Health related quality of life of people with non-epileptic seizures: The role of socio-demographic characteristics and stigma

Employment and seizure frequency as important predictors of health-related quality of life in people with functional/dissociative seizures

BACKGROUND

There are inconsistent results on health-related quality of life (HRQoL) in patients with functional/dissociative seizures (FDS), particularly in relation to the predictors. The aim of the present study was to investigate variables predicting HRQoL in a sample of patients with FDS who had been hospitalized for an average of 5.6 years.

METHODS

People with a confirmed diagnosis of FDS who had already received inpatient treatment years ago were contacted to participate to the survey by completing a self-report questionnaire. They were asked to rate their current HRQoL and provide information on seizure frequency at onset and current, employment and other clinical and sociodemographic variables.

RESULTS

Of the n = 443 treated inpatients over a period of 14 years, n = 63 patients could still be reached and participated in the study. Seizure frequency decreased significantly over the course of the disease. At the time of the survey, half of the participants were limited in their HRQoL. The three significant predictors of HRQoL were current seizure frequency, current employment status and seizure frequency at the onset of the disease.

CONCLUSIONS

Even years after inpatient treatment, half of the people with FDS reported limited HRQoL. The frequency of seizures (current and at the onset) and current employment status were identified as predictors of better HRQoL. These variables can be targeted in psychotherapeutic treatment, for instance on the basis of the concept of experiential avoidance.

Iatrogenic harm in functional neurological disorder

Functional neurological disorder (FND) is continuing to gain increasing recognition globally as a valid and potentially treatable disorder. Iatrogenic harm towards patients with FND is significant, however, and has been around for centuries. Despite advances in our understanding around the aetiology, pathophysiology and treatment of FND, many aspects of such harm continue to persist. Avoidance of iatrogenic harm has been highlighted by clinicians as one of the most important therapeutic considerations in FND; however, the sources and range of potential harms, or indeed ways to mitigate them, have not previously been summarized. Using a combination of clinical and research experience and scoping review methodology, this review aims to describe the main sources of iatrogenic harm towards patients with FND, including harm from misdiagnosis, delayed diagnosis and treatment, direct harm from professional interactions, other stigma-related harms, harm related to diagnostic overshadowing and over-diagnosis of FND. We also describe some potential ways to address and prevent such harms, such as ways to reduce misdiagnosis with a focus on rule in signs, optimizing teaching and communication, ensuring parity of FND with other medical conditions and continued integration of patient and professional organizations.

Stigma in functional neurological disorder (FND) - A systematic review

OBJECTIVE

The purpose of this systematic review was to evaluate stigma and Functional Neurological Disorder (FND) regarding: 1) prevalence and associated factors, 2) the nature and context of stigma in FND, and 3) stigma-reduction interventions.

METHODS

We searched four relevant databases from inception to December 2023, using search terms relevant to FND and stigma themes. We employed the method of synthesis by "aggregation and configuration" to synthesise and analyse the data into emergent themes.

RESULTS

We found 127 studies, spanning 148 countries, involving 18,886 participants. Of these, 4889 were patients, 13,123 were healthcare professionals, and 526 were caregivers. Quantitatively, stigma has been mainly studied in patients with functional seizures, and was higher than patients with epilepsy in three studies. Stigma experienced by patients is associated with poorer quality of life and caregiver burden. We found 10 themes and 29 subthemes revealing stigma as a systemic process, with intrapersonal, interpersonal and structural aspects. Few studies examined the perspective of caregivers, the public or online community. We identified six anti-stigma interventions.

CONCLUSION

Stigma in FND is a layered process, and affects patient quality of life and provision of care. Stigma needs to be addressed from the top structures, at governmental level, so that appropriate care pathways can be created, giving patients with FND parity of esteem with other medical conditions.

Psychoeducation interventions for people with non-epileptic seizures: A scoping review

BACKGROUND

Cognitive behavioural therapy (CBT) and other psychological approaches have a growing evidence base for treating Non-Epileptic Seizures (NES). However, communication about the diagnosis can be difficult for clinicians and is not always well received. It is thought that Psychoeducation about NES may improve engagement with treatment such as CBT and may contribute to reductions in the frequency of seizures and improvements in health related quality of life. However, psychoeducational components of treatment are often not evaluated in isolation meaning the specific benefit to patients is not currently well understood.

AIMS

The researchers aimed to examine the outcomes associated with psychoeducational interventions and the content of these programmes for NES.

METHOD

A scoping review was undertaken across four databases with seventeen eligible studies identified which were charted to analyse the data.

RESULTS

Findings revealed that components and modalities of interventions varied as did methods of evaluating the interventions. A number of different outcome measures were used and not all studies reported the significance of findings. Results across studies were inconsistent; however, there was a general trend across the studies of symptom reduction and improvement in mental health.

CONCLUSIONS

Findings illustrate that psychoeducation has potential benefits as an intervention in its own right. However, it may be best placed as a second step in a stepped care model, between initial diagnosis and further psychological treatment. The present literature needs replication and more robust studies for more certain conclusions to be drawn.

Physical fitness in Indian women with epilepsy on anti-seizure medications and its association with reproductive status, quality of life and stigma: A cross-sectional study

PURPOSE

To determine the status of physical fitness, reproductive abnormalities, QOL and epilepsy associated stigma in women with epilepsy (WWE) and their association with ASM therapy and seizure frequency.

METHODS

This cross-sectional study included WWE of reproductive age (18-50 years) on antiseizure medications (ASMs) for at least three months before enrolment. Physical fitness was assessed using International Physical Activity Questionnaires (IPAQ) and Body composition analysis. Subjects were interviewed for menstrual abnormalities [menstrual disturbance or Polycystic Ovary Syndrome (PCOS)/hirsutism]. Validated questionnaires were used for assessment of, QOL (QOLIE-10) and Stigma in epilepsy (Epilepsy Stigma Scale). Sub-group analysis was done to compare the above parameters on the basis of a) type of therapy (mono or polytherapy), b) type of ASMs treatment (conventional, newer, or conventional + newer ASMs), and c) seizure type and (d) seizure frequency. Correlation and regression analysis were done to find out the association among different variables with physical fitness.

RESULTS

The overall prevalence of poor physical fitness, reproductive abnormalities, worsened QOL and stigma in the enrolled WWE (n = 203) were 21.18 %, 20.19 %, 52.7 %, and 21.67 %, respectively. Sub-group analysis revealed that WWE on monotherapy (n = 99) had higher median IPAQ score (p = 0.002), comparatively less reproductive abnormalities (24.03 %, p = 0.008), and higher stigma (24.03 %, p = 0.04) than polytherapy group. WWE on conventional ASMs had significantly higher IPAQ scores compared to newer and conventional + newer ASMs groups (p = 0.02). The prevalence of poor physical fitness and stigma was significantly higher in WWE with higher number of seizures (p = 0.007, <0.001, respectively). No significant difference in QOL was observed on the basis of ASM type and therapy; however, WWE with generalized onset seizures had worsened QOL compared to those with focal onset seizures (p = 0.04). A significant negative correlation was found among seizure frequency and IPAQ score in WWE (p = 0.04).

CONCLUSION

WWE on polytherapy were physically less active, higher occurrence of reproductive abnormalities, and stigma compared to the monotherapy group. WWE with higher seizure frequency had poor physical fitness, and higher stigma compared to those with lesser number of seizures. These findings may aid value in optimization of ASM treatment in WWE of reproductive age.

How stigma unfolds for patients with Functional Neurological Disorder

OBJECTIVE

The aim of this study was to explore experiences of stigma in Functional Neurological Disorder (FND) from the perspective of the patient as it manifests from the onset of symptoms, up to diagnosis and subsequently.

BACKGROUND

The existing literature clearly shows that stigma exists for many patients with FND, and is associated with poorer quality of life. However, it is less clear how stigma unfolds, and how it can be alleviated.

METHODS

We performed a qualitative interview study with patients who were diagnosed with FND, using data based on semi-structured interviews. Participants were recruited purposively via outpatient clinics. We analysed the data using a reflexive thematic analytic approach, through the lens of recognised stigma frameworks.

RESULTS

15 participants were included in the study, aged between 19 and 68 years, with varying presentations of FND. We identified six themes and 16 subthemes relevant to their stigma trajectory. We found that stigma unfolds through four main domains: 1) through their symptom experience; 2) through "othering" by the healthcare system; 3) through everyday interactions; and 4) from within the self. Across these four domains was a central theme of 5) stages of knowledge, which both fuelled and countered stigma. Lastly, 6) validation of the patient experience emerged as a theme that alleviated stigma.

CONCLUSIONS

Stigma did not unfold as a linear process, rather it came from multiple interacting sources. Interventions to target stigma could take the form of improved clinician training, communication, especially around point of diagnosis, and public interventions, co-produced with patients with FND.

A meta-ethnographic synthesis of the experiences of stigma amongst people with functional neurological disorder

PURPOSE

Functional neurological disorder (FND) causes many neurological symptoms and significant disability. It is often misunderstood by medical professionals and the public meaning stigma is regularly reported. The aim of this review was to synthesise the qualitative findings in the literature to develop a more in-depth understanding of how people with FND experience stigma to inform future interventions.

METHOD

This review used a meta-ethnography approach. Five databases were searched (PsycINFO, Web of Science, CINAHL, MEDLINE, and EMBASE) in February 2021 and updated in July 2022 for qualitative papers in FND. Included papers were critically assessed using the critical appraisal skills programme (CASP) checklist. Data were analysed and synthesised utilising meta-ethnography.

RESULTS AND CONCLUSION

Sixteen papers were included in the final synthesis. Four major themes emerged: stigmatized by delegitimization; stigmatized by social exclusion and rejection; coping with stigma; and stigma and identity. The results identified negative, stigmatizing attitudes towards people experiencing FND symptoms in a variety of contexts including healthcare and other social institutions. The effects of stigma led to further exclusion for participants and appeared to trigger coping styles that led to additional difficulty. Stigma is a key part of the illness experience of FND and needs to be addressed.

Stigma Affects the Health-Related Quality of Life of People Living with HIV by Activating Posttraumatic Stress Symptoms

Stigma is a strong concern in the effort to manage the impact of many chronic diseases on patients and affects the quality of life (QoL) of patients, but little is understood regarding how this happens. We explored the perspective that stigma reduces health-related QoL (HRQoL) by evoking the traumatic experiences associated with HIV diagnosis. Outpatients (n = 250) receiving HIV-related care were recruited from 2 hospitals in the southeastern region of Nigeria. Participants completed measures of stigma, posttraumatic stress symptoms, and HRQoL. Mediation analyses were conducted using Hayes PROCESS Macro for SPSS. Result showed that stigma was negatively associated with HRQoL; patients who reported more traumatic symptoms also reported poorer HRQoL. Traumatic stress symptoms mediated the path between stigma and all the dimensions of HRQoL. Findings suggest that recognizing and addressing trauma symptoms are important in the management of PLWH. Perhaps addressing trauma would reduce the impact of stigma on HRQoL.

Psycho-socio-clinical profiles and quality of life in seizure disorders: A cross-sectional registry study

OBJECTIVE

This prospective study aimed at comparing quality of life (QoL) and psycho-socio-clinical profiles between patients with epilepsy, psychogenic nonepileptic seizures (PNES), and syncope. We also intended to identify predictors of QoL in these three seizure disorders.

METHODS

A total of 245 inpatients (epilepsy n = 182, PNES n = 50, syncope n = 13) from a tertiary epilepsy clinic were included. Information on QoL as well as on psychological, sociodemographic, and clinical profiles was retrieved using questionnaires and medical records. Group comparisons on QoL and psycho-socio-clinical profiles were performed via analyses of variance, chi-square tests, and related post hoc tests. Predictors of QoL in epilepsy and PNES were determined using general linear modeling, which was not possible for syncope due to a small sample size.

RESULTS

Patients with epilepsy, PNES, and syncope reported levels of QoL impairment that did not differ significantly between groups (p = 0.266). However, there were significant group differences regarding sex distribution (p < 0.001), seizure disorder duration (p = 0.004), seizure frequency (p = 0.019), current treatment with antiseizure medications (ASM) (p < 0.001), number of current ASM (p < 0.001), and adverse ASM events (p = 0.019). More depressive symptoms (p = 0.001), more adverse ASM events (p = 0.036), and unemployment (p = 0.046) (in this order) independently predicted a diminished QoL in epilepsy. For PNES, more depressive symptoms were the only independent predictor of lower QoL (p = 0.029).

CONCLUSIONS

Patients with epilepsy, PNES, and syncope experience similarly diminished QoL and show a general psycho-socio-clinical burden with a specific pattern for each seizure disorder diagnosis. Although clinical aspects play an undisputed role for QoL in epilepsy, the psychosocial aspects and consequences are equally, or for PNES probably even more, meaningful. A comprehensive approach to research and treatment of seizure disorders seems mandatory to increase QoL for these patients. More research on QoL in syncope is needed.

Quality of Life in Psychogenic Nonepileptic Seizures: An Evolutionary Concept Analysis

Psychogenic nonepileptic seizures (PNES) pose a serious threat to quality of life (QOL) in patients who battle the disorder. As psychological treatment options have progressed, improvement in QOL has become a more common desired outcome. Despite its relevance in PNES research and treatment, QOL has not been defined in the PNES population. Rodgers' Evolutionary Method of concept analysis was used to analyze 47 articles and clarify the concept of QOL in PNES. QOL in PNES is subjective, multidimensional, associated with symptoms, and dynamic in nature. This conceptualization of QOL in PNES may be useful in future PNES research and treatment.

Stigma in functional seizures: A scoping review

OBJECTIVE

The purpose of this scoping review was to explore the extent, range and nature of knowledge on stigma in functional seizures (FS).

METHODS

This scoping review was conducted in accordance with the Joanna Briggs Institute Manual for Evidence Synthesis (JBIMES) guidelines and the five-step framework by Arksey and O'Malley. We searched for data sources written in English using MEDLINE, Scopus, EBSCOhost, Ovid, PubMed, Science Direct, Web of Science, Wiley Online Library, Microsoft Academic, Google Scholar, as well as grey literature sources, with no date limitations up to September 2021. The extracted data were analysed using basic frequency counts and thematic synthesis.

RESULTS

The systematic search yielded a set of 988 potentially relevant data sources, of which 70 met the inclusion criteria. The retrieved sources reflected data from 85 countries and 5949 study participants. The thematic synthesis highlighted the prevalence of FS stigma, as well as its potential origins, context and impact on patients and families. The majority of studies were conducted in healthcare settings with healthcare providers, with fewer data sources reporting on family, patient, and broader society perspectives relating to FS stigma.

CONCLUSION

Our scoping review suggests that FS stigma is prevalent but remains understudied. We need more research with a specific focus on stigma in FS, and factors that contribute to FS stigma (e.g. culture and context, naming of the condition), as well as accessible interventions and guidelines addressing FS stigma through education and training. Supportive attitudes and knowledge appear to be protective factors against FS stigma.

Diagnosis and management of functional neurological disorder

Functional neurological disorder (FND), previously regarded as a diagnosis of exclusion, is now a rule-in diagnosis with available treatments. This represents a major step toward destigmatizing the disorder, which was often doubted and deemed untreatable. FND is prevalent, generally affecting young and middle aged adults, and can cause severe disability in some individuals. An early diagnosis, with subsequent access to evidence based rehabilitative and/or psychological treatments, can promote recovery-albeit not all patients respond to currently available treatments. This review presents the latest advances in the use of validated rule-in examination signs to guide diagnosis, and the range of therapeutic approaches available to care for patients with FND. The article focuses on the two most frequently identified subtypes of FND: motor (weakness and/or movement disorders) and seizure type symptoms. Twenty two studies on motor and 27 studies on seizure type symptoms report high specificities of clinical signs (64-100%), and individual signs are reviewed. Rehabilitative interventions (physical and occupational therapy) are treatments of choice for functional motor symptoms, while psychotherapy is an emerging evidence based treatment across FND subtypes. The literature to date highlights heterogeneity in responses to treatment, underscoring that more research is needed to individualize treatments and develop novel interventions.

Attachment style of patients diagnosed with psychogenic non-epileptic seizures at a tertiary Epilepsy Center in the Czech Republic

OBJECTIVE

Quality and type of early relationships with primary caregivers is considered one of the key factors in the etiopathogenesis of many mental disorders including depression, anxiety, and conversion disorders. This study focused on the type and quality of attachment style in adult patients with psychogenic non-epileptic seizures (PNES).

MATERIALS AND METHODS

We evaluated the demographic data and profiles of PNES patients (n = 262) and group of healthy volunteers (n = 51) measured by the Parental Bonding Inventory (PBI) and Experiences in Close Relationships (ECR) and Experiences in Close Relationships-Relationship Structure (ECR-RS).

RESULTS

Significant differences in measured values between the two groups were identified; specifically, differences in the caregiver style-father and mother overprotection (PBI) was higher in the PNES group. The most frequent type of attachment in PNES was type 2 (preoccupied). Correlations between the PBI and ECR results were also found.

CONCLUSION

This study highlighted certain attachment styles in patients with PNES and statistically significant differences between patients with PNES and a healthy sample. Some correlations between the results of the questionnaires with socio-demographic factors were found. The identification of specific patterns in attachment may be useful for further use in reaching a differential diagnosis and administering tailored psychotherapy of patients with PNES.

Shame in patients with psychogenic nonepileptic seizure: A narrative review

Psychogenic Nonepileptic Seizures (PNES) have been linked to dysregulated emotions and arousal. However, the question which emotions may be most relevant has received much less attention. In this multidisciplinary narrative review, we argue that the self-conscious emotion of shame is likely to be of particular importance for PNES. We summarize current concepts of the development of shame processing and its relationship with other emotional states. We demonstrate the potential of acute shame to cause a sudden disruption of normal cognitive function and trigger powerful behavioral, cognitive, physiological and secondary emotional responses which closely resemble key components of PNES. These responses may lead to the development of shame avoidance strategies which can become disabling in themselves. We discuss how excessive shame proneness and shame dysregulation are linked to several psychopathologies often associated with PNES (including depression and PTSD) and how they may predispose to, precipitate and perpetuate PNES disorders, not least by interacting with stigma. We consider current knowledge of the neurobiological underpinnings of shame and PNES. We explore how shame could be the link between PNES and a heterogeneous range of possible etiological factors, and how it may link historical aversive experiences with individual PNES events occurring much later and without apparent external trigger. We argue that, in view of the potential direct links between shame and PNES, the well-documented associations of shame with common comorbidities of this seizure disorder and the well-characterized relationship between chronic shame and stigma, there is a compelling case to pay greater attention to shame in relation to PNES. Its role in the treatment of patients with PNES is discussed in a separate, linked review incorporating case vignettes to highlight the complex interactions of different but interlinked shame-related issues in individual patients.

A Broader Perspective: Functional Symptoms Beyond Neurology

•

Functional (psychogenic) symptoms exist in all specialties.

•

They are by definition not under voluntary control, unlike factitious disorders and malingering.

•

The diagnostic approach to functional symptoms varies among specialties.

Validation of the PHQ-9 in adults with dissociative seizures

BACKGROUND

The PHQ-9 is a self-administered depression screening instrument. Little is known about its utility and accuracy in detecting depression in adults with dissociative seizures (DS).

OBJECTIVES

Using the Mini - International Neuropsychiatric Interview as a reference, we evaluated the diagnostic accuracy of the PHQ-9 in adults with DS, and examined its convergent and discriminant validity and uniformity.

METHODS

Our sample comprised 368 people with DS who completed the pre-randomisation assessment of the CODES trial. The uniformity of the PHQ-9 was determined using factor analysis for categorical data. Optimal cut-offs were determined using the area under the curve (AUC), Youden Index, and diagnostic odds ratio (DOR). Convergent and discriminant validity were assessed against pre-randomisation measures.

RESULTS

Internal consistency of the PHQ-9 was high (α = 0.87). While the diagnostic odds ratio suggested that a cut-off of ≥10 had the best predictive performance (DOR = 14.7), specificity at this cut off was only 0.49. AUC (0.74) and Youden Index (0.48) suggested a ≥ 13 cut-off would yield an optimal sensitivity (0.81) and specificity (0.67) balance. However, a cut-off score of ≥20 would be required to match specificity resulting from a cut-off of ≥13 in other medical conditions. We found good convergent and discriminant validity and one main factor for the PHQ-9.

CONCLUSIONS

In terms of internal consistency and structure, our findings were consistent with previous validation studies but indicated that a higher cut-off would be required to identify DS patients with depression with similar specificity achieved with PHQ-9 screening in different clinical and non-clinical populations.

Quality of Life and Stigma among Women with Epilepsy during Their Reproductive Years

Background and Purpose

The purpose of this study was to understand the relationship between quality of life and stigma among reproductive age group women with epilepsy.

Methods

A cross-sectional descriptive study was conducted to assess the data from the 49 women with epilepsy from a tertiary care hospital in India. Quality of life was evaluated with the quality of life in epilepsy-31 questionnaire and stigma was evaluated with the stigma scale of epilepsy. Data also included socio-demographic and clinical characteristics.

Results

The mean age of the participants was 24.67±3.72 years. Quality of life total score (r=−0.485**) and seizure worry domain (r=−0.427**) were significantly negatively correlated with stigma total score at p<0.01 level. Being uneducated, married, unemployed, having children, having generalized tonic-clonic seizures, duration of illness (>10 years), and consuming levetiracetam, anti-epileptic drug (AED), were the significant contributing factors for low quality of life among women with epilepsy during the reproductive age group. Belonging to lower socio-economic status and taking more than two AEDs were also associated with lower quality of life among women with epilepsy, which are trending towards significance.

Conclusions

The study assessed the relationship between the quality of life and the Stigma scale of epilepsy and demonstrated the impact of stigma and quality of life on socio-demographic and clinical variables of women with epilepsy under the reproductive age group. To enhance the quality of life and reduce the stigma levels among women with epilepsy, some of the modifiable parameters can be considered by the multidisciplinary health care professionals from the findings of the current research.

Cognitive-behavioural therapy compared with standardised medical care for adults with dissociative non-epileptic seizures: the CODES RCT

BACKGROUND

Dissociative (non-epileptic) seizures are potentially treatable by psychotherapeutic interventions; however, the evidence for this is limited.

OBJECTIVES

To evaluate the clinical effectiveness and cost-effectiveness of dissociative seizure-specific cognitive-behavioural therapy for adults with dissociative seizures.

DESIGN

This was a pragmatic, multicentre, parallel-arm, mixed-methods randomised controlled trial.

SETTING

This took place in 27 UK-based neurology/epilepsy services, 17 liaison psychiatry/neuropsychiatry services and 18 cognitive-behavioural therapy services.

PARTICIPANTS

Adults with dissociative seizures in the previous 8 weeks and no epileptic seizures in the previous year and meeting other eligibility criteria were recruited to a screening phase from neurology/epilepsy services between October 2014 and February 2017. After psychiatric assessment around 3 months later, eligible and interested participants were randomised between January 2015 and May 2017.

INTERVENTIONS

Standardised medical care consisted of input from neurologists and psychiatrists who were given guidance regarding diagnosis delivery and management; they provided patients with information booklets. The intervention consisted of 12 dissociative seizure-specific cognitive-behavioural therapy 1-hour sessions (plus one booster session) that were delivered by trained therapists, in addition to standardised medical care.

MAIN OUTCOME MEASURES

The primary outcome was monthly seizure frequency at 12 months post randomisation. The secondary outcomes were aspects of seizure occurrence, quality of life, mood, anxiety, distress, symptoms, psychosocial functioning, clinical global change, satisfaction with treatment, quality-adjusted life-years, costs and cost-effectiveness.

RESULTS

In total, 698 patients were screened and 368 were randomised (standardised medical care alone, n = 182; and cognitive-behavioural therapy plus standardised medical care, n = 186). Primary outcome data were obtained for 85% of participants. An intention-to-treat analysis with multivariate imputation by chained equations revealed no significant between-group difference in dissociative seizure frequency at 12 months [standardised medical care: median of seven dissociative seizures (interquartile range 1-35 dissociative seizures); cognitive-behavioural therapy and standardised medical care: median of four dissociative seizures (interquartile range 0-20 dissociative seizures); incidence rate ratio 0.78, 95% confidence interval 0.56 to 1.09; p = 0.144]. Of the 16 secondary outcomes analysed, nine were significantly better in the arm receiving cognitive-behavioural therapy at a p-value < 0.05, including the following at a p-value ≤ 0.001: the longest dissociative seizure-free period in months 7-12 inclusive post randomisation (incidence rate ratio 1.64, 95% confidence interval 1.22 to 2.20; p = 0.001); better psychosocial functioning (Work and Social Adjustment Scale, standardised treatment effect -0.39, 95% confidence interval -0.61 to -0.18; p < 0.001); greater self-rated and clinician-rated clinical improvement (self-rated: standardised treatment effect 0.39, 95% confidence interval 0.16 to 0.62; p = 0.001; clinician rated: standardised treatment effect 0.37, 95% confidence interval 0.17 to 0.57; p < 0.001); and satisfaction with treatment (standardised treatment effect 0.50, 95% confidence interval 0.27 to 0.73; p < 0.001). Rates of adverse events were similar across arms. Cognitive-behavioural therapy plus standardised medical care produced 0.0152 more quality-adjusted life-years (95% confidence interval -0.0106 to 0.0392 quality-adjusted life-years) than standardised medical care alone. The incremental cost-effectiveness ratio (cost per quality-adjusted life-year) for cognitive-behavioural therapy plus standardised medical care versus standardised medical care alone based on the EuroQol-5 Dimensions, five-level version, and imputed data was £120,658. In sensitivity analyses, incremental cost-effectiveness ratios ranged between £85,724 and £206,067. Qualitative and quantitative process evaluations highlighted useful study components, the importance of clinical experience in treating patients with dissociative seizures and potential benefits of our multidisciplinary care pathway.

LIMITATIONS

Unlike outcome assessors, participants and clinicians were not blinded to the interventions.

CONCLUSIONS

There was no significant additional benefit of dissociative seizure-specific cognitive-behavioural therapy in reducing dissociative seizure frequency, and cost-effectiveness over standardised medical care was low. However, this large, adequately powered, multicentre randomised controlled trial highlights benefits of adjunctive dissociative seizure-specific cognitive-behavioural therapy for several clinical outcomes, with no evidence of greater harm from dissociative seizure-specific cognitive-behavioural therapy.

FUTURE WORK

Examination of moderators and mediators of outcome.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN05681227 and ClinicalTrials.gov NCT02325544.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 43. See the NIHR Journals Library website for further project information.

Social aspects of life in patients with functional seizures: Closing the gap in the biopsychosocial formulation

The human, as a biological system, is an open system embedded within larger systems -including the family, culture, and socio-political environment. In this context, a patient with functional seizures (FS) is embedded in relationships, educational/professional institutions, culture, and society. Both connection to these broader systems and the quality of these connections, as well as the soundness of each system in and of itself, influence the health and well-being of patients in positive or negative ways. The social aspects of life are important determinants of health and quality of life across the lifespan. The current narrative review brings out several overarching themes in patients with FS. Sections on attachment, marriage, social networking, and stigma highlight the central roles of supportive and affirmative relationships across the lifespan. The section on education underscores the importance of keeping children and youth with FS connected within their school environments, as well as managing any barriers - learning difficulties, school response to FS events, stigma, etc.-that can diminish this connection. Finally, the sections on employment and driving highlight the value of being an active participant in one's society. In summary, FS impacts patients across most social aspects of life domains regardless of age - factors that are important when developing biopsychosocial formulations. This review concludes that the multidisciplinary management of FS requires careful assessment of social aspects of life in patients which can then be targeted for treatment, to improve their quality of life, facilitating recovery, and reducing the risk of relapse.

Correlates of health-related quality of life in youth with psychogenic non-epileptic seizures

BACKGROUND

Few studies have examined factors associated with health-related quality of life (HRQoL) in youth with psychogenic non-epileptic seizures (PNES). In adults, internalizing symptoms such as depression have been shown to be more closely associated with HRQoL than seizure frequency, however, this has not been studied in samples of youth. Investigations into these areas are needed in order to enhance our understanding of the impact of this condition on children and adolescents and inform future clinical intervention.

METHODS

The current study includes 37 youth and one of their parents who attended a clinic visit for treatment of PNES. Children and parents completed measures of psychological functioning, and medical data were extracted from patient charts.

RESULTS

Parent-reported anxiety (B=-0.45, p = 0.05) and depression (B=-0.60, p = 0.01) were related to parent-report of HRQoL; self-report of depression was related to self-reported HRQoL (B=-0.90, p < 0.001). Seizure frequency, somatic complaints, and social problems were not related to HRQoL in this sample.

CONCLUSIONS

Internalizing symptoms, not seizure frequency, are associated with poorer overall functioning in youth with PNES. Interventions focused on improving anxiety and depression in addition to seizure cessation may contribute to improved HRQoL in youth with PNES more so than those focused on seizure cessation alone.

Psychosocial long-term outcome in patients with psychogenic non-epileptic seizures

PURPOSE

To evaluate psychosocial long-term outcome in patients diagnosed with psychogenic nonepileptic seizures (PNES) and to predict outcome of PNES, economic status, and quality of life (QoL) at follow-up.

METHODS

Patients diagnosed with PNES in the video-EEG-monitoring unit at our Epilepsy center between 2002-2016 were contacted by phone 1-16 years after communicating the diagnosis. Patients underwent a structured interview asking for current PNES status, psychosocial situation (economic status, marital status, setting of living, driving), depression, and QoL.

RESULTS

Of 70 PNES patients without comorbid epilepsy (age: 41.1 ± 13.5 years; 74 % female, follow-up: 5.2 ± 4.2 years), 23 patients (33 %) reported to be free of PNES during the last 12 months. Patients with cessation of PNES were younger at PNES onset (p < .01) and diagnosis (p < .01) and had a higher education (p < .05). At follow-up, the proportion of economically active patients only increased in individuals with cessation of PNES (p < .001) while an increased number of patients with persisting PNES relied on governmental support (p < .001). Cessation of PNES was associated with better mood (p < .01) and QoL (p < .001). In multiple regression models, cessation of PNES was only predicted by younger age at onset, while good economic outcome was determined by younger age and good economic status at diagnosis and cessation of PNES at follow-up. Good QoL at follow-up was predicted by low depressive symptoms, freedom of PNES, and economic activity at follow-up.

CONCLUSION

Long-term outcome in patients with PNES remains to be poor and the majority of patients continue to have PNES. Cessation of PNES was associated with good economic outcome, mood, and QoL.

Epilepsy: Workup and Management in Adults

When managing epilepsy, there is a temptation to focus care with respect to the last and the next seizure. However, epilepsy is a multifaceted chronic condition and should be treated as such. Epilepsy comes with many physical risks, psychological effects, and socioeconomic ramifications, demanding a long-term commitment from the treating physician. Patients with epilepsy, compared to other chronically ill patient populations, have a worse quality of life, family function, and less social support. The majority of patients are well controlled on antiseizure drugs. However, approximately one-third will continue to have seizures despite optimized medical management. The primary aim of this article is to explore the long-term management of chronic epilepsy, and to address some of the particular needs of patients with chronic epilepsy.

Catastrophising and repetitive negative thinking tendencies in patients with psychogenic non-epileptic seizures or epilepsy

PURPOSE

Previous research suggests that catastrophisation and perseverative, or repetitive negative thinking (RNT) could play an important role in the aetiology of Psychogenic Nonepileptic Seizures (PNES). This study was designed to explore whether these cognitive tendencies are more prevalent in patients with PNES than those with epilepsy and to examine the relationship between these cognitions, depression, anxiety, seizure frequency and diagnosis.

METHODS

26 patients with PNES (PWPNES) and 29 with epilepsy (PWE) self-reported RNT (Perseverative Thinking Questionnaire), catastrophisation tendencies (modified Safety Behaviors and Catastrophizing Scale), symptoms of anxiety (Generalised Anxiety Disorder Assessment 7) and depression (Primary Health Questionnaire 9) as well as seizure frequency.

RESULTS

RNT and catastrophic thinking were highly correlated with each other and more prevalent in PWPNES than PWE. Positive correlations were also found between all other self-report measures and seizure frequency. The PNES diagnosis predicted RNT (perseverative thinking) independently of catastrophic thinking, anxiety, depression and seizure frequency.

CONCLUSION

PWPNES exhibit greater negative perseverative and catastrophising cognitive tendencies than PWE. PNES as a diagnosis independently predicted RNT. Hence, RNT and catastrophisation should be considered as possible specific targets for psychological interventions in patients with PNES.

Virtual Reality-Delivered Mirror Visual Feedback and Exposure Therapy for FND: A Midpoint Report of a Randomized Controlled Feasibility Study

OBJECTIVE

The aim was to provide preliminary feasibility, safety, and efficacy data for a personalized virtual reality-delivered mirror visual feedback (VR-MVF) and exposure therapy (VR-ET) intervention for functional neurological disorder (FND).

METHODS

Midpoint results of a single-blind, randomized controlled pilot are presented. Fourteen adults were randomly assigned to eight weekly 30-minute VR sessions-seven in the treatment arm and seven in the control arm. The treatment arm consisted of an immersive avatar-embodied VR-MVF treatment, plus optional weekly VR-ET starting at session 4 if participants had identifiable FND triggers. The control arm received equally immersive nonembodied sessions involving exploration of a virtual interactive space. Feasibility was measured by acceptability of randomization, completion rates, side effects, adverse events, and integrity of blinding procedures. Exploratory primary and secondary outcome measures were weekly symptom frequency and the Oxford Handicap Scale, respectively.

RESULTS

Two early dropouts occurred in the treatment arm, resulting in an 86% completion rate (N=12/14). No side effects or adverse events were reported. Blind assessment at study end indicated that two of the seven treatment arm and three of the seven control arm participants incorrectly guessed their assignment. Changes in mean symptom frequency and disability were reported, but data will not be statistically analyzed until study end.

CONCLUSIONS

This study is the first to report on MVF and VR for treatment of FND. Results generated thus far support feasibility and justify continuation of the study and further investigation into the efficacy of VR interventions for FND.

Stigma in psychogenic nonepileptic seizures

OBJECTIVE

There is scarce literature on stigma in families living with psychogenic nonepileptic seizures (PNES). Using a cohort of patients with epileptic seizures (ES) and their caregivers as controls, we aimed to quantify the level of patient and caregiver stigma in PNES and identify associations of patient and caregiver characteristics with it.

METHODS

Patients with PNES and ES and their caregivers completed surveys about demographic, clinical, and psychosocial characteristics. Multivariate regression analysis was used to identify correlates of patient and caregiver stigma.

RESULTS

Forty-three patients with PNES and 165 patients with ES were recruited. Compared with patients with ES, patients with PNES had shorter disease duration, higher seizure frequency, normal diagnostic data, poorer psychosocial health, and fewer antiseizure medications (ASMs). A total of 76.5% of patients with PNES and 59.5% of patients with ES felt stigmatized. Patient stigma level was higher in patients with PNES compared with those with ES, and it was negatively associated with patient quality of life (QOL). Additionally, 28 caregivers of patients with PNES and 99 caregivers of patients with ES were recruited. There were no significant demographic, caregiving, or psychosocial differences between the two caregiver cohorts. Seventy-two percent of caregivers of patients with PNES and 47% of caregivers of patients with ES felt stigmatized. Caregiver stigma level was also higher in caregivers of patients with PNES compared with caregivers of patients with ES, and it was negatively associated with patient QOL and positively associated with patient and caregiver anxiety.

CONCLUSION

Compared with those with ES, patients and caregivers living with PNES experience stigma more frequently and to a higher extent. Patient QOL emerges as a consistent correlate of that stigma.

Stigma experienced by Chinese patients with stroke during inpatient rehabilitation and its correlated factors: a cross-sectional study

Background: Stroke-related stigma can have a negative effect on patients, and is associated with stereotyping, prejudice, and discrimination; however, the exact stigma experienced by patients remains ambiguous. Objectives: To evaluate the stigma experienced by patients with stroke, determine associated factors, and explore relationships between stigma and early rehabilitation. Methods: Overall, we examined 288 patients with stroke. Patient characteristics were determined through medical records and investigations, while stigma status (comprising total stigma, internalized stigma, and enacted stigma), depression level, functional independence, and functional outcome were also assessed. Demographic and clinical characteristics were evaluated through univariate analysis, and significant variables were further analyzed through linear regression. The relationships between stigma and early rehabilitation (depression, functional independence, and functional outcomes) were also analyzed. Results: The sample's total stigma, internalized stigma, and enacted stigma scores were 47.76 ± 18.00, 30.07 ± 12.25, and 17.69 ± 6.37, respectively. Employment status before stroke, caregivers, physical impairment, and number of impairments were all relevant to all types of stigma (P< .05). The regression analysis showed that caregivers and physical impairment are the two main predictors of total, internalized, and enacted stigma (P< .01). The correlation analysis revealed that stigma is associated with depression (r = 0.671 ~ 0.690, P< .001), functional independence (r = -0.562~-0.707, P< .001), and functional outcomes (r = 0.436 ~ 0.637, P< .001). Conclusions: Stigma was moderate, and internalized stigma may be more apparent; therefore, physicians should pay more attention to patients who report or show signs of experiencing stroke-related stigma.

Health-related quality of life in Veterans with epileptic and psychogenic nonepileptic seizures

RATIONALE

Health-related quality of life (HRQoL) is compromised in civilians with epileptic seizures (ES) or psychogenic nonepileptic seizures (PNES). U.S. Veterans are a distinct patient group with regard to gender, age, and background. We studied HRQoL in Veterans and asked the following: (1) Is there a difference in HRQoL in Veterans with ES vs. PNES?; (2) What factors influence HRQoL in each group?; (3) What factors influenced the difference between seizure groups?

METHODS

We studied consecutive Veterans entering the epilepsy monitoring units (EMUs) of three VA Epilepsy Centers of Excellence. Patients underwent continuous video-EEG monitoring. Seizure diagnoses followed established criteria. Health-related quality of life was measured with the Quality of Life in Epilepsy Inventory-31 (QOLIE-31). Evaluations included the Structured Clinical Interview for Diagnostic and Statistical Manual-IV (DSM IV), the posttraumatic stress disorder (PTSD) Checklist (PCL), the Beck Depression Inventory II (BDI-II), and the Minnesota Multiphasic Personality Inventory-2 Restructured form (MMPI-2RF). Between-group differences were tested with Wilcoxon tests. Nested regression analysis was used to evaluate the influence of demographic, social, military, seizure-related, and psychological factors on QOLIE-31 scores.

RESULTS

The median QOLIE-31 total score was 14 points lower in Veterans with PNES vs. ES (p < 0.001; Cohen's d = 0.73). Within each seizure group, psychological factors accounted for ≥50% of the variance in QOLIE scores while combined demographic, social, and seizure-related factors accounted for 18% (group with ES) and 7% (PNES). Psychological measures, particularly PCL and the BDI-II scores, accounted for all of the difference in QOLIE-31 total scores between Veterans with ES and those with PNES.

CONCLUSIONS

Health-related quality of life as measured by the QOLIE-31 is worse in Veterans with PNES as compared with those with ES. Psychological factors account for the most of the variance in QOLIE-31 scores regardless of seizure type and also account for the difference between groups with PNES and ES. Demographic, military, social, and seizure-related factors have minimal influence on HRQoL. These results in U.S. Veterans are similar to those found in civilians despite differences in patient age, gender, and background.

Nonepileptic Episodic Events

PURPOSE OF REVIEW

This review addresses the scope, evaluation, treatments, and outcomes of patients with nonepileptic episodic events with a focus on psychogenic nonepileptic seizures. Differentiation of the types of events, including a review of terminology, is included, as well as a brief review of special patient populations with these disorders.

RECENT FINDINGS

There are continued efforts to develop tools to improve the diagnosis of these disorders. A thorough evaluation with trained personnel and physicians knowledgeable in the assessment and treatment of these disorders is important. Although inpatient video-EEG monitoring in an epilepsy monitoring unit remains the gold standard for diagnosis, the assessment of clinical and historical factors is critical and can be useful in expediting the process and improving diagnostic certainty. International efforts have recently assisted in providing guidelines for the evaluation of the psychogenic disorders and may help target educational and other resources to underserved areas.

SUMMARY

The prompt and accurate diagnosis of nonepileptic episodic events and psychogenic nonepileptic seizures is possible with current technology, and the appropriate and targeted use of evidence-based treatments may help improve patient quality of life and avoid unnecessary disability in patients with these disorders.

Dissociative (non-epileptic) seizures: tackling common challenges after the diagnosis

Dissociative (non-epileptic) seizures are one of the three major causes of transient loss of consciousness. As such, their treatment cannot be left to superspecialised experts. In this article I draw on personal experience to suggest ways to tackle some challenges that commonly arise after diagnosing dissociative seizures, focusing on three issues: “I want to know what is wrong with me,” “I hear what you are saying but it doesn’t apply to me” and “What if I have a seizure?” The suggestions detail both actions and words that may help at a crucial point in the patient’s journey. If handled well, the process can leave the patient better equipped to understand their seizures and to engage in further treatment; if handled badly, patients may be left more traumatised, angry and with additional disability.