Childhood trauma in patients with epileptic vs nonepileptic seizures

Comparative study of perceived invalidating environment and stress coping strategies between patients with drug resistant epilepsy and functional dissociative seizures

BACKGROUND AND OBJECTIVES

We investigated perceived invalidating environment during childhood and stress-coping strategies in patients with; functional dissociative seizures (FDS, n=26), drug-resistant epilepsy patients with no psychiatric comorbidity (DREnc, n=23), and drug-resistant epilepsy patients with psychiatric comorbidity (DREpc, n=34).

DESIGN/METHODS

We performed a cross-sectional study. Patients underwent Video Electroencephalography to confirm the diagnosis and completed a psychiatric assessment supported by clinical instruments. Invalidating environment and stress coping were studied through the ICES and CAE questionaries, respectively. A series of multinomial logistic regression analyses were performed with the explored variables.

RESULTS

The maternal negative response model predicted a higher probability of FDS condition. A chaotic family type increased the likelihood of DREpc instead of FDS. DREpc and FDS patients displayed many different behaviors to cope with stress other than trying to solve the problem, the most used strategy in the DREnc group. Parental invalidation was higher in DREpc than in FDS.

CONCLUSIONS

Our results deepen the data provided by previous studies indicating that multiple variables of biosocial origin have significant effects on these groups of patients. The presence of an invalidating environment may predict FDS but also the presence of psychiatric disorders among DRE. Psychotherapeutic strategies to enhance these variables might be necessary for this population.

Maladaptive personality traits in patients with epilepsy and psychogenic non-epileptic seizures

OBJECTIVE

We aimed to evaluate the sociodemographic, clinical, and psychological characteristics associated with psychogenic non-epileptic seizures (PNES) in patients with epilepsy, with particular emphasis on the personality profile assessed from a dimensional perspective.

METHODS

The cohort study included 77 consecutive inpatients with active epilepsy aged 36-55 years; 52 (67.5%) were female. The presence of PNES was confirmed by video-EEG monitoring. All patients underwent the Mini-International Neuropsychiatric Interview to diagnose psychiatric disorders. All participants completed the Neurological Disorders Depression Inventory in Epilepsy, the Epilepsy Anxiety Survey Instrument - brief version, and the Personality Inventory for DSM-5 and ICD-11 Brief Form Plus Modified. Chi-square and Fisher's exact tests were used to compare categorical variables, and the Brunner-Munzel test was used for quantitative variables.

RESULTS

Twenty-four patients (31.2%) had both epilepsy and PNES. There were no significant differences in social, demographic or clinical characteristics, psychiatric diagnoses or depression severity. Compared to patients with epilepsy alone, patients with epilepsy and PNES had higher anxiety scores and more pronounced maladaptive personality traits such as disinhibition and psychoticism.

SIGNIFICANCE

The main novelty of our study is that using the recently proposed dimensional approach to personality disorders and an appropriate instrument we assessed all personality domains listed in two of the most widely used classifications of mental disorders (DSM-5 and ICD-11) in PWE with and without PNES. To our knowledge, this is the first study to demonstrate the association of the maladaptive traits of psychoticism and disinhibition with the development of PNES in PWE.

An update on psychogenic nonepileptic seizures

PURPOSE OF REVIEW

The understanding of psychogenic nonepileptic seizures (PNES) has advanced steadily over recent decades. This update summarizes new insights from the last three years.

RECENT FINDINGS

The process of diagnosing PNES has shifted from the exclusion of epilepsy to one based on the recognition of typical clinical features. While the diagnosis cannot rely on any single feature in isolation, a range of semiological features characterising PNES are now recognised and a number of studies hint at the potential for machine learning and AI to improve the diagnostic process. Advances in data processing and analysis may also help to make sense of the heterogeneity of PNES populations demonstrated by recent studies focussing on aetiology and patient subgroups. It is now clear that PNES are associated with high rates of mental and physical comorbidities and premature death, highlighting that they are only one manifestation of a complex disorder extending beyond the nervous system and the seizures themselves.

SUMMARY

PNES are now understood as a manifestation of dysfunction in interacting brain networks. This understanding provides an explanation for the psychopathological and semiological heterogeneity of PNES patient populations. New insights into medical comorbidities and increased rates of premature death call for more research into associated pathological processes outside the nervous system.

Very high epilepsy prevalence in rural Southern Rwanda: The underestimated burden of epilepsy in sub-Saharan Africa

OBJECTIVES

Up to 85% of people living with epilepsy (PwE) reside in low-and middle-income countries. In sub-Saharan Africa, the lifetime prevalence of epilepsy is 16 per 1000 persons. In Northern rural Rwanda, a 47.7 per 1000 prevalence has been reported. As variations in prevalence across geographical areas have been observed, we studied the prevalence in Southern rural Rwanda using the same robust methodology as applied in the North.

METHODS

We conducted a three-stage, cross-sectional, door-to-door survey in two rural villages in Southern Rwanda from June 2022 to April 2023. First, trained enumerators administered the validated Limoges questionnaire for epilepsy screening. Second, neurologists examined the persons who had screened positively to confirm the epilepsy diagnosis. Third, cases with an inconclusive assessment were separately reexamined by two neurologists to reevaluate the diagnosis.

RESULTS

Enumerators screened 1745 persons (54.4% female, mean age: 24 ± 19.3 years), of whom 304 (17.4%) screened positive. Epilepsy diagnosis was confirmed in 133 (52.6% female, mean age: 30 ± 18.2 years) and active epilepsy in 130 persons. Lifetime epilepsy prevalence was 76.2 per 1000 (95% CI: 64.2-89.7‰). The highest age-specific rate occurred in the 29-49 age group. No gender-specific differences were noted. In 22.6% of the PwE, only non-convulsive seizures occurred. The treatment gap was 92.2%, including a diagnosis gap of 79.4%.

CONCLUSION

We demonstrated a very high epilepsy prevalence in Southern rural Rwanda, with over 20% of cases having only non-convulsive seizures, which are often underdiagnosed in rural Africa. In line with previous Rwandan reports, we reiterate the high burden of the disease in the country. Geographic variation in prevalence throughout Africa may result from differences in risk and aetiological factors. Case-control studies are underway to understand such differences and propose adapted health policies for epilepsy prevention.

Case study of invalid to valid shift in cognitive performance following successful treatment of psychogenic nonepileptic seizure events

Patients with psychogenic nonepileptic seizure (PNES) who fail performance validity testing (PVT) may appear to produce non-valid cognitive profiles. Consequently, they may not get referred to treatment and events persist, with worsening disability and high resource utilization. As a result, we report pre- and post-treatment neuropsychological evaluation findings in a 59-year-old woman with a confirmed diagnosis of PNES established using video-EEG monitoring. At pre-treatment baseline neuropsychological evaluation, PNES events occurred weekly to daily. Performance was impaired across PVTs and across multiple cognitive domains. After behavioral intervention specific to PNES, these events substantially reduced in frequency to rare stress-induced flares. Post-treatment neuropsychological evaluation revealed marked improvement of most cognitive and behavioral scores from baseline, and valid PVT scores. We review predisposing, precipitating, and perpetuating factors for PNES and cognitive impairment in this case and discuss the patient's outcome from treatment. Effectively managing PNES events and dissociative tendencies while reducing unnecessary pharmacological interventions appears to have allowed this patient to function closer to her optimal state. This case illustrates the complexity of Functional Neurologic Disorder (FND) clinical presentation and challenges the assumption that suboptimal neuropsychological performance predicts poor treatment engagement and outcome. We showcase the reversibility of PNES and cognitive manifestations of FND using targeted psychotherapeutic interventions, which resulted in reduced disability and associated healthcare costs, as well as re-engagement in life.

Socioecologic Factors Associated With Obesity in Adolescents With Epilepsy in the United States

BACKGROUND

Obesity among youth with epilepsy has multifactorial etiology, yet socioecologic obesity risk factors (eg, neighborhood factors) have not been examined in this population. This study examined (1) the prevalence of obesity adjusting for relevant covariates and (2) socioecologic correlates of obesity in adolescents with epilepsy aged 10-17 years.

METHODS

This cross-sectional study used 2017-2018 National Survey of Children's Health data (total n = 27,094; epilepsy n = 184). Chi-square tests compared weighted prevalence of obesity with relevant covariates among all adolescents and adolescents with epilepsy. Weighted multiple logistic regression models were conducted to adjust for covariates.

RESULTS

The prevalence of obesity in adolescents with epilepsy was 27.8% (95% confidence interval [CI] 15.4%-40.3%) vs 15.1% (95% CI 14.1%-16.2%) for the non-epilepsy group. Adolescents with epilepsy also had higher odds of obesity after adjusting for age, gender, race/ethnicity, household income, physical activity, and medical home (odds ratio [OR] 2.1, 95% CI 1.2-3.8). Adjusting for sociodemographics, anxiety (OR 4.5, 95% CI 1.3-15.6), 2 or more adverse childhood experiences (OR 7.3, 95% CI 1.6-33.4), neighborhood detracting elements (eg, OR 5.2, 95% CI 1.5-18.5 for 1 detracting element), and forgone care (ie, unmet health care needs) (OR 22.4, 95% CI 3.8-132.8) were associated with obesity in adolescents with epilepsy. Adjusting for multiple comparisons, neighborhood detracting elements (P < .0001) and forgone care (P < .0007) remained significant.

CONCLUSION

Variables related to mental health, family functioning, built environment, and forgone care were associated with obesity in adolescents with epilepsy, but the association was not fully explained by these factors. Obesity interventions for this population should consider multiple levels of influence including the community and special health care needs of this population.

Evidence-Based Mind-Body Interventions for Children and Adolescents with Functional Neurological Disorder

LEARNING OBJECTIVES

• Develop and implement treatment plans for children and adolescents with functional neurological disorder (FND)• Outline a plan to increase awareness and standardize the care for patients with FND using evidence-based interventions.

ABSTRACT

Functional neurological disorder (FND) in children and adolescents involves the biological embedding of lived experience in the body and brain. This embedding culminates in stress-system activation or dysregulation and in aberrant changes in neural network function. In pediatric neurology clinics, FND represents up to one-fifth of patients. Current research shows good outcomes with prompt diagnosis and treatment using a biopsychosocial, stepped-care approach. At present, however-and worldwide-FND services are scarce, the result of long-standing stigma and ingrained belief that patients with FND do not suffer from a real ("organic") disorder and that they therefore do not require, or even deserve, treatment. Since 1994, the Mind-Body Program for children and adolescents with FND at The Children's Hospital at Westmead in Sydney, Australia-run by a consultation-liaison team-has delivered inpatient care to hundreds of patients with FND and outpatient care to hundreds of others. For less-disabled patients, the program enables community-based clinicians to implement biopsychosocial interventions locally by providing a positive diagnosis (by a neurologist or pediatrician), a biopsychosocial assessment and formulation (by clinicians from the consultation-liaison team), a physical therapy assessment, and clinical support (from the consultation-liaison team and the physiotherapist). In this Perspective we describe the elements of a biopsychosocial mind-body program intervention capable of providing, as needed, effective treatment to children and adolescents with FND. Our aim is to communicate to clinicians and institutions around the world what is needed to establish effective community treatment programs, as well as hospital inpatient and outpatient interventions, in their own health care settings.