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Lewis EC, Jaeger A, Girn M, Omene E, Brendle M, Argento E. Exploring psychedelic-assisted therapy in the treatment of functional seizures: A review of underlying mechanisms and associated brain networks. J Psychopharmacol 2024; 38:407-416. [PMID: 38654554 PMCID: PMC11102649 DOI: 10.1177/02698811241248395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
Functional seizures (FS), the most common subtype of functional neurological disorder (FND), cause serious neurological disability and significantly impact quality of life. Characterized by episodic disturbances of functioning that resemble epileptic seizures, FS coincide with multiple comorbidities and are treated poorly by existing approaches. Novel treatment approaches are sorely needed. Notably, mounting evidence supports the safety and efficacy of psychedelic-assisted therapy (PAT) for several psychiatric conditions, motivating investigations into whether this efficacy also extends to neurological disorders. Here, we synthesize past empirical findings and frameworks to construct a biopsychosocial mechanistic argument for the potential of PAT as a treatment for FS. In doing so, we highlight FS as a well-defined cohort to further understand the large-scale neural mechanisms underpinning PAT. Our synthesis is guided by a complexity science perspective which we contend can afford unique mechanistic insight into both FS and PAT, as well as help bridge these two domains. We also leverage this perspective to propose a novel analytic roadmap to identify markers of FS diagnostic specificity and treatment success. This endeavor continues the effort to bridge clinical neurology with psychedelic medicine and helps pave the way for a new field of psychedelic neurology.
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Affiliation(s)
- Evan Cole Lewis
- Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | | | - Manesh Girn
- Neuroscape, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | | | - Madeline Brendle
- Numinus Wellness Inc., Vancouver, BC, Canada
- Health Outcomes Division, College of Pharmacy, University of Texas at Austin, Austin, TX, USA
| | - Elena Argento
- Numinus Wellness Inc., Vancouver, BC, Canada
- Department of Psychology, University of British Columbia, Kelowna, BC, Canada
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2
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Pick S, Millman LM, Ward E, Short E, Stanton B, Reinders AS, Winston JS, Nicholson TR, Edwards MJ, Goldstein LH, David AS, Chalder T, Hotopf M, Mehta MA. Unravelling the influence of affective stimulation on functional neurological symptoms: a pilot experiment examining potential mechanisms. J Neurol Neurosurg Psychiatry 2024; 95:461-470. [PMID: 37963722 DOI: 10.1136/jnnp-2023-332364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 10/19/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND Differences in affective processing have previously been shown in functional neurological disorder (FND); however, the mechanistic relevance is uncertain. We tested the hypotheses that highly arousing affective stimulation would result in elevated subjective functional neurological symptoms (FNS), and this would be associated with elevated autonomic reactivity. The possible influence of cognitive detachment was also explored. METHOD Individuals diagnosed with FND (motor symptoms/seizures; n=14) and healthy controls (n=14) viewed Positive, Negative and Neutral images in blocks, while passively observing the stimuli ('Watch') or detaching themselves ('Distance'). The FND group rated their primary FNS, and all participants rated subjective physical (arousal, pain, fatigue) and psychological states (positive/negative affect, dissociation), immediately after each block. Skin conductance (SC) and heart rate (HR) were monitored continuously. RESULTS FNS ratings were higher after Negative compared with Positive and Neutral blocks in the FND group (p=0.002, ηp 2=0.386); however, this effect was diminished in the Distance condition relative to the Watch condition (p=0.018, ηp 2=0.267). SC and/or HR correlated with FNS ratings in the Negative-Watch and Neutral-Distance conditions (r values=0.527-0.672, p values=0.006-0.035). The groups did not differ in subjective affect or perceived arousal (p values=0.541-0.919, ηp 2=<0.001-0.015). CONCLUSIONS Emotionally significant events may exert an influence on FNS which is related to autonomic activation rather than altered subjective affect or perceived arousal. This influence may be modulated by cognitive detachment. Further work is needed to determine the relevance and neural bases of these processes in specific FND phenotypes.
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Affiliation(s)
- Susannah Pick
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Ls Merritt Millman
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Emily Ward
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Eleanor Short
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Biba Stanton
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
- King's College Hospital NHS Foundation Trust, London, UK
| | - Aat Simone Reinders
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Joel S Winston
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
- King's College Hospital NHS Foundation Trust, London, UK
| | - Timothy R Nicholson
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Mark J Edwards
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Laura H Goldstein
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Anthony S David
- Institute of Mental Health, University College London, London, UK
| | - Trudie Chalder
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Matthew Hotopf
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Mitul A Mehta
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
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3
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Ryan JM, Wagner KT, Yerram S, Concannon C, Lin JX, Rooney P, Hanrahan B, Titoff V, Connolly NL, Cranmer R, DeMaria N, Xia X, Mykins B, Erickson S, Couderc JP, Schifitto G, Hughes I, Wang D, Erba G, Auerbach DS. Heart rate and autonomic biomarkers distinguish convulsive epileptic vs. functional or dissociative seizures. Seizure 2023; 111:178-186. [PMID: 37660533 DOI: 10.1016/j.seizure.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 08/19/2023] [Accepted: 08/22/2023] [Indexed: 09/05/2023] Open
Abstract
OBJECTIVE 20-40% of individuals whose seizures are not controlled by anti-seizure medications exhibit manifestations comparable to epileptic seizures (ES), but there are no EEG correlates. These events are called functional or dissociative seizures (FDS). Due to limited access to EEG-monitoring and inconclusive results, we aimed to develop an alternative diagnostic tool that distinguishes ES vs. FDS. We evaluated the temporal evolution of ECG-based measures of autonomic function (heart rate variability, HRV) to determine whether they distinguish ES vs. FDS. METHODS The prospective study includes patients admitted to the University of Rochester Epilepsy Monitoring Unit. Participants are 18-65 years old, without therapies or co-morbidities associated with altered autonomics. A habitual ES or FDS is recorded during admission. HRV analysis is performed to evaluate the temporal changes in autonomic function during the peri‑ictal period (150-minutes each pre-/post-ictal). We determined if autonomic measures distinguish ES vs. FDS. RESULTS The study includes 53 ES and 46 FDS. Temporal evolution of HR and autonomics significantly differ surrounding ES vs. FDS. The pre-to-post-ictal change (delta) in HR differs surrounding ES vs. FDS, stratified for convulsive and non-convulsive events. Post-ictal HR, total autonomic (SDNN & Total Power), vagal (RMSSD & HF), and baroreflex (LF) function differ for convulsive ES vs. convulsive FDS. HR distinguishes non-convulsive ES vs. non-convulsive FDS with ROC>0.7, sensitivity>70%, but specificity<50%. HR-delta and post-ictal HR, SDNN, RMSSD, LF, HF, and Total Power each distinguish convulsive ES vs. convulsive FDS (ROC, 0.83-0.98). Models with HR-delta and post-ictal HR provide the highest diagnostic accuracy for convulsive ES vs. convulsive FDS: 92% sensitivity, 94% specificity, ROC 0.99). SIGNIFICANCE HR and HRV measures accurately distinguish convulsive, but not non-convulsive, events (ES vs. FDS). Results establish the framework for future studies to apply this diagnostic tool to more heterogeneous populations, and on out-of-hospital recordings, particularly for populations without access to epilepsy monitoring units.
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Affiliation(s)
- Justin M Ryan
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Kyle T Wagner
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Sushma Yerram
- Department of Neurology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Cathleen Concannon
- Department of Neurology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Jennifer X Lin
- School of Medicine, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Patrick Rooney
- Department of Neurology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Brian Hanrahan
- Department of Neurology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Victoria Titoff
- Department of Neurology-Epilepsy, SUNY Upstate Medical University, Syracuse, NY 13210, United States; Department of Neurology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Noreen L Connolly
- Department of Neurology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Ramona Cranmer
- Department of Neurology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Natalia DeMaria
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Xiaojuan Xia
- Clinical Cardiology Research Center Medicine-Cardiology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Betty Mykins
- Clinical Cardiology Research Center Medicine-Cardiology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Steven Erickson
- Department of Neurology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Jean-Philippe Couderc
- Clinical Cardiology Research Center Medicine-Cardiology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Giovanni Schifitto
- Department of Neurology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Inna Hughes
- Department of Neurology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Dongliang Wang
- Department of Public Health, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Giuseppe Erba
- Department of Neurology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - David S Auerbach
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, NY 13210, United States.
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Malekpour M, Jafari A, Kashkooli M, Salarikia SR, Negahdaripour M. A systems biology approach for discovering the cellular and molecular aspects of psychogenic non-epileptic seizure. Front Psychiatry 2023; 14:1116892. [PMID: 37252132 PMCID: PMC10213457 DOI: 10.3389/fpsyt.2023.1116892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 04/26/2023] [Indexed: 05/31/2023] Open
Abstract
Objectives Psychogenic non-epileptic seizure (PNES) is the most common non-epileptic disorder in patients referring to epilepsy centers. Contrary to common beliefs about the disease's harmlessness, the death rate of PNES patients is similar to drug-resistant epilepsy. Meanwhile, the molecular pathomechanism of PNES is unknown with very limited related research. Thus, the aim of this in silico study was to find different proteins and hormones associated with PNES via a systems biology approach. Methods Different bioinformatics databases and literature review were used to find proteins associated with PNES. The protein-hormone interaction network of PNES was constructed to discover its most influential compartments. The pathways associated with PNES pathomechanism were found by enrichment analysis of the identified proteins. Besides, the relationship between PNES-related molecules and psychiatric diseases was discovered, and the brain regions that could express altered levels of blood proteins were discovered. Results Eight genes and three hormones were found associated with PNES through the review process. Proopiomelanocortin (POMC), neuropeptide Y (NPY), cortisol, norepinephrine, and brain-derived neurotrophic factor (BDNF) were identified to have a high impact on the disease pathogenesis network. Moreover, activation of Janus kinase-signaling transducer and activator of transcription (JAK-STAT) and JAK, as well as signaling of growth hormone receptor, phosphatidylinositol 3-kinase /protein kinase B (PI3K/AKT), and neurotrophin were found associated with PNES molecular mechanism. Several psychiatric diseases such as depression, schizophrenia, and alcohol-related disorders were shown to be associated with PNES predominantly through signaling molecules. Significance This study was the first to gather the biochemicals associated with PNES. Multiple components and pathways and several psychiatric diseases associated with PNES, and some brain regions that could be altered during PNES were suggested, which should be confirmed in further studies. Altogether, these findings could be used in future molecular research on PNES patients.
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Affiliation(s)
- Mahdi Malekpour
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Aida Jafari
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Kashkooli
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Manica Negahdaripour
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Science, Shiraz, Iran
- Department of Pharmaceutical Biotechnology, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
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5
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Milano BA, Moutoussis M, Convertino L. The neurobiology of functional neurological disorders characterised by impaired awareness. Front Psychiatry 2023; 14:1122865. [PMID: 37009094 PMCID: PMC10060839 DOI: 10.3389/fpsyt.2023.1122865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/24/2023] [Indexed: 03/18/2023] Open
Abstract
We review the neurobiology of Functional Neurological Disorders (FND), i.e., neurological disorders not explained by currently identifiable histopathological processes, in order to focus on those characterised by impaired awareness (functionally impaired awareness disorders, FIAD), and especially, on the paradigmatic case of Resignation Syndrome (RS). We thus provide an improved more integrated theory of FIAD, able to guide both research priorities and the diagnostic formulation of FIAD. We systematically address the diverse spectrum of clinical presentations of FND with impaired awareness, and offer a new framework for understanding FIAD. We find that unraveling the historical development of neurobiological theory of FIAD is of paramount importance for its current understanding. Then, we integrate contemporary clinical material in order to contextualise the neurobiology of FIAD within social, cultural, and psychological perspectives. We thus review neuro-computational insights in FND in general, to arrive at a more coherent account of FIAD. FIAD may be based on maladaptive predictive coding, shaped by stress, attention, uncertainty, and, ultimately, neurally encoded beliefs and their updates. We also critically appraise arguments in support of and against such Bayesian models. Finally, we discuss implications of our theoretical account and provide pointers towards an improved clinical diagnostic formulation of FIAD. We suggest directions for future research towards a more unified theory on which future interventions and management strategies could be based, as effective treatments and clinical trial evidence remain limited.
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Affiliation(s)
- Beatrice Annunziata Milano
- Institute of Life Sciences, Sant'Anna School of Advanced Studies, Pisa, Italy
- Faculty of Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Michael Moutoussis
- Wellcome Centre for Human Neuroimaging, University College London, London, United Kingdom
- Max Planck UCL Centre for Computational Psychiatry and Ageing Research, University College London, London, United Kingdom
- National Hospital of Neurology and Neurosurgery (UCLH), London, United Kingdom
| | - Laura Convertino
- Wellcome Centre for Human Neuroimaging, University College London, London, United Kingdom
- National Hospital of Neurology and Neurosurgery (UCLH), London, United Kingdom
- Institute of Cognitive Neuroscience, University College London, London, United Kingdom
- *Correspondence: Laura Convertino,
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6
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Perez DL. Epilepsy & Behavior: At the forefront of functional (dissociative) seizures. Epilepsy Behav 2022; 137:108698. [PMID: 36463060 DOI: 10.1016/j.yebeh.2022.108698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 04/03/2022] [Indexed: 12/05/2022]
Affiliation(s)
- David L Perez
- Functional Neurological Disorder Unit, Division of Cognitive Behavioral Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Division of Neuropsychiatry, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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7
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Xiong W, Kameneva T, Lambert E, Cook MJ, Richardson MP, Nurse ES. Forecasting psychogenic non-epileptic seizure likelihood from ambulatory EEG and ECG. J Neural Eng 2022; 19. [PMID: 36270501 DOI: 10.1088/1741-2552/ac9c97] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 10/21/2022] [Indexed: 12/24/2022]
Abstract
Objective.Critical slowing features (variance and autocorrelation) of long-term continuous electroencephalography (EEG) and electrocardiography (ECG) data have previously been used to forecast epileptic seizure onset. This study tested the feasibility of forecasting non-epileptic seizures using the same methods. In doing so, we examined if long-term cycles of brain and cardiac activity are present in clinical physiological recordings of psychogenic non-epileptic seizures (PNES).Approach.Retrospectively accessed ambulatory EEG and ECG data from 15 patients with non-epileptic seizures and no background of epilepsy were used for developing the forecasting system. The median period of recordings was 161 h, with a median of 7 non-epileptic seizures per patient. The phases of different cycles (5 min, 1 h, 6 h, 12 h, 24 h) of EEG and RR interval (RRI) critical slowing features were investigated. Forecasters were generated using combinations of the variance and autocorrelation of both EEG and the RRI of the ECG at each of the aforementioned cycle lengths. Optimal forecasters were selected as those with the highest area under the receiver-operator curve (AUC).Main results.It was found that PNES events occurred in the rising phases of EEG feature cycles of 12 and 24 h in duration at a rate significantly above chance. We demonstrated that the proposed forecasters achieved performance significantly better than chance in 8/15 of patients, and the mean AUC of the best forecaster across patients was 0.79.Significance.To our knowledge, this is the first study to retrospectively forecast non-epileptic seizures using both EEG and ECG data. The significance of EEG in the forecasting models suggests that cyclic EEG features of non-epileptic seizures exist. This study opens the potential of seizure forecasting beyond epilepsy, into other disorders of episodic loss of consciousness or dissociation.
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Affiliation(s)
- Wenjuan Xiong
- School of Science, Computing and Engineering Technologies, Swinburne University of Technology, Melbourne, Australia
| | - Tatiana Kameneva
- School of Science, Computing and Engineering Technologies, Swinburne University of Technology, Melbourne, Australia.,Iverson Health Innovation Institute, Swinburne University of Technology, Melbourne, Australia.,Department of Biomedical Engineering, The University of Melbourne, Melbourne, Australia
| | - Elisabeth Lambert
- Iverson Health Innovation Institute, Swinburne University of Technology, Melbourne, Australia.,School of Health Sciences, Swinburne University of Technology, Melbourne, Australia
| | - Mark J Cook
- Department of Medicine, St Vincent's Hospital Melbourne, The University of Melbourne, Melbourne, Australia.,Graeme Clark Institute, The University of Melbourne, Melbourne, Australia
| | - Mark P Richardson
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.,Centre for Epilepsy, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Ewan S Nurse
- Department of Medicine, St Vincent's Hospital Melbourne, The University of Melbourne, Melbourne, Australia.,Seer Medical, Melbourne, Australia
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8
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Schneider G, Levin L, Herskovitz M. Psychogenic nonepileptic seizures: Are they a freeze reaction? Epilepsy Behav 2022; 129:108655. [PMID: 35299088 DOI: 10.1016/j.yebeh.2022.108655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 02/27/2022] [Accepted: 02/28/2022] [Indexed: 11/03/2022]
Abstract
Psychogenic nonepileptic seizures (PNES) clinically resemble epileptic seizures (ES) but lack epileptic activity at the time of the seizure and are also not due to any other pathophysiological disorder. The integrative cognitive model (ICM) suggests that PNES is an automatic reaction generated from distorted memory and is perceived as uncontrollable and unwanted. Furthermore, the ICM model implies that a PNES event occurs due to an external or internal cue. Intrigued by this assumption, we wanted to examine why a PNES event occurs at a particular moment by investigating the pre-ictal behavior. This study is a retrospective study. We included all patients diagnosed with PNES or ES admitted to our long-term video-EEG monitoring unit (LTVEM) between 01/01/2018 and 30/08/2020. Using thorough video analysis, we checked the patient's state at the onset of the event and looked back to see what the patient was doing before the event onset. We defined 4 types of pre-ictal behavior A. Inactivity. B. Environment arrangement c. Other. D. No apparent pre-ictal behavior. Thirty patients with PNES and 30 patients with ES were included in the study. In total, 46 PNES events and 56 ES events were recorded and analyzed. In 33 /46 PNES seizures (72%), a type A, A + B or C pre-ictal behavior was observed compared to 1/56 ES (1.78%) with type A pre-ictal behavior. All other pre-ictal behavior in the ES group were of type D. Patients with PNES have a unique pre-ictal behavior before most PNES events with motor manifestations. Since the pre-ictal behavior consists mainly of inactivity, we believe it may imply that PNES represents a freeze reaction or a reconstruction of a freeze reaction.
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Affiliation(s)
- Galit Schneider
- Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel
| | - Lera Levin
- Department of Psychology, Rambam Health Care Campus, Haifa, Israel
| | - Moshe Herskovitz
- Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel; Department of Neurology, Rambam Health Care Campus, Haifa, Israel.
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9
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Reuber M, Roberts NA, Levita L, Gray C, Myers L. Shame in patients with psychogenic nonepileptic seizure: A narrative review. Seizure 2021; 94:165-175. [PMID: 34844847 DOI: 10.1016/j.seizure.2021.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 10/02/2021] [Accepted: 10/21/2021] [Indexed: 10/20/2022] Open
Abstract
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.
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Affiliation(s)
- M Reuber
- Academic Neurology Unit, University of Sheffield, Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2JF, United Kingdom.
| | - Nicole A Roberts
- School of Social and Behavioral Sciences, Arizona State University, Phoenix, AZ, USA
| | - Liat Levita
- Department of Psychology, University of Sheffield, Sheffield, UK
| | - Cordelia Gray
- Specialist Psychotherapist, Neurology Psychotherapy Service, Sheffield Teaching Hospital, Academic Neurology Unit, University of Sheffield, Sheffield, UK
| | - Lorna Myers
- Director, Northeast Regional Epilepsy Group, New York, United States
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10
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Boulet C, Lopez-Castroman J, Mouchabac S, Olié E, Courtet P, Thouvenot E, Abbar M, Conejero I. Stress response in dissociation and conversion disorders: A systematic review. Neurosci Biobehav Rev 2021; 132:957-967. [PMID: 34740754 DOI: 10.1016/j.neubiorev.2021.10.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/14/2021] [Accepted: 10/28/2021] [Indexed: 12/28/2022]
Abstract
Dissociative disorders (DD) and conversion disorders (CD) are frequent in general and psychiatric populations. Some evidence suggest that the hypothalamic-pituitary axis (HPA) and autonomic nervous system (ANS) are dysregulated in both disorders. We carried out a systematic review of the literature to summarize the existing knowledge on the stress response, via HPA and/or ANS, in patients with DD, CD, or dissociative symptoms. We systematically searched Medline and Web of Science using the Medical Subject Headings related to stress axis, CD, DD, and dissociative symptoms following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results suggest that in participants without psychiatric history, high cortisol secretion is related to high dissociation scores. Conversely the stress system might be blunted in patients with post-traumatic stress disorder who develop dissociative symptoms. Stress response changes seem to be associated with the emergence and persistence of dissociative and conversion disorders. Hence, monitoring the stress response and examining closely the history of stress exposure in DD and CD should be encouraged in future larger studies.
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Affiliation(s)
- Charlotte Boulet
- Department of Psychiatry, Nîmes University Hospital, Nîmes, France
| | - Jorge Lopez-Castroman
- Department of Psychiatry, Nîmes University Hospital, Nîmes, France; IGF, Univ. Montpellier, CNRS, INSERM, Montpellier, France
| | - Stéphane Mouchabac
- Saint-Antoine Hospital Center APHP, Department of Psychiatry, iCRIN Psychiatry (Infrastructure of Clinical Research in Neurosciences-Psychiatry), Brain and Spine Institute (ICM), Sorbonne University, INSERM, CNRS, 75013, Paris, France
| | - Emilie Olié
- Department of Emergency Psychiatry and Acute Care, Lapeyronie Hospital CHU Montpellier, IGF, Univ. Montpellier, CNRS, INSERM, Montpellier, France
| | - Philippe Courtet
- Department of Emergency Psychiatry and Acute Care, Lapeyronie Hospital CHU Montpellier, IGF, Univ. Montpellier, CNRS, INSERM, Montpellier, France
| | - Eric Thouvenot
- Department of Neurology, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Mocrane Abbar
- Department of Psychiatry, Nîmes University Hospital, Nîmes, France
| | - Ismael Conejero
- Department of Psychiatry, Nîmes University Hospital, Nîmes, France; IGF, Univ. Montpellier, CNRS, INSERM, Montpellier, France; Centre de Biochimie Structurale, University of Montpellier, Montpellier, France.
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11
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Paredes-Echeverri S, Maggio J, Bègue I, Pick S, Nicholson TR, Perez DL. Autonomic, Endocrine, and Inflammation Profiles in Functional Neurological Disorder: A Systematic Review and Meta-Analysis. J Neuropsychiatry Clin Neurosci 2021; 34:30-43. [PMID: 34711069 PMCID: PMC8813876 DOI: 10.1176/appi.neuropsych.21010025] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Functional neurological disorder (FND) is a core neuropsychiatric condition. To date, promising yet inconsistently identified neural circuit profiles have been observed in patients with FND, suggesting that gaps remain in our systems-level neurobiological understanding. As such, other important physiological variables, including autonomic, endocrine, and inflammation findings, need to be contextualized for a more complete mechanistic picture. METHODS The investigators conducted a systematic review and meta-analysis of available case-control and cohort studies of FND. PubMed, PsycINFO, and Embase databases were searched for studies from January 1, 1900, to September 1, 2020, that investigated autonomic, endocrine, and inflammation markers in patients with FND. Sixty-six of 2,056 screened records were included in the review, representing 1,699 patients; data from 20 articles were used in the meta-analysis. RESULTS Findings revealed that children and adolescents with FND, compared with healthy control subjects (HCs), have increased resting heart rate (HR); there is also a tendency toward reduced resting HR variability in patients with FND across the lifespan compared with HCs. In adults, peri-ictal HR differentiated patients with functional seizures from those with epileptic seizures. Other autonomic and endocrine profiles for patients with FND were heterogeneous, with several studies highlighting the importance of individual differences. CONCLUSIONS Inflammation research in FND remains in its early stages. Moving forward, there is a need for the use of larger sample sizes to consider the complex interplay between functional neurological symptoms and behavioral, psychological, autonomic, endocrine, inflammation, neuroimaging, and epigenetic/genetic data. More research is also needed to determine whether FND is mechanistically (and etiologically) similar or distinct across phenotypes.
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Affiliation(s)
- Sara Paredes-Echeverri
- Functional Neurological Disorder Research Program, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Julie Maggio
- Functional Neurological Disorder Research Program, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Physical Therapy, Massachusetts General Hospital, Boston, MA, USA
| | - Indrit Bègue
- Adult Psychiatry Division, Department of Mental Health and Psychiatry, University Hospitals of Geneva, Geneva, Switzerland
- Laboratory for Clinical and Experimental Psychopathology, Department of Psychiatry, University of Geneva, Geneva, Switzerland
| | - Susannah Pick
- Institute of Psychiatry, Psychology and Neuroscience, King’s College, London, United Kingdom
| | - Timothy R. Nicholson
- Institute of Psychiatry, Psychology and Neuroscience, King’s College, London, United Kingdom
| | - David L. Perez
- Functional Neurological Disorder Research Program, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Division of Neuropsychiatry, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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12
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Hamouda K, Senf-Beckenbach PA, Gerhardt C, Irorutola F, Rose M, Hinkelmann K. Executive Functions and Attention in Patients With Psychogenic Nonepileptic Seizures Compared With Healthy Controls: A Cross-Sectional Study. Psychosom Med 2021; 83:880-886. [PMID: 34292202 DOI: 10.1097/psy.0000000000000981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Psychogenic nonepileptic seizures (PNESs) are considered functional neurological symptoms and are highly prevalent in specialized epilepsy clinics. The underlying mechanisms of PNES are not fully understood. Recent findings point toward possible alterations in attention and executive functions. This study aimed to extend the current knowledge of attention and executive function in patients with PNES and to assess possible relationships between seizures and dissociation, childhood trauma, and cognitive function. METHODS We recruited 40 patients with PNES and 40 sex-, age-, and education-matched healthy controls (HCs) in this study. Participants completed self-report questionnaires to assess early life stress (Childhood Trauma Questionnaire [CTQ]), dissociation (the German version of the Dissociative Experience Scale, or Fragebogen zu dissoziativen Symptomen), and depression (Patient Health Questionnaire-9). Executive functions and attention were assessed with the Trail Making Test (TMT), Digit Span, and Attention Network Task. RESULTS Compared with HCs, patients with PNES reported significantly higher levels of childhood trauma, depression, and dissociation. Patients with PNES also had reduced performance indices for Digit Span Forward (d = 0.62), Digit Span Backward (d = 0.62), and TMT (d = 0.67) but not Attention Network Task. CTQ scores positively correlated with TMT and Digit Span Backward performance in patients with PNES. Adjusting for CTQ scores attenuated the observed group difference in TMT performance. Depression and dissociation did not explain the observed findings. CONCLUSIONS These results contribute to the evidence of impaired executive functions in patients with PNES. Furthermore, childhood trauma scores, but not (trait) dissociation or depression scores, seem to drive group differences (HC versus patients with PNES).
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Affiliation(s)
- Karim Hamouda
- From the Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin; and Department of Psychosomatic Medicine, Center of Internal Medicine and Dermatology, Berlin Institute of Health, Berlin, Germany
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13
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Baslet G, Bajestan SN, Aybek S, Modirrousta M, D Clin Psy JP, Cavanna A, Perez DL, Lazarow SS, Raynor G, Voon V, Ducharme S, LaFrance WC. Evidence-Based Practice for the Clinical Assessment of Psychogenic Nonepileptic Seizures: A Report From the American Neuropsychiatric Association Committee on Research. J Neuropsychiatry Clin Neurosci 2021; 33:27-42. [PMID: 32778006 DOI: 10.1176/appi.neuropsych.19120354] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Gaston Baslet
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Sepideh N Bajestan
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Selma Aybek
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Mandana Modirrousta
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Jason Price D Clin Psy
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Andrea Cavanna
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - David L Perez
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Shelby Scott Lazarow
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Geoffrey Raynor
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Valerie Voon
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - Simon Ducharme
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
| | - W Curt LaFrance
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Baslet); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif. (Bajestan); Department of Neurology, Inselspital University Hospital and Clinical Neuroscience Bern Network, University of Bern, Bern, Switzerland (Aybek); Department of Psychiatry, University of Manitoba, Winnipeg, MB, Canada (Modirrousta); South Tees Hospitals National Health Service Foundation Trust, Middlesbrough, United Kingdom (Price); Department of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom (Cavanna); Departments of Neurology and Psychiatry, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston (Perez); California Pacific Medical Center, San Francisco (Lazarow); Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston (Raynor); Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom (Voon); Department of Psychiatry, Montreal Neurological Institute, McGill University, Montreal (Ducharme); Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, R.I. (LaFrance)
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14
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Yeom JS, Bernard H, Koh S. Myths and truths about pediatric psychogenic nonepileptic seizures. Clin Exp Pediatr 2021; 64:251-259. [PMID: 33091974 PMCID: PMC8181023 DOI: 10.3345/cep.2020.00892] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/12/2020] [Indexed: 11/27/2022] Open
Abstract
Psychogenic nonepileptic seizures (PNES) is a neuropsychiatric condition that causes a transient alteration of consciousness and loss of self-control. PNES, which occur in vulnerable individuals who often have experienced trauma and are precipitated by overwhelming circumstances, are a body's expression of a distressed mind, a cry for help. PNES are misunderstood, mistreated, under-recognized, and underdiagnosed. The mindbody dichotomy, an artificial divide between physical and mental health and brain disorders into neurology and psychiatry, contributes to undue delays in the diagnosis and treatment of PNES. One of the major barriers in the effective diagnosis and treatment of PNES is the dissonance caused by different illness perceptions between patients and providers. While patients are bewildered by their experiences of disabling attacks beyond their control or comprehension, providers consider PNES trivial because they are not epileptic seizures and are caused by psychological stress. The belief that patients with PNES are feigning or controlling their symptoms leads to negative attitudes of healthcare providers, which in turn lead to a failure to provide the support and respect that patients with PNES so desperately need and deserve. A biopsychosocial perspective and better understanding of the neurobiology of PNES may help bridge this great divide between brain and behavior and improve our interaction with patients, thereby improving prognosis. Knowledge of dysregulated stress hormones, autonomic nervous system dysfunction, and altered brain connectivity in PNES will better prepare providers to communicate with patients how intangible emotional stressors could cause tangible involuntary movements and altered awareness.
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Affiliation(s)
- Jung Sook Yeom
- Department of Pediatrics, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Jinju, Korea.,Gyeongsang Institute of Health Science, Gyeongsang National University College of Medicine, Jinju, Korea.,Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Heather Bernard
- Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Sookyong Koh
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, GA, USA
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15
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Widyadharma IPE, Soejitno A, Samatra DPGP, Sinardja AMG. Clinical differentiation of psychogenic non-epileptic seizure: a practical diagnostic approach. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2021. [DOI: 10.1186/s41983-021-00272-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
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.
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16
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Psychogenic non-epileptic seizures in children - psychophysiology & dissociative characteristics. Psychiatry Res 2020; 294:113544. [PMID: 33161178 DOI: 10.1016/j.psychres.2020.113544] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 10/24/2020] [Indexed: 11/21/2022]
Abstract
The purpose of this study was to determine psychophysiology and dissociative characteristics of psychogenic non-epileptic seizures (PNES) in a clinical pediatric setting. A retrospective chart review was conducted over a 5-year period that included children meeting criteria for probable, clinically established or documented PNES. Of these, 33 patients (81%) underwent psychophysiology assessment as part of standardized care and were selected for study inclusion. Ages ranged from 10 to 17 years inclusive (70% female). The majority of patients were found to have some form of autonomic decompensation at baseline (82%) and lack of autonomic recovery from a cognitive stressor (58%). Inhibition of electrodermal skin response to laboratory stressor was associated with significantly longer duration of PNES illness (t=2.65, p=.013), while elevated heart rate (above 90th percentile) was associated with significantly higher frequency of PNES events in the month preceding diagnosis (t=3.1, p=.004). High levels of dissociation and hyperventilation symptoms were self-reported by adolescent patients (n=19) with a moderate degree of positive association (r=0.35, p=.038). The majority of patients (n= 25, 89%) were taught to correct respiratory CO2 levels during a single biofeedback training session. Conclusions: Child PNES populations appear to be characterized by chronic autonomic hyperarousal reflecting severity of their symptoms, which can feasibly be targeted for behavioral treatment.
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17
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Roberts NA, Burleson MH, Torres DL, Parkhurst DK, Garrett R, Mitchell LB, Duncan CJ, Mintert M, Wang NC. Emotional Reactivity as a Vulnerability for Psychogenic Nonepileptic Seizures? Responses While Reliving Specific Emotions. J Neuropsychiatry Clin Neurosci 2020; 32:95-100. [PMID: 31662092 DOI: 10.1176/appi.neuropsych.19040084] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Dysfunction in emotional processes is a hypothesized contributor to functional neurological disorders (FNDs), yet few studies have evoked real-time emotion during multimethod assessment incorporating subjective, behavioral, and psychophysiological indicators. This approach may reveal clinical and neurobiological vulnerability to FND and clarify how dysfunctional emotional processes serve as perpetuating factors. METHODS Eleven participants with video-EEG-confirmed diagnoses of psychogenic nonepileptic seizures (PNES) were compared with 49 seizure-free trauma control subjects (TCs) with or without clinically elevated posttraumatic stress symptoms (25 clinically elevated [TC-clin], 24 not clinically elevated [TC-nonclin]). Participants recalled and described memories evoking anger, shame, happiness, and neutral feelings. RESULTS Even though PNES patients and TCs reported similar amounts of emotional experience, PNES patients reported more difficulty reliving emotions and were less likely to complete the relived shame task. During and after reliving happiness, PNES and TC-clin groups showed respiratory sinus arrhythmia (RSA) decreases, indicating parasympathetic withdrawal, whereas the TC-nonclin group showed RSA increases. CONCLUSIONS Findings from this pilot study are consistent with previous research and clinical observations that emotional engagement may be more effortful for PNES patients. Patterns of RSA change, which may also point to greater effortful engagement, were similar in PNES and TC-clin groups, suggesting that traumatic stress reactions may play a part. At the same time, experience of greater difficulty or avoidance may be even greater among PNES patients. Especially when regulatory resources are already limited, accumulated effort, coupled with self-threatening contexts such as shame, may be particularly problematic for those with PNES and perhaps other FNDs.
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Affiliation(s)
- Nicole A Roberts
- School of Social and Behavioral Sciences, Arizona State University, Phoenix (Roberts, Burleson, Torres, Parkhurst, Mitchell, Duncan, Mintert); and Banner-University Medical Center Neuroscience Institute, Phoenix (Garrett, Wang)
| | - Mary H Burleson
- School of Social and Behavioral Sciences, Arizona State University, Phoenix (Roberts, Burleson, Torres, Parkhurst, Mitchell, Duncan, Mintert); and Banner-University Medical Center Neuroscience Institute, Phoenix (Garrett, Wang)
| | - Dhannia L Torres
- School of Social and Behavioral Sciences, Arizona State University, Phoenix (Roberts, Burleson, Torres, Parkhurst, Mitchell, Duncan, Mintert); and Banner-University Medical Center Neuroscience Institute, Phoenix (Garrett, Wang)
| | - David K Parkhurst
- School of Social and Behavioral Sciences, Arizona State University, Phoenix (Roberts, Burleson, Torres, Parkhurst, Mitchell, Duncan, Mintert); and Banner-University Medical Center Neuroscience Institute, Phoenix (Garrett, Wang)
| | - Robin Garrett
- School of Social and Behavioral Sciences, Arizona State University, Phoenix (Roberts, Burleson, Torres, Parkhurst, Mitchell, Duncan, Mintert); and Banner-University Medical Center Neuroscience Institute, Phoenix (Garrett, Wang)
| | - Lauren B Mitchell
- School of Social and Behavioral Sciences, Arizona State University, Phoenix (Roberts, Burleson, Torres, Parkhurst, Mitchell, Duncan, Mintert); and Banner-University Medical Center Neuroscience Institute, Phoenix (Garrett, Wang)
| | - Cayla J Duncan
- School of Social and Behavioral Sciences, Arizona State University, Phoenix (Roberts, Burleson, Torres, Parkhurst, Mitchell, Duncan, Mintert); and Banner-University Medical Center Neuroscience Institute, Phoenix (Garrett, Wang)
| | - Mallory Mintert
- School of Social and Behavioral Sciences, Arizona State University, Phoenix (Roberts, Burleson, Torres, Parkhurst, Mitchell, Duncan, Mintert); and Banner-University Medical Center Neuroscience Institute, Phoenix (Garrett, Wang)
| | - Norman C Wang
- School of Social and Behavioral Sciences, Arizona State University, Phoenix (Roberts, Burleson, Torres, Parkhurst, Mitchell, Duncan, Mintert); and Banner-University Medical Center Neuroscience Institute, Phoenix (Garrett, Wang)
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Herrero H, Tarrada A, Haffen E, Mignot T, Sense C, Schwan R, El-Hage W, Maillard L, Hingray C. Skin conductance response and emotional response in women with psychogenic non-epileptic seizures. Seizure 2020; 81:123-131. [PMID: 32795943 DOI: 10.1016/j.seizure.2020.07.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 07/26/2020] [Accepted: 07/28/2020] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Recent etiopathogenic models place emotional dysregulation at the core of psychogenic nonepileptic seizure (PNES). Our purpose was to assess physiological, cognitive, and behavioral emotional responses of PNES patients. METHODS This study compared three types of emotional responses to visual emotional stimuli between 34 female PNES group and 34 matched healthy controls: physiological response measured by skin conductance response (SCR) (rate, amplitude and latency) and heart rate deceleration; cognitive response measured by valence and arousal elicited by the images; and behavioural response measured by latency of ratings. The groups were characterized on psychiatric comorbidities, traumatic history, alexithymia, and dissociation. RESULTS Compared to controls, PNES group displayed lower SCR for all images (p = 0.038), shorter amplitude of heart rate deceleration (p = 0.024) and faster arousal rating for all images (p = 0.019), but no difference on cognitive rating of images. Within-groups analyses showed only in PNES subjects increased rate (+19.35%, p = 0.046) SCR for negative stimuli with strong arousal compared to negative with low arousal. PNES physiological response (SCR and heart rate deceleration) was negatively correlated to dissociation tendency (r=-0.48, p = 0.0083) and alexithymia (r=-0.44, p = 0.012)). For cognitive response, no correlation was found. CONCLUSION These results are in favour of a lower physiological emotional response but with an over-reactivity at behavioral level contrasting with similar cognitive assessment. For strong aversive stimuli, PNES might present a trend to overreact at physiological and behavioural levels. Our results suggest that dissociation and difficulty in describing feelings are associated with an altered physiological response in PNES women only.
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Affiliation(s)
- Hugo Herrero
- Groupe Hospitalier Paul Guiraud, 94800 Villejuif, France; Pôle Universitaire du Grand Nancy, Centre Psychothérapique de Nancy, Laxou, France
| | | | - Emmanuel Haffen
- Inserm, EA 481Neurosciences,Department of Clinical Psychiatry, Besançon, France
| | - Thibault Mignot
- Pôle Universitaire du Grand Nancy, Centre Psychothérapique de Nancy, Laxou, France
| | - Charlotte Sense
- Pôle Universitaire du Grand Nancy, Centre Psychothérapique de Nancy, Laxou, France
| | - Raymund Schwan
- Pôle Universitaire du Grand Nancy, Centre Psychothérapique de Nancy, Laxou, France
| | | | - Louis Maillard
- Service de Neurologie, CHRU Nancy Nancy, France; CNRS, CRAN - UMR 7039, Nancy F-54000, France
| | - Coraline Hingray
- Pôle Universitaire du Grand Nancy, Centre Psychothérapique de Nancy, Laxou, France; Service de Neurologie, CHRU Nancy Nancy, France
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19
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Romigi A, Ricciardo Rizzo G, Izzi F, Guerrisi M, Caccamo M, Testa F, Centonze D, Mercuri NB, Toschi N. Heart Rate Variability Parameters During Psychogenic Non-epileptic Seizures: Comparison Between Patients With Pure PNES and Comorbid Epilepsy. Front Neurol 2020; 11:713. [PMID: 32849194 PMCID: PMC7426492 DOI: 10.3389/fneur.2020.00713] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 06/10/2020] [Indexed: 11/24/2022] Open
Abstract
Introduction: Psychogenic non-epileptic seizures (PNES) may resemble epileptic seizures. There are few data about ictal ANS activity alterations induced by PNES in patients with pure PNES (pPNES) compared to PNES with comorbid epilepsy (PNES/ES). We aimed to compare heart rate variability (HRV) parameters and hence autonomic regulation in PNES in epileptic and non-epileptic patients. Methods: We obtained HRV data from video-electroencephalography recordings in 22 patients presenting PNES (11 pPNES and 11 PNES/ES) in awake, and supine states. We calculated HRV parameters in both time and frequency domains including low frequency (LF) power, high frequency power (HF), LF/HF ratio, square root of the mean of the sum of the squares of differences between adjacent R wave intervals (RMSSD) and the standard deviation of all consecutive R wave intervals (SDNN). We also evaluated approximate entropy (ApEn), cardiosympathetic index (CSI), and cardiovagal index (CVI). Four conditions were considered: basal condition (BAS), before PNES (PRE), during PNES (ICT) and after PNES (POST). Results: HRV analysis showed significantly higher ICT LF and LF/HF ratio vs. each condition. We also found higher POST HF vs. PRE and BAS, lower RRI in ICT vs. each condition and PRE vs. BAS. POST RMSSD was significantly higher compared to all other states. ICT CSI was significantly higher compared to all other states, whereas CSI was significantly lower in POST vs. PRE and PRE CVI lower than ICT and higher in POST vs. BAS and PRE. Also, ICT ApEn was lower than in all other states. Higher LF in pPNES vs. PNES/ES was also evident when compared across groups. Significance: A few studies examined HRV alterations in PNES, reporting high sympathetic tone (although less evident than in epileptic seizures). Our data suggest a sympathetic overdrive before and during PNES followed by a post-PNES increase in vagal tone. A sympathovagal imbalance was more evident in pPNES as compared to PNES/ES.
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Affiliation(s)
- Andrea Romigi
- IRCCS Neuromed Sleep Medicine Centre, Pozzilli, Italy
| | | | - Francesca Izzi
- Neurophysiopathology Unit, Department of Systems Medicine, Sleep Medicine Centre, Tor Vergata University and Hospital, Rome, Italy
| | - Maria Guerrisi
- Medical Physics Section, Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy
| | - Marco Caccamo
- IRCCS Neuromed Sleep Medicine Centre, Pozzilli, Italy
| | | | | | - Nicola B Mercuri
- Department of Neuroscience, "Tor Vergata" University, Rome, Italy
| | - Nicola Toschi
- Medical Physics Section, Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy.,Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
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20
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ÖZDEMIR PINARGÜZEL, KIRLI UMUT, ISÇIK MESUT, TAPAN SÇÜHEDA. The role of thought suppression in conversion disorder in relation to depression, symptom interpretation and sleep hygiene: a case-control study. ARCH CLIN PSYCHIAT 2020. [DOI: 10.1590/0101-60830000000233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
| | - UMUT KIRLI
- Yuzuncu Yil University, Turkey; Maastricht University, The Netherlands
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21
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Indranada AM, Mullen SA, Wong MJ, D'Souza WJ, Kanaan RAA. Preictal autonomic dynamics in psychogenic nonepileptic seizures. Epilepsy Behav 2019; 92:206-212. [PMID: 30684800 DOI: 10.1016/j.yebeh.2018.12.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 12/19/2018] [Accepted: 12/26/2018] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Psychogenic nonepileptic seizures (PNES) resemble seizures but are psychological in origin. The etiology of PNES remains poorly understood, yet several theories argue for the importance of autonomic dysregulation in its pathophysiology. We therefore conducted a retrospective study to investigate autonomic dynamics leading up to a seizure to inform their mechanistic relevance. METHODS One hundred one patients with PNES and 45 patients with epileptic seizure (ES) were analyzed for preictal heart rate (HR) and respiratory rate (RR) at baseline and at minute intervals from 5 min to onset. RESULTS Patients with PNES showed rising HR (p < 0.001, repeated-measures analysis of variance (ANOVA)) and rising RR (p = 0.012, repeated-measures ANOVA) from baseline to the onset of their seizures. Patients with ES did not exhibit significant preictal HR or RR increase. Patients with PNES had nonsignificantly higher preictal HR and RR than patients with ES. SIGNIFICANCE Patients with PNES exhibit increasing autonomic arousal prior to seizure events unlike patients with epilepsy. This may reflect increasing levels of preictal anxiety, and future studies could study patients' subjective experiences of the preictal period, and more definitive measures of ventilation to see if this supported a model of PNES as "panic without panic".
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Affiliation(s)
- Alaric M Indranada
- The University of Melbourne, Department of Psychiatry, Austin Health, Heidelberg, VIC 3084, Australia
| | - Saul A Mullen
- The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC 3084, Australia
| | - Melanie J Wong
- The University of Melbourne, Department of Clinical Neurosciences, St Vincent's Health, VIC 3065, Australia
| | - Wendyl J D'Souza
- The University of Melbourne, Department of Clinical Neurosciences, St Vincent's Health, VIC 3065, Australia
| | - Richard A A Kanaan
- The University of Melbourne, Department of Psychiatry, Austin Health, Heidelberg, VIC 3084, Australia; The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC 3084, Australia; King's College London, Department of Psychological Medicine, Institute of Psychiatry, Weston Education Centre, Denmark Hill, London SE5 9RJ, UK.
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22
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Elbers J, Jaradeh S, Yeh AM, Golianu B. Wired for Threat: Clinical Features of Nervous System Dysregulation in 80 Children. Pediatr Neurol 2018; 89:39-48. [PMID: 30343833 DOI: 10.1016/j.pediatrneurol.2018.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 07/22/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND The negative effect of perceived stress on health has become a cultural epidemic. Despite many health implications, the clinical impact of stress on the nervous system is not well understood. This case series describes the symptom profiles of 80 children with nervous system dysregulation attributed to maladaptive neuroendocrine responses to stress. METHODS We reviewed of 80 children with nervous system dysregulation identified from a single, tertiary care pediatric neurology clinic. Included patients were between five and 17 years of age, with unexplained medical symptoms lasting three months or longer affecting at least four of six neurological domains: (1) somatization, (2) executive function, (3) autonomic function, (4) digestion, (5) sleep, and (6) emotional regulation. Medical symptoms, diagnoses, and detailed social histories were collected. RESULTS Of 80 children, 57 were female (71%), 57 were Caucasian (71%), with median age of 14 years. Symptoms had a mean duration of 32 months, and included: 100% somatic symptoms, 100% emotional dysregulation, 92.5% disrupted sleep, 82.5% autonomic dysregulation, 75% executive dysfunction, and 66% digestive problems. Overall, 94% reported chronic or traumatic stressors; adverse childhood experiences were present in 65%. CONCLUSIONS Perceived stress impacts many functions of the neuroendocrine system through experience-dependent plasticity, resulting in a constellation of symptoms and functional impairments we describe as nervous system dysregulation. The pathophysiology of these symptoms involves dysregulation of subcortical, hormonal, and autonomic circuits, which remain largely untested. Recognition and understanding of maladaptive neurophysiology in stress-related symptoms has important implications for diagnosis, treatment, and advances in health research.
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Affiliation(s)
- Jorina Elbers
- Division of Child Neurology, Department of Neurology and Neurological Sciences, Stanford University, Stanford, California.
| | - Safwan Jaradeh
- Division of Autonomic Disorders, Department of Neurology and Neurological Sciences, Stanford University, Stanford, California
| | - Ann Ming Yeh
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Stanford University, Stanford, California
| | - Brenda Golianu
- Division of Pediatric Anesthesia and Pain Management, Department of Anesthesiology and Pain Medicine, Stanford University, Stanford, California
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23
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Statello R, Carnevali L, Alinovi D, Pisani F, Sgoifo A. Heart rate variability in neonatal patients with seizures. Clin Neurophysiol 2018; 129:2534-2540. [PMID: 30384023 DOI: 10.1016/j.clinph.2018.10.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 09/05/2018] [Accepted: 10/03/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Seizures are frequently observed in neurological conditions affecting newborns. Since autonomic alterations are commonly associated with neonatal seizures (NS), we investigated the utility of heart rate variability (HRV) indexes of cardiac autonomic regulation for NS detection. METHODS HRV analysis was conducted on ECG tracings recorded during video-EEG monitoring in newborns with NS and matched-controls. The effects of gestational age on HRV were also evaluated. RESULTS Newborns with NS showed lower resting state HRV compared to controls. Moreover, seizure episodes were characterized by a short-lasting increase in vagal indexes of HRV. Pre-term newborns with NS had a lower HRV than full-term at rest. In pre-term newborns, no changes in HRV were observed before and during NS. On the contrary, full-term newborns showed significantly higher HRV before and during NS compared to the respective baseline values. CONCLUSION Our data point to resting autonomic impairment in newborns with NS. In addition, an increment in HRV has been observed during NS only in full term newborns. SIGNIFICANCE Although these findings do not allow validation of HRV measures for NS prediction and detection, they suggest that a putative protective vagal mechanism might be adopted when an advanced maturation of autonomic nervous system is achieved.
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Affiliation(s)
- Rosario Statello
- Department of Chemistry, Life Sciences and Environmental Sustainability, Stress Physiology Lab, University of Parma, Italy
| | - Luca Carnevali
- Department of Chemistry, Life Sciences and Environmental Sustainability, Stress Physiology Lab, University of Parma, Italy
| | - Davide Alinovi
- Department of Engineering and Architecture, Information Engineering Unit, University of Parma, Italy
| | - Francesco Pisani
- Child Neuropsychiatry Unit, Neuroscience Unit, Department of Medicine and Surgery, University of Parma, Italy
| | - Andrea Sgoifo
- Department of Chemistry, Life Sciences and Environmental Sustainability, Stress Physiology Lab, University of Parma, Italy.
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24
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Sojka P, Bareš M, Kašpárek T, Světlák M. Processing of Emotion in Functional Neurological Disorder. Front Psychiatry 2018; 9:479. [PMID: 30344497 PMCID: PMC6182079 DOI: 10.3389/fpsyt.2018.00479] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 09/13/2018] [Indexed: 01/25/2023] Open
Abstract
Emotions have traditionally been considered crucial in the development of functional neurological disorder, but the evidence underpinning this association is not clear. We aimed to summarize evidence for association between functional neurological disorder and emotions as formulated by Breuer and Freud in their conception of hysterical conversion. Based on a systematic literature search, we identified 34 controlled studies and categorized them into four groups: (i) autonomic arousal, (ii) emotion-motion interactions, (iii) social modulation of symptoms, and (iv) bodily awareness in FND. We found evidence for autonomic dysregulation in FND; convergent neuroimaging findings implicate abnormal limbic-motor interactions in response to emotional stimuli in FND. Our results do not provide enough empirical evidence for social modulation of the symptoms, but there is a clinical support for the role of suggestion and placebo in FND. Our results provide evidence for abnormal bodily awareness in FND. Based on these findings, we propose that functional neurological symptoms are forms of emotional reactions shaped into symptoms by previous experience with illness and possibly reinforced by actual social contexts. Additional research should investigate the effect of social context on the intensity of functional neurological symptoms and associated brain regions.
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Affiliation(s)
- Petr Sojka
- Department of Neurology, Faculty of Medicine, Masaryk University and St Anne's University Hospital Brno, Brno, Czechia
| | - Martin Bareš
- Department of Neurology, Faculty of Medicine, Masaryk University and St Anne's University Hospital Brno, Brno, Czechia
- Department of Psychiatry, Faculty of Medicine, Masaryk University and University Hospital Brno, Brno, Czechia
| | - Tomáš Kašpárek
- Department of Neurology, Faculty of Medicine, Masaryk University and St Anne's University Hospital Brno, Brno, Czechia
- Department of Psychiatry, Faculty of Medicine, Masaryk University and University Hospital Brno, Brno, Czechia
| | - Miroslav Světlák
- Department of Neurology, Faculty of Medicine, Masaryk University and St Anne's University Hospital Brno, Brno, Czechia
- Department of Psychology and Psychosomatics, Faculty of Medicine, Masaryk University and University Hospital Brno, Brno, Czechia
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25
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Kananen J, Tuovinen T, Ansakorpi H, Rytky S, Helakari H, Huotari N, Raitamaa L, Raatikainen V, Rasila A, Borchardt V, Korhonen V, LeVan P, Nedergaard M, Kiviniemi V. Altered physiological brain variation in drug-resistant epilepsy. Brain Behav 2018; 8:e01090. [PMID: 30112813 PMCID: PMC6160661 DOI: 10.1002/brb3.1090] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 07/04/2018] [Accepted: 07/08/2018] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Functional magnetic resonance imaging (fMRI) combined with simultaneous electroencephalography (EEG-fMRI) has become a major tool in mapping epilepsy sources. In the absence of detectable epileptiform activity, the resting state fMRI may still detect changes in the blood oxygen level-dependent signal, suggesting intrinsic alterations in the underlying brain physiology. METHODS In this study, we used coefficient of variation (CV) of critically sampled 10 Hz ultra-fast fMRI (magnetoencephalography, MREG) signal to compare physiological variance between healthy controls (n = 10) and patients (n = 10) with drug-resistant epilepsy (DRE). RESULTS We showed highly significant voxel-level (p < 0.01, TFCE-corrected) increase in the physiological variance in DRE patients. At individual level, the elevations range over three standard deviations (σ) above the control mean (μ) CVMREG values solely in DRE patients, enabling patient-specific mapping of elevated physiological variance. The most apparent differences in group-level analysis are found on white matter, brainstem, and cerebellum. Respiratory (0.12-0.4 Hz) and very-low-frequency (VLF = 0.009-0.1 Hz) signal variances were most affected. CONCLUSIONS The CVMREG increase was not explained by head motion or physiological cardiorespiratory activity, that is, it seems to be linked to intrinsic physiological pulsations. We suggest that intrinsic brain pulsations play a role in DRE and that critically sampled fMRI may provide a powerful tool for their identification.
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Affiliation(s)
- Janne Kananen
- Department of Diagnostic Radiology, Medical Research Center, Oulu University Hospital, Oulu, Finland.,Oulu Functional NeuroImaging-Group, Research Unit of Medical Imaging, Physics and Technology, University of Oulu, Oulu, Finland
| | - Timo Tuovinen
- Department of Diagnostic Radiology, Medical Research Center, Oulu University Hospital, Oulu, Finland.,Oulu Functional NeuroImaging-Group, Research Unit of Medical Imaging, Physics and Technology, University of Oulu, Oulu, Finland
| | - Hanna Ansakorpi
- Research Unit of Neuroscience, Neurology, University of Oulu, Oulu, Finland.,Department of Neurology and Medical Research Center Oulu, Oulu University Hospital, Oulu, Finland
| | - Seppo Rytky
- Department of Clinical Neurophysiology, Medical Research Center Oulu, Oulu University Hospital, Oulu, Finland
| | - Heta Helakari
- Department of Diagnostic Radiology, Medical Research Center, Oulu University Hospital, Oulu, Finland.,Oulu Functional NeuroImaging-Group, Research Unit of Medical Imaging, Physics and Technology, University of Oulu, Oulu, Finland
| | - Niko Huotari
- Department of Diagnostic Radiology, Medical Research Center, Oulu University Hospital, Oulu, Finland.,Oulu Functional NeuroImaging-Group, Research Unit of Medical Imaging, Physics and Technology, University of Oulu, Oulu, Finland
| | - Lauri Raitamaa
- Department of Diagnostic Radiology, Medical Research Center, Oulu University Hospital, Oulu, Finland.,Oulu Functional NeuroImaging-Group, Research Unit of Medical Imaging, Physics and Technology, University of Oulu, Oulu, Finland
| | - Ville Raatikainen
- Department of Diagnostic Radiology, Medical Research Center, Oulu University Hospital, Oulu, Finland.,Oulu Functional NeuroImaging-Group, Research Unit of Medical Imaging, Physics and Technology, University of Oulu, Oulu, Finland
| | - Aleksi Rasila
- Department of Diagnostic Radiology, Medical Research Center, Oulu University Hospital, Oulu, Finland.,Oulu Functional NeuroImaging-Group, Research Unit of Medical Imaging, Physics and Technology, University of Oulu, Oulu, Finland
| | - Viola Borchardt
- Department of Diagnostic Radiology, Medical Research Center, Oulu University Hospital, Oulu, Finland.,Oulu Functional NeuroImaging-Group, Research Unit of Medical Imaging, Physics and Technology, University of Oulu, Oulu, Finland
| | - Vesa Korhonen
- Department of Diagnostic Radiology, Medical Research Center, Oulu University Hospital, Oulu, Finland.,Oulu Functional NeuroImaging-Group, Research Unit of Medical Imaging, Physics and Technology, University of Oulu, Oulu, Finland
| | - Pierre LeVan
- Faculty of Medicine, Department of Radiology - Medical Physics, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Maiken Nedergaard
- Center for Translational Neuromedicine, Department of Neurosurgery, University of Rochester, Rochester, New York.,Faculty of Health and Medical Sciences, Center for Basic and Translational Neuroscience, University of Copenhagen, Copenhagen, Denmark
| | - Vesa Kiviniemi
- Department of Diagnostic Radiology, Medical Research Center, Oulu University Hospital, Oulu, Finland.,Oulu Functional NeuroImaging-Group, Research Unit of Medical Imaging, Physics and Technology, University of Oulu, Oulu, Finland
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26
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Ghaderyan P, Abbasi A. Dynamic Hilbert warping, a new measure of RR-interval signals evaluated in the cognitive load estimation. Med Eng Phys 2017; 40:103-109. [PMID: 28100405 DOI: 10.1016/j.medengphy.2016.12.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Revised: 12/02/2016] [Accepted: 12/21/2016] [Indexed: 11/20/2022]
Abstract
RR interval (RRI) signals represent the time intervals between successive heart R-waves. These signals are influenced by many cognitive and psychological processes. In this study, a new technique based on the combination of empirical mode decomposition and dynamic Hilbert warping (DHW) was proposed to inference cognitive states from measured RRI signals. Moreover, a set of entropic and statistical measures was extracted to characterize the regularity and temporal distribution in the phase spectra and amplitude envelope of the analytic signals. The discriminating capability of the proposed method was studied in 45 healthy subjects. They performed an arithmetic task with five levels of difficulty. The study indicated the importance of phase information in cognitive load estimation (CLE). The new phase characteristics were able to extract hidden information from the RRI signals. The results revealed a striking decrease in DHW value with increasing load level. The entropic measures of analytic signal also showed an increasing trend as the mental load increased. Although, phase information had an ability to discriminate between more distinct levels as well as between more similar ones, amplitude information was effective only in discriminating between more distinct levels.
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Affiliation(s)
- Peyvand Ghaderyan
- Department of Biomedical Engineering, Computational Neuroscience Laboratory, Faculty of Electrical Engineering, Sahand University of Technology, Tabriz, Iran.
| | - Ataollah Abbasi
- Department of Biomedical Engineering, Computational Neuroscience Laboratory, Faculty of Electrical Engineering, Sahand University of Technology, Tabriz, Iran.
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27
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Reuber M, Brown RJ. Understanding psychogenic nonepileptic seizures—Phenomenology, semiology and the Integrative Cognitive Model. Seizure 2017; 44:199-205. [DOI: 10.1016/j.seizure.2016.10.029] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 10/25/2016] [Indexed: 12/20/2022] Open
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28
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Bajestan SN, LaFrance WC. Clinical Approaches to Psychogenic Nonepileptic Seizures. FOCUS: JOURNAL OF LIFE LONG LEARNING IN PSYCHIATRY 2016; 14:422-431. [PMID: 31975822 DOI: 10.1176/appi.focus.20160020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Psychogenic nonepileptic seizures (PNES) are a subtype of conversion disorder (also called functional neurological symptom disorder in DSM-5). Patients with PNES are high utilizers of health care and can have disability levels similar to those of patients with epilepsy. PNES is a common, complex neuropsychiatric somatoform disorder at the interface of neurology and psychiatry disciplines and is largely overlooked and avoided by mental health providers. Despite advances in establishing accurate diagnosis and evidence-based treatments, recent knowledge about PNES has not been well translated into clinical practice. Long diagnostic delays have been associated with poor prognosis. Recent advances in possible neurophysiological biomarkers include functional MRI studies that show abnormalities in emotional, cognitive, executive, and sensorimotor neurocircuits. Although the gold standard for diagnosis is video electroencephalograph, this test is underused by psychiatrists. The International League Against Epilepsy proposed a staged approach to PNES diagnosis using history, semiologic features, and EEG. Thorough psychiatric assessment can identify relevant biopsychosocial and predisposing, precipitating, and perpetuating factors, as well as assess the comorbid psychiatric disorders, which can inform a treatment plan. Clear and thoughtful delivery of diagnosis is the first step in treatment. Regular follow-up with the patient's neurologist, in addition to treatment by mental health professionals familiar with somatic symptom disorders, is recommended. Psychotherapy is the mainstay of treatment, and randomized clinical trials using cognitive-behavioral therapies reveal significant reduction in seizures and other psychiatric symptoms. After centuries, mental health providers now have access to the tools to diagnose and effectively treat PNES and other conversion disorders.
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Affiliation(s)
- Sepideh N Bajestan
- Dr. Bajestan is with the Neuropsychiatry Service, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California. Dr. LaFrance is with the Departments of Psychiatry and Neurology, Division of Neuropsychiatry and Behavioral Neurology, Rhode Island Hospital, Providence. Send correspondence to Dr. LaFrance (e-mail: )
| | - W Curt LaFrance
- Dr. Bajestan is with the Neuropsychiatry Service, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California. Dr. LaFrance is with the Departments of Psychiatry and Neurology, Division of Neuropsychiatry and Behavioral Neurology, Rhode Island Hospital, Providence. Send correspondence to Dr. LaFrance (e-mail: )
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29
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Brown RJ, Reuber M. Towards an integrative theory of psychogenic non-epileptic seizures (PNES). Clin Psychol Rev 2016; 47:55-70. [DOI: 10.1016/j.cpr.2016.06.003] [Citation(s) in RCA: 143] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 06/16/2016] [Accepted: 06/16/2016] [Indexed: 01/10/2023]
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30
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Maurer CW, Liu VD, LaFaver K, Ameli R, Wu T, Toledo R, Epstein SA, Hallett M. Impaired resting vagal tone in patients with functional movement disorders. Parkinsonism Relat Disord 2016; 30:18-22. [PMID: 27334304 DOI: 10.1016/j.parkreldis.2016.06.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 05/23/2016] [Accepted: 06/15/2016] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The autonomic nervous system plays an integral role in the maintenance of homeostasis during times of stress. The functioning of the autonomic nervous system in patients with functional movement disorders (FMD) is of particular interest given the hypothesis that converted psychological stress plays a critical role in FMD disease pathogenesis. We sought to investigate autonomic nervous system activity in FMD patients by examining heart rate variability (HRV), a quantitative marker of autonomic function. METHODS 35 clinically definite FMD patients and 38 age- and sex-matched healthy controls were hospitalized overnight for continuous electrocardiogram recording. Standard time and frequency domain measures of HRV were calculated in the awake and asleep stages. All participants underwent a thorough neuropsychological battery, including the Hamilton Anxiety and Depression scales and the Beck Depression Inventory. RESULTS Compared to controls, patients with FMD exhibited decreased root mean square of successive differences between adjacent NN intervals (RMSSD) (p = 0.02), a marker of parasympathetic activity, as well as increased mean heart rate (p = 0.03). These measures did not correlate with the depression and anxiety scores included in our assessment as potential covariates. CONCLUSION In this exploratory study, patients with FMD showed evidence of impaired resting state vagal tone, as demonstrated by reduced RMSSD. This decreased vagal tone may reflect increased stress vulnerability in patients with FMD.
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Affiliation(s)
- Carine W Maurer
- Human Motor Control Section, Medical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA.
| | - Victoria D Liu
- Human Motor Control Section, Medical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA.
| | - Kathrin LaFaver
- Human Motor Control Section, Medical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA; University of Louisville, Department of Neurology, Louisville, KY, USA.
| | - Rezvan Ameli
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA.
| | - Tianxia Wu
- Office of the Clinical Director, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA.
| | - Ryan Toledo
- Human Motor Control Section, Medical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA.
| | - Steven A Epstein
- Georgetown University, Department of Psychiatry, Washington, DC, USA.
| | - Mark Hallett
- Human Motor Control Section, Medical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA.
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