Supplementary motor seizures mimicking pseudoseizures: some clinical differences

Long-term Home Video EEG for Recording Clinical Events

SUMMARY

Around 50 years after the first EEG acquisition by Hans Berger, its use in ambulatory setting was demonstrated. Ever since, ambulatory EEG has been widely available and routinely used in the United States (and to a lesser extent in Europe) for diagnosis and management of patients with epilepsy. This technology alone cannot help with semiological characterization, and absence of video is one of its main drawbacks. Addition of video to ambulatory EEG potentially improves diagnostic yield and opens new aspects of utility for better characterization of patient's events, including differential diagnosis, classification, and quantification of seizure burden. Studies evaluating quality of ambulatory video EEG (aVEEG) suggest good quality recordings are feasible. In the utilization of aVEEG, to maximize yield, it is important to consider pretest probability. Having clear pretest questions and a strong index of suspicion for focal, generalized convulsive or non-epileptic seizures further increases the usefulness of aVEEG. In this article, which is part of the topical issue "Ambulatory EEG," the authors compare long-term home aVEEG to inpatient video EEG monitoring, discuss aVEEG's use in diagnosis and follow-up of patients, and present the authors' own experience of the utility of aVEEG in a teaching hospital setting.

Clinical differentiation of psychogenic non-epileptic seizure: a practical diagnostic approach

Background

Psychogenic non-epileptic seizure (PNES) has long been the counterpart of epileptic seizure (ES). Despite ample of evidence differentiating the two, PNES mistakenly diagnosed as ES was still common, resulting in unnecessary exposure to long-term antiepileptic medications and reduced patient’s and caregiver’s quality of life, not to mention the burgeoning financial costs.

Objectives

In this review, we aimed to elucidate various differences between PNES and epileptic seizure with respect to baseline characteristics, seizure semiology, EEG pattern, and other key hallmark features.

Methods

An unstructured search was carried out in PubMed, MEDLINE, and EMBASE using keywords pertinent to PNES and ES differentiation. Relevant information was subsequently summarized herein.

Results

PNES differs significantly with ES in terms of baseline characteristics, prodromal symptoms, seizure semiology, presence of pseudosleep, and other hallmark features (for instance provoking seizure with suggestion). The combined approach, if applied appropriately, can yield high diagnostic yield.

Conclusions

PNES can be clearly differentiated from ES via careful adherence to a set of valid clinical cues. The summarized clinical hallmarks is highly useful to prevent unnecessary ES diagnosis and treatment with AEDs.

Focal bilateral motor seizures precipitated by abrupt cessation of chronic lormetazepam abuse and amitriptyline overdose

We report the case of an adult psychiatric patient who developed new-onset focal bilateral motor seizures (FBMS) in the context of a severe benzodiazepine withdrawal syndrome. The patient was forced to interrupt chronic lormetazepam abuse and overdosed on amitriptyline (800 mg in an oral solution) before the onset of seizures. Typical signs of amitriptyline intoxication such as sedation and anticholinergic effects were not observed. Video-EEG recordings revealed a stereotypical ictal motor pattern with asymmetric tonic posturing and bilateral clonic movements of the upper limbs, but there were no abnormalities identified by EEG. Seizures recurred multiple times per day but resolved simultaneously when withdrawal symptomatology subsided eight days after onset. Nonepileptic seizures (NES) were considered in the differential diagnosis because of the patient's psychiatric history including preserved awareness during the bilateral convulsions, the absence of postictal confusion, and normal EEG. The present case indicates that FBMS may occur during benzodiazepine withdrawal in patients who overdosed on amitriptyline. The diagnosis may be challenging as FBMS may mimic NES in the absence of abnormal neurophysiologic findings. This may be especially challenging in patients with an underlying psychiatric disease.

Interaction of Temporal Lobe Epilepsy and Posttraumatic Stress Disorder: Network Analysis of a Single Case

In this case study, we present a 21 years old female with long-standing Temporal Lobe Epilepsy (TLE) who, following a sexual assault, also developed Posttraumatic Stress Disorder (PTSD), leading to a change in her seizure semiology. The new seizures seemed to be a re-enactment of the sexual assault and accordingly were at first thought to be Psychogenic Non-Epileptic Seizures (PNES). Nevertheless, electroencephalography (EEG) recording at the Epilepsy Monitoring Unit (EMU) revealed ictal epileptic brain activity during these new attacks. In order to further explore the nature of the relation between epileptic seizures and PTSD symptomatology, a functional MRI (fMRI) scan was conducted focusing on neural response to threat (fearful faces). The results indicated that the response to threat elicited bilateral amygdala activation, as well as enhanced amygdala connectivity with the insula and anterior cingulate cortex (ACC), all central nodes of the fear circuitry. Accordingly, we suggest that this unique presentation of "pseudo" PNES might stem from the anatomical proximity of the epileptic network in this patient (temporal-insular-frontal) to the fear circuitry, allowing abnormal epileptic activity to "exploit" or activate the fear circuit or vice versa. We further propose that the traumatic experience may have changed the patient's ictal semiology by modifying the course of the spread of the ictal activity toward the PTSD network.

How reliable is ictal duration to differentiate psychogenic nonepileptic seizures from epileptic seizures?

We sought to investigate (1) differences in ictal duration between psychogenic nonepileptic seizures (PNES) and epileptic seizures (ES), (2) the odds of being PNES when seizures last ≥5min, and (3) the value of ictal duration as a diagnostic test to differentiate PNES from ES. We retrospectively reviewed video-EEG recordings and tabulated ictal durations of all PNES and ES. We estimated the mean ictal durations of PNES and ES using linear mixed models. The odds of being PNES when seizures last ≥5min were estimated using logistic regression. We used receiver operating characteristics (ROC) curves to study the overall diagnostic accuracy of ictal duration in differentiating PNES from ES. We studied 441 ES and 341 PNES recorded from 138 patients. The mean ictal duration of PNES (148.7s, 95% CI: 115.2-191.8) was significantly longer (p<0.001) than that of ES (47.7s, 95% CI: 37.6-60.6). The odds of being PNES was about 24 times higher (Odds ratio: 23.8, 95% CI: 7.9-71.3) when the ictal duration was ≥5min. The ROC curve yielded an area under the curve of 0.80 (95% CI 0.73-0.88). Youden's index identified 123.5s as the optimal threshold to diagnose PNES with 65% sensitivity and 93% specificity. Our results indicate that ictal duration is a useful test to raise suspicion of PNES. When a seizure lasts ≥5min, it is 24 times more likely to be PNES with the potential risk of misdiagnosis as status epilepticus.

Treating Pseudoseizures and Related Behaviors in an Adult Male with an Intractable Seizure Disorder

AD, a 42-year-old male diagnosed with an intractable seizure disorder, profound mental retardation, and numerous medical diagnoses, manifested pseudoseizures and related behaviors. To reduce the frequency of these behaviors, treatment procedures were developed and implemented. In conjunction with direct care staff members, target behaviors were identified and defined: pseudoseizures, falling, and sliding from chair. The behavioral treatment applied combined antecedent control and a progressive intervention approach using verbal cueing, visually checking, tactile attention, and edible reinforcement. Data collection occurred over an 18-month period. Results show an increase in the number of days occurring without charted behaviors within consecutive 28-day reporting periods. Data collection consisted of 7,068 observations of AD's behaviors. This allowed correlations to be conducted with significant correlations existing between pseudoseizures and falling ( r = .59) and chair sliding and positive observations ( r = —.63). t tests were computed resulting in significant differences between AD's target behaviors and pseudoseizures.

Psychogenic nonepileptic seizures: EEG and investigation

In the investigation of psychogenic nonepileptic seizures (PNES), the main differential diagnoses are between convulsive PNES and tonic-clonic seizures, between swoon PNES and syncope, and between pseudoabsence PNES and absence seizures. For the best diagnostic certainty, events must be captured, ideally using video-electroencephalogram (EEG), including an electrocardiographic channel. The "video" part of video-EEG allows EEG changes (or lack of them) to be interpreted in the appropriate clinical context. When the diagnosis is based on less good data (e.g., video alone or EEG alone), then the limitations and constraints of the tests should borne in mind, and a lesser degree of certainty must be accepted. Tests such as serum prolactin (PRL) level and postictal EEG should be regarded as adjunctive rather than definitive. Excluding additional epilepsy with a good probability is not possible using investigations alone. In particular, one standard interictal EEG recording is of little value in excluding additional epilepsy, though multiple or prolonged recordings may offer additional sensitivity.

[French guidelines on electroencephalogram]

Electroencephalography allows the functional analysis of electrical brain cortical activity and is the gold standard for analyzing electrophysiological processes involved in epilepsy but also in several other dysfunctions of the central nervous system. Morphological imaging yields complementary data, yet it cannot replace the essential functional analysis tool that is EEG. Furthermore, EEG has the great advantage of being non-invasive, easy to perform and allows control tests when follow-up is necessary, even at the patient's bedside. Faced with the advances in knowledge, techniques and indications, the Société de Neurophysiologie Clinique de Langue Française (SNCLF) and the Ligue Française Contre l'Épilepsie (LFCE) found it necessary to provide an update on EEG recommendations. This article will review the methodology applied to this work, refine the various topics detailed in the following chapters. It will go over the summary of recommendations for each of these chapters and underline proposals for writing an EEG report. Some questions could not be answered by the review of the literature; in those cases, an expert advice was given by the working and reading groups in addition to the guidelines.

Nonepileptic behavioral disorders: diagnosis and treatment

PURPOSE OF REVIEW

This article will review the important steps in making an accurate diagnosis of psychogenic nonepileptic events or episodes (PNEE), and recent developments in diagnosis and treatment.

RECENT FINDINGS

Several clues can be obtained from the history to help the clinician suspect the diagnosis of PNEE. While none of these clues are diagnostic on their own, each is valuable, and there are often multiple clues in a given patient. Clinical clues have limitations, and once PNEE is suspected, video-EEG monitoring remains the gold standard and the only way to make a definite diagnosis of PNEE. Like most tests, video EEG has its limitations, but in most cases the diagnosis can be made and is not difficult. Regarding treatment, growing evidence exists that psychotherapy, especially cognitive behavior therapy, is effective, and a recent finding is that pharmacotherapy may have a role.

SUMMARY

The diagnosis of PNEE can be made reliably, but the management of PNEE remains problematic, in large part because of the insufficient involvement of mental health professionals.

Clinical profile of psychogenic non-epileptic seizures in adults: A study of 63 cases

AIMS

To evaluate clinical profile and short-term outcome of psychogenic non-epileptic seizures (PNES) in Indian adult population.

SETTING AND DESIGN

A prospective observational study, conducted at tertiary teaching institute at New Delhi.

MATERIALS AND METHODS

Sixty-three patients with confirmed PNES were enrolled. The diagnosis was based on witnessing the event during video-electroencephalography (Video-EEG) monitoring. A detailed clinical evaluation was done including evaluation for coexistent anxiety or depressive disorders. Patients were divided into two groups on the basis of excessive or paucity of movements during PNES attacks. Patients were followed-up to 12 months for their PNES frequency.

STATISTICAL ANALYSIS

Means and standard deviations were calculated for continuous variables. Chi-square and Students t-test were used to compare categorical and continuous variables respectively.

RESULTS

The mean age at onset of PNES was 25.44 years; with F:M ratio of 9.5:1. Coexistent epilepsy was present in 13 (20.63%) cases. Twenty-two patients (44%) with only PNES (n = 50) had received antiepileptic drugs. Out of 63 patients of PNES 24 (38.1%) had predominant motor phenomenon, whereas 39 (61.9%) had limp attacks. The common features observed were pre-ictal headache, ictal eye closure, jaw clenching, resistant behavior, ictal weeping, ictal vocalization, and unresponsiveness during episodes. Comorbid anxiety and depressive disorders was seen in 62.3% and 90.16% patients, respectively. Short-term (6-12 months) outcome of 45 patients was good (seizure freedom in 46.66% and >50% improvement in 24.44% cases).

CONCLUSION

PNES is common, but frequently misdiagnosed and treated as epileptic seizures. A high index of suspicion is required for an early diagnosis. Proper disclosure of diagnosis and management of the psychiatric comorbidities can improve their outcome.

LIMITATION

Limited sample size and change in seizures frequency as the only parameter for the assessment of the outcome are the two major limitations of our study.

Psychogenic nonepileptic seizures

Treatment for PNES must be individualized. A combination of approaches is probably the most beneficial for improvement. Treatment should not simply emphasize removing maladaptive PNES behaviour, but should also focus on learning new coping skills and removing secondary gains. If PNES persist, therapy should be re-evaluated.

Ictal characteristics of psychogenic nonepileptic seizures: what we have learned from video/EEG recordings--a literature review

Psychogenic nonepileptic seizures (PNES) are highly prevalent in selected populations, with a strong impact in terms of morbidity and social cost. The gold standard for PNES diagnosis is video/EEG recording of a typical attack. However this technique is costly and not always available. In addition, many patients are treated with antiepileptic drugs for several years before undergoing video/EEG recording. The diagnosis is further complicated by concomitant epileptic seizures in some patients with PNES. Therefore, a good knowledge of PNES semiology is important for early screening of patients for video/EEG recording and for correct interpretation of the examination. We reviewed the literature on video/EEG studies reporting ictal PNES semiology to identify features indicative of psychogenic or epileptic seizures. Several features appeared to be useful in the clinical setting.

Quantitative movement analysis differentiates focal seizures characterized by automatisms

The analysis of epileptic seizures is typically performed by visual inspection, limited by interrater variation. Our aim was to differentiate seizures characterized by automatisms with an objective, quantitative movement analysis. In part 1 of this study we found parameters (extent and speed of movement of the wrist and trunk) separating seizures with predominant proximal (hyperkinetic, n=10) and distal (automotor, n=10) limb automatisms (P<0.002). For each movement parameter we used the lowest value recorded for a hyperkinetic seizure in part 1 as the cutoff parameter in part 2 on a consecutive sample of 100 motor seizures. As in part 1, the difference between hyperkinetic and non-hyperkinetic seizures was highly significant (<0.001). When all movement parameters were above the threshold, a hyperkinetic seizure was identified with a probability of 80.8%, but the probability for a non-hyperkinetic seizure to have all parameters above the threshold was only 0.02%.

Post-ictal alpha activity in supplementary motor seizures mimics nonepileptic seizures

Supplementary motor area seizures may present with bilateral tonic-clonic movements with no loss of consciousness and no postictal confusion, and patients may be erroneously thought to have psychogenic nonepileptic seizures. We describe the rapid emergence of alpha activity in the immediate postictal period in patients with supplementary motor area seizures as an additional confounding factor that may lead to the erroneous diagnosis of nonepileptic seizures in these patients. We present two cases of patients with intractable supplementary motor area seizures investigated with video/EEG monitoring. Their postictal EEG records revealed an immediate postictal recovery of alpha activity, mimicking the pattern seen with psychogenic nonepileptic seizures. Prolonged video/EEG monitoring is mandatory in establishing the diagnosis of supplementary motor area seizures and in distinguishing this condition from nonepileptic seizures.

Semiology of epileptic seizures: a critical review

Epileptic seizures are characterized by a variety of symptoms. Their typical semiology served for a long time as the major tool to classify epilepsy syndromes. The signs and symptoms of epileptic seizures include the following spheres: sensorial sphere, consciousness, motor and autonomic spheres. Most seizures involve more than one sphere, however, some like for instance aura (sensorial sphere) or dialeptic seizures (consciousness) involve only one sphere. The predominant clinical features of a seizure determines the seizure classification. The following review gives an introduction into the semiological seizure classification. This approach enables us to better identify the epileptogenic zone of our patients and to choose the most effective medical or surgical treatment.

The differential diagnosis of epilepsy: a critical review

The wrong diagnosis of epilepsy is common. At referral epilepsy centers, psychogenic non-epileptic attacks are by far the most common condition found to have been misdiagnosed as epilepsy, with an average delay of 7-10 years. There are many "red flags" that can raise the suspicion of psychogenic non-epileptic attacks. Syncope is the second most common condition misdiagnosed as epilepsy, and it is probably more common in outpatient populations. Other conditions more rarely misdiagnosed as epilepsy include hypoglycemia, panic attacks, paroxysmal movement disorders, paroxysmal sleep disorders, TIAs, migraines, and TGA. Conditions specific to children include nonepileptic staring spells, breath-holding spells, and shudder attacks. At all ages, the over-interpretation of EEGs plays an important part in the misdiagnosis of epilepsy.

Psychogenic nonepileptic seizures

PURPOSE OF REVIEW

This review summarizes the recent studies assessing patients with psychogenic nonepileptic seizures and developments in treatment.

RECENT FINDINGS

The misdiagnosis of nonepileptic seizure is costly to patients, the healthcare system, and to society. Patients with nonepileptic seizures are prescribed antiepileptic drugs that do not treat nonepileptic seizures, have multiple laboratory tests performed, and may not receive the necessary mental healthcare that could benefit them.The first step in nonepileptic seizure treatment is proper diagnosis. Video electroencephalography remains the gold standard for nonepileptic seizure diagnosis. Certain seizure types, such as frontal lobe seizures, may mimic nonepileptic seizure semiology. Bedside observations may augment video electroencephalography to establish nonepileptic seizure diagnosis. The methodology in nonepileptic seizure treatment trials is examined, describing the challenges in conducting clinical trials with patients with overlapping neurologic and psychiatric disorders. Finally, realizing that nonepileptic seizures are in a spectrum of somatoform disorders, diagnostic literature is reviewed in other conversion disorders.

SUMMARY

Nonepileptic seizure patients remain one of the most challenging populations to diagnose and treat in medical practice. Clinical findings and laboratory advances exist that more clearly establish the diagnosis of nonepileptic seizures. With the appropriate diagnosis, neurologists and mental health providers are better equipped to treat the underlying causes of nonepileptic seizures.

The EEG in Nonepileptic Seizures

Nonepileptic seizures are episodes that resemble seizures but are not epileptic. The importance of EEG in the diagnosis of NES is that misread (overread) EEGs are an important contributor to the misdiagnosis of epilepsy. About 20% to 30% of patients with refractory "seizures" seen at epilepsy centers have been misdiagnosed, and the vast majority have psychogenic nonepileptic seizures (PNES). Many such patients have had previous EEGs interpreted as epileptiform. These misdiagnoses based on EEG are easily perpetuated, complicate management, and adversely affect outcome. The reasons for the overinterpretation of EEGs include the common misconception that phase reversals indicate abnormalities and not applying strict criteria to make sharp transients epileptiform. The diagnosis of PNES typically begins with a clinical suspicion and then is confirmed with EEG-video monitoring. However, ictal EEG may be negative in some partial seizures and may be uninterpretable because of artifacts. Movements can generate rhythmic artifacts that mimic an electrographic seizure. Analysis of the ictal semiology (i.e., video) is at least as important as the ictal EEG. Provocative techniques, activation procedures, or "inductions" can also be useful for the diagnosis of PNES.

Psychiatric disorders in patients with psychogenic non-epileptic seizures, with and without comorbid epilepsy

PURPOSE

The aim of this study is to describe similarities and differences in epidemiological, psychiatric and semiologic variables between patients with psychogenic none epileptic seizures (PNES) and comorbid epilepsy (mixed PNES), and patients with PNES without comorbid epilepsy (pure PNES).

RESULTS

Forty-three patients with PNES diagnosed by Video-EEG were included. Twenty-four had pure PNES, and ninteen mixed PNES. Female population, age, duration of PNES, psychiatric institutionalization, psychopharmacotherapy, dissociative disorders and posttraumatic stress disorder (PTSD), were significantly higher in the pure PNES patients. Suicide attempts, antiepileptic therapy, conversive, affective and personality disorders were frequent in both groups. In the analysis of seizure semiology, the total lack of responsiveness was significantly higher in the mixed PNES group.

CONCLUSIONS

Pure PNES patients showed similarities and differences in the psychiatric profile, with a greater prevalence of dissociative disorders and PTSD, factors related to psychiatric severity.

Sleep and epilepsy

This article examines the relationship between sleep and epilepsy, an association that has been recognized since antiquity. The mechanisms whereby sleep facilitates seizures are under investigation, although the synchronizing role of thalamocortic networks seems contributory. Recognition of the variety of generalized and partial epileptic syndromes associated with sleep, familiarity with the differential diagnosis of nocturnal spells, and awareness of the role that antiepileptic drugs and sleep disorders may play in epilepsy are helpful in evaluating patients presenting with behavioral and motor disturbances of sleep.

Frontal lobe seizures

Despite the fact that clinical characteristics of frontal lobe seizures have been recently described better, differentiating seizures of frontal lobe origin from NES on clinical grounds alone is difficult. The difficulty has been compounded by the fact that both inter-ictal and ictal EEG can be normal or nonspecific, and the same is true of imaging studies. A detailed clinical history as well as video monitoring can be helpful diagnostic tools. A multidisciplinary approach is warranted and is at times essential to improve the diagnosis and care of these difficult patients.

Propagation of tonic posturing in supplementary motor area (SMA) seizures

We analyzed ictal motor symptoms in 10 patients diagnosed to have supplementary motor area (SMA) seizures based on ictal encephalographic (EEG) findings and ictal clinical semiology. Inclusion criteria were (1) EEG seizure pattern in the vertex for the scalp recording or in the area over and/or adjacent to SMA for epicortical recording and (2) ictal motor semiology characterized, as previously reported, by sudden and a brief tonic posturing of extremities and trunk mainly occurring during sleep without loss of consciousness. In 50% (5/10) of the patients, tonic posturing began in one part of the body and moved to other part(s) in 5-10s. Unlike Jacksonian march seen in seizures involving the primary sensorimotor area (S1-M1), it spread in no accordance with the somatotopy in S1-M1. The sequential propagation of tonic posturing may represent the somatotopic organization within the SMA proper.

Pseudosleep events in patients with psychogenic non-epileptic seizures: prevalence and associations

OBJECTIVES

To determine the prevalence and clinical associations of a history of events during sleep in patients with psychogenic non-epileptic seizures (PNES, pseudoseizures), and to compare the prevalence of a history of sleep events with that in poorly controlled epilepsy.

METHODS

Prospective study by semistructured interview of the history of event patterns and their clinical associations in 142 patients with video EEG confirmed PNES, and 100 patients with poorly controlled epilepsy.

RESULTS

84/142 patients with PNES (59%) and 47/100 with epilepsy (47%) gave a history of events during sleep (p = 0.062). In patients with PNES, significant associations were found between a history of sleep events and: convulsive clinical semiology, antiepileptic drug treatment, fatigue, suicide attempts, mood disorder, and physical abuse. A particularly strong association with social security benefit was also found (odds ratio 4.0, p<0.001).

CONCLUSIONS

The prevalence of a history of sleep events is similar in PNES and epilepsy, and is of no value in discriminating between the two, although a history of events occurring exclusively during sleep does suggest epileptic seizures. The clinical associations found indicate that a combination of psychopathological and external influences may be important in determining whether or not a patient with PNES gives a history of events during sleep.

[Prolonged vídeo-EEG monitoring in nonepileptic seizures: clinical semiology]

The purpose of this study was to point out the effectiveness of prolonged video EEG monitoring (PVEM) in the diagnosis of nonepileptic seizures (NES) as well as to estimate its prevalence in a reference center of epilepsy (EP). A sample of 47 patients with the diagnosis of NES with spontaneous or provoked seizures was observed. A protocol with the clinical history and semiology of seizures was analyzed; Fisher's exact test and cluster analysis were used for statistical observation. The results showed a prevalence of 10% of NES; more prevalence in females (63.8%); the crises were spontaneous in 57% of the patients. The mean age was 32.5 +/- 11 years and the most frequent semiological sign was apparent sleep (82.2%). Either EP or NES was observed in 9% of the patients. There were three groups according to the cluster analysis: hypermotor NES of the extremities with tonus alteration; NES with automatism; and axial NES with eye movements. In conclusion, the study of clinical semiology of NES during the PVEM provides both this nosological entity and the differential EP diagnoses while the provocative test helps to obtain the seizures.

Seizure disorders, depression, and health-related quality of life

Disease and mood states are important determinants of quality of life (QOL). Low QOL, due to mood states, can be expected especially in psychiatric disorders such as depression. However, patients with seizure disorders may be even more affected because of the combined burden of physical episodes, psychiatric comorbidities, and psychosocial factors (e.g., stigma). In this study, we compare the quality of life in seizure disorders and clinical depression. Based on our earlier findings, we hypothesize that epilepsy patients fare better than patients with psychogenic, nonepileptic seizures (PNES), and we speculate that QOL in PNES is also lower relative to clinical depression. We estimate the relationships between type of seizures (epilepsy vs PNES), depression, and QOL (SF-36) using multiple regression, and we compare the SF-36 scores of patients with epilepsy and PNES (n=194) with the normative data for clinical depression using one-sample t tests. Our findings indicate that depression contributes to the poor QOL in both epilepsy and PNES, but the patients with PNES, even those without depression, have worse QOL compared with both the epilepsy patients and the depression norms. We conclude that evaluating and treating mood states is as important as treating PNES itself when caring for patients with PNES, and it might be the first step toward improving their QOL.

Controversies in the diagnosis and management of psychogenic pseudoseizures

Since the advent of video-EEG telemetry studies (V-EEG) neurologists have become increasingly aware of psychogenic pseudoseizures (PPS) given the relatively high prevalence of these events among patients seen in epilepsy centers. The use of V-EEG has been accepted as the gold standard study in establishing this diagnosis; some clinicians, however, have suggested that the clinical phenomena of PPS are so obvious in many patients that V-EEG may not be necessary. This is one of many controversial points that clinicians face when evaluating patients suspected of having PPS. In this article, we review some of these controversies, specifically the need for a video-EEG monitoring study in all patients suspected of having PPS and the role of induction protocols in the evaluation of PPS, the question of whether patients have any control over their events, and finally some of the therapeutic strategies for PPS including the need to limit these patients' driving privileges.

Psychogenic nonepileptic seizures: review and update

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

New horizons in ambulatory electroencephalography

Since its inception 30 years ago, AEEG has continued to evolve--from four-channel tape recorders to 32-channel digital recorders with sophisticated automatic spike and seizure detection algorithms. AEEG remains an important tool in epilepsy evaluation. In the near future, smaller, faster, and more sophisticated AEEGs will be developed. Seizure detection/anticipation systems will allow the wearer to be forewarned of a seizure so that appropriate safety measures can be taken. With further refinement in our understanding of nonlinear dynamic analysis to define the pre-ictal state, AEEG will be coupled with an accurate seizure anticipation device in a closed-loop system, providing a time window during which therapeutic intervention can occur, to prevent a seizure. The therapeutic intervention will most likely involve vagus nerve or deep brain stimulation. An alternative is that the patient may learn to recognize early symptoms of the pre-ictal state and use behavioral biofeedback interventions to avoid a clinical seizure. In order to achieve convenient ambulatory recording and seizure detection that could realistically improve the lives of patients with refractory epilepsy, the process of miniaturization of such a device to a convenient size must be accomplished. One of the aspects of epilepsy that patients find most frustrating, and that most limits activities, is the vulnerability to sudden unexpected incapacitation due to the occurrence of a seizure. With miniaturization of AEEG and seizure anticipation technology, and advancements in our ability to identify the transition from pre-ictal to ictal state, there is realistic hope that patients with refractory epilepsy may gain control over their seizures and enjoy significantly improved quality of life.

Psychogenic, nonepileptic seizures associated with video-EEG-verified sleep

PURPOSE

Nonepileptic seizures (NES) are expressions of a psychiatric disease state, usually conversion disorder, that mimic epileptic seizures (ES) but are not associated with the neurophysiologic changes of epilepsy. Conversion has not been demonstrated to emerge from the sleeping state. Emergence out of sleep is usually considered a virtual exclusion criterion for NES, signifying the presence instead of ES. We sought to test this hypothesis.

METHODS

We retrospectively reviewed the video-EEG of all patients admitted to our epilepsy unit over a 3-year period, who were suspected of manifesting NES. We examined the relation between NES and the patients' sleep/wake state in this cohort. Two epileptologists blindly reviewed an intermixture of cases suspected to represent NES emerging out of sleep, together with control cases. Classification of each case was made independently.

RESULTS

We found that in a small minority of patients (<1%), NES began either while the patient was sleeping, or within several seconds of arousal, well before a plan to simulate a seizure could likely have been formulated in the wakeful state.

CONCLUSIONS

In some cases, NES are not the product of the awake mind, but rather represent a psychiatric condition that can be manifest in sleep.

A review of diagnostic techniques in the differential diagnosis of epileptic and nonepileptic seizures

The diagnosis of psychogenic nonepileptic seizures (PNES) is complex. Long-term electroencephalogram monitoring with video recording (video EEG) is the most common method of differential diagnosis of epilepsy and PNES. However, video EEG is complex, costly, and unavailable in some areas. Thus, alternative diagnostic techniques have been studied in the search for a diagnostic method that is as accurate as video EEG, but more cost effective, convenient, and readily available. This paper reviews the literature regarding possible diagnostic alternatives and organizes findings into 7 areas of study: demographic and medical history variables, seizure semiology, provocative testing, prolactin levels, single photon emission computed tomography, psychological testing, and neuropsychological testing. For each area, the literature is summarized, and conclusions about the accuracy of the technique as a diagnostic tool are drawn. Overall, it appears unlikely that any of the reviewed alternative techniques will replace video EEG monitoring; rather they may be more successful as complementary diagnostic tools. An important focus for further investigations involves combinations of diagnostic techniques for the differential diagnosis of epilepsy and PNES.

Sleep disorders in children with neurologic diseases

Pediatric neurologic diseases are often associated with different kinds of sleep disruption (mainly insomnia, less frequently hypersomnia or parasomnias). Due to the key-role of sleep for development, the effort to ameliorate sleep patterns in these children could have important prognostic benefits. Study of sleep architecture and organization in neurologic disorders could lead to a better comprehension of the pathogenesis and a better treatment of the disorders. This article focuses on the following specific neurologic diseases: nocturnal frontal lobe epilepsy and abnormal motor behaviors of epileptic origin, evaluating differential diagnosis with parasomnias; achondroplasia, confirming the crucial role of craniofacial deformity in determining sleep-disordered breathing; neuromuscular diseases, mainly Duchenne's muscular dystrophy and myotonic dystrophy; cerebral palsy, evaluating either the features of sleep architecture and the importance of the respiratory problems associated; headaches, confirming the strict relationships with sleep in terms of neurochemical and neurobehavioral substrates; and finally a review on the effectiveness of melatonin for sleep problems in children with neurologic syndromes and mental retardation, blindness, and epilepsy.

Evaluation of the accuracy of seizure descriptions by the relatives of patients with epilepsy

The descriptions of seizures by witnesses are important in the diagnosis and classification of epileptic seizures. The aim of the study was to evaluate the accuracy of this information obtained from relatives of patients with epileptic and non-epileptic attacks. Thirty patients with epileptic or non-epileptic attacks had seizures videorecorded whilst inpatients at the Assessment and Treatment Centre of the National Society for Epilepsy and the National Hospital for Neurology and Neurosurgery, Chalfont, Buckinghamshire, UK. A relative or close friend of each patient viewed the recording and subsequently completed a structured questionnaire, testing recall of 15 separate elements of the episode. This account was compared to a definitive evaluation completed by medical staff. An accuracy of describing seizures was therefore obtained. Our results showed that there was a wide variation in the accuracy of recall with convulsive episodes described less well than non-convulsive (median accuracies 44.5 and 70%, respectively, P<0.05). Attacks in which the diagnosis had been changed, following admission, from the one obtained on history alone were particularly inaccurately described (median accuracy 26%). Elements of the questionnaire that were most inaccurately recalled were description of limb movement and post-ictal behaviour. Those most accurately described were facial appearance and vocalization. Features only present in non-epileptic attacks included reactivity to eyelash stimulation, opisthotonic posturing, flailing or protective limb movements. In conclusion, our results confirm that inaccuracy exists when witnesses describe attacks and that this may lead to errors in diagnosis and subsequent treatment.

A unique effect of clonazepam on frontal lobe seizure control

In a 16-year-old female, clonazepam (CZP) changed randomly occurring intractable tonic seizures of frontal lobe origin to a few sleep seizures when used as an adjunctive therapy. The significance of this change in the seizure pattern is discussed with an explanation of possible pathophysiologic mechanism.

A comprehensive profile of clinical, psychiatric, and psychosocial characteristics of patients with psychogenic nonepileptic seizures

PURPOSE

To attain a comprehensive profile of clinical, psychiatric and psychosocial characteristics of patients with psychogenic nonepileptic seizures (NESs), and to assess the relation of these factors to NES outcome.

METHODS

We administered a telephone-based structured questionnaire to 56 patients with NESs (16 male and 40 female patients; mean age, 35 years) at a mean follow-up time of 18 months after making the diagnosis of NES.

RESULTS

Mean age of NES onset was 28 years with a mean duration of 8 years. Episodes resolved in 29 (51.8%) cases, decreased in 24 (42.9%), persisted unchanged in two (3.6%), and increased in frequency in one (1.8%). Thirty (53.6%) patients, including 13 (44.8%) of patients whose NESs resolved, were rehospitalized for NESs or for other symptoms. Twenty-nine (51.8%) had significant depressive symptoms, 22 (39.3%) had suicidal ideation, and 11 (19.6%) attempted suicide [including 6 (21%) of the patients whose NESs resolved]. Believing the NES diagnosis was associated with resolution or improvement of NES frequency (p<0.029), whereas anger in response to receiving the diagnosis did not predict a poorer outcome. Patients' perceptions of having good health (p<0.02) and good occupational functioning (p<0.04) were highly correlated with NES resolution. Only patients whose episodes resolved were employed at the time of follow-up.

CONCLUSIONS

At a mean of 1.5 years, NES outcome was poor, with resolution in only half the group and with frequent rehospitalizations after NES diagnosis, even among patients whose NES resolved. Depressive symptoms, suicidal ideation, and suicide attempts were common. Believing the NES diagnosis and patient perceptions of having good health and good occupational functioning correlated well with NES resolution.

Are we overusing the diagnosis of psychogenic non-epileptic events?

In order to determine how often results of video/EEG (V-EEG) studies may change the clinical diagnosis of paroxysmal events, we prospectively studied 100 consecutive patients (75 females, 25 males) admitted for diagnosis of recurrent paroxysmal spells. The presumed diagnosis of the referring physician was obtained. Episodes were classified as epileptic seizures (ES), psychogenic non-epileptic events (PNEE), or physiologic non-epileptic events (PhysNEE). Eighty-seven patients had diagnostic events. A final diagnosis of ES was made in 21 patients, PNEE in 39, PNEE + ES in 20, and PhysNEE in seven. All PhysNEE were unsuspected. ES were misdiagnosed as PNEE more frequently than the reverse (57% vs. 12%, P < 0.001). Among the 64 patients with recorded events who had been suspected of having PNEE, 14 (21.9%) were misdiagnosed: two had PhysNEE and 12 (18.75%) had ES. Among the 23 patients with recorded events who were thought to have ES, 12 (39.1%) were misdiagnosed: seven had PNEE, five PhysNEE. V-EEG changed the clinical diagnosis in 29.8% of the patients with recorded events. Our data suggests that clinicians have become more aware of PNEE since the advent of V-EEG and have little problem recognizing them. However, they may be more prone to make a false-positive diagnosis of PNEE in ES with some atypical features. At this point, efforts should be channeled to better training in the proper recognition of ES that mimic PNEE.

Mesial frontal epilepsy

The mesiofrontal cortex comprises a number of distinct anatomic and functional areas. Structural lesions and cortical dysgenesis are recognized causes of mesial frontal epilepsy, but a specific gene defect may also be important, as seen in some forms of familial frontal lobe epilepsy. The predominant seizure manifestations, which are not necessarily strictly correlated with a specific ictal onset zone, are absence, hypermotor, and postural tonic seizures. Other seizure types also occur. The task of localization of the epileptogenic zone can be challenging, whether EEG or imaging methods are used. Successful localization can lead to a rewarding outcome after epilepsy surgery, particularly in those with an imaged lesion.

Ictal behaviors during nonepileptic seizures differ in patients with temporal lobe interictal epileptiform EEG activity and patients without interictal epileptiform EEG abnormalities

PURPOSE

Ictal behaviors during psychogenic nonepileptic seizures (NES) vary considerably among individuals, and can closely resemble common semiologies of epileptic seizures (ES). We tested the hypothesis that behaviors during NES in patients who have temporal spikes would more closely resemble behaviors during ES in patients with temporal lobe epilepsy than would behaviors during NES in patients who do not have EEG spikes.

METHODS

We identified 20 patients who had interictal temporal EEG spikes and EEG-video recorded NES (Study Group), 133 patients with temporal EEG spikes and recorded ES, without NES (Epileptic Group), and 24 patients with recorded NES and no epileptiform EEG abnormalities, without ES (Nonepileptic Group).

RESULTS

The hypothesis was supported with regard to ictal motor behaviors. Motionless staring or complex automatisms occurred mainly during NES in the Study Group and during ES in the Epileptic Group. In contrast, convulsive movements or flaccid falls were most common during NES in the Nonepileptic Group. Duration of unresponsiveness was longer, and there were fewer postictal states in NES both in the Study and Nonepileptic Groups. Unresponsiveness was briefer and postictal states were more consistent in ES in the Epileptic Group, however.

CONCLUSIONS

Stereotyped motor activities during NES presumably represent learned behaviors. Processes underlying acquisition of ictal behaviors of NES probably differ in patients with interictal epileptiform EEG abnormalities compared to those without. Prior experiences and temporal lobe dysfunctions that are associated with epilepsy, and psychological characteristics that are unrelated to interictal epileptic dysfunctions, may determine ictal behaviors during NES.