Treatment of Psychogenic Nonepileptic Seizures

The role of neuropsychology in the care of patients with functional neurological symptom disorder

OBJECTIVE

Functional neurological symptom disorder (FNSD) is a neuropsychiatric condition characterized by signs/symptoms associated with brain network dysfunction. FNSDs are common and are associated with high healthcare costs. FNSDs are relevant to neuropsychologists, as they frequently present with chronic neuropsychiatric symptoms, subjective cognitive concerns, and/or low neuropsychological test scores, with associated disability and reduced quality of life. However, neuropsychologists in some settings are not involved in care of patients with FNSDs. This review summarizes relevant FNSD literature with a focus on the role of neuropsychologists.

METHODS

A brief review of the literature is provided with respect to epidemiology, public health impact, symptomatology, pathophysiology, and treatment.

RESULTS

Two primary areas of focus for this review are the following: (1) increasing neuropsychologists' training in FNSDs, and (2) increasing neuropsychologists' role in assessment and treatment of FNSD patients.

CONCLUSIONS

Patients with FNSD would benefit from increased involvement of neuropsychologists in their care.

Factors Influencing Triage to Rehabilitation in Functional Movement Disorder

BACKGROUND

Treatment of functional movement disorder (FMD) should be individualized, yet factors determining rehabilitation engagement have not been evaluated. Subspecialty FMD clinics are uniquely poised to explore factors influencing treatment suitability and triage.

OBJECTIVES

To describe our approach and explore factors associated with triage to FMD rehabilitation.

METHODS

We conducted a retrospective chart review of 158 consecutive patients with FMD seen for integrated assessment by movement disorders neurology and psychiatry, with the purpose of triage to rehabilitation. Demographic and clinical variables were compared between patients triaged to therapy versus no therapy, and logistic regression was used to explore factors predictive of triage outcome. Change in primary outcome scores were analyzed.

RESULTS

Sixty-six patients (42%) were triaged to FMD therapy from July 2019 to December 2021. Patients triaged to therapy were more likely to have a constant movement disorder, gait disorder and/or tremor, hyperarousal, readiness for change, and people pleasing traits. Patients triaged to no therapy demonstrated persistent diagnostic disagreement, an inability to appreciate motor symptom inconsistency, low self-agency, a propensity to dissociate, and cluster B traits. 90% of patients triaged to rehabilitation had improved outcomes.

CONCLUSIONS

The ability to "opt-in" to FMD rehabilitation relies on different factors than those relevant to establishing a diagnosis. Unlike many other neurological disorders, a triage and treatment planning step is recommended to identify those likely to meaningfully engage at that time. Holistic assessment through a transdisciplinary lens, and working collaboratively with the patient is essential to prioritize symptoms, determine engagement, and identify treatment targets.

Which terms should be used to describe medications used in the treatment of seizure disorders? An ILAE position paper

A variety of terms, such as "antiepileptic," "anticonvulsant," and "antiseizure" have been historically applied to medications for the treatment of seizure disorders. Terminology is important because using terms that do not accurately reflect the action of specific treatments may result in a misunderstanding of their effects and inappropriate use. The present International League Against Epilepsy (ILAE) position paper used a Delphi approach to develop recommendations on English-language terminology applicable to pharmacological agents currently approved for treating seizure disorders. There was consensus that these medications should be collectively named "antiseizure medications". This term accurately reflects their primarily symptomatic effect against seizures and reduces the possibility of health care practitioners, patients, or caregivers having undue expectations or an incorrect understanding of the real action of these medications. The term "antiseizure" to describe these agents does not exclude the possibility of beneficial effects on the course of the disease and comorbidities that result from the downstream effects of seizures, whenever these beneficial effects can be explained solely by the suppression of seizure activity. It is acknowledged that other treatments, mostly under development, can exert direct favorable actions on the underlying disease or its progression, by having "antiepileptogenic" or "disease-modifying" effects. A more-refined terminology to describe precisely these actions needs to be developed.

Psychogenic non-epileptic seizures with and without epilepsy: Exploring the influence of co-existing psychiatric disorders on clinical characteristics and outcomes

BACKGROUND AND OBJECTIVES

Psychogenic non-epileptic seizures (PNES) are commonly associated with co-existing psychiatric disorders. The relationship between psychiatric factors and PNES episodes with and without epilepsy remains understudied. We reviewed co-existing psychiatric disorders in PNES-only, PNES with epilepsy aiming to examine whether these co-existing disorders associated with PNES clinical presentation and long-term outcomes.

METHODS

We conducted a retrospective, longitudinal cohort study of patients with PNES diagnosed at our EMU from May 2000 to April 2008, with follow-up clinical data until September 2015. We categorized patients into three groups: PNES-only, PNES+ definite epilepsy, and PNES+ possible/probable epilepsy.

RESULTS

In total, 271 patients with PNES were identified: 194 had PNES-only, 30 had PNES+ possible or probable epilepsy, and 47 had PNES+ definite epilepsy. No significant differences were observed in the prevalence of depression, anxiety, post-traumatic stress disorder (PTSD), substance abuse, or suicidal thoughts among the three groups. Similarly, no differences in co-existing psychiatric disorders characteristics were discovered among patients grouped by various durations and frequencies of PNES episodes. At EMU admission, for PNES-only patients total of 130/194 patients (67%) were on ASMs, and 64/194 (32.9%) were not. PNES-only not on ASM were the most likely to report at least two of the three main psychiatric disorders (depression, anxiety, and PTSD; p = 0.01). At the final follow-up, 68/130 (52.3%) and 92/130 (70.8%) patients were able to discontinue or reduce their ASM intake, respectively, with no significant differences in co-existing psychiatric disorders among them (p < 0.001). Overall, 51.6% or 31.3% of patients reported reduced or resolved PNES episodes, respectively. Further, this reduction and resolution of PNES episode were not affected by any psychological variable.

CONCLUSIONS

Co-existing psychiatric disorders prevalence did not differ between patients with PNES-only and those with coexisting epilepsy. Further, co-existing psychiatric disorders characteristics did not reliably predict PNES episode duration, frequency, reduction, or resolution. For patients with PNES-only, the presence of co-existing psychiatric disorders did not predict the rate at which ASMs could be reduced or discontinued.

Psychogenic Nonepileptic Seizures Associated with an Eating Disorder and PTSD Are Responsive to Cognitive Processing Therapy

Objective

Eating disorders (EDs) are often associated with prior histories of trauma, subsequent PTSD and related psychiatric comorbidities. There is a paucity of information about their relationship to somatic symptom disorders, specifically psychogenic nonepileptic seizures (PNES), a type of functional neurological symptom disorder or conversion disorder.

Methods

We report a case of a 39-year-old bisexual female with bulimia nervosa (BN), PTSD, recurrent major depressive disorder (MDD), cannabis use disorder, and PNES who responded to integrated trauma-focused treatment during residential ED treatment using cognitive processing therapy (CPT). Symptoms of ED, PTSD, major depression, and state-trait anxiety were measured using validated assessment instruments.

Results

During the course of CPT treatment, the patient's total scores on the PTSD Symptom Checklist for DSM-5 (PCL-5) went from 59 to 26, which is below the diagnostic threshold for PTSD. In addition, she demonstrated improvements in the Eating Disorder Examination Questionnaire (EDE-Q) Global Severity score, the Eating Disorder Inventory (EDI-2) total score, the Patient Health Questionnaire (PHQ-9) total score, the Spielberger State and Trait Anxiety Inventory scores, and the Eating Disorder Quality of Life (EDQOL) total score. Furthermore, her PNES also abated, and she remained seizure free for ∼1 year following discharge with the exception of one short seizure, per report of the patient.

Conclusion

The use of CPT as part of an integrated trauma-informed treatment approach during residential ED treatment was successful in a woman with PNES, BN, PTSD, MDD, and cannabis use disorder.

Functional Neurological Disorder in Saudi Arabia: An Update

Functional neurological disorder (FND) is characterized by neurological symptoms that lack congruence with traditional neurological diagnoses. Historically viewed through a Freudian psychoanalytic lens, FND has been conceptualized as a purely psychogenic disorder. However, the contemporary biopsychosocial perspective on FND emphasizes contributions of cognitive and neural circuit dysfunction and the disabling and involuntary nature of the illness. In Saudi Arabia, evidence suggests the prevalence of FND is significant. However, clinical programs and research focused on FND have been lacking. Studies from the region indicate that practitioners may have outdated views of FND. To address this, this narrative review provides an updated perspective on FND that is relevant to Saudi Arabia and the region. It delves into the evolving perception of FND, its underlying pathophysiology, risk factors, clinical presentations, and recent diagnostic and management advances. Unique features of FND in Saudi Arabia may include a significant role for family disputes as a risk factor, prevalent supernatural perceptions of FND, high prevalence of somatization, and cognitive dysfunction, and a potential favorable prognosis. The article concludes by providing the following recommendations related to FND in Saudi Arabia and the region: i) building educational programs to update clinicians about contemporary biopsychosocial perspectives on FND; ii) emphasizing a positive diagnostic approach based on clinical findings in FND; iii) instituting multidisciplinary programs to care for FND patients; iv) supporting systematic research efforts to explore culture-specific FND risk factors, patient outcome measures, and attitudes toward the disorder; v) developing national FND clinical practice guidelines; and vi) launching awareness campaigns to reduce FND stigma.

White Matter Structural Connectivity and Its Impact on Psychogenic Non-Epileptic Seizures: An Evidence-Based Review

Psychiatric non-epileptic seizure (PNES), also known as a form of functional neurological disorders (FND), is a common but still underrecognized disorder presenting seizure-like symptoms and no electrophysiological abnormality. Despite the significant burden of this disorder, the neurobiological mechanisms are not clearly understood, which hinders the development of better diagnosis and treatment. In the recent neuroimaging research on PNES, brain network analysis has become a relevant topic beyond conventional methodologies. The human brain is a highly intricate system of interconnected regions that collaborate to facilitate a wide range of cognitive and behavioral functions. White matter tracts, which are comprised of bundles of axonal fibers, are the primary means by which information is transmitted between different brain regions. As such, comprehending the organization and structure of the brain's white matter network is critical for gaining insight into its functional architecture. This review article aims to provide an overview of the brain mechanisms underlying PNES, with a special focus on analyzing brain networks.

Sense of control, selective attention, cognitive inhibition, and psychosocial outcomes after Retraining and Control Therapy (ReACT) in pediatric functional seizures

BACKGROUND

Differences in sense of control, cognitive inhibition, and selective attention in pediatric functional seizures (FS) versus matched controls implicate these as potential novel treatment targets. Retraining and Control Therapy (ReACT), which targets these factors, has been shown in a randomized controlled trial to be effective in improving pediatric FS with 82% of patients having complete symptom remission at 60 days following treatment. However, post-intervention data on sense of control, cognitive inhibition, and selective attention are not yet available. In this study, we assess changes in these and other psychosocial factors after ReACT.

METHODS

Children with FS (N = 14, Mage = 15.00, 64.3% female, 64.3% White) completed 8 weeks of ReACT and reported FS frequency at pre and post-1 (7 days before and after ReACT). At pre, post-1, and post-2 (60 days after ReACT), all 14 children completed the Pediatric Quality of Life Inventory Generic Core Scales, Behavior Assessment System (BASC2), and Children's Somatic Symptoms Inventory-24 (CSSI-24), and 8 children completed a modified Stroop task with seizure symptoms condition in which participants are presented with a word and respond to the ink color (e.g., "unconscious" in red) to assess selective attention and cognitive inhibition. At pre and post-1, ten children completed the magic and turbulence task (MAT) which assesses sense of control via 3 conditions (magic, lag, turbulence). In this computer-based task, participants attempt to catch falling X's while avoiding falling O's while their control over the task is manipulated in different ways. ANCOVAs controlling for change in FS from pre- to post-1 compared Stroop reaction time (RT) across all time points and MAT conditions between pre and post-1. Correlations assessed the relationships between changes in Stroop and MAT performance and change in FS from pre- to post-1. Paired samples t-tests assessed changes in quality of life (QOL), somatic symptoms, and mood pre to post-2.

RESULTS

Awareness that control was manipulated in the turbulence condition of the MAT increased at post-1 vs. pre- (p = 0.02, η2 = 0.57). This change correlated with a reduction in FS frequency after ReACT (r = 0.84, p < 0.01). Reaction time significantly improved for the seizure symptoms Stroop condition at post-2 compared to pre- (p = 0.02, η2 = 0.50), while the congruent and incongruent conditions were not different across time points. Quality of life was significantly improved at post-2, but the improvement was not significant when controlling for change in FS. Somatic symptom measures were significantly lower at post-2 vs. pre (BASC2: t(12) = 2.25, p = 0.04; CSSI-24: t(11) = 4.17, p < 0.01). No differences were observed regarding mood.

CONCLUSION

Sense of control improved after ReACT, and this improvement was proportional to a decrease in FS, suggesting this as a possible mechanism by which ReACT treats pediatric FS. Selective attention and cognitive inhibition were significantly increased 60 days after ReACT. The lack of improvement in QOL after controlling for change in FS suggests QOL changes may be mediated by decreases in FS. ReACT also improved general somatic symptoms independent of FS changes.

The neurobiology of functional neurological disorders characterised by impaired awareness

We review the neurobiology of Functional Neurological Disorders (FND), i.e., neurological disorders not explained by currently identifiable histopathological processes, in order to focus on those characterised by impaired awareness (functionally impaired awareness disorders, FIAD), and especially, on the paradigmatic case of Resignation Syndrome (RS). We thus provide an improved more integrated theory of FIAD, able to guide both research priorities and the diagnostic formulation of FIAD. We systematically address the diverse spectrum of clinical presentations of FND with impaired awareness, and offer a new framework for understanding FIAD. We find that unraveling the historical development of neurobiological theory of FIAD is of paramount importance for its current understanding. Then, we integrate contemporary clinical material in order to contextualise the neurobiology of FIAD within social, cultural, and psychological perspectives. We thus review neuro-computational insights in FND in general, to arrive at a more coherent account of FIAD. FIAD may be based on maladaptive predictive coding, shaped by stress, attention, uncertainty, and, ultimately, neurally encoded beliefs and their updates. We also critically appraise arguments in support of and against such Bayesian models. Finally, we discuss implications of our theoretical account and provide pointers towards an improved clinical diagnostic formulation of FIAD. We suggest directions for future research towards a more unified theory on which future interventions and management strategies could be based, as effective treatments and clinical trial evidence remain limited.

Clinician-rated outcomes of patients with functional neurological disorders treated in an outpatient clinic

BACKGROUND

Patients with functional neurological (conversion) disorder (FND) have historically been difficult to treat. Outcomes have been studied in research trials, documenting improvements; however, limited information is available from a community-treated FND cohort.

OBJECTIVES

We aimed to examine clinical outcomes in outpatients with FND treated with the Neuro-Behavioral Therapy (NBT) approach. These uncontrolled setting treatment data could complement more structured clinical studies results.

METHODS

We conducted a retrospective chart review of consecutive patients diagnosed with FND, ages 17 to 75, who were treated with the NBT workbook at the Rhode Island Hospital Behavioral Health clinic between 2014 and 2022. NBT consisted of 45-minute, individual, outpatient sessions, in clinic or via telehealth with one clinician. Global Assessment of Functioning (GAF), and Clinical Global Impression (CGI) -Severity, and -Improvement were scored for every appointment.

RESULTS

Baseline characteristics are available for 107 patients. Mean age at FND symptom onset was 37 years. Patients had a mix of FND semiologies, which included Psychogenic Nonepileptic Seizures (71%), Functional Movement Disorder (24.3%), Functional Sensory Disorder (14%), Functional Weakness (6.5%), and Functional Speech Disorder (5.6%). Clinical evaluation scores revealed improvements over time.

CONCLUSIONS

We describe a well-characterized sample of patients with various and mixed FND semiologies, who received manualized therapy, NBT, in an outpatient clinic. Patients had similar psychosocial profiles to those in clinical studies and displayed improvement in clinical measures. These results demonstrate the practicability of NBT for motor FND semiologies and for PNES, in a "real-world" outpatient practice, extending care beyond structured clinical trials.

The P2X7 Receptor as a Mechanistic Biomarker for Epilepsy

Epilepsy, characterized by recurrent spontaneous seizures, is a heterogeneous group of brain diseases affecting over 70 million people worldwide. Major challenges in the management of epilepsy include its diagnosis and treatment. To date, video electroencephalogram (EEG) monitoring is the gold-standard diagnostic method, with no molecular biomarker in routine clinical use. Moreover, treatment based on anti-seizure medications (ASMs) remains ineffective in 30% of patients, and, even if seizure-suppressive, lacks disease-modifying potential. Current epilepsy research is, therefore, mainly focussed on the identification of new drugs with a different mechanism of action effective in patients not responding to current ASMs. The vast heterogeneity of epilepsy syndromes, including differences in underlying pathology, comorbidities and disease progression, represents, however, a particular challenge in drug discovery. Optimal treatment most likely requires the identification of new drug targets combined with diagnostic methods to identify patients in need of a specific treatment. Purinergic signalling via extracellularly released ATP is increasingly recognized to contribute to brain hyperexcitability and, consequently, drugs targeting this signalling system have been proposed as a new therapeutic strategy for epilepsy. Among the purinergic ATP receptors, the P2X7 receptor (P2X7R) has attracted particular attention as a novel target for epilepsy treatment, with P2X7Rs contributing to unresponsiveness to ASMs and drugs targeting the P2X7R modulating acute seizure severity and suppressing seizures during epilepsy. In addition, P2X7R expression has been reported to be altered in the brain and circulation in experimental models of epilepsy and patients, making it both a potential therapeutic and diagnostic target. The present review provides an update on the newest findings regarding P2X7R-based treatments for epilepsy and discusses the potential of P2X7R as a mechanistic biomarker.

Traumatic brain injury: Mechanisms, manifestations, and visual sequelae

Traumatic brain injury (TBI) results when external physical forces impact the head with sufficient intensity to cause damage to the brain. TBI can be mild, moderate, or severe and may have long-term consequences including visual difficulties, cognitive deficits, headache, pain, sleep disturbances, and post-traumatic epilepsy. Disruption of the normal functioning of the brain leads to a cascade of effects with molecular and anatomical changes, persistent neuronal hyperexcitation, neuroinflammation, and neuronal loss. Destructive processes that occur at the cellular and molecular level lead to inflammation, oxidative stress, calcium dysregulation, and apoptosis. Vascular damage, ischemia and loss of blood brain barrier integrity contribute to destruction of brain tissue. This review focuses on the cellular damage incited during TBI and the frequently life-altering lasting effects of this destruction on vision, cognition, balance, and sleep. The wide range of visual complaints associated with TBI are addressed and repair processes where there is potential for intervention and neuronal preservation are highlighted.

More than a drug target: Purinergic signalling as a source for diagnostic tools in epilepsy

Epilepsy is one of the most common and disabling chronic neurological diseases affecting people of all ages. Major challenges of epilepsy management include the persistently high percentage of drug-refractoriness among patients, the absence of disease-modifying treatments, and its diagnosis and prognosis. To date, long-term video-electroencephalogram (EEG) recordings remain the gold standard for an epilepsy diagnosis. However, this is very costly, has low throughput, and in some instances has very limited availability. Therefore, much effort is put into the search for non-invasive diagnostic tests. Purinergic signalling, via extracellularly released adenosine triphosphate (ATP), is gaining increasing traction as a therapeutic strategy for epilepsy treatment which is supported by evidence from both experimental models and patients. This includes in particular the ionotropic P2X7 receptor. Besides that, other components from the ATPergic signalling cascade such as the metabotropic P2Y receptors (e.g., P2Y₁ receptor) and ATP-release channels (e.g., pannexin-1), have also been shown to contribute to seizures and epilepsy. In addition to the therapeutic potential of purinergic signalling, emerging evidence has also shown its potential as a diagnostic tool. Following seizures and epilepsy, the concentration of purines in the blood and the expression of different compounds of the purinergic signalling cascade are significantly altered. Herein, this review will provide a detailed discussion of recent findings on the diagnostic potential of purinergic signalling for epilepsy management and the prospect of translating it for clinical application. This article is part of the Special Issue on 'Purinergic Signaling: 50 years'.