Incidence and prevalence of psychogenic nonepileptic seizures (functional seizures): a systematic review and an analytical study

Distinguishing epileptic seizures from imitators: A video-based evaluation of non-epileptologist physicians

OBJECTIVES

Epileptic seizures can present with various clinical manifestations, often resembling other conditions-referred to as "imitators of epileptic seizures"-making differential diagnosis challenging. Among them, psychogenic non-epileptic seizures (PNES) or functional/dissociative seizures (FDS) are particularly prevalent in females. This study aimed to evaluate the ability of various non-epileptologist physicians to distinguish epileptic seizures from imitators by viewing video recordings of several paroxysmal events. We also assessed whether variables, such as medical specialty and years of professional experience, could impact diagnostic accuracy.

MATERIALS AND METHODS

Ten video recordings of authorized informational material were presented to non-epileptologist physicians. Five videos depicted non-epileptic events, including syncope, hyperkinetic movement disorder episodes, cataplexy, PNES/FDS, and REM behavior disorder. The remaining videos featured focal and generalized seizures. Participants completed an anonymous questionnaire to classify each event as epileptic or non-epileptic.

RESULTS

Seventy specialists (44 men, 26 women) from psychiatry (12.9%), internal medicine (12.9%), neurosurgery (14.3%), neurology (14.3%), emergency (18.6%), anesthesiology. (18.6 %) and others (7.1 %) were enrolled. The mean age was 49.9 ± 8.7 years; years of work experience were 0-20 years for 53 % and 21-40 years for 47 %. Epileptic seizures were correctly. recognized in 50.3% of cases, whereas non-epileptic paroxysmal events were. misdiagnosed in 49.7% of cases. The most accurately recognized event was tonic-clonic seizure (88.6%), while the most frequently misdiagnosed was PNES/FDS (94.3%).

DISCUSSION AND CONCLUSION

Correctly diagnosing epileptic and non-epileptic paroxysmal events can be challenging when relying solely on video recordings. This study highlights the importance of implementing training for adequate diagnosis and subsequent correct management of these conditions.

Validation of ICD codes for the identification of patients with functional seizures

OBJECTIVE

To evaluate the validity of ICD-9-CM and ICD-10 codes for the identification of patients with functional seizures (FS).

METHODS

We evaluated the charts of 800 patients including 400 in an institution wide sample and 400 in an epilepsy monitoring unit (EMU) sample. Half of the patients from each sample came from 2012-2013 and 2022-2023 since ICD-9-CM codes and ICD-10 codes were exclusively used in these respective periods. The charts of each patient were manually reviewed and evaluated for the presence of epilepsy and FS. Based on the 2013 International League Against Epilepsy (ILAE) Nonepileptic Seizures Task Force guidelines we determined whether a patient had either presumptive (clinically established or documented) or probable/possible FS. We evaluated ICD-9-CM codes 300.11 (conversion disorder) and 780.39 (other convulsions) as well as ICD-10 codes F44.5 (conversion disorder or functional neurological disorder with seizures or convulsions) and R56.9 (unspecified convulsions). The positive predictive value (PPV) of each ICD code was calculated in the institution wide sample and the sensitivity, specificity, PPV and negative predictive values (NPV) were calculated in the EMU sample.

RESULTS

In the institution wide sample, F44.5 had a PPV of 74.0 % (64.6-81.6) for presumptive FS and 80.0 % (71.1-86.7) when probable/possible FS patients were included. The code 300.11 had a PPV of 52.0 % (42.3-61.5) for presumptive FS and 59.0 % (49.2-68.1) when probable/possible FS patients were included. Codes R56.9 and 780.39 had PPVs that were equal to or less than 20 %. In the EMU sample, the code F44.5 had a sensitivity, specificity, PPV and NPV of 67.1 % (56.3-76.3), 95.8 % (90.5-98.2), 91.7 % (81.9-96.4), and 80.7 % (73.4-86.4), respectively for presumptive FS. The code 300.11 had a sensitivity, specificity, PPV and NPV of 30.1 % (20.8-41.4), 95.3 % (90.1-97.8), 78.6 % (60.5-89.8), and 70.4 % (63.1-76.7), respectively for presumptive FS. The codes R56.9 and 780.39 performed poorly.

SIGNIFICANCE

ICD codes had a mixed performance when used to identify patients with FS. ICD-10 code F44.5 appeared to perform the best overall.

The Relationship Between Functional Seizures, Dissociation, and Gender Dysphoria: A Case Report and Review

Psychogenic non-epileptic seizures (PNES), also known as functional seizures, clinically mimic seizure-like activity without the presence of brain wave abnormalities on electroencephalogram (EEG). PNES, among other functional neurological disorders, demonstrates an increased prevalence among transgender and non-binary individuals, particularly those with ongoing gender dysphoria. It is established that PNES episodes can be triggered by states of severe distress and that mirror-gazing may cause distress in individuals with gender dysphoria. Herein, we review the available research on the pathophysiology of PNES. We also describe a 16-year-old non-binary patient with gender dysphoria, initially admitted following a suicide attempt, who experienced multiple PNES episodes upon entering their bathroom. Once bathroom access was restricted and the patient was supervised with a bedside commode, they experienced no further episodes on the unit. With no other potential triggers identified, we hypothesized that the patient's symptoms were evoked by their reflection in the bathroom mirror, causing such great distress that it resulted in dissociation and PNES. This is a case of mirror-gazing potentially inducing PNES in a non-binary patient.

Evaluation of the relationships between psychiatric comorbidity and seizure semiology in psychogenic non-epileptic seizure patients

Psychogenic non-epileptic seizures (PNES) are episodic events that bear a resemblance to epileptic seizures (ES) in their outward manifestations, yet they lack pathological electroencephalographic (EEG) activity during the ictal phase. In the Diagnostic and Statistical Manual 5th Edition (DSM-5), PNES is designated as "Functional Neurological Symptom Disorder with seizures". Individuals diagnosed with PNES commonly present with concurrent psychiatric disorders, notably depression, panic disorder, and chronic anxiety. This phenomenon renders PNES a shared affliction within the domains of neurology and psychiatry, thereby mandating the implementation of diverse therapeutic approaches in the management of the condition. Indeed, identifying the presence of concurrent psychiatric disorders in a patient with PNES during the early stages is crucial for devising an appropriate treatment plan. In this study, an assessment was conducted to examine the correlation between PNES semiology and psychiatric disorder comorbidity, to elucidate whether semiological characteristics serve as predictors for the presence of comorbid psychiatric disorders. The PNES patients enrolled were divided into two subgroups based on the presence or absence of accompanying psychiatric disorders (onlyPNES and PNES+). The study assessed disparities in semiological characteristics between the two subgroups of PNES and the results obtained indicate that individual variations in semiotic features are not influenced by the presence of psychiatric comorbidity.

A Multidisciplinary Approach to Nonepileptic Events

OBJECTIVE

This article provides a guide for neurologists managing nonepileptic events (NEEs), a complex intersection of neurology and psychiatry. It covers risk factors, pathophysiology, current treatment approaches, and prognosis, with specific management strategies for challenging scenarios such as patients with intellectual disabilities and comorbid epilepsy.

LATEST DEVELOPMENTS

An emphasis on strong communication and coordinated care among health care specialists improves patient outcomes and reduces unnecessary medical consultations and procedures. This approach is now recognized as essential for addressing the complex presentation and comorbidities associated with NEEs.

ESSENTIAL POINTS

NEEs are prevalent and highly disabling, and multiple pathophysiologic mechanisms for these events have been proposed. Mortality is comparable with that of patients with treatment-refractory epilepsy, and prognosis is better for children than adults. Achievable treatment goals for adults include improved quality of life and reduced frequency and severity of events, even if complete remission of NEEs is not achieved. Enhanced communication and coordinated care through multidisciplinary care teams enable the efficient use of individual expertise at different treatment stages to address the presentation, risk factors, and comorbidities associated with NEEs, resulting in a better quality of life for patients.

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.

New-onset psychogenic nonepileptic seizures after intracranial neurosurgery: A meta-analysis

BACKGROUND

The epidemiology of psychogenic non-epileptic seizures (PNES) is still unclear. Although approximately 14 million people need neurosurgical care annually, there is a dearth of thorough analysis on PNES occurrence following surgery. This study seeks to estimate the proportion of newly diagnosed PNES.

METHODS

We conducted a literature search of the PubMed, Ovid, CINAHL, and Cochrane Library databases up to December 2023. We identified studies using an observational design on the occurrence of PNES in patients who underwent intracranial surgery, and confirmed diagnosis using video-EEG. Estimates are reported as proportions using random effects models. We reported both 95 % CIs and prediction intervals (PI). We assessed the risk of bias and identified the pooled odds ratio (OR) for mutually exclusive groups. The heterogeneity was investigated using the I² statistic and significance determined using Cochran's Q-test. Post-hoc Egger's regression test, and several sensitivity analyses were performed. This study was registered in PROSPERO (CRD42023488611).

RESULTS

Of the 1766 unique studies identified, 86 were selected for full-text review. Eight studies (n = 3,699) were eligible for inclusion. Studies, spanning from 1995 to 2017, primarily focused on epilepsy surgeries. The pooled proportion was 3 % (95 % CI 2 %-5 %; 95 % PI 0 %-11 %). Temporal resections indicated twofold increase of PNES comparing to either resections (OR 2.05, 95 %CI 0.81-5.19). The risk of bias assessment indicated satisfactory quality for included studies, and heterogeneity in estimates was mainly explained by publication year of studies and their rounded sample size.

CONCLUSIONS

Given the estimations, there is expected impact of intracranial procedures on functional seizures epidemiology. Further efforts need to understand the contribution of brain resections to PNES incidence.

Maladaptive personality traits in patients with epilepsy and psychogenic non-epileptic seizures

OBJECTIVE

We aimed to evaluate the sociodemographic, clinical, and psychological characteristics associated with psychogenic non-epileptic seizures (PNES) in patients with epilepsy, with particular emphasis on the personality profile assessed from a dimensional perspective.

METHODS

The cohort study included 77 consecutive inpatients with active epilepsy aged 36-55 years; 52 (67.5%) were female. The presence of PNES was confirmed by video-EEG monitoring. All patients underwent the Mini-International Neuropsychiatric Interview to diagnose psychiatric disorders. All participants completed the Neurological Disorders Depression Inventory in Epilepsy, the Epilepsy Anxiety Survey Instrument - brief version, and the Personality Inventory for DSM-5 and ICD-11 Brief Form Plus Modified. Chi-square and Fisher's exact tests were used to compare categorical variables, and the Brunner-Munzel test was used for quantitative variables.

RESULTS

Twenty-four patients (31.2%) had both epilepsy and PNES. There were no significant differences in social, demographic or clinical characteristics, psychiatric diagnoses or depression severity. Compared to patients with epilepsy alone, patients with epilepsy and PNES had higher anxiety scores and more pronounced maladaptive personality traits such as disinhibition and psychoticism.

SIGNIFICANCE

The main novelty of our study is that using the recently proposed dimensional approach to personality disorders and an appropriate instrument we assessed all personality domains listed in two of the most widely used classifications of mental disorders (DSM-5 and ICD-11) in PWE with and without PNES. To our knowledge, this is the first study to demonstrate the association of the maladaptive traits of psychoticism and disinhibition with the development of PNES in PWE.

Characteristics and outcomes of youth with functional seizures attending intensive interdisciplinary pain treatment

Functional seizures (FS) can be debilitating and negatively impact quality of life. Yet intervention research for FS is limited, especially for youth. This study examined clinical characteristics and outcomes of youth with FS (13-23 years) presenting to a pediatric intensive interdisciplinary pain treatment (IIPT) program in the midwestern United States. Sixty youth (mean age = 16.5 years; 83.3 % female) met inclusion criteria. At intake, comorbid chronic pain, somatic symptoms, autonomic dysfunction, eating and weight disturbances, and mental health concerns were common. Despite this high symptom burden, youth with FS reported significant improvements in functioning measured with the Functional Disability Inventory, t(53) = 9.80, p <.001, d = 1.32; depression measured with the Center for Epidemiological Studies - Depression Scale for Children, t(53) = 6.76, p <.001, d = 0.91; anxiety measured with the Spence Children's Anxiety Scale, t(53) = 3.97, p < .001, d = 0.53; and catastrophizing measured with the Pain Catastrophizing Scale for Children, t(53) = 6.44, p <.001, d = 0.86, following completion of the program, suggesting that IIPT may be an effective treatment option for highly disabled and emotionally distressed youth with FS. Future research is needed to continue to refine best practices for youth with FS to reduce suffering and improve outcomes.

Reduced Subjective Cognitive Concerns With Neurobehavioral Therapy in Functional Seizures and Traumatic Brain Injury

OBJECTIVE

Functional seizures are common among people with traumatic brain injury (TBI). Subjective cognitive concerns refer to a person's own perception of problems with cognitive functioning in everyday life. The authors investigated the presence and correlates of subjective cognitive concerns and the response to neurobehavioral therapy among adults with TBI and functional seizures (TBI+FS group).

METHODS

In this observational study, participants in the TBI+FS group (N=47) completed a 12-session neurobehavioral therapy protocol for seizures, while participants in the comparison group (TBI without seizures) (N=50) received usual treatment. Subjective cognitive concerns, objective cognition, mental health, and quality of life were assessed before and after treatment. Data collection occurred from 2018 to 2022.

RESULTS

Baseline subjective cognitive concerns were reported for 37 (79%) participants in the TBI+FS group and 20 (40%) participants in the comparison group. In a multivariable regression model in the TBI+FS group, baseline global mental health (β=-0.97) and obsessive-compulsive symptoms (β=-1.01) were associated with subjective cognitive concerns at baseline. The TBI+FS group had fewer subjective cognitive concerns after treatment (η2=0.09), whereas the TBI comparison group showed a nonsignificant increase in subjective cognitive concerns.

CONCLUSIONS

Subjective cognitive concerns are common among people with TBI and functional seizures and may be related to general mental health and obsessive-compulsive symptoms. Evidence-based neurobehavioral therapy for functional seizures is a reasonable treatment option to address such concerns in this population, although additional studies in culturally diverse samples are needed. In addition, people with functional seizures would likely benefit from rehabilitation specifically targeted toward cognitive functioning.

Changes in the heartbeat-evoked potential are associated with functional seizures

BACKGROUND

Patients with functional seizures (FS) can experience dissociation (depersonalisation) before their seizures. Depersonalisation reflects disembodiment, which may be related to changes in interoceptive processing. The heartbeat-evoked potential (HEP) is an electroencephalogram (EEG) marker of interoceptive processing.

AIM

To assess whether alterations in interoceptive processing indexed by HEP occur prior to FS and compare this with epileptic seizures (ES).

METHODS

HEP amplitudes were calculated from EEG during video-EEG monitoring in 25 patients with FS and 19 patients with ES, and were compared between interictal and preictal states. HEP amplitude difference was calculated as preictal HEP amplitude minus interictal HEP amplitude. A receiver operating characteristic (ROC) curve analysis was used to evaluate the diagnostic performance of HEP amplitude difference in discriminating FS from ES.

RESULTS

The FS group demonstrated a significant reduction in HEP amplitude between interictal and preictal states at F8 (effect size rB=0.612, false discovery rate (FDR)-corrected q=0.030) and C4 (rB=0.600, FDR-corrected q=0.035). No differences in HEP amplitude were found between states in the ES group. Between diagnostic groups, HEP amplitude difference differed between the FS and ES groups at F8 (rB=0.423, FDR-corrected q=0.085) and C4 (rB=0.457, FDR-corrected q=0.085). Using HEP amplitude difference at frontal and central electrodes plus sex, we found that the ROC curve demonstrated an area under the curve of 0.893, with sensitivity=0.840 and specificity=0.842.

CONCLUSION

Our data support the notion that aberrant interoception occurs prior to FS. Changes in HEP amplitude may reflect a neurophysiological biomarker of FS and may have diagnostic utility in differentiating FS and ES.

A systems biology approach for discovering the cellular and molecular aspects of psychogenic non-epileptic seizure

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.

Does explaining psychogenic nonepileptic seizures using either a biomedical or biopsychosocial framework affect young people's illness representations? An experimental vignette study

Lay representations of psychogenic nonepileptic seizures (PNES) are important both for understanding public stigma and anticipating patient responses to PNES diagnosis. The current study presents the first evidence of the general public's representations of PNES and the malleability of these understandings to different ways of explaining PNES. An online experimental study exposed participants (n = 193, aged 18-25 years) to a vignette describing a case of PNES in biomedical terms, PNES in biopsychosocial terms, or epilepsy. Subsequent questionnaires assessed participants' illness representations, causal attributions, and stigmatising attitudes regarding the case about which they read. Results suggest that compared with biomedical framings, biopsychosocial explanations increased perceptions of PNES as threatening. While epilepsy was attributed to significantly more biological and less social causes than either of the PNES vignettes, causal attributions did not differ between biomedically- vs. biopsychosocially-framed PNES. Neither were there any differences between the three conditions in stigmatising attitudes towards people who experience seizures. These findings are useful for clinicians delivering a PNES diagnosis and patients disclosing a PNES diagnosis, in helping anticipate responses to these communications. Further research is required to confirm the clinical and societal significance of the study's first insights into the dynamics of lay responses to PNES.

Adverse Childhood Experiences Are Associated With Seizures in Children: A Cross-sectional Analysis

Background and Objective

To assess the relationship between adverse childhood experiences (ACE/ACEs) and epilepsy.

Methods

We performed a cross-sectional retrospective cohort analysis using population-based data from the 2018 and 2019 National Survey of Children's Health to examine caregiver-reported ACE exposures and their relationship to caregiver-reported physician diagnoses of epilepsy or seizure disorder in children. ACEs elicited in the survey included questions about experience of violence, household dysfunction, and food and housing insecurity. Adjusting for age, race, and income level, we used logistic regression to test the relationships between cumulative ACE score and current seizure disorder or epilepsy diagnosis and to examine which specific ACEs were individually associated with current seizure disorder or epilepsy diagnosis.

Results

The study population consisted of 59,963 participants; 52.2% were female, and 47.8% were male. Participant ages ranged from 0 to 17 years. A current diagnosis of epilepsy or seizure disorder was reported in 377 (0.63%) participants, and 22,749 (37.9%) participants had one or more ACE exposures. As the number of ACEs increased, odds of current epilepsy or seizure disorder diagnosis increased by 1.14 (95% confidence interval 1.07-1.22). Five ACE exposures demonstrated a high association with a current diagnosis of epilepsy or seizure disorder: food/housing insecurity, witnessing domestic violence, household mental illness, neighborhood violence, and parent/guardian incarceration.

Discussion

Multiple ACE exposures were individually associated with reporting a diagnosis of epilepsy or seizure disorder. An increase in cumulative ACE exposures increased odds of having current diagnosis of epilepsy or seizure disorder.

Are brain MRI abnormalities associated with the semiology of functional seizures?

PURPOSE

To investigate whether radiologically apparent brain magnetic resonance imaging (MRI) abnormalities are associated with the functional seizure (FS) semiology.

METHODS

All patients with a diagnosis of FS at the epilepsy centers at Shiraz University of Medical Sciences, Iran; Aichi Medical University Hospital, Japan; University of Michigan, USA; University of California, Los Angeles, USA; Emory University School of Medicine, USA; and Hospital el Cruce, Argentina, were studied.

RESULTS

One hundred patients were included; 77 (77%) had motor functional seizures. Lobar location of brain abnormality did not have an association with the semiology (p = .83). There was no significant difference between ictal behaviors in patients with frontal or parietal lesions compared to those with temporal or occipital lesions.

CONCLUSION

There were no associations between functional seizure ictal behaviors and locations of the radiologically apparent brain MRI abnormalities. Further studies are needed to evaluate the underpinnings of varying behaviors in FS.

An international study of the effects of the COVID-19 pandemic on characteristics of functional seizures

OBJECTIVE

We investigated whether the COVID-19 pandemic has affected the clinical characteristics of patients with functional seizure (FS) (at the time of diagnosis) in a large multicenter international study.

METHODS

This was a retrospective study. We investigated all patients with FS, who were admitted at the epilepsy monitoring units at six centers in the world: 1. Shiraz, Iran; 2. Salzburg, Austria; 3. Nancy, France; 4. Atlanta, USA; 5. Kuwait City, Kuwait; and 6. Cairo, Egypt. Patients were studied during two time periods: admitted in 2018-2019 (pre-COVID era) and 2020-2021 (COVID era).

RESULTS

Three hundred and twenty-six patients were studied. Two hundred and twenty-four (68.7%) patients were diagnosed before and 102 (31.3%) persons during the COVID-19 pandemic. Only, a history of family dysfunction was significantly associated with the COVID-19 pandemic era (Odds Ratio: 1.925, 95% Confidence Interval: 1.099-3.371; p = 0.022). A low level of education might also be associated with FS during the COVID-19 pandemic, at least in some cultures (e.g., the Middle-East).

CONCLUSION

The COVID-19 pandemic has not affected the clinical characteristics of patients with FS (at the time of diagnosis). However, a history of family dysfunction was significantly more frequently associated with FS during the COVID-19 pandemic. Multiagency integration of law enforcement responses, social services, and social awareness is recommended to address family dysfunction and domestic violence and support the victims during this pandemic.

Functional seizures: Cluster analysis may predict the associated risk factors

OBJECTIVES

We applied the Two-Step cluster analysis on a large cohort of patients with functional seizures (FS). We studied whether the background risk factors differed between the patient clusters.

METHODS

All patients with a diagnosis of FS were studied at the outpatient epilepsy clinic at Shiraz University of Medical Sciences, Shiraz, Iran, from 2008 until 2021. The Two-Step cluster analysis was applied considering the age at onset, sex, and seizure semiology. We also studied whether the background risk factors (e.g., a history of sexual abuse, physical abuse, etc.) differed between these patient clusters.

RESULTS

Three-hundred and fifty four patients were studied. The Two-Step cluster analysis was applied to the 230 patients who reported any associated risk factors; there were three clusters of patients. The most prominent feature of cluster 1 included akinetic seizures. The most prominent features of cluster 2 included motor seizures and no ictal injury. The most prominent features of cluster 3 included motor seizures with ictal injury. Compared with patients in cluster 3, a history of sexual abuse was more often reported by patients in cluster 1 (OR: 3.26, 95%CI: 1.12-9.47; p = 0.03). Compared with patients in cluster 3, a history of physical abuse was less often reported by patients in cluster 2 (OR: 0.45, 95%CI: 0.22-0.90; p = 0.026).

CONCLUSION

The Two-Step cluster analysis could identify three distinct clusters of patients based on their demographic and clinical characteristics. These clusters had correlations with the associated risk factors in patients with FS.

Functional seizures are not less important than epilepsy

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People with functional seizures often suffer from psychiatric comorbidities.

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People with FS report detrimental effects on social aspects of their lives.

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FS are associated with a considerable direct and indirect economic burden.

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FS have increased rates of mortality compared to healthy controls.

Functional seizures (FS) are frequently encountered in neurology clinics, often affect young adults, and have significant negative impacts on many aspects of a person’s life. In the current narrative review, we searched the literature regarding some of the consequences of FS (i.e., psychiatric comorbidities, social consequences, costs that are associated with the condition, cognitive impairment in patients with FS, the quality of life of the people with FS, and the increased risk of mortality that is associated with FS). Evidence shows that FS have significant negative consequences, comparable in their magnitude to those affecting patients with epilepsy. The clinical and scientific communities should take steps to address these consequences through clinical care and research that prioritizes, facilitates, and expedites evidence-based diagnosis and treatment for FS.

Epilepsy and psychogenic non-epileptic seizures in forcibly displaced people: A scoping review

With a growing number of forcibly displaced people (FDP) globally, the focus on their medical needs has necessarily increased. Studies about the prevalence and incidence of epilepsy and psychogenic non-epileptic seizures (PNES) in this population are, though, sparse. This Review highlights the importance of exploring and managing both conditions in these vulnerable people to promote global health. We performed an exhaustive review of 10 databases, as well as a manual search of relevant websites related to global health and refugee-related organizations. We analyzed data related to the prevalence and incidence of epilepsy and PNES; health visits; costs of medical care and challenges faced by healthcare workers in relation to FDP with these conditions. Fifty six papers met our inclusion criteria. Of these, 53 reported directly or indirectly on the prevalence of epilepsy and its costs in FDP. Two articles reported on the prevalence of PNES in forcibly displaced people. The reported prevalence of epilepsy in FDP varied from 0.2% to 39.13%, being highest in people with pre-existing neurological or psychiatric comorbidities. Only one study reported on the incidence of epilepsy in internally displaced children. Data from the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) have identified a tendency to higher incidence of epilepsy in children following wars. While within displaced women without a history of sexual violence the rate of PNES was 16.7%, in FDP women with such a history the rate of PNES was 43.7% (p=0.02). The healthcare costs for epilepsy can be high, with recurrent health visits related to seizures being the most common cause of health encounters in refugee camps. Increasing awareness and further studies of multicultural aspects to improve shared understanding of seizure phenomenon in vulnerable displaced populations would seem crucial.