Psychogenic non-epileptic seizures: so-called psychiatric comorbidity and underlying defense mechanisms

Psychogenic non-epileptic seizures in individuals with intellectual disability/borderline cognitive function: Characterization through a comparison study

PURPOSE

We set out to characterize psychogenic non-epileptic seizures (PNES) in individuals with either intellectual disability (ID) or borderline intellectual function (BIF) in comparison to those with normal cognitive function. We aimed to identify differences between the two groups to improve clinical management protocols.

METHODS

We conducted a retrospective, observational, single-center study. The medical records of individuals (aged ≥ 14 years) diagnosed with PNES, confirmed through video-electroencephalography (vEEG) at a specialized epilepsy center between January 2008 and December 2021, were reviewed. We restricted our study to individuals who underwent comprehensive neuropsychological evaluations. Furthermore, demographic, clinical, and neuropsychological data with potential prognostic indicators, alongside the reevaluation of vEEG recordings were studied. We compared two study groups based on intelligence quotient (IQ): individuals without ID (IQ≥85; n = 25) and those with either mild ID or BIF (n = 25).

RESULTS

No statistically significant clinical differences were observed between the two groups. Individuals with mild ID/BIF didn't show a longer diagnostic delay, and the prescription of inappropriate antiseizure medications (ASMs) was comparable in both cohorts. Most individuals with mild ID/BIF were treated with behavioral psychotherapeutic approaches with similar outcomes in both subgroups.

CONCLUSIONS

Individuals with mild ID/BIF and PNES don't differ in clinical management. Demographic and clinical data, as well as semiology, were comparable to those of individuals with normal cognitive function. Cognitive behavioral therapy (CBT) appears to be an effective treatment approach for individuals with and without mild ID/BIF. Further studies are needed to validate and ascertain their possible applicability in individuals with moderate/severe ID.

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

PURPOSE

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Effects of attachment styles, childhood traumas, and alexithymia in Turkish patients with epilepsy and functional seizures

INTRODUCTION

In this cross-sectional study, we used self-report scales to compare childhood traumas, attachment styles, and alexithymia among patients with functional seizures (FS) to patients with epilepsy and healthy controls. We also investigated risk factors associated with FS.

MATERIAL AND METHODS

A total of 44 patients with epilepsy, 14 patients with FS, and 25 healthy controls were included. All participants were over the age of 18 and were referred to the Baskent University Adana Epilepsy and Video-EEG Center. The patients underwent neurological examinations, brain MRIs, and video-EEG evaluations. Epileptic seizures were classified based on video EEG. The control group consisted of healthy individuals without neurological or psychiatric illness and a history of epileptic seizures or syncope. Beck Depression Inventory (BDI), Childhood Trauma Questionnaire (CTQ), Adult Attachment Scale (AAS), and Toronto Alexithymia Scale-20 (TAS-20) were applied to all participants.

RESULTS

Patients with FS had lower educational levels, higher rates of unemployment and single-marital status. The FS group had higher depression, childhood trauma, and alexithymia scores than the other groups. Furthermore, FS patients had a higher prevalence of avoidant attachment. The alexithymia and childhood trauma scores were both correlated with depression. Through the logistic regression analysis, childhood trauma scores and alexithymia were significant risk factors for FS.

CONCLUSION

The use of video-EEG for diagnosing FS can reduce the risk of misdiagnosis and inappropriate antiepileptic treatment. Psychiatric comorbidities, childhood traumas, and alexithymia are prevalent in patients with FS. Therefore, implementing a multidisciplinary treatment approach that addresses the psychological, medical, and social aspects of FS can significantly improve outcomes.

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Functional (psychogenic non-epileptic/dissociative) seizures: why and how?

Functional seizures (FS) known also as psychogenic non-epileptic seizures or dissociative seizures, present with ictal semiological manifestations, along with various comorbid neurological and psychological disorders. Terminology inconsistencies and discrepancies in nomenclatures of FS may reflect limitations in understanding the neuropsychiatric intricacies of this disorder. Psychological and neurobiological processes of FS are incompletely understood. Nevertheless, important advances have been made on underlying neuropsychopathophysiological mechanisms of FS. These advances provide valuable information about the underlying mechanisms of mind-body interactions. From this perspective, this narrative review summarises recent studies about aetiopathogenesis of FS at two levels: possible risk factors (why) and different aetiopathogenic models of FS (how). We divided possible risk factors for FS into three categories, namely neurobiological, psychological and cognitive risk factors. We also presented different models of FS based on psychological and neuroanatomical understanding, multilevel models and integrative understanding of FS. This work should help professionals to better understand current views on the multifactorial mechanisms involved in the development of FS. Shedding light on the different FS profiles in terms of aetiopathogenesis will help guide how best to direct therapy, based on these different underlying mechanisms.

Clinical physiologists' experiences of working with people with nonepileptic attack disorder: A qualitative study

OBJECTIVES

To explore the perspectives of clinical physiologists on working with patients with nonepileptic attack disorder (NEAD). Nonepileptic attack disorder is a medically unexplained symptom frequently encountered by clinical physiologists in the field of neurophysiology. Studies in healthcare professionals show that they often find patients with medically unexplained symptoms challenging, uncomfortable, and frustrating to interact with. Clinical physiologists spend a substantial amount of time with patients and are key to the assessment of the condition. It is not known how physiologists experience working with patients with NEAD.

METHODS

Semi-structured interviews were conducted with clinical physiologists who frequently work with these patients. Interviews were recorded, transcribed, and analyzed according to grounded theory methodology.

RESULTS

Twelve participants including current trainees and qualified clinical physiologists working in neurophysiology were interviewed for the study. Participants described the experience of working with people with NEAD as anxiety provoking and unpredictable. The sources of this anxiety were the nature of the psychological aspects of the condition, the need to preserve professional boundaries and a lack of preparedness to manage conversations about distress or the psychological factors impacting the NEAD.

CONCLUSIONS

There is a risk that patient care is compromised by the lack of preparation and skills training of physiologists.

PRACTICE IMPLICATIONS

Physiologists need further training in counseling skills to increase tolerance to emotionally laden content in patient accounts and knowledge of suitable referral routes.

Attachment style of patients diagnosed with psychogenic non-epileptic seizures at a tertiary Epilepsy Center in the Czech Republic

OBJECTIVE

Quality and type of early relationships with primary caregivers is considered one of the key factors in the etiopathogenesis of many mental disorders including depression, anxiety, and conversion disorders. This study focused on the type and quality of attachment style in adult patients with psychogenic non-epileptic seizures (PNES).

MATERIALS AND METHODS

We evaluated the demographic data and profiles of PNES patients (n = 262) and group of healthy volunteers (n = 51) measured by the Parental Bonding Inventory (PBI) and Experiences in Close Relationships (ECR) and Experiences in Close Relationships-Relationship Structure (ECR-RS).

RESULTS

Significant differences in measured values between the two groups were identified; specifically, differences in the caregiver style-father and mother overprotection (PBI) was higher in the PNES group. The most frequent type of attachment in PNES was type 2 (preoccupied). Correlations between the PBI and ECR results were also found.

CONCLUSION

This study highlighted certain attachment styles in patients with PNES and statistically significant differences between patients with PNES and a healthy sample. Some correlations between the results of the questionnaires with socio-demographic factors were found. The identification of specific patterns in attachment may be useful for further use in reaching a differential diagnosis and administering tailored psychotherapy of patients with PNES.

Combined Fainting and Psychogenic Non-epileptic Seizures as Significant Therapy Hurdles in Blood-Injury-Injection Phobia: A Mini-Review and Case Report

BACKGROUND

Anxiety disorders are the most frequent mental disorders. Among the different subtypes, specific phobias are the commonest. Due to the ongoing SARS-CoV-19 pandemic, blood-injury-injection phobia (BII) has gained wider attention in the context of large-scale vaccination campaigns and public health. In this BII phobia mini-review and case report, we describe the successful treatment of a severe BII phobia case with combined fainting and psychogenic non-epileptic seizures (PNES) and demonstrate the role of specialized outpatient care.

CASE REPORT

The patient was a 28-year-old woman. She suffered from intense fear and recurrent fainting with regard to needles, injections, injuries, and at the sight of blood since early childhood. Medical history revealed infrequent events suggestive of PNES following panic attacks after sustained exposure to phobic stimuli. Family history was positive for circulation problems and BII fears. Psychopathological evaluation confirmed BII phobia symptoms and diagnosis was made according to the DSM-5. The Multidimensional Blood/Injury Phobia Inventory short version (MBPI-K) revealed severe manifestation of the disease. Neurological examination was ordinary. Repeated electroencephalography detected no epileptic pattern. Cranial magnetic resonance imaging showed normal morphology. Treatment was carried out by a seasoned, multidisciplinary team. Cognitive behavior therapy and exposure were performed. Modification of standard treatment protocol was necessary due to hurdles posed by recurrent fainting and a severe panic-triggered dissociative PNES during in vivo exposure. Modification was implemented by limiting in vivo exposure intensity to moderate anxiety levels. In addition to applied muscle tension and ventilation techniques, increased psychoeducation, cognitive restructuring, and distress tolerance skills (e.g., ice pack, verbal self-instructions) were used to strengthen the patient's situational control during in vivo exposure. A total of 15 sessions were performed. Therapy success was proven by 83% reduction in MBPI-K rating, SARS-CoV-19 vaccination, and a blood draw without psychological assistance, fainting, or seizure.

CONCLUSION

Taken together, this case demonstrates the potential of and need for specialized outpatient care and individualized treatment for severe BII phobia patients in order to provide them the perspective to have necessary medical procedures done and get vaccinated.

Shame in patients with psychogenic nonepileptic seizure: A narrative review

Psychogenic Nonepileptic Seizures (PNES) have been linked to dysregulated emotions and arousal. However, the question which emotions may be most relevant has received much less attention. In this multidisciplinary narrative review, we argue that the self-conscious emotion of shame is likely to be of particular importance for PNES. We summarize current concepts of the development of shame processing and its relationship with other emotional states. We demonstrate the potential of acute shame to cause a sudden disruption of normal cognitive function and trigger powerful behavioral, cognitive, physiological and secondary emotional responses which closely resemble key components of PNES. These responses may lead to the development of shame avoidance strategies which can become disabling in themselves. We discuss how excessive shame proneness and shame dysregulation are linked to several psychopathologies often associated with PNES (including depression and PTSD) and how they may predispose to, precipitate and perpetuate PNES disorders, not least by interacting with stigma. We consider current knowledge of the neurobiological underpinnings of shame and PNES. We explore how shame could be the link between PNES and a heterogeneous range of possible etiological factors, and how it may link historical aversive experiences with individual PNES events occurring much later and without apparent external trigger. We argue that, in view of the potential direct links between shame and PNES, the well-documented associations of shame with common comorbidities of this seizure disorder and the well-characterized relationship between chronic shame and stigma, there is a compelling case to pay greater attention to shame in relation to PNES. Its role in the treatment of patients with PNES is discussed in a separate, linked review incorporating case vignettes to highlight the complex interactions of different but interlinked shame-related issues in individual patients.

Outcomes in the treatment of psychogenic nonepileptic seizures (PNES) with CBTip: Response in seizure frequency, depression, anxiety, and quality of life

RATIONALE

Psychogenic Nonepileptic Seizures (PNES) are seizure-like episodes without EEG abnormality, and are of psychological origin. Cognitive Behavioral Therapy (CBT), a type of psychological counseling, is known to be the best intervention to treat PNES and the underlying psychiatric symptoms. Yet, many remain untreated because of limited access to specialized counseling programs. In this study, first we intended to see if the positive outcomes of the CBTip can be replicated in our patient population using within-group comparison. We also aimed to examine the outcomes of patients who received a variable dose of treatment than the established treatment protocol.

METHOD

We obtained retrospective patient reported outcomes (PRO) data from patients treated with Cognitive Behavioral Therapy-informed psychotherapy (CBT-ip) from January 2015 to January 2020 in an outpatient tertiary care epilepsy center. The CBTip program is a 12-session intervention delivered weekly by a seizure counselor. Although the program comprises 12 sessions of treatment, we included patients who attended at least 7 sessions consistent with previous research that used a similar cutoff. We had a total of 160 patient PROs included in the analysis. Outcome variables including seizure frequency, depression, anxiety, and quality of life were examined using self-report outcome scores. Demographic and other clinical and psychosocial confounding variables were controlled.

RESULTS

In the first analysis in which we compared pre-treatment scores with 3-month posttreatment scores, there was no significant change in seizure frequency, depression, anxiety, and quality-of-life outcomes. In the second analysis when we compared pre- and posttreatment scores in patients who completed the treatment in longer than 3-month time, there were significant improvement in primary and secondary outcomes. For seizure frequency, 10 patients had data for "seizures per day in the last 6 months" and 5 participants (50%) improved by 50% or more in the number of seizures per day. There were also significant reductions in depression and anxiety scores but not in quality of life.

IMPLICATION AND CONCLUSIONS

Our analysis showed that patients treated with CBTip with a minimum of 7 sessions in 3 months did not have significant improvement. However, attending at least 7 sessions of CBTip in longer than 3 months was effective for seizure control, depression, and anxiety. The observational and exploratory nature of our study, however, limits the generalizability of our findings outside of the single tertiary clinical care setting.

Effective connectivity between emotional and motor brain regions in people with psychogenic nonepileptic seizures (PNES)

OBJECTIVE

To characterize the effective connectivity (EC) between the emotion and motor brain regions in patients with psychogenic nonepileptic seizures (PNES), based on resting-state spectral dynamic causal modeling (spDCM).

METHODS

Twenty-three patients with PNES and twenty-five healthy control (HC) subjects underwent resting-state fMRI scanning. The coupling parameters indicating the causal interactions between eight brain regions associated with emotion, executive control, and motion were estimated for both groups, using resting-state fMRI spDCM.

RESULTS

Compared to the HC subjects, in patients with PNES: (i) the left insula (INS) and left and right inferior frontal gyri (IFG) are more inhibited by the amygdala (AMYG), anterior cingulate cortex (ACC), and precentral gyrus (PCG); (ii) the left AMYG has greater inhibitory effects on the INS, IFG, dorsolateral prefrontal cortex (DLPFC), PCG, and supplementary motor area (SMA); (iii) the left ACC has more inhibitory effects on the INS and IFG; (iv) the right ACC is more inhibited by the INS and IFG, and has a less inhibitory effect on the SMA and PCG; and (v) the left caudate (CAU) had increased inhibitory effects on the AMYG and IFG and a more excitatory effect on the SMA.

CONCLUSION

Our results suggest that in patients with PNES, the emotion-processing regions have inhibitory effects on the executive control areas and motor regions. Our findings may provide further insight into the influence of emotional arousal on functional movements and the underlying mechanisms of involuntary movements during functional seizures. Furthermore, they may suggest that emotion regulation through cognitive behavioral psychotherapies can be a potentially effective treatment modality.

Is sexual trauma a risk factor for functional (psychogenic) seizures?

The relationship between functional seizures (FS) and sexual trauma has received attention in many previous studies. However, the mechanisms underlying this relationship have not been elucidated yet. The purpose of this narrative review is to explore and speculate on the underpinning neurobiological mechanisms for the association and link between sexual trauma and functional seizures. While existence of a causal relationship between a history of sexual trauma and functional seizures is plausible, it should be viewed and treated as a hypothesis. In explaining this hypothesis, we can speculate that interactions between genetic factors and a history of sexual trauma may contribute to the risk of experiencing functional seizures. Childhood sexual trauma may lead to structural and functional connectivity changes in the brain and dysregulation of the biological stress systems, particularly in women. These neurobiological changes speculatively may predispose patients to functional seizures later in life. Importantly, a history of sexual trauma has many other implications beyond the predisposition towards FS.

Social aspects of life in patients with functional (psychogenic nonepileptic) seizures: An international study

PURPOSE

To explore various social aspects of life (i.e., employment, education, and driving) in a large sample of patients with functional seizures (FS) living in seven countries from four continents.

METHODS

In this retrospective study, we investigated adult patients with FS, who were admitted to the epilepsy monitoring units at centers in Iran, Qatar, USA, France, Georgia, Egypt, and United Arab Emirates (UAE). We studied the social aspects of life in the whole cohort. Then, we compared the social aspects of life between different world regions.

RESULTS

Four hundred and forty patients were included (241 from Iran, 56 from Qatar, 52 from France, 41 from the USA, 19 from UAE, 18 from Egypt, and 13 from Georgia). One hundred and twenty six people (30%) had college education, 142 (33%) were employed, and 101 (28%) drove a motor vehicle in their routine daily lives. People with FS and college education were more likely to report a history of sexual abuse compared with those with a lower education. Patients with no loss of responsiveness with their FS were more likely to be employed. Male patients and patients without aura were more likely to drive a motor vehicle in their routine daily lives. None of the social characteristics of the patients with FS showed significant differences among the two large culturally different groups (Muslim nations vs. Christian nations).

CONCLUSION

It appears that patients with FS across cultures have significant problems in their social aspects of life.

Correlates of health-related quality of life in youth with psychogenic non-epileptic seizures

BACKGROUND

Few studies have examined factors associated with health-related quality of life (HRQoL) in youth with psychogenic non-epileptic seizures (PNES). In adults, internalizing symptoms such as depression have been shown to be more closely associated with HRQoL than seizure frequency, however, this has not been studied in samples of youth. Investigations into these areas are needed in order to enhance our understanding of the impact of this condition on children and adolescents and inform future clinical intervention.

METHODS

The current study includes 37 youth and one of their parents who attended a clinic visit for treatment of PNES. Children and parents completed measures of psychological functioning, and medical data were extracted from patient charts.

RESULTS

Parent-reported anxiety (B=-0.45, p = 0.05) and depression (B=-0.60, p = 0.01) were related to parent-report of HRQoL; self-report of depression was related to self-reported HRQoL (B=-0.90, p < 0.001). Seizure frequency, somatic complaints, and social problems were not related to HRQoL in this sample.

CONCLUSIONS

Internalizing symptoms, not seizure frequency, are associated with poorer overall functioning in youth with PNES. Interventions focused on improving anxiety and depression in addition to seizure cessation may contribute to improved HRQoL in youth with PNES more so than those focused on seizure cessation alone.

Is patient acceptance of the diagnosis of functional (psychogenic nonepileptic) seizures linked to their clinical characteristics?

PURPOSE

We investigated the rate of acceptance of functional seizures (FS) or psychogenic nonepileptic seizures (PNES) diagnosis in a cross-sectional study in a cohort from Iran. We hypothesized that the acceptance of FS diagnosis has association with clinical characteristics of the patients.

METHODS

In this cross-sectional study, all patients with FS, who were diagnosed at Shiraz Comprehensive Epilepsy Center, Iran, from 2008 until 2018, were investigated. In a phone call interview in February 2020, we obtained the following information: whether they have accepted the diagnosis that was delivered to them; what is their seizure outcome (seizure-free during the past 12 months or not).

RESULTS

100 patients participated; at the time of the follow-up call, 74 (74%) patients expressed that they have accepted the diagnosis of FS. At the follow-up call, 48 patients (48%) were seizure-free and 52 patients (52%) were suffering from FS yet; 34 of seizure-free patients (71%) and 40 of those patients who still had seizures (77%) expressed that they have accepted the diagnosis of FS (p = .504; Fisher's exact test). Patients' characteristics and seizure semiology were not associated with the acceptance of the diagnosis of FS.

CONCLUSION

That the majority of patients with FS accept their diagnosis if it is delivered to them appropriately, and demographic and clinical characteristics of the patients do not have associations with this.

Insecure and Unresolved/Disorganized Attachment in Patients With Psychogenic Nonepileptic Seizures

BACKGROUND

Psychogenic nonepileptic seizures (PNES) are still poorly understood and difficult to treat. Attachment theory could add new aspects to the understanding of the multifactorial genesis and maintenance of PNES and the therapeutic needs of this patient group.

OBJECTIVE

The aim of the present study is to systematically assess attachment in adult patients with PNES with a focus on the role of unresolved/disorganized attachment.

METHODS

A cross-sectional design was chosen to compare patients with confirmed PNES (n = 44) and healthy controls (n = 44) matched for gender, age, and education. Attachment was assessed using the Adult Attachment Projective Picture System. Psychometric questionnaires included the Childhood Trauma Questionnaire; Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) axis II disorders, Patient Questionnaire; the Somatoform Dissociation Questionnaire; and the Patient Health Questionnaire.

RESULTS

We found significantly less secure (P = 0.006) and more unresolved/disorganized (P = 0.041) attachment classifications in the PNES group. Among patients with PNES, 7% were classified secure and 43% were classified unresolved/disorganized. Patients with an unresolved attachment representation were significantly more likely to be screened positive for personality pathology in the Structured Clinical Interview for DSM-IV axis II disorders, Patient Questionnaire (P = 0.03) and to report more emotional abuse in the Childhood Trauma Questionnaire (P = 0.007) than patients with other attachment classifications.

CONCLUSIONS

Our findings suggest that unresolved/disorganized attachment might be the predominant attachment style in patients with PNES and might be associated with more severe personality pathology. This could be of therapeutic relevance. The present study is the first to assess adult attachment in patients with PNES using a semi-structured interview in comparison to matched healthy controls.

Medical comorbidities in patients with psychogenic non-epileptic seizures (functional seizures)

PURPOSE

We investigated medical comorbidities in patients with psychogenic non-epileptic seizures (PNES). We hypothesized that these patients commonly have significant medical comorbidities.

METHODS

In this retrospective study, all patients with PNES, who were diagnosed at Shiraz Comprehensive Epilepsy Center, Iran, from 2008 until 2019, were investigated. Age, gender, age at seizure onset, seizure semiology, and characteristics, known medical (organic) comorbidities reported by the patients and video-electroencephalography recordings of all patients were registered routinely.

RESULTS

During the study period, 272 patients with PNES-only had the inclusion criteria and were studied. Sixty-five patients (24%) reported having a medical (organic) comorbidity. The most commonly reported medical comorbidity was thyroid disorder. Age at onset (OR: 1.058; 95% CI: 1.026-1.090; p = 0.0001), duration of disease before the diagnosis (OR: 1.071; 95% CI: 1.025-1.119; p = 0.002), and sex (female) (OR: 1.97; 95% CI: 1.016-3.834; p = 0.04) were significantly associated with having medical comorbidities.

CONCLUSION

While we did not have a control group to provide the number and type of medical problems that are expected in the general population, and therefore our results should be interpreted with caution, we had some intriguing observations. About one quarter of patients with PNES reported having medical comorbidities. The exact nature of the relationship between medical illnesses and PNES is not clear; however, hypothetically they could have a complex relationship. This study provides valuable information on the frequency and nature of medical comorbidities in patients with PNES and opens new horizons for future research.

Borderline personality disorder: part 1 – assessment and diagnosis

General adult psychiatrists are largely responsible for the care of patients with personality disorders in community and in-patient settings, and this can be associated with diagnostic and management challenges. In the first of two articles focusing specifically on borderline personality disorder (BPD), we summarise the core clinical features of the disorder and discuss appropriate diagnostic practice.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

SIGNIFICANCE

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

Sex differences in demographic and clinical characteristics of psychogenic nonepileptic seizures: A retrospective multicenter international study

PURPOSE

Sex-related differences have been reported in patients with neurological and psychiatric disorders. It is also plausible to assume that there might be differences between females and males with psychogenic nonepileptic seizures (PNES).

METHODS

In this retrospective study, we investigated patients with PNES, who were admitted to the epilepsy monitoring units at centers in Iran, the USA, Canada, Brazil, Argentina, and Venezuela. Age, sex, age at seizure onset, seizure semiology, factors potentially predisposing to PNES, and video-electroencephalography recording of all patients were registered routinely.

RESULTS

Four hundred and fifty-one patients had PNES-only and were eligible for inclusion; 305 patients (67.6%) were females. We executed a logistic regression analysis, evaluating significant variables in univariate analyses (i.e., age, age at onset, aura, presence of historical sexual or physical abuse, and family dysfunction). The only variables retaining significance were historical sexual abuse (p = 0.005) and presence of aura (p = 0.01); physical abuse was borderline significant (p = 0.05) (all three were more prevalent among females).

CONCLUSION

Similarities between females and males outweigh the differences with regard to the demographic and clinical characteristics of PNES. However, notable differences are that females more often report lifetime adverse experiences (sexual and probably physical abuse) and auras. While social, psychological, and genetic factors may interact with lifetime adverse experiences in the inception of PNES, the link is not yet clear. This is an interesting avenue for future studies.

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

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

METHODS

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

RESULTS

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

CONCLUSION

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

Psychopathological constellation in patients with PNES: A new hypothesis

Depression symptoms have often reported in patients with psychogenic nonepileptic seizures (PNES), although the underlying psychopathological symptomatology has been poorly understood. Our aim was to compare constellations of psychological and behavioral disturbance in PNES with respect to patients with mild-major depressive disorder (MDD), hypothesizing that the construct of depression might be different in the two groups. Ten patients with PNES and ten sex-/age-matched patients with mild-MDD newly-diagnosed, were enrolled in this study. A wide neuropsychiatric battery was employed including the following: symptoms checklist 90-R (SCL-90-R), Toronto alexithymia scale (TAS-20), Hamilton anxiety rating scale (HAMA), Beck depression inventory (BDI II), dissociative experiences scale (DES), traumatic experience checklist (TEC), somatoform dissociation questionnaire (SDQ-20), and temperament and character inventory-revised (TCI-R). No significant difference was detected in the large part of psychopathological examination including personality profile between the two groups. However, PNES showed high scores in alexithymia (p=0.02); anxiety (p=0.03), and somatoform symptomatology (p's<0.03) with respect to patients with mild-MDD. Moreover, somatoform symptoms strongly correlated with depression scores in both groups, whereas alexithymia was influenced by high anxiety level only in the group with PNES. No significant relationship was found between traumatic experience (as measured by TEC) and construct of depression. Our proof-of-concept study suggests that patients with PNES are characterized by their inability to verbalize emotions when dealing with anxiety symptoms, therefore expressing them in a somatic dimension. Further researches, including the investigation of the relationship between anxiety status and emotional expression, are warranted to better understand the pathogenesis of PNES.

Semiology of psychogenic nonepileptic seizures: An international cross-cultural study

PURPOSE

We compared the semiology of psychogenic nonepileptic seizures (PNES) between patients from the USA and Brazil. This international cross-cultural comparative study may expand understanding of PNES across the borders.

METHODS

We retrospectively investigated all patients with PNES admitted to one epilepsy center in the USA and one in Brazil. We classified their seizures into four classes: generalized motor, akinetic, focal motor, and subjective symptoms. All patients were interviewed by an epileptologist in both countries and were administered psychological assessment measures, including questions about PNES risk factors. For the statistical analyses, we compared patients from the two nations.

RESULTS

Eighty-nine patients (49 from the USA and 40 from Brazil) were studied. Patients from the two countries were not significantly different with regard to sex and age, but patients from Brazil had earlier age at onset (26years vs. 34years; P=0.004) and a significantly greater delay in diagnosis (9.9years vs. 5.6years; P=0.001). Some characteristics of PNES were different between the two groups; patients from the USA had generally more seizure types and more often reported subjective seizures (55% in the USA vs. 10% in Brazil; P=0.0001). Clinical and historical characteristics of the patients were not significantly different.

CONCLUSION

Delay in diagnosis of PNES may represent a major factor in resource-limited countries. Large multicenter cross-cultural studies may reveal subtle but significant cross-cultural differences with respect to the semiological, clinical, and historical aspects of PNES; however, patients with PNES share more similarities than differences.

PNES around the world: Where we are now and how we can close the diagnosis and treatment gaps-an ILAE PNES Task Force report

An international consensus clinical practice statement issued in 2011 ranked psychogenic nonepileptic seizures (PNES) among the top three neuropsychiatric problems. An ILAE PNES Task Force was founded and initially charged with summarizing the current state of the art in terms of diagnosis and treatment, resulting in two publications. The first described different levels of diagnostic certainty. The second summarized current knowledge of management approaches. The present paper summarizes an international workshop of the ILAE PNES Task Force that focused on the current understanding and management of PNES around the world. We initially provide a knowledge update about the etiology, epidemiology, and prognosis of PNES-in adults and in special patient groups, such as children, older adults, and those with intellectual disability. We then explore clinical management pathways and obstacles to optimal care for this disorder around the world by focusing on a number of countries with different cultural backgrounds and at very different stages of social and economic development (United Kingdom, U.S.A., Zambia, Georgia, China, and Japan). Although evidence-based methods for the diagnosis and treatment of PNES have now been described, and much is known about the biopsychosocial underpinnings of this disorder, this paper describes gaps in care (not only in less developed countries) that result in patients with PNES not having adequate access to healthcare provisions. A range of challenges requiring solutions tailored to different healthcare systems emerges. Continued attention to PNES by the ILAE and other national and international neurologic, psychiatric, and health organizations, along with ongoing international collaboration, should ensure that patients with PNES do not lose out as healthcare services evolve around the world.

Genetic background contributes to the co-morbidity of anxiety and depression with audiogenic seizure propensity and responses to fluoxetine treatment

BACKGROUND

Anxiety and depression are the most frequent comorbidities of different types of convulsive and non-convulsive epilepsies. Increased anxiety and depression-like phenotype have been described in the genetic absence epilepsy models as well as in models of limbic epilepsy and acquired seizure models, suggesting a neurobiological connection. However, whether anxiety and/or depression are comorbid to audiogenic epilepsy remains unclear. The aim of this study was to investigate whether anxiety or depression-like behavior can be found in rat strains with different susceptibility to audiogenic seizures (AS) and whether chronic fluoxetine treatment affects this co-morbidity.

METHODS

Behavior in the elevated plus-maze and the forced swimming test was studied in four strains: Wistar rats non-susceptible to AS; Krushinsky-Molodkina (KM) strain, selectively bred for AS propensity from outbred Wistar rats; and a selection lines bred for maximal AS expression (strain "4") and for a lack of AS (strain "0") from KM×Wistar F2 hybrids. Effects of chronic antidepressant treatment on AS and behavior were also evaluated.

RESULTS

Anxiety and depression levels were higher in KM rats (with AS) compared with Wistar rats (without AS), indicating the comorbidity with AS. However, in strains "4" and "0" with contrasting AS expression, but with a genetic background close to KM rats, anxiety and depression were not as divergent as in KMs versus Wistars. Fluoxetine treatment exerted an antidepressant effect in all rat strains irrespective of its effect on AS.

CONCLUSIONS

Genetic background contributes substantively to the co-morbidity of anxiety and depression with AS propensity.

Semiological classification of psychogenic nonepileptic seizures

PURPOSE

We classified patients with psychogenic nonepileptic seizures (PNESs) according to a newly proposed classification system. Then, we investigated the demographic and clinical differences between various classes of the patients.

METHODS

We retrospectively investigated all patients with PNESs admitted to the Jefferson Comprehensive Epilepsy Center from 2012 through 2016. We classified the patients into four distinct classes: patients with generalized motor seizures, patients with akinetic seizures, patients with focal motor seizures, and patients with seizures with subjective symptoms. All patients were interviewed by a neuropsychologist and were administered psychological assessment measures, including questions about PNES risk factors. For the statistical analyses, we compared patients who had generalized motor seizures with patients who had nonmotor seizures.

RESULTS

Sixty-three patients were studied. Thirty-five (55.6%) patients had generalized motor seizures, 14 (22.2%) had seizures with subjective symptoms, 12 (19%) had akinetic seizures, and two (3.2%) patients had focal motor seizures. Patients with generalized motor seizures (35 patients) demonstrated a trend for later age at onset (p=0.06), more frequently had a history of substance abuse (p=0.001), and more often had loss of responsiveness with their seizures (p=0.04) compared with patients who had nonmotor seizures (26 patients).

CONCLUSION

The recently proposed PNES classification system is useful and practical. This proposed classification of PNESs may address proper diagnosis and provide standardization across future studies. This may also potentially shed light on the etiologic understanding and management of various classes of patients affected with PNESs.

Psychiatric comorbidity in psychogenic nonepileptic seizures compared with epilepsy

OBJECTIVES

Psychogenic nonepileptic seizures (PNESs) are closely linked with psychological distress, but their etiology is not well-understood. We reviewed psychiatric comorbidity in PNESs and epileptic seizures (ESs) with an aim to assist understanding, diagnosis, and management of PNESs.

METHODS

A search of Web of Science, MEDLINE (PubMed), PsycINFO, and Scopus identified 32 relevant studies on the prevalence of psychiatric comorbidity in PNESs. We used meta-analysis to compare psychiatric comorbidity between PNESs and ESs.

RESULTS

Samples with PNESs had high rates of psychiatric comorbidity overall (53-100%), notably including posttraumatic stress disorder (PTSD), depression, and personality and anxiety disorders. Compared with ESs, samples with PNESs had more psychiatric comorbidity overall (RR: 1.30, 95% CI: 1.14-1.48, p<0.0001) with significantly elevated risks found for PTSD, personality disorder, and anxiety but not depression.

CONCLUSIONS

Psychiatric disorders are more common in PNESs than ESs. Because of methodological limitations of available studies, causality cannot be established; prospective longitudinal designs are required.