of PNES illness longer than 12 months (at diagnosis) increased odds of not achieving full remission by discharge (odds ratio = 5.94, p = 0.02). Developmental period of onset (child versus adolescent), having abnormal electroencephalogram (EEG) result, previous concussion, chronic versus acute stressor, more than one PNES event type, or additional functional neurological symptoms did not significantly impact treatment response.

CONCLUSIONS

This study demonstrates, for the first time prospectively in a pediatric setting, that standardized care for PNES leads to improved clinical outcomes and reduced healthcare utilization. Delayed diagnosis and treatment of PNES longer than 12 months also appears to be associated with less favorable outcomes in children.

Othello Syndrome Secondary to Cerebral Tuberculoma: A Case Report

INTRODUCTION

Othello syndrome, an eponym of Shakespeare's character, is a transnosological diagnostic term that designates a clinical picture characterised by the presence of delusions of infidelity with respect to a partner and that, consequently, can lead to typical jealousy attitudes and violent behaviour towards the partner. In its pure form, it corresponds to delusional disorder of infidelity, but it may also be secondary to brain organicity and drug use.

METHODS

Case report and non-systematic review of the relevant literature.

CASE PRESENTATION

A 26-year-old man, with a history of drug abuse and a victim of domestic violence as a child, presented with tonic-clonic seizures and intracranial hypertension three years ago, for which he underwent a craniotomy with the finding of a right frontal cerebral tuberculoma. After a lapse, he developed a clinical picture of delusions of infidelity regarding his partner and violent behaviour towards her.

LITERATURE REVIEW

Delusional jealousy is associated, like other delusions, with lesions of the right frontal lobe. Despite the high and growing prevalence of tuberculosis worldwide, there are no reported cases of Othello syndrome secondary to cerebral tuberculoma in the literature.

CONCLUSION

Othello syndrome, although not the main cause of domestic violence, can be associated with particularly violent manifestations and be secondary to cerebral tuberculoma. This is the first published case of its kind.

Welfare consequences for people diagnosed with nonepileptic seizures: A matched nationwide study in Denmark

OBJECTIVE

We aimed to evaluate the excess direct and indirect costs associated with nonepileptic seizures.

METHODS

From the Danish National Patient Registry (2011-2016), we identified 1057 people of any age with a diagnosis of psychogenic nonepileptic seizures (PNESs) and matched them with 2113 control individuals. Additionally, 239 partners of patients with PNES aged ≥18 years were identified and compared with 471 control partners. Direct costs included frequencies and costs of hospitalizations and outpatient use weighted by diagnosis-related group, and specific outpatient costs based on data from the Danish Ministry of Health. The use and costs of drugs were based on data from the Danish Medicines Agency. The frequencies of visits and hospitalizations and costs of general practice were derived from National Health Security data. Indirect costs included labor supply-based income data, and all social transfer payments were obtained from Coherent Social Statistics.

RESULTS

A higher percentage of people with PNES and their partners compared with respective control subjects received welfare benefits (sick pay, disability pension, home care). Those with PNES had a lower employment rate than did controls for equivalent periods up to three years before the diagnosis was made. The additional direct and indirect annual costs for those aged ≥18 years, including transfers to patients with PNES, compared with controls, were €33,697 for people with PNES and €15,121 for their partners.

SIGNIFICANCE

Psychogenic nonepileptic seizures have substantial socioeconomic consequences for individual patients, their partners, and society.

Morbidity and mortality of nonepileptic seizures (NES): A controlled national study

Nonepileptic seizures (NES, psychogenic NES-PNES) are associated with significant morbidities. We evaluated the morbidities and mortality in a national group of children, adolescent, and adult patients before and after a first diagnosis of PNES.

METHODS

From the Danish National Patient Registry (1998-2013), we identified 1057 people of all ages with a diagnosis of NES and matched them with 2113 control individuals by age, gender, and geography. Comorbidities were calculated three years before and after diagnoses.

RESULTS

Patients with PNES showed increased comorbidities 3 years before and after diagnosis in almost all the diagnostic domains. The strongest associations were identified with other neurological diseases (after diagnosis, Hazard Ratio (HR): 38.63; 95% Confidence Interval (CI): 21.58-69.13; P < 0.001), abnormal clinical and laboratory findings (HR: 46.59; 95 CI: 27.30-79.52; P < 0.001), other health-related factors (HR: 12.83; 95%CI: 8.45-19.46; P < 0.001), and psychiatric comorbidities (HR: 15.45; 95% CI: 9.81-24.33). Epilepsy was identified in 8% of the patients with PNES. We found especially frequent comorbidity involving overweight, depression, anxiety, dissociative somatoform condition, other convulsions, lipothymias, reports of pain and other symptoms in several organ systems, and several reports of minimal traumas to the head, trunk, and extremities. Mortality was higher in patients with NES than in controls (HR: 3.21; 95% CI: 1.92-5.34; P < 0.001).

CONCLUSION

Morbidity is more frequent in several domains, including neurological, psychiatric, and other diseases, before and after a diagnosis of NES. Mortality is significantly higher in patients with PNES as compared to controls.

Semiological characteristics of patients with psychogenic nonepileptic seizures: Gender-related differences

Psychogenic nonepileptic seizures (PNES) are more prevalent among women, and diagnosis may sometimes be delayed by as much as seven years. Understanding the effect of gender on the presentation of a PNES may assist with diagnosis based on semiological details in the clinical setting. Although video-EEG monitoring (VEM) is the gold standard for diagnosing PNES, determining gender-related seizure semiology through careful history may prevent diagnostic delay while waiting for VEM. The aim of this study was to investigate gender-related differences in the semiology of PNES. Patients, all aged at least 16 years, diagnosed with PNES following VEM between December 2005 and November 2016 were included in this study. All patients' medical records and video-EEG-documented PNES were reviewed, and the presence or absence of semiological signs was recorded for each documented attack. Demographic features and semiological signs of PNES were compared between female and male patients. Forty-one patients (31 females, 10 males) aged 27.2 ± 12.2 years (range: 16-65) were included in the study. Mean age at onset of PNES was higher for female patients than males, at 24.3 ± 11.5 versus 17.5 ± 3.2 years (p = 0.005). The median duration of PNES was longer for female patients than males, at 10 min (range: 5 s-120 min) versus 2 min (range: 10 s-60 min) (p = 0.016). The most common symptom was forced eye closure in both genders. No significant gender-specific differences were observed in terms of the type or semiology of PNES. Although there are no major gender-related differences in PNES semiology, our findings highlight the importance of greater caution, especially in male patients, when diagnosing PNES, remembering that onset may also occur at young ages and that a short seizure duration does not exclude PNES.

Neuropsychiatric expression and catatonia in 22q11.2 deletion syndrome: An overview and case series

Individuals with 22q11.2 deletion syndrome (22q11.2DS) are at elevated risk of developing treatable psychiatric and neurological disorders, including anxiety disorders, schizophrenia, seizures, and movement disorders, often beginning in adolescence or early to mid-adulthood. Here, we provide an overview of neuropsychiatric features associated with 22q11.2DS in adulthood. Results of a new case series of 13 individuals with 22q11.2DS and catatonic features together with 5 previously reported cases support a potential association of this serious psychomotor phenotype with the 22q11.2 deletion. As in the general population, catatonic features in 22q11.2DS occurred in individuals with schizophrenia, other psychotic and non-psychotic psychiatric disorders, and neurological disorders like Parkinson's disease. We place the results in the context of an updated review of catatonia in other genetic conditions. The complex neuropsychiatric expression and risk profile of 22q11.2DS highlights the need to consider co-morbid factors and provide care tailored to the individual patient. The results reinforce the need for periodic monitoring for the emergence of psychiatric and neurological manifestations including catatonic features. Pending further research, enhanced recognition and informed anticipatory care promise to facilitate the early diagnosis that allows for timely implementation and optimization of effective treatments.