Treating patients with psychogenic non-epileptic seizures

Psychogenic nonepileptic seizures: clinical characteristics and outcome

BACKGROUND

Clinical characteristics, outpatient situation, and outcome in patients with psychogenic nonepileptic seizures (PNES) remain to be elucidated.

METHODS

Patients diagnosed with PNES after video-electroencephalography (EEG) monitoring (VEM) 03/2000-01/2016 at the Erlangen Epilepsy Center were surveyed between June 2016 and February 2017. Primary outcome was PNES cessation defined as no PNES episodes within > = 12 months prior to the interview. Secondary outcome variables included quality of life (QoL) and dependency. Sensitivity analysis included patients with proven PNES during VEM without comorbid epilepsy.

RESULTS

Ninety-nine patients were included (median age 38 (interquartile range (IQR 29-52)) years; 68 (69%) females, follow-up 4 (IQR 2.1-7.7) years). Twenty-eight (28%) patients suffered from comorbid epilepsy. Twenty-five (25%) patients reported PNES cessation. Older age at symptom onset (odds ratio (OR) related to PNES cessation: 0.95 (95% CI 0.90-0.99)), comorbid epilepsy (OR 0.16 (95% CI 0.03-0.83)), anxiety disorder (OR 0.15 (95% CI 0.04-0.61)), and tongue biting (OR 0.22 (95% CI 0.03-0.91)) remained independently associated with ongoing PNES activity after adjustment. Sensitivity analysis (n = 63) revealed depressive disorder (OR 0.03 (95% CI 0.003-0.34)) instead of anxiety as independent predictor, while this seemed relevant only in patients older than 26 years at onset (OR 0.04 (95% CI 0.002-0.78) versus OR 0.21 (95% CI 0.02-1.84) in patients  younger than 26 years). PNES cessation was associated with increased median QoL (8 (IQR 7-9) versus 5.5 (IQR 4-7); p < .001) and an increased frequency of financial independency (14 (56%) versus 21 (28%); p = .01).

CONCLUSIONS

We found poor outcomes in PNES especially in older patients at onset with comorbid depressive disorder. Comorbid epilepsy also seems to be a major risk factor of ongoing PNES activity, which in turn affects patients' daily living.

Recognition of Psychogenic Versus Epileptic Seizures Based on Videos

OBJECTIVE

Ictal semiology interpretation for differentiating psychogenic nonepileptic seizures (PNESs) and epileptic seizures (ESs) is important for the institution of appropriate treatment. Our objective was to assess the ability of different health care professionals (HCPs) or students to distinguish PNES from ES based on video-recorded seizure semiology.

METHODS

This study was designed following the Standards for Reporting of Diagnostic Accuracy Studies (STARD) guidelines. We showed in a random mix 36 videos of PNES or ES (18 each) and asked 558 participants to classify each seizure. The diagnostic accuracy of various groups of HCPs or students for PNES versus ES was assessed, as well as the effect of patient age and sex. Measures of diagnostic accuracy included sensitivity, specificity, and area under the curve (AUC).

RESULTS

The descending order of diagnostic accuracy (AUC) was the following (p ≤ 0.001): (1) neurologists and epileptologists; (2) neurology residents; (3) other specialists and nurses with experience in epilepsy; and (4) undergraduate medical students. Although there was a strong trend toward statistical difference, with AUC 95% confidence intervals (CIs) that were not overlapping, between epileptologists (95% CI 93, 97) compared to neurologists (95% CI 88, 91), and neurologists compared to electroencephalography technicians (95% CI 82, 87), multiple pairwise comparisons with the conservative Tukey-Kramer honest significant difference test revealed no statistical difference (p = 0.25 and 0.1, respectively). Patient age and sex did not have an effect on diagnostic accuracy in neurology specialists.

CONCLUSION

Visual recognition of PNES by HCPs or students varies overall proportionately with the level of expertise in the field of neurology/epilepsy.

A pilot randomised controlled trial of a home-based writing intervention for individuals with seizures

OBJECTIVE

We investigated the feasibility, acceptability and preliminary effectiveness of a writing intervention for individuals with epilepsy or psychogenic nonepileptic seizures.

METHODS

Individuals were randomised to write about potentially 'therapeutic' topics (n = 43) or about their daily events (n = 25). Participants were asked to write on four separate occasions for at least 20 min. Repeated-measures analysis of variance was used to investigate change in measures of health-related quality of life (NEWQoL-6D), depression (NDDI-E), anxiety (GAD-7) and illness perception (B-IPQ) from baseline to one and three-month follow-ups. Qualitative and quantitative data taken from a Writing Task Questionnaire was analysed between the two conditions.

RESULTS

Recruitment was acceptable with 52% of those randomised completing the full writing intervention. In both conditions, participants wrote for longer than 20 min suggesting those who completed the study engaged well with the procedure. Greater benefits were observed in the 'therapeutic' condition (p < 0.05), which was associated with an improvement in health-related quality of life at one-month follow-up (p = 0.02). No differences were found in the other measures.

CONCLUSIONS

A writing intervention is acceptable in this population. Self-reported benefits were modest, suggesting therapeutic writing may be more suitable as a supplement to other therapies rather than a stand-alone therapeutic intervention.

Written accounts of living with psychogenic nonepileptic seizures: A thematic analysis

PURPOSE

Qualitative studies examining lived experiences of psychogenic nonepileptic seizures (PNES) have predominantly relied on datasets collected using clinical or research interviews. This study pursued a different approach by investigating individuals' written accounts of their condition.

METHODS

Participants (n=19) were recruited from membership-led organisations for individuals living with seizures and from a United Kingdom hospital. Participants were instructed to produce four pieces of writing: 1) about their thoughts and feelings about their condition; 2) a letter to their condition; 3) a letter to their younger self; and 4) about a personal value. All writings were analysed using thematic analysis.

RESULTS

Six main-themes emerged from the data. Theme 1: 'living with PNES' demonstrated that all participants presented the condition as having a debilitating effect. Theme 2: 'Emotions' revealed that individuals were struggling with anxiety, low mood and self-worth. Theme 3: 'Seizure symptoms' showed variability was a prominent feature in the description of ictal events. Theme 4: 'Treatment and outcomes' demonstrated that individual's perception of diagnosis and therapy differed greatly. Theme 5: 'Causation and development' revealed that the majority of participants spontaneously reported experiencing a traumatic event in the past. Theme 6: 'Lack of understanding' by themselves, the public and healthcare professionals appeared to pose considerable challenges to participants.

CONCLUSIONS

Qualitative research has an important role to play for improving our understanding of PNES. The findings contribute to the literature by highlighting the nature of stigma that people with PNES experience, and also their proneness to demonstrate problems with self-worth.

Predictors of health-related quality of life in patients with epilepsy and psychogenic nonepileptic seizures

Epilepsy and psychogenic nonepileptic seizures (PNES) are associated with reduced health-related quality of life (HRQoL). The present study investigated the profile, relationship, and predictive power of illness perceptions, psychological distress (depression and anxiety), seizure activity, and demographic factors on HRQoL in these patient groups. Patients with epilepsy (n=62) and PNES (n=45) were recruited from a United Kingdom hospital and from membership-led organizations for individuals living with seizures. Patients completed a series of self-report questionnaires assessing: anxiety (GAD-7), depression (NDDI-E), illness perceptions (B-IPQ), HRQoL (NEWQOL-6D), and seizure frequency and severity (LSSS-3). Correlational and hierarchical multiple regression analyses were conducted. Patients with epilepsy reported higher HRQoL and scored lower on measures of depression and anxiety. Patients with PNES perceived their condition as more threatening overall. In both conditions, HRQoL was negatively correlated with more severe illness perceptions and psychological distress. In epilepsy and PNES, psychological distress (epilepsy: 27%; PNES: 24.8%) and illness perceptions (epilepsy: 23.1%; PNES: 23.3%) accounted for the largest amount of variance in HRQoL. Clinical factors were found not to be significant predictors, while demographic factors predicted HRQoL in epilepsy (12.6%), but not in PNES. Our findings support the notion that psychological factors are a stronger predictor of HRQoL in epilepsy and PNES than condition-related and demographic variables. Prior research suggests that anxiety and depression are key predictors of HRQoL; this study demonstrates that the relationship between illness perceptions and HRQoL is similarly close. These findings highlight the importance of addressing patients' beliefs about their condition.

Long-term follow-up of psychogenic pseudosyncope

OBJECTIVE

To determine the outcome of patients with psychogenic pseudosyncope (PPS) after communication of the diagnosis.

METHODS

This was a retrospective cohort study of patients with PPS referred in 2007 to 2015 to a tertiary referral center for syncope. We reviewed patient records and studied attack frequency, factors affecting attack frequency, health care use, and quality of life using a questionnaire. We explored influences on attack freedom and attack frequency in the 6 months before follow-up for age, sex, education level, duration until diagnosis, probability of diagnosis, additional syncope, and acceptance of diagnosis.

RESULTS

Forty-seven of 57 patients with PPS could be traced, of whom 35 (74%) participated. Twelve (34%) were attack-free for at least 6 months. The median time from diagnosis to follow-up was 50 months (range 6-103 months). Communicating and explaining the diagnosis resulted in immediate reduction of attack frequency (p = 0.007) from the month before diagnosis (median one attack, range 0-156) to the month after (median one attack, range 0-16). In the 6 months before follow-up, the number of admissions decreased from 19 of 35 to 0 of 35 (p = 0.002). The use of somatic and mental health care shifted toward the latter (p < 0.0001). Quality of life at follow-up (Short Form Health Survey 36) showed lower scores for 7 of 8 domains compared to matched Dutch control values; quality of life was not influenced by attack freedom.

CONCLUSIONS

After communication of the diagnosis in PPS, attack frequency decreased and health care use shifted toward mental care. Low quality of life underlines that PPS is a serious condition.

Barriers and facilitators to reaching a diagnosis of PNES from the patients' perspective: Preliminary findings

PURPOSE

This qualitative study aimed at examining the subjective experiences of patients during the complicated and often prolonged diagnostic process of psychogenic non-epileptic seizures (PNES).

METHODS

Thematic analyses were used to explore the semi-structured interviews that were conducted with ten individuals who have been diagnosed with PNES.

RESULTS

Six main themes, namely inexpert healthcare providers, limited medical insurance and loss of independence were identified as barriers, while social support, comprehensive medical insurance and knowledgeable healthcare providers were identified as facilitators through the process of thematic analysis.

CONCLUSIONS

The patients' perspectives revealed that an earlier diagnosis of PNES is essential to address the loss of independence and limit inappropriate and potentially harmful treatment as well as the costly burden of this condition on both the patient and the healthcare system. It was evident in this study that healthcare providers play an essential role in the subjective experiences of these individuals during the diagnostic process. The implementation of continuous education programmes for healthcare providers in particular could contribute positively to the diagnostic process of PNES for patients.

Theory of mind abilities in patients with psychogenic nonepileptic seizures

BACKGROUND

Psychogenic nonepileptic seizures (PNES) have been frequently linked to deficits in affect regulation and altered processing of emotionally salient information. However, less is known about how patients suffering from PNES actually process and interpret affective social stimuli. Thus, the present study aimed to investigate basal facial affect recognition as well as mind-reading skills in a sample of patients with PNES and matched control subjects.

METHODS

Patients with PNES (N=15) and healthy controls (N=15) completed self-report questionnaires that measured alexithymia and perceived stress vulnerability. Affect perception was tested using a series of computerized movies of models whose facial expressions slowly change from neutral to full-blown emotions (anger, fear, sadness, happiness, disgust, and surprise), allowing for a fine-grained assessment of facial emotion recognition impairments. Further, all participants were presented with the Movie for the Assessment of Social Cognition, a well-validated video-based test for the evaluation of subtle mind-reading deficits.

RESULTS

Data analyses revealed increased alexithymic traits and, impaired mentalizing skills in individuals with PNES, while basal facial expression recognition was not compromised.

DISCUSSION

The present findings are the first to demonstrate that patients with PNES exhibit several deficits in reasoning about their own and other people's mental states. Patients with PNES may benefit from psychotherapeutic interventions that focus on disturbed affect regulation and aim to enhance emotional awareness.

Life after being diagnosed with psychogenic non-epileptic seizures (PNES): a South African perspective

PURPOSE

The aim of the study was to explore the life experiences of South Africans who have been diagnosed as having PNES, with a focus on the aspects of the challenges which these individuals face, as well as the resources and coping strategies which are either made available to them or used by them in order to cope with PNES.

METHODS

Ten semi-structured interviews were analysed by means of thematic analysis in order to explore themes around challenges and resources for those diagnosed with PNES.

RESULTS

Various challenges were revealed by participants, as well as the resources used in order to deal with these challenges associated with being diagnosed with PNES. Some of the challenges included unexpected seizures, medical professionals, belief systems as well as family. However, resources to counteract these challenges were social support, medical professional as well as religion and spirituality.

CONCLUSION

Although many challenges are encountered by those who are diagnosed with PNES, there are substantial resources from which these individuals draw in order to live fulfilling and satisfactory lives. As more information and research is accumulated, more resources may become available to benefit these individuals and allow them to recover from PNES. It should be noted that medical professionals were described as both a challenge as well as a resource for people with PNES. Therefore, we can conclude that these individuals are key in the experiences of those who have been diagnosed with PNES, and that they play a role on not only a diagnostic level, but also in providing support, information, as well as therapeutic benefits.

Multimodular psychotherapy intervention for nonepileptic attack disorder: an individualized pragmatic approach

Nonepileptic attack disorder (NEAD) is a highly distressing and costly condition commonly seen in specialist epilepsy clinics. Consistently effective treatments for NEAD remain elusive, and findings from research indicate that there is no one form of psychological therapy that will be effective in such a heterogeneous group of patients. In this paper, we propose a multimodular approach to psychological therapy in NEAD, which allows the clinician to tailor an individualized management program for the patient appropriate to his/her needs.

Providers' perspectives on treating psychogenic nonepileptic seizures: frustration and hope

Recent diagnostic and treatment advances in psychogenic nonepileptic seizures (PNES) have the potential to improve care for patients, but little is known about the current state of PNES care delivery in the Veterans Health Administration (VA). We conducted semistructured interviews with 74 health-care clinicians and workers in the VA, eliciting provider perceptions of PNES care. Data were analyzed according to principles of Grounded Theory. The results revealed variation in care and two emergent domain themes of frustration and hope. Frustration was manifest in subthemes including Complexity, Patient Acceptance, Uncertainty About Treatment, Need for Evidence-based Treatment, and Failure of Cross-Disciplinary Collaboration between neurologists and mental health providers. Hope encompassed subthemes of Positive Attitudes, Developing Cross-Disciplinary Treatment, and Specific PNES Care. Increased resources for diagnosing, treating, and researching PNES have improved awareness of the disorder. More research is needed to understand patients' and caregivers' perceptions of PNES care.

Understanding the perceived treatment needs of patients with psychogenic nonepileptic seizures

Psychological therapy is generally considered the treatment of choice for psychogenic nonepileptic seizures (PNES), but there is a paucity of research on patients' attitudes towards psychological referral. We conducted semistructured interviews with twelve patients with PNES awaiting psychological treatment in order to understand their perceived treatment needs. Data were analyzed inductively according to the principles of thematic analysis. The results indicated that our patients had clear ideas about their treatment needs and a desire to recover by 'returning to normality'. Many participants felt 'caught in limbo' following their PNES diagnosis, however, because of uncertainties about their condition and a lack of support from professionals. This linked with participants feeling unsure whether psychological treatment would meet their needs; there was also apprehension for some participants about the potential negative consequences of therapy. The clinical implications of these findings are discussed, and recommendations for future research are made.

Psychologic treatment of patients with psychogenic nonepileptic seizures

Psychogenic nonepileptic seizures are relatively common, often disabling and costly to patients and society. Most authorities consider psychologic treatment as the therapeutic intervention of choice. This review is intended primarily for psychologists and therapists who treat patients with psychogenic nonepileptic seizures, and for neurologists who make the diagnosis and wish to find out more about psychologic treatment options. The first section describes the nature and etiology of psychogenic nonepileptic seizures. General questions regarding the psychologic treatment of patients with psychogenic nonepileptic seizures are addressed, before discussing specific therapeutic approaches. The final part summarizes the authors' views on optimal treatment and the direction of future research.

Subgroup classification in patients with psychogenic non-epileptic seizures

INTRODUCTION

In this open non-controlled clinical cohort study, the applicability of a theoretical model for the diagnosis of psychogenic non-epileptic seizures (PNES) was studied in order to define a general psychological profile and to specify possible subgroups.

METHODS

Forty PNES patients were assessed with a PNES "test battery" consisting of eleven psychological instruments, e.g., a trauma checklist, the global cognitive level, mental flexibility, speed of information processing, personality factors, dissociation, daily hassles and stress and coping factors.

RESULTS

The total PNES group was characterized by multiple trauma, personality vulnerability (in a lesser extent, neuropsychological vulnerabilities), no increased dissociation, many complaints about daily hassles that may trigger seizures and negative coping strategies that may contribute to prolongation of the seizures. Using factor analysis, specific subgroups were revealed: a 'psychotrauma subgroup', a 'high vulnerability somatizing subgroup' (with high and low cognitive levels) and a 'high vulnerability sensitive personality problem subgroup'.

CONCLUSION

Using a theoretical model in PNES diagnosis, PNES seem to be a symptom of distinct underlying etiological factors with different accents in the model. Hence, describing a general profile seems to conceal specific subgroups with subsequent treatment implications. This study identified three factors, representing two dimensions of the model, that are essential for subgroup classification: psychological etiology (psychotrauma or not), vulnerability, e.g., the somatization tendency, and sensitive personality problems/characteristics ('novelty seeking'). For treatment, this means that interventions could be tailored to the main underlying etiological problem. Also, further research could focus on differentiating subgroups with subsequent treatment indications and possible different prognoses.

Audio-induced psychogenic non-epileptic seizures

A 45-year-old woman presented with vague attacks, which consisted of headaches, confusion and sleepiness. An electroencephalograph was normal, but subsequent scans revealed the presence of a right-sided convexity meningioma. This was excised and complications led to the removal of an infected bone flap in a separate procedure the following year. Various types of 'seizures' resulted from the operation. These were described to involve both tonic-clonic and absence seizures. This continued for 18 years, unaffected by medication, until a specialist diagnosed pseudo-epilepsy, by fortune of a hospital fire alarm. The patient began a psychological intervention programme including cognitive-behavioural therapy, which has significantly reduced episodes. In conclusion, psychogenic non-epileptic seizures may develop after intracranial neurosurgery undertaken for indications other than the control of refractory epileptic seizures. A diagnosis of psychogenic non-epileptic seizures should be considered in patients who develop refractory seizures after neurosurgery and managed appropriately.

Psychogenic nonepileptic seizures

Treatment for PNES must be individualized. A combination of approaches is probably the most beneficial for improvement. Treatment should not simply emphasize removing maladaptive PNES behaviour, but should also focus on learning new coping skills and removing secondary gains. If PNES persist, therapy should be re-evaluated.

Patients with psychogenic non-epileptic seizures referred to a tertiary epilepsy centre: patient characteristics in relation to diagnostic delay

OBJECTIVE

This clinical study examines patient and seizure characteristics of patients with psychogenic non-epileptic seizures (PNES) in a tertiary epilepsy centre. The main focus was whether a new subgroup of PNES patients emerged with a relatively short referral time and possible specific characteristics.

METHODS

All PNES patients referred to a specialist program in our centre between mid 2007 and mid 2009 were consecutively included. This yielded a study cohort of 90 patients.

RESULTS

The majority of the patients have a patient history with many medical symptoms and they were or had been in treatment by a medical specialist. Furthermore diffuse psychological/psychiatric symptoms and subsequent treatments are also remarkably common, in general without a clear psychological diagnosis. The average time between seizure onset and referral to an epilepsy centre is remarkably low (4.29 years). About 50% of the patients were referred within 2 years of seizure onset. This 'active high speed referral group' had significantly more previous psychological complaints, significantly more previous psychological/psychiatric treatments and a trend towards more previous medical investigations.

CONCLUSION

There seems to be a new subgroup of PNES patients with a short referral time, characterized by a more active attitude towards examination of the symptoms in combination with an active attitude to apply for treatment. However, the PNES cohort as a whole is characterized by having somatoform symptoms based on a process of somatization.

MMPI-II personality profiles of patients with psychogenic nonepileptic seizures

This comparative study explored whether psychogenic nonepileptic seizures (PNES) are a unique disorder with distinctive personality characteristics or (seen from the personality profile) PNES are allied with the domain of a general functional somatic symptom and syndrome (FSSS). We compared the Minnesota Multiphasic Personality Inventory 2 (MMPI-2) results for 41 patients with newly diagnosed PNES and 43 patients with newly diagnosed insomnia. There were no statistically significant quantitative scoring differences on the main clinical scales, indicating that there is no substantial difference in "personality makeup" between the two groups with a FSSS. Additional subscale analysis indicated that patients with PNES reported significantly more somatic complaints (Hysteria 4) and bizarre sensory experiences (Schizophrenia 6). Further profile analysis revealed that the personality pattern of patients with PNES was characterized by a strong tendency toward "conversion V, a lack of control pattern and less excessive worries" as compared with patients with insomnia. Patients with PNES are characterized by a stronger tendency toward somatization and externalization, which has treatment implications.

Psychogenic seizures: A review and description of pitfalls in their acute diagnosis and management in the emergency department

Patients with psychogenic (nonepileptic) seizures (PS) are frequently encountered by clinicians in the emergency medicine setting. Despite the tendency for these patients to seek frequent medical attention, the time between onset of symptoms and diagnosis is often more than 7 years. The cause of PS is multifactorial, but most patients are thought to have an underlying dissociative condition. The diagnostic evaluation in the emergency department is challenging and relies heavily on clinical suspicion, based on historical and physical features. Laboratory testing and therapeutic maneuvers are of limited utility; prolonged video electroencephalography is the diagnostic gold standard. Once the diagnosis has been secured, the mainstay of treatment involves addressing the underlying psychological distress.

Psychogenic nonepileptic seizures after head injury: a case report

Psychogenic nonepileptic seizures (PNESs) are diagnosed when disruptive changes in behaviour, thinking, or emotion resemble epileptic seizures (ESs), but no paroxysmal discharges are seen on electroencephalogram (EEG) and do not originate from another medical illness. The gold standard for PNES diagnosis is video electroencephalogram (Video-EEG). PNESs are defined by modern psychiatry as conversion and dissociative disorders but these disorders may coexist with many others psychiatric disorders, including depression, posttraumatic stress disorder, and personality disorders. It is well known that epileptic seizures are a frequent and well-studied complication of traumatic head injury (THI). However, THI may also generate psychic symptoms including PNES. In this paper we describe a patient who developed PNES after THI in a bus accident and received a diagnosis of refractory epilepsy for 24 years until she underwent Video-EEG.

Psychogenic non-epileptic seizures--definition, etiology, treatment and prognostic issues: a critical review

In this review we systematically assess our currently available knowledge about psychogenic non-epileptic seizures (PNES) with an emphasis on the psychological mechanisms that underlie PNES, possibilities for psychological treatment as well as prognosis. Relevant studies were identified by searching the electronic databases. Case reports were not considered. 93 papers were identified; 65 of which were studies. An open non-randomized design, comparing patients with PNES to patients with epilepsy is the dominant design. A working definition for PNES is proposed. With respect to psychological etiology, a heterogeneous set of factors have been identified. Not all factors have a similar impact, though. On the basis of this review we propose a model with several factors that may interact in both the development and prolongation of PNES. These factors involve psychological etiology, vulnerability, shaping, as well as triggering and prolongation factors. A necessary first step of intervention in patients with PNES seems to be explaining the diagnosis with care. Although the evidence for the efficacy of additional treatment strategies is limited, variants of cognitive (behavioural) therapy showed to be the preferred type of treatment for most patients. The exact choice of treatment should be based on individual differences in the underlying factors. Outcome can be measured in terms of seizure occurrence (frequency, severity), but other measures might be of greater importance for the patient. Prognosis is unclear but studies consistently report that 1/3rd to 1/4th of the patients become chronic.

Optimism, pessimism, and neuropsychological performance across semiology-based subtypes of psychogenic nonepileptic seizures

Past research has suggested that pessimistic attributional style may be a risk factor for psychopathology among patients with seizure disorders. In addition, classifying psychogenic nonepileptic seizures (PNES) into subtypes has been found to be clinically relevant. However, very few studies have addressed differences in optimism, pessimism, or neuropsychological performance among PNES subtypes. We previously classified adults with PNES into semiology-based subtypes (catatonic, minor motor, major motor). In the study described here, we compared subtypes on optimism, pessimism, depressive symptoms, and neuropsychological performance. We found that patients with PNES with low optimism had significantly greater depressive symptoms than patients with high optimism, F(2, 39)=36.49, P<0.01). Moreover, patients with high pessimism had significantly greater depressive symptoms than patients with low pessimism, F(2, 39)=13.66, P<0.01. We also found that the catatonic subtype was associated with fewer depressive symptoms and better verbal memory than the other PNES subtypes. Our results support relationships between optimism, pessimism, and depressive symptoms and extend these findings to a PNES sample. Overall, the results of the present study suggest that classification into semiology-based subtypes and study of normal personality traits among patients with PNES may have clinical significance.

Primary care and emergency physician attitudes and beliefs related to patients with psychogenic nonepileptic spells

Psychogenic nonepileptic spells (PNES) are typically evaluated by primary care and emergency physicians before neurologists. The attitudes and beliefs of such physicians about PNES may impact long-term outcomes and quality of care for these challenging patients. A 21-question survey was created to assess knowledge of, beliefs about, and attitudes toward the diagnosis and management of PNES. The survey found misperceptions that PNES are voluntary, that video/EEG monitoring is not needed to confirm the diagnosis of PNES, and that clinical history is sufficient for diagnosis. Ninety-five percent believe that counseling and psychotherapy are the most appropriate therapies. Ongoing education and outreach to referring physicians about PNES are indicated, especially because early diagnosis of PNES has been associated with better outcomes.

Anxiety and mood disorders in psychogenic nonepileptic seizures

The diagnosis of psychogenic nonepileptic seizures (PNES), particularly in patients with epilepsy, poses a special challenge to the physician in care of these patients. Psychiatric disorders (PD) are more common among patients with epilepsy than in the general population, and this appears to be even more important in patients with PNES. Depression and other mood disorders, as well as anxiety disorders - particularly panic attacks - may make the management of these patients even more difficult in the clinical practice. Concomitant psychiatric conditions have been associated with a poor outcome in patients with PNES]. Psychiatric and psychological intervention has been shown to be associated with improved outcome in PNES in outcome studies, although data is conflicting in this matter. The intricacies and practical implications of such issues are discussed.

Nondrug treatments for psychogenic nonepileptic seizures: what's the evidence?

OBJECTIVE

The purpose of this Cochrane Review was to establish the evidence base for treatment of psychogenic nonepileptic seizures.

METHODS

Six hundred eight references were identified using a search strategy designed with the support of the Cochrane Review Epilepsy Group library. The search employed Medline and PsychInfo, and included hand searches of relevant journals (Seizure, Epilepsia, Epilepsy &Behavior, Epilepsy Research).

RESULTS

Three studies were found that met the inclusion criteria; two used hypnosis and one used paradoxical therapy. None included detailed reports of improved seizure frequency or quality of life, although reduction in seizure frequency was mentioned. All three studies concluded that the intervention used was beneficial in the treatment of psychogenic nonepileptic seizures.

CONCLUSIONS

The limited number of studies and poor methodology preclude these results from being generalizable. There is a need for well-designed clinical trials to identify the most suitable treatments for this population.

Clinical characteristics and outcome of patients diagnosed with psychogenic nonepileptic seizures: a 5-year review

OBJECTIVE

The goal of this article was to describe the clinical characteristics and outcomes of patients diagnosed with psychogenic nonepileptic seizures (PNES).

METHODS

We conducted a retrospective review of patients diagnosed with PNES in a 5-year period.

RESULTS

Fifty patients with PNES were identified, giving an estimated incidence of 0.91/100,000 per annum. Thirty-eight were included for review, 15 of whom were male (39%). Eighteen patients had been diagnosed with epilepsy as well as PNES (47%). We demonstrated a gender difference in our patients, with males having higher seizure frequencies, more antiepileptic drug use, and a longer interval before diagnosis of PNES. Females were diagnosed with other conversion disorders more often than males. Impaired social function was observed in PNES, as was resistance to psychological interventions with a subsequent poor response to treatments.

CONCLUSIONS

PNES remains a difficult condition to treat, and may affect males in proportions higher than those described in previous studies.

Factors involved in the long-term prognosis of psychogenic nonepileptic seizures

INTRODUCTION

Information on the long-term effects of psychogenic nonepileptic seizures (PNES) is limited. We therefore reassessed 22 patients 4-6 years after the initial diagnosis of PNES in a tertiary referral epilepsy center. The diagnosis was confirmed using clinical description and additional electroencephalogram investigations in 1998, 1999, and 2000. Patients with epilepsy and PNES as comorbid symptoms were not included. Reassessments were aimed at seizure reduction and possible psychogenic factors.

METHODS

Three psychological tests were used at baseline at the time of diagnosis and repeated at end point. These three tests assessed different "levels" of psychological function [i.e., complaints (The Symptoms Check List Revised), coping strategy (The Dissociation Questionnaire), and personality factors/psychopathology Nederlandse Verkorte MMPI].

RESULTS

Twenty-two patients were included. Seizure frequency showed statistically significant reduction. At the time of diagnosis, none of the patients was seizure-free or had only yearly seizures, whereas at end point, 7 of 22 patients were completely in remission and 3 patients had only occasional seizures. The number of patients with daily seizures dropped from nine to two. It has not been fully clarified which factors caused this improvement, but the common denominators are that a definitive expert diagnosis in a tertiary center was made and all possible efforts were made to inform the patient in a respectful manner about the diagnosis. In addition to seizure reduction, there was improvement on different levels of psychological function, showing reduction in psychological distress, reduction in dissociative features such as amnesia, increase in self-control, reduction in feelings of dissatisfaction and passive avoidant behavior, and a more active attitude towards social contact.

CONCLUSION

In the long term, the patients with PNES who were included in our study have more self-control and approach social contact with a more self-confident attitude. This does not necessary reflect a causal relationship with the observed seizure reduction. Nonetheless, it is noteworthy that, post aut propter, the eradication of a symptom (i.e., seizures) with social consequences is followed by or is associated with a more confident social attitude. This opens possibilities for treatment strategies.

Treatments for non-epileptic attack disorder

BACKGROUND

Psychogenic non-epileptic seizures (NES) have the outward appearance of epilepsy in the absence of physiological or electroencephalographic correlates. Non-epileptic seizures can occur in isolation or in combination with epileptic seizures. The development and maintenance of non-epileptic seizures has been well documented and there is a growing literature on the treatment of NES which includes non-psychological (including anti-anxiety and antidepressant pharmacological treatment) and psychological therapies (including cognitive behavioural therapy (CBT), hypnotherapy and paradoxical therapy). Various treatment methodologies have been tried with variable success. The purpose of this Cochrane review was to establish the evidence base for the treatment of NES.

OBJECTIVES

To assess whether treatments for NES result in a reduction in frequency of seizures and/or improvement in quality of life, and whether any treatment is significantly more effective than others.

SEARCH STRATEGY

We searched the Cochrane Epilepsy Group's Specialised Register (September 2005), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2005), MEDLINE (1966 to July 2005), and PsycINFO (1806 to July 2005). No language restrictions were imposed. We checked the reference lists of retrieved studies for additional reports of relevant studies

SELECTION CRITERIA

Randomised or quasi-randomised studies were included that assessed one or more types of psychological or non-psychological interventions for the treatment of NES. Studies of childhood NES were excluded from our review.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed the trials for inclusion and extracted data. Outcomes included reduction in seizure frequency and improvements in quality of life.

MAIN RESULTS

Three small studies met our inclusion criteria and were of poor methodological quality. Two assessed hypnosis and the other paradoxical therapy. There were no detailed reports of improved seizure frequency or quality of life outcomes, and these trials provide no reliable evidence of a beneficial effect of these interventions.

AUTHORS' CONCLUSIONS

In view of the methodological limitations and the small number of studies, we have no reliable evidence to support the use of any treatment including hypnosis or paradoxical injunction therapy in the treatment of NES. Randomised studies of these and other interventions are needed.

Non-epileptic seizures and child sexual abuse: A critical review of the literature

Non-epileptic seizures have received a substantial amount of attention in the psychiatric and medical literature, but comparatively little attention from psychologists. Non-epileptic seizures resemble epileptic seizures but lack the physiological symptoms of genuine epilepsy and are psychological in origin. Many authors have emphasized the role that child sexual abuse may play in the etiology of this disorder. In the present paper, we provide a review of 34 studies examining this relationship, followed by a meta-analysis of 19 effect sizes. While our statistical results support the professed link between child sexual abuse and non-epileptic seizures, we suggest that because of research design limitations, it is premature to draw any definitive conclusions regarding a relationship. Eight of these research design limitations are identified and discussed (e.g., the absence of comparison groups; an explicit and public definition of child sexual abuse). Alternatives to a traditional psychoanalytic perspective that emphasizes the role of child sexual abuse in the etiology of NES are presented. Specific recommendations for future research are made and psychologists are strongly encouraged to play a more active role in both researching and treating non-epileptic seizures.

The opinion of the general practitioner toward clinical management of patients with psychogenic nonepileptic seizures

OBJECTIVE

The purpose of this work was to assess the opinion of general practitioners (GPs) regarding the diagnosis of psychogenic nonepileptic seizures (PNES) and the role they feel they should play in the management of the disorder.

METHODS

Patients with PNES were identified from hospital records. Seizure and patient characteristics were recorded. Their GPs were surveyed regarding their understanding of the diagnosis and ongoing management of PNES.

RESULTS

Twenty-three patients were identified over a 3-year period as having been diagnosed with PNES. Sixty-five percent of GPs agreed with the diagnosis, and when asked to grade their understanding of the diagnosis (poor = 1, excellent = 10), the mean score was 5.7 (+/-SD 2.3). Thirty-five percent of GPs felt psychological input was of benefit to their patients. Fifty-two percent of GPs felt comfortable following up these patients, either with or without neurology outpatient services.

CONCLUSIONS

PNES remains a difficult disease to manage. There is a high level of uncertainty regarding the optimum management of PNES among primary care physicians, for which further education is needed.

Psychogenic nonepileptic seizures are associated with an increased risk of obesity

Psychogenic nonepileptic seizures (NES) are somatic manifestations of psychological distress. There is some evidence that weight problems are more common in patients with psychiatric illness. We have observed that patients admitted for video-EEG monitoring who we diagnosed with NES commonly have a larger body habitus than patients with epilepsy. The goal of this study was to test our hypothesis that there was a significant difference in body mass index (BMI) in patients with nonepileptic seizures compared with their epileptic counterparts. We compared the BMIs of 46 NES patients and 46 age- and gender-matched epileptic controls and found that the NES patients had significantly higher BMIs (30.5 vs 26.1, P=0.006) than controls. This remained true after controlling for weight-gain properties of antiepileptic drugs. These results are compared with the prevalence of overweight and obesity in the general population. Possible explanations of the findings and limitations of the study are discussed.

Psychogenic nonepileptic seizures: review and update

The population incidence of psychogenic nonepileptic seizures (PNES) may be only 4% that of epilepsy, but many patients with PNES have a tendency to seek medical attention, and PNES make up a larger share of the workload of neurologists and emergency and general physicians. Although a great number of publications describe how PNES can be distinguished from epileptic seizures, it usually takes several years to arrive at this diagnosis, and three-quarters of patients (with no additional epilepsy) are treated with anticonvulsants initially. However, the management of PNES as epileptic seizures can lead to significant iatrogenic harm. Moreover, the failure to recognize the psychological cause of the disorder detracts from addressing associated psychopathology and enhances secondary somatization processes. This review provides an overview of studies of the diagnosis, etiology, treatment, and prognosis of PNES. Physicians should always consider PNES in the differential diagnosis of a seizure disorder. If a diagnosis of PNES is possible, or a diagnosis of epilepsy in doubt, a clear diagnostic categorization should be sought. This should involve the assessment of the patient by a physician versed in the diagnosis of seizure disorders and, in many cases, the documentation of a typical seizure by video-EEG. Outcome may be improved if the diagnosis is more actively sought, made earlier, and communicated more convincingly.

Diagnosis and Treatment of Nonconvulsive Status Epilepticus in an Intensive Care Unit Setting

Nonconvulsive status epilepticus (NCSE) in adults is a heterogeneous epileptic emergency and includes absence status (AS), complex-partial status epilepticus (CPSE), and the status epilepticus of epileptic encephalopathy (SEEE). The latter seems to be strikingly frequent among patients in intensive care units (ICU). Diagnosis of NCSE is difficult, but has to be made quickly. It relies on clinical signs and a confirmation electroencephalography (EEG). According to the different etiologies and outcomes of AS, CPSE, and SEEE, treatment has to be individually adapted, but needs to follow some basic principles--treatment should take place in the ICU and be monitored by continuous EEG. With a few exceptions, the first drug is an intravenous benzodiazepine, mainly lorazepam. Intravenous fosphenytoin or phenytoin or valproate may follow next. If some forms of NCSE are resistant to first- and second-line treatments, single or combinations of anesthetics and enteral antiepileptic drugs (AEDs) may be added. This opinion is not evidence-based, and randomized controlled prospective trials to evaluate optimal treatment of NCSE are of first priority.

Outcome in psychogenic nonepileptic seizures: 1 to 10-year follow-up in 164 patients

Our knowledge of longer term outcome in psychogenic nonepileptic seizures (PNESs) patients is limited; we know less still about factors predicting prognosis. This study was intended to describe outcome in a large cohort and to identify predictive clinical and psychological factors to generate new ideas for treatment. One hundred sixty-four adult patients with PNESs (66.7%) responded to outcome, personality, and psychosymptomatology questionnaires (Dimensional Assessment of Personality Pathology-Basic Questionnaire [DAPP-BQ], Dissociative Experiences Scale, and Screening Test for Somatoform Symptoms) a mean of 11.9 years after manifestation and 4.1 years after diagnosis of PNES. Additional clinical data were retrieved from hospital records. The responses showed that 71.2% of patients continued to have seizures and 56.4% were dependent on social security. Dependence increased with follow-up. Outcome was better in patients with greater educational attainments, younger onset and diagnosis, attacks with less dramatic features, fewer additional somatoform complaints, and lower dissociation scores. Better outcome was associated with lower scores of the higher order personality dimensions "inhibitedness," "emotional dysregulation," and "compulsivity" but not "dissocial behavior" (DAPP-BQ). Outcome in PNESs is poor but variable. Clinical and personality factors can be used to provide an individualized prognosis. By generating a patient-specific profile, they show particular maladaptive traits or tendencies that can identify goals for psychological therapy.

Treatment of nonepileptic seizures

Studies on nonepileptic seizures (NES) provide dichotomous data sets: extensive observational findings, but a paucity of controlled treatment data. Psychosocial stressors, whose full impact may lie outside a patient's awareness, often underlie NES. These stressors, along with patient's learned patterns of coping, may bring forth or potentiate comorbid psychiatric disorders. Patients with NES often have dysfunction in emotion regulation and family dynamics, as well as unemployment/disability. High percentages of comorbid disorders such as major depressive disorder, post-traumatic stress disorder, and cluster B personality with impulsivity (all disorders associated with serotonin system function) also exist in the NES population. The preliminary observational evidence suggests that specific psychotherapies and pharmacotherapy directed at comorbid conditions may be the most effective treatment for NES.