Patients with epilepsy and patients with psychogenic non-epileptic seizures: Video-EEG, clinical and neuropsychological evaluation

Neuropsychological morbidity in the First Seizure Clinic: Prominent mood symptoms and memory issues in epilepsy

OBJECTIVE

To examine the neuropsychological morbidity across the spectrum of patients presenting to a First Seizure Clinic, and test the hypothesis that cognitive and psychological compromise is especially prominent in those diagnosed with epilepsy.

METHODS

A sample of 201 patients referred to the Austin Hospital First Seizure Clinic (FSC) underwent cognitive screening via telephone and psychological screening via online questionnaire, all prior to their diagnostic evaluation (and any attendant treatment recommendation) at the FSC. Rates of cognitive (i.e., scores <10th percentile) and psychological impairment (using established clinical cut scores) were compared against 35 demographically matched controls. Cognitive differences were explored between the most frequently encountered patient subgroups (epilepsy, n = 48; first unprovoked seizure, n = 24; acute symptomatic seizure, n = 24; syncope, n = 35) via a multivariate analysis of variance, with diagnostic labels applied retrospectively after a period of follow-up.

RESULTS

People with epilepsy were most likely to show cognitive impairments, particularly in learning and memory, with performances worse than all other FSC groups (F [3127] = 2.44, p = 0.03). Clinically significant depressive symptoms were similarly prevalent in all patient groups, with one in three at risk for Major Depressive Disorder. Elevated anxiety symptoms were common across patient groups; however, not significantly different to controls.

SIGNIFICANCE

Cognitive impairment in epilepsy and mood problems in all FSC groups are detectable via remote screening as early as the first seizure. Learning and memory difficulties are particularly prevalent in new-onset epilepsy and may lend diagnostic information when paired with clinical factors.

PLAIN LANGUAGE SUMMARY

This study explored cognitive and psychological differences between various patient groups attending an Australian First Seizure Clinic. We found that learning and memory abilities were poorer in people with epilepsy than other patient groups including those with non-epileptic seizures, and seizure-mimics (fainting episodes). Therefore, along with standard epilepsy investigations, memory performances could help to predict which patients have epilepsy versus a non-epileptic condition after a first suspected seizure. Further, approximately one in three from each patient group showed high symptoms of depression and anxiety. The findings highlight the importance of evaluating cognition and mood in people with first 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.

Decreased uncinate fasciculus integrity in functional seizures following traumatic brain injury

OBJECTIVE

The uncinate fasciculus (UF) has been implicated previously in contributing to the pathophysiology of functional (nonepileptic) seizures (FS). FS are frequently preceded by adverse life events (ALEs) and present with comorbid psychiatric symptoms, yet neurobiological correlates of these factors remain unclear. To address this gap, using advanced diffusion magnetic resonance imaging (dMRI), UF tracts in a large cohort of patients with FS and pre-existing traumatic brain injury (TBI + FS) were compared to those in patients with TBI without FS (TBI-only). We hypothesized that dMRI measures in UF structural connectivity would reveal UF differences when controlling for TBI status. Partial correlation tests assessed the potential relationships with psychiatric symptom severity measures.

METHODS

Participants with TBI-only (N = 46) and TBI + FS (N = 55) completed a series of symptom questionnaires and MRI scanning. Deterministic tractography via diffusion spectrum imaging (DSI) was implemented in DSI studio (https://dsi-studio.labsolver.org) with q-space diffeomorphic reconstruction (QSDR), streamline production, and manual segmentation to assess bilateral UF integrity. Fractional anisotropy (FA), radial diffusivity (RD), streamline counts, and their respective asymmetry indices (AIs) served as estimates of white matter integrity.

RESULTS

Compared to TBI-only, TBI + FS participants demonstrated decreased left hemisphere FA and RD asymmetry index (AI) for UF tracts (both p < .05, false discovery rate [FDR] corrected). Additionally, TBI + FS reported higher symptom severity in depression, anxiety, and PTSD measures (all p < .01). Correlation tests comparing UF white matter integrity differences to psychiatric symptom severity failed to reach criteria for significance (all p > .05, FDR corrected).

SIGNIFICANCE

In a large, well-characterized sample, participants with FS had decreased white matter health after controlling for the history of TBI. Planned follow-up analysis found no evidence to suggest that UF connectivity measures are a feature of group differences in mood or anxiety comorbidities for FS. These findings suggest that frontolimbic structural connectivity may play a role in FS symptomology, after accounting for prior ALEs and comorbid psychopathology severity.

Neuropsychological characteristics of drug resistant epilepsy patients with and without comorbid functional seizures

INTRODUCTION

Neuropsychological testing is a mandatory component in the evaluation of drug resistant epilepsy. The results of testing may assist with both the localization of an epilepsy as well as assessment of surgical risk. Previous studies have demonstrated differences in the neuropsychological performance of patients with epilepsy and functional seizures. We hypothesized that comorbid functional seizures could potentially influence neuropsychological test performance. Therefore, we evaluated whether there is a difference in the neuropsychological test results between drug resistant epilepsy patients with and without comorbid functional seizures.

METHOD

Neuropsychological test results were compared between 25 patients with drug resistant focal epilepsy and 25 patients that also had documented functional seizures. Univariate analyses and multiple logistic regression models were used to both assess performance differences between the groups and to assess whether test results could be used to accurately identify which patients had comorbid functional seizures.

RESULTS

Epilepsy patients with comorbid functional seizures performed significantly worse on the FAS Verbal Fluency Test compared to ES patients (p = 0.047). Digit Span Backwards (p = 0.10), Digit Span Forwards (p = 0.14) and Working Memory Index (p = 0.10) tended to be lower in the epilepsy and functional seizures group but was not statistically significant. A multiple logistic regression model using the results of four neuropsychological tests was able to identify patients with comorbid functional seizures with 83.33% accuracy.

CONCLUSIONS

There are appeared to be some differences in the neuropsychological performance among drug resistant epilepsy patients based on whether they have comorbid functional seizures. These findings may have relevant implications for the interpretation of neuropsychological test results.

EEG and MRI Abnormalities in Patients With Psychogenic Nonepileptic Seizures

OBJECTIVE

To compare the rate of EEG and MRI abnormalities in psychogenic nonepileptic seizures (PNES) patients with and without suspected epilepsy. Patients were also compared in terms of their demographic and clinical profiles.

METHODS

A retrospective analysis of 271 newly diagnosed PNES patients admitted to the epilepsy monitoring unit between May 2000 and April 2008, with follow-up clinical data collected until September 2015.

RESULTS

One hundred ninety-four patients were determined to have PNES alone, 16 PNES plus possible epilepsy, 14 PNES plus probable epilepsy, and 47 PNES plus confirmed epilepsy. Fifty-seven of the 77 patients (74.0%) with possible, probable, or definite epilepsy exhibited epileptiform activity on EEG, versus only 16 of the 194 patients (8.2%) in whom epilepsy was excluded. Twenty-four of these 194 patients (12.4%) had MRI abnormalities. Three of 38 patients (7.9%) with both EEG and MRI abnormalities were confirmed not to have epilepsy. In PNES patients with EEG or MRI abnormalities compared with those without, patients with abnormalities were more likely to have epilepsy risk factors, such as central nervous system structural abnormalities, and less likely to report minor head trauma. The presence of EEG abnormalities in PNES-only patients did not influence antiseizure medication reduction, whereas those with MRI abnormalities were less likely to have their antiseizure medications reduced.

CONCLUSIONS

Psychogenic nonepileptic seizure patients without MRI or EEG abnormalities are less likely to have associated epilepsy, risk factors for epilepsy, and had different demographic profiles. There is a higher-than-expected level of EEG and MRI abnormalities in PNES patients without epilepsy.

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.

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.

The Comparison Between Neuropsychological Features of Psychogenic Non-epileptic Seizures and Epileptic Seizures

Background: Both epileptic seizures (ES) and psychogenic non-epileptic seizures (PNES) are often associated with some degree of cognitive impairment. Video electroencephalography (EEG) monitoring is the gold standard for diagnosing PNES. This diagnostic procedure is costly and available in specific tertiary centers. Neuropsychological assessment can provide clues for the differential diagnosis of PNES and ES and help clarify the nature and etiology of these two disorders. Objectives: Therefore, this study aimed to compare the neuropsychological profiles of PNES and ES patients. Methods: In this analytical cross-sectional study, 30 patients with ES and 31 patients with PNES were compared by neuropsychiatric tests, such as the Wechsler Adult Intelligence scale (WAIS), Addenbrooke’s Cognitive examination (ACE), and California Verbal Learning test (CVLT). Results: There was a female predominance in the PNES group (female-to-male ratio = 4.16/1, P = 0.003). In the PNES group, 77.4% of the patients had a psychiatric disorder versus 66.7% of the patients in the ES group; however, the difference was not statistically significant (P = 0.34). The mean score of total intelligence was higher in the PNES group (84.77 ± 16.94), compared to the ES group (83.63 ± 10.04); however, the difference was not significant (P = 0.75). Based on the mean subscale scores, the digit symbol score (WAIS-IV subscale) and memory score (ACE subscale) were significantly higher in the PNES group compared to the ES group (P = 0.037 and 0.032, respectively). Conclusions: This study showed that neuropsychological assessments might not differentiate ES from non-epileptic seizures.

Evidence-Based Practice for the Clinical Assessment of Psychogenic Nonepileptic Seizures: A Report From the American Neuropsychiatric Association Committee on Research

The American Neuropsychiatric Association's Committee on Research assigned the task of defining the most helpful clinical factors and tests in establishing the diagnosis of psychogenic nonepileptic seizures (PNES) during a neuropsychiatric assessment. A systematic review of the literature was conducted using three search engines and specified search terms for PNES and the predetermined clinical factors and diagnostic tests, followed by a selection process with specific criteria. Data extraction results from selected articles are presented for clinical factors (semiology, psychiatric comorbidities, medical comorbidities, psychological traits) and diagnostic tests (EEG, psychometric and neuropsychological measures, prolactin level, clinical neuroimaging, autonomic testing). Semiology with video EEG (vEEG) remains the most valuable tool to determine the diagnosis of PNES. With the exception of semiology, very few studies revealed the predictive value of a clinical factor for PNES, and such findings were isolated and not replicated in most cases. Induction techniques, especially when coupled with vEEG, can lead to a captured event, which then confirms the diagnosis. In the absence of a captured event, postevent prolactin level and personality assessment can support the diagnosis but need to be carefully contextualized with other clinical factors. A comprehensive clinical assessment in patients with suspected PNES can identify several clinical factors and may include a number of tests that can support the diagnosis of PNES. This is especially relevant when the gold standard of a captured event with typical semiology on vEEG cannot be obtained.

Potential surgical therapies for drug-resistant focal epilepsy

Drug-resistant focal epilepsy (DRFE), defined by failure of two antiepileptic drugs, affects 30% of epileptic patients. Epilepsy surgeries are alternative options for this population. Preoperative evaluation is critical to include potential candidates, and to choose the most appropriate procedure to maximize efficacy and simultaneously minimize side effects. Traditional procedures involve open skull surgeries and epileptic focus resection. Alternatively, neuromodulation surgeries use peripheral nerve or deep brain stimulation to reduce the activities of epileptogenic focus. With the advanced improvement of laser-induced thermal therapy (LITT) technique and its utilization in neurosurgery, magnetic resonance-guided LITT (MRgLITT) emerges as a minimal invasive approach for drug-resistant focal epilepsy. In the present review, we first introduce drug-resistant focal epilepsy and summarize the indications, pros and cons of traditional surgical procedures and neuromodulation procedures. And then, focusing on MRgLITT, we thoroughly discuss its history, its technical details, its safety issues, and current evidence on its clinical applications. A case report on MRgLITT is also included to illustrate the preoperational evaluation. We believe that MRgLITT is a promising approach in selected patients with drug-resistant focal epilepsy, although large prospective studies are required to evaluate its efficacy and side effects, as well as to implement a standardized protocol for its application.

Psychogenic nonepileptic seizures: The effect of accurate diagnosis on cognition

OBJECTIVE

Much remains to be elucidated about the cognitive profile of patients with psychogenic nonepileptic seizures (PNES) and about how this changes over time and compares to that of patients with epilepsy. The aim of this study was to study the neuropsychological profile of patients with PNES and an age-matched group of patients with temporal lobe epilepsy (TLE) during admission to a video electroencephalography monitoring unit (VEMU) and 1 year after discharge.

METHODS

Patients diagnosed with PNES or TLE at a VEMU were prospectively recruited. Neuropsychological, demographic, clinical, and treatment variables were collected at baseline and 1 year. To minimize multiple comparisons, scores from different cognitive tests were computed for attention and psychomotor speed, verbal memory, visual memory, language, and executive function. A global cognitive impairment index (GCII) was also created. Post hoc analyses were conducted to identify clinical variables that might mediate the differences observed in cognition over time between the groups. These included seizure frequency, number of antiseizure medication (ASM), number of psychotropic drugs, depression, and quality of life.

RESULTS

We studied 24 patients with PNES and 24 patients with TLE. The groups performed similarly in the baseline neuropsychological tests. There was a significant time (baseline to 1-year follow-up) by group (PNES vs TLE) interaction for the GCII (p = 0.006), language (p = 0.04), and executive function (p = 0.013), with PNES patients showing improvement and TLE patients remaining stable. The time by group interaction for attention and psychomotor speed showed a trend toward significance (p = 0.056), Reduction in number of ASM was associated with improved cognition in PNES patients at 1 year.

CONCLUSION

PNES patients showed improved cognition at 1 year of follow-up, particularly in language and executive functions. This finding shows the potential benefits of an early, accurate diagnosis, which range from improved cognition to better management.

The COVID-19 outbreak and PNES: The impact of a ubiquitously felt stressor

OBJECTIVE

We aimed to assess frequency of functional seizures or psychogenic nonepileptic seizures (PNES) during the COVID-19 outbreak and to recognize possible factors associated with worsening in this population.

METHODS

In this cross-sectional study conducted during the second phase of the pandemic, adult patients with PNES documented by video-EEG and followed up in two tertiary epilepsy centers responded to a structured telephone survey. Data were gathered on demographics, clinical features and frequency of PNES, history of psychiatric comorbidity, access to treatment, as well as on anxiety (GAD-7 items) and depressive symptoms (NDDI-E).

RESULTS

Fifty-four patients (78% female; mean age of 31.36 years [SD = 10.6]) were contacted and 15 (28%) reported increased frequency of PNES during the pandemic. Higher scores of GAD-7 items (p < 0.001) and NDDI-E (p < 0.001) were associated with PNES worsening. There was strong evidence of a correlation between higher stress levels (p < 0.001) and poor sleep quality (p 0.005) with PNES aggravation. After regression, stress was the strongest predictor of PNES increased frequency.

SIGNIFICANCE

Patients with functional neurological disorders are vulnerable during ubiquitously felt stressors. However, the atmosphere of uncertainty did not affect these patients equally. Patients with PNES showing symptoms of anxiety and depression are at higher risk of seizure worsening. Early identification of this subset of patients may prevent this detrimental outcome.

Clinical differentiation of psychogenic non-epileptic seizure: a practical diagnostic approach

Background

Psychogenic non-epileptic seizure (PNES) has long been the counterpart of epileptic seizure (ES). Despite ample of evidence differentiating the two, PNES mistakenly diagnosed as ES was still common, resulting in unnecessary exposure to long-term antiepileptic medications and reduced patient’s and caregiver’s quality of life, not to mention the burgeoning financial costs.

Objectives

In this review, we aimed to elucidate various differences between PNES and epileptic seizure with respect to baseline characteristics, seizure semiology, EEG pattern, and other key hallmark features.

Methods

An unstructured search was carried out in PubMed, MEDLINE, and EMBASE using keywords pertinent to PNES and ES differentiation. Relevant information was subsequently summarized herein.

Results

PNES differs significantly with ES in terms of baseline characteristics, prodromal symptoms, seizure semiology, presence of pseudosleep, and other hallmark features (for instance provoking seizure with suggestion). The combined approach, if applied appropriately, can yield high diagnostic yield.

Conclusions

PNES can be clearly differentiated from ES via careful adherence to a set of valid clinical cues. The summarized clinical hallmarks is highly useful to prevent unnecessary ES diagnosis and treatment with AEDs.

Cognitive profiles in patients with epileptic and nonepileptic seizures evaluated using a brief cognitive assessment tool

BACKGROUND

There is a need for the development of brief tools to screen for cognitive impairments in epilepsy patients in order to prioritize and direct formal comprehensive cognitive testing. Yet, shorter cognitive screening tools are limited in their breadth of cognitive domains or have not been intensively studied on an epilepsy population. This study used a brief cognitive screening tool in order to compare cognitive profiles between patients with epilepsy and those with nonepileptic seizures.

METHODS

Patients admitted to the Royal Melbourne Hospital video-EEG monitoring unit between 2005 and 2017 were included. Patients were categorized according to seizure etiology (epileptic, psychogenic or other nonepileptic seizures), epilepsy syndrome (focal or generalized; temporal lobe (TLE) or extra-temporal lobe epilepsy (ETLE)), seizure frequency, and anti-seizure medications (ASMs). Attention, visuoconstructional, memory, executive, and language functioning were assessed with the Neuropsychiatry Unit Cognitive Assessment Tool (NUCOG). General linear mixed models were computed to investigate cognitive profiles according to diagnostic group and other clinicodemographic variables.

RESULTS

800 patients were included in the analysis (61% female and 39 % male, median age 36 years). Patients with both epileptic seizures and psychogenic seizures (n = 25) had the lowest total scores on NUCOG, followed by patients with epileptic seizures (n = 411), psychogenic seizures (n = 185), and nonepileptic seizures (n = 179, p = 0.002). Specifically, patients with epileptic seizures performed worse than those with nonepileptic seizures in the executive, language, and memory domain, and had lower language domain scores than those with psychogenic seizures. Patients with bilateral TLE had poorer performance than those with unilateral TLE, particularly for memory function. Specific ASMs and polypharmacy but not seizure frequency had a negative effect on cognition (p < 0.001). NUCOG scores did not differ between focal and generalized epilepsies, or between TLE and ETLE.

CONCLUSION

The NUCOG differentiated cognitive profiles in patients with uncontrolled seizures due to different etiologies. Bilateral TLE and medication adversely affected cognitive performance, and overall patients with epilepsy performed worse than those with nonepileptic seizures. These results provide further evidence for sensitivity of the NUCOG for detecting cognitive impairment in patients with seizure disorders.

Differential Semiology Based on Video Electroencephalography Monitoring Between Psychogenic Nonepileptic Seizures and Temporal Lobe Epileptic Seizures

BACKGROUND

Psychogenic nonepileptic seizures (PNESs) are disruptive changes in behavior without ictal correlate of epileptic activity and high prevalence of psychiatric morbidity. Differential diagnosis is difficult particularly with temporal lobe epilepsy (TLE), which is also associated with high prevalence of psychiatric comorbidity. Although video electroencephalography is the gold standard for differential diagnosis, clinical semiology analysis may help the clinician in general medical practice.

OBJECTIVE

In this study, the differential semiology, based on video electroencephalography, between PNESs and TLE seizures was analyzed.

METHODS

The video electroencephalography of patients with diagnosis of PNES and TLE were reviewed and compared between groups. Clinical semiology of all episodes recorded by video electroencephalography in each patient was analyzed and classified in accordance with the presence of behavioral arrest, motor hyperkinetic activity, impaired awareness, aura, and automatisms. Chi square test and binary logistic regression were determined.

RESULTS

Thirty-two patients with PNES (32 ± 11 y) and 34 with TLE (32 ± 12 y) were included. Female patients were predominant in the PNES group (P < 0.05). Mean time duration of episodes was 6.8 ± 10 minutes in PNES and 1.6 ± 0.8 minutes in TLE (P < 0.05). Impaired awareness (odds ratio = 24.4; 95% confidence interval = 3.79 -157.3, P < 0.01), automatisms (odds ratio = 13.9; 95% confidence interval = 2.1- 90.5, P < 0.01), and shorter duration of the events (odds ratio = 2.261, 95% confidence interval = 1.149 - 4.449, P = 0.018) were found as independent factors for detecting TLE seizures comparing PNESs.

CONCLUSION

Clinical semiology analysis may orientate the differential diagnosis in general medical practice, between PNESs and TLE seizures. Further studies comparing PNES semiology with other subtypes of epilepsies may complete these preliminary findings.

[The problem of comorbidity of epilepsy and psychogenic paroxysms]

A review of publications over the last two decades is presented. Psychogenic paroxysms develop in approximately 12% of patients with epilepsy. The analysis of social and demographic data, history details, semiological features and results of electrophysiological and neuroimaging studies does not unequivocally support the comorbidity of epilepsy and psychogenic paroxysms. The pathogenetic mechanisms of the development of comorbidity are various and depend on the presence of pharmacoresistance, psychological traumas in the past, intellectual disability etc. Video-EEG-monitoring is the gold standard in the diagnosis of comorbidity of epilepsy and psychogenic paroxysms. Treatment of such cases includes anticonvulsants and cognitive-behavioral therapy.

Factors associated with subjective cognitive function in epilepsy and psychogenic non-epileptic seizures

OBJECTIVE

To identify factors associated with subjective cognitive complaints in people with presumed seizure disorders referred for video electroencephalogram monitoring (VEM).

METHODS

Adult patients admitted for inpatient VEM were recruited. Objective cognitive function was measured with the Neuropsychiatry Unit Cognitive Screening Tool, subjective cognitive function with the Quality of Life in Epilepsy Inventory-89 subscales, and anxiety and depressive symptoms with the Hospital Anxiety and Depression Scale. Multivariate Bayesian general linear models were used to identify predictors of subjective cognitive function.

RESULTS

331 patients met inclusion criteria. Mean age was 39.3 years and 61.9 % patients were female. Diagnoses included epilepsy, psychogenic non-epileptic seizures (PNES) or both conditions. Depression, anxiety and objective cognitive function were predictors of subjective cognitive function across all domains. Depression was the strongest predictor of subjective memory and attention, whilst objective cognition was the strongest predictor of subjective language function. Mood also mediated the relationship between objective function and subjective function across all domains to varying extents; depression exerted the strongest effect of 22 % for the memory domain; conversely, language domain was least influenced by mood, with depression mediating 11 % and anxiety mediating only 9% of the subjective-objective relationship.

SIGNIFICANCE

Mood and objective cognitive function are both important contributors to subjective cognitive function for patients undergoing VEM. Clinicians should consider referring patients with cognitive complaints for both neurocognitive workup and neuropsychiatric evaluation. Future work may examine the effects of treating concomitant mood disorders on subjective cognitive function.

Objective Structured Clinical Exams (OSCE) are a feasible method of teaching how to discuss a nonepileptic seizure diagnosis

OBJECTIVE

Presenting the diagnosis of psychogenic nonepileptic seizures (PNES) can be a difficult task, but disclosing this information effectively is important to optimize patient outcomes. We sought to develop a standardized method to teach neurology residents how to introduce the diagnosis of PNES via an objective structured clinical examination (OSCE) with a standardized patient (SP).

METHODS

In conjunction with the New York University School of Medicine Simulation Center (NYSIM), we designed an OSCE in which a resident had to inform a SP of her diagnosis of PNES and discuss a treatment plan. The SP was provided with details to gradually disclose depending on what the resident said about the history of her episodes, triggers for her episodes and her history of sexual abuse. Each encounter was observed by an attending physician who provided real-time feedback to the resident after the session. Additionally, the SP completed an objective written checklist of items the resident should have covered in the session and gave them verbal feedback.

RESULTS

Twenty-six adult neurology (n = 22), child neurology (n = 3), and neuropsychiatry (n = 1) residents participated in this OSCE in 2018 and 2019, with full data available for 25 participants. Residents reported the OSCE was very useful (mean Likert score of 4.9/5). They felt moderately prepared (mean Likert score 3.8/5) and rated their performance as a mean of 3.3/5. On the SP's checklist, most residents were rated as Well Done in the domains of information gathering, relationship development, and education and counseling. Only in the domain of psychosocial assessment were most residents rated as Not Done (only 7/25 inquired about past trauma as a risk factor for PNES).

SIGNIFICANCE

The OSCEs are a feasible and useful way to teach neurology residents about discussing PNES, as they allow for provision of real-time practice and feedback in a safe environment without real patients.

Dual diagnosis of epilepsy and psychogenic nonepileptic seizures: Systematic review and meta-analysis of frequency, correlates, and outcomes

Comorbid epilepsy and psychogenic nonepileptic seizures (PNES) represent a serious challenge for the clinicians. However, the frequency, associations, and outcomes of dual diagnosis of epilepsy and PNES are unclear. The aim of the review was to determine the frequency, correlates, and outcomes of a dual diagnosis. A systematic review of all published observational studies (from inception to Dec. 2016) was conducted to determine the frequency, correlates, and outcomes of dual diagnosis. We included studies of individuals of any age reporting a dual diagnosis of epilepsy and PNES. All observational study designs were included with the exception of case reports and case series with fewer than 10 participants. The mean frequency of epilepsy in patients with PNES across all studies was 22% (95% confidence intervals [CI] 20 to 25%, range: 0% to 90%) while the mean frequency of PNES in patients with epilepsy was 12% (95% CI 10 to 14%, range: 1% to 62%). High heterogeneity means that these pooled estimates should be viewed with caution. A number of correlates of dual diagnosis were reported. Some studies delineated differences in semiology of seizures in patients with dual diagnosis vs. PNES or epilepsy only. However, most of the correlates were inconclusive. Only a few studies examined outcome in patients with dual diagnosis. Dual diagnosis is common in clinical practice, especially among patients referred to specialized services, and requires careful diagnosis and management.

A unifying theory for cognitive abnormalities in functional neurological disorders, fibromyalgia and chronic fatigue syndrome: systematic review

BACKGROUND

Functional cognitive disorder (FCD) describes cognitive dysfunction in the absence of an organic cause. It is increasingly prevalent in healthcare settings yet its key neuropsychological features have not been reported in large patient cohorts. We hypothesised that cognitive profiles in fibromyalgia (FM), chronic fatigue syndrome (CFS) and functional neurological disorders (FNDs) would provide a template for characterising FCD.

METHODS

We conducted a systematic review of studies with cognition-related outcomes in FM, CFS and FND.

RESULTS

We selected 52 studies on FM, 95 on CFS and 39 on FND. We found a general discordance between high rates of subjective cognitive symptoms, including forgetfulness, distractibility and word-finding difficulties, and inconsistent objective neuropsychological deficits. Objective deficits were reported, including poor selective and divided attention, slow information processing and vulnerability to distraction. In some studies, cognitive performance was inversely correlated with pain, exertion and fatigue. Performance validity testing demonstrated poor effort in only a minority of subjects, and patients with CFS showed a heightened perception of effort.

DISCUSSION

The cognitive profiles of FM, CFS and non-cognitive FND are similar to the proposed features of FCD, suggesting common mechanistic underpinnings. Similar findings have been reported in patients with mild traumatic brain injury and whiplash. We hypothesise that pain, fatigue and excessive interoceptive monitoring produce a decrease in externally directed attention. This increases susceptibility to distraction and slows information processing, interfering with cognitive function, in particular multitasking. Routine cognitive processes are experienced as unduly effortful. This may reflect a switch from an automatic to a less efficient controlled or explicit cognitive mode, a mechanism that has also been proposed for impaired motor control in FND. These experiences might then be overinterpreted due to memory perfectionism and heightened self-monitoring of cognitive performance.

Psychiatric disorders and trauma history in patients with pure PNES and patients with PNES and coexisting epilepsy

Several studies found high prevalence rates of psychiatric disorders in patients with pure psychogenic nonepileptic seizures (PNES). Traumatic experiences were also reported to be elevated in patients with PNES and were discussed as a crucial risk factor for the development of PNES. Much less is known about psychiatric comorbidities and specifically, about trauma history in patients with PNES and coexisting epilepsy. Here, we aimed at directly comparing psychiatric disorders and traumatic life experiences in patients with pure PNES and in patients with PNES and coexisting epilepsy. We assessed the presence of current axes I and II disorders in 109 patients with either pure PNES (n = 67) or with PNES + epilepsy (n = 42) by using structured clinical interviews. We also compared the trauma histories by using the posttraumatic diagnostic scale (PDS) as an interview and the extent of physical, sexual, and emotional childhood maltreatment measured with the Childhood Trauma Questionnaire (CTQ). Patients of both groups had very high rates of psychiatric disorders: 79.1% of the patients with pure PNES and 76.2% of the patients with PNES + epilepsy had at least one psychiatric disorder. The frequencies of psychiatric disorders did not differ between groups. However, there was a trend towards higher rates of posttraumatic stress disorder (PTSD) in patients with PNES (32.9%) compared with patients with PNES + epilepsy (16.7%). In both groups, the proportion of patients who recalled traumatic events in the PDS was high (72.6% in the patients with pure PNES, 64.3% in the patients with PNES + epilepsy) and did not differ significantly between groups. The age at first traumatization, the types of trauma events experienced, the number of patients with single traumatization, and those with repeated traumatic experiences also did not differ between groups. We found high frequencies of childhood maltreatment in both groups. Our findings show that patients with PNES and patients with PNES and coexisting epilepsy could neither be differentiated by the amount of psychiatric additional disorders nor by the nature and extent of trauma and maltreatment experiences. Our results suggest that patients with PNES + epilepsy rather resemble patients with pure PNES than patients with epilepsy in respect to psychopathological characteristics and adverse life experiences. Trauma and maltreatment history are therefore assumed to be predisposing factors to PNES in both patients with pure PNES and patients with PNES and coexisting epilepsy.

The prevalence of depression in general hospital inpatients: a systematic review and meta-analysis of interview-based studies

BACKGROUND

Comorbid depression in the medically ill is clinically important. Admission to a general hospital offers an opportunity to identify and initiate treatment for depression. However, we first need to know how common depression is in general hospital inpatients. We aimed to address this question by systematically reviewing the relevant literature.

METHODS

We reviewed published prevalence studies in any language which had used diagnostic interviews of general hospital inpatients and met basic methodological quality criteria. We focussed on interview-based studies in order to estimate the proportion of patients with a diagnosis of depressive illness.

RESULTS

Of 158 relevant articles, 65 (41%) describing 60 separate studies met our inclusion criteria. The 31 studies that focussed on general medical and surgical inpatients reported prevalence estimates ranging from 5% to 34%. There was substantial, highly statistically significant, heterogeneity between studies which was not materially explained by the covariates we were able to consider. The average of the reported prevalences was 12% (95% CI 10-15), with a 95% prediction interval of 4-32%. The remaining 29 studies, of a variety of specific clinical populations, are described.

CONCLUSIONS

The available evidence suggests a likely prevalence high enough to make it worthwhile screening hospital inpatients for depression and initiating treatment where appropriate. Further, higher quality, research is needed to clarify the prevalence of depression in specific settings and to further explore the reasons for the observed heterogeneity in estimates.

Neuropsychiatric features of the coexistence of epilepsy and psychogenic nonepileptic seizures

OBJECTIVE

To investigate demographic, epidemiologic and psychiatric features suggestive of the coexistence epilepsy (ES) and psychogenic nonepileptic seizures (PNES) that may contribute to precocious suspicion of the association.

METHODS

In this exploratory study, all patients older than 16 years admitted to prolonged video-electroencephalogram monitoring were evaluated about demographic, epileptological and psychiatric features. Detailed psychiatric assessment using M.I.N.I.-plus 5.0, Beck Anxiety Inventory, Beck Depression Inventory and the Childhood Trauma Questionnaire (CTQ) was performed. Data were collected previous to the final diagnosis and patients with ES-only, PNES-only or coexistence of ES/PNES were compared.

RESULTS

Of 122 patients admitted to epilepsy monitoring unit, 86 patients were included and 25 (29%) had PNES. Twelve (14%) had PNES-only, 13 (15%) had ES/PNES and the remaining 61 (71%) had only ES. A coexistence of ES and PNES was associated with clinical report of more than one seizure type (p˂0.001), nonspecific white matter hyperintensities on MRI (p < .001) and a past of psychotic disorder (p = .005). In addition, these patients had significantly more emotional abuse and neglect (p < .002 and 0.001, respectively). Somatization (including conversion disorder) was the most common diagnosis in patients with PNES- only (83%) and co-existing of PNES and ES (69.2%), differentiating both from ES-only patients (p < .001).

CONCLUSION

The high prevalence of this coexistence ES/PNES in this study reinforces a need to properly investigate PNES, especially in patients with confirmed ES who become refractory to medical treatment with antiepileptic drugs. The neuropsychiatric assessment may help to diagnostic suspicion and in the planning of therapeutic interventions.

Lennox-Gastaut syndrome in adulthood: Long-term clinical follow-up of 38 patients and analysis of their recorded seizures

Lennox-Gastaut syndrome (LGS) is a severe epileptic encephalopathy with childhood onset that usually continues through adolescence and into adulthood. In the long term, patients with this condition still have intractable seizures, intellectual disability, behavioral problems, and physical comorbidities. The aim of this study was to describe the clinical and EEG characteristics of a group of adults with Lennox-Gastaut syndrome. We identified 38 (22 females, 16 males) patients with LGS older than age 18years at their last evaluation, with mean age of 43.3±10.6years. Median follow-up was 14.4years (range: 2-40). All of our patients had 3 or more seizure types during their clinical history. The most prevalent seizure types at follow-up were atypical absences (28/38), tonic (28/38), generalized tonic-clonic (17/38), focal (11/38), and myoclonic seizures (9/38). All patients had drug-resistant seizures. Besides epilepsy, intellectual disability and behavioral problems were prominent features. Surprisingly, paroxysmal nonepileptic seizures were reported in 3 patients. Our observations confirm the poor outcome of Lennox-Gastaut syndrome through adulthood, regardless of age at seizure onset, etiology, and history of previous West syndrome.

Differentiating PNES from epileptic seizures using conversational analysis

We applied conversation analysis in an unselected continuous series of 70 patients to discriminate patients with psychogenic nonepileptic seizures (PNES) from patients with epilepsy. Two psychologists examined the patients' recorded reports. Patients were also submitted to an extensive neuropsychological battery in order to verify whether specific cognitive deficits or mental health problems are typical of patients with PNES and whether some cognitive deficits could prevent the correct diagnosis. The results showed a good percentage of correct diagnosis, with a sensitivity of 0.795 and a specificity of 0.83, while no difference in the cognitive profile was found between patients with PNES and patients with epilepsy. The results also suggest that psychologists can apply the conversation analysis as well as linguists, which is an important finding since psychologists are employed in specialized centers, while linguists in general are not part of the team.

Which patients with epilepsy are at risk for psychogenic nonepileptic seizures (PNES)? A multicenter case-control study

OBJECTIVE

We sought to examine the clinical and electrographic differences between patients with combined epileptic (ES) and psychogenic nonepileptic seizures (PNES) and age- and gender-matched patients with ES-only and PNES-only.

METHODS

Data from 138 patients (105 women [77%]), including 46 with PNES/ES (39±12years), 46 with PNES-only (39±11years), and 46 with ES-only (39±11years), were compared using logistic regression analysis after adjusting for clustering effect.

RESULTS

In the cohort with PNES/ES, ES antedated PNES in 28 patients (70%) and occurred simultaneously in 11 (27.5%), while PNES were the initial presentation in only 1 case (2.5%); disease duration was undetermined in 6. Compared with those with ES-only, patients with PNES/ES had higher depression and anxiety scores, shorter-duration electrographic seizures, less ES absence/staring semiology (all p≤0.01), and more ES arising in the right hemisphere, both in isolation and in combination with contralateral brain regions (61% vs. 41%; p=0.024, adjusted for anxiety and depression) and tended to have less ES arising in the left temporal lobe (13% vs. 28%; p=0.054). Compared with those with PNES-only, patients with PNES/ES tended to show fewer right-hemibody PNES events (7% vs. 23%; p=0.054) and more myoclonic semiology (10% vs. 2%; p=0.073).

CONCLUSIONS

Right-hemispheric electrographic seizures may be more common among patients with ES who develop comorbid PNES, in agreement with prior neurobiological studies on functional neurological disorders.

Health related quality of life in patients admitted for video-electroencephalography monitoring diagnosed with epilepsy or psychogenic non-epileptic seizures

Objective:

To determine the health related quality of life (HRQOL) in patients with epilepsy or psychogenic non-epileptic seizures (PNES).

Methods:

This cross-sectional study was carried out between December 2010 and December 2014 in the Department of Neurology and Psychiatry, Faculty of Medicine, Baskent University, Adana, Turkey. Patients who were admitted for video-electroencephalography monitoring and diagnosed of epileptic seizures or PNES were asked to complete a questionnaire from the World Health Organization Quality of Life, and psychiatric comorbidities were diagnosed using the structured clinical interview for Diagnostic and Statistical Manual of Mental Disorders Fourth Edition.

Results:

Patients with epilepsy and PNES were found to have similar HRQOL in physical, psychological, social, and environmental domains. However, the percentage of comorbid psychiatric disorders were higher in patients with PNES than patients with epilepsy.

Conclusion:

Patients with epilepsy and PNES have similar HRQOL, and PNES are resistant to the standard medical therapies used for the treatment of epileptic seizures. The direct lifetime cost of undiagnosed PNES may be of equal with intractable epilepsy. A better understanding of the impact of PNES manifestations and epilepsy would help to provide appropriate clinical, psychological and social care.

Psychological and psychiatric aspects of psychogenic non-epileptic seizures (PNES): A systematic review

Psychogenic non-epileptic seizures (PNES) are common in neurological settings and often associated with considerable distress and disability. The psychological mechanisms underlying PNES are poorly understood and there is a lack of well-established, evidence-based treatments. This paper advances our understanding of PNES by providing a comprehensive systematic review of the evidence pertaining to the main theoretical models of this phenomenon. Methodological quality appraisal and effect size calculation were conducted on one hundred forty empirical studies on the following aspects of PNES: life adversity, dissociation, anxiety, suggestibility, attentional dysfunction, family/relationship problems, insecure attachment, defence mechanisms, somatization/conversion, coping, emotion regulation, alexithymia, emotional processing, symptom modelling, learning and expectancy. Although most of the studies were only of low to moderate quality, some findings are sufficiently consistent to warrant tentative conclusions: (i) physical symptom reporting is elevated in patients with PNES; (ii) trait dissociation and exposure to traumatic events are common but not inevitable correlates of PNES; (iii) there is a mismatch between subjective reports of anxiety and physical arousal during PNES; and (iv) inconsistent findings in this area are likely to be attributable to the heterogeneity of patients with PNES. Empirical, theoretical and clinical implications are discussed.

Variables associated with co-existing epileptic and psychogenic nonepileptic seizures: a systematic review

PURPOSE

Epileptic seizures (ES) have many mimickers, perhaps the most relevant being psychogenic nonepileptic seizures (PNES). The picture is even more challenging when PNES are associated with ES in a given patient. The aim of this research paper was to delineate the demographic, epileptological and psychiatric profile of that specific population.

METHODS

A systematic review was carried out from 2000 to 2015 for articles in English, French, Italian, Spanish and Portuguese in PUBMED and EMBASE. Cohort or case-control studies reporting prospective or retrospective original data comparing patients with co-existing ES and PNES with those who had PNES only and ES only have been included. In retained studies, the presence of PNES was confirmed by video-electroencephalography (V-EEG). Forty-eight abstracts were identified.

RESULTS

Nine studies were retained. Most showed that female gender predominated in both groups with PNES. Patients with co-existing ES and PNES take higher number of antiepileptic drugs (AEDs) than PNES alone. Two studies showed association of concomitant ES and PNES with earlier age of seizure onset. Localizing EEG features and ES type were evaluated in only two studies and their association with either group was inconclusive. Somatoform, conversion or cluster B personality disorders were more frequent in subjects with PNES than with ES.

DISCUSSION

Patients with concomitant ES and PNES are highly heterogeneous, challenging differentiation on clinical grounds. A diagnosis of conversion or somatoform, anxiety disorders, and the use of a higher number of AEDs than psychiatric medications may have an association with co-existing ES and PNES. Further studies are warranted to differentiate patients who only have PNES from those with co-existing ES and PNES.

Psychiatric comorbidity in psychogenic nonepileptic seizures compared with epilepsy

OBJECTIVES

Psychogenic nonepileptic seizures (PNESs) are closely linked with psychological distress, but their etiology is not well-understood. We reviewed psychiatric comorbidity in PNESs and epileptic seizures (ESs) with an aim to assist understanding, diagnosis, and management of PNESs.

METHODS

A search of Web of Science, MEDLINE (PubMed), PsycINFO, and Scopus identified 32 relevant studies on the prevalence of psychiatric comorbidity in PNESs. We used meta-analysis to compare psychiatric comorbidity between PNESs and ESs.

RESULTS

Samples with PNESs had high rates of psychiatric comorbidity overall (53-100%), notably including posttraumatic stress disorder (PTSD), depression, and personality and anxiety disorders. Compared with ESs, samples with PNESs had more psychiatric comorbidity overall (RR: 1.30, 95% CI: 1.14-1.48, p<0.0001) with significantly elevated risks found for PTSD, personality disorder, and anxiety but not depression.

CONCLUSIONS

Psychiatric disorders are more common in PNESs than ESs. Because of methodological limitations of available studies, causality cannot be established; prospective longitudinal designs are required.

Psychogenic seizures: long-term outcome in patients with and without epilepsy

OBJECTIVES

Psychogenic non-epileptic seizures (PNES) may resemble epileptic events. Epileptic and non-epileptic seizures are not mutually exclusive phenomena and may coexist in the same patient. The aim of this study was to evaluate the long-term outcome of psychogenic events in patients with PNES alone and those with both PNES and epilepsy (PNES + EPI) as diagnosed by video-EEG (vEEG) monitoring.

MATERIALS AND METHODS

All adult admissions to the Tel-Aviv Medical Center's vEEG unit between 2004 and 2009 were screened for the presence of PNES. We retrospectively retrieved data from their medical files and supplemented the follow-up by a telephonic questionnaire.

RESULTS

Eligible patients (n = 51) were divided into those with PNES + EPI (n = 24) and those with PNES alone (n = 27). The follow-up period was 4.8 ± 0.3 and 4.3 ± 0.3 years, respectively. Both groups had similar female predominance and similar age at admission to the vEEG unit. Time from PNES onset to hospitalization was longer in PNES patients compared to those with PNES + EPI. The majority of subjects in each group reported a history of at least one major stressful life event. Opisthotonus was significantly more frequently observed in PNES patients, and they had more events during vEEG hospitalization. Psychogenic events ceased during the follow-up period in 22% of the PNES patients and in 58% of the PNES + EPI patients (P > 0.001).

CONCLUSION

Our results indicate that following vEEG-based diagnosis of PNES, the long-term outcome of PNES cessation may be more favorable for patients with concomitant epilepsy than for patients without epilepsy.

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

BACKGROUND

Psychogenic non-epileptic seizures (PNES) is a disabling disorder which has a negative effect on the quality of life of individuals with PNES. A clear understanding of the disorder is necessary, however, to date, research about PNES in South Africa is limited.

OBJECTIVES

The aims of this study were to explore the demographic variables of individuals with PNES in South Africa, to review the available body of research on PNES, and to compare it with our results.

METHOD

Twenty-two people with PNES, with confirmed video EEG, were recruited by means of convenience sampling from two hospitals. Descriptive statistics were used to describe the demographic variables of the participants.

RESULTS

Internationally comparable results revealed misdiagnoses and low treatment delivery amongst a primarily female population.

CONCLUSION

This study provided greater insight into individuals with PNES in South Africa, highlighting the need for more information, support, effective treatment and accurate diagnosis of PNES.

Psychiatric and neuropsychological profiles of people with psychogenic nonepileptic seizures

OBJECTIVE

This study examined the psychiatric and neuropsychological profiles of people with psychogenic nonepileptic seizures (PNES).

METHODS

Twenty-people who had been diagnosed with psychogenic nonepileptic seizures (PNES), but not epilepsy, were recruited into this study. A healthy control group was also recruited and was matched for age and gender. All participants underwent structured psychiatric assessment and psychometric assessment. Neuropsychological assessment was carried out using the Cambridge Neuropsychological Test Battery (CANTAB) after participants passed the Medical Symptom Validity Test (MSVT) of effort.

RESULTS

One patient failed the MSVT and was excluded from the analysis. Therefore, data from 19 people with PNES and their matched healthy controls were analyzed. Compared with controls, people with PNES had significantly higher levels of depressive symptoms, anxiety symptoms, dissociative experiences, and alexithymic traits. In addition, people with PNES had impairments in spatial working memory and attention when compared with healthy controls.

CONCLUSION

To our knowledge, this is the first study to report that, compared with controls, people with PNES have abnormal cognitive functioning after controlling for effects of effort and FSIQ. People with PNES also have high levels of anxiety, depressive, and dissociative symptoms. In addition, they appear to particularly focus on health problems and show evidence of chronic emotional dysregulation. Further studies are required to replicate our results and to help clarify the pathogenic mechanisms underlying PNES.

Cognitive impairment and evaluation in psychogenic nonepileptic seizures: an integrated cognitive-emotional approach

Neuropsychological studies comparing patients with psychogenic nonepileptic seizures (PNES) to those with epilepsy have been largely equivocal. The variability in the neuropsychological literature highlights the heterogeneity of the PNES population across a number of psychiatric and neurologic factors. Phenotypic presentations in PNES arise from complex interactions between vulnerable cognitive and emotional systems. We propose that variability in neuropsychological findings in PNES emerge in the context of diverse psychiatric, neurologic, and clinical factors. Traditional assessments that fail to integrate cognitive and emotional/behavioral profiles sufficiently would fall short in characterizing the complexity of brain-behavior relationships in this population. To advance the neuropsychology of PNES, we propose a systematic approach to measure a number of factors that influence cognitive impairment in this population. We begin by reviewing the current neuropsychological literature in PNES and discussing a number of factors that influence cognitive deficits. We then present a comprehensive neuropsychological battery designed to capture elements (cognitive dysfunction, psychopathology, emotion processing deficits) underlying the proposed vulnerable cognitive-emotional system in PNES. It is our hope that the proposed battery will facilitate the aggregation of data across neuropsychological investigations, to allow more advanced statistical analyses, and ultimately enhance our understanding of PNES and the development of effective management and treatment options.

Psychogenic non-epileptic seizures: so-called psychiatric comorbidity and underlying defense mechanisms

In Diagnostic and Statistical Manual of Mental Disorders, fifth edition, psychogenic non-epileptic seizures (PNES) do not have a unique classification as they can be found within different categories: conversion, dissociative, and somatization disorders. The ICD-10, instead, considers PNES within dissociative disorders, merging the dissociative disorders and conversion disorders, although the underlying defense mechanisms are different. The literature data show that PNES are associated with cluster B (mainly borderline) personality disorders and/or to people with depressive or anxiety disorders. Defense mechanisms in patients with PNES with a prevalence of anxious/depressive symptoms are of "neurotic" type; their goal is to lead to a "split", either vertical (dissociation) or horizontal (repression). The majority of patients with this type of PNES have alexithymia traits, meaning that they had difficulties in feeling or perceiving emotions. In subjects where PNES are associated with a borderline personality, in which the symbolic function is lost, the defense mechanisms are of a more archaic nature (denial). PNES with different underlying defense mechanisms have different prognoses (despite similar severity of PNES) and need usually a different treatment (pharmacological or psychological). Thus, it appears superfluous to talk about psychiatric comorbidity, since PNES are a different symptomatic expression of specific psychiatric disorders.

Long-term outcome of psychogenic nonepileptic seizures: the role of induction by suggestion

PURPOSE

The aims of our retrospective observational study were to evaluate the long-term outcome of PNESs after communication of the diagnosis and to define predictors of good outcome.

METHOD

Twenty-seven consecutive patients with a certain diagnosis of psychogenic nonepileptic seizures (PNESs) were included in the study. Follow-up information was obtained from each participant through a questionnaire designed for the study. Regarding seizure frequency, the patients were asked to report how many seizures they had experienced on average every month before the communication of the diagnosis and after it.

RESULTS

After the communication of the diagnosis, the median seizure frequency had dropped to 4 every month (p < 0.001). Seventeen participants (63%) were seizure-free at follow-up, and a further five (18.5%) showed a greater than 50% improvement in seizure frequency. Regarding the predictive value of clinical and sociodemographic variables for PNES global outcome, the factors gender, education, economic status, interval of time from onset, comorbidity with epilepsy, psychiatric history, mental retardation, psychological therapy, psychiatric therapy, and the presence of stressful and traumatic events were not related to prognosis; the only factor associated with a better outcome was the diagnosis made after the induction of PNESs by suggestion (p = 0.000, χ(2) = 4.654).

CONCLUSION

A substantial majority of our patients became seizure-free with communication of the diagnosis as the only intervention. The use of the induction by suggestion test was an important predictor of good outcome.

Psychiatric disorders in patients with psychogenic nonepileptic seizures and drug-resistant epilepsy: a study of an Argentine population

Epidemiological data show that up to 20-30% of patients with psychogenic nonepileptic seizures (PNESs), resembling drug-resistant epilepsy (DRE), are referred to tertiary epilepsy centers. Furthermore, both disorders present high psychiatric comorbidity, and video-EEG is the gold standard to make differential diagnoses. In this study, we described and compared the clinical presentation and the frequency of psychiatric disorders codified in DSM IV in two groups of patients, one with PNESs and the other with DRE, admitted in a tertiary care epilepsy center of Buenos Aires, Argentina. We included 35 patients with PNESs and 49 with DRE; all were admitted in the video-EEG unit in order to confirm an epilepsy diagnosis and determine surgical treatment possibilities. All patients underwent a neurological and psychiatric assessment, according to standardized protocol (SCID I and II; DSM IV criteria). Student's t test was performed to compare continuous variables and Chi square test to compare qualitative variables. In this study, 33 (67%) patients with DRE and 35 (100%) patients with PNESs met criteria for at least one disorder codified in Axis I of DSM IV (p=0.003). Differences in the frequency of psychiatric disorder presentation were found between groups. Anxiety disorders (16.32% vs 40%; p=0.015), trauma history (24.5% vs 48.57%; p=0.02), posttraumatic stress disorder (4.08% vs 22.85%; p=0.009), and personality cluster B disorders (18.37% vs 42.86%; p=0.02) were more frequent in the group with PNESs. Psychotic disorders were more frequent in the group with DRE (20.4% vs 2.85%; p=0.019). Depression was equally prevalent in both groups. Standardized psychiatric assessment provides information that could be used by the mental health professional who receives the referral in order to improve quality of care and smooth transitions to proper PNES treatment, which should include a multidisciplinary approach including neurology and psychiatry.

Epilepsy and neuropsychological comorbidities

PURPOSE OF REVIEW

Epilepsy is a chronic disorder with several associated comorbidities requiring timely recognition and treatment. This article discusses aspects of cognitive impairment; psychiatric disorders including depression, anxiety, and psychosis; and health-related quality-of-life issues pertaining to patients with epilepsy.

RECENT FINDINGS

Cognitive problems in epilepsy may be present early in the disease course. Advances in imaging techniques are allowing correlation of structure and function as they relate to cognitive impairment in epilepsy. The relationship between epilepsy, depression, and anxiety is increasingly recognized, and these psychiatric comorbidities may affect suicide risk, patient-reported adverse antiepileptic drug effects, and quality of life. Psychiatric disorders are underrecognized and undertreated in patients with epilepsy.

SUMMARY

Physicians who treat patients with epilepsy should be aware of the major impact that cognitive impairment and psychiatric comorbidities have on these patients. Identifying and treating these comorbidities in epilepsy patients is just as important as seizure treatment.

Psychogenic non-epileptic seizures at a tertiary care center in Brazil

Although psychogenic non-epileptic seizures (PNES) are a worldwide phenomenon, most of our knowledge addressing clinical characteristics is based on studies conducted in the USA, Europe, and Australia. There are scarce data about PNES in South American countries. This study provided a detailed analysis of the demographic, clinical, and psychosocial characteristics of 102 Brazilian patients with PNES. Seventy-eight patients (76.4%) were female with mean age of 35.27 years. Mean age at onset was 27.85 years; mean time to diagnosis was 7.89 years; 87.25% lived with their families; 56.89% were single; and only 33 (39.75%) worked on a regular basis. Depression was diagnosed in 48.03%. Thirty-three patients misdiagnosed as having epilepsy were using antiepileptic drugs. Stress factors were identified in 57.84%. This is the first Brazilian study that involves a large sample of patients with video-EEG-documented PNES and corroborates the idea that PNES are a worldwide phenomenon sharing several similarities, despite cultural and socioeconomic differences.