Discriminating between epileptic and nonepileptic events: the utility of hypnotic seizure induction

Hypnotic suggestibility in dissociative and related disorders: A meta-analysis

Elevated responsiveness to verbal suggestions is hypothesized to represent a predisposing factor for dissociative disorders (DDs) and related conditions. However, the magnitude of this effect has not been estimated in these populations nor has the potential moderating influence of methodological limitations on effect size variability across studies. This study assessed whether patients with DDs, trauma- and stressor-related disorders (TSDs), and functional neurological disorder (FND) display elevated hypnotic suggestibility. A systematic literature search identified 20 datasets. A random-effects meta-analysis revealed that patients displayed greater hypnotic suggestibility than controls, Hedges's g=0.92 [0.66, 1.18]. This effect was observed in all subgroups but was most pronounced in the DDs. Although there was some evidence for publication bias, a bias-corrected estimate of the group effect remained significant, g=0.57 [0.30, 0.85]. Moderation analyses did not yield evidence for a link between effect sizes and methodological limitations. These results demonstrate that DDs and related conditions are characterized by elevated hypnotic suggestibility and have implications for the mechanisms, risk factors, and treatment of dissociative psychopathology.

Minimum standards for inpatient long-term video-EEG monitoring: A clinical practice guideline of the international league against epilepsy and international federation of clinical neurophysiology

The objective of this clinical practice guideline is to provide recommendations on the indications and minimum standards for inpatient long-term video-electroencephalographic monitoring (LTVEM). The Working Group of the International League Against Epilepsy and the International Federation of Clinical Neurophysiology develop guidelines aligned with the Epilepsy Guidelines Task Force. We reviewed published evidence using The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. We found limited high-level evidence aimed at specific aspects of diagnosis for LTVEM performed to evaluate patients with seizures and nonepileptic events (see Table S1). For classification of evidence, we used the Clinical Practice Guideline Process Manual of the American Academy of Neurology. We formulated recommendations for the indications, technical requirements, and essential practice elements of LTVEM to derive minimum standards used in the evaluation of patients with suspected epilepsy using GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). Further research is needed to obtain evidence about long-term outcome effects of LTVEM and establish its clinical utility.

Minimum standards for inpatient long-term video-electroencephalographic monitoring: A clinical practice guideline of the International League Against Epilepsy and International Federation of Clinical Neurophysiology

The objective of this clinical practice guideline is to provide recommendations on the indications and minimum standards for inpatient long-term video-electroencephalographic monitoring (LTVEM). The Working Group of the International League Against Epilepsy and the International Federation of Clinical Neurophysiology develop guidelines aligned with the Epilepsy Guidelines Task Force. We reviewed published evidence using the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) statement. We found limited high-level evidence aimed at specific aspects of diagnosis for LTVEM performed to evaluate patients with seizures and nonepileptic events. For classification of evidence, we used the Clinical Practice Guideline Process Manual of the American Academy of Neurology. We formulated recommendations for the indications, technical requirements, and essential practice elements of LTVEM to derive minimum standards used in the evaluation of patients with suspected epilepsy using GRADE (Grading of Recommendations Assessment, Development, and Evaluation). Further research is needed to obtain evidence about long-term outcome effects of LTVEM and to establish its clinical utility.

Clinical Approaches to Psychogenic Nonepileptic Seizures

Psychogenic nonepileptic seizures (PNES) are a subtype of conversion disorder (also called functional neurological symptom disorder in DSM-5). Patients with PNES are high utilizers of health care and can have disability levels similar to those of patients with epilepsy. PNES is a common, complex neuropsychiatric somatoform disorder at the interface of neurology and psychiatry disciplines and is largely overlooked and avoided by mental health providers. Despite advances in establishing accurate diagnosis and evidence-based treatments, recent knowledge about PNES has not been well translated into clinical practice. Long diagnostic delays have been associated with poor prognosis. Recent advances in possible neurophysiological biomarkers include functional MRI studies that show abnormalities in emotional, cognitive, executive, and sensorimotor neurocircuits. Although the gold standard for diagnosis is video electroencephalograph, this test is underused by psychiatrists. The International League Against Epilepsy proposed a staged approach to PNES diagnosis using history, semiologic features, and EEG. Thorough psychiatric assessment can identify relevant biopsychosocial and predisposing, precipitating, and perpetuating factors, as well as assess the comorbid psychiatric disorders, which can inform a treatment plan. Clear and thoughtful delivery of diagnosis is the first step in treatment. Regular follow-up with the patient's neurologist, in addition to treatment by mental health professionals familiar with somatic symptom disorders, is recommended. Psychotherapy is the mainstay of treatment, and randomized clinical trials using cognitive-behavioral therapies reveal significant reduction in seizures and other psychiatric symptoms. After centuries, mental health providers now have access to the tools to diagnose and effectively treat PNES and other conversion disorders.

Psychogenic Explanations of Physical Illness

In some patients with chronic physical complaints, detailed examination fails to reveal a well-recognized underlying disease process. In this situation, the physician may suspect a psychological cause. In this review, we critically evaluated the evidence for this causal claim, focusing on complaints presenting as neurological disorders. There were four main conclusions. First, patients with these complaints frequently exhibit psychopathology but not consistently more often than patients with a comparable “organic” diagnosis, so a causal role cannot be inferred. Second, these patients report a high incidence of adverse life experiences, but again, there is insufficient evidence to indicate a causal role for any particular type of experience. Third, although psychogenic illnesses are believed to be more responsive to psychological interventions than comparable “organic” illnesses, there is currently no evidence to support this claim. Finally, recent evidence suggests that biological and physical factors play a much greater causal role in these illnesses than previously believed. We conclude that there is currently little evidential support for psychogenic theories of illness in the neurological domain. In future research, researchers need to take a wider view concerning the etiology of these illnesses.

Psychological and psychiatric aspects of psychogenic non-epileptic seizures (PNES): A systematic review

Psychogenic non-epileptic seizures (PNES) are common in neurological settings and often associated with considerable distress and disability. The psychological mechanisms underlying PNES are poorly understood and there is a lack of well-established, evidence-based treatments. This paper advances our understanding of PNES by providing a comprehensive systematic review of the evidence pertaining to the main theoretical models of this phenomenon. Methodological quality appraisal and effect size calculation were conducted on one hundred forty empirical studies on the following aspects of PNES: life adversity, dissociation, anxiety, suggestibility, attentional dysfunction, family/relationship problems, insecure attachment, defence mechanisms, somatization/conversion, coping, emotion regulation, alexithymia, emotional processing, symptom modelling, learning and expectancy. Although most of the studies were only of low to moderate quality, some findings are sufficiently consistent to warrant tentative conclusions: (i) physical symptom reporting is elevated in patients with PNES; (ii) trait dissociation and exposure to traumatic events are common but not inevitable correlates of PNES; (iii) there is a mismatch between subjective reports of anxiety and physical arousal during PNES; and (iv) inconsistent findings in this area are likely to be attributable to the heterogeneity of patients with PNES. Empirical, theoretical and clinical implications are discussed.

Dissociation and functional neurologic disorders

Dissociation has been cited as a possible psychologic mechanism underpinning functional neurologic disorders (FND) since the 19th century. Since that time, changes in psychiatric classification have created confusion about what the term dissociation actually means. The available evidence suggests that it now refers to at least two qualitatively distinct types of phenomena: detachment (an altered state of consciousness characterized by a sense of separation from the self or world) and compartmentalization (a reversible loss of voluntary control over apparently intact processes and functions), as well as their underlying mechanisms. This chapter considers some of the problems with conflating these phenomena under a single heading as well as the relationship between detachment, compartmentalization, and FND. It is argued that FNDs are fundamentally compartmentalization disorders, but that detachment is often part of the clinical picture and may contribute to the development and maintenance of functional symptoms in many cases. By this view, understanding compartmentalization requires an appreciation of the mechanisms involved in controlling and accessing mental processes and contents. Two possible mechanisms in this regard are described and the evidence for these is considered, followed by a discussion of clinical and empiric implications.

Closing the Major Gap in PNES Research: Finding a Home for a Borderland Disorder

Psychogenic nonepileptic seizures (PNES) are events commonly encountered by primary care physicians, neurologists, pediatricians, and emergency medicine physicians in their practices, yet there continues to be significant variability in the way they are evaluated, diagnosed, and treated. Lack of understanding this condition and limited data on long-term outcome from current treatment paradigms have resulted in an environment with iatrogenic injury, morbidity, and significant costs to the patient and healthcare system. This article will review the current state of research addressing PNES treatment both in the adult and pediatric populations.

Utility of different seizure induction protocols in psychogenic nonepileptic seizures

Psychogenic non epileptic seizure (PNES) can be induced by several induction tests but their relative usefulness has not been evaluated. In this study, we report the sensitivity and specificity of various induction tests in the diagnosis of PNES and assess their discomfort level. The induction tests were: (a) compression of temple region (CTR), (b) verbal suggestion (VS), (c) tuning fork application (TFA), (d) moist swab application (MSA), (e) torch light stimulation (TLS) and (f) saline injection (SI). Up to 3 trials were done for each test except for normal saline injection which was given once. For comparison of these tests, patients with epileptic seizures were included as controls. The time to precipitate PNES was recorded and patients' discomfort levels were noted on a 0-10 scale. Video EEG was recorded in the PNES patients. 140 patients with PNES and 50 controls with epileptic seizures were included. The diagnostic yield of CTR was 65.7%, TFA 61.4%, MSA 60.7%, SI 55.6%, VS 54.3% and TLS 40.7%. These tests did not induce seizures in the controls. All these tests had 100% specificity and 100% positive predictive value in the diagnosis of PNES. The maximum discomfort was reported with SI and minimum with MSA. The similarity of efficacy and discomfort with CTR and TFA appear to be the most optimal induction techniques when compared with VS, AMS, TLS, and SI.

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.

Video-electroencephalography investigation of ictal alterations of consciousness in epilepsy and nonepileptic attack disorder: practical considerations

The ictal assessment of consciousness is of central importance in the differential diagnosis of epilepsy and nonepileptic attack disorder (NEAD). Long-term video-electroencephalography (video-EEG) is currently considered the gold standard investigative technique for the evaluation of patients with recurrent attacks associated with transient alterations of arousal (responsiveness) and/or awareness (experiential states). This paper offers a concise review focusing on the practical aspects of clinical relevance in the video-EEG diagnostic workout of inpatients with suspected epilepsy or NEAD, as outlined in existing guidelines and recommendations. The reviewed literature implies that both implementation of specific procedures (e.g., activation maneuvers) and interpersonal approach (e.g., monitoring protocols) during video-EEG should be tailored to the individual patient's presentation.

Tranceformations: hypnosis in brain and body

In this review, the role of hypnosis and related psychotherapeutic techniques are discussed in relation to the anxiety disorders. In particular, anxiety is addressed as a special form of mind/body problem involving reverberating interaction between mental and physical distress. The history of hypnosis as a therapeutic discipline is reviewed, after which neurobiological evidence of the effect of hypnosis on modulation of perception in the brain. Specific brain regions involved in hypnosis are reviewed, notably the dorsal anterior cingulate gyrus and the dorsolateral prefrontal cortex. The importance of hypnotizability as a trait, stable variability in hypnotic responsiveness, is discussed. Analogies between the hypnotic state and dissociative reactions to trauma are presented, and the uses of hypnosis in treating posttraumatic stress disorder, stressful situations, and phobias as well as outcome data are reviewed. Effects of hypnosis on control of somatic processes are discussed, and then effects of psychosocial support involving Supportive-Expressive Group Therapy and hypnosis on survival time for cancer patients are evaluated. The evidence indicates an important role for hypnosis in managing anxiety disorders and anxiety related to medical illness.

Functional brain basis of hypnotizability

CONTEXT

Focused hypnotic concentration is a model for brain control over sensation and behavior. Pain and anxiety can be effectively alleviated by hypnotic suggestion, which modulates activity in brain regions associated with focused attention, but the specific neural network underlying this phenomenon is not known.

OBJECTIVE

To investigate the brain basis of hypnotizability.

DESIGN

Cross-sectional, in vivo neuroimaging study performed from November 2005 through July 2006.

SETTING

Academic medical center at Stanford University School of Medicine.

PATIENTS

Twelve adults with high and 12 adults with low hypnotizability.

MAIN OUTCOME MEASURES

Functional magnetic resonance imaging to measure functional connectivity networks at rest, including default-mode, salience, and executive-control networks; structural T1 magnetic resonance imaging to measure regional gray and white matter volumes; and diffusion tensor imaging to measure white matter microstructural integrity.

RESULTS

High compared with low hypnotizable individuals had greater functional connectivity between the left dorsolateral prefrontal cortex, an executive-control region of the brain, and the salience network composed of the dorsal anterior cingulate cortex, anterior insula, amygdala, and ventral striatum, involved in detecting, integrating, and filtering relevant somatic, autonomic, and emotional information using independent component analysis. Seed-based analysis confirmed elevated functional coupling between the dorsal anterior cingulate cortex and the dorsolateral prefrontal cortex in high compared with low hypnotizable individuals. These functional differences were not due to any variation in brain structure in these regions, including regional gray and white matter volumes and white matter microstructure.

CONCLUSIONS

Our results provide novel evidence that altered functional connectivity in the dorsolateral prefrontal cortex and dorsal anterior cingulate cortex may underlie hypnotizability. Future studies focusing on how these functional networks change and interact during hypnosis are warranted.

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.

Psychogenic nonepileptic seizures: a treatment review. What have we learned since the beginning of the millennium?

Psychogenic nonepileptic seizures (PNES) can significantly affect an individual's quality of life, the health care system, and even society. The first decade of the new millennium has seen renewed interest in this condition, but etiological understanding and evidence-based treatment availability remain limited. After the diagnosis of PNES is established, the first therapeutic step includes a presentation of the diagnosis that facilitates engagement in treatment. The purpose of this review is to present the current evidence of treatments for PNES published since the year 2000 and to discuss further needs for clinical treatment implementation and research. This article reviews clinical trials that have evaluated the efficacy of structured, standardized psychotherapeutic and psychopharmacological interventions. The primary outcome measure in clinical trials for PNES is event frequency, although it is questionable whether this is the most accurate indicator of functional recovery. Cognitive behavioral therapy has evidence of efficacy, including one pilot randomized, controlled trial where cognitive behavioral therapy was compared with standard medical care. The antidepressant sertraline did not show a significant difference in event frequency change when compared to placebo in a pilot randomized, double-blind, controlled trial, but it did show a significant pre- versus posttreatment decrease in the active arm. Other interventions that have shown efficacy in uncontrolled trials include augmented psychodynamic interpersonal psychotherapy, group psychodynamic psychotherapy, group psychoeducation, and the antidepressant venlafaxine. Larger clinical trials of these promising treatments are necessary, while other psychotherapeutic interventions such as hypnotherapy, mindfulness-based therapies, and eye movement desensitization and reprocessing may deserve exploration. Flexible delivery of treatment that considers the heterogeneous backgrounds of patients is emphasized as necessary for successful outcomes in clinical practice.

Psychogenic non-epileptic seizures: a model of their pathogenic mechanism

Psychogenic non-epileptic seizures (PNES) consist of paroxystic events facilitated by a dysfunction in emotion processing. Models explaining the pathogenic mechanisms leading to these seizure-like episodes are limited. In this article, evidence that supports dysfunction at the level of arousal tolerance, cognitive-emotional information processing and volitional control is reviewed. A hypothetical pathophysiological mechanism is discussed based on functional neuroimaging evidence from PNES-related conditions and traits. This pathophysiological model suggests an alteration in the influence and connection of brain areas involved in emotion processing onto other brain areas responsible for sensorimotor and cognitive processes. Integrating this information, PNES are conceptualized as brief episodes facilitated by an unstable cognitive-emotional attention system. During the episodes, sensorimotor and cognitive processes are modified or not properly integrated, allowing the deployment of autonomous prewired behavioral tendencies. Finally, I elaborate on how therapeutic applications could be modified based on the proposed hypothetical model, potentially improving clinical outcomes.

Can hypnosis differentiate epileptic from nonepileptic events in the video/EEG monitoring unit? Data from a pilot study

OBJECTIVE

An estimated 24% of patients referred to epilepsy clinics actually have nonepileptic seizures. Various procedures have been used to precipitate nonepileptic events. The goal of this study was to use hypnosis in seizure provocation and differentiation between epileptic and nonepileptic seizure events.

METHODS

Fifty study participants were enrolled from the Via Christi Comprehensive Epilepsy Center's video/electroencephalography unit. Patients underwent the Hypnotic Induction Profile (HIP) to assess susceptibility to hypnosis. After completion of the HIP, participants underwent hypnosis by a physician trained to do so. They received a hypnotic suggestion to have a seizure. All seizure-like events were classified as either an epileptic, nonepileptic, or undetermined event based on whether or not the patient had abnormal EEG activity during the event.

RESULTS

Of the 50 participants enrolled, 3 withdrew consent, resulting in 47 participants. Seven (15%) participants failed to have an event of any type and were classified as undetermined. Sixteen (34%) participants were classified as having epileptic seizure events, and 24 (51%) participants had nonepileptic events. Most participants were Caucasian (87%), female (57%), and unemployed (55%). HIP scores ranged from 0 to 10. Participants classified with nonepileptic scores had higher mean HIP scores (8.08, SD 2.483) than those diagnosed with epileptic seizures [5.94, SD 3.492, t(25)=2.126, P=0.044]. The sensitivity of eliciting a nonepileptic event during hypnosis was only 0.46, but the specificity was 0.88.

CONCLUSION

Hypnosis may be considered as a method of seizure provocation. Events provoked by hypnotic suggestion were more likely than not to be nonepileptic events. However, the current study has moderate specificity and poor sensitivity. Seizures could not be induced in patients who did not also have spontaneous seizures. Additional methodologies for seizure provocation need to be explored.

Provocative techniques should be used for the diagnosis of psychogenic nonepileptic seizures

Many epilepsy centers use provocative techniques (inductions) during EEG-video monitoring to aid in the diagnosis of psychogenic nonepileptic seizures. Provocative techniques are not always necessary, and they should only be used when they help establish the diagnosis. There are several situations where inductions have significant advantages. When attacks do not occur spontaneously, provocative techniques can turn an inconclusive evaluation into a diagnostic one. Triggering an attack with induction can shorten the evaluation, decreasing its cost and reducing waiting time in the monitoring unit. Patients with infrequent episodes (that do not occur frequently enough to obtain a spontaneous event during monitoring) can be scheduled for a brief outpatient monitoring with induction. In clinical scenarios where symptoms are consistent with a ''simple partial" seizure, the very presence of suggestibility is in itself a very strong additional argument to support a psychogenic etiology. The arguments against inductions are mainly based on ethical concerns. While these concerns have some validity, they are, in the real world, far outweighed by the alternatives. It is far more unethical to not obtain a definitive diagnosis when it would be possible, since the consequences of perpetuating the wrong diagnosis are many and serious. Even with placebo the benefits far outweigh the very minor ethical theoretical concerns, and the use of placebo is not even necessary. When correctly performed and interpreted, the specificity of inductions is over 90%. All tests have limitations, with some false positives and false negatives. Like all other tests, inductions must be used appropriately and with awareness of their limitations.

Group therapy for patients with psychogenic nonepileptic seizures: a pilot study

Great advances have been made in the diagnosis of people with psychogenic nonepileptic seizures (PNES) since the advent of video/EEG monitoring. However, treatment options for this population have lagged significantly. This pilot study was undertaken to evaluate whether group therapy done with a psychodynamic focus would offer a useful intervention. Twelve patients entered the study and seven completed at least 75% of the 32 weekly sessions. The Beck Depression Inventory and the Global Severity Index of the Symptom Checklist-90 showed improvement as well as an overall decrease in PNES frequency. The data suggest that group therapy focusing on interpersonal issues may benefit patients with PNES.

Hypnosis-provoked nonepileptic events in children

OBJECTIVE

The purpose of this study was to describe the use of hypnotic suggestion as a means of precipitating nonepileptic events in children while they are undergoing video electroencephalographic monitoring (VEEG) for differential diagnosis of seizurelike behavior.

METHODS

Nine children aged 8-16 years were referred for VEEG to differentiate between epileptic seizures and nonepileptic events. All subjects underwent psychiatric consultation. Hypnosis was attempted in all subjects to try to provoke typical seizurelike events.

RESULTS

In eight of nine patients, their typical seizurelike events were provoked by hypnosis. In all eight children, video and EEG analysis of the provoked events demonstrated them to be nonepileptic. No epileptiform abnormalities were present on interictal EEGs. No epileptic seizures occurred.

CONCLUSION

Hypnosis is a useful and ethical means of provoking psychogenic nonepileptic events in children. Hypnotic suggestion should be considered as a provocative method when possibly psychogenic nonepileptic events have not occurred spontaneously during diagnostic evaluation.

Recommendations Regarding the Requirements and Applications for Long-term Recordings in Epilepsy

The purpose of this paper is to update the state of knowledge with respect to long-term monitoring (LTM) in epilepsy and to formulate recommendations regarding the application of LTM in clinical practice. LTM is an established technique in use both in a hospital setting and, increasingly, in an ambulatory and more recently in a community-based setting. There has been sufficient evidence to substantiate the claim that LTM is of crucial importance in documenting electroclinical correlations both in epilepsy and in paroxysmally occurring behavioral changes often mistaken for epilepsy. Internationally recognized neurophysiological equipment standards, data acquisition and data transfer protocols and widely accepted safety standards have made widespread access to LTM facilities in epilepsy possible. Recommendations on efficient and effective use of resources as well as regarding training and competencies for personnel involved in LTM in epilepsy have been formulated. The DMC Neurophysiology Subcommittee of the ILAE recommends use of hospital-based LTM in the documentation of seizures including its application for assessing seizure type and frequency, in the evaluation of status epilepticus, in noninvasive and invasive video/EEG investigations for epilepsy surgery and for the differential diagnosis between epilepsy and paroxysmally occurring nonepileptic conditions, in children and in adults. Ambulatory outpatient and community-based LTM may be used as a substitute for inpatient LTM in cases where the latter is not cost-effective or feasible or when activation procedures aimed at increasing seizure yield are not indicated. However, outpatient ambulatory monitoring may be less informative than is inpatient monitoring in some cases because: (1) reduction of medication to provoke seizures may not be safe as an outpatient; (2) faulty electrode contacts cannot quickly be noticed and repaired; (3) the patient may move out of video surveillance; and (4) duration of ambulatory monitoring can be limited by technical constraints.

Is it epilepsy?

Detainees in police stations frequently claim to suffer from epilepsy. The diagnosis of epilepsy is not always straight forward and a misdiagnosis can be easily made, even by specialists. The case of a detained person claiming to suffer from epilepsy is described. The differential diagnosis and management is discussed with particular attention given to non epileptic attack disorder and the problems that this condition may cause for the examining forensic physician.

Transcendental meditation: a double-edged sword in epilepsy?

Transcendental Meditation (TM) is derived from ancient yogic teachings. Both short- and long-term physiological correlates of TM practice have been studied. EEG effects include increased alpha, theta, and gamma frequencies and increased coherence and synchrony. Neuronal hypersynchrony is also a cardinal feature of epilepsy, and subjective psychic symptoms, apnea, and myoclonic jerking are characteristic of both epileptic seizures and meditative states. Clinical vignettes have highlighted the potential risk of human kindling from repetitive meditation in persons practicing TM, but clinical studies of similar techniques suggest that meditation may also be a potential antiepileptic therapy. Future clinical studies of meditating subjects using video/EEG monitoring are warranted to determine whether behavioral phenomena have an underlying epileptic basis, and prospective clinical trials of TM in subjects with well-delineated epilepsy syndromes are necessary to establish the safety of this technique and its potential efficacy for seizure reduction and improvement of quality of life.

Alternative approaches to conventional antiepileptic drugs in the management of paediatric epilepsy

Over the last two decades, there has been a rapid expansion in the number and types of available antiepileptic drugs (AEDs), but there is increasing concern amongst parents and carers about their unwanted side effects. Seizure control is achieved in approximately 75% of children treated with conventional AEDs, but non-conventional (or non-standard) medical treatments, surgical procedures, dietary approaches, and other non-pharmacological treatment approaches may have a role to play in those with intractable seizures or AED toxicity. Many of the approaches are largely common sense and are already incorporated into our current practice, including, for example, avoidance techniques and lifestyle advice, while others require further investigation or appear to be impractical in children.

The approach to patients with "non-epileptic seizures"

Up to one fifth of patients who present to specialist clinics with seizures do not have epilepsy. The majority of such patients suffer from psychologically mediated episodes; dissociative seizures, often referred to as "non-epileptic seizures". This paper describes the diagnostic evaluation of seizure disorders, including clinical assessment and the role of special investigations. The organic and psychiatric imitators of epilepsy are outlined and findings on psychiatric assessment are reviewed. This group of patients often proves difficult to engage in appropriate treatment and an approach to explaining the diagnosis is described. As yet there are no controlled trials of treatment in this disorder but preliminary evidence suggests cognitive behavioural therapy is both a rational and promising way forward.

Update on treatments of psychological nonepileptic seizures

The literature on treatment of psychological nonepileptic seizures (NES) is limited, marked by a number of case reports and anecdotal approaches to this difficult-to-treat population. A recent review of the NES treatment literature revealed 20 reports dealing with NES treatment. The majority of the reports were class IV studies. Since the prior review, a number of pilot trials in NES treatment have been published. In this article, we summarize the etiologic conceptualizations of NES, and link these to mechanism informed treatments. We describe the recent literature on NES treatments and propose future directions for intervention research.

Sensitivity and specificity of procedures for the differential diagnosis of epileptic and non-epileptic seizures: a systematic review

OBJECTIVES

Non-epileptic seizures (NES) present a considerable challenge in clinical practice. This paper reviews published evidence for the reliability of a number of procedures for the differential diagnosis of NES and epilepsy.

METHODS

Papers identified from MEDLINE and PsychInfo Databases (1980-2001) and additional hand searches were independently reviewed using methods for evaluating evidence in systematic reviews [Liddle, J., Williamson, M. Irwig, L. Method for evaluating research guideline evidence. New South Wales Department of Health; 1996 [State Health publication no. (CEB) 96-204]; SIGN. An introduction to SIGN methodology for the development of evidence based clinical guidelines. Scottish Intercollegiate Network; 1999]. Included studies had to have an NES group and a control group of people with epilepsy (each n> or =10), allocated using EEG linked video-recording of concurrent behaviour, and sensitivity and specificity values had to be stated or be calculable.

RESULTS

Thirty-three papers were identified, of which 13 satisfied criteria. Excluded studies are briefly described. Those retained comprised a range of procedures [seizure induction, MMPI assessment, physiological assessment (prolactin, SPECT), pre-ictal pseudosleep, and ictal/post-ictal characteristics]. No procedure emerged with both high sensitivity and specificity and adequately replicated findings, although high levels of specificity were more commonly reported than high levels of sensitivity. This suggests that procedures were generally better at excluding a possible diagnosis.

CONCLUSIONS

No procedure attains reliability equivalent to EEG video-telemetry. Further rigorous evaluation, using standardised and replicable methodologies, is required. The range of symptoms presented in NES suggests that a multi-method approach may be required. This too would require evaluation.

Pediatric stress-related seizures: conceptualization, evaluation, and treatment of nonepileptic seizures in children and adolescents

PURPOSE OF REVIEW

Nonepileptic seizures are seizure-like symptoms that occur in the absence of epileptogenic brain activity. They can cause severe compromise of daily function and impede development in children, and are frequently misdiagnosed, leading to inadequate or potentially harmful medical treatment. This review will characterize nonepileptic seizures, identify associated factors, propose to a reconceptualization of the phenomenon as stress-related seizures, and suggest guidelines for valid diagnosis and intervention.

RECENT FINDINGS

Nonepileptic seizures occur in 10 to 20% of children who present to epilepsy centers, and are more common in females. Early intervention improves prognosis. Factors associated are physical, sexual and other trauma, family dysfunction, and other acute or chronic stressors. They are frequently misdiagnosed and inappropriately treated. Therapy redirecting preoccupation with worries has been effective.

SUMMARY

Nonepileptic seizures are best conceptualized and referred to as stress-related seizures. Long Term Video-EEG Monitoring (LTM) is the gold standard for diagnosis. Diagnosis and intervention requires collaboration between primary care physicians, neurologists, and medically oriented clinicians providing individual and family psychotherapeutic intervention.

Hypnosis provoked pseudoseizures: a case report and literature review

Only a few studies have been reported in which suggestion was used to provoke pseudoseizures (PS). In these studies PS were video EEG monitored, and saline injections were administered as placebo. This method may be somewhat unethical and carries a low success rate. The authors, two child psychiatrists (GZ and DS) and a neurologist (NG), applied hypnosis to provoke PS which were monitored by video-EEG. Pre-, intra- and post-ictal serum prolactin levels were determined. The first hypnotic session was diagnostic and for this reason featured controlled attempts to determine whether there might be childhood trauma material. The following sessions easily provoked PS during which the EEG was normal and pre-, intra- and post-ictal serum prolactin levels were identical and within normal values. We conclude that hypnosis (with informed consent) for PS monitored by video-EEG telemetry, seems to be an ethical, cheap and quite easy way to demonstrate PS.

Nonepileptic seizures: an overview

Since before the time of Charcot, nonepileptic seizures (NES) have intrigued and perplexed physicians. With the advent of the electroencephalogram, particularly with the addition of continuous video monitoring, the diagnosis of NES has received increasing evaluation. Characteristic historical features and clinical signs of NES, coupled with new diagnostic techniques, have progressively refined our understanding of the disorder. The treatment of patients who have NES has received much less attention and the prognosis of these patients illustrates the need for a more comprehensive, systematic, and validated intervention. These issues are discussed with an emphasis on the need for future research.

Etiology, diagnosis, and treatment of nonepileptic seizures

Psychogenic nonepileptic seizures (NES) can be classified into five categories. This review focuses on NES associated with emotional conflict, by far the most common and important group. Etiology is speculative, but the background histories of these patients are often similar. The presence of a trauma history, depression, post-traumatic stress symptoms, and the use of dissociation plus cognitive dysfunction possibly point to an organic etiology. The presentation of NES in children and adults is discussed, along with the differential diagnosis. The diagnostic differential is lengthy, with epileptic seizures of frontal lobe origin presenting a unique challenge. Diagnostic procedures are reviewed with an emphasis on the utility of hypnosis with seizure induction. Presenting the diagnosis to the patient, the role of the neurologist, and the role of the mental health consultant are reviewed. Issues in the doctor-patient relationship are also addressed, as well as the overall prognosis.

Dissociation, hypnotizability, coping styles and health locus of control: characteristics of pseudoseizure patients

Although literature in this area is relatively sparse, the occurrence of psychogenic non-epileptic seizures (pseudoseizures) has been linked to stress, anxiety and possible dissociative tendencies. An association between dissociation and hypnotic susceptibility has also been proposed and dissociative tendencies have themselves been found to relate to the use of emotion-focused coping strategies. In order to investigate the hypothesis that pseudoseizure patients may exhibit higher levels of dissociation, a more emotion-focused coping style, and greater hypnotic susceptibility than the general population, the questionnaire responses of 20 patients with pseudoseizures were compared with those obtained from a non-clinical control group. As predicted, pseudoseizure patients demonstrated some evidence of higher levels of dissociation and escape-avoidance coping strategies. They also expressed a greater belief in external control over health and higher depression scores, compared to the control group, but the previously reported elevation in hypnotizability scores in the pseudoseizure patients was not found. Possible explanations for this pattern of results are discussed.