Pilot pharmacologic randomized controlled trial for psychogenic nonepileptic seizures

Optimizing outcomes when treating functional neurological disorder in acute care settings: case reports depicting the value of diagnostic precision and timely and appropriate psychological interventions using an interdisciplinary framework

Introduction

Unexplained physical signs and symptoms represent a significant portion of patient presentations in acute care settings. Even in cases where a patient presents with a known medical condition, functional or somatic symptoms may complicate the diagnostic and treatment processes and prognostic outcome. One umbrella category for neurologically related somatic symptoms, functional neurological disorder (FND), presents as involuntary neurological symptoms incompatible with another medical condition. Symptoms may include weakness and/or paralysis, movement disorders, non-epileptic seizures, speech or visual impairment, swallowing difficulty, sensory disturbances, or cognitive symptoms (1). While FND presents as neuropsychiatric, providers commonly report feeling hesitant to diagnose these disorders. Inexperience or lack of appropriate education on relevant research regarding evidence-based practices or standard of practice (SOP) may result in over- or underperforming diagnostic workups and consultations, utilizing inappropriate medications, and failing to offer evidence-based psychological interventions. Being mindful of these challenges when treating patients presenting with functional symptoms in acute care settings can help to support and protect the patients and care team and appropriately control healthcare costs.

Methods

The University of Alabama at Birmingham Medical Center identified cases representing categories of quality and safety problems that arise in treating FND in acute care settings. Patients signed a consent form to participate in the case report. The case information for each was presented without identifying information.

Discussion

The cases highlight potential challenges when caring for patients presenting with FND in acute care settings. The challenges covered include over- or underutilization of diagnostic workups and consultation, over- or underutilization of psychopharmacological medications, and over- or undertreating a medical condition when a functional symptom is present. In each case, these lapses and errors caused the patient distress, additional treatments, care delays, and delayed symptom remission. Additionally, these challenges have direct and indirect fiscal costs, which can be mitigated with the appropriate education and training, resources, and protocols. Hospitals can benefit from system-wide SOP to improve the identification and management of FND to prevent harm to patients. An SOP commonly presents to specific specialties and ensures the appropriate diagnostic workup, consultations, and timely evidence-based interventions.

[Validated care programs for patients with functional neurological disorders]

Functional neurological disorder (FND) is a common cause of persistent and disabling neurological symptoms. Diagnostic delay may lead to no treatment, inappropriate treatment or even iatrogenic symptoms. Yet, several treatments significantly reduce physical symptoms and improve functioning in FND patients even though not all patients respond to the currently available treatments. This review aims to describe the range of evidence-based rehabilitative and/or psychological therapeutic approaches available for FND patients. The most effective treatments are multidisciplinary and coordinated; using an outpatient or inpatient setting. Building a network of FND-trained healthcare professionals around the patient is an essential aspect of optimal patient management. Indeed, a supportive environment coupled with a collaborative therapeutic relationship improves understanding of FND and appears to help patients engage in appropriate treatments. Patients need to be invested in their own care and have to understand that recovery may depend on their commitment. The conventional treatment combines psychoeducation, physical rehabilitation and psychotherapy (cognitive and behavioral therapy, hypnosis, psychodynamic interpersonal therapy). Early referral of patients to physical therapy is recommended; however, the optimal parameters of treatment, duration and intensity are unknown and seem to vary with the severity and chronicity of symptoms. The goal is to minimize self-awareness by diverting attention or by stimulating automatically generated movements with non-specific and gradual exercises. The use of compensatory technical aids should be avoided as much as possible. Psychotherapeutic management should encourage self-evaluation of cognitive distortions, emotional reactions and maladaptive behaviors while empowering the patient in managing symptoms. Symptom management can use anchoring strategies to fight against dissociation. The aim is to connect to the immediate environment and to enrich one's sensoriality. The psychological interventions should then be adapted to the individual psychopathology, cognitive style and personality functioning of each patient. There is currently no known curative pharmacological treatment for FND. The pharmacological approach rather consists of progressively discontinuing medication that was introduced by default and that could lead to undesirable side effects. Finally, neurostimulation (transcranial magnetic stimulation, transcranial direct current stimulation) can be effective on motor FND.

Sense of control, selective attention, cognitive inhibition, and psychosocial outcomes after Retraining and Control Therapy (ReACT) in pediatric functional seizures

BACKGROUND

Differences in sense of control, cognitive inhibition, and selective attention in pediatric functional seizures (FS) versus matched controls implicate these as potential novel treatment targets. Retraining and Control Therapy (ReACT), which targets these factors, has been shown in a randomized controlled trial to be effective in improving pediatric FS with 82% of patients having complete symptom remission at 60 days following treatment. However, post-intervention data on sense of control, cognitive inhibition, and selective attention are not yet available. In this study, we assess changes in these and other psychosocial factors after ReACT.

METHODS

Children with FS (N = 14, Mage = 15.00, 64.3% female, 64.3% White) completed 8 weeks of ReACT and reported FS frequency at pre and post-1 (7 days before and after ReACT). At pre, post-1, and post-2 (60 days after ReACT), all 14 children completed the Pediatric Quality of Life Inventory Generic Core Scales, Behavior Assessment System (BASC2), and Children's Somatic Symptoms Inventory-24 (CSSI-24), and 8 children completed a modified Stroop task with seizure symptoms condition in which participants are presented with a word and respond to the ink color (e.g., "unconscious" in red) to assess selective attention and cognitive inhibition. At pre and post-1, ten children completed the magic and turbulence task (MAT) which assesses sense of control via 3 conditions (magic, lag, turbulence). In this computer-based task, participants attempt to catch falling X's while avoiding falling O's while their control over the task is manipulated in different ways. ANCOVAs controlling for change in FS from pre- to post-1 compared Stroop reaction time (RT) across all time points and MAT conditions between pre and post-1. Correlations assessed the relationships between changes in Stroop and MAT performance and change in FS from pre- to post-1. Paired samples t-tests assessed changes in quality of life (QOL), somatic symptoms, and mood pre to post-2.

RESULTS

Awareness that control was manipulated in the turbulence condition of the MAT increased at post-1 vs. pre- (p = 0.02, η2 = 0.57). This change correlated with a reduction in FS frequency after ReACT (r = 0.84, p < 0.01). Reaction time significantly improved for the seizure symptoms Stroop condition at post-2 compared to pre- (p = 0.02, η2 = 0.50), while the congruent and incongruent conditions were not different across time points. Quality of life was significantly improved at post-2, but the improvement was not significant when controlling for change in FS. Somatic symptom measures were significantly lower at post-2 vs. pre (BASC2: t(12) = 2.25, p = 0.04; CSSI-24: t(11) = 4.17, p < 0.01). No differences were observed regarding mood.

CONCLUSION

Sense of control improved after ReACT, and this improvement was proportional to a decrease in FS, suggesting this as a possible mechanism by which ReACT treats pediatric FS. Selective attention and cognitive inhibition were significantly increased 60 days after ReACT. The lack of improvement in QOL after controlling for change in FS suggests QOL changes may be mediated by decreases in FS. ReACT also improved general somatic symptoms independent of FS changes.

Why functional neurological disorder is not feigning or malingering

Functional neurological disorder (FND) is one of the commonest reasons that people seek help from a neurologist and is for many people a lifelong cause of disability and impaired quality of life. Although the evidence base regarding FND pathophysiology, treatment and service development has grown substantially in recent years, a persistent ambivalence remains amongst health professionals and others as to the veracity of symptom reporting in those with FND and whether the symptoms are not, in the end, just the same as feigned symptoms or malingering. Here, we provide our perspective on the range of evidence available, which in our view provides a clear separation between FND and feigning and malingering. We hope this will provide a further important step forward in the clinical and academic approach to people with FND, leading to improved attitudes, knowledge, treatments, care pathways and outcomes.

Functional Neurological Disorder-Old Problem New Perspective

Functional neurological disorder (FND) is a common issue in the pediatric population. The concept and our understanding of functional neurological disorders have changed over the past years, and new etiologic models and treatment plans have been explored. Knowledge about FND in the pediatric population, however, is lacking. The aim of this review is to provide an update on pediatric functional neurological disorder. We conducted a literature search of PubMed and SCOPUS databases and reviewed a total of 85 articles to gain insight into the current understanding of FND etiology, diagnosis, treatment, and prognosis in children and adolescents. Functional and high resolution MRI revealed abnormal connectivity and structural changes in patients with functional symptoms. The diagnostic criteria no longer require the presence of a psychological factor and instead focus on a rule-in diagnosis. Treatment of FND includes a clear communication of the diagnosis and the support of a multidisciplinary team. Although FND typically has a poor prognosis, better outcomes appear to have been achieved in children and young adults. We conclude that pediatric functional neurological disorder is a prevalent pathology and that this patient population has additional specific needs compared to the adult population.

Treatment of Psychogenic Nonepileptic Seizures

PURPOSE OF REVIEW

Psychogenic nonepileptic seizures (PNES) are the most common Functional Neurological Disorder/Conversion Disorder subtype. Significant advances have been made related to diagnosis, neurobiology, and treatment. In this review, we summarize updates in diagnosis and management over the past 3 years.

RECENT FINDINGS

Although evidence is mixed for the treatment of PNES, psychotherapeutic modalities remain a powerful instrument to empower patients and reduce seizures. A multidisciplinary, holistic approach is beneficial. While seizure freedom in all patients may not be the achieved endpoint in this chronic, paroxysmal disorder, quality of life can be improved with treatment. Additional treatment modalities and further research are needed for patients who are refractory to current treatment. Evidence-based therapies exist for PNES, and recent findings represent an increased understanding of the clinical and neurophysiologic aspects of PNES.

Diagnostic delay in functional seizures is associated with abnormal processing of facial emotions

PURPOSE

In patients with functional seizures (FS), delay in diagnosis (DD) may negatively affect outcomes. Altered brain responses to emotional stimuli have been shown in adults with FS. We hypothesized that DD would be associated with differential fMRI activation in emotion processing circuits.

METHODS

Fifty-two adults (38 females) with video-EEG confirmed FS prospectively completed assessments related to symptoms of depression (BDI-II), anxiety (BAI), post-traumatic stress disorder (PCL-S), a measure of how their symptoms affect day-to-day life (GAF), and fMRI at 3T with emotional faces task (EFT). During fMRI, subjects indicated "male" or "female" via button press while implicitly processing happy, sad, fearful, and neutral faces. Functional magnetic resonance imaging (FMRI) response to each emotion was modeled and group analyses were performed in AFNI within pre-specified regions-of-interest involved in emotion processing. A median split (507 days) defined short- (s-DD) and long-delay diagnosis (l-DD) groups. Voxelwise regression analyses were also performed to examine linear relationship between DD and emotion processing. FMRI signal was extracted from clusters showing group differences and Spearman's correlations assessed relationships with symptom scores.

RESULTS

Groups did not differ in FS age of onset, sex distribution, years of education, TBI characteristics, EFT in-scanner or post-test performance, or scores on the GAF, BDI-II, BAI, and PCL-S measures. The s-DD group was younger than l-DD (mean age 32.6 vs. 40.1; p = 0.022) at the time of study participation. After correcting for age, compared to s-DD, the l-DD group showed greater fMRI activation to sad faces in the bilateral posterior cingulate cortex (PCC) and to neutral faces in the right anterior insula. Within-group linear regression revealed that with increasing DD, there was increased fMRI activation to sad faces in the PCC and to happy faces in the right anterior insula/inferior frontal gyrus (AI/IFG). There were positive correlations between PCC response to sad faces and BDI-II scores in the l-DD group (rho = 0.48, p = 0.012) and the combined sample (rho = 0.30, p = 0.029). Increased PCC activation to sad faces in those in the l-DD group was associated with worse symptoms of depression (i.e. higher BDI-II score).

CONCLUSIONS

Delay in FS diagnosis is associated with fMRI changes in PCC and AI/IFG. As part of the default mode network, PCC is implicated in mood control, self-referencing, and other emotion-relevant processes. In our study, PCC changes are linked to depression. Future studies should assess the effects of interventions on these abnormalities.

Sense of control, selective attention and cognitive inhibition in pediatric functional seizures: A prospective case-control study

PURPOSE

To date, laboratory-based experimental behavioral methods have not been used to identify factors associated with pediatric functional seizures (FS), leaving a critical gap for effective treatment development.

METHODS

Children ages 13-18 with video-EEG-confirmed FS were matched to controls (MCs) based on income, sex, race, and age. A modified Stroop task which included a condition requiring participants to report the ink colors in which seizure symptom words were written (e.g., "shaking" in blue) measured selective attention and cognitive inhibition through response time. The magic and turbulence task assessed sense of control in three conditions (magic, lag, turbulence). Children with FS were asked to report premonitory symptoms predicting FS.

RESULTS

Participants included 26 children with FS and 26 MCs (Meanage=15.2, 74% female, 59% white). On Stroop, children with FS had a slower reaction time (Mean=1193.83) than MCs (Mean=949.26, p = 0.022) for seizure symptom words. Children with FS had significantly poorer sense of control in the turbulence condition of the magic and turbulence task (Mean=-3.99, SD=8.83) than MCs (Mean=-11.51, SD=7.87; t(20)=-2.61, p =0.017). Children with FS (Mean=-1.80, SD=6.54) also had significantly poorer sense of control in the magic condition than MCs (Mean=-5.57, SD=6.01; p =0.028). Ninety-eight percent of patients endorsed premonitory symptoms.

CONCLUSION

Compared with MCs, children with FS have (1) poorer selective attention and cognitive inhibition when presented with seizure-related information and (2) lower sense of control (i.e. poorer awareness that their control was manipulated). Premonitory symptoms were common. Sense of control, selective attention, and inhibition may be novel treatment targets for FS intervention.

Management of Functional Vision Disorders

PURPOSE OF REVIEW

The purpose of this review is to summarize current approaches to management of functional vision disorder (FVD).

RECENT FINDINGS

Several retrospective studies of FVD in both adults and children have shed light on the range of outcomes and the prevalence of psychosocial stressors among FVD patients. While the first line of treatment for FVD is reassurance and education, recent case reports highlight the use of additional treatment modalities including psychotherapy, hypnosis, and transcranial magnetic stimulation in specific cases. Although the epidemiology and diagnosis of functional vision disorder are well described, there is limited evidence supporting treatment modalities. Nevertheless, the majority of patients improve with conservative management including reassurance, education, and appropriate follow-up. Additional approaches such as mental health care referral can be considered in refractory cases.

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.

Neuroinflammation as a pathophysiological factor in the development and maintenance of functional seizures: A hypothesis

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Early-life stress may be a priming neuroinflammatory factor for later development of FS.

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Secondary trauma has emerged as an important predisposing factor for FS initiation.

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We propose an explanatory, two-hit hypothesis for FS development.

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The proposed hypothesis is based on findings from neuroimaging and biomarker studies.

The neurobiological underpinnings of functional seizure (FS) development and maintenance represent an active research area. Recent work has focused on hardware (brain structure) and software (brain function and connectivity). However, understanding whether FS are an adaptive consequence of changes in brain structure, function, and/or connectivity is important for identifying a causative mechanism and for FS treatment and prevention. Further, investigation must also uncover what causes these structural and functional phenomena. Pioneering work in the field of psychoneuroimmunology has established a strong, consistent link between psychopathology, immune dysfunction, and brain structure/function. Based on this and recent FS biomarker findings, we propose a new etiologic model of FS pathophysiology. We hypothesize that early-life stressors cause neuroinflammatory and neuroendocrine changes that prime the brain for later FS development following secondary trauma (e.g., traumatic brain injury or psychological trauma). This framework coalesces existing knowledge regarding brain aberrations underlying FS and established neurobiological theories on the pathophysiology of underlying psychiatric disorders. We also propose brain temperature mapping as a way of indirectly visualizing neuroinflammation in patients with FS, particularly in emotion regulation, fear processing, and sensory-motor integration circuits. We offer a foundation on which future research can be built, with clear recommendations for future studies.

Assessing the hidden burden of psychiatric disease in patients with nonepileptic seizures

Nonepileptic seizures are commonly associated with psychiatric comorbidities, and specifically PTSD. Despite increased prevalence of psychiatric disease noted on referral of patients to our dedicated clinic for nonepileptic seizures, we found even higher rates of comorbid psychiatric disease or significant symptomatology after our initial clinic intakes, whereby patients are formally evaluated by a behavioral health provider, in addition to an epileptologist. After intake, an additional 21% of patients were identified as having PTSD or significant trauma-related symptoms, an additional 7% of patients were identified with significant anxiety or panic-related symptoms, and an additional 11% of patients were identified with significant depressive symptoms. While highly effective treatment of nonepileptic seizures remains elusive, well-developed treatment paradigms with proven efficacy exist for depression, anxiety, and PTSD. Eliciting these psychiatric comorbidities and pursuing targeted treatments, especially for those patients that do not have easy access to providers with dedicated expertise in the management of nonepileptic seizures, may be a more easily scalable and implementable treatment modality for these patients.

Neurostimulation for the treatment of functional neurological disorder: A systematic review

Functional Neurological Disorder (FND), also known as conversion disorder, is characterized by neurological symptoms that are incompatible with any known structural disorder and best explained by a biopsychosocial model. Evidence-based treatments for FND are limited, with cognitive behavioral therapy (CBT) and physiotherapy being the most effective interventions [1]. In recent years, functional neuroimaging studies have provided robust evidence of alterations in activity and connectivity in multiple brain networks in FND. This body of evidence suggests that neurocircuitry-based interventions, such as non-invasive brain stimulation techniques (NIBS), may also represent an effective therapeutic option for patients with FND. In this systematic review, we outline the current state of knowledge of NIBS in FND, and discuss limitations and future directions that may help establish the efficacy of NIBS as a therapeutic option for FND.

Identifying and evaluating novel treatment targets for the development of evidence-based interventions for functional neurological disorder

Historically, functional neurological disorder (FND) has been described in psychodynamic terms as the physical manifestation of psychological distress. It is often explained to patients and caregivers as the result of anxiety, stress, trauma or other psychiatric comorbidities. However, recent evidence indicates that targeting mood and stress is not equivalent to the treatment of FND and may have limited to no effect on FND symptoms. Given the few randomized controlled trials for FND treatments and the limited evidence of mood and stress as effective treatment targets, the identification and evaluation of novel treatment targets or mediators is an area of great opportunity and should be the focus of future research. Identifying and targeting modifiable disease mechanisms directly as opposed to only treating psychiatric comorbidities may result in greater efficacy in treating FND symptoms, better patient outcomes and lower healthcare costs. Several novel mechanisms have been identified that warrant additional investigation as potential treatment targets including abnormal attentional focus on the affected area, beliefs and expectations about illness, impairments in habituation, and decreased sense of control over actions. Future intervention studies should take a mechanism-based approach and utilize valid and reliable measures or specific biomarkers to determine whether improvements in FND symptoms are associated with changes in the treatment targets. This transdiagnostic approach will allow researchers to translate the novel mechanistic outcomes emerging from neurophysiological and neuroscience studies into new or improved evidence-based approaches to FND treatment and prevention.

Validation of the PHQ-9 in adults with dissociative seizures

BACKGROUND

The PHQ-9 is a self-administered depression screening instrument. Little is known about its utility and accuracy in detecting depression in adults with dissociative seizures (DS).

OBJECTIVES

Using the Mini - International Neuropsychiatric Interview as a reference, we evaluated the diagnostic accuracy of the PHQ-9 in adults with DS, and examined its convergent and discriminant validity and uniformity.

METHODS

Our sample comprised 368 people with DS who completed the pre-randomisation assessment of the CODES trial. The uniformity of the PHQ-9 was determined using factor analysis for categorical data. Optimal cut-offs were determined using the area under the curve (AUC), Youden Index, and diagnostic odds ratio (DOR). Convergent and discriminant validity were assessed against pre-randomisation measures.

RESULTS

Internal consistency of the PHQ-9 was high (α = 0.87). While the diagnostic odds ratio suggested that a cut-off of ≥10 had the best predictive performance (DOR = 14.7), specificity at this cut off was only 0.49. AUC (0.74) and Youden Index (0.48) suggested a ≥ 13 cut-off would yield an optimal sensitivity (0.81) and specificity (0.67) balance. However, a cut-off score of ≥20 would be required to match specificity resulting from a cut-off of ≥13 in other medical conditions. We found good convergent and discriminant validity and one main factor for the PHQ-9.

CONCLUSIONS

In terms of internal consistency and structure, our findings were consistent with previous validation studies but indicated that a higher cut-off would be required to identify DS patients with depression with similar specificity achieved with PHQ-9 screening in different clinical and non-clinical populations.

Cognitive-behavioural therapy compared with standardised medical care for adults with dissociative non-epileptic seizures: the CODES RCT

BACKGROUND

Dissociative (non-epileptic) seizures are potentially treatable by psychotherapeutic interventions; however, the evidence for this is limited.

OBJECTIVES

To evaluate the clinical effectiveness and cost-effectiveness of dissociative seizure-specific cognitive-behavioural therapy for adults with dissociative seizures.

DESIGN

This was a pragmatic, multicentre, parallel-arm, mixed-methods randomised controlled trial.

SETTING

This took place in 27 UK-based neurology/epilepsy services, 17 liaison psychiatry/neuropsychiatry services and 18 cognitive-behavioural therapy services.

PARTICIPANTS

Adults with dissociative seizures in the previous 8 weeks and no epileptic seizures in the previous year and meeting other eligibility criteria were recruited to a screening phase from neurology/epilepsy services between October 2014 and February 2017. After psychiatric assessment around 3 months later, eligible and interested participants were randomised between January 2015 and May 2017.

INTERVENTIONS

Standardised medical care consisted of input from neurologists and psychiatrists who were given guidance regarding diagnosis delivery and management; they provided patients with information booklets. The intervention consisted of 12 dissociative seizure-specific cognitive-behavioural therapy 1-hour sessions (plus one booster session) that were delivered by trained therapists, in addition to standardised medical care.

MAIN OUTCOME MEASURES

The primary outcome was monthly seizure frequency at 12 months post randomisation. The secondary outcomes were aspects of seizure occurrence, quality of life, mood, anxiety, distress, symptoms, psychosocial functioning, clinical global change, satisfaction with treatment, quality-adjusted life-years, costs and cost-effectiveness.

RESULTS

In total, 698 patients were screened and 368 were randomised (standardised medical care alone, n = 182; and cognitive-behavioural therapy plus standardised medical care, n = 186). Primary outcome data were obtained for 85% of participants. An intention-to-treat analysis with multivariate imputation by chained equations revealed no significant between-group difference in dissociative seizure frequency at 12 months [standardised medical care: median of seven dissociative seizures (interquartile range 1-35 dissociative seizures); cognitive-behavioural therapy and standardised medical care: median of four dissociative seizures (interquartile range 0-20 dissociative seizures); incidence rate ratio 0.78, 95% confidence interval 0.56 to 1.09; p = 0.144]. Of the 16 secondary outcomes analysed, nine were significantly better in the arm receiving cognitive-behavioural therapy at a p-value < 0.05, including the following at a p-value ≤ 0.001: the longest dissociative seizure-free period in months 7-12 inclusive post randomisation (incidence rate ratio 1.64, 95% confidence interval 1.22 to 2.20; p = 0.001); better psychosocial functioning (Work and Social Adjustment Scale, standardised treatment effect -0.39, 95% confidence interval -0.61 to -0.18; p < 0.001); greater self-rated and clinician-rated clinical improvement (self-rated: standardised treatment effect 0.39, 95% confidence interval 0.16 to 0.62; p = 0.001; clinician rated: standardised treatment effect 0.37, 95% confidence interval 0.17 to 0.57; p < 0.001); and satisfaction with treatment (standardised treatment effect 0.50, 95% confidence interval 0.27 to 0.73; p < 0.001). Rates of adverse events were similar across arms. Cognitive-behavioural therapy plus standardised medical care produced 0.0152 more quality-adjusted life-years (95% confidence interval -0.0106 to 0.0392 quality-adjusted life-years) than standardised medical care alone. The incremental cost-effectiveness ratio (cost per quality-adjusted life-year) for cognitive-behavioural therapy plus standardised medical care versus standardised medical care alone based on the EuroQol-5 Dimensions, five-level version, and imputed data was £120,658. In sensitivity analyses, incremental cost-effectiveness ratios ranged between £85,724 and £206,067. Qualitative and quantitative process evaluations highlighted useful study components, the importance of clinical experience in treating patients with dissociative seizures and potential benefits of our multidisciplinary care pathway.

LIMITATIONS

Unlike outcome assessors, participants and clinicians were not blinded to the interventions.

CONCLUSIONS

There was no significant additional benefit of dissociative seizure-specific cognitive-behavioural therapy in reducing dissociative seizure frequency, and cost-effectiveness over standardised medical care was low. However, this large, adequately powered, multicentre randomised controlled trial highlights benefits of adjunctive dissociative seizure-specific cognitive-behavioural therapy for several clinical outcomes, with no evidence of greater harm from dissociative seizure-specific cognitive-behavioural therapy.

FUTURE WORK

Examination of moderators and mediators of outcome.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN05681227 and ClinicalTrials.gov NCT02325544.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 43. See the NIHR Journals Library website for further project information.

Dissociations and Cognitive Distortions: True, True, and Possibly Related

Cognitive Behavioural Therapy for Adults With Dissociative Seizures (CODES): A Pragmatic, Multicentre, Randomized Controlled Trial.

Goldstein LH, Robinson EJ, Mellers JDC, et al Lancet Psych. 2020;7(6):491-505. doi:10.1016/S2215-0366(20)30128-0.

Background:

Dissociative seizures are paroxysmal events resembling epilepsy or syncope with characteristic features that allow them to be distinguished from other medical conditions. We aimed to compare the effectiveness of cognitive behavioral therapy (CBT) plus standardized medical care with standardized medical care alone for the reduction of dissociative seizure frequency.

Methods:

In this pragmatic, parallel-arm, multicenter, randomized controlled trial, we initially recruited participants at 27 neurology or epilepsy services in England, Scotland, and Wales. Adults (≥18 years) who had dissociative seizures in the previous 8 weeks and no epileptic seizures in the previous 12 months were subsequently randomly assigned (1:1) from 17 liaison or neuropsychiatry services following psychiatric assessment, to receive standardized medical care or CBT plus standardized medical care, using a web-based system. Randomization was stratified by neuropsychiatry or liaison psychiatry recruitment site. The trial manager, chief investigator, all treating clinicians, and patients were aware of treatment allocation, but outcome data collectors and trial statisticians were unaware of treatment allocation. Patients were followed up 6 months and 12 months after randomization. The primary outcome was monthly dissociative seizure frequency (ie, frequency in the previous 4 weeks) assessed at 12 months. Secondary outcomes assessed at 12 months were seizure severity (intensity) and bothersomeness; longest period of seizure freedom in the previous 6 months; complete seizure freedom in the previous 3 months; a greater than 50% reduction in seizure frequency relative to baseline; changes in dissociative seizures (rated by others); health-related quality of life; psychosocial functioning; psychiatric symptoms, psychological distress, and somatic symptom burden; and clinical impression of improvement and satisfaction. P values and statistical significance for outcomes were reported without correction for multiple comparisons as per our protocol. Primary and secondary outcomes were assessed in the intention-to-treat population with multiple imputation for missing observations. This trial is registered with the International Standard Randomised Controlled Trial registry, ISRCTN05681227, and ClinicalTrials.gov, NCT02325544.

Findings:

Between January 16, 2015, and May 31, 2017, we randomly assigned 368 patients to receive CBT plus standardized medical care (n = 186) or standardized medical care alone (n = 182); of whom 313 had primary outcome data at 12 months (156 [84%] of 186 patients in the CBT plus standardized medical care group and 157 [86%] of 182 patients in the standardized medical care group). At 12 months, no significant difference in monthly dissociative seizure frequency was identified between the groups (median: 4 seizures [interquartile range: 0–-0] in the CBT plus standardized medical care group vs 7 seizures [1-35] in the standardized medical care group; estimated incidence rate ratio [IRR]: 0.78 [95% CI: 0·56-1.09]; P = .144). Dissociative seizures were rated as less bothersome in the CBT plus standardized medical care group than the standardized medical care group (estimated mean difference: −0.53 [95% CI: −0.97 to −0.08]; P = .020). The CBT plus standardized medical care group had a longer period of dissociative seizure freedom in the previous 6 months (estimated IRR: 1.64 [95% CI: 1.22-2.20]; P = .001), reported better health-related quality of life on the EuroQoL-5 Dimensions-5 Level Health Today visual analog scale (estimated mean difference: 6.16 [95% CI: 1.48-10.84]; P = .010), less impairment in psychosocial functioning on the Work and Social Adjustment Scale (estimated mean difference: −4.12 [95% CI: −6·35 to −1.89]; P < .001), less overall psychological distress than the standardized medical care group on the Clinical Outcomes in Routine Evaluation-10 scale (estimated mean difference: −1.65 [95% CI: −2.96 to −0.35]; P = .013), and fewer somatic symptoms on the modified Patient Health Questionnaire-15 scale (estimated mean difference: −1.67 [95% CI: −2.90 to −0.44]; P = .008). Clinical improvement at 12 months was greater in the CBT plus standardized medical care group than the standardized medical care alone group as reported by patients (estimated mean difference: 0.66 [95% CI: 0.26-1.04]; P = .001) and by clinicians (estimated mean difference: 0·47 [95% CI: 0.21-0.73]; P < .001), and the CBT plus standardized medical care group had greater satisfaction with treatment than did the standardized medical care group (estimated mean difference: 0.90 [95% CI: 0.48-1.31]; P < .001). No significant differences in patient-reported seizure severity (estimated mean difference: −0·11 [95% CI: −0.50 to 0.29]; P = .593) or seizure freedom in the last 3 months of the study (estimated odds ratio [OR]: 1.77 [95% CI: 0.93-3.37]; P = .083) were identified between the groups. Furthermore, there were no significant differences in dissociative seizure frequency reduction compared with baseline (OR: 1.27 [95% CI: 0.80-2.02]; P = .313). Additionally, the 12-item Short Form survey–version 2 scores (estimated mean difference for the Physical Component Summary score: 1.78 [95% CI: −0.37 to 3.92]; P = .105; estimated mean difference for the Mental Component Summary score: 2.22 [95% CI: −0.30 to 4.75]; P = .084), the Generalized Anxiety Disorder-7 Scale score (estimated mean difference: −1·09 [95% CI: −2.27 to 0.09]; P = .069), and the Patient Health Questionnaire-9 Scale depression score (estimated mean difference: −1.10 [95% CI: −2.41 to 0.21]; P = .099) did not differ significantly between groups. Changes in dissociative seizures (rated by others) could not be assessed due to insufficient data. During the 12-month period, the number of adverse events was similar between the groups: 57 (31%) of 186 participants in the CBT plus standardized medical care group reported 97 adverse events and 53 (29%) of 182 participants in the standardized medical care group reported 79 adverse events.

Interpretation:

Cognitive behavioral therapy plus standardized medical care had no statistically significant advantage compared with standardized medical care alone for the reduction of monthly seizures. However, improvements were observed in a number of clinically relevant secondary outcomes following CBT plus standardized medical care when compared with standardized medical care alone. Thus, adults with dissociative seizures might benefit from the addition of dissociative seizure-specific CBT to specialist care from neurologists and psychiatrists. Future work is needed to identify patients who would benefit most from a dissociative seizure-specific CBT approach.

[Functional neurological disorders]

This paper reviews the literature on functional neurological disorders (Dissociative (conversion disorders - F44). The authors present a change in views on the etiology and the main mechanisms of the pathogenesis of this pathology during the period of its study. The modern ideas about the types of cerebral dysfunction characteristic of functional neurological disorders are considered. The description of the most characteristic mental and somatic symptoms observed in dissociative disorders and the features of their clinical manifestations are given. The current approaches to the therapy of functional neurological disorders are considered.

A South African review of routinely-collected health data of psychogenic nonepileptic seizure patients referred to psychiatrists in Johannesburg

Patients with psychogenic nonepileptic seizures (PNES) are often referred to psychiatrists for treatment of functional neurological symptom disorder (FNSD). However, not all patients with FNSD have an identified psychiatric comorbidity [1]. The aim of this observational study was to characterize the clinical and psychiatric features of patients with PNES from Johannesburg, South Africa, where a high frequency of PNES has been reported [2], and compare these findings to other reports. We hypothesized that patient outcomes regarding treatment adherence and episode frequency would improve when treated within a closed multidisciplinary team. The data included a retrospective record review of patients diagnosed with PNES from an epilepsy monitoring unit and referred for psychiatric assessment and treatment between November 2013 and July 2017. Fifty-nine cases met the criteria for the study. There were 7 male and 52 female participants, aged between 14 and 72 years (M = 33.76, SD = 13.88). The most frequently reported comorbid symptoms were anxiety (90%); dissociative symptoms (51%); headaches (76%) and gastrointestinal symptoms (36%). Important patient characteristics included past substance abuse (76%); impaired attachment (86%); past trauma (69%) and sexual trauma (29%). Generalized anxiety disorder (76%), major depressive disorder (64%) and PTSD (22%) were the most prevalent psychiatric diagnoses. After receiving psychiatric treatment, 47% of patients experienced a decrease in the frequency of episodes, while 86% became aware of the precipitants of their episodes. Psychiatric data can valuably inform current theories of PNES management. This study contributes to the understanding of comorbid, aetiological, and prognostic factors that are crucial to refining coherent models that will guide practice.

Epidemiology of Functional Seizures Among Adults Treated at a University Hospital

Importance

Functional seizures (formerly psychogenic nonepileptic seizures), paroxysmal episodes that are often similar to epileptic seizures in their clinical presentation and display no aberrant brain electrical patterns, are understudied. Patients experience a long diagnostic delay, few treatment modalities, a high rate of comorbidities, and significant stigma due to the lack of knowledge about functional seizures.

Objective

To characterize the clinical epidemiology of a population of patients with functional seizures observed at Vanderbilt University Medical Center (VUMC).

Design, Setting, and Participants

This case-control study included patients with functional seizures identified in the VUMC electronic health record (VUMC-EHR) system from October 1989 to October 2018. Patients with epilepsy were excluded from the study and all remaining patients in the VUMC medical center system were used as controls. In total, the study included 1431 patients diagnosed with functional seizures, 2251 with epilepsy and functional seizures, 4715 with epilepsy without functional seizures, and 502 200 control patients who received treatment at VUMC for a minimum of a 3 years. Data were analyzed from November 2018 to March 2020.

Exposure

Diagnosis of functional seizures, as identified from the VUMC-EHR system by an automated phenotyping algorithm that incorporated International Classification of Diseases, Ninth Revision (ICD-9) codes, International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes, Current Procedural Terminology codes, and natural language processing.

Main Outcomes and Measures

Associations of functional seizures with comorbidities and risk factors, measured in odds ratios (ORs).

Results

Of 2 346 808 total patients in the VUMC-EHR aged 18 years or older, 3341 patients with functional seizures were identified (period prevalence, 0.14%), 1062 (74.2%) of whom were women and for which the median (interquartile range) age was 49.3 (39.4-59.9) years. This assessment replicated previously reported associations with psychiatric disorders including posttraumatic stress disorder (PTSD) (OR, 1.22; 95% CI, 1.21-1.24; P < 3.02 × 10-5), anxiety (OR, 1.14; 95% CI, 1.13-1.15; P < 3.02 × 10-5), and depression (OR, 1.14; 95% CI, 1.13-1.15; P < 3.02 × 10-5), and identified novel associations with cerebrovascular disease (OR, 1.08; 95% CI, 1.06-1.09; P < 3.02 × 10-5). An association was found between functional seizures and the known risk factor sexual assault trauma (OR, 10.26; 95% CI, 10.09-10.44; P < 3.02 × 10-5), and sexual assault trauma was found to mediate nearly a quarter of the association between female sex and functional seizures in the VUMC-EHR.

Conclusions and Relevance

This case-control study found evidence to support previously reported associations, discovered new associations between functional seizures and PTSD, anxiety, and depression. An association between cerebrovascular disease and functional seizures was also found. Results suggested that sexual trauma may be a mediating factor in the association between female sex and functional seizures.

Virtual Reality-Delivered Mirror Visual Feedback and Exposure Therapy for FND: A Midpoint Report of a Randomized Controlled Feasibility Study

OBJECTIVE

The aim was to provide preliminary feasibility, safety, and efficacy data for a personalized virtual reality-delivered mirror visual feedback (VR-MVF) and exposure therapy (VR-ET) intervention for functional neurological disorder (FND).

METHODS

Midpoint results of a single-blind, randomized controlled pilot are presented. Fourteen adults were randomly assigned to eight weekly 30-minute VR sessions-seven in the treatment arm and seven in the control arm. The treatment arm consisted of an immersive avatar-embodied VR-MVF treatment, plus optional weekly VR-ET starting at session 4 if participants had identifiable FND triggers. The control arm received equally immersive nonembodied sessions involving exploration of a virtual interactive space. Feasibility was measured by acceptability of randomization, completion rates, side effects, adverse events, and integrity of blinding procedures. Exploratory primary and secondary outcome measures were weekly symptom frequency and the Oxford Handicap Scale, respectively.

RESULTS

Two early dropouts occurred in the treatment arm, resulting in an 86% completion rate (N=12/14). No side effects or adverse events were reported. Blind assessment at study end indicated that two of the seven treatment arm and three of the seven control arm participants incorrectly guessed their assignment. Changes in mean symptom frequency and disability were reported, but data will not be statistically analyzed until study end.

CONCLUSIONS

This study is the first to report on MVF and VR for treatment of FND. Results generated thus far support feasibility and justify continuation of the study and further investigation into the efficacy of VR interventions for FND.

Retraining and control therapy for pediatric psychogenic non-epileptic seizures

Objective

Our aim was to conduct a pilot randomized controlled trial of a novel cognitive behaviorally based intervention for pediatric PNES called Retraining and Control Therapy (ReACT).

Methods

Participants were randomized to receive either eight sessions of ReACT or supportive therapy, and participants completed follow‐up visits at 7‐ and 60‐days posttreatment. The primary outcome measure was PNES frequency at 7‐days posttreatment. Eligibility criteria included children with video‐EEG confirmed PNES and participant/parent or guardian willingness to participate in treatment. Exclusion criteria included substance use, psychosis, and severe intellectual disability. Forty‐two patients were assessed for eligibility and 32 were randomized. ReACT aimed to retrain classically conditioned, involuntary PNES by targeting catastrophic symptom expectations and a low sense of control over symptoms using principles of habit reversal. Supportive therapy was based on the assumption that relief from stress or problems can be achieved by discussion with a therapist.

Results

Twenty‐nine participants (M_age = 15.1 years, SD_age = 2.5; 72.2% female; 57.1% Caucasian, 28.6% African American) completed 7‐days postprocedures. For PNES frequency, the Wilcoxon Rank Sum test statistic was 273.5 yielding a normal approximation of Z = 4.725 (P < 0.0001), indicating a significant improvement in PNES frequency for ReACT at 7‐days posttreatment compared to supportive therapy. Participants with PNES in the 7‐days posttreatment were removed from the study for additional treatment, resulting in no 60‐day follow‐up data for supportive therapy.

Interpretation

ReACT resulted in significantly greater PNES reduction than supportive therapy, with 100% of patients experiencing no PNES in 7 days after ReACT. Additionally, 82% remained PNES‐free for 60 days after ReACT.

Outcome measurement in functional neurological disorder: a systematic review and recommendations

OBJECTIVES

We aimed to identify existing outcome measures for functional neurological disorder (FND), to inform the development of recommendations and to guide future research on FND outcomes.

METHODS

A systematic review was conducted to identify existing FND-specific outcome measures and the most common measurement domains and measures in previous treatment studies. Searches of Embase, MEDLINE and PsycINFO were conducted between January 1965 and June 2019. The findings were discussed during two international meetings of the FND-Core Outcome Measures group.

RESULTS

Five FND-specific measures were identified-three clinician-rated and two patient-rated-but their measurement properties have not been rigorously evaluated. No single measure was identified for use across the range of FND symptoms in adults. Across randomised controlled trials (k=40) and observational treatment studies (k=40), outcome measures most often assessed core FND symptom change. Other domains measured commonly were additional physical and psychological symptoms, life impact (ie, quality of life, disability and general functioning) and health economics/cost-utility (eg, healthcare resource use and quality-adjusted life years).

CONCLUSIONS

There are few well-validated FND-specific outcome measures. Thus, at present, we recommend that existing outcome measures, known to be reliable, valid and responsive in FND or closely related populations, are used to capture key outcome domains. Increased consistency in outcome measurement will facilitate comparison of treatment effects across FND symptom types and treatment modalities. Future work needs to more rigorously validate outcome measures used in this population.

Cognitive behavior therapy for comorbid dissociative seizures in patients with epilepsy

OBJECTIVES

The main aim of this study was to assess the effectiveness of cognitive behavior therapy (CBT) for comorbid dissociative seizures (DS) in patients with epilepsy.

METHODS

We conducted a retrospective case note review of 14 patients with epilepsy who underwent outpatient CBT for DS in a tertiary neuropsychiatry service. The diagnosis of DS was confirmed by neurologists clinically and/or following video-telemetry electroencephalogram (EEG). We evaluated the outcome of the CBT treatment with respect to frequency of DS, measures of depression, anxiety, and social functioning.

RESULTS

Measures of depression and anxiety significantly reduced following CBT treatment. Overall, frequency of DS reduced following CBT treatment but did not reach statistical significance.

SIGNIFICANCE

This study provides evidence that CBT can be effective in reducing depression and anxiety in patients with both epilepsy and DS. Anxiety and depression are likely to be associated with DS. Further research in larger samples and longitudinal studies are recommended to evaluate the long-term efficacy of CBT in this patient group.

A Novel Integrative Psychotherapy for Psychogenic Nonepileptic Seizures Based on the Biopsychosocial Model: A Retrospective Pilot Outcome Study

BACKGROUND

Psychogenic nonepileptic seizures (PNES) represent one of the most sizable treatment challenges in neuropsychiatry. Although the underlying mechanism is far from being understood, several interventions have been suggested. However, patients with comorbid psychiatric diagnoses and epilepsy are excluded from most intervention studies.

OBJECTIVE

To To present a within-group posttreatment vs pretreatment study representing the retrospective clinical results of an integrative psychotherapy model.

METHODS

We present the clinical results of 22 patients with PNES diagnosed in an epilepsy center and treated in our neuropsychiatry clinic using an integrative rehabilitative psychotherapy. Therapy included presenting the diagnosis, psychoeducation, seizure reduction behavioral techniques, and coping with past and present stressors. Insomuch as integrative biopsychosocial psychotherapy is based on an individualized treatment protocol for each patient, treatment was individualized and case specific.

RESULTS

By the end of treatment, 36% of patients had become seizure free and a further 54% achieved a major seizure reduction (reduction of more than 70%). Seventy-two percent of patients kept at least 70% seizure reduction at follow-up. Global Assessment of Functioning scores improved from a mean of 43.09 to a mean of 72.81 at the end of treatment and 69.72 at follow-up. In addition, we present 3 case descriptions that emphasize the individualized nature of psychotherapeutic decisions.

CONCLUSIONS

Our results support the feasibility and effectiveness of biopsychosocial based integrative psychotherapy for PNES and set principles for future treatment and prospective clinical trials in the field of individualized psychotherapy.

Mindfulness-based therapy for psychogenic nonepileptic seizures

BACKGROUND

Mindfulness-based therapies (MBTs) are effective in many neuropsychiatric disorders, and represent a potential therapeutic strategy for psychogenic nonepileptic seizures (PNES).

OBJECTIVE

The objective of this study was to investigate the clinical effect of a manualized 12-session MBT for PNES in an uncontrolled trial. We hypothesized reductions in PNES frequency, intensity, and duration, and improvements in quality of life and psychiatric symptom severity at treatment completion.

METHODS

Between August 2014 and February 2018, 49 patients with documented PNES (with video electroencephalography [EEG]) were recruited at Brigham and Women's Hospital to participate in the MBT for PNES treatment study. Baseline demographic and clinical information and self-rating scales were obtained during the diagnostic evaluation (T0). Baseline PNES frequency, intensity, and duration were collected at the first follow-up postdiagnosis (T1). Frequency was obtained at each subsequent MBT session and analyzed over time with median regression analysis. Outcomes for other measures were collected at the last MBT session (T3), and compared to baseline measures using linear mixed models.

RESULTS

Twenty-six patients completed the 12-session MBT program and were included in the analysis. Median PNES frequency decreased by 0.12 events/week on average with each successive MBT session (p = 0.002). At session 12, 70% of participants endorsed a reduction in PNES frequency of at least 50%. Freedom from PNES was reported by 50% of participants by treatment conclusion. Seventy percent reported a 50% reduction in frequency from baseline and 50% reported remission at session 12. By treatment end, PNES intensity decreased (p = 0.012) and quality of life improved (p = 0.002). Event duration and psychiatric symptom severity were lower after treatment, but reductions were not statistically significant.

CONCLUSIONS

Completion of a manualized 12-session MBT for PNES provides improvement in PNES frequency, intensity, and quality of life. The high dropout rate is consistent with adherence studies in PNES. Possible reasons for dropout are discussed. Randomized controlled trials and longer-term outcomes are needed to demonstrate the efficacy of MBT in PNES.

Functional non-epileptic attacks: essential information for psychiatrists

Functional non-epileptic attacks (FNEA) are seizure-like events occurring in the absence of epilepsy. Having had many different names over the years including dissociative convulsions and pseudo-seizures, they now fall in the borderland between neurology and psychiatry, often not accepted by either specialty. However, there is evidence that there is a high rate of psychiatric comorbidity in these patients and therefore it is likely that psychiatrists will come across patients with FNEA and they should know the broad principles of assessment and management.

We have provided a clinically based overview of the evidence regarding epidemiology, risk factors, clinical features, differentiation from epilepsy, prognosis, assessment and treatment.

By the end of this article, readers should be able to understand the difference between epileptic seizures and FNEA, know how to manage acute FNEA, and understand the principles of neuropsychiatric assessment and management of these patients, based on knowledge of the evidence base.

Medication prescriptions in 322 motor functional neurological disorder patients in a large UK mental health service: A case control study

OBJECTIVE

This study describes medication prescribing patterns in patients with motor functional neurological disorder (mFND) treated in South London and Maudsley NHS Foundation Trust (SLaM), comparing outcomes to a control group of psychiatric patients from the same hospital trust.

METHOD

This is a retrospective case-control study using a psychiatric case register. Cross-sectional data were obtained from 322 mFND patients and 644 psychiatry controls who had had contact with SLaM between 1st January 2006 and 31st December 2016.

RESULTS

A slightly lower proportion of mFND patients received medication compared to controls (76.6% v. 83.4%, OR: 0.59, CI: 0.39-0.89, p < 0.05). Of medication recipients, mFND patients were prescribed a higher number of agents (mean: 4.7 v 2.9, p = 0.001) and had higher prescription rates of antidepressants, anti-epileptics, analgesics, and certain non-psychotropic medications. Higher numbers of prescriptions were associated with co-morbid physical conditions, and previous psychiatric admissions.

CONCLUSIONS

This is the first study to describe medication prescriptions in a large cohort of mFND patients. Patients were prescribed a wide range of psychiatric and physical health medications, with higher rates of polypharmacy than controls. Psychotropic medication prescription is not necessarily the first line treatment for mFND, where physiotherapy and psychotherapy may be offered initially. There is limited, early-phase evidence for pharmacological therapies for mFND, and as such, the benefit-to-risk ratio of prescribing in this complex and poorly understood disorder should be carefully assessed.

Long-term outcome in a sample of underprivileged patients with psychogenic nonepileptic seizures (PNES) living in Argentina

OBJECTIVE

The objective of the present study was to perform a long-term follow-up of economically disadvantaged Latin American patients diagnosed as having psychogenic nonepileptic seizures (PNES) and contribute to the field's understanding of outcome in this population.

BACKGROUND

A handful of studies have examined outcome of patients once the diagnosis of PNES has been communicated. However, the vast majority of these have been conducted in the first world countries with samples that were predominantly Caucasian. There is limited knowledge about outcome in economically disadvantaged Latin American patients diagnosed as having PNES.

METHODS

This is a study of 23 patients (20 women, 3 men) with PNES in which demographic data (age, education, nationality, presence of psychological trauma, age of onset) were retrospectively retrieved from medical files. Follow-up was done through a telephonic questionnaire in which investigators collected clinical information (seizure characteristics at follow-up, and treatments employed) and changes in demographic data.

RESULTS

Patients from this Argentinian PNES sample demonstrated having many similar demographic and clinical characteristics to samples from US and European studies. Long-term follow-up revealed, however, decreased seizure frequency and intensity as well as a substantial improvement in occupational status. A majority had engaged in psychotherapy as well as alternative and complementary approaches. A majority had also developed what are suspected to be other functional symptoms.

CONCLUSIONS

Argentinian patients from economically disadvantaged backgrounds, diagnosed as having PNES reported improvements in seizure frequency and occupational status during long-term follow-up. Future studies will need to focus on what (e.g., communication of diagnosis, psychotherapy, alternative treatments) may have contributed to these changes.

Characteristics of patients with confirmed epilepsy and psychogenic nonepileptic seizures in Qatar

OBJECTIVE

The Middle Eastern country of Qatar opened its first epilepsy monitoring unit (EMU) in late 2015. This study compared demographic and clinical characteristics of patients with confirmed epilepsy to those of patients with confirmed psychogenic nonepileptic seizures (PNES).

METHODS

Data were collected via retrospective chart review on 113 patients admitted for evaluation to the Qatar national health system EMU between November 2015 and May 2017.

RESULTS

Seventy-one patients had a confirmed diagnosis (20 had PNES, 46 had epilepsy, 5 had both PNES and epilepsy). Evaluation in 33 patients was inconclusive, and 9 had other medical conditions. Patients with PNES were significantly more likely to be primary Arabic speakers (p = 0.003), and this difference was not explained by education or employment status. The most common referral request in patients with PNES was for recurrent/refractory seizures (p = 0.011), and there was a trend for patients with PNES to have more frequent seizures compared with patients with epilepsy (daily to several per week versus several times a month or less, p = 0.051). Depression was identified in 47% of patients with epilepsy and 65% of patients with PNES, and patients with PNES had higher mean depression scores on the PHQ-9 than patients with epilepsy (p = 0.014). Patients with PNES experienced significantly more fatigue (p = 0.021). Seventy percent of patients with PNES and 50% of patients with epilepsy reported sleep problems.

CONCLUSIONS

The characteristics of patients with epilepsy and PNES at the EMU in Qatar were generally similar to those found worldwide. Patients with PNES more often suffered from frequent depression, sleep problems, and fatigue than those with epilepsy, but these were significant concerns for both groups.

Survey of physician attitudes towards psychogenic nonepileptic seizures and driving

BACKGROUND

Physicians from various disciplines encounter patients presenting with psychogenic nonepileptic seizures (PNES) as part of their routine clinical practice. Recommendations towards assessing fitness to drive and reporting are clearer for conditions such as neurocognitive disorders and epilepsy, but such guidelines do not exist for patients with PNES. Here, we assess physicians' attitudes towards driving for patients diagnosed with PNES.

METHODS

Electronic questionnaires were sent to Neurology and Family Medicine physicians practicing at Creighton University Medical Center and Psychiatry physicians practicing at Creighton-Nebraska Psychiatry Residency Program to assess their opinion regarding driving risk when encountering PNES.

RESULTS

The survey request was sent to 125 physicians, of which close to 60% completed the survey. Eighty-eight percent of participants encountered PNES in their clinical practice, and 69.1% agreed it was a difficult problem to assess, with only 8.3% endorsing a belief that these patients should drive without restrictions. Ninety-three percent felt having guidelines would help them assess the driving risk in this population.

CONCLUSION

Psychogenic nonepileptic seizures are common across neurology, psychiatry, and primary care, and most physicians find assessing driving risk in such individuals highly warranted yet difficult. Developing such assessment guidelines and recommendations is of great need for clinicians.

Facial emotion processing in patients with seizure disorders

Studies of emotion processing are needed to better understand the pathophysiology of psychogenic nonepileptic seizures (PNES). We examined the differences in facial emotion processing between 12 patients with PNES, 12 patients with temporal lobe epilepsy (TLE), and 24 matched healthy controls (HCs) using fMRI with emotional faces task (EFT) (happy/sad/fearful/neutral) and resting state connectivity. Compared with TLE, patients with PNES exhibited increased fMRI response to happy, neutral, and fearful faces in visual, temporal, and/or parietal regions and decreased fMRI response to sad faces in the putamen bilaterally. Regions showing significant differences between PNES and TLE were used as functional seed regions of interest (ROIs), in addition to amygdala structural seed ROIs for resting state functional connectivity analyses. Whole brain analyses showed that compared with TLE and HCs, patients with PNES exhibited increased functional connectivity of the functional seed ROIs to several brain regions, particularly to cerebellar, visual, motor, and frontotemporal regions. Connectograms showed increased functional connections between left parahippocampal gyrus/uncus ROIs and right temporal ROIs in PNES compared with both the TLE and HC groups. Resting state functional connectivity of the left and right amygdala to various brain regions including emotion regulation and motor control circuits was increased in PNES when compared with those with TLE. This study provides preliminary evidence that patients with PNES exhibit altered facial emotion processing compared with patients with TLE and HCs and increased amygdala functional connectivity compared with TLE. These findings identify potential key differences in facial emotion processing reflective of neurophysiologic markers of neural circuitry alterations that can be used to generate further hypotheses for developing studies that examine the contributions of emotion processing to the development and maintenance of PNES.

The Brief Assessment of Family Functioning Scale (BAFFS): a three-item version of the General Functioning Scale of the Family Assessment Device

The purpose of the present study is to compare results from the 12-item General Functioning Scale (GF-FAD) of the Family Assessment Device (FAD) to a three-item version, the Brief Assessment of Family Functioning Scale (BAFFS), designed to be used when brevity is especially important. We used principal components analysis of the GF-FAD, followed by multiple sample confirmatory factor analyses to test the robustness of the BAFFS in different samples. The BAFFS correlated highly with the GF-FAD, and demonstrated good concurrent validity with another measure of global marital functioning, the Dyadic Adjustment Scale-4 in a help-seeking sample. Like the 12-item version, the BAFFS moderately correlated with an objective, interview-based rating of family functioning, the McMaster Clinical Rating Scale. The BAFFS appears to serve as a good proxy for the GF-FAD when an ultra-brief family assessment measure is needed.

Psychogenic non-epileptic seizures: aetiology, diagnosis and management

Psychogenic non-epileptic seizures (PNES) have a significant impact on most patients in terms of distress, disability, loss of income and iatrogenic harm. Three-quarters of patients with PNES are initially misdiagnosed and treated for epilepsy. Misdiagnosis exposes patients to multiple iatrogenic harms and prevents them from accessing psychological treatment. In most cases, the patient's history (and witness accounts) should alert clinicians to the likely diagnosis of PNES. Since this diagnosis may be resisted by patients and may involve ‘un-diagnosing’ epilepsy, video-electroencephalogram recording of typical seizures is often helpful. The underlying causes of PNES are diverse: a model combining predisposing, precipitating and perpetuating factors is a useful way of conceptualising their aetiology. The initial step of treatment should be to limit iatrogenic harm. There is some evidence for the effectiveness of psychotherapy.

Access to diagnostic and therapeutic facilities for psychogenic nonepileptic seizures: An international survey by the ILAE PNES Task Force

OBJECTIVE

Studies from a small number of countries suggest that patients with psychogenic nonepileptic seizures (PNES) have limited access to diagnostic and treatment services. The PNES Task Force of the International League Against Epilepsy (ILAE) carried out 2 surveys to explore the diagnosis and treatment of PNES around the world.

METHODS

A short survey (8 questions) was sent to all 114 chapters of the ILAE. A longer survey (36 questions) was completed by healthcare professionals who see patients with seizures. Questions were separated into 5 sections: professional role, diagnostic methods, management, etiology, and access to health care.

RESULTS

Responses were received from 63 different countries. The short survey was completed by 48 ILAE chapters, and the long survey by 1098 health professionals from 28 countries. PNES were recognized as a diagnostic and therapeutic problem in all countries. Trauma and mental health issues were most commonly recognized as etiologic factors. There was a clear relationship between income and access to diagnostic tests and expertise. Psychological therapy was most commonly considered the treatment of choice. Although financial difficulties were the most commonly reported problem with service access in low-income countries, in all countries stigma, lack of popular awareness, and lack of information posed challenges.

SIGNIFICANCE

This global provider survey demonstrates that PNES are a health problem around the world. Health care for PNES could be improved with better education of healthcare professionals, the development of reliable and simple diagnostic procedures that do not rely on costly tests, and the provision of accessible information.

Implementation of psychological clinical trials in epilepsy: Review and guide

The International League Against Epilepsy (ILAE) Neuropsychiatry commission and United States Institute of Medicine report both identified cognitive and psychological comorbidities as a significant issue for individuals with epilepsy, with rates as high as 60%. However, there is a paucity of evidence-based treatments for many psychological conditions (e.g., learning disorders, cognitive disorders, behavioral disorders). Because of inherent challenges in the implementation of psychological therapy trials and specific considerations for the population with epilepsy, the focus of the current review was to provide guidance and recommendations to conduct psychological trials for individuals with epilepsy. Several key areas will be discussed, including selection of patients, trial design, psychological intervention considerations, outcomes and evaluation of results, publication of trial results, and special issues related to pediatric clinical trials. Rigorously designed psychological therapy trials will set the stage for evidence-based practice in the care of individuals with epilepsy, with the goal of improving seizures, side effects, and HRQOL.

Cluster reduction in patients in a pilot treatment trial for psychogenic nonepileptic seizures

INTRODUCTION

The present study examined seizure clusters as a primary outcome in patients receiving treatment for PNES. Cluster reduction is examined longitudinally using frequency threshold and statistical definitions of seizure cluster for patients. Possible risk factors for clustering will be examined along with clustering as a risk factor for poorer secondary outcomes.

METHODS

Participants were from a pilot randomized treatment trial for PNES where they received cognitive behavioral therapy-informed psychotherapy (CBT-ip), sertraline, combination therapy, or treatment as usual. Seizure data are from patients' seizure dairies.

RESULTS

Cluster reduction was observed for those receiving CBT-ip or combination treatment using all definitions of daily clusters and weekly clusters. No risk factors of clustering were observed. Those who were identified as having clusters during the trial had poorer secondary outcomes on several measures at baseline relative to those who were not identified as having clusters.

DISCUSSION

This is the first study known to the authors to not only examined seizure clusters as a primary outcome for those with PNES, but also the first study to suggest that CBT-ip and combination therapy may be effective in reducing the frequency of clusters.