Sleep in psychogenic nonepileptic seizures: Time to raise a red flag

Sleep disorders in functional neurological disorder - a systematic review and meta-analysis

INTRODUCTION

Functional neurological disorders (FND) are conditions marked by disruptions in brain network function without structural abnormalities. Sleep disturbances, though under-researched, are commonly observed in FND patients and may worsen symptoms and overall health.

METHODS

This systematic review had been registered prospectively in PROSPERO with the registration number: CRD42023446306. Search of PubMed, MEDLINE, Embase, and Cochrane databases identified 218 articles. After removing duplicates and applying exclusion criteria, 9 studies were included in the final analysis.

RESULTS

The analysis showed a significant prevalence of sleep disorders among FND patients, with 58% reporting sleep disturbances, similar to other neuropsychiatric conditions. Studies on psychogenic non-epileptic seizures (PNES) indicated poorer subjective sleep quality and higher insomnia rates compared to epilepsy controls. Limited data on specific measures such as wake after sleep onset (WASO) and Epworth Sleepiness Scale (ESS) scores prevented definitive conclusions.

DISCUSSION

This review is the first systematic examination of sleep disorders in FND. The findings reveal a high prevalence of sleep disturbances, especially among PNES patients, correlating with lower quality of life and increased symptom severity. However, the heterogeneity of studies and limited reporting of specific sleep metrics weaken these conclusions. Further research is needed to investigate the direct impact of sleep quality on FND pathogenesis and management.

CONCLUSION

Sleep disturbances are prevalent in FND patients and can significantly affect their quality of life. Increased awareness and routine evaluation of sleep in FND patients are recommended. Future studies should explore the relationship between sleep deprivation and FND to develop targeted therapeutic interventions.

Prevalence of posttraumatic stress disorder in adults with epilepsy: A meta-analysis

Many studies highlight the increased risk of posttraumatic stress disorder (PTSD) in people with epilepsy (PWE). Despite the presence of significant research focusing on PTSD in PWE, the methodologies and results of these studies are heterogenous. Therefore, we aim to synthetize the literature and assess the prevalence of PTSD in PWE. We conducted a systematic literature to calculate a pooled prevalence of PTSD in adults with epilepsy. If the studies included patients with functional/dissociative seizure (FDS), a pooled prevalence of PTSD was also calculated for this group. The literature search yielded 10,732 articles, of which 38 studies met our inclusion criteria. High heterogeneity in PTSD prevalence estimates was found across studies for both epilepsy (I2= 97.0 %) and FDS (I2 = 90.7 %). The pooled prevalence of PTSD among the epilepsy group (n = 5545) was 7.7 % [95 % CI: 5.2 %; 11.2 %], whereas for the FDS group (n = 1409), it was 33.4 % [95 % CI: 23.4 %; 45.2 %]. Our sensitivity analysis, including only studies with semi-structured interviews and validated questionnaires, found a pooled PTSD prevalence of 6.7 % [95 % CI: 4.3 to 10.3] in epilepsy patients and 33.1 % [95 % CI: 21.8 to 46.8] in FDS patients. Our study underscores the importance of systematically evaluating traumatic experiences as using standardized, validated scales combined with structured clinical interviews for PTSD diagnosis.

Hypertension and other vascular risk factors in patients with functional seizures

OBJECTIVE

Recent literature has suggested that functional seizures are associated with an elevated risk for vascular disease and mortality. We investigated the prevalence of risk factors for vascular disease in patients who were admitted to the epilepsy monitoring unit.

METHODS

Patients who were admitted to the epilepsy monitoring unit and received a definitive diagnosis of either functional seizures or epilepsy were identified. Data collected included demographic, clinical characteristics, medication list, comorbidities, and scheduled blood pressure measurements that occurred every 12 h during the admission. The mean blood pressures were calculated and if they were above the American College of Cardiology and the American Heart Association guideline cutoff of 130/80 mm Hg or the patient had a documented history of hypertension the patient was counted as having the condition. A multiple logistic regression model was developed to evaluate the independent association of the patient's diagnosis (i.e., epilepsy or functional seizures) and vascular risk factors that controlled for the number of blood pressure measurements, age, sex, and if the patient was taking antihypertensive medications.

RESULTS

270 patients were included in this study of which 147 patients had epilepsy and 123 had functional seizures. Among those with functional seizures, 57.72 % had either a history of hypertension or a mean blood pressure above 130/80 compared to 38.78 % of those with epilepsy (p = 0.0022). In addition, 30.89 % of functional seizures patients had hyperlipidemia and 63.41 % were obese. The logistic regression model indicated that functional seizures were independently associated with high blood pressure (OR: 2.47, 95 % CI 1.10-5.69), hyperlipidemia (OR: 3.38, 95 % CI 1.35-8.86), and obesity (OR: 4.25, 95 % CI 2.22-8.36) compared to those with epilepsy. There was no significant difference in the prevalence of diabetes (OR: 0.81, 95 % CI 0.24-2.77) or current tobacco use (OR: 1.04, 95 % CI 0.48-2.25) between the groups.

SIGNIFICANCE

Patients with functional seizures had an elevated prevalence of several vascular risk factors. These findings may partially account for complications associated with functional seizures and have implications related to their pathophysiology.

Psychiatric and psychological assessment of Spanish patients with drug-resistant epilepsy and psychogenic nonepileptic seizures (PNES) with no response to previous treatments

OBJECTIVE

Psychogenic nonepileptic seizures (PNES) are common imitators of epileptic seizures. Refractoriness to antiseizure medication hinders the differential diagnosis between ES and PNES, carrying deleterious consequences in patients with PNES. Psychiatric and psychological characteristics may assist in the differential diagnosis between drug-resistant epilepsy (DRE) and PNES. Nevertheless, current comprehensive psychiatric and psychological descriptive studies on both patient groups are scarce and with several study limitations. This study provides a comprehensive psychiatric and psychological characterization of Spanish patients with DRE and PNES.

METHOD

A cross-sectional and comparative study was completed with 104 patients with DRE and 21 with PNES. Psychiatric and psychological characteristics were assessed with the HADS, SCL-90-R, NEO-FFI-R, PDQ-4+, COPE, and QOLIE-31 tests. Parametric and non-parametric tests were used, and regression models were fit to further explore factors affecting patients' life quality.

RESULTS

Patients with PNES had greater levels of somatization and extraversion and were associated with benzodiazepine intake. Patients with DRE showed greater narcissistic personality disorder symptoms than those with PNES. In patients with DRE, difficulty in performing basic needs-related tasks and greater psychological distress severity and seizure frequency were associated with poorer life quality. In contrast, being a woman, having a psychiatric disorder history, and greater psychiatric symptoms' intensity were associated with poorer life quality in patients with PNES.

CONCLUSION

Patients with DRE and PNES share similar psychiatric and psychological characteristics, with only very few being significantly different.

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

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

Nonpharmacologic Interventions and Seizure Frequency in Patients With Psychogenic Nonepileptic Seizures: An Integrative Review

BACKGROUND

Psychogenic nonepileptic seizures (PNES) pose a heavy burden on patients' lives and the health care system. The symptoms of PNES are often debilitating and cause high rates of disability and poor quality of life. Many treatment options are available, but there is no clear consensus on best practices.

AIM

To critique and synthesize the current literature on nonpharmacologic interventions and effects on seizure frequency in patients with PNES.

METHODS

An integrative review guided by the Whittemore and Knafl approach.

RESULTS

The review included 24 studies published from 2010 to 2020. Interventions for PNES included individualized psychotherapies, group therapies, multimodal psychotherapies, self-help therapies, and complementary and alternative medicine therapies. Individual psychotherapies such as cognitive behavioral therapy and psychoeducation were the most used treatment modalities. The most effective treatments for seizure frequency reduction were those that included multiple psychotherapy sessions with a health care provider and covered multiple domains (e.g., understanding of diagnosis, identifying triggers, and developing effective coping strategies).

CONCLUSIONS

Seizure frequency can be reduced in patients with PNES with multiple nonpharmacologic interventions. However, seizure frequency is not considered a comprehensive outcome measure and provides little insight into other important life domains. Further research is needed on nonpharmacologic interventions for PNES and effects on other areas of life such as sleep, employment status, global functioning, and self-efficacy.

Psychogenic nonepileptic seizures during the COVID-19 pandemic in New York City - A distinct response from the epilepsy experience

Although psychogenic nonepileptic seizures (PNES) are a common neurologic condition, there remains a paucity of literature on the COVID-19 pandemic's effect on these patients. Using a cross-sectional questionnaire study, our group examined the experience of patients with PNES at a single Comprehensive Epilepsy Center in New York City, the epicenter of the initial COVID-19 outbreak in the United States. Among our cohort of 18 subjects with PNES, 22.2% reported an improvement in seizure control during the peak of the COVID-19 pandemic in New York City. Compared to the cohort of subjects with epilepsy without PNES, subjects with PNES were significantly more likely to report an improvement (p = 0.033). Our findings signal that sleep and stress may be relevant variables in both conditions that should be further investigated and potentially intervened upon. Larger dedicated studies of patients with PNES are needed to understand the impact of the pandemic's widespread societal effects on these patients.

Evidence of objective sleep impairment in nonepileptic attack disorder: A naturalistic prospective controlled study using actigraphy and daily sleep diaries over six nights

Poor sleep is reported by many with nonepileptic attack disorder (NEAD) with correlations evident between self-reported sleep quality and mood and functional impairment. However, it is contended that self-reported sleep impairment in NEAD is a subjective phenomenon, which represents a general tendency to over-report symptoms or misinterpret bodily states in those with NEAD. The present study was therefore designed to investigate the extent of subjective and objective sleep impairments in those with NEAD. Over six nights we prospectively recorded comparable nightly objective (actigraphy) and subjective (consensus sleep diary) sleep parameters in a sample of 17 people with NEAD, and an age- and gender-matched normative control group (N = 20). Participants recorded daily measures of attacks, dissociation, and mood. Alongside higher subjective sleep impairment, the NEAD group had significantly worse objective sleep on several metrics compared to the normative controls, characterized by disrupted sleep (frequent awakenings and wake after sleep onset, low efficiency). Exploratory analyses using mixed effects models showed that attacks were more likely to occur on days preceded by longer, more restful sleep. This study, which had good ecological validity, evidences the presence of objective sleep impairment in NEAD, suggesting that in patient reports of problems with sleep should be given careful consideration in clinical practice.

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

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

Sleep Disturbances in Patients with Nonepileptic Seizures

OBJECTIVE

Up to 20% of patients treated for epileptic seizures experience psychogenic nonepileptic paroxysms (PNES). These patients present a significant burden for the health care systems because of poor treatment outcomes. The presented review aims to summarize the current state of knowledge on sleep disturbances in patients with nonepileptic seizures.

METHODS

Articles were acquired via PubMed and Web of Science, and papers between January 1990 and March 2020 were extracted. Inclusion criteria were (1) published in a peer-reviewed journal: (2) studies in humans only; or (3) reviews on a related topic; (4) English language. The exclusion criteria were: (1) abstracts from conferences; (2) commentaries; (3) subjects younger than 18 years. From primary assessment, 122 articles were extracted; after obtaining full texts and secondary articles from reference lists, 45 papers were used in this review.

RESULTS

Limited data are available regarding sleep disorders in PNES patients, over the last 30 years only nine original research papers addressed sleep problems in patients with PNES with only six studies assessing objectively measured changes in sleep. Current literature supports the subjective perception of the sleep disturbances with mixed results in objective pathophysiological findings. Conflicting results regarding the REM phase can be found, and studies reported both shortening and prolonging of the REM phase with methodological limitations. Poor sleep quality and shortened duration have been consistently described in most of the studies.

CONCLUSION

Further research on a broader spectrum of patients with PNES is needed, primarily focusing on objective neurophysiological findings. Quality of life in patients suffering from PNES can be increased by good sleep habits and treatment of comorbid sleep disorders.

Psychogenic nonepileptic seizures in adults with epilepsy: a tertiary hospital-based study

Objectives: Many studies describe and characterize psychogenic nonepileptic seizures (PNES) in high-income but few come from low/middle and low income countries.Design/methods: We aimed to determine the prevalence of PNES coexisted in adults with epilepsy and to characterize their semiology, comorbidities and predictors whether presented with epilepsy (n = 563) or alone (n = 73). Patients were recruited from a tertiary referral epilepsy clinic. Clinical suspicion and diagnosis were done by the neurologist based on histories and clinical cues. Psychiatric evaluation included structured psychiatric interviewing and assessment of symptoms of depression, anxiety and stress using Depression Anxiety Stress Scale (DASS 21).Results: The prevalence of PNES with epilepsy was 4.97% and diagnosed after a mean interval of 7.12yrs from onset of the first attack. Patients with PNES were predominantly females in their 2nd-3rd decades. Semiology of PNES included loss of consciousness, drop attacks, involuntary movements and speech arrest. Compared to patients with PNES coexisted with epilepsy, those with PNES alone were younger at presentation (p = 0.01) and age at onset (p = 0.002) and had frequent attacks (p = 0.001), psychosocial stressors and comorbid medical illnesses (p = 0.0001) and higher scores of depression, anxiety (p = 0.01) and stress (p = 0.001). In multivariate analysis, the significant predictors of high DASS scores with PNES were psychosocial stressors and comorbid medical conditions.Conclusions: The prevalence of PNES among adults with epilepsy is ∼5%. They are frequently misdiagnosed and treated as epilepsy. Specialist neurologists are more comfortable to diagnose patients with PNES. The multidisciplinary neurology and psychiatric assessments will help in the patient's therapeutic plan.

Machine learning as a diagnostic decision aid for patients with transient loss of consciousness

Background

Transient loss of consciousness (TLOC) is a common reason for presentation to primary/emergency care; over 90% are because of epilepsy, syncope, or psychogenic non-epileptic seizures (PNES). Misdiagnoses are common, and there are currently no validated decision rules to aid diagnosis and management. We seek to explore the utility of machine-learning techniques to develop a short diagnostic instrument by extracting features with optimal discriminatory values from responses to detailed questionnaires about TLOC manifestations and comorbidities (86 questions to patients, 31 to TLOC witnesses).

Methods

Multi-center retrospective self- and witness-report questionnaire study in secondary care settings. Feature selection was performed by an iterative algorithm based on random forest analysis. Data were randomly divided in a 2:1 ratio into training and validation sets (163:86 for all data; 208:92 for analysis excluding witness reports).

Results

Three hundred patients with proven diagnoses (100 each: epilepsy, syncope and PNES) were recruited from epilepsy and syncope services. Two hundred forty-nine completed patient and witness questionnaires: 86 epilepsy (64 female), 84 PNES (61 female), and 79 syncope (59 female). Responses to 36 questions optimally predicted diagnoses. A classifier trained on these features classified 74/86 (86.0% [95% confidence interval 76.9%-92.6%]) of patients correctly in validation (100 [86.7%-100%] syncope, 85.7 [67.3%-96.0%] epilepsy, 75.0 [56.6%-88.5%] PNES). Excluding witness reports, 34 features provided optimal prediction (classifier accuracy of 72/92 [78.3 (68.4%-86.2%)] in validation, 83.8 [68.0%-93.8%] syncope, 81.5 [61.9%-93.7%] epilepsy, 67.9 [47.7%-84.1%] PNES).

Conclusions

A tool based on patient symptoms/comorbidities and witness reports separates well between syncope and other common causes of TLOC. It can help to differentiate epilepsy and PNES. Validated decision rules may improve diagnostic processes and reduce misdiagnosis rates.

Classification of evidence

This study provides Class III evidence that for patients with TLOC, patient and witness questionnaires discriminate between syncope, epilepsy and PNES.

Atypical Prodromal Symptoms Help to Distinguish Patients With Psychogenic Nonsyncopal Collapse Among Youth Referred for Fainting

BACKGROUND

Distinguishing patients with psychogenic nonsyncopal collapse (PNSC), a conversion disorder that resembles syncope, can pose a difficult clinical challenge. Using the open-ended question "what does it feel like to faint?," the present study aimed to characterize how patients with PNSC perceive and communicate the prodromal symptoms associated with their attacks by comparing narratives between patients with PNSC and those with syncope.

METHODS

During a 42-month database-type study of tilt-table diagnoses, all patients with a history of fainting were asked the open-ended question. Symptom descriptions were compared, qualitatively and quantitatively, between patients with PNSC and those with tilt-induced syncope (n = 121 in both cohorts).

RESULTS

Twenty-nine patients (24%) diagnosed with PNSC and eight (6.6%) diagnosed with syncope either denied having any prodromal symptoms or could not recall any symptoms (P < 0.001). Among patients who reported prodromal symptoms, patient narratives led to the formation of 26 symptom categories. Symptom frequencies differed between cohorts in 19 of the symptom categories (each P value <0.05). Qualitative differences in the descriptions of symptoms were often present, even when symptom frequencies did not differ. More patients with PNSC described atypical symptoms than patients with syncope, 54 of 92 (58.7%) versus eight of 113 (7.1%), P < 0.001.

CONCLUSIONS

Symptom narratives can help to distinguish patients with PNSC from those with syncope. The use of a single, open-ended question as a screening tool for conversion disorder has immediate clinical relevance because it can be instituted easily in a busy clinical setting.

Sleep disturbances in patients with psychogenic non-epileptic seizures: Is it all subjective? A prospective pilot study of sleep-wake patterns

PURPOSE

Patients with psychogenic non-epileptic seizures (PNES) frequently complain of poor sleep, yet there are few and inconsistent data supporting objective sleep disturbances in this population. In this prospective observational study, we aimed to compare objective and subjective sleep-wake patterns in patients with PNES with those with epilepsy.

METHODS

Subjects were recruited through the Brigham and Women's Epilepsy Monitoring Unit (EMU) over a 6-month period, and were diagnosed as having PNES or epilepsy by experts using video-electroencephalography (v-EEG). Sleep-wake patterns were objectively examined using EEG and actigraphy during EMU admission. Subjects also completed several validated questionnaires on sleep.

RESULTS

Twenty-seven subjects, including 17 with PNES and 10 with epilepsy were enrolled in the study. Compared to controls with epilepsy, PNES subjects showed greater sleep onset latency (48.7 ± 47.5 min vs 14.0 ± 13.4 min; p = 0.02). Otherwise, sleep architecture was similar between the groups. However, subjectively, PNES subjects reported worse sleep quality (10.8 ± 5.1 vs 5.8 ± 2.9; p = 0.01) and were more likely to meet clinical criteria for insomnia relative to epilepsy subjects (50% vs 10%, p = 0.05). Moreover, a higher proportion of PNES subjects reported taking medications for sleep (44% vs 0%, p = 0.01).

CONCLUSION

Overall, we found more evidence for a subjective basis rather than a pathophysiological nature for the reported sleep disturbances in PNES subjects. In addition to educating PNES patients on the importance of maintaining good sleep habits, clinicians should address sleep complaints and screen for insomnia, as effective treatments are available and may improve overall health.