Management of psychogenic non-epileptic seizures: a multidisciplinary approach

Mechanistic approach and therapeutic strategies in menstrual and non-menstrual migraine

Migraine is a common condition that can cause intense headaches, often on one side of the head, along with symptoms like nausea and sensitivity to light and sound. These headaches can be triggered by various factors, including stress, changes in hormones, sleep disturbances, diet, and even gut health. Migraines are more frequent in women, particularly those under 45, and this may be linked to hormones. After age 45, this difference between men and women becomes less noticeable. Women tend to experience migraines that are more severe and last longer than men, with menstrual migraines affecting about 22% of women during nearly half of their menstrual cycles, and 7.6% of women with migraines. Treatments for migraines include medications, lifestyle changes, and alternative therapies, all of which aim to address the different ways migraines can affect people. This review explores these aspects in detail.

The role of seizure video recordings in the diagnosis of referred drug-resistant epilepsy: A stepwise approach

BACKGROUND

Patient-recorded videos offer a practical alternative for diagnosing epilepsy and psychogenic nonepileptic seizures (PNES), yet their diagnostic value across sequential clinical questions remains underexplored.

OBJECTIVE

To assess the diagnostic utility of patient-recorded seizure videos in distinguishing epilepsy from PNES, classifying seizure types, and localizing and lateralizing epileptic foci, as well as their impact on physician confidence and interrater reliability.

METHODS

In this prospective two-phase study, 40 patients referred for drug-resistant epilepsy evaluation were screened, 30 of whom met the inclusion criteria. Diagnoses were made by one neurologist and confirmed by an independent neurologist via clinical data, electroencephalography, neuroimaging, and patient-recorded videos. Three neurologists independently reviewed cases across four diagnostic steps: (1) epilepsy vs. PNES, (2) focal vs. generalized epilepsy, (3) seizure localization: temporal vs. extratemporal, and (4) seizure lateralization: right vs. left. Diagnostic accuracy, physician confidence, and interrater reliability were analyzed before and after video integration.

RESULTS

Diagnostic accuracy achieved excellent results before and after watching videos in Step 1 (91.67-95 %) and Step 2 (95.93-100 %). After the videos were reviewed, the accuracies in Steps 3 and 4 were good, reaching 83.87 % and 81.48 %, respectively. Videos significantly increased physician confidence across all steps. Interrater reliability improved for Steps 1 and 2-0.67 and 1.00, respectively. Those of seizure localization and lateralization slightly decreased, accompanied by increased accuracy, reflecting a trend toward inconsistent alterations to correct diagnoses among physicians.

CONCLUSION

The accuracy of epilepsy diagnosis in steps 1 and 2 is excellent, and that in steps 3 and 4 is good. Their integration with v-EEG and other diagnostic modalities, such as neuroimaging and invasive techniques, can enhance diagnostic workflows by providing complementary semiological information. Further studies with larger cohorts are warranted to confirm these findings and optimize their application in clinical practice.

What contributes to recovery in the long term? Young people's experiences with psychogenic non-epileptic seizures (PNES)

OBJECTIVE

The aim was to explore young people's experiences with PNES 2-9 years post-discharge from a multidisciplinary epilepsy center. We were particularly interested in their understanding of the underlying causes of their seizures, and the factors that may have contributed to their recovery.

METHODS

A total of 52 patients with PNES participated in a telephone interview. The mean age was 20.9 years (range: 16-28 years), and 45 (87 %) were women. The patients had received psychoeducation from a multidisciplinary team during a 2-4 week inpatient stay at our hospital between 2012 and 2020. We qualitatively analyzed the data using thematic analysis.

RESULTS

After a mean of 4.7 years (ranging from 2-9 years) post-hospital discharge, 90.4 % (47/52) of the participants were able to identify underlying stressors for the seizures. The cumulative burden of physical, social, and psychological stressors was considered overwhelming and was attributed to causing seizures, especially among those under 18. Elder participants were more likely to believe the seizures were related to one or more past traumas. Overall, a lower level of anxiety and stress was perceived essential for achieving seizure control. Four key factors were identified as crucial to the recovery process: 1) psychoeducation; 2) reduction in psychosocial stressors; 3) establishing good everyday routines; and 4) professional treatment, such as trauma therapy.

CONCLUSIONS

A low level of anxiety and stress was found to be crucial for the recovery process. The study suggests that psychoeducation, stress management assistance, and practical facilitation in everyday life should all be components of the standard therapy for young individuals with PNES.

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.

The Patients' Long-Term Insight into Day-to-Day Functioning After Establishing the Functional Seizures Diagnosis

BACKGROUND/OBJECTIVES

Functional seizures (FSs) are paroxysmal, time-limited events with motor, sensory, autonomic, or cognitive manifestations related to pathophysiological processes other than abnormal electric discharges in the brain. However, these seizures are often followed by different psychiatric comorbidities. Their impact on the overall quality of life and the cofounding factors, especially the ones that can be treated, were the main investigation aims of this study.

METHODS

This study comprised 76 patients who were diagnosed with FSs. This study included patients who were diagnosed with FSs via video-EEG telemetry. We used the "Likert scale" from the QOLIE 31 questionnaire to evaluate patients' subjective perception of their quality of life. We researched the association of various clinical factors with the subjective QoL score.

RESULTS

A statistically significant marginal association was shown for seven variables, four of them with a positive association (subjective perception of disease severity, belief in treatments' positive effects, functional seizure cessation, and not being afraid of next seizure) and three of them with a negative association (age at FS onset, depression symptoms, and current age of life). After Bonferroni correction for multiple testing only symptoms of depression stayed statistically significantly associated with outcome. Multivariable logistic regression following variable selection identified that six variables (age at FS onset, absence of psychiatric testing, perceiving oneself as mentally changed due to the disease, seizure severity, depressive symptoms, and fear of therapy side effects) were statistically significantly negatively associated with the outcome.

CONCLUSIONS

It seems that patients who have FSs coexisting with depressive symptoms and also those with worse disease perception have less chances to be satisfied with their overall quality of life.

Associations between violent and sexual childhood trauma and maladaptive coping in patients with functional seizures

OBJECTIVE

Functional seizures (FS) are a highly debilitating symptom of functional neurological disorder (FND). FS requires a multi-disciplinary approach to treatment because the patient's initial presentation is to neurology, emergency medicine, or primary care and treatment consists of psychotherapy. People with FS commonly experience severe childhood trauma, particularly sexual trauma. The authors aimed to investigate associations between reported trauma and maladaptive coping mechanisms in the FS population.

METHODS

This retrospective, observational study reports on 137 patients enrolled in the FS Clinic at the University of Colorado between March 2020 - March 2021. Multiple linear regression was used to reveal associations between self-reported childhood sexual and violent trauma and maladaptive coping mechanisms of self-blame and disengagement on the Brief COPE. A quantile regression was generated for each of these outcomes.

RESULTS

Results showed that violent and sexual trauma were experienced by 47.5% and 61.6% of the population sample, respectively. Of those exposed to violent trauma, 27.2% perceived it as extremely severe while 43.4% of those exposed to sexual trauma perceived it as extremely severe. Quantile regressions for self-blame and disengagement showed significance for the 25th percentile of those who experienced violent trauma. Self-blame was significantly associated with the 50th and 75th percentile of those exposed to sexual trauma.

CONCLUSIONS

This evidence supports the value of identifying trauma experienced by individuals with FS as it is associated with specific coping mechanisms that may affect treatment. Identifying prior trauma and resulting coping mechanisms can potentially assist in individualizing care for people with FS.

Functional seizures and binge eating disorder: A cross-sectional study

OBJECTIVE

Functional seizures (FS) are brief, involuntary changes in behaviour or consciousness, distinct from epileptic seizures, potentially associated with psychological dissociation. Binge eating disorder (BED) was linked to psychological and somatic dissociation also. However, any connection between FS and BED is insufficiently explored. We aimed to assess BED prevalence in individuals with FS, anxiety/depression (AD), and healthy subjects (HS), to investigate dissociation's link to binge eating, and to explore psychological characteristics of FS individuals.

METHOD

Participants underwent evaluations based on ILAE guidelines and DSM-5 criteria, including questionnaires assessing binge eating, dissociation, anxiety, depression and personality traits. Inclusion criteria were age > 18 years, no history of substance abuse, no history of epilepsy, and no use of medications inducing eating disorders.

RESULTS

We found significantly more frequent and severe binge-eating symptoms in individuals with FS and AD compared to HS. Depression and dissociation correlated with binge-eating symptoms in both AD and FS groups. The PID-5 facet 'Perseveration' predicted binge-eating attitudes only in FS individuals; they reported more childhood emotional neglect and increased disinhibition compared do AD people.

DISCUSSION

This study underscores the commonality of binge-eating symptoms in FS individuals, emphasizing its association with dissociation symptoms. This finding support the hypothesis of a link between dissociation and eating disorders. Unique clinical characteristics in individuals with FS were identified, as a compulsive dimension related to binge-eating symptoms, providing a comprehensive understanding of their psychological profile and guiding targeted therapeutic interventions.

Young people diagnosed with psychogenic nonepileptic seizures (PNES) years ago - How are they now?

BACKGROUND

Up to 30% of patients referred to epilepsy centres for drug-resistant epilepsy turn out to have psychogenic nonepileptic seizures (PNES). Patients with PNES are a very heterogeneous population with large differences in regard to underlying causes, seizures severity, and impact on quality of life. There is limited knowledge regarding the long-term seizure prognosis of youth with PNES and its influential factors.

METHODS

We have performed a retrospective study on adolescents diagnosed with PNES who were receiving inpatient care at our hospital for 2-4 weeks in the period of 2012-2020. They all attended psychoeducational courses to educate them about PNES, coping with the seizures, and possible contributors to seizure susceptibility. There were 258 patients who fulfilled the inclusion criteria. We contacted them by text messages, through which they received brief information about the study and an invitation to participate. There were 62 patients (24 %) who agreed and participated in structured telephone interviews. We excluded 10 patients due to concomitant epilepsy. The mean age of the remaining 52 participants was 20.9 years (16-28 years), and 45 (87 %) were women.

RESULTS

After a mean of 4.7 years (2-9 years) since discharge from our hospital, 28 patients (54 %) had been free of seizures in the last 6 months. There were 16 patients (31 %) who had better situations in regard to seizures but were not completely seizure free, while 8 patients (15 %) were either unchanged (3 patients) or worse (5 patients). There were 39 patients (75 %) who had received conversation therapy, and 37 patients (71 %) had been treated by a psychologist or psychiatrist. There were 10 patients (19 %) who had dropped out of school or work, and the percentage increased with age. There were 42 patients (80 %) who perceived their health as good or very good.

CONCLUSION

Patients had a relatively favourable seizure prognosis as 54% were free of seizures and 31% had a better seizure situation, at the time of this study. However, the fact that 19% had dropped out of school or work was worrying. Young age and satisfaction with treatment were associated with being employed or receiving education. Satisfaction with perceived treatment was significantly associated with personal experience of good health. This emphasizes the importance of early diagnosis, adapted interventional measures, and long-term follow-up by healthcare for young people with PNES.

Exploring therapeutic interventions for functional neurological disorders: a comprehensive scoping review

Functional Neurological Disorders (FNDs) are characterized by the symptoms experienced by the individuals but also by how they express personal experiences and concerns related to the clinical condition. Access to care programs for functional neurological symptoms appears challenging and may entail circular, self-perpetuating healthcare pathways. Given the challenging and misleading interpretations around FND, in advocating for care pathways beyond medical therapies, we designed a scoping review to map recently suggested practices and interventions. We identified 31 relevant papers published between January 2018 and December 2022. Most of the literature was gathered from the US and UK healthcare experiences, with documented interventions provided by multi-professional teams or stand-alone psychotherapists. We found different care pathways addressing either motor or non-motor manifestations. Persons with Functional Motor Disorder are more likely to be referred to physical therapy first, while Persons suffering from Non-Epileptic Seizures are to mental health services. A narrow focus was given to minor components of multimodal approaches (e.g. social workers, and occupational therapists). High heterogeneity was found between assessment instruments as well, reflecting different perspectives in selecting treatment outcomes (e.g., reduction of non-epileptic events, psychological functioning, motor symptoms). Among healthcare professionals, neurologists and (neuro)psychiatrists are typically engaged in formulating and delivering diagnoses, while treatment is often administered by physiotherapists and/or psychologists. In the context of FNDs, the complex etiopathological nature of the condition, including comorbidities, suggests the recommendation of multidisciplinary treatments adopting a stepped care model progressing from standard to higher level individualized modules may better suit individual complexities.

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.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Psychogenic Nonepileptic Seizures Associated with an Eating Disorder and PTSD Are Responsive to Cognitive Processing Therapy

Objective

Eating disorders (EDs) are often associated with prior histories of trauma, subsequent PTSD and related psychiatric comorbidities. There is a paucity of information about their relationship to somatic symptom disorders, specifically psychogenic nonepileptic seizures (PNES), a type of functional neurological symptom disorder or conversion disorder.

Methods

We report a case of a 39-year-old bisexual female with bulimia nervosa (BN), PTSD, recurrent major depressive disorder (MDD), cannabis use disorder, and PNES who responded to integrated trauma-focused treatment during residential ED treatment using cognitive processing therapy (CPT). Symptoms of ED, PTSD, major depression, and state-trait anxiety were measured using validated assessment instruments.

Results

During the course of CPT treatment, the patient's total scores on the PTSD Symptom Checklist for DSM-5 (PCL-5) went from 59 to 26, which is below the diagnostic threshold for PTSD. In addition, she demonstrated improvements in the Eating Disorder Examination Questionnaire (EDE-Q) Global Severity score, the Eating Disorder Inventory (EDI-2) total score, the Patient Health Questionnaire (PHQ-9) total score, the Spielberger State and Trait Anxiety Inventory scores, and the Eating Disorder Quality of Life (EDQOL) total score. Furthermore, her PNES also abated, and she remained seizure free for ∼1 year following discharge with the exception of one short seizure, per report of the patient.

Conclusion

The use of CPT as part of an integrated trauma-informed treatment approach during residential ED treatment was successful in a woman with PNES, BN, PTSD, MDD, and cannabis use disorder.

Brain cell-specific origin of circulating microRNA biomarkers in experimental temporal lobe epilepsy

The diagnosis of epilepsy is complex and challenging and would benefit from the availability of molecular biomarkers, ideally measurable in a biofluid such as blood. Experimental and human epilepsy are associated with altered brain and blood levels of various microRNAs (miRNAs). Evidence is lacking, however, as to whether any of the circulating pool of miRNAs originates from the brain. To explore the link between circulating miRNAs and the pathophysiology of epilepsy, we first sequenced argonaute 2 (Ago2)-bound miRNAs in plasma samples collected from mice subject to status epilepticus induced by intraamygdala microinjection of kainic acid. This identified time-dependent changes in plasma levels of miRNAs with known neuronal and microglial-cell origins. To explore whether the circulating miRNAs had originated from the brain, we generated mice expressing FLAG-Ago2 in neurons or microglia using tamoxifen-inducible Thy1 or Cx3cr1 promoters, respectively. FLAG immunoprecipitates from the plasma of these mice after seizures contained miRNAs, including let-7i-5p and miR-19b-3p. Taken together, these studies confirm that a portion of the circulating pool of miRNAs in experimental epilepsy originates from the brain, increasing support for miRNAs as mechanistic biomarkers of epilepsy.

[Diagnostic criteria, epidemiology and assessment of patients with functional neurological disorders]

Functional neurological disorders (FND) are symptoms that can affect a variety of functions including motor, sensory and cognitive. These symptoms are genuinely experienced by the patient and are related to a functional disorder rather than a structural one. There is little epidemiological data on these disorders, but their frequency is well established in clinical practice, it is the second most frequent reason for consultation in Neurology. Despite of the frequency of the disorder, general practitioners and specialists are insufficiently trained in the disease, and patients often suffer from stigmatization and/or unnecessary investigations. It is therefore important to be aware of the diagnostic approach to FND, which mostly relies on positive clinical signs. Psychiatric evaluation can help with the characterization of predisposing, precipitating and perpetuating factors of the symptoms (according to the 3P biopsychosocial model related to FND), and guide their management. Finally, diagnosis explanation is a crucial step in the management of the disease, which can in itself have a therapeutic effect, and allow the patient to adhere to the treatments.

A global survey on the attitudes of neurologists and psychiatrists about functional/psychogenic/dissociative/nonepileptic-seizures/attacks, in the search of its name

PURPOSE

We conducted an observational study to investigate the opinions of neurologists and psychiatrists all around the world who are taking care of patients with seizures [epilepsy and functional seizures (FS)].

METHODS

Practicing neurologists and psychiatrists from around the world were invited to participate in an online survey. On 29th September 2022, an e-mail including a questionnaire was sent to the members of the International Research in Epilepsy (IR-Epil) Consortium. The study was closed on 1st March 2023. The survey, conducted in English, included questions about physicians' opinions about FS and anonymously collected data.

RESULTS

In total, 1003 physicians from different regions of the world participated in the study. Both neurologists and psychiatrists identified "seizures" as their preferred term. Overall, the most preferred modifiers for "seizures" were "psychogenic" followed by "functional" by both groups. Most participants (57.9%) considered FS more difficult to treat compared to epilepsy. Both psychological and biological problems were considered as the underlying cause of FS by 61% of the respondents. Psychotherapy was considered the first treatment option for patients with FS (79.9%).

CONCLUSION

Our study represents the first large-scale attempt of investigating physicianś attitudes and opinions about a condition that is both frequent and clinically important. It shows that there is a broad spectrum of terms used by physicians to refer to FS. It also suggests that the biopsychosocial model has gained its status as a widely used framework to interpret and inform clinical practice on the management of patients.

Psychogenic Nonepileptic Seizures-High Mortality Rate Is a 'Wake-Up Call'

Patients with epilepsy have an elevated mortality rate compared to the general population and now studies are showing a comparable death ratio in patients diagnosed with psychogenic nonepileptic seizures. The latter is a top differential diagnosis for epilepsy and the unexpected mortality rate in these patients underscores the importance of an accurate diagnosis. Experts have called for more studies to elucidate this finding but the explanation is already available, embedded in the existing data. To illustrate, a review of the diagnostic practice in epilepsy monitoring units, of the studies examining mortality in PNES and epilepsy patients, and of the general clinical literature on the two populations was conducted. The analysis reveals that the scalp EEG test result, which distinguishes a psychogenic from an epileptic seizure, is highly fallible; that the clinical profiles of the PNES and epilepsy patient populations are virtually identical; and that both are dying of natural and non-natural causes including sudden unexpected death associated with confirmed or suspected seizure activity. The recent data showing a similar mortality rate simply constitutes more confirmatory evidence that the PNES population consists largely of patients with drug-resistant scalp EEG-negative epileptic seizures. To reduce the morbidity and mortality in these patients, they must be given access to treatments for epilepsy.

The neurobiology of functional neurological disorders characterised by impaired awareness

We review the neurobiology of Functional Neurological Disorders (FND), i.e., neurological disorders not explained by currently identifiable histopathological processes, in order to focus on those characterised by impaired awareness (functionally impaired awareness disorders, FIAD), and especially, on the paradigmatic case of Resignation Syndrome (RS). We thus provide an improved more integrated theory of FIAD, able to guide both research priorities and the diagnostic formulation of FIAD. We systematically address the diverse spectrum of clinical presentations of FND with impaired awareness, and offer a new framework for understanding FIAD. We find that unraveling the historical development of neurobiological theory of FIAD is of paramount importance for its current understanding. Then, we integrate contemporary clinical material in order to contextualise the neurobiology of FIAD within social, cultural, and psychological perspectives. We thus review neuro-computational insights in FND in general, to arrive at a more coherent account of FIAD. FIAD may be based on maladaptive predictive coding, shaped by stress, attention, uncertainty, and, ultimately, neurally encoded beliefs and their updates. We also critically appraise arguments in support of and against such Bayesian models. Finally, we discuss implications of our theoretical account and provide pointers towards an improved clinical diagnostic formulation of FIAD. We suggest directions for future research towards a more unified theory on which future interventions and management strategies could be based, as effective treatments and clinical trial evidence remain limited.

Self-injurious thoughts and behaviors in Russian patients with epilepsy: A prospective observational study

OBJECTIVE

A two-stage study aimed to estimate the prevalence of different types of self-injurious behaviors (suicidal ideation (SI), suicide attempts (SA), and nonsuicidal self-injury (NSSI)) in Russian patients with epilepsy (PWE), to identify factors associated with such behaviors, and to assess their impact on 3-year mortality.

METHODS

We enrolled 459 consecutive adult PWE from two level 2 outpatient epilepsy centers in Moscow. The study consisted of two phases - first, we assessed all demographic and clinical characteristics and patients' history of SI, SA, and NSSI. In the second phase, three years after the initial screening, we analyzed patients' medical records to assess how self-injurious thoughts and behaviors were related to actual mortality.

RESULTS

In our sample, the total lifetime and 12-month prevalence of SI was 20% and 5.7%, of SA was 8.3% and 0.7%, and of NSSI was 15.3% and 2.8%, respectively. We found no differences between deceased and alive PWE regarding lifetime and 12-month prevalence of SI, SA, and NSSI. Higher seizure frequency, lifetime NSSI and lifetime diagnosis of mental disorder were associated with SI, whereas traumatic brain injury (TBI), substance abuse, and NSSI were associated with SA in PWE.

SIGNIFICANCE

Our study adds to the existing data on the prevalence of different types of suicidal behaviors in PWE and advances research on NSSI in this population. However, more research is needed on the long-term consequences of different types of self-injurious behaviors.

Is depression in patients with temporal lobe epilepsy related to hippocampal sclerosis? A meta-analysis

OBJECTIVE

To systematically evaluate the association between hippocampal sclerosis (HS) and depression in patients with temporal lobe epilepsy (TLE) through a meta-analysis.

METHODS

Chinese and English databases, such as the China National Knowledge Infrastructure (CNKI), Chinese Scientific Journals (VIP), WanFang, the Chinese Biomedical Literature Service System (SinoMed), PubMed and the Web of Science, were searched.

RESULTS

Two evaluators independently screened the literature, extracted data and evaluated the risk of bias in the included studies in accordance with the inclusion and exclusion criteria. RevMan 5.1 was used to analyze the data. A total of 786 patients with epilepsy were included in the study, including 82 depressive patients with HS and 64 depressive patients without HS. The results showed that the TLE patients with HS were more likely to develop depression than those without HS (odds ratio (OR)= 2.14, 95% confidence interval (CI) [1.45, 3.16], Z = 3.85, p = 0.0001).

CONCLUSION

HS can be considered a high-risk factor for depression in patients with TLE, and the correlation is significant. However, the sample size included in the study was small; additional high-quality studies are needed in the future.

[Psychogenic non-epileptic seizures in autistic spectrum disorder]

Psychogenic non-epileptic seizures (PNES) are paroxysmal conditions that resemble epileptic seizures, but are not accompanied by epileptiform activity on the electroencephalogram and are not associated with other neurological or somatic disorders. Unrecognized PNES places a heavy burden on the patient and family, and on the health care system. Among many possible combinations of PNES with psychiatric disorders, autistic spectrum disorders are the least studied. This article presents a case of a 19-year-old female patient with autistic spectrum disorder and paroxysmal events and the presence of potentially epileptogenic changes in the brain. A multidisciplinary approach made it possible to diagnose PNEP in the patient.

Convolutional Neural Network Classification of Rest EEG Signals among People with Epilepsy, Psychogenic Non Epileptic Seizures and Control Subjects

Identifying subjects with epileptic seizures or psychogenic non-epileptic seizures from healthy subjects via interictal EEG analysis can be a very challenging issue. Indeed, at visual inspection, EEG can be normal in both cases. This paper proposes an automatic diagnosis approach based on deep learning to differentiate three classes: subjects with epileptic seizures (ES), subjects with non-epileptic psychogenic seizures (PNES) and control subjects (CS), analyzed by non-invasive low-density interictal scalp EEG recordings. The EEGs of 42 patients with new-onset ES, 42 patients with PNES video recorded and 19 patients with CS all with normal interictal EEG on visual inspection, were analyzed in the study; none of them was taking psychotropic drugs before registration. The processing pipeline applies empirical mode decomposition (EMD) to 5s EEG segments of 19 channels in order to extract enhanced features learned automatically from the customized convolutional neural network (CNN). The resulting CNN has been shown to perform well during classification, with an accuracy of 85.7%; these results encourage the use of deep processing systems to assist clinicians in difficult clinical settings.

Exploring seizure management in hospitals, unmet need, and the impact of the COVID-19 pandemic on seizure presentations to hospital

Purpose

This study assesses investigations, referrals and admissions in patients presenting to the Emergency Department (ED) with seizures, and the effect of the COVID-19 pandemic on such management. Outcomes in patients with learning disabilities, active significant mental health concerns, and from the most socioeconomically deprived areas were compared to those of the general cohort.

Methods

Investigations, referrals and admissions were recorded for 120 patients across two cohorts; pre-pandemic (September 2019) and during the pandemic (December 2020). Retrospective review of individual patient electronic health care records was used for data collection.

Results

There was a decrease in patient numbers from 2019 to 2020. A greater proportion of patients presented with organic cause seizures and fewer presented with non-epileptic attacks. Frequent use of CT heads (45%) is likely to represent improper use of limited resources. There were low referral rates, both to acute neurology (28%) and to the adult epilepsy team (32%). Patients with active significant mental health concerns were significantly less likely to be referred to neurology or admitted.

Conclusions

Despite a greater proportion of admissions during the Covid-19 pandemic, referrals to acute neurology and the epilepsy team remained low. Failure to refer prevents the most vulnerable seizure patients from receiving appropriate support, as seen in patients with active significant mental health concerns. Neurology staff were unaware of a significant number of patients presenting with seizures, which is of concern in an already over-stretched department. This offers an opportunity to improve care for people with epilepsy.

Characterizing differences in psychiatric profiles between male and female veterans with epilepsy and psychogenic non-epileptic seizures

OBJECTIVE

While previous studies have described psychiatric profiles in patients with psychogenic non-epileptic seizures (PNES) and epileptic seizures (ES), a well-matched comparison between males and females has been lacking. To address this shortcoming, the present study sought to explore sex differences between male and female Veterans with ES and PNES in terms of psychiatric diagnoses, trauma histories, and psychiatric treatment.

METHODS

A male Veteran sample (PNES n = 87, ES n = 28) was identified matching age and seizure diagnosis with our previously-gathered female Veteran sample (PNES n = 90, ES n = 28). Retrospective chart review was used to obtain demographic, psychiatric, and seizure-related variables. Group differences between PNES and ES were first assessed among males followed by differences between males and females.

RESULTS

Males with PNES were more likely to receive psychiatric treatment (82.6 % vs. 60.7 %, p = 0.017), be prescribed more psychotropics (1.6 vs. 0.9, p = 0.003), and more likely to have childhood physical abuse (27.9 % vs. 3.6 %, p = 0.007) than those with ES. Compared to PNES, males with ES presented to the epilepsy monitoring unit (EMU) significantly later (12.8 years vs. 6.1 years, p = 0.009), and were prescribed more anti-seizure medications (ASMs) previously (2.1 vs. 0.8, p = 0.009) and currently (1.6 vs. 1.0, p = 0.001). Between males and females with PNES, females evidenced more depression (76.7 % vs. 26.3 %, p < 0.001), borderline personality disorder (18.9 % vs. 4.7 %, p = 0.004), suicidality (65.6 % vs. 33.7 %, p < 0.001), and childhood sexual abuse (37.8 % vs. 11.6 %, p < 0.001), while males had higher rates of substance use disorders (37.2 % vs. 8.9 %, p < 0.001).

SIGNIFICANCE

A greater psychiatric burden is seen among females compared to males with PNES, especially diagnoses of borderline personality disorder and depression. Higher rates of suicidality and inpatient psychiatric hospitalization may warrant particular consideration in screening and intervention efforts among female Veterans with PNES.

Treatment of Psychogenic Nonepileptic Seizures

PURPOSE OF REVIEW

Psychogenic nonepileptic seizures (PNES) are the most common Functional Neurological Disorder/Conversion Disorder subtype. Significant advances have been made related to diagnosis, neurobiology, and treatment. In this review, we summarize updates in diagnosis and management over the past 3 years.

RECENT FINDINGS

Although evidence is mixed for the treatment of PNES, psychotherapeutic modalities remain a powerful instrument to empower patients and reduce seizures. A multidisciplinary, holistic approach is beneficial. While seizure freedom in all patients may not be the achieved endpoint in this chronic, paroxysmal disorder, quality of life can be improved with treatment. Additional treatment modalities and further research are needed for patients who are refractory to current treatment. Evidence-based therapies exist for PNES, and recent findings represent an increased understanding of the clinical and neurophysiologic aspects of PNES.

Neuropsychiatric and Cognitive Comorbidities in Epilepsy

PURPOSE OF REVIEW

This article discusses psychiatric and cognitive comorbidities of epilepsy over the lifespan and illustrates opportunities to improve the quality of care of children and adults with epilepsy.

RECENT FINDINGS

One in 3 people with epilepsy have a lifetime history of psychiatric disorders, and they represent an important prognostic marker of epilepsy. Contributors are diverse and display a complex relationship. Cognitive comorbidities are also common among those living with epilepsy and are increasingly recognized as a reflection of changes to underlying brain networks. Among the cognitive comorbidities, intellectual disability and dementia are common and can complicate the diagnostic process when cognitive and/or behavioral features resemble seizures.

SUMMARY

Comorbidities require consideration from the first point of contact with a patient because they can determine the presentation of symptoms, responsiveness to treatment, and the patient's day-to-day functioning and quality of life. In epilepsy, psychiatric and cognitive comorbidities may prove a greater source of disability for the patient and family than the seizures themselves, and in the case of essential comorbidities, they are regarded as core to the disorder in terms of etiology, diagnosis, and treatment.

Functional neurological disorder: new subtypes and shared mechanisms

Functional neurological disorder is common in neurological practice. A new approach to the positive diagnosis of this disorder focuses on recognisable patterns of genuinely experienced symptoms and signs that show variability within the same task and between different tasks over time. Psychological stressors are common risk factors for functional neurological disorder, but are often absent. Four entities-functional seizures, functional movement disorders, persistent perceptual postural dizziness, and functional cognitive disorder-show similarities in aetiology and pathophysiology and are variants of a disorder at the interface between neurology and psychiatry. All four entities have distinctive features and can be diagnosed with the support of clinical neurophysiological studies and other biomarkers. The pathophysiology of functional neurological disorder includes overactivity of the limbic system, the development of an internal symptom model as part of a predictive coding framework, and dysfunction of brain networks that gives movement the sense of voluntariness. Evidence supports tailored multidisciplinary treatment that can involve physical and psychological therapy approaches.

Neuropsychiatric Treatment Approaches for Functional Neurological Disorder: A How to Guide

There is a growing body of knowledge regarding management of functional neurological disorder (FND). The aim of this article is to guide the clinician through FND clinical management, from delivery of the diagnosis, to creation of a biopsychosocially-informed treatment plan, to troubleshooting common issues that arise throughout longitudinal care. We review the evidence and core principles of both rehabilitative therapies (physical therapy, occupational therapy, and speech and language therapy) and psychological therapies for the treatment of FND, and discuss the benefits of engaging a multidisciplinary and interdisciplinary team. The optimal timing of specific therapeutic interventions is also discussed, emphasizing a patient-centered perspective. Resources for further reading, for both patients and clinicians, are provided throughout. Additional research is needed to further optimize the therapeutic approach to patients with FND, including the need to develop novel treatments for those that do not positively respond to currently available interventions.

Permutation Entropy-Based Interpretability of Convolutional Neural Network Models for Interictal EEG Discrimination of Subjects with Epileptic Seizures vs. Psychogenic Non-Epileptic Seizures

The differential diagnosis of epileptic seizures (ES) and psychogenic non-epileptic seizures (PNES) may be difficult, due to the lack of distinctive clinical features. The interictal electroencephalographic (EEG) signal may also be normal in patients with ES. Innovative diagnostic tools that exploit non-linear EEG analysis and deep learning (DL) could provide important support to physicians for clinical diagnosis. In this work, 18 patients with new-onset ES (12 males, 6 females) and 18 patients with video-recorded PNES (2 males, 16 females) with normal interictal EEG at visual inspection were enrolled. None of them was taking psychotropic drugs. A convolutional neural network (CNN) scheme using DL classification was designed to classify the two categories of subjects (ES vs. PNES). The proposed architecture performs an EEG time-frequency transformation and a classification step with a CNN. The CNN was able to classify the EEG recordings of subjects with ES vs. subjects with PNES with 94.4% accuracy. CNN provided high performance in the assigned binary classification when compared to standard learning algorithms (multi-layer perceptron, support vector machine, linear discriminant analysis and quadratic discriminant analysis). In order to interpret how the CNN achieved this performance, information theoretical analysis was carried out. Specifically, the permutation entropy (PE) of the feature maps was evaluated and compared in the two classes. The achieved results, although preliminary, encourage the use of these innovative techniques to support neurologists in early diagnoses.

Assessing the hidden burden of psychiatric disease in patients with nonepileptic seizures

Nonepileptic seizures are commonly associated with psychiatric comorbidities, and specifically PTSD. Despite increased prevalence of psychiatric disease noted on referral of patients to our dedicated clinic for nonepileptic seizures, we found even higher rates of comorbid psychiatric disease or significant symptomatology after our initial clinic intakes, whereby patients are formally evaluated by a behavioral health provider, in addition to an epileptologist. After intake, an additional 21% of patients were identified as having PTSD or significant trauma-related symptoms, an additional 7% of patients were identified with significant anxiety or panic-related symptoms, and an additional 11% of patients were identified with significant depressive symptoms. While highly effective treatment of nonepileptic seizures remains elusive, well-developed treatment paradigms with proven efficacy exist for depression, anxiety, and PTSD. Eliciting these psychiatric comorbidities and pursuing targeted treatments, especially for those patients that do not have easy access to providers with dedicated expertise in the management of nonepileptic seizures, may be a more easily scalable and implementable treatment modality for these patients.

The Psychiatric Comorbidities of Migraine in Children and Adolescents

PURPOSE OF REVIEW

Understanding comorbidities in migraine is important because it can help us understand disease pathophysiology while also aiding the development of more effective treatment strategies. Additionally, it can provide greater awareness about appropriate diagnosis, the need for additional disease screening, and the natural history of migraine. Psychiatric comorbidities have been independently studied in both adults and children with migraine because their presentations can be distinct, and the physiology in these two groups can be different.

RECENT FINDINGS

While symptoms of anxiety and depression seem to be comorbid with migraine in children, clinically significant disease does not appear to be, though the clarity of these data is limited by overlap between migraine symptomatology and that assessed by many screening tools. Functional neurologic disorders like psychogenic non-epileptic episodes (PNEE) and other functional movement disorders are not common but can be comorbid with migraine in this population and tend to improve with migraine treatment. The number of adverse childhood experiences (ACEs) a child is exposed to seems to be near-linearly associated with risk of migraine, but not with tension-type headache (TTH). The findings from these studies underscore the importance of utilizing appropriate screening methodologies for identifying psychiatric disorders in children with migraine. Additionally, the role of the insula, the hypothalamic-pituitary-adrenal axis, the serotonergic system, and the instability of hyperactivated neural networks may underlie the pathophysiology of both migraine and its psychiatric comorbidities.

[Psychogenic non-epileptic seizures]

The review provides epidemiological data and discuss the associated burden of non-epileptic seizures (PNES). Data on the prevalence, socio-demographic and clinical risk factors for the development of PNES are presented. The hypotheses of the PNES origin, including the contribution of psychological trauma, are considered. We also describe contemporary methods for differential diagnosis of epileptic seizures and PNES, including biomarkers and the use of diagnostic questionnaires. Special attention is given to the issues of the psychiatric comorbidity of PNES.

Diagnostic accuracy of clinical signs and symptoms for psychogenic nonepileptic attacks versus epileptic seizures: A systematic review and meta-analysis

BACKGROUND

Psychogenic nonepileptic attacks (PNEA) are events of altered behavior that resemble epileptic seizures (ES) but are not caused by abnormal electrical cortical activity. Understanding which clinical signs and symptoms are associated with PNEA may allow better triaging for video-electroencephalogram monitoring (VEM) and for a more accurate prediction when such testing is unavailable.

METHODS

We performed a systematic review searching Medline, Embase, and Cochrane Central from inception to March 29, 2019. We included original research that reported at least one clinical sign or symptom, included distinct groups of adult ES and PNEA with no overlap, and used VEM for the reference standard. Two authors independently assessed quality of the studies using the Quality Assessment of Diagnostic Accuracy Studies tool. Pooled estimates of sensitivity and specificity of studies were evaluated using a bivariate random effects model.

RESULTS

We identified 4028 articles, of which 33 were included. There was a female sex predominance in the PNEA population (n = 22). From our meta-analysis, pooled sensitivities (0.27-0.72) and specificities (0.51-0.89) for PNEA were modest for individual signs. History of sexual abuse had the highest pooled specificity (89%), while the most sensitive feature was female sex (72%). Individual studies (n = 4) reported high levels of accuracy for ictal eye closure (sensitivity 64-73.7% and specificity 76.9-100%) and post-traumatic stress disorder (no reported sensitivity or specificity). Assuming the pre-test probability for PNEA in a tertiary care epilepsy center is 14%, even the strongest meta-analyzed features only exert modest diagnostic value, increasing post-test probabilities to a maximum of 33%.

CONCLUSIONS

This review reflects the limited certainty afforded by individual clinical features to distinguish between PNEA and ES. Specific demographic and comorbid features, even despite moderately high specificities, impart minimal impact on diagnostic decision making. This emphasizes the need for the development of multisource predictive tools to optimize diagnostic likelihood ratios.

Comorbidities in patients with epilepsy: Frequency, mechanisms and effects on long-term outcome

OBJECTIVE

To assess frequency, types, and mechanisms of comorbidities in people with epilepsy and verify their association with disease features and outcome.

METHODS

This cohort study was performed in 13 Italian epilepsy centers with nationwide distribution and accurate records. Eligible patients were children and adults diagnosed before December 31, 2005, and followed for a minimum of 10 years. Two pairs of raters independently reviewed patients' records and classified each comorbidity. In case of disagreement, a third reviewer made the final decision. Comorbidities were classified according to type (organ/system) and underlying mechanism (causal, shared risk factors, chance association). Comorbidity types and mechanisms were described in the entire sample and according to epilepsy prognostic patterns (sustained remission, relapsing-remitting course, no remission).

RESULTS

Of 1006 included patients, 266 (26.4%) had at least one comorbidity. The most common were developmental/perinatal (7.5% of cases), psychiatric (6.2%), cardiovascular (5.3%), and endocrine/metabolic (3.8%). Among 408 reported comorbidities, the underlying mechanisms were, in decreasing order, chance association (42.2%), shared risk factors (31.1%), and causal (26.7%). Psychiatric diseases were present in 13.3% of patients with no remission, 5.9% of patients with relapsing-remitting course, and 4.8% of patients with sustained remission (p = .016). The corresponding numbers for endocrine/metabolic diseases were respectively, 9.6%, 3.4%, and 2.9% (p = .013); for respiratory diseases were 3.6%, .3%, and .3% (p = .001), and for urogenital diseases were 3.6%, .7%, and 1.6% (p = .048). The association of endocrine/metabolic, psychiatric, and respiratory comorbidities with epilepsy prognosis was confirmed by multivariable analysis adjusted for the main demographic and clinical variables, with patients with these comorbidities showing a lower probability of achieving remission.

SIGNIFICANCE

Comorbidities in epilepsy are not uncommon and reflect differing underlying mechanisms. Psychiatric, endocrine/metabolic, and respiratory disorders are associated with a worse long-term epileptological outcome.

Psychogenic non-epileptic seizures in children

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

Discontinuation of antiseizure medications in seizure-free patients with long-term follow-up: Patients' profile, seizure recurrence, and risk factors

OBJECTIVE

To compare withdrawal of antiseizure medications (ASM) to continued treatment in newly diagnosed individuals achieving seizure freedom, and assess the risk of relapse and factors associated with relapse.

METHODS

This is a multicenter retrospective cohort study with long-term follow-up. Patients with newly diagnosed epilepsy were identified from the medical records of 13 Italian epilepsy centers and followed up until the most recent visit or death. Seizure-free patients discontinuing treatment were compared to patients who maintained treatment for baseline characteristics. Treatment was stopped upon clinical judgment. The probability of relapse was calculated with the Kaplan-Meier method. Demographic, clinical, and instrumental variables associated with relapse were assessed with Cox proportional hazards models.

RESULTS

One thousand and six patients aged 1 month to 72 years at diagnosis were enrolled and followed up for 17,892 person-years (median follow-up, 9.9 years). Three hundred and twenty patients (31.8%) underwent one or more treatment discontinuations. Factors associated with ASM withdrawal were younger age at remission and normal psychiatric examination. The probability of relapse after the first withdrawal was 16% at six months, 24% at 12 months, and 36%, 45%, and 53% at three, five, and ten years, respectively. The probability of remission after the first relapse was 59% at one month, 67%, 72, and 76% at three, six, and 12 months, respectively. Variables associated with relapse were age 14+ years, structural etiology, abnormal neuroimaging, ASM initiation after a single seizure, and symptomatic/cryptogenic epilepsy.

CONCLUSIONS

About one half of seizure-free patients stopping ASM relapse in 10 years. However, the possibility of remission after relapse is high, particularly in children and patients with idiopathic/cryptogenic epilepsy. Treatment deprescription might be encouraged at least in these patients.

Employment and disability status in patients with functional (psychogenic nonepileptic) seizures

PURPOSE

We investigated the rate of employment in patients with functional seizures (FS) in a follow-up study. We also investigated the rate of receiving disability benefits in these patients. Finally, we investigated factors that are potentially associated with their employment status.

METHODS

In this long-term study, all patients with FS, who were diagnosed at Shiraz Comprehensive Epilepsy Center, Iran, from 2008 to 2018, were investigated. In a phone call interview to the patients in February 2020, we tried to obtain the following information: seizure outcome, employment status, receiving disability benefits, and their current drug regimen, if any. The first call was made in the evening and after working hours. In case of no response, we made two more attempts in the following weeks to contact the patients during different time periods of the day.

RESULTS

Eighty- four patients participated. Thirty-one patients (37%) were employed, and 53 people (63%) were not; at the first visit, the rate of employment was 23%. Female sex (Odds Ratio [OR]: 12.18; 95% Confidence Interval [CI]: 3.51-42.18; p = .0001), taking psychiatric drugs (OR: 4.93; 95% CI: 1.17-20.73; p = .02), and being employed previously (OR: 0.19; 95% CI: 0.04-0.77; p = .02) were independently significantly associated with the current employment status. Three patients (4%) reported receiving disability social benefits, two women and one man.

CONCLUSION

This study highlights that unemployment is a serious issue in patients with FS and psychiatric comorbidities play a significant role in the employment status in these patients.

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.

Structural neuroimaging of somatoform disorders: A systematic review

Although there has been an increment in neuroimaging research in somatoform disorders (SD), to date little is known about the neural correlates of these diseases. Therefore, in this systematic, review we aimed at summarizing the existing evidence of structural brain alterations in SD as per DSM-IV and DSM-5 criteria. Three electronic databases (Scopus, PubMed and Web of Science) were searched. Only case-control studies using structural neuroimaging were included. Forty-five out of 369 articles fulfilled inclusion criteria and were reviewed. Compared to controls, subjects with SD showed morphological alterations encompassing motor, limbic and somatosensory circuits. Although far from being conclusive, the results suggested that SD are characterized by selective alterations of large-scale brain networks implicated in cognitive control, emotion regulation and processing, stress and somatic-visceral perception. This review highlights the need for further multimodal neuroimaging studies with longitudinal designs, in larger and better-characterized samples, to elucidate the temporal and causal relationship between neuroanatomical changes and SD, which is paramount for informing tailored treatments.

The impact of sexual abuse on psychopathology of patients with psychogenic nonepileptic seizures

OBJECTIVES

In the present study, we evaluated if the presence of sexual abuse in the clinical history of patients with psychogenic non-epileptic seizures (PNES) is associated with a different psychopathological profile.

MATERIALS AND METHODS

In a consecutive population of 63 PNES patients, we compared two demographically and clinically matched groups of patients with (no. 15) and without (no. 48) a history of sexual abuse using a comprehensive psychopathological assessment (Beck Depression Inventory, Hamilton Anxiety Rating Scale, Dissociative Experience Scale, Somatoform Dissociation Questionnaire, and Toronto Alexithymia Scale).

RESULTS

We found that the group of patients reporting sexual abuse is characterized by higher scores on Dissociative Experience Scale (p = 0.003) and Beck Depression Inventory (p = 0.001) with respect to the other group. No significant statistical differences in Hamilton Anxiety Rating Scale (p = 0.103), Toronto Alexithymia Scale (p = 0.137), and Somatoform Dissociation Questionnaire (p = 0.486) were captured. Moreover, we found that the negative effect on dissociate symptoms was also hampered by the increasing of seizure frequency.

CONCLUSIONS

This study reinforces the importance of traumatic screening in the clinical spectrum of PNES in order to implement and improve specific therapeutic strategies.

Medico-legal assessment of personal damage in older people: report from a multidisciplinary consensus conference

Ageing of the global population represents a challenge for national healthcare systems and healthcare professionals, including medico-legal experts, who assess personal damage in an increasing number of older people. Personal damage evaluation in older people is complex, and the scarcity of evidence is hindering the development of formal guidelines on the subject. The main objectives of the first multidisciplinary Consensus Conference on Medico-Legal Assessment of Personal Damage in Older People were to increase knowledge on the subject and establish standard procedures in this field. The conference, organized according to the guidelines issued by the Italian National Institute of Health (ISS), was held in Bologna (Italy) on June 8, 2019 with the support of national scientific societies, professional organizations, and stakeholders. The Scientific Technical Committee prepared 16 questions on 4 thematic areas: (1) differences in injury outcomes in older people compared to younger people and their relevance in personal damage assessment; (2) pre-existing status reconstruction and evaluation; (3) medico-legal examination procedures; (4) multidimensional assessment and scales. The Scientific Secretariat reviewed relevant literature and documents, rated their quality, and summarized evidence. During conference plenary public sessions, 4 pairs of experts reported on each thematic area. After the last session, a multidisciplinary Jury Panel (15 members) drafted the consensus statements. The present report describes Conference methods and results, including a summary of evidence supporting each statement, and areas requiring further investigation. The methodological recommendations issued during the Conference may be useful in several contexts of damage assessment, or to other medico-legal evaluation fields.

Management of functional neurological disorder

Functional neurological disorder (FND) is a common cause of persistent and disabling neurological symptoms. These symptoms are varied and include abnormal control of movement, episodes of altered awareness resembling epileptic seizures and abnormal sensation and are often comorbid with chronic pain, fatigue and cognitive symptoms. There is increasing evidence for the role of neurologists in both the assessment and management of FND. The aim of this review is to discuss strategies for the management of FND by focusing on the diagnostic discussion and general principles, as well as specific treatment strategies for various FND symptoms, highlighting the role of the neurologist and proposing a structure for an interdisciplinary FND service.

Psychogenic Non-epileptic Seizures and Pseudo-Refractory Epilepsy, a Management Challenge

Psychogenic nonepileptic seizures (PNES) are neurobehavioral conditions positioned in a gray zone, not infrequently a no-man land, that lies in the intersection between Neurology and Psychiatry. According to the DSM 5, PNES are a subgroup of conversion disorders (CD), while the ICD 10 classifies PNES as dissociative disorders. The incidence of PNES is estimated to be in the range of 1.4-4.9/100,000/year, and the prevalence range is between 2 and 33 per 100,000. The International League Against Epilepsy (ILAE) has identified PNES as one of the 10 most critical neuropsychiatric conditions associated with epilepsy. Comorbidity between epilepsy and PNES, a condition leading to "dual diagnosis," is a serious diagnostic and therapeutic challenge for clinicians. The lack of prompt identification of PNES in epileptic patients can lead to potentially harmful increases in the dosage of anti-seizure drugs (ASD) as well as erroneous diagnoses of refractory epilepsy. Hence, pseudo-refractory epilepsy is the other critical side of the PNES coin as one out of four to five patients admitted to video-EEG monitoring units with a diagnosis of pharmaco-resistant epilepsy is later found to suffer from non-epileptic events. The majority of these events are of psychogenic origin. Thus, the diagnostic differentiation between pseudo and true refractory epilepsy is essential to prevent actions that lead to unnecessary treatments and ASD-related side effects as well as produce a negative impact on the patient's quality of life. In this article, we review and discuss recent evidence related to the neurobiology of PNES. We also provide an overview of the classifications and diagnostic steps that are employed in PNES management and dwell on the concept of pseudo-resistant epilepsy.

Psychiatric Comorbidities in People With Epilepsy

Purpose of Review

To review the latest evidence concerning the epidemiology, clinical implications, and management of psychiatric disorders in epilepsy.

Recent Findings

People with epilepsy have a 2-5 times increased risk of developing any psychiatric disorder, and 1 in 3 patients with epilepsy have a lifetime psychiatric diagnosis. Psychiatric comorbidities represent a poor prognostic marker as they have been associated with a poor response to treatment (drugs and surgery), increased morbidity, and mortality. Validated screening instruments are available for mood and anxiety disorders in adults as well as attention-deficit hyperactivity disorder in children with epilepsy.

Summary

All patients with epilepsy should be routinely screened for psychiatric disorder at the onset and at least once a year. Patients with epilepsy and their relatives should be informed of the risk of mental health problems and the implications.