Psychological long‐term outcome in patients with psychogenic nonepileptic seizures

Longitudinal Comparison of PNES spell and ASM reduction in PNES Patients with and without Epilepsy Discharged from an Epilepsy Monitoring Unit

OBJECTIVE

To examine trends of Antiseizure Medication (ASM) reduction and discontinuation, as well as Psychogenic Non-Epileptic Seizure (PNES) spell reduction and resolution in patients with PNES, with and without comorbid epileptic seizures (ES).

METHODS

A retrospective analysis was conducted on data from 145 patients with PNES, including 109 with PNES alone and 36 with PNES plus comorbid epilepsy. Patients were admitted to the Epilepsy Monitoring Unit (EMU) between May 2000 and April 2008, with follow-up clinical data collected until September 2015. Clinical records were thoroughly examined, encompassing the period preceding the PNES diagnosis until either loss to follow-up or September 2015. A subsequent chart review was conducted by two neurologists, covering the period following the diagnosis of PNES until either loss to follow-up or September 2015, which ever came first.

RESULTS

Patients with PNES alone had higher rates of ASM reduction for all variables of ASM reduction measured compared to those with comorbid epilepsy (all at p < 001). Among patients with PNES alone, reductions in ASMs were observed after EMU discharge, but an uptick and plateau were seen in later follow-up years (100% of patients free of ASMs at years 2-3, 20% on at least one ASM by year 7). This pattern differs greatly in PNES + ES patients, in which the only time point at which any patient was able to discontinue all ASMs was at EMU discharge (4.5% of patients), with all patients taking at least one ASM for every other follow-up time point. Reductions in PNES spell frequency did not differ significantly between the two groups (for example PNES spells reduced at final FU 47.2% vs 42.9%, p = 0.65). In both groups, despite an initial drop in variables of PNES spell reduction and resolution in the early years post discharge, there is an eventual rebound and plateau (for example in PNES only patients, 33.9% of patients having no resolution in 1st year FU, which rises to 78% at years 4-5, and plateus around 52.8% at more than 7 years follow-up.) SIGNIFICANCE: This study contributes to the growing body of research focused on improving the current approach to management and prognostic outlook of PNES. Although PNES only patients had higher rates of ASM reduction, the uptick and plateau observed in later years highlights the challenges in managing PNES. Similarly, the continued persistence and rebound of PNES spells underline the continued poor prognostic outcomes associated with this condition.

Outcome of psychogenic non-epileptic seizures following diagnosis in the epilepsy monitoring unit

Objective

To study the outcome of patients with psychogenic non-epileptic seizures (PNES) after their diagnosis in the epilepsy monitoring unit (EMU).

Methods

Patients diagnosed in our EMU with definite PNES between January 2009 and May 2023 were contacted by phone, and those who agreed to participate were asked a set of predetermined questions. Comparative analyses were carried out on several variables before and after diagnosis: number of participants with daily PNES, number of visits to the emergency department, number of participants who consulted their general practitioner or a neurologist outside of a scheduled follow-up, number of participants who took antiseizure medications (ASMs) or psychotropic drugs, and employment status.

Results

Out of the 103 patients with a definite diagnosis of PNES, 61 patients (79% female) accepted to participate in our study. The median age at PNES onset was 35 years, and the median delay to diagnosis was 3 years. Almost two-thirds (62%) were receiving ASMs and 40% psychotropic drugs. The mean stay at the EMU was 5 days. PNES diagnosis was explained to almost all patients (97%) by the end of their EMU stay and was well-accepted by most (89%). When contacted, 46% of participants no longer had PNES; 32% mentioned that their PNES had ceased immediately upon communication of the diagnosis. The median follow-up duration was 51 months. Fewer patients had daily seizures after the diagnosis (18 vs. 38%; p < 0.0455). Similarly, the median number of emergency department visits was significantly lower (0 vs. 2; p < 0.001). Only 17 patients consulted their general practitioner (vs. 40, p < 0.001) and 20 a neurologist (vs. 55, p < 0.001) after a PNES attack outside of a scheduled follow-up. The use of ASMs was also significantly reduced from 70 to 33% (p < 0.01), with only one still taking an ASM for its antiseizure properties. Significantly more participants were working at last follow-up than at PNES diagnosis (49 vs. 25%; p < 0.001).

Conclusion

Our study revealed a relatively favorable long-term outcome of definite PNES diagnosed in the EMU that translated in significant reductions in PNES frequency, health care utilization and ASM use, as well as a significant increase in employment rate.

Right temporoparietal junction transcranial direct current stimulation in the treatment of functional dissociative seizures: a case series

Functional dissociative seizures (FDSs) are clinical events that resemble epileptic seizures but are not associated with abnormal brain electrical discharges or other physiological problems. In this pilot case series, ten adults with FDSs were recruited from our psychiatry department after being referred by a neurologist who made the diagnosis of FDS based on video EEG results. Each subject received ten sessions of cathodal tDCS focused on the right temporoparietal junction. A significant decrease in weekly seizure frequency was seen in all participants between baseline (30.2 ± 70.3 events) and 1 month after tDCS treatment (0.2 ± 0.3events) (p = 0.006). Main predisposing factors were unchanged after treatment.

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.

The Financial Burden of Functional Neurological Disorders

PURPOSE OF REVIEW

Functional neurological disorder (FND) is a common and severely debilitating condition lacking clinical ownership, existing between neurology and psychiatry. This article reports the findings of recent research investigating the economic costs of FND diagnosis and management. We define what the costs are, why they exist, and suggest actionable steps to reduce them.

RECENT FINDINGS

The financial burden of FND exists across the globe characterized by high healthcare utilization resulting in exorbitant direct and indirect costs for the patient, healthcare system, and society. Inadequate medical education and stigmatization of the disorder prolong the time to diagnosis, during which cyclical utilization of inpatient and emergency department services drive up costs. Despite being cost-effective, lack of accessible treatment compounds the issue, leaving patients without a reliable exit. Recent findings support an increased awareness and the need for a cultural shift to overcome the financial burden associated with this underserved population.

Patients with psychogenic nonepileptic seizures and suspected epilepsy: An antiseizure medication reduction study

OBJECTIVE

To examine predictors of ASM reduction/discontinuation and PNES reduction/resolution in patients with PNES with a confirmed or strong suspicion of comorbid ES.

METHODS

A retrospective analysis of 271 newly diagnosed Patients with PNESs admitted to the EMU between May 2000 and April 2008, with follow-up clinical data collected until September 2015. Forty-seven patients met our criteria of PNES with either confirmed or probable ES.

RESULTS

Patients with PNES reduction were significantly more likely to have come off all ASMs by the time of final follow-up (21.7 vs. 0.0%, p = 0.018), while documented generalized (i.e. epileptic) seizures were much more common in patients with no reduction in PNES frequency (47.8 vs 8.7%, p = 0.003). When comparing patients that reduced their ASMs (n = 18) with those that did not (n = 27), the former were more likely to have neurological comorbid disorders (p = 0.004). When comparing patients with PNES resolution (n = 12) vs not (n = 34), those with PNES resolution were more likely to have a neurological comorbid disorder (p = 0.027), had a younger age at EMU admission (29.8 vs 37.4, p = 0.05) and a greater proportion of patients with ASMs reduced in EMU (66.7% vs 30.3%, p = 0.028). Similarly, those with ASM reduction had more unknown (non-generalized, non-focal) seizures (33.3 vs 3.7%, p = 0.029). On hierarchical regression analysis, a higher level of education and absence of generalized epilepsy remain as positive predictors of PNES reduction (p = 0.042, 0.015), while the presence of some other neurological disorder besides epilepsy (p = 0.04) and being on more ASMs at EMU admission (p = 0.03) were positive predictors of ASM reduction by final follow-up.

SIGNIFICANCE

Patients with PNES and epilepsy have distinct demographic predictors of PNES frequency and ASM reduction by final follow-up. Patients with PNES reduction and resolution had higher level education, less generalized epileptic seizures, younger age at EMU admission, more likely to have presence of a neurological disorder besides epilepsy, and a greater proportion of patients had a reduction in the number of ASMs in the EMU. Similarly, patients with ASM reduction and discontinuation were on more ASMs at initial EMU admission and also were more likely to have a neurological disorder besides epilepsy. The positive relationship between reduction in psychogenic nonepileptic seizure frequency and discontinuation of ASMs at final follow-up elucidates that tapering medication in a safe environment may reinforce psychogenic nonepileptic seizure diagnosis. This can be reassuring to both patients and clinicians, resulting in the observed improvements at the final follow-up.

Dissociation and its biological and clinical associations in functional neurological disorder: systematic review and meta-analysis

BACKGROUND

Studies have reported elevated rates of dissociative symptoms and comorbid dissociative disorders in functional neurological disorder (FND); however, a comprehensive review is lacking.

AIMS

To systematically review the severity of dissociative symptoms and prevalence of comorbid dissociative disorders in FND and summarise their biological and clinical associations.

METHOD

We searched Embase, PsycInfo and MEDLINE up to June 2021, combining terms for FND and dissociation. Studies were eligible if reporting dissociative symptom scores or rates of comorbid dissociative disorder in FND samples. Risk of bias was appraised using modified Newcastle-Ottawa criteria. The findings were synthesised qualitatively and dissociative symptom scores were included in a meta-analysis (PROSPERO CRD42020173263).

RESULTS

Seventy-five studies were eligible (FND n = 3940; control n = 3073), most commonly prospective case-control studies (k = 54). Dissociative disorders were frequently comorbid in FND. Psychoform dissociation was elevated in FND compared with healthy (g = 0.90, 95% CI 0.66-1.14, I² = 70%) and neurological controls (g = 0.56, 95% CI 0.19-0.92, I² = 67%). Greater psychoform dissociation was observed in FND samples with seizure symptoms versus healthy controls (g = 0.94, 95% CI 0.65-1.22, I² = 42%) and FND samples with motor symptoms (g = 0.40, 95% CI -0.18 to 1.00, I² = 54%). Somatoform dissociation was elevated in FND versus healthy controls (g = 1.80, 95% CI 1.25-2.34, I² = 75%). Dissociation in FND was associated with more severe functional symptoms, worse quality of life and brain alterations.

CONCLUSIONS

Our findings highlight the potential clinical utility of assessing patients with FND for dissociative symptomatology. However, fewer studies investigated FND samples with motor symptoms and heterogeneity between studies and risk of bias were high. Rigorous investigation of the prevalence, features and mechanistic relevance of dissociation in FND is needed.

The effect of attachment style on long-term outcomes in psychogenic nonepileptic seizures: Results from a prospective study

INTRODUCTION

Insecure and fearful attachment styles have been reported in psychogenic nonepileptic seizures (PNES). We have investigated associations between long-term clinical outcome in PNES, parenting and attachment styles and demographic, clinical, and neuropsychiatric factors.

MATERIAL AND METHODS

Patients aged at least 16 years and with documented PNES, according to criteria from the International League Against Epilepsy, were prospectively recruited to this study. They were assessed at baseline to determine clinical characteristics, experience of attachment and perceptions of experienced parenting styles, trauma history, dissociation, and health-related quality of life. At a mean of 70.45 (SD 29.0, range 22-130) months after inclusion, participants were contacted by telephone and asked about their current medical status and psychiatric/psychological interventions.

RESULTS

Of 53 patients included in the study, 51 (96 %) provided follow-up data. Most (84.9 %) patients were female, and the mean age of PNES onset was 25.6 years. At follow-up, 20 patients (39 %) were free of PNES. Those patients that had achieved PNES freedom at follow-up had lower levels of attachment anxiety (p = 0.01) and reported to have experienced their fathers as less controlling (p = 0.02) and their mothers as more caring (p = 0.04) at baseline compared with those patients still suffering from PNES. Seizure freedom at follow-up was predicted by male gender, younger age at PNES onset, and less attachment anxiety.

CONCLUSION

In our cohort from a tertiary epilepsy center the long-term prognosis of PNES is poor. Attachment anxiety is a risk factor for persistent PNES. It may be of therapeutic relevance to assess attachment patterns in patients with PNES.

Quality of Life in Psychogenic Nonepileptic Seizures: An Evolutionary Concept Analysis

Psychogenic nonepileptic seizures (PNES) pose a serious threat to quality of life (QOL) in patients who battle the disorder. As psychological treatment options have progressed, improvement in QOL has become a more common desired outcome. Despite its relevance in PNES research and treatment, QOL has not been defined in the PNES population. Rodgers' Evolutionary Method of concept analysis was used to analyze 47 articles and clarify the concept of QOL in PNES. QOL in PNES is subjective, multidimensional, associated with symptoms, and dynamic in nature. This conceptualization of QOL in PNES may be useful in future PNES research and treatment.

Nonpharmacologic Interventions and Seizure Frequency in Patients With Psychogenic Nonepileptic Seizures: An Integrative Review

BACKGROUND

Psychogenic nonepileptic seizures (PNES) pose a heavy burden on patients' lives and the health care system. The symptoms of PNES are often debilitating and cause high rates of disability and poor quality of life. Many treatment options are available, but there is no clear consensus on best practices.

AIM

To critique and synthesize the current literature on nonpharmacologic interventions and effects on seizure frequency in patients with PNES.

METHODS

An integrative review guided by the Whittemore and Knafl approach.

RESULTS

The review included 24 studies published from 2010 to 2020. Interventions for PNES included individualized psychotherapies, group therapies, multimodal psychotherapies, self-help therapies, and complementary and alternative medicine therapies. Individual psychotherapies such as cognitive behavioral therapy and psychoeducation were the most used treatment modalities. The most effective treatments for seizure frequency reduction were those that included multiple psychotherapy sessions with a health care provider and covered multiple domains (e.g., understanding of diagnosis, identifying triggers, and developing effective coping strategies).

CONCLUSIONS

Seizure frequency can be reduced in patients with PNES with multiple nonpharmacologic interventions. However, seizure frequency is not considered a comprehensive outcome measure and provides little insight into other important life domains. Further research is needed on nonpharmacologic interventions for PNES and effects on other areas of life such as sleep, employment status, global functioning, and self-efficacy.

Psychogenic nonepileptic seizures: clinical characteristics and outcome

BACKGROUND

Clinical characteristics, outpatient situation, and outcome in patients with psychogenic nonepileptic seizures (PNES) remain to be elucidated.

METHODS

Patients diagnosed with PNES after video-electroencephalography (EEG) monitoring (VEM) 03/2000-01/2016 at the Erlangen Epilepsy Center were surveyed between June 2016 and February 2017. Primary outcome was PNES cessation defined as no PNES episodes within > = 12 months prior to the interview. Secondary outcome variables included quality of life (QoL) and dependency. Sensitivity analysis included patients with proven PNES during VEM without comorbid epilepsy.

RESULTS

Ninety-nine patients were included (median age 38 (interquartile range (IQR 29-52)) years; 68 (69%) females, follow-up 4 (IQR 2.1-7.7) years). Twenty-eight (28%) patients suffered from comorbid epilepsy. Twenty-five (25%) patients reported PNES cessation. Older age at symptom onset (odds ratio (OR) related to PNES cessation: 0.95 (95% CI 0.90-0.99)), comorbid epilepsy (OR 0.16 (95% CI 0.03-0.83)), anxiety disorder (OR 0.15 (95% CI 0.04-0.61)), and tongue biting (OR 0.22 (95% CI 0.03-0.91)) remained independently associated with ongoing PNES activity after adjustment. Sensitivity analysis (n = 63) revealed depressive disorder (OR 0.03 (95% CI 0.003-0.34)) instead of anxiety as independent predictor, while this seemed relevant only in patients older than 26 years at onset (OR 0.04 (95% CI 0.002-0.78) versus OR 0.21 (95% CI 0.02-1.84) in patients  younger than 26 years). PNES cessation was associated with increased median QoL (8 (IQR 7-9) versus 5.5 (IQR 4-7); p < .001) and an increased frequency of financial independency (14 (56%) versus 21 (28%); p = .01).

CONCLUSIONS

We found poor outcomes in PNES especially in older patients at onset with comorbid depressive disorder. Comorbid epilepsy also seems to be a major risk factor of ongoing PNES activity, which in turn affects patients' daily living.

Diagnosis and management of functional neurological disorder

Functional neurological disorder (FND), previously regarded as a diagnosis of exclusion, is now a rule-in diagnosis with available treatments. This represents a major step toward destigmatizing the disorder, which was often doubted and deemed untreatable. FND is prevalent, generally affecting young and middle aged adults, and can cause severe disability in some individuals. An early diagnosis, with subsequent access to evidence based rehabilitative and/or psychological treatments, can promote recovery-albeit not all patients respond to currently available treatments. This review presents the latest advances in the use of validated rule-in examination signs to guide diagnosis, and the range of therapeutic approaches available to care for patients with FND. The article focuses on the two most frequently identified subtypes of FND: motor (weakness and/or movement disorders) and seizure type symptoms. Twenty two studies on motor and 27 studies on seizure type symptoms report high specificities of clinical signs (64-100%), and individual signs are reviewed. Rehabilitative interventions (physical and occupational therapy) are treatments of choice for functional motor symptoms, while psychotherapy is an emerging evidence based treatment across FND subtypes. The literature to date highlights heterogeneity in responses to treatment, underscoring that more research is needed to individualize treatments and develop novel interventions.

Sustained improvement with mindfulness-based therapy for psychogenic nonepileptic seizures

BACKGROUND

We previously reported on the efficacy of a manualized 12-session mindfulness-based therapy (MBT) for psychogenic nonepileptic seizures (PNES). Completion of MBT provided improvements in weekly PNES frequency and self-rated intensity.

OBJECTIVES

In this study, we aimed to determine sustainability of improvement of seizure-related measures at 3- to 6-month follow-up after treatment completion. We also examined changes at treatment end and at follow-up on therapeutic targets of the MBT program.

METHODS

Patients with documented PNES were recruited from 2014 to 2018. Baseline measures were collected at time of diagnosis (T0) and at first follow-up post-diagnosis (T1). Outcomes are reported at MBT treatment completion (T3) and 3- to 6-month follow-up (T4). The Wilcoxon signed-rank test was used for pair-wise comparisons of PNES frequency; linear mixed models were used for other outcomes.

RESULTS

Fourteen of the 26 MBT completers (54%) attended follow-up (median 147.5 days between T3 and T4). PNES frequency, intensity, and number of days/week with PNES remained reduced at T4 (p < 0.01 for all; median frequency reduction 1.3/week from T1). Illness perception and feeling understood remained improved at T4 (p < 0.001 for both) as did worry about PNES (p < 0.05). Illness attribution (physical, mental or both) changed from T0 to T3 (p < 0.01), but not to T4. Psychological flexibility did not change over time.

CONCLUSION

Previously reported improvements in seizure-related measures with MBT at treatment conclusion were maintained at 3- to 6-month follow-up. There were sustained improvements in some underlying processes (illness perception, feeling understood, and symptom worry) over the course of treatment and at follow-up. Long-term benefits of MBT need to be established with randomized controlled trials.

Screening for Psychiatric Comorbidities and Psychotherapeutic Assessment in Inpatient Epilepsy Care: Preliminary Results of an Implementation Study

Background: Anxiety and depression remain underdiagnosed in routine clinical practice in up to two thirds of epilepsy patients despite significant impact on medical and psychosocial outcome. Barriers to adequate mental health care for epilepsy and/or psychogenic non-epileptic seizures (PNES) include a lack of integrated mental health specialists and standardized procedures. This naturalistic study outlines the procedures and outcome of a recently established psychotherapeutic service.

Methods: Routine screening included the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E, cut-off value > 13) and Generalized Anxiety Disorder scale (GAD-7, cut-off value > 5). Positively (above cut-off in at least one questionnaire) screened patients were seen for a standardized interview for mental health disorders and the development of a personalized treatment plan. PNES patients were seen irrespective of their screening score. Resources were provided to support self-help and access to psychotherapy. Patients were contacted 1 month after discharge to evaluate adherence to therapeutic recommendations.

Results: 120 patients were screened. Overall, 56 of 77 positively screened patients (77%) were found to have a psychiatric diagnosis through standardized interview. More epilepsy patients with an anxiety disorder had previously been undiagnosed compared to those with a depressive episode (63% vs. 30%); 24 epilepsy patients (62%) with a psychiatric comorbidity and 10 PNES patients (59%) were not receiving any mental health care. At follow-up, 16/17 (94%) epilepsy patients and 7/7 PNES patients without prior psychiatric treatment were adhering to therapeutic recommendations.

Conclusion: Integrating mental health specialists and establishing standardized screening and follow-up procedures improve adherence to mental health care recommendations in epilepsy and PNES patients.

Outcomes of children and adolescents 1 year after being seen in a multidisciplinary psychogenic nonepileptic seizures clinic

OBJECTIVE

Psychogenic nonepileptic seizures (PNES) are paroxysmal events that may involve altered subjective experience and change in motor activity with a psychological cause. The aim of this work is to describe a population of pediatric patients with PNES and identify factors predictive of 12-month outcomes.

METHODS

We conducted a prospective observational study of children and adolescents referred to the multidisciplinary Nationwide Children's Hospital PNES clinic between November 2017 and July 2019. Information was collected from patients during clinic visits and semistructured follow-up phone calls. Descriptive statistics and Fisher exact test were used for analysis.

RESULTS

Of the 139 consecutive patients referred to the PNES clinic, 104 were seen in clinic and 63 answered 12-month follow-up calls. Patients with comorbid epilepsy had increased rates of participation at 12-month follow-up (p = .04). Complete remission was achieved by 32% (20/63) of patients at 12 months. Combined PNES remission and improvement was 89% (56/63) at 12 months. Patients and families who were linked with counseling at 1 month were more likely to achieve remission at 12 months (p = .005). Less than half (44%, 28/63) of patients reached at 12 months had their events documented on video-electroencephalogram (EEG) at diagnosis; however, those who did were not more likely to be accepting of the diagnosis at 12 months (p = 1.0), be linked with counseling at 12 months (p = .59), or be event-free at 12 months (p = .79).

SIGNIFICANCE

Remission occurred in one third of patients by 12 months; however, improvement in events was seen in 89%. Connection to counseling by 1 month was associated with increased remission rates at 12 months. Capturing events on video-EEG was not associated with increased acceptance or event freedom at 12 months. Diagnosis should be followed by strong encouragement to connect with counseling quickly to achieve a goal of increasing 12-month PNES remission rates.

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.

Incidence and prevalence of psychogenic nonepileptic seizures (functional seizures): a systematic review and an analytical study

AIM

Psychogenic nonepileptic seizures (PNES) or functional seizures are universal phenomena. However, data on their epidemiology is limited. The aim of the current study was to review the literature on the epidemiology of PNES and to provide analytical estimates of its incidence and prevalence based on the direct data that are available from previous studies on PNES.

METHODS

The methods of this work had two parts: (1) MEDLINE, PsycINFO, and Scopus from inception to 19 October 2019 were systematically searched. (2) The analytical study of the incidence and prevalence of PNES was performed, based on the following data from previous studies: incidence of PNES, duration of PNES before making a diagnosis, outcome and mortality of PNES.

RESULTS

The search strategy yielded five articles; three were on the incidence and two on the prevalence. In the analytical part of the study, the incidence of PNES was calculated to be 3.1 (95% Confidence Interval: 1.1-5.1) per 100,000 population per year. The calculated prevalence rate of PNES in 2019 was 108.5 (95% Confidence Interval: 39.2-177.8) per 100,000 population, in the USA.

CONCLUSION

While, the generalizability of these calculated incidence and prevalence rates to other places in the world is limited, they give us a reasonable hint that PNES is a common condition and the prevalence is much more than that it was thought before.Supplemental data for this article is available online at https://doi.org/10.1080/00207454.2021.1942870.

Post-traumatic factors are involved in the evolution of the number of seizures in patients with PNES

OBJECTIVE

The purpose of this prospective study was to identify predictive factors of the evolution of the number of seizures.

METHODS

We included 85 individuals with a diagnosis of Psychogenic Nonepileptic Seizure (PNES) who completed at least two clinical interviews spaced by 6 months during a 24-month follow-up. Participants underwent a structured interview with an experimented clinician in PNES to complete standardized evaluation and validated scales. We collected sociodemographic and clinical data on PNES (number of seizures, duration of the disease), anxiety, depression, history of traumas, alexithymia, dissociation, and post-traumatic stress disorder (PTSD). We used a multivariate linear regression analysis to predict the characteristics independently associated with the evolution of the number of seizures in percentage.

RESULTS

Dissociation score was significantly associated with a negative evolution of the number of seizures (p < 0.002). Conversely, the diagnosis of PTSD at inclusion was correlated to a positive evolution of the number of seizures (p < 0.029).

CONCLUSION

Dissociation was related to a more pejorative evolution of the number of seizures while PTSD diagnosis was associated with a decreased number of seizures. It is therefore essential to improve detection and treatment of post-traumatic dissociation. Further studies are required to understand the impact of PTSD on the evolution of the number of seizures.

Psychosocial long-term outcome in patients with psychogenic non-epileptic seizures

PURPOSE

To evaluate psychosocial long-term outcome in patients diagnosed with psychogenic nonepileptic seizures (PNES) and to predict outcome of PNES, economic status, and quality of life (QoL) at follow-up.

METHODS

Patients diagnosed with PNES in the video-EEG-monitoring unit at our Epilepsy center between 2002-2016 were contacted by phone 1-16 years after communicating the diagnosis. Patients underwent a structured interview asking for current PNES status, psychosocial situation (economic status, marital status, setting of living, driving), depression, and QoL.

RESULTS

Of 70 PNES patients without comorbid epilepsy (age: 41.1 ± 13.5 years; 74 % female, follow-up: 5.2 ± 4.2 years), 23 patients (33 %) reported to be free of PNES during the last 12 months. Patients with cessation of PNES were younger at PNES onset (p < .01) and diagnosis (p < .01) and had a higher education (p < .05). At follow-up, the proportion of economically active patients only increased in individuals with cessation of PNES (p < .001) while an increased number of patients with persisting PNES relied on governmental support (p < .001). Cessation of PNES was associated with better mood (p < .01) and QoL (p < .001). In multiple regression models, cessation of PNES was only predicted by younger age at onset, while good economic outcome was determined by younger age and good economic status at diagnosis and cessation of PNES at follow-up. Good QoL at follow-up was predicted by low depressive symptoms, freedom of PNES, and economic activity at follow-up.

CONCLUSION

Long-term outcome in patients with PNES remains to be poor and the majority of patients continue to have PNES. Cessation of PNES was associated with good economic outcome, mood, and QoL.

Nonepileptic seizures in individuals attending neurological services in New Zealand

OBJECTIVES

This study examined the demographic, social, and clinical (neurological and psychiatric) characteristics of people with psychogenic nonepileptic seizures (PNES) presenting to tertiary neurological services at Auckland District Health Board, New Zealand.

METHODS

Electronic notes and video-electroencephalography (video-EEG) data gathered from the telemetry unit based on synchronized acquisition (motor activity and brain electrophysiology) over a five-year period (2011 to 2015 inclusive) were retrospectively examined. Two groups were compared: people with PNES only or people with combined PNES and epileptic seizures (ES) (the group with PNES) and a control group with ES only, matched 1:1 by age and gender.

RESULTS

Sixty-six people in the group with PNES were matched with an equivalent number of ES controls. As a cohort, there was high psychiatric and medical comorbidity in both groups, but overall, those with PNES experienced higher rates than their ES counterparts. An older age of onset, female gender, and history of abuse were more frequently seen in those with PNES. Compared with controls, people with PNES more commonly had daily seizures (rather than monthly) but presented less frequently to neurology services. A high proportion of people with PNES experienced historical traumas, ongoing stressors, and disability. Almost half of the people with PNES were on antiepileptic drugs (AEDs) and received limited psychiatric or psychological input. In contrast, people with ES were more likely to be on psychotropic medication.

CONCLUSION

Both PNES and ES are associated with high levels of psychiatric and medical comorbidity. Additionally, PNES were found to be associated with iatrogenic harm and disability. Though people with PNES and ES often have a range of associated needs, there is, however, limited access to appropriate services. The needs of these populations should be better met through enhanced integration across psychiatry, neurology, and multidisciplinary services.