Epilepsy in patients with psychogenic non-epileptic seizures

Functional Neurological Disorders: Clinical Spectrum, Diagnosis, and Treatment

BACKGROUND

Functional neurological disorders (FNDs) are common but often misdiagnosed.

REVIEW SUMMARY

The incidence of FNDs is between 4 and 12 per 100,000, comparable to multiple sclerosis and amyotrophic lateral sclerosis, and it is the second most common diagnosis in neurology clinics. Some clues in the history are sudden onset, intermittent time course, variability of manifestation over time, childhood trauma, and history of other somatic symptoms. Anxiety and depression are common, but not necessarily more than in the general population. Although there are no tests currently capable of demonstrating whether symptoms are willfully produced, there may not be a clear categorical difference between voluntary and involuntary symptoms. The prognosis of an FND is linked to early diagnosis and symptom duration, but unfortunately, the majority of the patients are diagnosed after considerable delays.

CONCLUSIONS

A positive diagnosis of FNDs can be made on the basis of history and neurological signs without reliance on psychological stressors. Past sensitizing events and neurobiological abnormalities contribute to the pathogenesis of FNDs. Physical rehabilitation and psychological interventions alone or in combination are helpful in the treatment.

Psychiatric Comorbidities in Epilepsy

BACKGROUND AND PURPOSE

Psychiatric comorbidities (PC) occur more frequently in patients with epilepsy than in the general population. To determine the main PC associated with epilepsy and its association with demographic data and clinical features of epilepsy.

METHODS

A retrospective study was carried out on patients with epilepsy at the Medical Specialties Center of the Municipal Health Department. Demographic data, crisis onset, time range of seizures evolution, type of epileptic seizures, types of epilepsy, etiology, brain injury, topographic location, hemispheric location, type of antiepileptic drugs (AEDs), use of monotherapy or polytherapy, control of epileptic seizures and the PC were recorded.

RESULTS

One hundred forty adult patients were studied 51.4% male, mean age 44.9 years, time of evolution of the crises was 14 years, focal crisis 88.6%, mesial temporal sclerosis 42%, controlled 92.4%, monotherapy 66.1%, and the most used AEDs were carbamazepine (33.1%), valproic acid (28.2%), and phenobarbital (10.4%). The PC present in 67.1% of the patients was depression (22.8%), anxiety disorder (AD) (17.8%), psychosis (10%), dementia (9.2%) and bipolar affective disorder (BAD) (8.5%). The relationship between PC and crisis control was significant (p<0.009).

CONCLUSIONS

Schooling was lower than that reported in the general population in Brazil, and we found a low rate of unemployment or retirement. Epilepsy is associated with PC, the most frequent being depression, AD, psychosis, dementia and BAD. The absence of a relationship between depression and brain damage; anxiety disorder with education, types of epilepsy and etiology; psychosis with sex and time of epilepsy evolution were significant.

Immunization stress-related responses presenting as psychogenic non-epileptic seizures following HPV vaccination in Rio Branco, Brazil

IMPORTANCE

The absence of a positive diagnosis of psychogenic non-epileptic seizures (PNES) in immunization stress-related response (ISRR) clusters may have not only a direct impact on affected patients' health but may also reduce compliance to national vaccination programs. It is therefore crucial to develop efficient diagnostic tools and a feasible proposal for proper communication and treatment of ISRR.

PURPOSE

To explore the psychogenic nature of patients' convulsive seizures in a suspected outbreak of an ISRR cluster following human papillomavirus vaccination in Rio Branco, Brazil.

METHODS

Twelve patients with convulsive seizures were submitted to prolonged intensive video-electroencephalography monitoring, brain magnetic resonance imaging, cerebrospinal fluid diagnostic testing, laboratory subsidiary examinations, and complete neurological and psychiatric evaluations.

RESULTS

Ten patients received the positive diagnosis of PNES, and two patients received the diagnosis of idiopathic generalized epilepsy. No biological association was found between the HPV vaccine and the clinical problems presented by the patients.

CONCLUSIONS

Prolonged VEEG monitoring can contribute significantly to the positive diagnosis of PNES in ISRR clusters and to avoid hesitancy to vaccinate.

Outcome of CBT-based multimodal psychotherapy in patients with psychogenic nonepileptic seizures: A prospective naturalistic study

PURPOSE

Psychotherapy is recommended in patients with psychogenic nonepileptic seizures (PNES). To date, however, a limited number of studies have attempted to assess the long-term effectiveness of psychotherapy in patients with PNES. Here, we report the short and six-month follow-up seizure and psychopathological outcomes in patients with PNES who have undergone a combination of cognitive-behavioral individual and group therapy.

METHODS

In this prospective, naturalistic study, 80 patients with PNES underwent cognitive behavioral psychotherapy in an inpatient setting (mean duration: 64.5 days) and were evaluated prior to treatment (T1) and at its end (T2). Six months after treatment, 55 patients participated in the follow-up assessment (T3). Psychopathology questionnaires and PNES ratings were used at T1, T2, and T3 to determine outcomes.

RESULTS

At T2, 23% of the patients were free from PNES for ≥2 weeks. At T3, 21.8% were seizure-free for ≥1 month and 10.9% for ≥3 months. Only two patients who were free from PNES at T2 remained free from PNES until T3. Ten further patients achieved seizure freedom during the follow-up period and were free from seizures for ≥1 month at T3. Nevertheless, a subjective improvement of the seizure situation was reported by 74.1% of the patients. Patients' psychopathology scores decreased from T1 to T2 and remained stable after discharge (except for a slight increase of depression score from T2 to T3). Those patients who were PNES-free at T3 had less severe psychopathology, experienced less traumatic events, and PNES were prolonged prior to treatment than those who did not become seizure-free.

SIGNIFICANCE

Inpatient psychotherapy led to PNES freedom in a minority of patients. Pretreatment psychopathology was the key factor affecting six-month follow-up seizure outcomes. Expectations should be formed in accordance with these perspectives, i.e., seizure freedom is difficult to achieve in many patients, but psychotherapy may be useful to treat underlying psychopathology. As our results stem from a specific patient sample (i.e., patients with chronic and refractory PNES) treated in a very specific setting, the generalizability of our findings is limited.

Psychiatric disorders and trauma history in patients with pure PNES and patients with PNES and coexisting epilepsy

Several studies found high prevalence rates of psychiatric disorders in patients with pure psychogenic nonepileptic seizures (PNES). Traumatic experiences were also reported to be elevated in patients with PNES and were discussed as a crucial risk factor for the development of PNES. Much less is known about psychiatric comorbidities and specifically, about trauma history in patients with PNES and coexisting epilepsy. Here, we aimed at directly comparing psychiatric disorders and traumatic life experiences in patients with pure PNES and in patients with PNES and coexisting epilepsy. We assessed the presence of current axes I and II disorders in 109 patients with either pure PNES (n = 67) or with PNES + epilepsy (n = 42) by using structured clinical interviews. We also compared the trauma histories by using the posttraumatic diagnostic scale (PDS) as an interview and the extent of physical, sexual, and emotional childhood maltreatment measured with the Childhood Trauma Questionnaire (CTQ). Patients of both groups had very high rates of psychiatric disorders: 79.1% of the patients with pure PNES and 76.2% of the patients with PNES + epilepsy had at least one psychiatric disorder. The frequencies of psychiatric disorders did not differ between groups. However, there was a trend towards higher rates of posttraumatic stress disorder (PTSD) in patients with PNES (32.9%) compared with patients with PNES + epilepsy (16.7%). In both groups, the proportion of patients who recalled traumatic events in the PDS was high (72.6% in the patients with pure PNES, 64.3% in the patients with PNES + epilepsy) and did not differ significantly between groups. The age at first traumatization, the types of trauma events experienced, the number of patients with single traumatization, and those with repeated traumatic experiences also did not differ between groups. We found high frequencies of childhood maltreatment in both groups. Our findings show that patients with PNES and patients with PNES and coexisting epilepsy could neither be differentiated by the amount of psychiatric additional disorders nor by the nature and extent of trauma and maltreatment experiences. Our results suggest that patients with PNES + epilepsy rather resemble patients with pure PNES than patients with epilepsy in respect to psychopathological characteristics and adverse life experiences. Trauma and maltreatment history are therefore assumed to be predisposing factors to PNES in both patients with pure PNES and patients with PNES and coexisting epilepsy.

Psychogenic nonepileptic seizures: a concise review

Psychogenic nonepileptic seizures (PNES) are commonly diagnosed and treated at epilepsy centers; however, their neurobiology is still poorly understood. Diagnosis relies on a multidisciplinary evaluation and is usually based on different combinations of data. They are diagnosed most reliably by recording a seizure while under video-EEG monitoring. Treatment includes multiple phases. Fewer than 40% of adults with PNES are expected to become seizure-free within 5 years after diagnosis. This article presents a concise review of the current literature about the definition, diagnosis, epidemiology, clinical characteristics, treatment, and prognosis of PNES.

Video-EEG results and clinical characteristics in patients with psychogenic nonepileptic spells: The effect of a coexistent epilepsy

RATIONALE

Epilepsy and psychogenic nonepileptic spells (PNES) can coexist, often posing diagnostic and therapeutic challenges. We sought to identify clinical and historical characteristics of two groups of patients, those with coexisting epilepsy and PNES and those with PNES alone, and determine the prevalence of coexisting epilepsy/PNES with strict diagnostic criteria in a large group of epilepsy monitoring unit (EMU) patients.

METHODS

We reviewed the medical records of all consecutive patients admitted to the Vanderbilt University Medical Center Adult EMU between July 1, 2007 and June 30, 2012. We identified patients with recorded PNES and classified them as having coexisting epilepsy/PNES or PNES alone and then systematically compared the clinical characteristics of these two groups.

RESULTS

A total of 1567 patient medical records were reviewed. The prevalence rate of coexisting epilepsy/PNES was 5.2% among all EMU admissions (12.3% of all patients with epilepsy and 14.8% of all patients with PNES). These rates were lower when patients with interictal epileptiform activity (IEA) alone and no recorded ictal discharges were not included in the group with epilepsy (2.6%, 6.2%, and 7.4%, respectively). The accuracy of pre-EMU clinical suspicion was significantly higher in the group with PNES-only. Patients with epilepsy/PNES were significantly more likely to require more than one EMU admission for definitive diagnosis. The first PNES event preceded an epileptic seizure (ES) in 94.4% of patients with epilepsy/PNES. The group with PNES-only had significantly higher suggestibility, and the group with epilepsy/PNES had a significantly higher presence of epilepsy risk factors. Abnormal neurological examination and abnormal brain MRI were also significantly more common in the group with epilepsy/PNES.

CONCLUSIONS

Our study defined the prevalence of coexisting epilepsy/PNES in a large cohort with strict diagnostic criteria and outlined specific clinical and historical characteristics differentiating the two groups of patients with coexisting epilepsy/PNES and PNES-only. These findings should help guide clinicians to reach the correct diagnosis faster and provide appropriate treatment earlier.

Epidemiology of psychogenic nonepileptic seizures

We critically review the existing literature about the epidemiology (i.e., diagnosis, occurrence, age, gender, comorbidity with epilepsy, associated factors, prognosis, mortality, and cost) of psychogenic nonepileptic seizures (PNES) and provide suggestions for future research. Psychogenic nonepileptic seizures are commonly diagnosed at epilepsy centers. The diagnosis of PNES relies on a multidisciplinary evaluation and is usually based on different combinations of data. Recording a seizure, while under video-EEG monitoring, is the most reliable diagnostic test. However, not all patients present with seizures while under video-EEG monitoring. Furthermore, not all epileptic seizures produce visible changes in the scalp EEG. The incidence of PNES was estimated to be 1.4-4.9/100,000/year in three previous studies, and the prevalence was calculated to be between 2 to 33 per 100,000 in one study, making it a significant neuropsychiatric condition. However, there remains a scarcity of data about the epidemiology of PNES, and extant studies that assessed the epidemiological characteristics of PNES have significant limitations. For example, inconsistencies with regard to the age of patients studied and lack of standardization of the diagnostic criteria are some of the significant limitations among studies. In conclusion, PNES merit further epidemiological and pathophysiological investigation. A more precise definition and clear guidance on standards for the diagnosis might influence the direction of future research. Well-designed prospective population-based studies to clarify the epidemiology of PNES in various parts of the world, including an evaluation of the predisposing, precipitating, and perpetuating factors in cross-cultural comparisons is required.

Psychogenic nonepileptic seizures and psychogenic movement disorders: two sides of the same coin?

Psychogenic nonepileptic seizures (PNES) and psychogenic movement disorders (PMD) are commonly seen in Neurology practice and are categorized in the DSM-5 as functional neurological disorders/conversion disorders. This review encompasses historical and epidemiological data, clinical aspects, diagnostic criteria, treatment and prognosis of these rather challenging and often neglected patients. As a group they have puzzled generations of neurologists and psychiatrists and in some ways continue to do so, perhaps embodying and justifying the ultimate and necessary link between these specialties.

Psychogenic non-epileptic seizures at a tertiary care center in Brazil

Although psychogenic non-epileptic seizures (PNES) are a worldwide phenomenon, most of our knowledge addressing clinical characteristics is based on studies conducted in the USA, Europe, and Australia. There are scarce data about PNES in South American countries. This study provided a detailed analysis of the demographic, clinical, and psychosocial characteristics of 102 Brazilian patients with PNES. Seventy-eight patients (76.4%) were female with mean age of 35.27 years. Mean age at onset was 27.85 years; mean time to diagnosis was 7.89 years; 87.25% lived with their families; 56.89% were single; and only 33 (39.75%) worked on a regular basis. Depression was diagnosed in 48.03%. Thirty-three patients misdiagnosed as having epilepsy were using antiepileptic drugs. Stress factors were identified in 57.84%. This is the first Brazilian study that involves a large sample of patients with video-EEG-documented PNES and corroborates the idea that PNES are a worldwide phenomenon sharing several similarities, despite cultural and socioeconomic differences.

Comparing standard medical care for nonepileptic seizures in Chile and the United States

OBJECTIVE

We sought to compare the diagnostic and treatment practices for psychogenic nonepileptic seizures (PNES) in the United States (US) to Chile.

METHODS

A survey on the diagnostic and treatment practices for PNES was administered to practicing clinicians in Chile. Results from 96 Chilean respondents were compared to results from 307 US clinicians. Type I error (alpha) was set to 0.005 for multiple comparisons.

DIAGNOSIS

The diagnosis of PNES is made by inpatient video-EEG/LTM in 89% of the US respondents compared to 25% of the Chilean respondents (p<0.0001). The diagnosis of PNES is made by history and exam alone at twice the rate in Chile (38%) than in the US (16%; p<0.0001).

TREATMENT

A higher proportion of the Chilean respondents (65%) endorsed psychopharmacotherapy as potentially beneficial compared to the US respondents (31%; p<0.0001).

DISCUSSION

This cross-cultural multi-site survey reveals some differences in PNES evaluation and management between neurologists and other clinicians in the US and in Chile. Access to video EEG may improve PNES diagnosis and treatment.