Closing the Major Gap in PNES Research: Finding a Home for a Borderland Disorder

Death of a loved one: A potential risk factor for onset of functional seizures

Functional seizures (FS) are a symptom of Functional Neurological Disorder (FND), the second most common neurological diagnosis made worldwide. Childhood trauma is associated with the development of FS, but more research is needed to truly understand the effects of trauma on FS onset. A sample of 256 responses by adults with FS to the Childhood Traumatic Events Scale were analyzed using a Cox proportional hazard model. When investigating each unique childhood traumatic exposure and its associated self-reported severity together, experiencing death of a loved one and experiencing violence were significantly associated with FS onset, suggesting reduced time from trauma exposure to first FS. Death of a loved one in childhood is often overlooked as an influential risk factor for future development of serious mental illnesses such as FS. In this study we show death of a loved one in childhood should be considered as an influential traumatic experience and recommend FND researchers examine its prevalence in patient histories and the potential effects on attachment-related processes and clinical treatment formulations. We recommend future studies incorporate loss of a loved one during childhood (before age 18) in both quantitative and qualitative assessments of persons with FND.

Psychiatric and psychological assessment of patients with drug-resistant epilepsy and psychogenic nonepileptic seizures (PNES) with no response to previous treatments

OBJECTIVE

Psychogenic nonepileptic seizures (PNES) are common imitators of epileptic seizures. Refractoriness to antiseizure medication hinders the differential diagnosis between ES and PNES, carrying deleterious consequences in patients with PNES. Psychiatric and psychological characteristics may assist in the differential diagnosis between drug-resistant epilepsy (DRE) and PNES. Nevertheless, current comprehensive psychiatric and psychological descriptive studies on both patient groups are scarce and with several study limitations. This study provides a comprehensive psychiatric and psychological characterization of Spanish patients with DRE and PNES.

METHOD

A cross-sectional and comparative study was completed with 104 patients with DRE and 21 with PNES. Psychiatric and psychological characteristics were assessed with the HADS, SCL-90-R, NEO-FFI-R, PDQ-4+, COPE, and QOLIE-31 tests. Parametric and non-parametric tests were used, and regression models were fit to further explore factors affecting patients' life quality.

RESULTS

Patients with PNES had greater levels of somatization and extraversion and were associated with benzodiazepine intake. Patients with DRE showed greater narcissistic personality disorder symptoms than those with PNES. In patients with DRE, difficulty in performing basic needs-related tasks and greater psychological distress severity and seizure frequency were associated with poorer life quality. In contrast, being a woman, having a psychiatric disorder history, and greater psychiatric symptoms' intensity were associated with poorer life quality in patients with PNES.

CONCLUSION

Patients with DRE and PNES share similar psychiatric and psychological characteristics, with only very few being significantly different.

Exploring the influence of telehealth on patient engagement with a multidisciplinary Non-Epileptic Seizure (NES) Clinic during the COVID-19 pandemic

The ILAE task force has identified a gap in treatment access for patients with nonepileptic seizures (NES) [1]. Access to multidisciplinary treatment clinics for adults with NES is limited with only 18 institutions delivering care across the United States [2]. Patient engagement has been low in the University of Colorado, NES Clinic treatment program despite our clinic's status as the only clinic of its kind in the mountain west. We analyzed patient factors of those who engaged in treatment before and after COVID-19 regulations were imposed and found a 23.6% increase in treatment engagement using telehealth. Those who engaged using telehealth were more likely to be of white race, of non-Hispanic ethnicity, publicly insured, employed, have a Charlson Comorbidity Index (CCI) of zero, a daily seizure rate of 0-1, did not have suicidal ideation or attempts, and live greater than 25 miles from the NES clinic. Delivering NES treatment via telehealth reduced the logistical and psychological barriers to initiating recovery and with a severe lack of accessible treatments for patients with NES, barrier reduction is necessary. This study describes patient factors that result in higher engagement with NES treatment using telehealth and emphasizes the importance of telehealth utilization to improve access to available treatment.

A pilot study assessing the feasibility and acceptability of Project UPLIFT adapted for patients with psychogenic nonepileptic seizures

BACKGROUND

People with psychogenic nonepileptic seizures (PNES) are at elevated risk of multiple psychiatric comorbidities. Current treatment gaps highlight the need for time-limited, distance-delivered interventions that can be cost-effectively delivered to patients with PNES. Project UPLIFT is a self-management program addressing mood problems in epilepsy that has not previously been adapted for PNES. The purpose of this study was to assess the feasibility and acceptability of UPLIFT for patients with PNES.

METHODS

Project UPLIFT was minimally adapted by a multidisciplinary research group at Dartmouth-Hitchcock Medical Center. Participants were recruited into a nonrandomized pilot study and were assessed at baseline, after completing the intervention, and at 1-month follow-up.

RESULTS

The intervention was adapted and delivered without additional modification. A total of eight participants enrolled in the trial, and six participated in the first session. All six participants who started UPLIFT completed the intervention, with a 98% attendance record across the eight sessions. At follow-up, 100% reported that UPLIFT provided useful tools for daily life. All participants continued using UPLIFT after completing the program, and 83% felt it helped with seizure management. Preliminary results provide proof-of-concept for future efficacy trials.

CONCLUSION

This study provides initial support for the feasibility and acceptability of Project UPLIFT, minimally adapted for patients with PNES. As a time-limited program that can be distance-delivered to groups of patients, UPLIFT may be well-suited for the healthcare environment brought on by the COVID-19 pandemic.

Functional seizures: The patient’s perspective of a diagnostic and treatment odyssey

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Functional seizures remains a complex neuropsychiatric condition to identify and treat.

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Practitioners must address management of physical symptoms and underlying causes.

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Management strategies can fail if their reasoning is not properly communicated.

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Better outcomes may result where treatment rationale is emphasized from outset.

Functional seizures can be challenging to properly diagnose, often leading to delays in treatment. The etiology of functional seizures is multifactorial, with psychological factors identified in many, but not all cases. Misdiagnosis may occur due to clinical features mimicking other medical conditions. Once a correct diagnosis is reached, delivery of definitive, evidence-based treatment may be challenging due to limited availability of specialized resources. Research shows psychological education and cognitive behavioral therapy (CBT) have the greatest efficacy. However, individual differences, including acceptance of the diagnosis, therapeutic alliance, duration of symptoms, comorbidities, and access to care may influence outcomes. There is a critical need for reports that can help identify barriers to effective diagnosis and treatment. We present the diagnosis and treatment of a woman who visited the emergency room after an attack of predominant left-sided paralysis, speech dysfunction and altered awareness. Following multiple daily episodes and visits to multiple medical practitioners, testing led to a diagnosis of functional seizures. While the patient was recommended to undergo a variety of therapeutic interventions, including CBT, she ultimately terminated treatment. In a subsequent interview, the patient revealed her personal experience with perceived limitations of acute management strategies. We explore the complexities of diagnosing and treating individuals with functional seizures.

[Psychogenic non-epileptic seizures]

The review provides epidemiological data and discuss the associated burden of non-epileptic seizures (PNES). Data on the prevalence, socio-demographic and clinical risk factors for the development of PNES are presented. The hypotheses of the PNES origin, including the contribution of psychological trauma, are considered. We also describe contemporary methods for differential diagnosis of epileptic seizures and PNES, including biomarkers and the use of diagnostic questionnaires. Special attention is given to the issues of the psychiatric comorbidity of PNES.

Myths and truths about pediatric psychogenic nonepileptic seizures

Psychogenic nonepileptic seizures (PNES) is a neuropsychiatric condition that causes a transient alteration of consciousness and loss of self-control. PNES, which occur in vulnerable individuals who often have experienced trauma and are precipitated by overwhelming circumstances, are a body's expression of a distressed mind, a cry for help. PNES are misunderstood, mistreated, under-recognized, and underdiagnosed. The mindbody dichotomy, an artificial divide between physical and mental health and brain disorders into neurology and psychiatry, contributes to undue delays in the diagnosis and treatment of PNES. One of the major barriers in the effective diagnosis and treatment of PNES is the dissonance caused by different illness perceptions between patients and providers. While patients are bewildered by their experiences of disabling attacks beyond their control or comprehension, providers consider PNES trivial because they are not epileptic seizures and are caused by psychological stress. The belief that patients with PNES are feigning or controlling their symptoms leads to negative attitudes of healthcare providers, which in turn lead to a failure to provide the support and respect that patients with PNES so desperately need and deserve. A biopsychosocial perspective and better understanding of the neurobiology of PNES may help bridge this great divide between brain and behavior and improve our interaction with patients, thereby improving prognosis. Knowledge of dysregulated stress hormones, autonomic nervous system dysfunction, and altered brain connectivity in PNES will better prepare providers to communicate with patients how intangible emotional stressors could cause tangible involuntary movements and altered awareness.

Psychogenic Nonepileptic Seizures and Psychosocial Management: A Narrative Review

Psychogenic non-epileptic seizure (PNES) is a common disorder that imitates epileptic seizures and has its etiological roots in psychological distress. Due to its “epileptic” similarity, it is often dealt with not only by mental health professionals but also by physicians, pediatricians and neurologists. There is a growing consensus towards the psychotherapeutic treatment of the disorder, albeit a lack of clarity in choosing a gold-standard approach. This paper seeks to serve as a compendium of different psychotherapeutic approaches and their efficacy in the management of PNES. The paper employed the search strategy by selecting the keywords: “Psychogenic Non-Epileptic Seizures (PNES) and psychosocial management”, “PNES Treatment approach”, “PNES and psychotherapy” in PUBMED, EBSCO host, PsycINFO, and SCOPUS database. Eventually, specific therapies were cross-searched with PNES for an exhaustive review. Several studies were found employing various psychotherapeutic approaches for the treatment of PNES in pilot studies, randomized controlled, or open uncontrolled trials. Cognitive Behavior Therapy was demonstrated as an efficacious treatment for PNES in a randomized controlled trial (RCT). Other approaches that were effective in ameliorating the symptoms were psychodynamic therapies or psychoeducation based group therapies. Some therapies like Novel Integrative psychotherapy, Eye Movement Desensitisation Therapy and Mindfulness-based therapies require further exploration in larger clinical trials. The findings demonstrate that psychological intervention for PNES is a promising alternative treatment approach with a need for more RCTs with a larger sample and robust methodology for better generalization.

Surgical outcome of a female patient with comorbid epilepsy and psychogenic non-epileptic seizures confirmed with video-EEG monitoring

Despite common comorbidities of epileptic seizure (ES) and psychogenic nonepileptic seizure (PNES), reports regarding the clinical management of the two coexisting disorders have traditionally only focused on non-surgical approaches such as medication and psychotherapy. Epileptogenic zonectomy following comprehensive presurgical evaluation could lead to seizure control and even seizure free in refractory epilepsy patients. However, its effect on PNES which is of clinical significance remains to be explored. Here, we present a favorable surgical outcome in a middle-aged woman with refractory epilepsy with concomitant video-electroencephalograph-confirmed PNES. The patient has been ES free post right-sided anterior temporal lobectomy with unchanged antiepileptic medication. Meanwhile, remarkable improvement of her PNES has been reported although she did not undergo psychiatric or psychological therapy following surgery. The treatment success achieved in this case suggests that comorbid PNES should not deprive patients with intractable epilepsy patients a chance to undergo surgical intervention if their epileptogenic zones could be identified during presurgical evaluation. Some patients could obtain relieves of both ES and PNES from appropriately performed epilepsy surgery. Nevertheless, the mechanisms underlying the findings in this report are still unknown. Further study is needed to investigate whether epileptogenic zonectomy itself or the patient's positive mood brought by ES control contributes to postoperative alleviation of PNES.

EEG-based classification of epilepsy and PNES: EEG microstate and functional brain network features

Epilepsy and psychogenic non-epileptic seizures (PNES) often show over-lap in symptoms, especially at an early disease stage. During a PNES, the electrical activity of the brain remains normal but in case of an epileptic seizure the brain will show epileptiform discharges on the electroencephalogram (EEG). In many cases an accurate diagnosis can only be achieved after a long-term video monitoring combined with EEG recording which is quite expensive and time-consuming. In this paper using short-term EEG data, the classification of epilepsy and PNES subjects is analyzed based on signal, functional network and EEG microstate features. Our results showed that the beta-band is the most useful EEG frequency sub-band as it performs best for classifying subjects. Also the results depicted that when the coverage feature of the EEG microstate analysis is calculated in beta-band, the classification shows fairly high accuracy and precision. Hence, the beta-band and the coverage are the most important features for classification of epilepsy and PNES patients.

Nonepileptic seizures in individuals attending neurological services in New Zealand

OBJECTIVES

This study examined the demographic, social, and clinical (neurological and psychiatric) characteristics of people with psychogenic nonepileptic seizures (PNES) presenting to tertiary neurological services at Auckland District Health Board, New Zealand.

METHODS

Electronic notes and video-electroencephalography (video-EEG) data gathered from the telemetry unit based on synchronized acquisition (motor activity and brain electrophysiology) over a five-year period (2011 to 2015 inclusive) were retrospectively examined. Two groups were compared: people with PNES only or people with combined PNES and epileptic seizures (ES) (the group with PNES) and a control group with ES only, matched 1:1 by age and gender.

RESULTS

Sixty-six people in the group with PNES were matched with an equivalent number of ES controls. As a cohort, there was high psychiatric and medical comorbidity in both groups, but overall, those with PNES experienced higher rates than their ES counterparts. An older age of onset, female gender, and history of abuse were more frequently seen in those with PNES. Compared with controls, people with PNES more commonly had daily seizures (rather than monthly) but presented less frequently to neurology services. A high proportion of people with PNES experienced historical traumas, ongoing stressors, and disability. Almost half of the people with PNES were on antiepileptic drugs (AEDs) and received limited psychiatric or psychological input. In contrast, people with ES were more likely to be on psychotropic medication.

CONCLUSION

Both PNES and ES are associated with high levels of psychiatric and medical comorbidity. Additionally, PNES were found to be associated with iatrogenic harm and disability. Though people with PNES and ES often have a range of associated needs, there is, however, limited access to appropriate services. The needs of these populations should be better met through enhanced integration across psychiatry, neurology, and multidisciplinary services.

Management of uncertainty in the diagnosis communication of psychogenic nonepileptic seizures in a South African context

The process of communicating a diagnosis of psychogenic nonepileptic seizures (PNES) is an integral part of the treatment process. Many international studies have therefore focused on the PNES diagnosis communication process, but to date, none with a specific focus on the South African context. This current study considered the factors that influence the patient's experience of uncertainty and the strategies employed to manage that uncertainty within the provider-patient communication. This was considered from the healthcare provider's point of view, within the specific context of diagnosis communication. We conducted 13 semi-structured interviews with providers, eliciting their perceptions related to the communication of a PNES diagnosis to patients. Data were analyzed using thematic analysis, and themes were grouped according to the main tenets of the interpersonal health communication theory of uncertainty management, which included, the experience, appraisal, and management of uncertainty. The results revealed medical, personal, and social forms of uncertainty. The social sources of uncertainty, which include challenges related to the South African healthcare system, cultural, and language variability within the South African context, as well as possible stigmatization, seemed to have the biggest influence not only on the other areas of uncertainty, but was also indicated as a barrier to effective uncertainty management by providers. Providers in this study identified the importance of building the provider-patient relationship and ensuring patient understanding, as the main strategies used to reduce uncertainty. There was some evidence to suggest varied emotional appraisals of uncertainty by patients, but because of the subjective nature of this information, further research would be needed to confirm these findings. These findings suggest that as providers, one cannot apply a one-size-fits-all approach when aiding in uncertainty management. Furthermore, it is pertinent to remain cognizant of the social realities of the South African context and its impact on the patient's uncertainty experience. More research is needed to understand patients' perceptions of uncertainty management within the context of PNES diagnosis communication, and how they align with the perceptions of the providers provided here.

An Integrative Review of School-Based Mental Health Interventions and Implications for Psychogenic Nonepileptic Seizures

Millions of students with mental health concerns attend school each day. It is unknown how many of those students experience psychogenic nonepileptic seizures (PNES); however, quality of life, academic, and mental health outcomes for students experiencing PNES can be bleak. Currently, no authors have addressed potential school nurse interventions for students with PNES. Because PNES is a mental health condition and is often influenced by underlying anxiety and/or depression, an integrative review of school nurse interventions and outcomes for students with general mental health concerns was conducted. An integrative review resulted in the identification of 13 quantitative and 2 qualitative studies that met inclusion criteria. The findings from this review suggest school nurses, following principles from the Framework for 21st Century School Nursing Practice, play an active role in mental health interventions and should be involved in replicating and testing known mental health interventions to investigate their effectiveness for students with PNES.

Cognition, mood and quality-of-life outcomes among low literacy adults living with epilepsy in rural Kenya: A preliminary study

Epilepsy is frequently associated with neurocognitive impairments, mental health, and psychosocial problems but these are rarely documented in low- and middle-income countries. The aim of this study was to examine the neurocognitive outcomes, depressive symptoms, and psychosocial adjustments of people with epilepsy (PWE) in Kilifi, Kenya. We evaluated the impact of these outcomes on health-related quality of life. Self-report, interviewer-administered measures of depression (Major Depression Inventory) and quality of life (RAND SF-36) were administered to 63 PWE and 83 community controls. Neurocognitive functioning was assessed using Raven's Standard Progressive Matrices, Digit Span, and Contingency Naming Test. The results show that PWE have poorer scores for executive function, working memory, intelligence quotient (IQ), depression, and quality of life than controls. Twenty-seven (27%) of PWE had depressive symptoms, which was significantly greater than in controls (6%); P < 0.001. Quality-of-life scores were significantly lower in PWE with depressive symptoms than in those without depressive symptoms (Mean QoL scores (standard deviation (SD)): 46.43 (13.27) versus 64.18 (17.69); P = 0.01. On adjusted linear regression models, depression affected total quality-of-life scores (P = 0.07) as well as individual health indicator domains touching on pain (P = 0.04), lethargy/fatigue (P = 0.01), and emotional well-being (P = 0.02). Our results show that epilepsy is associated with a significant burden of mental health and neurocognitive impairments in the community; however, community-based studies are needed to provide precise estimates of these disorders.

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 Case of Dissociative Seizures Presented like Myoclonic Epilepsy

Psychogenic seizures are often underdiagnosed and epilepsy is very often over-treated which leads to multiple financial, social and stigma related difficulties. The myoclonic seizure itself is a rare phenomenon and when functional movement disorder presents like myoclonus then it's extremely difficult to pinpoint the exact cause. Here, we are presenting a case who was misdiagnosed as having a myoclonic seizure disorder and treated in multiple places without any improvement which ultimately turned out to be functional movement disorder of a rare variety.

A simple clinical score for prediction of nonepileptic seizures

Psychogenic nonepileptic seizures (PNES), often mistaken for epilepsy in community practice, require inpatient video-EEG (VEEG) monitoring for diagnostic confirmation. We developed a simple score designed for use in an outpatient setting to predict the subsequent VEEG diagnosis of PNES. We retrospectively compared fifty-five consecutive patients with VEEG-proven PNES (N₁=55) with a group of randomly selected patients with VEEG-proven epilepsy (N₂=55). Patients were divided into two groups: I) a 'truly retrospective' group of 27 patients with PNES and 27 patients with epilepsy whose data served to develop the score, and II) a 'pseudoprospective' group of 28 patients each with PNES and epilepsy to whom the score was applied. Six features in the history of the Group I cohort appeared more prominent in patients with PNES than patients with epilepsy and were assigned escalating numerical values as follows: number of declared drug allergies (0, 0.5, 1), number of declared comorbidities (0, 0.5, 1), number of previous invasive medical interventions of any type (0, 0.5, 1), and a history of significant psychological or physical trauma (0 or 1). In addition, a score was assigned to verbal description of the seizures themselves as being consistent (=0), atypical (=1), or indeterminate (=0.5) for epilepsy. The values were added to yield an omnibus score ranging from 0 to 6. Scoring of Group II subjects in a blinded fashion revealed that in general patients with PNES had higher scores, and the majority obtained a score >2; most patients with epilepsy scored <1.5. Group difference in the mean between the PNES and epilepsy cohort was highly significant (p<0.0001, Wilcoxon rank-sum test). Our score is a simple clinical instrument based on the patient history that may find use in the triage of patients awaiting hospitalization for VEEG and in pre-VEEG counseling.

Identifying seizure clusters in patients with psychogenic nonepileptic seizures

The present study explored how seizure clusters may be defined for those with psychogenic nonepileptic seizures (PNES), a topic for which there is a paucity of literature. The sample was drawn from a multisite randomized clinical trial for PNES; seizure data are from participants' seizure diaries. Three possible cluster definitions were examined: 1) common clinical definition, where ≥3 seizures in a day is considered a cluster, along with two novel statistical definitions, where ≥3 seizures in a day are considered a cluster if the observed number of seizures statistically exceeds what would be expected relative to a patient's: 1) average seizure rate prior to the trial, 2) observed seizure rate for the previous seven days. Prevalence of clusters was 62-68% depending on cluster definition used, and occurrence rate of clusters was 6-19% depending on cluster definition. Based on these data, clusters seem to be common in patients with PNES, and more research is needed to identify if clusters are related to triggers and outcomes.

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.

Reasons for prolonged length of stay in the epilepsy monitoring unit

Epilepsy monitoring unit (EMU) admissions are essential for the classification/localization of epileptic seizures (ES) and psychogenic non-epileptic seizures (PNES). However, the duration of admissions is highly variable. Accordingly, we evaluated the duration of 596 EMU admissions and reasons for prolonged (>7 days) lengths of stay (LOS). The average LOS was longer for patients diagnosed with ES (8.0 days, SD 4.1 days) than all others (6.0 days, SD 3.9 days, p<0.001). Of the 596 admissions, 231 (38.8%) had prolonged LOS. The most commonly reported reason for prolonged stay was need to record additional seizures (33%). Other contributors included complications such as seizure clusters (6.9%), status epilepticus (1.6%), test complications (3.7%), psychiatric concerns (4.3%), and medication side effects (1.6%). Our results suggest multiple factors produce prolonged LOS with no factor accounting for the majority. Recording an insufficient number of all habitual seizures was the leading cause, which was over twice the percentage of reported complications (17.6%). However, being able to prolong admissions when necessary resulted in only 14.9% of admissions being inconclusive, potentially justifying the extra expense. Efforts to shorten LOS may be best directed at faster recording of seizures, but this may increase LOS due to complications. Our results may be helpful when assessing whether efforts to shorten LOS are useful in improving the quality and cost of care.

Psychogenic Nonepileptic Seizures: Diagnosis, Management, and Bioethics

BACKGROUND

The diagnosis and management of psychogenic nonepileptic seizures (PNES) is often challenging and fraught with discord and disagreement between patients, parents, and physicians. Furthermore, there are ethical challenges when making the diagnosis, communicating this information, and instituting management.

METHODS

We reviewed the current body of knowledge regarding the characteristic differences between epileptic seizures and PNES, and the high incidence of psychiatric comorbidities. An ethical analysis was made of diagnosis and management based on ethical principles, virtue ethics, and the social contract that health professionals have with patients.

RESULTS

Key distinctions between PNES and epilepsy lie in both patient and seizure characteristics. Long duration, eye closure, asynchronous movements, frequent recurrence in the same context, intra-ictal awareness, and lack of post ictal state are useful in helping establish the diagnosis. Psychiatric comorbidities, history of abuse, cognitive impairment, and multiple non specific somatic complaints are some salient patient features that should increase suspicion for the diagnosis of PNES. However, definitive diagnosis rests on capturing the events on video EEG.

CONCLUSION

Effective diagnosis and management of PNES requires the use of video EEG and an early collaborative approach between pediatricians, neurologists, psychiatrists, nursing staff, and other professional colleagues. Ethical questions that may arise should be addressed with the virtues of competence, courage, compassion, prudence, and honesty; and the principles of respect beneficence, and the avoidance of unnecessary harm.

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.

Bridging a clinical gap in psychogenic nonepileptic seizures: Mental health provider preferences of biopsychosocial assessment approaches

Management of psychogenic nonepileptic seizures (PNES) is complex, requiring multidisciplinary care. A standardized assessment and formulation approach to PNES is lacking, yet use of a comprehensive model may alleviate problems such as mental health aftercare noncompliance. Although a biopsychosocial (BPS) approach to PNES balancing predisposing, precipitating, and perpetuating (PPP) variables has been described and has been recently tested in pilot form, it is unclear how this assessment style is perceived among community mental health practitioners such as psychotherapists (including psychologists, counselors, and social workers). We predicted preference of a comprehensive "BPS/PPP" assessment style by those most involved in PNES care (i.e., community psychotherapists). One hundred and forty-three community-based social workers and counselors completed a survey featuring a fictional PNES case followed by assessment style options ("Multiaxial," "Narrative," and "BPS/PPP"). Respondents clearly preferred the robust BPS/PPP approach over less-comprehensive multiaxial and narrative assessments (p<0.0001). Reasons for choosing the BPS/PPP by respondents include ease of organization, clear therapeutic goals, and comprehensive nature. This assessment of acceptability of a BPS/PPP approach to PNES assessment among community mental health practitioners may provide a patient-centered mechanism to enhance referrals from the neurological to mental health setting. Implications and future directions are explored.

Improving first responders' psychogenic nonepileptic seizures diagnosis accuracy: Development and validation of a 6-item bedside diagnostic tool

OBJECTIVE

Epileptic seizures (ES) are often seen as a medical emergency, and their immediate and accurate recognition are pivotal in providing acute care. However, a number of clinical situations may mimic ES, potentially leading to misdiagnosis at the emergency room and to inappropriate prescription of antiepileptic drugs (AED) in the acute and chronic settings. Psychogenic nonepileptic seizures (PNES) play a major role in this scenario and often delay the correct diagnosis and increase treatment morbidity and cost. First responders often conduct the initial assessment of these patients, and their impression may be decisive in the prehospital approach to seizures. We sought to investigate and improve the accuracy of PNES diagnosis among professionals involved in the initial assistance to patients with seizures.

METHODS

Fifty-three registered nurses, 34 emergency physicians, 33 senior year medical students, and 12 neurology residents took a short training program consisting of an initial video-based seizure assessment test (pretest), immediately followed by a 30-minute presentation of a 6-item bedside diagnostic tool and then a video-based reassessment (posttest). Baseline status and learning curves were determined.

RESULTS

The distinct professional categories showed no significant differences in their ability to diagnose PNES on both pretests and posttests. All groups improved diagnostic skills after the instructional program.

SIGNIFICANCE

The findings helped determine the best identifiable PNES clinical signs and to provide initial validation to a novel diagnostic instrument. In addition, our results showed that educational measures might help in the identification of PNES by first responders, which may decrease the treatment gap.

Biomarkers in the diagnosis and study of psychogenic nonepileptic seizures: A systematic review

OBJECTIVE

Video electroencephalography (vEEG) is the gold-standard method for diagnosing psychogenic nonepileptic seizures (PNES), but such assessment is expensive, unavailable in many centers, requires prolonged hospitalization, and many times is unable to capture an actual seizure episode. This paper systematically reviews other non-vEEG candidate biomarkers that may facilitate both diagnosis and study of PNES as differentiated from epileptic seizures (ES).

METHODS

PubMed database was searched to identify articles between 1980 and 2015 (inclusion: adult PNES population with or without controls, English language; exclusion: review articles, meta-analyses, single case reports).

RESULTS

A total of 49 studies were examined, including neuroimaging, autonomic nervous system, prolactin, other (non-prolactin) hormonal, enzyme, and miscellaneous marker studies. Functional MRI studies have shown PNES is hyperlinked with dissociation and emotional dysregulation centers in the brain, although conflicting findings are seen across studies and none used psychiatric comparators. Heart rate variability suggests increased vagal tone in PNES when compared to ES. Prolactin is elevated in ES but not PNES, although shows low diagnostic sensitivity. Postictal cortisol and creatine kinase are nonspecific. Other miscellaneous biomarkers (neuron specific enolase, brain derived neurotropic factor, ghrelin, leptin, leukocytosis) showed no conclusive evidence of utility. Many studies are limited by lack of psychiatric comparators, size, and other methodological issues.

CONCLUSION

No single biomarker successfully differentiates PNES from ES; in fact, PNES is only diagnosed via the negation of ES. Clinical assessment and rigorous investigation of psychosocial variables specific to PNES remain critical, and subtyping of PNES is warranted. Future investigational and clinical imperatives are discussed.

Psychogenic nonepileptic seizures in children - Psychological presentation, treatment, and short-term outcomes

PURPOSE

The purpose of this study was to better understand the etiologies, features, and care outcomes of psychogenic nonepileptic seizures (PNESs) in a pediatric setting.

METHOD

We performed a retrospective analysis of 32 sequentially referred children for suspected PNESs to a neurology psychology service over a 6-year period. After excluding non-PNES paroxysmal events (related to anxiety or migraine), 29 patients were identified with final diagnosis of PNESs. Charts were examined for presenting symptom data, demographics, comorbidities, neurological diagnoses and investigations, as well as psychological assessment, management, and outcome. Treatment consisted of education around diagnosis and of individual psychological treatment, which, in most cases, was cognitive behavioral therapy up to 14 sessions. Additional mental health services including psychiatric medication, family therapy, and admission to day or inpatient treatment were also utilized in a smaller number of cases. Total treatment periods ranged from 4 weeks to 12 months.

RESULTS

The majority of patients identified were adolescent (90%), Caucasian (72%), and female (76%). Preceding psychology referral, point of entry into medical care for PNESs was primarily through the emergency department (66%) or outpatient neurology clinic referral (31%). Whereas 39% of parents described significant internalizing symptoms in their child (BASC-2), patients themselves tended to underreport anxiety or depression as demonstrated by only 16% endorsement on the BYI-II. By contrast, MACI personality assessment response patterns for adolescents demonstrated high levels of psychic tension/anxiety (65%), depressive affect (55%), and maladaptive personality traits including inhibition (45%), submissiveness (35%), and introversion (30%). Appropriate psychological treatment was associated with high rates of full remission (no new events, n=17, 59%) and partial remission (50% or greater reduction in events, n=6, 21%) as self-reported at discharge. Accurate diagnosis and referral to psychology also led to a sevenfold reduction in PNES-related emergency department visits one year after initial psychology visit compared with the preceding year.

CONCLUSIONS

This study suggests that appropriate care for PNESs reduces inappropriate medical investigation and therapy, expedites rates of remission, and decreases health-care utilization in a pediatric setting.

A Therapeutic Approach to Psychogenic Nonepileptic Seizures

OPINION STATEMENT

The diagnosis of psychogenic nonepileptic seizures (PNES) is usually made in the seizure monitoring unit (SMU; also commonly named the epilepsy monitoring unit) after PNES are recorded on video-EEG. The diagnosis should be discussed with the patient thoroughly. The discussion should focus on how the diagnosis was reached and that the diagnosis is real and treatable. When the diagnosis is communicated well, some patients may improve significantly without further interventions. Next, a psychiatric evaluation should be completed, ideally before discharge from the SMU. After discharge, the patient should undergo cognitive behavioral therapy (CBT), the only treatment for PNES that is supported by high-quality evidence. Other therapies, including psychodynamic therapy and different types of group therapy can be considered in some patients, although high-level evidence to support their use is lacking. Some patients may benefit from selective serotonin-reuptake inhibitors (SSRIs), especially when psychiatric comorbidities are present. This should be considered on a case-by-case basis.

Psychogenic Paroxysmal Nonepileptic Events in Children: A Review

BACKGROUND

Paroxysmal nonepileptic events are common in children. Events with a psychological basis, historically referred to as pseudoseizures, are a large subset of paroxysmal nonepileptic events.

METHODS

A review of the relevant pediatric and adult literature was performed.

RESULTS

It was found that these events have many semioloigc features similar to epileptic events and can be challenging to correctly identify. The use of a detailed history in combination with video encephalography and knowledge of psychogenic paroxysmal nonepileptic events will facilitate making the correct diagnosis. Paroxysmal nonepileptic events are important to identify as comorbid disorders such as depression, anxiety disorder, family discord, and school issues are frequent. In addition, prior sexual, emotional, and/or physical abuse may be present.

CONCLUSIONS

Pediatric patients with paroxysmal nonepileptic events need to be recognized in order to avoid unnecessary antiepileptic drugs and emergency department or hospital visits and to facilitate appropriate psychological intervention to address the underlying etiologies. This review will focus on evaluation and identification of paroxysmal nonepileptic events, in addition to reviewing the various comorbidities, effective treatments, and outcomes for pediatric patients. The key differences between pediatric and adult patients with paroxysmal nonepileptic events are addressed.

Diagnostic assessment and case formulation in psychogenic nonepileptic seizures: A pilot comparison of approaches

Management of psychogenic nonepileptic seizures (PNES) is complex, requiring multidisciplinary care. A standardized assessment approach to PNES is lacking, yet use of a comprehensive model may alleviate problems such as mental health aftercare noncompliance. Although a biopsychosocial (BPS) approach to PNES balancing predisposing, precipitating, and perpetuating (PPP) variables has been described, it is unclear how this formulation style is perceived amongst clinicians. We predicted preference of a comprehensive, "BPS/PPP" assessment style by those most involved in PNES diagnosis and care (i.e., neurologists and psychologists). Sixty epileptologists, psychiatrists, and psychologists completed a survey featuring a fictional PNES case followed by assessment style options ("Multiaxial," "Narrative," and "BPS/PPP"). Epileptologists and psychologists ("nonpsychiatrists") differed from psychiatrists in PNES case formulation choice, with nonpsychiatrists preferring the robust BPS/PPP approach and with psychiatrists opting for less comprehensive Multiaxial and Narrative assessments (p=0.0009). Reasons for choosing the BPS/PPP by nonpsychiatrists included ease of organization, clear therapeutic goals, and comprehensive nature. Alternatively, psychiatrists cited time constraints and familiarity as reasons to prefer briefer Multiaxial or Narrative approaches. This pilot assessment of acceptability of a BPS/PPP approach to PNES case formulation, thus, reveals important gaps in formulation priorities between neurologists and psychiatrists. Implications and future directions are explored.

Reducing severity of comorbid psychiatric symptoms in an epilepsy clinic using a colocation model: results of a pilot intervention

RATIONALE

Patients with epilepsy (PWEs) and patients with nonepileptic seizures (PWNESs) constitute particularly vulnerable patient populations and have high rates of psychiatric comorbidities. This potentially decreases quality of life and increases health-care utilization and expenditures. However, lack of access to care or concern of stigma may preclude referral to outpatient psychiatric clinics. Furthermore, the optimal treatment for NESs includes longitudinal psychiatric management. No published literature has assessed the impact of colocated psychiatric services within outpatient epilepsy clinics. We, therefore, evaluated the colocation of psychiatric services within a level 4 epilepsy center.

METHODS

From July 2013 to June 2014, we piloted an intervention to colocate a psychiatrist in the Dartmouth-Hitchcock Epilepsy Center outpatient clinic one afternoon a week (0.1 FTE) to provide medication management and time-limited structural psychotherapeutic interventions to all patients who scored greater than 15 on the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) and who agreed to referral. Psychiatric symptom severity was assessed at baseline and follow-up visits using validated scales including NDDI-E, Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and cognitive subscale items from Quality of Life in Epilepsy-31 (QOLIE-31) scores.

RESULTS

Forty-three patients (18 males; 25 females) were referred to the clinic over a one-year interval; 27 (64.3%) were seen in follow-up with a median of 3 follow-up visits (range: 1 to 7). Thirty-seven percent of the patients had NESs exclusive of epilepsy, and 11% of the patients had dual diagnosis of epilepsy and NESs. Psychiatric symptom severity decreased in 84% of the patients, with PHQ-9 and GAD-7 scores improving significantly from baseline (4.6±0.4 SD improvement in PHQ-9 and 4.0±0.4 SD improvement in GAD-7, p-values<0.001). Cognitive subitem scores for NDDI-E and QOLIE-31 at their most recent visit were significantly improved compared with nadir scores (3.3±0.6 SD improvement in NDDI-E and 1.5±0.2 SD improvement in QOLIE-31, p-values<0.001). These results are, moreover, clinically significant-defined as improvement by 4-5 points on PHQ-9 and GAD-7 instruments-and are correlated with overall improvement as measured by NDDI-E and cognitive subscale QOLIE-31 items.

CONCLUSION

A colocated psychiatrist demonstrated reduction in psychiatric symptoms of PWEs and PWNESs, improving psychiatric access and streamlining their care. Epileptologists were able to dedicate more time to managing epilepsy as opposed to psychiatric comorbidities. As integrated models of collaborative and colocated care are becoming more widespread, mental health-care providers located in outpatient neurology clinics may benefit both patients and providers.

Ethical dilemmas in pediatric and adolescent psychogenic nonepileptic seizures

To date, only a very narrow window of ethical dilemmas in psychogenic nonepileptic seizures (PNES) has been explored. Numerous distinct ethical dilemmas arise in diagnosing and treating pediatric and adolescent patients with PNESs. Important ethical values at stake include trust, transparency, confidentiality, professionalism, autonomy of all stakeholders, and justice. In order to further elucidate the ethical challenges in caring for this population, an ethical analysis of the special challenges faced in four specific domains is undertaken: (1) conducting and communicating a diagnosis of PNESs, (2) advising patients about full transparency and disclosure to community including patients' peers, (3) responding to requests to continue antiepileptic drugs, and (4) managing challenges arising from school policy and procedure. An analysis of these ethical issues is essential for the advancement of best care practices that promote the overall well-being of patients and their families.

Quality Improvement Opportunities in Caring for Patients with Nonepileptic Seizures

Background. Patients with nonepileptic seizures (NES) are challenging to treat for myriad reasons. Often patients may be misdiagnosed with having epilepsy and then may suffer unintended consequences of treatment side effects with antiepileptic medication. In addition, patients may be maligned by health care providers due to a lack of ownership by both psychiatrists and neurologists and a dearth of dedicated professionals who are able to effectively treat and reduce severity and frequency of symptoms.Aims of Case Report. Many psychiatrists and neurologists are unaware of the extent of the barriers to care faced by patients with NES (PWNES) and the degree of perception of maltreatment or lack of therapeutic alliance at various stages of their care, including medical workup, video-EEG monitoring, and follow-up plans. We present the case of a patient with NES who experienced numerous barriers as well as incoordination to her care despite being offered a breadth of resources and discuss the quality improvement opportunities that may exist to improve care of patients with NES.Conclusion. No known literature has documented the extensive barriers to care of PWNES in parallel to quality improvement opportunities for improving their care. We endeavor to contribute to the overall formulation and development of a clinical care pathway for PWNES.