Which psychogenic nonepileptic seizure (PNES) patients are more likely to be treated with anti-seizure medications?

BACKGROUND

The average time for psychogenic nonepileptic seizures (PNES) diagnosis is about 7.5 years. Many patients receive inadequate treatment and sometimes even life-threatening treatments such as tracheal intubation during this time.

PURPOSE

To determine the risk factors for misdiagnosis of PNES as Epilepsy.

METHODS

The medical records of patients who underwent video-electroencephalogram (EEG) monitoring were reviewed retrospectively. Patients who had PNES without epileptic seizures (ES) were included in this study. Baseline personal and monitoring characteristics were collected. The patients were then divided into two groups based on their therapeutic status. Patients in the treatment group were again divided into two groups based on the number of anti-seizure medications (ASM) they were treated with.

RESULTS

Fifty-seven patients diagnosed with PNES were included in this study. Thirty-seven patients were under treatment, and 20 patients were not under treatment at the time of monitoring. Motor seizures, abnormal interictal EEG patterns, and pathological brain imaging findings were more frequent among patients in the treatment group (p<0.05). Patients with motor seizures were more likely to be treated with multiple ASM than patients with only dialeptic nonmotor seizures (p<0.05). Lastly, patients in the treatment group were monitored longer and had fewer seizures during monitoring (p<0.05).

CONCLUSION

PNES patients with abnormal EEG patterns and pathological brain imaging findings are more likely to be treated with ASM. The pure dialeptic nature of seizures is less likely to be misdiagnosed as ES. In addition, patients with such seizures are less likely to be treated with multiple treatment lines.

Inhibition of HIF-1α-AQP4 axis ameliorates brain edema and neurological functional deficits in a rat controlled cortical injury (CCI) model

Traumatic brain injury (TBI) is an important cause of death in young adults and children. Till now, the treatment of TBI in the short- and long-term complications is still a challenge. Our previous evidence implied aquaporin 4 (AQP4) and hypoxia inducible factor-1α (HIF-1α) might be potential targets for TBI. In this study, we explored the roles of AQP4 and HIF-1α on brain edema formation, neuronal damage and neurological functional deficits after TBI using the controlled cortical injury (CCI) model. The adult male Sprague Dawley rats were randomly divided into sham and TBI group, the latter group was further divided into neutralized-AQP4 antibody group, 2-methoxyestradiol (2-ME2) group, and their corresponding control, IgG and isotonic saline groups, respectively. Brain edema was examined by water content. Hippocampal neuronal injury was assessed by neuron loss and neuronal skeleton related protein expressions. Spatial learning and memory deficits were evaluated by Morris water maze test and memory-related proteins were detected by western blot. Our data showed that increased AQP4 protein level was closely correlated with severity of brain edema after TBI. Compared with that in the control group, both blockage of AQP4 with neutralized-AQP4 antibody and inhibition of HIF-1α with 2-ME2 for one-time treatment within 30-60 min post TBI significantly ameliorated brain edema on the 1st day post-TBI, and markedly alleviated hippocampal neuron loss and spatial learning and memory deficits on the 21st day post-TBI. In summary, our preliminary study revealed the short-term and long-term benefits of targeting HIF-1α-AQP4 axis after TBI, which may provide new clues for the selection of potential therapeutic targets for TBI in clinical practice.

The auditory startle response in relation to outcome in functional movement disorders

BACKGROUND

The auditory startle reflex (ASR) is enlarged in patients with functional movement disorders (FMD).

OBJECTIVES

To study whether the ASR relates to symptom reduction in FMD patients, who participated in a placebo controlled double blind treatment trial with Botulinum Neurotoxin (BoNT).

METHODS

Response to treatment in the BoNT study was assessed using the Clinical Global Impression - Improvement scale (CGI-I). The electromyography (EMG) muscle activity of 7 muscles following 110 dB tones was measured in 14 FMD patients before and after one-year treatment and compared to 11 matched controls. The early and a late (behaviorally affected) component of the ASR and the sympathetic skin response (SSR) were assessed.

RESULTS

10 of 14 patients (71.4%) showed symptom improvement, which was believed to be mainly caused by placebo effects. The early total response probability of the ASR at baseline tended to be larger in patients compared to controls (p = 0.08), but normalized at follow-up (p = 0.84). The late total response probability was larger in patients vs. controls at baseline (p < 0.05), a trend that still was present at follow-up (p = 0.08). The SSR was higher in patients vs. controls at baseline (p < 0.01), and normalized at follow-up (p = 0.71).

CONCLUSIONS

On a group level 71.4% of the patients showed clinical symptom improvement after treatment. The early part of the ASR, most likely reflecting anxiety and hyperarousal, normalized in line with the clinical improvement. Interestingly, the augmented late component of the ASR remained enlarged suggesting persistent altered behavioral processing in functional patients despite motor improvement.

[A patient diagnosed with conversion disorder who did not respond to therapy]

A 61-year-old woman with a conversion disorder (functional neurological symptom disorder) was referred by her neurologist to the outpatient psychiatric clinic for medically unexplained somatic symptoms. She did not respond well to our treatment, which we initially related to a comorbid mood disorder. Eventually, a progression of both motor and cognitive symptoms were found to be consistent with corticobasal degeneration, a rare neurodegenerative disorder. This case report illustrates the importance of a revised neurological examination when a patient with conversion disorder does not improve.

Serotonin Transporter Gene (SLC6A4) Polymorphism May Be Associated with Chinese Globus Pharyngeus and Its Antidepressant Effects

BACKGROUND

Although globus pharyngeus is not rare in clinical practice, little is known about its associated gene polymorphism. We investigated the association between the SLC6A4 polymorphism and globus pharyngeus and its response to treatment with antidepressants.

METHODS

A total of 84 patients were diagnosed with globus pharyngeus according to Rome III, and 160 healthy controls were genotyped for the SLC6A4 polymorphism using polymerase chain reaction amplification and agarose gel electrophoresis. All patients with globus were studied using high-resolution manometry pre-therapy. Globus patients were randomized into paroxetine or amitriptyline groups for a 6-week treatment and asked to complete the following pre- and post-therapy questionnaires: the Glasgow Edinburgh Throat Scale (GETS), the Pittsburgh Sleep Quality Index, and the Hamilton Rating Scale Anxiety/Depression. Treatment response was defined as a >50% reduction in the GETS scores.

RESULTS

A significant difference was observed in the globus S/S genotype with anxiety compared to that without anxiety (χ2 = 14.579, p = 0.006). The L/S genotype showed a significant difference between high upper esophageal sphincter pressure (>104 mm Hg) and non-high upper esophageal sphincter pressure patients (χ2 = 14.433, p = 0.006). A significant association between the S/S genotype and the response to antidepressant treatment was also observed, while patients with sleep disorders or depression showed no association.

CONCLUSION

A significant association was observed between the S/S genotype of the SLC6A4 polymorphism and globus pharyngeus, suggesting that SLC6A4 is a potential candidate gene involved in the pathogenesis of globus pharyngeus.

The role of placebo in the diagnosis and treatment of functional neurologic disorders

Placebo therapy can produce meaningful, clinical relief for a variety of conditions. While placebos are not without their ethically fraught history, they continue to be used, largely covertly, even today. Because the prognosis for psychogenic disorders is often poor and recovery may be highly dependent on the patient's belief in the diagnosis and treatment regimen, some physicians find placebo therapy for psychogenic disorders compelling, but also particularly contentious. Yet placebos also have a long tradition of being used for provocative diagnosis (wherein placebo is used to elicit and/or terminate the symptoms as a way of diagnosing symptoms as "psychogenic"). In this chapter we discuss cases describing placebo as therapy for psychogenic disorders and the challenges related to embedded Cartesian beliefs in Western medicine. The legitimate ethical reservations against placebo therapy, in general, have been related to assumptions about their "inertness" and a requirement for deception, both which are being refuted by emerging data. In this chapter, we also re-evaluate the concerns associated with placebo therapy for psychogenic disorders by asking, "Are we harming patients by withholding placebo treatment?"

Concurrent Presentation of Burning Mouth Syndrome and Globus Pharyngis in Enugu, Nigeria: A Ten-year Clinical Evaluation

PURPOSE

To review 22 patients with globus pharyngis among a group of 39 patients who presented with burning mouth syndrome and to highlight the clinical presentation and treatment outcome of these oropharyngeal symptoms, often ignored by practicing oral surgeons.

PATIENTS AND METHODS

We carried out a retrospective review of 39 patients with burning mouth syndrome seen at oral surgery units of three specialist hospitals in Enugu, Nigeria between 2001 and 2010. The focus was on the 22 of these patients with burning mouth syndrome and globus pharyngis (the persistent sensation of having phlegm, a pill or some other sort of obstruction in the throat when there is none). Relevant information included patients' oral habits and dental status, past medical history, sociodemographic data, onset of symptoms and treatment outcome.

RESULTS

Amongst the 22 patients, 8 (36.4%) were males while 14 (63.6%) were females, giving a male to female ratio of 1:1.8. Of the 8 male patients, 3 (37.5%) were retrenched workers, 2 (25%) were drug addicts, 2 (25%) had a history of psychiatric problems and 1 (12.5%) had post-radiation therapy due to diagnosis of adenocystic carcinoma. Amongst the 14 female patients, 6 (42.8%) were divorcees, 3 (21.4%) were unemployed and unmarried, 2 (14.3%) had menopausal problems, 2 (14.3%) had dental prostheses and 1 (7.2%) had a history of mental disorder.

CONCLUSION

Globus pharyngis can present at the same time in some individuals with burning mouth syndrome. The emotional aetiological factor in this unusual ailment calls for proper examinations and a multidisciplinary approach in the management of patients who presented with burning mouth syndrome, especially with a history of depression.

[Before you diagnose a patient with a conversion disorder, perform a thorough general medical and neurological examination. Case study]

INTRODUCTION

Dissociative and conversion disorders are classified together according to ICD-10 as states that are not confirmed by the presence of somatic diseases, which they suggest. According to the DSM-IV, both disorders are classified separately. Conversion disorders are a group of psychiatric disorders whose symptoms mimic the presence of malfunction or loss of motor or sensory function, whereas the nature and dynamics of the observed symptoms is not fully explained by the results of objective assessments and consultations, nor is the direct effect of a psychoactive substance. Impaired mental integration of different functions which normally interact simultaneously in the perception of reality and inner experience of the individual is found in dissociative disorders.

AIM

The article describes the case of 25-year old man, in whom after initial suspicion of myasthenia gravis and its exclusion, a diagnosis of conversion disorder was made on the basis of the clinical picture and treatment with an SSRI antidepressant and individual psychotherapy were recommended. No improvement in mental and neurological status after six month therapy resulted in an in-depth diagnostics in a clinical setting and diagnosis of brain stem tumor (aastrocytoma fibrillare).

CONCLUSIONS

(a) Neuroimaging is a source of important clinical data and in many cases should constitute an inherent element of a psychiatric diagnosis. (b) Diagnosis of conversion (dissociative) disorders requires a precise differential diagnosis, excluding the somatic causes of observed neurological ailments. (c) A late diagnosis of neurological or somatic causes of symptoms which arouse a suspicion of conversion (dissociative) disorders may make a radical treatment impossible or may considerably aggravate the remote prognosis and quality of the patients' life.

Clinical observations on 46 cases of globus hystericus treated with modified Banxia Houpu decoction

OBJECTIVE

To observe the therapeutic effect and mechanism of modified Banxia Houpu decoction on globus hystericus.

METHODS

The 95 patients with globus hystericus were randomly divided into a treatment group of 46 cases treated with modified Banxia Houpu decoction and a control group of 49 cases treated with Manyanshuning (Granula for Clearing the Throat). In addition, a normal group of 24 healthy people was set up. SCL-90 scale was adopted to observe the therapeutic effect, evaluate the psychological state of patients and build a database on combination of four diagnoses.

RESULTS

The effect of the modified Banxia Houpo decoction was better than that of the control group in relieving depression, anxiety and improving the psychological state (P<0.05 or P<0.01).

CONCLUSION

Modified Banxia Houpu decoction has definite therapeutic effect on globus hystericus. Its mechanism may be related to its function in relieving depression and anxiety and regulating the psychological state.

Antidepressant treatment outcomes of psychogenic movement disorder

BACKGROUND

Psychogenic movement disorder (PMD) is a subtype of conversion disorder. We describe the outcomes of a series of PMD patients following antidepressant treatment.

METHOD

Twenty-three outpatients with chronic PMD, diagnosed using Fahn and Williams' criteria, underwent psychiatric assessment. The patients were referred for assessment and management from January 2003 to July 2004. Fifteen agreed to be treated with antidepressants. Patients received citalopram or paroxetine; those who did not respond after 4 weeks of taking an optimal dose were switched to venlafaxine. Concurrently, 3 had supportive psychotherapy, and 1 had family intervention. Assessments included the DSM-IV-based Mini-International Neuropsychiatric Interview and scales measuring depression, anxiety, and motor and global severity.

RESULTS

Eighteen patients (78%) had at least 1 Axis I diagnosis in addition to the somatoform diagnosis, and 3 (13%) had somatization disorder. Five (22%) had previous psychiatric contact. Nine (39%) had previously been treated with antidepressants, but only 4 (17%) had adequate trials. No significant differences existed in patient characteristics between treated and untreated groups. Among treated patients, Montgomery-Asberg Depression Rating Scale scores improved from baseline (p < .01). Two treated subgroups were identified: 10 patients (67%) had primary conversion disorder, of whom 8 had marked motor and global improvements with 7 complete remissions, and 5 (33%) had primary hypochondriasis, somatization disorder, or probable factitious disorder/malingering, of whom none improved. All of the patients with primary conversion disorder had a current or previous depressive or anxiety disorder compared with 40% (N = 2) of the patients with additional somatoform diagnoses.

DISCUSSION

Our preliminary findings suggest that chronic PMD with primary conversion symptoms and with recent or current depression or anxiety may respond to antidepressants. Further well-designed studies, now under way, are required to confirm these findings.

The Treatment of Nonepileptic Seizures: Historical Perspectives and Future Directions

Nonepileptic seizures (NES) are neuropsychiatric disorders presenting with a combination of neurologic signs and underlying psychological conflicts. For more than a century, the medical community has accumulated data and insights about the phenomenology, epidemiology, risks, comorbidities, and prognosis of NES. However, we have not progressed much beyond anecdotal reports of treatments for NES, and no randomized, controlled trials of treatment for the disorder have been conducted. We review the diagnosis and treatment of NES and suggest directions for future research in these areas.

Pseudoseizures and hysterical stridor

Differentiation of pseudoseizures from epileptic seizures and hysterical stridor from asthma is key to the treatment of patients. Both pseudoseizures and hysterical stridor are associated commonly with sexual abuse, eating disorders, depression, substance abuse, anxiety disorders, and personality disorders. Failure to reach an appropriate diagnosis results in inappropriate medical care including recurrent intubations, antiepileptic drugs, and excessive hospitalizations. This case represents the first instance of reported pseudoseizures in a patient with hysterical stridor secondary to childhood sexual abuse.

Psychogenic nonepileptic seizures are associated with an increased risk of obesity

Psychogenic nonepileptic seizures (NES) are somatic manifestations of psychological distress. There is some evidence that weight problems are more common in patients with psychiatric illness. We have observed that patients admitted for video-EEG monitoring who we diagnosed with NES commonly have a larger body habitus than patients with epilepsy. The goal of this study was to test our hypothesis that there was a significant difference in body mass index (BMI) in patients with nonepileptic seizures compared with their epileptic counterparts. We compared the BMIs of 46 NES patients and 46 age- and gender-matched epileptic controls and found that the NES patients had significantly higher BMIs (30.5 vs 26.1, P=0.006) than controls. This remained true after controlling for weight-gain properties of antiepileptic drugs. These results are compared with the prevalence of overweight and obesity in the general population. Possible explanations of the findings and limitations of the study are discussed.

Hysterical stridor: a report of two cases

Stridor as an initial symptom of a conversion reaction (hysteria) is rare. We report cases of hysterical stridor in two older women, unrelated and unacquainted, from the same rural community in Oman. Once the diagnosis was made, both patients were successfully treated with a single dose of an anxiolytic. We also review the literature on hysterical stridor and discuss the diagnostic dilemmas and therapeutic options.

Brainstem conundrum: the Chiari I malformation

PURPOSE

To describe the Chairi I Malformation in relation to the anatomy of the brain and spinal cord, the common manifestations of the condition, diagnostic considerations, and management for the primary care provider.

DATA SOURCES

Extensive review of the world-wide scientific literature on the condition, supplemented with actual case studies.

CONCLUSIONS

The adult Chairi I Malformation is an insidious congenital brainstem anomaly that consists of caudal displacement of the cerebellar tonsils, brainstem and fourth ventricle into the upper cervical space, resulting in overcrowding of the posterior fossa.

IMPLICATIONS FOR PRACTICE

Due to the vague, and often ambiguous presenting symptoms of Chiari I Malformation, many patients are misdiagnosed with conditions such as multiple sclerosis, fibromyalgia, chronic fatigue syndrome, or psychiatric disorders. Patients frequently experience symptoms months to years prior to accurate diagnosis and often incur irreversible neurologic deficits.

Seizure suggestibility may not be an exclusive differential indicator between psychogenic and partial complex seizures: the presence of a third factor

Differential diagnosis between psychogenic or ('hysterical') pseudoseizures and clinical partial complex seizures has often employed an index or inference of suggestibility. However, recent research indicates a moderate association between complex partial epileptic-like signs and hypnotic capacity in the normal population as well as for complex partial epileptic patients. Consequently, the precipitation of overt, non-stereotyped seizures by instruction may not be a reliable diagnostic method when an insidious process is slowly elevating temporal/limbic lobe lability. Implications for treatment and contra-indication of antipsychotic (D2 antagonist) drugs are discussed.

The amytal interview in the treatment of conversion disorder: three case reports

The records of three consecutive patients who had a diagnosis of conversion disorder and received an amytal interview were reviewed. All diagnoses were made according to DSM-III-R criteria by a staff psychiatrist. Amytal was administered according to a previously published protocol. All patients were contacted 1 year following their hospital discharge. All patients tolerated the amytal interview without complications. The conversion symptoms in all patients remitted within several days of the interview and had not recurred at 1 year follow-up. In properly selected patients, the use of the amytal interview may be a safe, rapid, and efficacious intervention that can facilitate the resolution of conversion symptoms in the military setting.

Problems in treating globus pharyngis

Twenty-four out-patients with globus were assessed for current and past psychiatric illness with the 'Schedule for Affective Disorders and Schizophrenia-Lifetime Anxiety' version. Patients then received amitriptyline or placebo in a double-blind fashion. Treatment outcome was assessed using an inventory of throat symptoms, Beck Depression Inventory, Spielberger State Anxiety Scale, Crown-Crisp Experimental Index and General Health Questionnaire. Nine patients met the DMS-III criteria for psychiatric disorder in the past; six had suffered from panic disorder. Two further patients had been troubled by classic panic attacks. Nine of the 12 patients treated with amitriptyline and two of the placebo group discontinued treatment. In conclusion, clinical and psychometric associations were found between pathological anxiety and globus, and it appears that the recommendation that globus be treated 'aggressively' with tricyclic antidepressants is likely to lead to a high proportion of treatment failures.

A double-blind, placebo-controlled study of alpidem, a novel anxiolytic of imidazopyridine structure, in chronically anxious patients

In this double-blind study alpidem, a new imidazopyridine anxiolytic drug, was compared with placebo to assess its efficacy and safety in severely anxious patients at the fixed dose of 150 mg/day (50 mg t.i.d.) for 3 weeks. Fifty-nine patients with a score of at least 18 on the Hamilton Rating Scale for Anxiety (HRSA) entered the trial after a 3- to 7-day placebo run-in period. Symptom improvement was evaluated with the HRSA, the State and Trait Anxiety Inventory (STAI-1 and STAI-2), a Visual Analogue Scale (VAS) and the Clinical Global Impression (CGI). Alpidem was more effective than placebo in improving mean HRSA (total score and factorial scores for somatic and psychic anxiety), STAI-1 and STAI-2 and VAS scores. The efficacy index of the CGI was better for alpidem than for placebo. Side effects were negligible in both groups. Alpidem appears to be a new interesting anxiolytic drug devoid of significant sedative effects on mental functions.

Narcosuggestion in chronic conversion symptoms using combined intravenous amobarbital and methylphenidate

Five patients with chronic conversion symptoms were treated with narcoanalysis and narcosuggestion using combined methylphenidate and amobarbital. The combination of methylphenidate and amobarbital proved useful because methylphenidate antagonized sedation and allowed optimal patient cooperation. In four cases recovery of neurological function was obtained in the first or second interview and subsequently improved with practice and positive feedback. In each instance recovery of neurological function during a narcoanalytic interview confirmed the diagnosis of a conversion reaction. The narcoanalytic interview also confirmed or uncovered important psychopathology and psychodynamics which permitted more accurate treatment of the underlying psychiatric disorders.

The use of thiopentone in the treatment of non-organic locomotor disorders

Eleven patients who had been fully investigated and diagnosed by orthopaedic surgeons as suffering from non-organic locomotor disorders were assessed and treated by a psychiatrist (AW) using a technique involving one or more injections of thiopentone sodium. The patients had been ill for an average of 3.4 yr (3 mths to 10 yr) and suffered severe disablement. Injections of short-acting barbiturates have been used for many years to facilitate the release and discussion of repressed feelings and emotions (narcoanalysis). This paper describes the use of a similar injection but given to facilitate the movement and return to normality of muscles whose function is deranged. The authors suggest that this technique be called 'narcokinesis'. All eleven patients showed initial improvement with seven patients showing moderate or marked benefit from the treatment at the time of discharge from hospital. A detailed case study is described of the advantages of narcokinesis and possible mode of action discussed. The general practitioners of these patients were sent a questionnaire by post and all replied. At the time of follow-up (6-9 yr) the whereabouts of three patients were unknown, three had died, two remained ill and three patients remained well or moderately well.

Globus hystericus syndrome responsive to antidepressants

Three patients with globus hystericus responded to antidepressant medication. The authors discuss the syndrome's relationship to major depression, its diagnostic classification, and its treatment.

Conversion without hysteria: a case report and review of the literature

The term 'conversion' implies a correlation between conversion symptoms, hysteria, and hysterical personality. A clinical case of conversion related to chronic post-traumatic disorder, with paranoid features, was successfully treated by anti-psychotic drugs; it illustrates the non-specific nature of conversion symptoms. Mechanic's concept of 'illness behaviour' is a frame-work that meets the need for a broader understanding of conversion symptoms.

Case report of conversion symptom associated with major depressive disorder in a child

A 10-year-old boy had a prominent conversion symptom that obscured a major depressive episode as defined by DSM-III. After the conversion symptom was removed with amobarbital, his depressive symptoms became more obvious and subsequently improved with imipramine treatment.