Psychogenic non-epileptic seizures: a model of their pathogenic mechanism

Qualitative analysis of written accounts of functional/dissociative seizures

OBJECTIVE

Subjective experiences of functional/dissociative seizures (FDS) are important for diagnosis and treatment formulation. This study aims to improve the symptomatological understanding of these seizures by analysing written narratives provided by authors with personal FDS experience.

METHODS

Descriptions of FDS were extracted from contributions to the book "In Our Words: Personal Accounts of Living with Non-Epileptic Seizures". Immediately preictal, ictal or postictal seizure symptoms were identified and subjected to summative content analysis. Themes and subthemes were derived inductively and deductively.

RESULTS

Of 93 authors with FDS who submitted contributions to the book, 75 mentioned seizure symptoms. In most narratives, FDS involved a complex, multidimensional symptomatology. Six superordinate symptom domains emerged: 'consciousness', 'movements', 'sensations', 'arousal', 'emotions', and 'cognition'. Within the superordinate theme of 'consciousness' (63/75 writings), 'awareness' was most frequently topicalised, followed by impairment of 'self-control/ responsiveness' and 'disconnection'. The second most prominent superordinate theme of motor symptoms (58/75 authors) included 'positive' (excessive activity), 'negative' (reduced motor activity) and 'mixed' symptoms. Accounts of sensations similarly included 'hypersensitivity', 'hyposensitivity' and 'mixed' symptoms. 'Pain' was another prominent sensory subtheme (13/75 narratives). The 'arousal' theme (20/75 accounts) captured 'hyper-' more often than 'hypoarousal'. In the superordinate theme 'emotions' (22/75 authors) 'anxiety' symptoms were particularly prominent. The superordinate 'cognition' theme (14/45 writings) mainly captured 'foggy thinking' and 'memory deficits'.

CONCLUSIONS

In the words of individuals with personal experience, FDS emerge as complex and heterogeneous phenomena spanning physical, emotional, autonomic and cognitive domains. The characterization of FDS symptomatology should help with earlier diagnoses.

EEG microstates during resting-state and dissociative events in patients with psychogenic non-epileptic seizures

OBJECTIVE

Previous neuroimaging studies indicate complex network alterations in psychogenic non-epileptic seizures (PNES) patients, but brain activity modifications occurring during PNES remain unexplored. This study aimed to analyze EEG microstate metrics in PNES patients both during events and resting state to investigate the neurophysiological changes underlying these dissociative events.

METHODS

We recruited 22 PNES patients and 24 age- and sex-matched healthy controls. Inclusion criteria included a history of PNES and at least one recorded akinetic PNES during video-EEG.

RESULTS

A two-way repeated-measures ANOVA revealed significant class*condition interactions for microstate duration (p = 0.017), coverage (p = 0.012), and global field power (GFP) (p = 0.008). Post-hoc FDR-adjusted paired t-tests showed a significant decrease in microstate C duration (p = 0.036), coverage (p = 0.04), and GFP (p = 0.036) during PNES events compared to resting state. Mann-Whitney U tests showed significantly higher microstate C duration in PNES patients during resting state compared to controls (p = 0.009).

CONCLUSIONS

Microstate C, previously associated with the default mode network, showed increased duration during resting state and decreased representation during PNES, suggesting a prominent shift in neural activity dynamics within this network during dissociative events.

SIGNIFICANCE

These findings provide insights into neurophysiological changes occurring during PNES, suggestingan interplay between pathological and adaptive mechanisms in their pathophysiology.

Personality assessment inventory sex differences in people with epileptic and functional seizures

OBJECTIVE

Previous research has shown that the Personality Assessment Inventory (PAI) is useful in differentiating individuals with functional seizures (FS) from those with epileptic seizures (ES). In these two groups, sex differences in PAI validity and clinical subscales have not been investigated. Elucidating sex differences could improve the understanding of how males and females experience FS or ES and may improve differential diagnosis and treatment planning.

METHOD

We examined sex differences across PAI scales, subscales, and validity profiles amongst adults with FS (n = 62) and ES (n = 55). Participants were evaluated and classified at the Johns Hopkins Hospital Epilepsy Monitoring Unit based on continuous video electroencephalography (cEEG) confirmed diagnoses. Among valid profiles, we conducted the following analyses: calculation of odds ratios (OR) and associated confidence intervals (CI) for each clinical, treatment, and interpersonal scale; logistic regression models to examine whether diagnostic status could be predicted by PAI scale elevations and sex; positive predictive values (PPV) and negative predictive values (NPV) to understand the diagnostic utility of scale and subscale elevations; and receiver operating characteristic (ROC) curves to determine the area under the curve (AUC) and identify PAI scales with the greatest capacity to distinguish FS presence/absence.

RESULTS

There were no significant differences in validity scales between FS and ES groups, both in the combined sample and when stratifying by sex (p's > 0.05). On a clinical scale level, FS females produced higher elevations on stress (STR) and somatic complaints (SOM) (OR = 4.17, OR = 6.95, p's < 0.05), and FS males reported higher anxiety (ANX), anxiety-related disorders (ARD), and non-support (NON) (OR = 8.0, OR = 11.25, OR = 15.2, p's < 0.05) than sex-matched ES patients. On a subscale level, FS females were more likely than ES females to have clinically elevated conversion (SOM-C) and somatization (SOM-S) scales (OR = 4.72, OR = 5.78, p's < 0.05), and FS males were more likely than ES males to report clinically elevated SOM-C, physiological anxiety (ANX-P), and trauma-related distress (ARD-T) (OR = 10.53, OR = 9.52, OR = 9.52, p's < 0.05). ROC findings revealed that SOM-C (AUC = 0.72) and ANX-P (AUC = 0.78) had the greatest AUCs for FS females and males, respectively. In the combined sex sample, FS patients were more likely than ES patients to endorse mildly elevated paranoia (PAR) and STR and clinically elevated SOM, depression (DEP), and ARD (ORs = 4.86, 3.52, 5.10, 3.01, 4.38, respectively, p's < 0.05); when entering these scales in a logistic regression model, SOM was the best predictor of FS. However, overall classification rates did not exceed 80 % (PPV = 75.5 %, NPV = 65.5 %). Among subscales, the combined-sex FS cohort was more likely to endorse elevations on SOM-C, SOM-S, ANX-P, and ARD-T than the ES cohort (ORs = 5.24, 3.82, 4.38, 4.38, respectively, p's < 0.05); when entering these scales in a logistic regression model, SOM-C was the best predictor of FS. Within the combined sex sample, SOM-C and STR had the highest AUCs (0.70 and 0.68, respectively).

CONCLUSIONS

Our findings indicate that males and females with FS are both more likely than those with ES to endorse higher conversion symptoms but otherwise have different characteristics. These differences might influence predisposition to the development of FS or perpetuation of symptoms and could be useful in determining optimal treatment approaches.

Case Report: Successful management of psychogenic non-epileptic seizures with intranasal esketamine

Introduction

Psychogenic non-epileptic seizures (PNES), or functional seizures (FS), are episodes that resemble epileptic seizures but may be psychological in origin. Unlike epileptic seizures, which are linked to abnormal electrical activity in the brain, functional seizures may be associated with psychological and/or physical distress, and do not show the same electrical patterns on an electroencephalogram (EEG). Esketamine, a derivative of the anesthetic ketamine, is approved by the U.S. Food and Drug Administration (FDA) for treatment-resistant depression (TRD) and major depressive disorder (MDD) with suicidal thoughts or actions.

Methods/Results

This report discusses a patient with TRD and PNES, where the administration of esketamine effectively resolved both conditions.

Discussion

It explores the potential therapeutic effects of esketamine on PNES, in addition to its antidepressant properties.

Neuroplastic changes in patients with functional seizures following neurobehavioral therapy

Given the high prevalence of functional neurological symptom disorder and its negative effects on the individual, family, and society, the development of interventions to treat it-including the subtype of functional seizures (FS)-is critical.Although we have limited understanding of the neurobiological effects of neurobehavioral therapy (NBT), studies indicate that NBT reduces seizures and improves psychological comorbidities in FS. In this study, healthy adults (N = 33) and patients with a history of TBI with (TBI-FS; N = 50) and without FS (TBI-only; N = 50) underwent magnetic resonance imaging (MRI) at 3 T approximately 12 weeks apart. TBI-FS participants underwent up to 12 sessions of NBT between scans. Structural MRI data were analyzed using voxel-based morphometry. A voxelwise repeated measures ANOVA tested changes in grey matter volume (GMV) between groups over time. Following treatment with NBT, TBI-FS participants showed a 1.23 % GMV increase in the left inferior and middle temporal gyri (pFWE < 0.05) along with a 35.78 % reduction in seizure events and decrease in depressive (p < 0.001) and anxiety (p = 0.01) symptoms. Left temporal GMV increases were directly associated (p = 0.04, r = 0.26) with improvements in overall psychological, social, and occupational functioning (p < 0.001). We observed structural brain changes within the left inferior temporal gyrus following NBT that correspond to functional and psychological improvements in patients with TBI-FS. This work highlights the need for further research into the neurobiological effects of NBT, building on the relationship between NBT and brain plasticity and demonstrating putative targets for interventions.

Serum Ammonia as a Biomarker to Differentiate Between True Epileptic and Psychogenic Non-epileptic Seizures: A Cross-sectional Study

Background

A kind of conversion condition known as psychogenic non-epileptic seizures (PNES) is characterised by brief episodes that resemble epileptic fits but lack electroencephalographic (EEG) confirmation. Although the clinical history plays a significant role in the seizure diagnosis, imaging and serum markers are included in the initial evaluation for patients who present to the emergency.

Objectives

To validate the prevalence of serum ammonia as a biomarker in differentiating true epileptic and non-epileptic seizures.

Material Methods

The study was a hospital-based observational, prospective comparative study spanning over 2 years after surpassing the patient consent, inclusion and exclusion criteria.

Results

The mean of the study participants were middle-aged, males predominant in IES and females in PNES. A slightly higher proportion of the patients in the IES group had episodes of less than 5 minutes in the PNES group, where episodes lasted between 5 to 10 minutes. Awareness of symptoms was observed more frequently in the PNES group. The area under the curve (AUC) for the serum ammonia level at arrival was 0.972 (95% CI: 0.94-0.99) with a P value of < .001.

Conclusion

Mean serum ammonia levels at arrival and after 48 hours of admissions in the idiopathic epileptic seizure group were significantly higher compared to the PNES group with P value < .001, validating its use as a biomarker.

Neurocognitive performance in functional neurological disorder: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

Cognitive complaints are common in functional neurological disorder (FND), but it is unclear whether objective neurocognitive deficits are present. This systematic review summarized validated/standardized cognitive test performance in FND samples across cognitive domains.

METHODS

Embase, PsycInfo and MEDLINE were searched from inception to 15 May 2023, combining terms for FND and cognitive domains (e.g., attention, memory, executive functioning). Studies included a range of FND phenotypes (seizures, motor, cognitive disorder, mixed), compared to healthy or clinical controls. Risk of bias was assessed with the modified Newcastle-Ottawa Scale and a qualitative synthesis/narrative review of cognitive performance in FND was conducted. Test performance scores were extracted, and random effects meta-analyses were run where appropriate. This review was registered on PROSPERO, CRD42023423139.

RESULTS

Fifty-six studies including 2260 individuals with FND were eligible. Although evidence for some impairments emerged across domains of executive functioning, attention, memory and psychomotor/processing speed, this was inconsistent across studies and FND phenotypes. Common confounds included group differences in demographics, medication and intellectual functioning. Only 24% of studies objectively assessed performance validity. Meta-analyses revealed higher scores on tests of naming (g = 0.67, 95% confidence interval [CI] 0.50, 0.84) and long-term memory (g = 0.43, 95% CI 0.13, 0.74) in functional seizures versus epilepsy, but no significant differences in working (g = -0.08, 95% CI -0.44, 0.29) or immediate (g = 0.25, 95% CI -0.02, 0.53) memory and cognitive flexibility (g = -0.01, 95% CI -0.29, 0.28).

CONCLUSIONS

There is mixed evidence for objective cognitive deficits in FND. Future research should control for confounds, include tests of performance validity, and assess relationships between objective and subjective neurocognitive functioning.

Associations of cognitive test performance with self-reported mental health, cognition, and quality of life in adults with functional seizures: A systematic review and meta-analysis

Objective: People with functional seizures (FS) have frequent and disabling cognitive dysfunction and mental health symptoms, with low quality of life. However, interrelationships among these constructs are poorly understood. In this meta-analysis, we examined associations between objective (i.e. performance-based) cognitive testing and self-reported (i) mental health, (ii) cognition, and (iii) quality of life in FS. Method: We searched MEDLINE, Embase, PsycINFO, and Web of Science, with the final search on June 10, 2024. Inclusion criteria were studies documenting relationships between objective cognitive test scores and self-reported (i.e. subjective) mental health, cognition, and/or quality of life in adults with FS. Exclusion criteria were mixed FS/epilepsy samples. A modified Newcastle-Ottawa Scale evaluated risk of bias. This project is registered as CRD42023392385 in PROSPERO. Results: Initially, 4,054 unique reports were identified, with the final sample including 24 articles of 1,173 people with FS. Mean age was 35.9 (SD = 3.9), mean education was 12.6 (SD = 1.3), and proportion of women was 73.9%. Risk of bias was moderate, due in part to inconsistent reporting of confounding demographic variables. Significant relationships were found between global objective cognition and global self-reported mental health (k = 21, Z = -0.23 [0.04], 95% CI = -0.30, -0.16), depression (k = 11, Z = -0.13 [0.05], 95% CI = -0.21, -0.04), cognition (k = 5, Z = -0.16 [0.05], 95% CI = -0.26, -0.06), and quality of life (k = 5, Z = -0.17 [0.05], 95% CI = -0.24, -0.10). Exploratory analyses showed associations between select cognitive and mental health constructs. Conclusions: Objective cognition is reliably associated with self-reported mental health, cognition, and quality of life in people with FS. Scientific and clinical implications are discussed.

"What are your seizures telling you?": A therapeutic tool for functional seizures

BACKGROUND

Understanding illness representations is considered important for improving health outcomes, yet how people with functional seizures reflect on the possible psychological function of their seizures has not been studied.

METHODS

A semi-structured interview comprising open and closed questions was administered to 99 participants with a documented diagnosis of functional seizures. One item, 'What do you think your functional seizure symptoms are telling you?" sought to explore how individuals reflect on the possible function of their seizures. Qualitative analysis using NVivo comprised thematic content analysis of responses to the question, and pattern analysis, to determine association with diagnosis acceptance, and openness to a possible psychological aetiology.

RESULTS

Most patients (88 %) readily interpreted their seizures in response to this question. We identified one major theme, with the majority of participants interpreting seizure symptoms as an enforced hiatus. Two minor themes were identified: personal growth and contempt. Subthemes were identified within both the enforced hiatus (stop, slow down, relax) and personal growth (self-care, self-development, acceptance) themes. Individuals who did not accept the diagnosis of functional seizures referenced seizures with contempt towards the self or answered, 'don't know'. Respondents who did not know also tended to reject a psychological basis for their seizures in contrast to those who discussed themes of enforced hiatus, personal growth, and contempt.

CONCLUSIONS

Responses provide valuable insight into how individuals reflect on their condition in a non-acute setting. Themes can serve as a foundation for future therapeutic discussions and patient-centred communication strategies to build a mutual understanding of the potential function of physical symptoms regardless of whether a psychological basis for them is accepted or not. What is already known on this topic: Outcomes for functional seizures are generally poor and often attributed to patients rejecting psychiatric care or not accepting the diagnosis.

WHAT THIS STUDY ADDS

This study is the first to explore patient conceptualisations of the possible function of their functional seizures as a therapeutic tool for understanding the condition. How this study might affect research, practice, or policy: Findings may provide a basis for improved clinician-patient relationships, treatment engagement, and more targeted interventions for people with functional seizures.

Personality disorders in individuals with functional seizures: a systematic review

Functional seizures (FS) are classified as conversion disorders in the DSM-5 and dissociative disorders in the ICD-11, showing a multifactorial psychopathology with various psychiatric comorbidities, such as depression and anxiety. Several studies have found a correlation between FS and personality disorders, mainly those in cluster B. Within this cluster, borderline personality disorder (BPD) or borderline personality traits are the most prevalent in FS. Emotion dysregulation is a hallmark of BPD and is commonly reported in individuals with FS. Cluster C personality disorders, such as avoidant or obsessive-compulsive disorders, have also been reported in FS. In this review, we aim to evaluate the relationship between FS and personality disorders. Assessing personality disorders in the context of FS is relevant for determining the most appropriate intervention. Cognitive-behavioral therapy (CBT) is considered the first-line approach to treating FS. Among various CBT strategies, dialectical behavior therapy, which specifically targets emotion dysregulation, may be helpful for individuals with BPD. Future research should assess the advantages of systematically evaluating personality disorders in FS to address specific treatment planning and evaluate its effectiveness on seizure recurrence, psychological comorbidities, and quality of life.

Systematic review registration

https://www.crd.york.ac.uk/PROSPEROFILES/509286_STRATEGY_20240203.pdf, identifier CRD42024509286.

Comparative study of perceived invalidating environment and stress coping strategies between patients with drug resistant epilepsy and functional dissociative seizures

BACKGROUND AND OBJECTIVES

We investigated perceived invalidating environment during childhood and stress-coping strategies in patients with; functional dissociative seizures (FDS, n=26), drug-resistant epilepsy patients with no psychiatric comorbidity (DREnc, n=23), and drug-resistant epilepsy patients with psychiatric comorbidity (DREpc, n=34).

DESIGN/METHODS

We performed a cross-sectional study. Patients underwent Video Electroencephalography to confirm the diagnosis and completed a psychiatric assessment supported by clinical instruments. Invalidating environment and stress coping were studied through the ICES and CAE questionaries, respectively. A series of multinomial logistic regression analyses were performed with the explored variables.

RESULTS

The maternal negative response model predicted a higher probability of FDS condition. A chaotic family type increased the likelihood of DREpc instead of FDS. DREpc and FDS patients displayed many different behaviors to cope with stress other than trying to solve the problem, the most used strategy in the DREnc group. Parental invalidation was higher in DREpc than in FDS.

CONCLUSIONS

Our results deepen the data provided by previous studies indicating that multiple variables of biosocial origin have significant effects on these groups of patients. The presence of an invalidating environment may predict FDS but also the presence of psychiatric disorders among DRE. Psychotherapeutic strategies to enhance these variables might be necessary for this population.

Exploring psychedelic-assisted therapy in the treatment of functional seizures: A review of underlying mechanisms and associated brain networks

Functional seizures (FS), the most common subtype of functional neurological disorder (FND), cause serious neurological disability and significantly impact quality of life. Characterized by episodic disturbances of functioning that resemble epileptic seizures, FS coincide with multiple comorbidities and are treated poorly by existing approaches. Novel treatment approaches are sorely needed. Notably, mounting evidence supports the safety and efficacy of psychedelic-assisted therapy (PAT) for several psychiatric conditions, motivating investigations into whether this efficacy also extends to neurological disorders. Here, we synthesize past empirical findings and frameworks to construct a biopsychosocial mechanistic argument for the potential of PAT as a treatment for FS. In doing so, we highlight FS as a well-defined cohort to further understand the large-scale neural mechanisms underpinning PAT. Our synthesis is guided by a complexity science perspective which we contend can afford unique mechanistic insight into both FS and PAT, as well as help bridge these two domains. We also leverage this perspective to propose a novel analytic roadmap to identify markers of FS diagnostic specificity and treatment success. This endeavor continues the effort to bridge clinical neurology with psychedelic medicine and helps pave the way for a new field of psychedelic neurology.

Unravelling the influence of affective stimulation on functional neurological symptoms: a pilot experiment examining potential mechanisms

BACKGROUND

Differences in affective processing have previously been shown in functional neurological disorder (FND); however, the mechanistic relevance is uncertain. We tested the hypotheses that highly arousing affective stimulation would result in elevated subjective functional neurological symptoms (FNS), and this would be associated with elevated autonomic reactivity. The possible influence of cognitive detachment was also explored.

METHOD

Individuals diagnosed with FND (motor symptoms/seizures; n=14) and healthy controls (n=14) viewed Positive, Negative and Neutral images in blocks, while passively observing the stimuli ('Watch') or detaching themselves ('Distance'). The FND group rated their primary FNS, and all participants rated subjective physical (arousal, pain, fatigue) and psychological states (positive/negative affect, dissociation), immediately after each block. Skin conductance (SC) and heart rate (HR) were monitored continuously.

RESULTS

FNS ratings were higher after Negative compared with Positive and Neutral blocks in the FND group (p=0.002, ηp 2=0.386); however, this effect was diminished in the Distance condition relative to the Watch condition (p=0.018, ηp 2=0.267). SC and/or HR correlated with FNS ratings in the Negative-Watch and Neutral-Distance conditions (r values=0.527-0.672, p values=0.006-0.035). The groups did not differ in subjective affect or perceived arousal (p values=0.541-0.919, ηp 2=<0.001-0.015).

CONCLUSIONS

Emotionally significant events may exert an influence on FNS which is related to autonomic activation rather than altered subjective affect or perceived arousal. This influence may be modulated by cognitive detachment. Further work is needed to determine the relevance and neural bases of these processes in specific FND phenotypes.

Illness representations of people with later-onset functional seizures

PURPOSE

Although functional seizures can start at any age, little is known about the individuals for whom onset occurs after the age of 40. It has been proposed that health-related traumatic events are more relevant causal factors for people with 'later-onset functional seizures' than for those whose functional seizures begin earlier in life, however, the illness representations of people with later-onset functional seizures have not yet been investigated. This study aimed to understand the experiences and illness representations of people with later-onset functional seizures.

METHODS

This was a mixed-methods study. People with later-onset functional seizures were recruited via a neurologist's caseload and online membership-led organisations. Semi-structured interview transcripts were analysed using Template Analysis according to the Common-Sense Model (CSM). Self-report measures of demographic and clinical details were collected to characterise the sample and verify themes.

RESULTS

Eight people with later-onset functional seizures participated in the study. Illness representations relating to all domains of the CSM as well as an additional theme of 'Triggers' were identified. Functional seizures were characterised as a mysterious brain disorder analogous to a computer malfunction and involving involuntary movements associated with alterations in consciousness. Perceptions of duration were indefinite, and triggers were unknown or at the extremes of autonomic arousal. Half of the sample identified health-related events/trauma as causal. Opinions were divided on 'cumulative life stress' as a causal factor. Most perceived themselves to have limited or no control but having 'control' over seizures was conceptualised as different to reducing their likelihood, frequency, or impact. Later-onset functional seizures were viewed as being more detrimental for caring and financial responsibilities but to have advantages for acceptance.

CONCLUSIONS

This is the first study to assess the illness representations of people with later-onset functional seizures. Many themes were similar to those identified in samples including people with earlier-onset functional seizures. Health-related trauma or events were the most strongly endorsed perceived causal factor, but with the exception of 'consequences', all representations were characterised by uncertainty. Clinicians should hold in mind the interaction between life stage and the consequences of later-onset functional seizures.

Peripheral and Central Nervous System Biomarkers of Inflammation in Functional Seizures: Assessment with Magnetic Resonance Spectroscopy

Purpose

Inflammation may link trauma to clinical symptoms in functional seizures (FS). We compared brain temperature and metabolites in FS, psychiatric (PCs) and healthy controls (HCs) and quantified their associations with serum biomarkers of inflammation and clinical symptoms.

Patients and Methods

Brain temperature and metabolites were measured with whole-brain magnetic resonance spectroscopic imaging (MRSI) and compared between groups in regions of interest and the whole brain. Relationships with inflammatory biomarkers and symptoms were assessed with Pearson correlations.

Results

Brain temperature was higher in FS than HCs in the orbitofrontal cortex (OFC) and anterior cingulate gyrus (ACG) and lower in the occipital cortex and frontal lobe. PCs showed lower temperatures than HCs in the frontal lobe including precentral gyrus and in the cerebellum. Myo-inositol (MINO) was higher in FS than HCs in the precentral gyrus, posterior temporal gyrus, ACG and OFC, and choline (CHO) was higher in the occipital lobe. CHO was higher in PCs than HCs in the ACG and OFC, and N-acetylaspartate (NAA) was higher in the ACG. There were no significant correlations with the serum inflammatory biomarkers. In FS, brain temperature correlated with depression, quality of life, psychological symptoms, and disability, CHO correlated with disability, and MINO correlated with hostility, disability, and quality of life.

Conclusion

Some of the previously identified neuroimaging abnormalities in FS may be related to comorbid psychiatric symptoms, while others, such as abnormalities in sensorimotor cortex, occipital regions, and the temporo-parietal junction may be specific to FS. Overlapping MINO and temperature increases in the ACG and OFC in FS suggest neuroinflammation.

Objective and subjective neurocognitive functioning in functional motor symptoms and functional seizures: preliminary findings

INTRODUCTION

This study aimed to provide a preliminary assessment of objective and subjective neurocognitive functioning in individuals with functional motor symptoms (FMS) and/or functional seizures (FS). We tested the hypotheses that the FMS/FS group would display poorer objective attentional and executive functioning, altered social cognition, and reduced metacognitive accuracy.

METHOD

Individuals with FMS/FS (n = 16) and healthy controls (HCs, n = 17) completed an abbreviated CANTAB battery, and measures of intellectual functioning, subjective cognitive complaints, performance validity, and comorbid symptoms. Subjective performance ratings were obtained to assess local metacognitive accuracy.

RESULTS

The groups were comparable in age (p = 0.45), sex (p = 0.62), IQ (p = 0.57), and performance validity (p-values = 0.10-0.91). We observed no impairment on any CANTAB test in this FMS/FS sample compared to HCs, although the FMS/FS group displayed shorter reaction times on the Emotional Bias task (anger) (p = 0.01, np2 = 0.20). The groups did not differ in subjective performance ratings (p-values 0.15). Whilst CANTAB attentional set-shifting performance (total trials/errors) correlated with subjective performance ratings in HCs (p-values<0.005, rs = -0.85), these correlations were non-significant in the FMS/FS sample (p-values = 0.10-0.13, rs-values = -0.46-0.50). The FMS/FS group reported more daily cognitive complaints than HCs (p = 0.006, g = 0.92), which were associated with subjective performance ratings on CANTAB sustained attention (p = 0.001, rs = -0.74) and working memory tests (p < 0.001, rs = -0.75), and with depression (p = 0.003, rs = 0.70), and somatoform (p = 0.003, rs = 0.70) and psychological dissociation (p-values<0.005, rs-values = 0.67-0.85).

CONCLUSIONS

These results suggest a discordance between objective and subjective neurocognitive functioning in this FMS/FS sample, reflecting intact test performance alongside poorer subjective cognitive functioning. Further investigation of neurocognitive functioning in FND subgroups is necessary.

Improvements in Montreal Cognitive Assessment scores after neurobehavioral therapy in adults with functional (nonepileptic) seizures and traumatic brain injury

Cognitive functioning impacts clinical symptoms, treatment response, and quality of life in adults with functional/nonepileptic seizures (FS/NES), but no study to date examines effects of behavioral FS/NES treatment on cognition in these patients. We hypothesized that there would be a reduction in cognitive symptoms in participants with FS/NES and traumatic brain injury (TBI) following neurobehavioral therapy (NBT). We also hypothesized that select seizure-related, medication, subjective cognitive, and mental health symptoms would be negatively correlated with improvements in cognitive performance after NBT. Participants were 37 adults with TBI + FS/NES and 35 adults with TBI only, recruited from medical centers in the northeastern or southeastern U.S. TBI + FS/NES participants completed a 12 session NBT intervention, and TBI without seizures participants were not treated. All participants completed pre-post assessments of cognition (Montreal Cognitive Assessment [MoCA]) and baseline sociodemographic factors and mental health symptoms. Pre-post MoCA scores increased significantly in TBI + FS/NES participants (28/37 [75.7%] improved) but not in TBI comparisons (10/35 [28.6%] improved). Language, memory, and visuospatial/executive functions, but not attention, improved over time in the TBI + FS/NES group. Gains in cognition were concentrated in those TBI + FS/NES participants with likely baseline cognitive impairments (MoCA total score <26), and 9/17 of these participants moved from the "impaired" range at baseline (<26) to the "intact" range at endpoint (≥26). Lastly, participants taking fewer medications and reporting lower subjective cognitive difficulties at baseline showed larger pre-post MoCA total score improvements. Overall, results from this study suggest the potential for positive change in cognition in FS/NES and co-occurring TBI using evidence-based psychotherapy.

Psychogenic Nonepileptic Seizures (PNES) in the Setting of Trauma and Schizophrenia

Psychogenic nonepileptic seizures (PNES) are nonepileptic events characterized by seizure-like manifestations without abnormal electrical activity in the brain. Our case report illustrates the diagnostic journey of a young female with a history of schizophrenia and childhood trauma who had an initial misdiagnosis of epilepsy. The etiology of PNES is complex. Major depressive disorder and generalized anxiety disorder are common comorbid conditions in these patients. Additionally, previous trauma has been linked as a predisposing factor for the development of PNES. Psychotic disorders, specifically schizophrenia, have only recently been associated with PNES. We explore this relationship in depth, while also underscoring the diagnostic and treatment challenges of PNES that clinicians must remain aware of.

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.

[Functional neurological disorders: A clinical anthology]

Functional neurological disorders have a broad phenotypic spectrum and include different clinical syndromes, which are sometimes associated to each other or appear consecutively over the course of the disease. This clinical anthology provides details on the specific and sensitive positive signs that are to be sought in the context of a suspected functional neurological disorder. Beside these positive elements leading to the diagnosis of functional neurological disorder, we should keep in mind the possibility of an associated organic disorder as the combination of both organic and functional disorders is a relatively frequent situation in clinical practice. Here we describe the clinical characteristics of different functional neurological syndromes: motor deficits, abnormal hyperkinetic and hypokinetic movements, voice or speech disorders, sensory disorders, and functional dissociative seizures. The clinical examination and the identification of positive signs play a critical role in the diagnosis of functional neurological disorder. Knowledge of the specific signs associated with each phenotype render possible to make an early diagnosis. For that matter, it contributes to the improvement of patient care management. It allows to a better engagement in an appropriate care pathway, which influence their prognosis. Highlighting and discussing positive signs with patients can also be an interesting step in the process of explaining the disease and its management.

Dissociation in patients with epilepsy and functional seizures: A narrative review of the literature

Dissociation is a "disruption of the usually integrated functions of consciousness, memory, identity or perception of the environment" according to DSM-5.  It is commonly seen in psychiatric disorders including primary dissociative disorders, post-traumatic stress disorder, depression, and panic disorder. Dissociative phenomena are also described in the context of substance intoxication, sleep deprivation and medical illnesses including traumatic brain injury, migraines, and epilepsy. Patients with epilepsy have higher rates of dissociative experiences as measured on the Dissociative Experiences Scale compared to healthy controls. Ictal symptoms, especially in focal epilepsy of temporal lobe origin, may include dissociative-like experiences such as déjà vu/jamais vu, depersonalization, derealization and what has been described as a "dreamy state".  These descriptions are common in the setting of seizures that originate from mesial temporal lobe epilepsy and may involve the amygdala and hippocampus. Other ictal dissociative phenomena include autoscopy and out of body experiences, which are thought to be due to disruptions in networks responsible for the integration of one's own body and extra-personal space and involve the temporoparietal junction and posterior insula. In this narrative review, we will summarize the updated literature on dissociative experiences in epilepsy, as well as dissociative experiences in functional seizures. Using a case example, we will review the differential diagnosis of dissociative symptoms. We will also review neurobiological underpinnings of dissociative symptoms across different diagnostic entities and discuss how ictal symptoms may shed light on the neurobiology of complex mental processes including the subjective nature of consciousness and self-identity.

Case report: Improvement in refractory functional seizures, depression, and quality of life with ketamine-assisted therapy

Functional seizures, a primary subtype of functional neurological disorder (FND), are a known cause of serious neurological disability with an increasing awareness of their impact amongst the neuroscience community. Situated at the intersection of neurology and psychiatry, FND is characterized by a range of alterations in motor, sensory or cognitive performance, such as abnormal movements, limb weakness, and dissociative, seizure-like episodes. Functional seizures are known, in part, to have psychological underpinnings; however, the lack of effective and consistent treatment options requires research and novel approaches to better understand the etiology, diagnosis and what constitutes a successful intervention. Ketamine, a selective blocker of the N-methyl-D-aspartate receptor, has a well-established safety and efficacy profile. In recent years, ketamine-assisted therapy has shown increasing potential for treating a broad range of psychiatric conditions, building on its demonstrated rapid-acting antidepressant effects. Here we present a 51-year-old female with refractory daily functional seizures leading to significant disability and a medical history significant for major depressive disorder (MDD) and posttraumatic stress disorder (PTSD). After unsuccessful treatment attempts, the patient underwent a novel protocol with ketamine-assisted therapy. After 3 weeks of ketamine-assisted therapy followed by 20 weeks of intermittent ketamine treatment and ongoing integrative psychotherapy, the patient's seizures were significantly reduced in frequency and severity. She experienced significant improvements in depressive symptoms and functional ability scores. To our knowledge, this is the first reported case describing improvement in functional seizures following ketamine-assisted therapy. While rigorous studies are needed, this case report encourages further investigation of ketamine-assisted therapy for functional seizures and other functional neurological symptoms.

Impact of comorbid psychogenic non-epileptic seizures on migraine: An observational study

Objectives

There is a bidirectional and complex interplay between psychiatric comorbidities and migraine. Migraine has been observed in 50-60% of patients with psychogenic non-epileptic seizures (PNES). Studies describe migraine as a medical comorbidity in PNES. However, there are limited studies on impact of PNES on migraine. We aim to see the impact of PNES on migraine.

Materials and Methods

This cross-sectional and observational study was conducted at a tertiary-care center from June 2017 to May 2019. Fifty-two patients with migraine with PNES and 48 patients with migraine without PNES were included on the study. Migraine and PNES were diagnosed based on International Classification of Headache Disorders-3 (ICHD-3) and International League Against Epilepsy (ILAE) criteria, respectively. Headache intensity was assessed using visual analog scale. Comorbid depression, anxiety, and somatoform-symptom-disease were assessed using the Generalized Anxiety Disorder-7 Scale, Patient Health Questionnaire-9, and DSM-5 criteria, respectively.

Results

Females were common in both groups and the difference was statistically insignificant. Headache frequency was significantly more in patients with migraine with PNES (P < 0.05). However, headache intensity was similar in both groups. Patients with headaches and PNES identified triggers less commonly except for stress. Depression and somatoform symptom disorder were significantly more common in patients with migraine with PNES. Abnormal neurocircuitry involving frontal, limbic, and thalamic regions due to comorbid PNES may cause central sensitization, resulting in frequent migraine headaches which is further augmented by coexisting depression and somatoform-symptom-disease.

Conclusion

Migraine with PNES patients suffers more frequent headaches than patients with migraine without PNES. They differ in various headache triggers, with mental stress being the predominant trigger.

Functional Neurological Disorders: Clinical Spectrum, Diagnosis, and Treatment

BACKGROUND

Functional neurological disorders (FNDs) are common but often misdiagnosed.

REVIEW SUMMARY

The incidence of FNDs is between 4 and 12 per 100,000, comparable to multiple sclerosis and amyotrophic lateral sclerosis, and it is the second most common diagnosis in neurology clinics. Some clues in the history are sudden onset, intermittent time course, variability of manifestation over time, childhood trauma, and history of other somatic symptoms. Anxiety and depression are common, but not necessarily more than in the general population. Although there are no tests currently capable of demonstrating whether symptoms are willfully produced, there may not be a clear categorical difference between voluntary and involuntary symptoms. The prognosis of an FND is linked to early diagnosis and symptom duration, but unfortunately, the majority of the patients are diagnosed after considerable delays.

CONCLUSIONS

A positive diagnosis of FNDs can be made on the basis of history and neurological signs without reliance on psychological stressors. Past sensitizing events and neurobiological abnormalities contribute to the pathogenesis of FNDs. Physical rehabilitation and psychological interventions alone or in combination are helpful in the treatment.

A new science of emotion: implications for functional neurological disorder

Functional neurological disorder reflects impairments in brain networks leading to distressing motor, sensory and/or cognitive symptoms that demonstrate positive clinical signs on examination incongruent with other conditions. A central issue in historical and contemporary formulations of functional neurological disorder has been the mechanistic and aetiological role of emotions. However, the debate has mostly omitted fundamental questions about the nature of emotions in the first place. In this perspective article, we first outline a set of relevant working principles of the brain (e.g. allostasis, predictive processing, interoception and affect), followed by a focused review of the theory of constructed emotion to introduce a new understanding of what emotions are. Building on this theoretical framework, we formulate how altered emotion category construction can be an integral component of the pathophysiology of functional neurological disorder and related functional somatic symptoms. In doing so, we address several themes for the functional neurological disorder field including: (i) how energy regulation and the process of emotion category construction relate to symptom generation, including revisiting alexithymia, 'panic attack without panic', dissociation, insecure attachment and the influential role of life experiences; (ii) re-interpret select neurobiological research findings in functional neurological disorder cohorts through the lens of the theory of constructed emotion to illustrate its potential mechanistic relevance; and (iii) discuss therapeutic implications. While we continue to support that functional neurological disorder is mechanistically and aetiologically heterogenous, consideration of how the theory of constructed emotion relates to the generation and maintenance of functional neurological and functional somatic symptoms offers an integrated viewpoint that cuts across neurology, psychiatry, psychology and cognitive-affective neuroscience.

Diagnostic delay in functional seizures is associated with abnormal processing of facial emotions

PURPOSE

In patients with functional seizures (FS), delay in diagnosis (DD) may negatively affect outcomes. Altered brain responses to emotional stimuli have been shown in adults with FS. We hypothesized that DD would be associated with differential fMRI activation in emotion processing circuits.

METHODS

Fifty-two adults (38 females) with video-EEG confirmed FS prospectively completed assessments related to symptoms of depression (BDI-II), anxiety (BAI), post-traumatic stress disorder (PCL-S), a measure of how their symptoms affect day-to-day life (GAF), and fMRI at 3T with emotional faces task (EFT). During fMRI, subjects indicated "male" or "female" via button press while implicitly processing happy, sad, fearful, and neutral faces. Functional magnetic resonance imaging (FMRI) response to each emotion was modeled and group analyses were performed in AFNI within pre-specified regions-of-interest involved in emotion processing. A median split (507 days) defined short- (s-DD) and long-delay diagnosis (l-DD) groups. Voxelwise regression analyses were also performed to examine linear relationship between DD and emotion processing. FMRI signal was extracted from clusters showing group differences and Spearman's correlations assessed relationships with symptom scores.

RESULTS

Groups did not differ in FS age of onset, sex distribution, years of education, TBI characteristics, EFT in-scanner or post-test performance, or scores on the GAF, BDI-II, BAI, and PCL-S measures. The s-DD group was younger than l-DD (mean age 32.6 vs. 40.1; p = 0.022) at the time of study participation. After correcting for age, compared to s-DD, the l-DD group showed greater fMRI activation to sad faces in the bilateral posterior cingulate cortex (PCC) and to neutral faces in the right anterior insula. Within-group linear regression revealed that with increasing DD, there was increased fMRI activation to sad faces in the PCC and to happy faces in the right anterior insula/inferior frontal gyrus (AI/IFG). There were positive correlations between PCC response to sad faces and BDI-II scores in the l-DD group (rho = 0.48, p = 0.012) and the combined sample (rho = 0.30, p = 0.029). Increased PCC activation to sad faces in those in the l-DD group was associated with worse symptoms of depression (i.e. higher BDI-II score).

CONCLUSIONS

Delay in FS diagnosis is associated with fMRI changes in PCC and AI/IFG. As part of the default mode network, PCC is implicated in mood control, self-referencing, and other emotion-relevant processes. In our study, PCC changes are linked to depression. Future studies should assess the effects of interventions on these abnormalities.

Psychogenic nonepileptic seizures: Are they a freeze reaction?

Psychogenic nonepileptic seizures (PNES) clinically resemble epileptic seizures (ES) but lack epileptic activity at the time of the seizure and are also not due to any other pathophysiological disorder. The integrative cognitive model (ICM) suggests that PNES is an automatic reaction generated from distorted memory and is perceived as uncontrollable and unwanted. Furthermore, the ICM model implies that a PNES event occurs due to an external or internal cue. Intrigued by this assumption, we wanted to examine why a PNES event occurs at a particular moment by investigating the pre-ictal behavior. This study is a retrospective study. We included all patients diagnosed with PNES or ES admitted to our long-term video-EEG monitoring unit (LTVEM) between 01/01/2018 and 30/08/2020. Using thorough video analysis, we checked the patient's state at the onset of the event and looked back to see what the patient was doing before the event onset. We defined 4 types of pre-ictal behavior A. Inactivity. B. Environment arrangement c. Other. D. No apparent pre-ictal behavior. Thirty patients with PNES and 30 patients with ES were included in the study. In total, 46 PNES events and 56 ES events were recorded and analyzed. In 33 /46 PNES seizures (72%), a type A, A + B or C pre-ictal behavior was observed compared to 1/56 ES (1.78%) with type A pre-ictal behavior. All other pre-ictal behavior in the ES group were of type D. Patients with PNES have a unique pre-ictal behavior before most PNES events with motor manifestations. Since the pre-ictal behavior consists mainly of inactivity, we believe it may imply that PNES represents a freeze reaction or a reconstruction of a freeze reaction.

Psychogenic Nonepileptic Seizures in Children and Adolescents

Psychogenic nonepileptic seizures (PNES) are a common condition seen in children and adolescents. The diagnosis is clinical, based on a description of events, and can be supported using video electroencephalography recording. Children and adolescents with PNES often have comorbid psychiatric conditions and psychosocial stressors, although this is not a requisite for diagnosis. The pathophysiology is not fully understood but may be related to emotional processing and underlying aberrant functional connectivity. Communication of the diagnosis to patients and families in a compassionate way that leads to understanding is of paramount importance and the key first step to treatment. Psychotherapy that utilizes principles of cognitive behavioral therapy is the current standard for therapy. Symptoms can improve and many with PNES do experience remission of events with treatment, although not all. There is still much to be elucidated regarding underlying mechanisms and best treatments to help patients with this condition. In this article I review current knowledge about PNES in children and adolescents as well as share practical advice gleaned from clinical experience at Nationwide Children's Hospital's PNES Clinic.

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

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

Functional seizures: Cluster analysis may predict the associated risk factors

OBJECTIVES

We applied the Two-Step cluster analysis on a large cohort of patients with functional seizures (FS). We studied whether the background risk factors differed between the patient clusters.

METHODS

All patients with a diagnosis of FS were studied at the outpatient epilepsy clinic at Shiraz University of Medical Sciences, Shiraz, Iran, from 2008 until 2021. The Two-Step cluster analysis was applied considering the age at onset, sex, and seizure semiology. We also studied whether the background risk factors (e.g., a history of sexual abuse, physical abuse, etc.) differed between these patient clusters.

RESULTS

Three-hundred and fifty four patients were studied. The Two-Step cluster analysis was applied to the 230 patients who reported any associated risk factors; there were three clusters of patients. The most prominent feature of cluster 1 included akinetic seizures. The most prominent features of cluster 2 included motor seizures and no ictal injury. The most prominent features of cluster 3 included motor seizures with ictal injury. Compared with patients in cluster 3, a history of sexual abuse was more often reported by patients in cluster 1 (OR: 3.26, 95%CI: 1.12-9.47; p = 0.03). Compared with patients in cluster 3, a history of physical abuse was less often reported by patients in cluster 2 (OR: 0.45, 95%CI: 0.22-0.90; p = 0.026).

CONCLUSION

The Two-Step cluster analysis could identify three distinct clusters of patients based on their demographic and clinical characteristics. These clusters had correlations with the associated risk factors in patients with FS.

Psychogenic non-epileptic seizures: Chronology of multidisciplinary team approach to diagnosis and management

While the diagnosis and management of psychogenic non-epileptic seizures (PNES) remain challenging, certain evidence-based guidelines exist, which can help to optimize patient care. A multidisciplinary team approach appears to have many benefits. Current recommendations exist for some aspects of diagnosis and management of PNES, including levels of diagnostic certainty as proposed by the International League Against Epilepsy's expert Task Force on PNES. Other aspects of clinical still care lack clear consensus, including use of suggestion techniques for recording PNES and optimal terminology, since the term "functional seizures" has recently been proposed as a possible term to replace "PNES". The present article aims to (1) review current recommendations and (2) discuss our own team's experience in managing patients with PNES. This is organized chronologically in terms of the roles of the neurologist, psychiatrist and psychologist, and discusses diagnostic issues, psychiatric assessment and treatment, and psychotherapeutic approaches.

Neuroinflammation as a pathophysiological factor in the development and maintenance of functional seizures: A hypothesis

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Early-life stress may be a priming neuroinflammatory factor for later development of FS.

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Secondary trauma has emerged as an important predisposing factor for FS initiation.

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We propose an explanatory, two-hit hypothesis for FS development.

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The proposed hypothesis is based on findings from neuroimaging and biomarker studies.

The neurobiological underpinnings of functional seizure (FS) development and maintenance represent an active research area. Recent work has focused on hardware (brain structure) and software (brain function and connectivity). However, understanding whether FS are an adaptive consequence of changes in brain structure, function, and/or connectivity is important for identifying a causative mechanism and for FS treatment and prevention. Further, investigation must also uncover what causes these structural and functional phenomena. Pioneering work in the field of psychoneuroimmunology has established a strong, consistent link between psychopathology, immune dysfunction, and brain structure/function. Based on this and recent FS biomarker findings, we propose a new etiologic model of FS pathophysiology. We hypothesize that early-life stressors cause neuroinflammatory and neuroendocrine changes that prime the brain for later FS development following secondary trauma (e.g., traumatic brain injury or psychological trauma). This framework coalesces existing knowledge regarding brain aberrations underlying FS and established neurobiological theories on the pathophysiology of underlying psychiatric disorders. We also propose brain temperature mapping as a way of indirectly visualizing neuroinflammation in patients with FS, particularly in emotion regulation, fear processing, and sensory-motor integration circuits. We offer a foundation on which future research can be built, with clear recommendations for future studies.

Shame in the treatment of patients with psychogenic nonepileptic seizures: The elephant in the room

Previous research has established a link between psychogenic nonepileptic seizures (also known as dissociative or functional seizures) and abnormal emotion processing. In a companion article to this multidisciplinary narrative review, we have argued that, in the context of a biopsychosocial understanding of the condition, the emotion of shame is particularly likely to contribute to the aetiology, manifestation, semiology and perpetuation of psychogenic non-epileptic seizures (PNES). Here we demonstrate how unrecognised and unaddressed shame may cause difficulties when clinicians explain the diagnosis, attempt to engage patients in psychological treatment, construct a diagnostic formulation and undertake psychotherapy. Case vignettes are used to bring theoretical considerations to life and to illustrate the complex interactions which may be observed between high shame proneness, chronic and dysregulated shame, stigma and PNES. The particular focus on shame does not mean that recent explanatory models of PNES are obsolete. Rather, we demonstrate how the inclusion of shame helps to embed the emotional, cognitive and behavioural aspects of the Integrative Cognitive Model (ICM) of PNES in a social / interpersonal context. While we describe how a number of different psychotherapeutic approaches can help to address shame-related processes we conclude that specific modalities are less important than the eventual enhancement of emotional literacy and tolerance through a healing relationship with the psychotherapist.

Dissociation, Stressors, and Coping in Patients of Psychogenic Nonepileptic Seizures

BACKGROUND

Psychogenic nonepileptic seizures (PNES) commonly present both to neurologists and psychiatrists and include a wide range of psychopathology. In order to understand the demographics, dissociative experiences, stressful life events, abuse, and coping in these patients, this study was undertaken.

METHODS

This was a cross-sectional, observational study. A total of 71 patients of PNES, referred from neurology, were assessed on Dissociative Experience Scale (DES), Scale For Trauma and Abuse, Presumptive Stressful Life Events Scale (PSLES), and Ways of Coping Questionnaire to ascertain the dissociative experiences; the prevalence of trauma, abuse, and stressful life events, and the coping mechanisms.

RESULTS

Females predominated, with the duration of PNES up to 2 years. The mean ± SD total DES score was 38.14 ± 14.1, indicating high dissociation. On the PSLES, for the stressful life events in the last one year, the mean score was 98.28 ± 87.1. Marital and family conflicts and death were reported more. History of childhood or adult physical and sexual abuse was less reported. History of head trauma was present in 13 patients. Emotion-focused coping was used more than problem-solving strategies.

CONCLUSIONS

Very few Indian studies have looked into these nuances. This study has helped in improving the understanding of the various risk factors of PNES and the coping strategies, and in sensitizing psychiatrists and neurologists to enquire into trauma and abuse of these patients.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Orbito-frontal thinning together with a somatoform dissociation might be the fingerprint of PNES

OBJECTIVE

To investigate neuroanatomical changes in patients with psychogenic nonepileptic seizures (PNES) compared to major depressive disorder (MDD) and healthy controls.

METHODS

Forty-two drug-naïve PNES subjects and 25 patients with MDD, matched for demographic characteristics and level of depression (as measured by Beck Depression Inventory-II, BDI-II), were consecutively recruited. Patients performed an extensive neuropsychiatric assessment including: Hamilton Anxiety Rating Scale, Traumatic Experience Checklist, Dissociative Experiences Scale, Toronto Alexithymia Scale and Somatoform Dissociation Questionnaire (SDQ-20). All patients, together with 78 healthy matched controls, underwent 3T brain MRI followed by surface-based morphometry.

RESULTS

Cortical thickness analysis revealed significant cortical thinning in bilateral medial orbitofrontal cortex (OFC) and left rostral anterior cingulate cortex (ACC) in patients with MDD compared to subjects with PNES and controls. Interestingly, increased thickness of the right pars triangularis was found in PNES subjects compared to controls. PNES showed higher scores in SDQ-20 (p < 0.001) compared to MDD, which was corroborated by neuroimaging data, where somatoform dissociation scores correlated with morphological changes in the left medial OFC.

CONCLUSION

Our results show selective cortical thinning over the medial OFC in patients with PNES compared to wider regions of thinning in patients with MDD. Somatoform dissociation was the only psychopathological assessment significantly different in PNES and MDD.

What do we know about non-epileptic seizures in adults with intellectual disability: A narrative review

Psychogenic non-epileptic seizures (PNES) superficially resemble epileptic seizures, but are not associated with abnormal electrical activity in the brain. PNES are a heterogeneous entity and while there is increasing interest in the characterisation of PNES sub-groups, little is known about individuals with PNES who have an intellectual disability (ID). ID is a lifelong condition characterised by significant limitations in cognitive, social and practical skills. ID (commonly with comorbid epilepsy) has been identified as a risk factor for developing PNES. However, people with ID are often excluded from research in PNES. This has unfortunately resulted in a lack of evidence to help inform practice and policy for this population. This narrative review synthesises the currently available evidence in terms of the epidemiology, demographic and clinical profile of adults with PNES and ID. There is a particular focus on demographics, aetiological factors, PNES characteristics, diagnosis and treatment of the condition in this population. Throughout this article, we critique the existing evidence, discuss implications for clinical practice and highlight the need for further research and enquiry. What emerges from the evidence is that, even within the sub-group of those with ID, PNES are a heterogeneous condition. Individuals with ID and PNES are likely to present with diverse and complex needs requiring multidisciplinary care. This review is aimed at the broad range of healthcare professionals who may encounter this group. We hope that it will stimulate further discussion and research initiatives.

A descriptive study of patients diagnosed with psychogenic nonepileptic seizures at a tertiary epilepsy center in the Czech Republic: One-year follow-up

PURPOSE

To delineate sociodemographic data of a large sample of Czech Republic patients diagnosed with psychogenic non-epileptic seizures (PNES) at the time of diagnosis and at a follow-up visit one year after discharge. This study collected reports of past stressors, quality of relationships in childhood, family background, traumatic events, and recent adversities in patients diagnosed with PNES.

METHOD

Patients (219w/79m, 37.56 (13.15) years, 12.13 (2.05) years of education) were assessed through a semi-structured interview on clinical and historical data while they were inpatients at the Epilepsy Center, Na Homolce Hospital, Prague. Subsequently, they were re-evaluated one year after discharge from the hospital with the same method. A comparison of this sample to normal controls was subsequently conducted.

RESULTS

We found a higher female (73.5%) predominance; mean duration of seizures was 69.14 months. The majority of patients were single (46.13%) or divorced (16.84%), and 48% received disability benefits. A diversity of developmental risk factors as well as immediate precursors of PNES onset were identified. One year after hospitalization, significant changes were found in all seizure and healthcare characteristics of our sample. When compared to healthy volunteers, the patients also presented with a higher prevalence of stressors and traumatic events in childhood.

CONCLUSIONS

Cross-cultural research contributes important information on the universal components of PNES as well as the unique features observed in distinct localities of differing cultures and ethnicities. This study allows for comparison of sociodemographic features in a Central European sample to the more frequently studied English-speaking samples.

Post-traumatic factors are involved in the evolution of the number of seizures in patients with PNES

OBJECTIVE

The purpose of this prospective study was to identify predictive factors of the evolution of the number of seizures.

METHODS

We included 85 individuals with a diagnosis of Psychogenic Nonepileptic Seizure (PNES) who completed at least two clinical interviews spaced by 6 months during a 24-month follow-up. Participants underwent a structured interview with an experimented clinician in PNES to complete standardized evaluation and validated scales. We collected sociodemographic and clinical data on PNES (number of seizures, duration of the disease), anxiety, depression, history of traumas, alexithymia, dissociation, and post-traumatic stress disorder (PTSD). We used a multivariate linear regression analysis to predict the characteristics independently associated with the evolution of the number of seizures in percentage.

RESULTS

Dissociation score was significantly associated with a negative evolution of the number of seizures (p < 0.002). Conversely, the diagnosis of PTSD at inclusion was correlated to a positive evolution of the number of seizures (p < 0.029).

CONCLUSION

Dissociation was related to a more pejorative evolution of the number of seizures while PTSD diagnosis was associated with a decreased number of seizures. It is therefore essential to improve detection and treatment of post-traumatic dissociation. Further studies are required to understand the impact of PTSD on the evolution of the number of seizures.

Updated Review on the Diagnosis and Primary Management of Psychogenic Nonepileptic Seizure Disorders

Psychogenic nonepileptic seizures (PNES) are paroxystic and episodic events associated with motor, sensory, mental or autonomic manifestations, which resemble epileptic seizures (ES), but are not caused by epileptogenic activity. PNES affect between 20% and 30% of patients attending at epilepsy centers and constitute a serious mental health problem. PNES are often underdiagnosed, undertreated and mistaken with epilepsy. PNES are diagnosed after medical causes (epilepsy, syncope, stroke, etc.) have been ruled out, and psychological mechanisms are involved in their genesis and perpetuation. For psychiatry, there is not a single definition for PNES; the DSM-IV and ICD-10/11 describe the conversion and dissociative disorders, and the DSM-5 describes the functional neurological disorders. However, patients with PNES also have a high frequency of other comorbidities like depression, particularly trauma and post-traumatic stress disorder. It has been postulated that PNES are essentially dissociations that operate as a defensive psychological mechanism that use the mind as a defense to deal with traumas. With the advent of VEEG in the 90s, the recognition of PNES has significantly increased, and several psychological treatments have been developed. In this manuscript, we carried out a state-of-the-art review, with the aim to provide a critical approach to the extensive literature about PNES, focusing on diagnostic aspects, the primary management, and the available treatments that have been shown to be effective for the improvement of PNES.

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

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

Testing the 'seizure scaffold': What can experimental simulation tell us about functional seizures?

INTRODUCTION

It has been suggested for over 100 years that patterns of neurological symptoms and signs in functional neurological disorders may be shaped at a neural level by underlying ideas or preconceptions how neurological symptoms present. This study used experimental simulation to probe ideas about seizures in healthy volunteers, with a view to compare with features commonly observed in functional and epileptic seizure disorders.

METHODS

Sixty healthy volunteers were instructed to simulate an epileptic seizure. The episodes were video-recorded and assessed by three qualified markers for the presence of clinical features commonly observed in functional seizures (FS), epileptic seizures, and syncope.

RESULTS

Simulated seizures were hyperkinetic (83%), hypokinetic (7%), or staring (10%). Fifty-two percent had their eyes open and 45% eyes closed. Tremor was observed in 70%, while clonic jerking was only present in 17%. The majority of volunteers maintained a normal or floppy body posture. Head shaking side-to-side was observed in 38%, while guttural cries, stertorous breathing, tearfulness, and hyperventilation were absent in all volunteers.

DISCUSSION

Our results suggest that simulated seizures not only resemble FS more closely than epileptic seizures but also show some important differences. Subjective seizure experiences in people with FS, not captured by this experimental simulation, remain a core determinant of semiology.

Motivational Interviewing Techniques to Improve Psychotherapy Adherence and Outcomes for Patients With Psychogenic Nonepileptic Seizures

Psychogenic nonepileptic seizures (PNES) are a highly disabling disorder frequently encountered by neurologists, psychiatrists, and emergency medicine physicians. There is accumulating evidence for the efficacy of psychological therapies, yet the majority of patients do not complete treatment. A range of health care system-based, clinician-based, and patient-based barriers to treatment exists, including stigma, poor clinician-patient communication, and patient ambivalence about the diagnosis and treatment of PNES. These barriers frequently lead to treatment nonadherence. Motivational interviewing (MI) is a patient-centered counseling style targeting ambivalence about behavior change, which has been shown to be effective in improving psychotherapy adherence and outcomes among patients with PNES. The authors review MI processes and techniques that may be useful to health care providers helping patients with PNES and other functional neurological disorders to engage in psychotherapy. The authors examine common challenges arising during MI for patients with PNES, including somatic symptoms distracting from clinician-patient communication, ambivalence about making concrete plans for treatment, and psychiatric comorbidities. Strategies for overcoming these obstacles are reviewed, including the use of complex reflections to enhance patient engagement; the use of an ask-tell-ask format and specific, measurable, achievable, relevant, and time-limited (SMART) goals to facilitate treatment planning; and close collaboration between the neurology and psychotherapy teams.

An investigation into the preferred terminology for functional seizures

There is considerable debate in the literature regarding what to call functional seizures, with terms such as pseudoseizures, nonepileptic attack disorder (NEAD), and dissociative seizures being used. Provision of an accurate diagnosis and coherent explanation is a vital first step in the management of functional seizures and can result in cessation or reduced frequency for some individuals. This study investigated preferences for and offensiveness of terms used to describe functional seizures, and expectations for recovery with psychological treatment. A sample of 87 healthy adults completed an online survey, in which eight different diagnostic terms were ranked in order of preference (1 - most preferred, 8 - least preferred): functional nonepileptic attacks (FNEA), dissociative seizures, functional seizures, psychogenic seizures, NEAD, pseudoseizures, conversion disorder, and hysteria. Replicating Stone and colleagues protocol, each term was investigated for five connotations. Offense scores were calculated from the number of participants who selected 'yes' to at least one of the negative connotations ('Putting it on', 'Mad', and 'Imagining Symptoms'). Expectations about the possibility of recovering through medical or psychological treatment were also recorded. Functional nonepileptic attack was ranked the highest preferred term with dissociative seizures and functional seizures closely following. Nonepileptic attack disorder was the least offensive term, with FNEA and functional seizures joint second. Unsurprisingly, the three least preferred terms were also the most offensive: pseudoseizures, conversion disorder, and hysteria. Expectations of nonrecovery from psychological treatment were lowest for terms implicating a psychological cause: pseudoseizures, dissociative seizures, psychogenic seizures, and hysteria. The results suggest that either the terms FNEA or functional seizures should be adopted by healthcare professionals and patients, as they are the most preferred, least offensive, and expectations for nonrecovery with psychological treatment were moderate compared with the other terms. Limitations and areas for future research are discussed.