Health care utilization following diagnosis of psychogenic nonepileptic seizures

Level 4 seizure monitoring unit admissions are associated with reduced long-term health care costs

OBJECTIVE

This study was undertaken to determine whether admission to dedicated seizure monitoring units (SMUs) result in reduced health care use (HCU).

METHODS

This was a retrospective open cohort study covering the years 2010-2018 of patients residing in Alberta, Canada, who were referred to the Calgary Comprehensive Epilepsy Program and admitted to a level 4 SMU. Patients were required to have ≥3 years pre- and postadmission follow-up. The outcome was the change in trajectory of composite HCU (primary care, specialist outpatient visits, emergency department visits, and hospitalizations) for the 3 years prior to and 3 years following SMU admission using the point of admission as the "index date." Secondary outcomes were HCU limited to specific settings. We excluded the first 30 days following the point of admission to mitigate the confounding admission would have on the postadmission HCU trajectory. We used adjusted restricted maximum likelihood linear and nonlinear effects models to determine trajectories expressed as Canadian dollars.

RESULTS

A total of 315 of 600 (53%) patients met eligibility criteria. Mean age was 40 years (SD = 17.4), 176 (56%) were female, 220 (70%) had focal epilepsy, and 60 (19%) had functional seizures or physiologic seizure mimics without epilepsy as adjudicated by the attending physician at the point of discharge. Mean per person health care costs increased by CAD$341.28 (95% confidence interval [CI] = -25.17 to 707.74) for each successive 6-month interval prior to SMU admission (p = .07). Following admission, mean per person costs decreased by CAD$802.34 (95% CI = 699.62-905.06, p < .001) for each successive 6-month interval up to 3 years postdischarge. Similar trends were noted for primary and specialist care, emergency department, admitted care, and when nonlinear models were applied.

SIGNIFICANCE

Admission to an SMU is associated with significant and enduring declines in HCU. Each 6-months following discharge overall HCU declined by a mean of CAD$802.34 and acute inpatient, emergency department, and outpatient physician interactions declined by 25%, 26%, and 18% respectively. Comprehensive epilepsy care not only reduces morbidity and mortality but also reduces cost.

Ask the Patient: Goals for Functional seizure treatment

Treatment trials for functional seizure (FS) help improve functioning and reduce disability in affected individuals. Clinical trials have prioritized clinician-defined outcomes, but no studies have directly asked adults with FS what they hope to accomplish. This study examined patient-defined goals for treatment in a consecutive cohort of 826 adults with FS referred for outpatient treatment. Goals were reviewed and sorted into 6 categories with 32.5% of goals related to seizure management, 21.8% to abstract functional improvement, 20.3% to concrete functional improvement, 14.8% to seizure education, 10.1% to psychiatry tools, and 0.5% to Other. Although treatment trials have prioritized reduced event frequency as a primary outcome, people with FS most frequently prioritize goals for functional improvement. Data suggests that rehabilitation metrics of FS treatment outcome may be just as, or more important to adults with FS than what medical providers prioritize for outcome success. Study findings have implications for how to define FS treatment success and suggest equal prioritization of patient-centered goals to medically-defined goals in trial design.

Pain and functional neurological disorder: a systematic review and meta-analysis

BACKGROUND

Functional neurological disorder (FND) is characterised by neurological symptoms, such as seizures and abnormal movements. Despite its significance to patients, the clinical features of chronic pain in people with FND, and of FND in people with chronic pain, have not been comprehensively studied.

METHODS

We systematically reviewed PubMed, Embase and PsycINFO for studies of chronic pain in adults with FND and FND in patients with chronic pain. We described the proportions of patients reporting pain, pain rating and timing, pain-related diagnoses and responsiveness to treatment. We performed random effects meta-analyses of the proportions of patients with FND who reported pain or were diagnosed with pain-related disorders.

RESULTS

Seven hundred and fifteen articles were screened and 64 were included in the analysis. Eight case-control studies of 3476 patients described pain symptoms in a higher proportion of patients with FND than controls with other neurological disorders. A random effects model of 30 cohorts found that an estimated 55% (95% CI 46% to 64%) of 4272 patients with FND reported pain. Random effects models estimated diagnoses of complex regional pain syndrome in 22% (95% CI 6% to 39%) of patients, irritable bowel syndrome in 16% (95% CI 9% to 24%) and fibromyalgia in 10% (95% CI 8% to 13%). Five studies of FND diagnoses among 361 patients with chronic pain were identified. Most interventions for FND did not ameliorate pain, even when other symptoms improved.

CONCLUSIONS

Pain symptoms and pain-related diagnoses are common in FND. Classification systems and treatments should routinely consider pain as a comorbidity in patients with FND.

Outcome of psychogenic non-epileptic seizures following diagnosis in the epilepsy monitoring unit

Objective

To study the outcome of patients with psychogenic non-epileptic seizures (PNES) after their diagnosis in the epilepsy monitoring unit (EMU).

Methods

Patients diagnosed in our EMU with definite PNES between January 2009 and May 2023 were contacted by phone, and those who agreed to participate were asked a set of predetermined questions. Comparative analyses were carried out on several variables before and after diagnosis: number of participants with daily PNES, number of visits to the emergency department, number of participants who consulted their general practitioner or a neurologist outside of a scheduled follow-up, number of participants who took antiseizure medications (ASMs) or psychotropic drugs, and employment status.

Results

Out of the 103 patients with a definite diagnosis of PNES, 61 patients (79% female) accepted to participate in our study. The median age at PNES onset was 35 years, and the median delay to diagnosis was 3 years. Almost two-thirds (62%) were receiving ASMs and 40% psychotropic drugs. The mean stay at the EMU was 5 days. PNES diagnosis was explained to almost all patients (97%) by the end of their EMU stay and was well-accepted by most (89%). When contacted, 46% of participants no longer had PNES; 32% mentioned that their PNES had ceased immediately upon communication of the diagnosis. The median follow-up duration was 51 months. Fewer patients had daily seizures after the diagnosis (18 vs. 38%; p < 0.0455). Similarly, the median number of emergency department visits was significantly lower (0 vs. 2; p < 0.001). Only 17 patients consulted their general practitioner (vs. 40, p < 0.001) and 20 a neurologist (vs. 55, p < 0.001) after a PNES attack outside of a scheduled follow-up. The use of ASMs was also significantly reduced from 70 to 33% (p < 0.01), with only one still taking an ASM for its antiseizure properties. Significantly more participants were working at last follow-up than at PNES diagnosis (49 vs. 25%; p < 0.001).

Conclusion

Our study revealed a relatively favorable long-term outcome of definite PNES diagnosed in the EMU that translated in significant reductions in PNES frequency, health care utilization and ASM use, as well as a significant increase in employment rate.

Multidisciplinary Care for Pediatric Patients With Psychogenic Nonepileptic Seizures May Be Associated With Decreased Health Care Utilization

Background and Objectives

Psychogenic nonepileptic seizures (PNES) are paroxysmal events that resemble epileptic seizures but have psychological underpinnings. Patients with PNES have high health care utilization. We hypothesize that appropriate care would lead to decreases in utilization. The aim of this study was to measure the impact of a multidisciplinary PNES clinic in reducing health care utilization (HCU) in youth with PNES referred to the clinic.

Methods

We reviewed the frequency of visits to the emergency department (ED), urgent care (UC), planned and unplanned hospitalizations, neurodiagnostic studies, and total charges associated with these encounters 12 months before and 12 months after initial referral to the clinic. Manual chart review of all patients referred from November 2017 to March 2020 was performed.

Results

Two hundred and twelve unique patients were included in this retrospective study. Patient sex was identified as 71% female, 28% male, and 1% other, with an average age of 14 years at diagnosis. These patients visited the ED a total of 410 times before being seen in the PNES clinic, which decreased to 187 visits after (75% reduction). All measures of HCU decreased in the 12 months after the visit, and statistically significant differences were observed in all measures of HCU except for head MRIs, leading to an estimated potential cost savings of $7,978,447.

Discussion

Patients with PNES were found to have decreased health care utilization in the 12 months after referral to the Nationwide Children's Hospital multidisciplinary clinic, including significant decreases in emergency services and unnecessary diagnostic testing, in the 12 months after the referral.

Health Care Utilization in Functional Neurologic Disorders: Impact of Explaining the Diagnosis of Functional Seizures on Health Care Costs

Background and Objective

The objectives of this study were to investigate health care utilization costs of patients with video-electroencephalography (VEEG)-confirmed functional seizures (FS), determine whether patients who received a satisfactory functional neurologic disorder (FND) diagnosis explanation had reduced health care utilization compared with those with a poor explanation; and to quantify the overall health care costs 2 years prediagnosis and postdiagnosis for those receiving a different explanation.

Methods

Patients with VEEG-confirmed pure FS (pFS) or mixed (functional seizure plus epileptic seizures) diagnosis between July 1, 2017, and July 1, 2019, were evaluated. Explanation of the diagnosis was determined "unsatisfactory" or "satisfactory" using self-developed criteria, and health care utilization data were collected using an itemized list. The subsequent costs 2 years post-FND diagnosis were compared with those 2 years before, and cost outcomes were compared between both groups.

Results

In patients who received a satisfactory explanation (n = 18), total health care costs were reduced from $169,803 to $117,133 USD (-31%). An increase in costs was found ($73,430 to $186,553 USD = +154%) in patients with pPNES after an unsatisfactory explanation (n = 7). On an individual level, 78% with a satisfactory explanation saw a reduction in total health care costs per year (mean $5,111 USD to $1,728 USD), and in 57%, an unsatisfactory explanation led to an increase (mean $4,425 to $20,524 USD). A similar effect was seen from explanation on patients with a dual diagnosis.

Discussion

The method of communicating an FND diagnosis has a significant impact on subsequent health care utilization. Those receiving satisfactory explanations demonstrated reduced health care utilization, whereas an unsatisfactory explanation resulted in additional expenses.

Diagnosis and management of functional neurological disorder

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

Emergency department visits and readmissions in patients with psychogenic nonepileptic seizures (PNES) at a safety net hospital

INTRODUCTION

Readmissions and emergency department (ED) visits after an index admission have been become a quality measure due to associations with poor outcomes and increased healthcare costs. Readmissions and ED encounters have been studied in a variety of conditions including epilepsy but have not been examined exclusively in psychogenic nonepileptic seizures (PNES). In this study we examined the rate of readmissions and ED visits after a discharge from an Epilepsy Monitoring Unit (EMU) in a safety net hospital. We also determined patient phenotypes that are associated with readmissions.

MATERIAL AND METHODS

This was a retrospective chart review study with index admission being a discharge from an EMU between January 1 and December 31 2016 with follow-up until August 31 2020. We obtained data regarding demographics, medical and psychiatric history, and social history and treatment interventions. Our outcome variables were both all-cause and seizure-related hospital readmissions and ED visits 30 days following the index discharge and readmissions and ED visits 30 days thereafter.

RESULTS

Eleven of 122 patients (9%) had a non-seizure-related ED visit and/or hospitalization within 30 days of index discharge while 45 (37%) had re-contact with the health system thereafter for non-seizure-related issues. Seven of 122 patients (6%) had a seizure-related ED visit or hospital readmission within 30 days of discharge. Twenty-eight (23%) had a seizure-related readmission or ED visit after 30 days. Of these 28, 4 patients had been to an ER within 7 days of EMU discharge. The majority of subsequent encounters with the healthcare system were through the ED (n = 38) as compared to hospital (n = 10) and EMU readmissions (n = 9). On bivariate statistical analysis, charity or self-pay insurance status (p < 0.01), homelessness (p < 0.01), emergent EMU admission on index admission (p < 0.01), history of a psychiatric diagnosis (p < 0.02), and ED encounters 12 months prior to admission (p < 0.01) were significantly associated with readmission; however, on multivariate analysis only charity insurance status was a significant predictor.

CONCLUSIONS

In this study of readmissions and ED visits after discharge with a diagnosis of PNES at a safety net hospital, we found a seizure-related readmission rate of approximately 6% in 30 days and 23% thereafter with the majority of re-contact with the hospital being in the ED. On multi-variate analysis insurance status was a significant factor associated with readmission and ED visits. Our future research directions include examining referrals and treatment completion at the hospital's PNES clinic as well as creating a risk score to better identify patients with PNES at risk of readmission.

Psychogenic non-epileptic seizures in children

Psychogenic Non-Epileptic Seizures (PNES) are a relatively common condition in children. While their clinical presentation resembles epileptic seizures, the underlying cause for PNES involves a multitude of bio-psychosocial factors. Patients may be misdiagnosed with epilepsy and subjected to unnecessary treatments, often delaying the diagnosis for years. A strong understanding of its symptomatology is essential for diagnosis of PNES. Successful management depends on effective teamwork that involves the neurologist as well as mental health professionals. This paper reviews the various aspects of PNES in children with emphasis on the clinical presentation, diagnosis as well as the underlying psychological basis and treatment.

Examination of Potential Differences in Reporting of Sensitive Psychosocial Measures via Diagnostic Evaluation Using Computer Video Telehealth

OBJECTIVE

The authors compared baseline characteristics and reporting of psychosocial measures among veterans with seizures who were evaluated in-clinic or remotely via computer video telehealth (CVT). It was hypothesized that the CVT group would report less trauma history, drug use, and comorbid symptoms compared with veterans seen in-clinic.

METHODS

A cross-sectional design was used to compare 72 veterans diagnosed with psychogenic nonepileptic seizures (PNES) or concurrent mixed epilepsy and PNES who were consecutively evaluated by a single clinician at the Providence Veterans Affairs Medical Center (PVAMC) Neuropsychiatric Clinic. In-clinic evaluations of veterans were performed at the PVAMC Neuropsychiatric Clinic (N=16), and remote evaluations of veterans referred to the VA National TeleMental Health Center were performed via CVT (N=56). All 72 patients were given comprehensive neuropsychiatric evaluations by direct interview, medical examination, and medical record review. Veterans' reporting of trauma and abuse history, drug use, and psychiatric comorbidities was assessed, along with neurologic and psychiatric variables.

RESULTS

No significant differences were found between veterans evaluated in-clinic or remotely with regard to baseline characteristics and reporting of potentially sensitive information, including trauma and abuse history, substance use, and comorbid symptoms.

CONCLUSIONS

Veterans with PNES evaluated via telehealth did not appear to withhold sensitive or personal information compared with those evaluated in-clinic, suggesting that CVT may be a comparable alternative for conducting evaluations. Baseline evaluations are used to determine treatment suitability, and telehealth allows clinicians to gain access to important information that may improve or inform care.

Medical and psychosocial outcomes of youth with psychogenic nonepileptic seizures: An observational study

BACKGROUND

Few studies have examined both medical and psychosocial outcomes of youth with psychogenic nonepileptic seizures (PNES). The current observational study aimed to fill this gap by examining changes in seizure frequency, school absences, emergency department (ED) visits, psychological functioning, and health-related quality of life (HRQoL) in youth attending a clinic for brief treatment of PNES.

METHODS

Nineteen youth with PNES and their families presented to an integrated clinic and received psychoeducation and recommendations by medical and mental health professionals. Patients returned to the clinic, on average six months later, for follow-up. Parent proxy-report and self-report measures of psychological functioning and HRQoL were collected at each visit, and medical data were extracted from patient charts.

RESULTS

Forty-six percent of youth in the study experienced a reduction in seizure frequency, and 58% reported improvements in school attendance. Emergency department visits decreased by over 50%, and significant improvements in parent proxy-report of depression and HRQoL were observed.

CONCLUSIONS

Results provide valuable information regarding the clinical profiles of youth with PNES and demonstrate the possibility for improved medical and psychosocial prognoses in response to psychoeducation and treatment guidance. Information obtained in this study may aid in the design of future clinical trials and research, assisting in the development of appropriate interventions.

Outcomes in Children and Adolescents With Psychogenic Nonepileptic Events Using a Multidisciplinary Clinic Approach

BACKGROUND

Psychogenic nonepileptic events (PNEE) are paroxysmal events that resemble epileptic seizures but are caused by psychological factors. Coordination of care has been recommended as one strategy to integrate care and improve outcomes. We aim to evaluate patient outcomes in a multidisciplinary pediatric psychogenic nonepileptic events clinic that includes care coordination.

METHODS

All patients referred to the multidisciplinary psychogenic nonepileptic events clinic were entered into a prospective database. Follow-up calls were made by the clinic nurse at 1 and 3 months following the visit.

RESULTS

A total of 101 unique patients were reviewed. Ninety-six appointments were scheduled, and 83 appointments were completed (86%). Social work identified barriers in 38 patients, and 76% of those assisted completed their appointment. At 1 month, two-thirds of families were reached, 50% were accepting of the diagnosis, and 70% had clinical improvement in events. By 3 months, 75% had clinical improvement, 76% were receiving mental health services, and 73% were accepting of the diagnosis; however, more had also returned to the emergency department. Families needing assistance from social work tended to have worse outcomes. Increase in acceptance was nearly statistically significant (P = .058) from 1 to 3 months; however, it was not so for clinical improvement in events (P = .623).

CONCLUSIONS

Implementation of a multidisciplinary team with care coordination allowed for follow-up for children and adolescents with psychogenic nonepileptic events and mitigation of barriers to care and can improve clinical outcomes. After being seen in our clinic, many families had accepted the diagnosis, most of the patients reached had event improvement and were successfully linked with counseling at the 1- and 3-month follow-ups.

Clinical characteristics of video-EEG patients: Limited utility of prolonging VEEG study duration beyond 5 days for spell classification

OBJECTIVE

The objective of the study was to identify the probability of establishing a diagnosis based on the duration of video-electroencephalogram (VEEG) monitoring. Additional aims were to determine whether there is a relationship between clinical characteristics of epilepsy monitoring unit (EMU) patients and VEEG results.

METHODS

We studied EMU length of stay and assessed the utility of prolonging studies in patients who had not yet received a diagnosis. Clinical characteristics in 212 consecutive patients admitted for scalp VEEG monitoring were recorded. We collected data including reason for admission, frequency of seizures/spells, gender, age, age at seizure onset, handedness, family history, history of neurologic disease, current and past antiepileptic drugs (AEDs), and prior work-up. Subjects were categorized into five diagnostic groups: epileptic seizures (Epi), nonepileptic events (NEE), mixed epileptic and nonepileptic events (Mixed), nonepileptic events from a physiologic cause (NEEP), and nondiagnostic study without results recorded (ND).

RESULTS

The most diagnoses were made during the first day of admission (45%), and by day 3, 82 patients remained without a diagnosis. On day 3, 25 of these patients (33%) received a diagnosis, on day 4, seven (22%) additional patients received a diagnosis, on day 5, 5 patients (35%) received a diagnosis, and by day 6, only one additional patient (11%) was given a diagnosis. Significant differences were found between diagnostic groups for admission reason, duration of EMU stay, age at seizure onset, duration of epilepsy, seizure frequency, and number of current and previously tried AEDs.

CONCLUSIONS

Our findings show that the majority of patients are diagnosed in the first 2 days of admission, and we found a limited benefit of prolonging nonsurgical inpatient VEEG studies beyond 5 days for spell/seizure classification. Additionally, patient demographics were significantly different for patients depending on VEEG diagnosis, which can help predict the utility of completing VEEG studies in individual patients.

Psychogenic nonepileptic seizures treated with psychotherapy: Long-term outcome on seizures and healthcare utilization

Psychogenic nonepileptic seizures (PNES) are known to be associated with significant costs of healthcare services. Here, we report the impact of psychotherapy on behavior surrounding healthcare utilization and the potential economic benefits associated with long-term seizure control.

METHODS

This retrospective study describes patients seen between 2010 and 2016 at the epilepsy clinic at Glostrup University Hospital in Denmark and offered a psychotherapeutic treatment program for PNES. Forty-two patients were interviewed about seizure outcome 12-24 months after psychotherapy, and the annual changes in healthcare utilization and associated costs of services provided in a period of 24 months before and up to 24 months after treatment were compared.

RESULTS

At 12-month follow-up, 83% of the patients had achieved above 50% reduction in seizures. The 24-month pretreatment costs compared with the 24-month posttreatment costs directly associated with seizures dropped by 95.8%, and total healthcare costs were reduced by 63%. Estimation of annual savings from the program comes to 1060 € per patient. An association was found between seizure rate and number of healthcare contacts.

CONCLUSION

This study adds to the evidence that psychotherapy is a cost-effective way of treating PNES. The economic benefits from this form of intervention appear not only to diminish costs directly associated with PNES, but also healthcare utilization in general.

Welfare consequences for people diagnosed with nonepileptic seizures: A matched nationwide study in Denmark

OBJECTIVE

We aimed to evaluate the excess direct and indirect costs associated with nonepileptic seizures.

METHODS

From the Danish National Patient Registry (2011-2016), we identified 1057 people of any age with a diagnosis of psychogenic nonepileptic seizures (PNESs) and matched them with 2113 control individuals. Additionally, 239 partners of patients with PNES aged ≥18 years were identified and compared with 471 control partners. Direct costs included frequencies and costs of hospitalizations and outpatient use weighted by diagnosis-related group, and specific outpatient costs based on data from the Danish Ministry of Health. The use and costs of drugs were based on data from the Danish Medicines Agency. The frequencies of visits and hospitalizations and costs of general practice were derived from National Health Security data. Indirect costs included labor supply-based income data, and all social transfer payments were obtained from Coherent Social Statistics.

RESULTS

A higher percentage of people with PNES and their partners compared with respective control subjects received welfare benefits (sick pay, disability pension, home care). Those with PNES had a lower employment rate than did controls for equivalent periods up to three years before the diagnosis was made. The additional direct and indirect annual costs for those aged ≥18 years, including transfers to patients with PNES, compared with controls, were €33,697 for people with PNES and €15,121 for their partners.

SIGNIFICANCE

Psychogenic nonepileptic seizures have substantial socioeconomic consequences for individual patients, their partners, and society.

Morbidity and mortality of nonepileptic seizures (NES): A controlled national study

Nonepileptic seizures (NES, psychogenic NES-PNES) are associated with significant morbidities. We evaluated the morbidities and mortality in a national group of children, adolescent, and adult patients before and after a first diagnosis of PNES.

METHODS

From the Danish National Patient Registry (1998-2013), we identified 1057 people of all ages with a diagnosis of NES and matched them with 2113 control individuals by age, gender, and geography. Comorbidities were calculated three years before and after diagnoses.

RESULTS

Patients with PNES showed increased comorbidities 3 years before and after diagnosis in almost all the diagnostic domains. The strongest associations were identified with other neurological diseases (after diagnosis, Hazard Ratio (HR): 38.63; 95% Confidence Interval (CI): 21.58-69.13; P < 0.001), abnormal clinical and laboratory findings (HR: 46.59; 95 CI: 27.30-79.52; P < 0.001), other health-related factors (HR: 12.83; 95%CI: 8.45-19.46; P < 0.001), and psychiatric comorbidities (HR: 15.45; 95% CI: 9.81-24.33). Epilepsy was identified in 8% of the patients with PNES. We found especially frequent comorbidity involving overweight, depression, anxiety, dissociative somatoform condition, other convulsions, lipothymias, reports of pain and other symptoms in several organ systems, and several reports of minimal traumas to the head, trunk, and extremities. Mortality was higher in patients with NES than in controls (HR: 3.21; 95% CI: 1.92-5.34; P < 0.001).

CONCLUSION

Morbidity is more frequent in several domains, including neurological, psychiatric, and other diseases, before and after a diagnosis of NES. Mortality is significantly higher in patients with PNES as compared to controls.

Structural alterations in functional neurological disorder and related conditions: a software and hardware problem?

Functional neurological (conversion) disorder (FND) is a condition at the interface of neurology and psychiatry. A "software" vs. "hardware" analogy describes abnormal neurobiological mechanisms occurring in the context of intact macroscopic brain structure. While useful for explanatory and treatment models, this framework may require more nuanced considerations in the context of quantitative structural neuroimaging findings in FND. Moreover, high co-occurrence of FND and somatic symptom disorders (SSD) as defined in DSM-IV (somatization disorder, somatoform pain disorder, and undifferentiated somatoform disorder; referred to as SSD for brevity in this article) raises the possibility of a partially overlapping pathophysiology. In this systematic review, we use a transdiagnostic approach to review and appraise the structural neuroimaging literature in FND and SSD. While larger sample size studies are needed for definitive characterization, this article highlights that individuals with FND and SSD may exhibit sensorimotor, prefrontal, striatal-thalamic, paralimbic, and limbic structural alterations. The structural neuroimaging literature is contextualized within the neurobiology of stress-related neuroplasticity, gender differences, psychiatric comorbidities, and the greater spectrum of functional somatic disorders. Future directions that could accelerate the characterization of the pathophysiology of FND and DSM-5 SSD are outlined, including "disease staging" discussions to contextualize subgroups with or without structural changes. Emerging neuroimaging evidence suggests that some individuals with FND and SSD may have a "software" and "hardware" problem, although if structural alterations are present the neural mechanisms of functional disorders remain distinct from lesional neurological conditions. Furthermore, it remains unclear whether structural alterations relate to predisposing vulnerabilities or consequences of the disorder.

Sibling-Controlled Study of Parental Bonding, Coping, and Urgent Health-Care Use in Families With Children With Nonepileptic Seizures

Objectives

Pediatric psychogenic nonepileptic seizures (PNES) is a functional somatic symptom condition with significant health-care service burden. While both family and individual factors play an important role in the development and maintenance of PNES, little is known about what predicts urgent health-care use in families with children who have PNES. The aim of the current study was to explore whether child coping and parental bonding styles influence the decision to seek urgent medical care in these families.

Methods

Data were analyzed from youth of age 8-18 years, 47 with PNES, and their 25 sibling controls. Parents provided the number of youth emergency room visits and hospitalizations in the preceding year. Youth completed a questionnaire about their coping styles and a measure about their mothers' and fathers' bonding styles. Using a mixed model with family as a random effect, we regressed urgent health-care use on participant type (youth with PNES or sibling), parental bonding style, and youth coping style, controlling for number of child prescription medications.

Results

Higher urgent health-care use was associated with having PNES, coping via monitoring, and perceiving one's father to be rejecting and overprotective. Lower urgent health-care use was associated with coping via venting and with perceiving one's mother to be caring and overprotective.

Conclusions

This study provides preliminary empirical support for family-based clinical efforts to reduce child urgent health-care use by enhancing effective child coping skills and improving parental response to child impairment and distress in families with youth with PNES.

Psychogenic non-epileptic seizures among patients with functional neurological disorder: A case series from a Tanzanian referral hospital and literature review

Objective

Functional neurological disorders (FNDs) and psychogenic nonepileptic seizures (PNES) are likely as common in Sub-Saharan Africa (SSA) as in the rest of the world, but there is a dearth of literature on the epidemiology and clinical presentation of these disorders in Africa. The purpose of this paper is to describe a case series of FNDs presenting to a referral hospital in SSA. In addition, we review the existing literature on FNDs in Africa.

Methods

A hospital-based retrospective cross-sectional study was conducted to determine the prevalence, epidemiology, and clinical phenotype of FNDs and PNES in a referral hospital in Northern Tanzania over a 6-year period (2007-2013).

Results

Of 2,040 patients presenting with neurological complaints, 44 (2.2%) were diagnosed with FNDs. Half (n = 22) had the clinical presentation of PNES. Age of presentation for FNDs and PNES peaked in the teen years 12-19 (n = 21 48%; and n = 14, 63%, respectively), and the majority were female (n = 30, 68%; and n = 14, 63%, respectively). The majority presented acutely with short-lived and self-limiting symptoms (only 2 recurrent cases). Literature review revealed multiple reports of "mass hysteria" in SSA often meeting the clinical criteria of epidemic FNDs.

Significance

FNDs and PNES occur in Africa with age and gender distribution comparable to that found elsewhere. Although the percentage of FND cases overall was relatively low (2.2%), it is likely to be an underestimate because not all cases were recorded, and cases may be appropriately managed locally before patients are referred to a hospital. PNES was the most common phenotype of FNDs reported, and the African phenotype may be short-lived and self-limiting rather than chronic and recurrent, as reported elsewhere in the world. PNES presentations may also occur in clusters, which may have cultural significance in Africa. FNDs in Africa appear to be underreported, particularly over the last 30 years.

An Overview of Psychogenic Non-Epileptic Seizures: Etiology, Diagnosis and Management

The purpose of this review is to provide an update of the research regarding the etiology, diagnosis and management of psychogenic non-epileptic seizures (PNES). A literature search using Pubmed, Ovid MEDLINE and EMBASE database was performed from 2000 up to August 2017. We have evaluated the different factors leading to PNES as well as the diagnostic approach and management of this disorder which continue to be very difficult. The coexistence of epilepsy and PNES poses special challenges and requires the coordinated efforts of the family physicians, psychiatrists, psychologists and neurologists. Although this condition has an overall poor prognosis, a multidisciplinary approach in the diagnosis and management of this disorder would likely improve the outcomes. We have proposed a diagnostic and treatment algorithm for PNES and suggested a national registry of patients suffering from this condition. The registry would contain data regarding treatment and outcomes to aid in the understanding of this entity.

Postdiagnosis neurological care for patients with psychogenic nonepileptic spells (PNES)

OBJECTIVE

This study investigated continuity of neurological care for patients discharged from the epilepsy monitoring unit (EMU) with a diagnosis of psychogenic nonepileptic spells (PNES). Because PNES are seizure-like episodes that cannot be explained by abnormal electrical brain activity, they are challenging for patients to understand and accept. Consequently, after diagnosis, patients commonly fail to start recommended psychotherapy and instead pursue redundant medical care. As consistent relationships with healthcare providers may help, we instituted standard follow-up for patients diagnosed with PNES.

METHODS

We performed a retrospective observational cohort study of adults diagnosed with PNES in our EMU. In November 2013, we began routine scheduling of postdischarge follow-up neurology appointments. We compared preintervention (November 2010-October 2013) and postintervention (November 2013-May 2016) cohorts with regard to clinic attendance, understanding the diagnosis, compliance with recommendations, and event frequency.

RESULTS

We identified 55 patients in the preintervention cohort and 123 patients in the postintervention cohort. We successfully implemented the intended practice changes; more patients had follow-up scheduled by discharge (preintervention 2% vs. postintervention 36%, p<0.001), time to follow-up decreased (46days vs. 29, p=0.001), and providers more consistently queried understanding of diagnosis (38% vs. 67%, p=0.03). Explicit planning for continued care did not produce the anticipated patient-provider relationships, as follow-up in clinic was low (38% vs. 37%). For patients who attended clinic, the intervention did not improve establishment of psychiatric care, compliance with medication recommendations, understanding of diagnosis, or event frequency. The odds of reduced event frequency were nonsignificantly increased with understanding the diagnosis (OR 3.75, p=0.14). Recommending antiepileptic drug (AED) discontinuation was associated with increased odds of event freedom (OR 6.91, p<0.01).

SIGNIFICANCE

Scheduling follow-up for patients diagnosed with PNES did not facilitate ongoing patient-provider relationships due to poor clinic attendance. As follow-up is unreliable, the inpatient visit is a critical window of opportunity for intervention.