People with psychogenic non-epileptic seizures: A South African perspective

Functional seizures are not less important than epilepsy

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People with functional seizures often suffer from psychiatric comorbidities.

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People with FS report detrimental effects on social aspects of their lives.

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FS are associated with a considerable direct and indirect economic burden.

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FS have increased rates of mortality compared to healthy controls.

Functional seizures (FS) are frequently encountered in neurology clinics, often affect young adults, and have significant negative impacts on many aspects of a person’s life. In the current narrative review, we searched the literature regarding some of the consequences of FS (i.e., psychiatric comorbidities, social consequences, costs that are associated with the condition, cognitive impairment in patients with FS, the quality of life of the people with FS, and the increased risk of mortality that is associated with FS). Evidence shows that FS have significant negative consequences, comparable in their magnitude to those affecting patients with epilepsy. The clinical and scientific communities should take steps to address these consequences through clinical care and research that prioritizes, facilitates, and expedites evidence-based diagnosis and treatment for FS.

Social aspects of life in patients with functional seizures: Closing the gap in the biopsychosocial formulation

The human, as a biological system, is an open system embedded within larger systems -including the family, culture, and socio-political environment. In this context, a patient with functional seizures (FS) is embedded in relationships, educational/professional institutions, culture, and society. Both connection to these broader systems and the quality of these connections, as well as the soundness of each system in and of itself, influence the health and well-being of patients in positive or negative ways. The social aspects of life are important determinants of health and quality of life across the lifespan. The current narrative review brings out several overarching themes in patients with FS. Sections on attachment, marriage, social networking, and stigma highlight the central roles of supportive and affirmative relationships across the lifespan. The section on education underscores the importance of keeping children and youth with FS connected within their school environments, as well as managing any barriers - learning difficulties, school response to FS events, stigma, etc.-that can diminish this connection. Finally, the sections on employment and driving highlight the value of being an active participant in one's society. In summary, FS impacts patients across most social aspects of life domains regardless of age - factors that are important when developing biopsychosocial formulations. This review concludes that the multidisciplinary management of FS requires careful assessment of social aspects of life in patients which can then be targeted for treatment, to improve their quality of life, facilitating recovery, and reducing the risk of relapse.

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

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

Psychogenic nonepileptic seizures: Comparing what South African healthcare providers communicate to patients at the point of diagnosis against international guidelines

The process of communicating a diagnosis of psychogenic nonepileptic seizures (PNES) has been widely studied internationally and found to be an important factor in the reduction of symptoms as well as promoting the uptake of treatment. To date, no research has focused on diagnosis communication in the South African context. This study used applied thematic analysis to explore the content addressed by a sample of 11 South African healthcare providers (HCPs) when presenting a diagnosis of PNES to a patient. The purpose was to investigate the areas of alignment between the international guidelines and what is done in practice and to identify other elements communicated by South African HCPs that were not addressed in the guidelines. The key communication elements described in five international guidelines were grouped into nine main themes, and coding frequencies were used to identify areas of alignment. In general, the practices of the participants aligned closely to the international guidelines. There was close alignment between the guidelines and the practices of HCPs in respect of six themes, namely: that the diagnosis was not epilepsy; how the diagnosis was made; that PNES was a real, debilitating condition; an explanation of possible causes and maintaining factors; that antiepileptic drugs are not effective in treating PNES; and a description of appropriate treatment. Participants suggested four additional subthemes that may be included when presenting a diagnosis: what to do in the event of future seizures; that further investigations are not helpful; enquiry into the link between stressors and seizures; and a discussion about comorbid conditions. Participants noted the value of utilizing a guideline as a means to ensure that all HCPs involved with a patient communicate a consistent message. They emphasized that diagnosis presentation must be relevant to the South African population and discussed the need to tailor explanations for the patient's home language and level of education. Cross-cultural barriers and different cultural health beliefs may require a specially tailored communication approach grounded in a clear cultural understanding.

Personality traits, illness behaviors, and psychiatric comorbidity in individuals with psychogenic nonepileptic seizures (PNES), epilepsy, and other nonepileptic seizures (oNES): Differentiating between the conditions

OBJECTIVES

The study aimed to investigate if South African individuals with psychogenic nonepileptic seizures (PNES) differ from individuals with epileptic seizures (ES) and other nonepileptic seizures (oNES) in terms of demographic and seizure characteristics, personality traits, illness behaviors, and depression, anxiety, and posttraumatic stress disorder (PTSD) comorbidity in statistically significant ways; and if so, to test if these differences can be utilized in raising suspicion of PNES as the differential diagnosis to epilepsy and oNES in practice.

METHODS

Data were analyzed from 29 adults with seizure complaints recruited using convenience sampling from a private and a government hospital with video-electroencephalography (vEEG) technology. A quantitative double-blind convenient sampling comparative design was used. A demographic and seizure questionnaire, the NEO Five Factor Inventory-3 (NEO-FFI-3), an abbreviated version of Illness Behavior Questionnaire (IBQ), and the Beck Anxiety Inventory - Primary Care (BAI-PC) were administered. Cronbach's alphas, analysis of variance (ANOVA), cross-tabulation, Fisher exact test, and receiver operating characteristic (ROC) analyses were performed on the dataset.

RESULTS

The total sample consisted of 29 participants, of which 5 had PNES (17%), 21 ES (73%), and 3 oNES (10%). The final sample was comprised of 24 participants from the private hospital and 5 from the government hospital. The group with PNES was found to be significantly more male, to experience significantly more monthly seizures, and chronic pain when comparing the PNES with the ES group, and the PNES with the combined ES and oNES group in both private only sample, as well as the private and government hospital combined sample. Patients with PNES also had a higher level of education compared with the group with ES in the combined private and government hospital sample, something that was not evident in the private hospital only sample. No significant differences between groups were found in either sample in terms of age, population group, language, age at first seizure, and the NEO-FFI-3 subscales. All three groups scored above the cutoff point of 5 exhibiting depression, anxiety, and PTSD symptoms on the BAI-PC in both samples. However, the group with PNES tended to score significantly higher than the group with ES and the combined ES and oNES group in the private hospital sample. A cutoff point of 12 on the BAI-PC was found to predict PNES in this seizure population with 80% sensitivity and 89% specificity. However, once the analysis was repeated on the combined private and government hospital sample, significance in BAI-PC scores between groups was lost. All scales showed good reliability in our study, with the exception of the "Openness to Experience" subscale of the NEO-FFI-3 once reliability analysis was carried out on the combined private and government hospital group.

CONCLUSIONS

This study provides an important stepping stone in the understanding of demographic and seizure factors, personality domains, abnormal illness behaviors, and psychiatric comorbidity in the South African population with PNES. The study also reported on a cutoff score of 12 on the BAI-PC predicting PNES with 80% sensitivity and 89% specificity in a private hospital sample.

Diagnostic and treatment practices for psychogenic nonepileptic and epileptic seizures in Namibia

PURPOSE

Information about existing healthcare resources for the management of seizures in developing countries is lacking. These countries are often poorly equipped to deal with the immense burden of costs, mortality, stigma, seizure-related disability, and comorbidities presented by seizure disorders. This study aimed to contribute to the goals of the International League Against Epilepsy (ILAE) by investigating the resources available for patients with seizure in Namibia.

METHODS

Two separate surveys on the diagnostic and treatment practices for epileptic seizures (ES) and psychogenic nonepileptic seizures (PNES) were administered to private healthcare practitioners (HCPs) in Namibia.

RESULTS

The findings are based on 50 responses from HCPs involved in the management of seizures. The responses indicate that HCPs have less confidence in their ability to manage PNES than ES. Psychological/psychiatric assessments are seldom utilized. Although HCPs engage in face-to-face communication of diagnoses, they seldom refer patients to additional sources of information. Healthcare practitioners follow up patients with ES more regularly than those with PNES. Healthcare practitioners indicated their willingness to collaborate and recognize the role of traditional health practitioners (THPs) in a supportive capacity when it comes to the management of seizures. Financial constraints, limited availability of specialized equipment, and lack of knowledge and awareness regarding seizure disorders among both HCPs and patients were mentioned as major obstacles in accessing healthcare services.

CONCLUSION

The findings of this study add to the current literature by demonstrating some of the particular characteristics of HCPs from a lower middle-income African country regarding the diagnosis and treatment of PNES and ES.

A comparative retrospective exploration of the profiles of patients in South Africa diagnosed with epileptic and psychogenic non-epileptic seizures

Psychogenic non-epileptic seizures (PNES) have a high prevalence globally but the accurate diagnosis of this condition still remains a challenge. This is particularly the case in countries where there is scarce expertise and insufficient affordable medical facilities to which patients have access. The rate of PNES diagnosis in epilepsy units is typically within the range of 20 to 30%. In the context of developing countries, this rate tends to be higher and increases demand on the existing scarce health care capacities. Although the profiling of patients with different seizure presentations is essential for informing appropriate treatment, to date there has been no comparative analysis of the profiles of patients with PNES and epilepsy in South Africa. The aim of the present study was to explore retrospectively the demographic and medication characteristics of these patients and to compare these characteristics to those reported in patient populations from other countries and regions. The total sample of 246 participants included 85 (35%) male and 161 (65%) female patients who were admitted to the Epilepsy Monitoring Unit (EMU) at Milpark Hospital, South Africa. Following the video-EEG monitoring assessment, 123 patients (50%) were diagnosed with PNES, and for 123 patients (50%) the diagnosis of epilepsy was confirmed. The results indicated that the demographic profiles of the groups of patients with epilepsy and PNES were similar with reference to age and self-ascribed ethnicity. In both groups, the majority of the patients were females, but proportionally their prevalence was higher in the PNES patient group than in the epilepsy patient group, which is compatible with the trends found in the PNES patient populations internationally. Pre-diagnostically, the type and the number of medications prescribed to patients with PNES and epilepsy were comparable. Subsequent to the diagnosis at the EMU, there was a significant reduction of overall medications in each group, but this reducton was more pronounced in the group with PNES. It is concluded that the rate of misdiagnosis of PNES in South Africa surpasses the rates reported for the patient populations in other countries and is one of the highest documented worldwide. Considering that post-diagnostically, there was reduction in central nervous system (CNS) medications as well as anti-epileptic drugs (AEDs) in both patients with epilepsy and those with PNES, it is likely that pre-diagnostically a significant proportion of all patients were over medicated. Compared to the epilepsy diagnosis, the PNES diagnosis resulted in a more substantial reduction of medication. These findings outline important dimensions of the diagnostic and medication treatment practices of epilepsy and PNES and point to the urgent need to improve these practices in South Africa and the African continent.

Barriers and facilitators to reaching a diagnosis of PNES from the patients' perspective: Preliminary findings

PURPOSE

This qualitative study aimed at examining the subjective experiences of patients during the complicated and often prolonged diagnostic process of psychogenic non-epileptic seizures (PNES).

METHODS

Thematic analyses were used to explore the semi-structured interviews that were conducted with ten individuals who have been diagnosed with PNES.

RESULTS

Six main themes, namely inexpert healthcare providers, limited medical insurance and loss of independence were identified as barriers, while social support, comprehensive medical insurance and knowledgeable healthcare providers were identified as facilitators through the process of thematic analysis.

CONCLUSIONS

The patients' perspectives revealed that an earlier diagnosis of PNES is essential to address the loss of independence and limit inappropriate and potentially harmful treatment as well as the costly burden of this condition on both the patient and the healthcare system. It was evident in this study that healthcare providers play an essential role in the subjective experiences of these individuals during the diagnostic process. The implementation of continuous education programmes for healthcare providers in particular could contribute positively to the diagnostic process of PNES for patients.