Diagnosis Of Non-epileptic Attack Disorder Research Articles

‘I just need to know what they are and if you can help me’: Medicalization and the search for legitimacy in people diagnosed with non-epileptic attack disorder

This paper focuses on the struggles for legitimacy expressed by people with non-epileptic attack disorder (NEAD), one of the most common manifestations of functional neurological disorder presenting to emergency and secondary care services. Nonepileptic attacks are episodes of altered experience, awareness, and reduced self-control that superficially resemble epileptic seizures or other paroxysmal disorders but are not associated with physiological abnormalities sufficient to explain the semiological features. “Organic” or medicalized explanations are frequently sought by patients as the only legitimate explanation for symptoms, and consequently, a diagnosis of NEAD is often contested.Drawing on narrative interviews with patients from a small exploratory study and using a sociological perspective, we propose that a psychological account of NEAD does not provide a sufficiently legitimate path into a socially sanctioned sick role. This is a reflection of the dominance of biomedicine and the associated processes of medicalization. These processes are, we argue, the sole route to achieving legitimacy. The stress-based or psychologically oriented explanations offered to patients in contemporary medical models of the etiology of NEAD engender an uncertain identity and social position and fail to provide many patients with an account of the nature or origin of their symptoms that they find satisfactory or convincing.These struggles for legitimacy (shared by others with functional or somatoform conditions) are sharpened by key features of the contemporary healthcare landscape, such as the increasing framing of health through a lens of ‘responsibilization’.

Beyond the medical encounter: can the free association narrative interview method extend psychosocial understandings of non-epileptic attack disorder?

This exploratory interdisciplinary study was devised to explore how using the free association narrative interview (FANI) method might extend understanding of non-epileptic attack disorder (NEAD) within a psychosocial framework. NEAD is the medical definition of what can be described as embodied events that resemble epilepsy, but which are not associated with the abnormal electrical discharges in the brain found in epilepsy. They are the most frequent ‘functional’ disorder or medically unexplained symptom (MUS) seen by neurologists. While NEAD is associated with trauma, distress and negative life events, a significant minority of patients report no trauma history. The FANI method, we argue, produced narratives which shed light on events that patients have not acknowledged as traumatic, but which might be considered as such, and we explore what aspects of the method may facilitate this process. Previous work has highlighted that a diagnosis of NEAD is often experienced as deeply troubling and contentious to both give and to receive. We thus reflect on the need for patients to feel a sense of legitimacy and how the challenges of living with a NEAD diagnosis are negotiated. Drawing on the work of Benjamin (2004) on ‘thirdness’, we suggest that the FANI method can allow the research interview to become a space that facilitates novel ways of engaging around NEAD. We conclude that the method may be a powerful tool for studying NEAD, and that further studies should be undertaken using this approach since it may have broader utility in understanding the landscape of functional neurological disorders.

Optimising the use of EEG in non-epileptic attack disorder: Results of a UK national service evaluation

PurposeTo produce an evidence base to formulate guidelines for optimal performance of EEG in patients referred with a possible diagnosis of non-epileptic attack disorder (NEAD). Methods51 UK EEG departments participated in the prospective study. A pro-forma was completed for all consecutive patients aged 5 years and over referred for EEG over a six month period. Information obtained included referral diagnosis, occurrence/type of attack during EEG, the use of suggestion, length of recording and who was present during the EEG. Results11,298 patients were entered into the study. 376 psychogenic non-epileptic seizures (PNES) occurred of which 337 were considered to be of the habitual type. In those patients suspected of having NEAD prior to referral, the use of verbal suggestion increased the yield of habitual attacks by a factor of three in both adults and children. Using suggestive techniques twice, improved the yield further. Non-habitual attacks occurred equally whether or not suggestion was used. At least 90% of habitual PNES occurred within the first 30 min of recording even in those patients having prolonged EEGs. In EEGs where additional professional personnel were present, PNES occurred more frequently. ConclusionThis large multicentre study provides evidence to inform recommendations for EEG to investigate NEAD. We recommend the use of verbal suggestion at least twice and where practical the presence of additional professional staff. A thirty minute recording is sufficient to record a habitual PNES in most instances.

19 Non-epileptic attacks: establishing the patient population presenting to university hospital southampton

Objective To establish the prevalence of non-epileptic attack disorder within a large teaching hospital and compare this population with that in the current literature, Establish proportion of patients with co-morbid epilepsy, Identify prevalence of diagnosed psychiatric co-morbidity in this population group, Review of the management received by this patient cohort. Method A retrospective study over the time period June 2014 – May 2015, A search was performed on the trust electronic documents using the following keywords: “Non-epileptic attacks”; “NEAD”; “Pseudo seizures”; “Pseudo seizures”; “Dissociative seizures”; “Functional seizures”; “Psychogenic seizures”; “Conversion disorder”, NHS numbers of patients with any of the key word diagnoses were collected and electronic records of these patients were reviewed for demographics, diagnoses and management. Results 162 patients were identified who had a diagnosis of non-epileptic attack disorder. 78% female, 22% male, 50% of female patients and 42% of male patients were diagnosed before the age of 30. The most prevalent age range for women with NEAD was 18–30 years old. There were two most prevalent age ranges for men with NEAD: 18–30 years old and the older age range of 45 years and above. 96% of patients were seen by a neurologist; 42% were seen by a psychiatrist. 22% of patients presented to A and E with non-epileptic attacks. 35% of people with non-epileptic attacks had comorbid epilepsy. 57% of people had a diagnosed psychopathology: 26% had an anxiety-related disorder and 36% had depression. Of the 31 people with NEAD who were in employment, 45% worked in a health care setting, either as a nurse, medical student, health care assistant or in the ambulance service. Conclusion The demographics in the local area are similar to that described in the literature about non-epileptic attacks. The disorder is more common in women, with a higher proportion of younger women affected. Comorbid psychiatric illness is common, with anxiety and depression the most prevalent diagnoses. In the local population, neurology services saw the majority of patients, with just under half being seen by a psychiatrist. Almost a quarter of patients were seen in the emergency department with non-epileptic attacks. These findings are important in service developments for these patients.

Neurophysiological investigations for the diagnosis of non-epileptic attack disorder in neuropsychiatry services: from safety standards to improved effectiveness.

The discipline of clinical neuropsychiatry currently provides specialised services for a number of conditions that cross the traditional boundaries of neurology and psychiatry, including non-epileptic attack disorder. Neurophysiological investigations have an important role within neuropsychiatry services, with video-electroencephalography (EEG) telemetry being the gold standard investigation for the differential diagnosis between epileptic seizures and non-epileptic attacks. This article reviews existing evidence on best practices for neurophysiology investigations, with focus on safety measures for video-EEG telemetry. We conducted a systematic literature review using the PubMed database in order to identify the scientific literature on the best practices when using neurophysiological investigations in patients with suspected epileptic seizures or non-epileptic attacks. Specific measures need to be implemented for video-EEG telemetry to be safely and effectively carried out by neuropsychiatry services. A confirmed diagnosis of non-epileptic attack disorder following video-EEG telemetry carried out within neuropsychiatry units has the inherent advantage of allowing diagnosis communication and implementation of treatment strategies in a timely fashion, potentially improving clinical outcomes and cost-effectiveness significantly. The identified recommendations set the stage for the development of standardised guidelines to enable neuropsychiatry services to implement streamlined and evidence-based care pathways.

The experience of adjusting to a diagnosis of non-epileptic attack disorder (NEAD) and the subsequent process of psychological therapy

PurposeResearch suggests psychological therapy as the treatment of choice for individuals diagnosed with NEAD. This study explored the experience of adjusting to a diagnosis of NEAD and engagement with therapy through a qualitative methodology. MethodSemi-structured interviews were conducted with 6 people with a diagnosis of NEAD and analysed using thematic analysis. ResultsSix master-themes were generated, with four discussed. Two themes were not discussed due to previous coverage in the literature and their less direct relevance to the service context. Theme 1: ‘understanding NEAD’ incorporated participants’ evolving understanding of the diagnosis and their reflections on this. Theme 2: ‘I can’t deal with you’ centres on participants’ accounts of relationships with professionals in the context of NEAD. Theme 3: ‘experiences of psychological therapy’ reflected participants’ experience of being referred to psychology and gaining a deeper understanding of themselves through therapy. Theme 4: ‘adjusting to life with NEAD’ explores participants’ views on living with NEAD and their expectations for the future. ConclusionThis study extended previous research by highlighting the impact of how the diagnosis is received and understood on engagement in therapy. Improving awareness of NEAD amongst healthcare professionals is of key importance in reducing stigma and encouraging engagement in therapy.

NON-EPILEPTIC ATTACK DISORDER AND TODD'S PARESIS: A CASE SERIES AND LITERATURE REVIEW

BackgroundTodd's paresis is a transient focal weakness of the hand, arm or leg which follows partial seizure activity within that limb. This was first described by Robert Bentley Todd in...

P18 Non epileptic seizures and Todd's paresis: case series and literature review

Objective Todd9s paresis is a transient focal weakness of a hand, arm or leg which follows a partial seizure activity within that limb. This was first described by Robert Bentley Todd in 1849. The weakness can range from severity from mild to complete paralysis and usually occurs on just one side of the body. The paralysis can last from minutes to hours. There have been case reports of longer duration of paresis, ranging to as long as days. It may occur in up to 13% of seizure cases. Todd9s paresis may affect speech, eye gaze or vision. It most commonly occurs after generalised tonic clonic seizures. There is literature on Todd9s paresis and its association with epilepsy since it was first described in 1849. There is dearth of literature on its association with non-epileptic seizures. Its presentation in patients with NEAD whether represents a true epileptic event or it represents a pseudo paralysis was something we were interested in. The interest was primarily driven by the three patients we had of non-epileptic attack disorder who presented with focal weakness. Method We did an electronic literature search using PubMed, Medline and Trip database. The key words used were—epilepsy, Todd9s paresis, non-epileptic attack disorder, post ictal paresis, pseudo Todd9s paresis and pseudoneurological symptoms. The case series is as follows: Case 1 : A 48-year-old gentleman with history of non-epileptic attack disorder (NEAD) was admitted to hospital following another episode of NEAD. He reported having an attack of cluster of absent seizures following which he complained of being paralysed down one side. He complained of loss of function of left arm and leg. He was admitted to hospital where he had a full neurological screen done. Objectively, there was no evidence of any focal deficits. He reported being unable to feel anything on left side but was able to respond appropriately to lateralised tactile stimulation with eyes closed. Gate was antalgic with a reduced support phase on left. He had video telemetry done with no evidence of seizures and CT exam was unremarkable. Patient was discharged with the diagnosis of NEAD. Case 2 : 37-year-old, female with history of non-epileptic attack disorder was admitted to hospital following an episode of non-epileptic seizure. Patient reported right sided paresis; difficulty lifting her right arm and leg. The weakness lasted 2–3 h, settled on its own. No evidence of any focal deficits on neurological examination. EEG was unremarkable. MRI showed slight asymmetry of left pre central gyrus. No convincing signal abnormality and the appearances were constitutional. Case 3 : A 33-year-old lady with history of non-epileptic attack disorder was seen in the outpatient clinics. She had an NEAD attack which was generalised and following that she complained of left sided facial weakness. No dysphasia or problems with vision reported. The weakness lasted for only few minutes and subsided on its own. She had further episodes of seizures but never had a weakness afterwards. On assessment there was no evidence of any change in the nature or degree of her seizure pattern. Results Our three patients above had diagnosis of NEAD and they all complained of motor weakness or Todd9s paresis which is more characteristic of Epilepsy. This raised doubts in our minds that whether these patients actually had a seizure and that resulted in Todd9s paresis. The first two patients had investigations re done to establish that but no cause was found. The third patient was seen well after the episode of facial weakness. We did not notice any change in her seizure episodes from the past so further investigations were not carried out. We wanted to establish if there is any association between Todd9s paresis and NEAD .We tried to find the answer by doing a literature search but unfortunately it did not help much as we could find only one case report and nothing else useful. Conclusion There will always be ethical dilemma that whether patients with NEAD should be re investigated or not if they complained of neurological symptoms. We believe that each case should be dealt on its merit and the patients to be managed accordingly. It is not uncommon for patients with NEAD to have epilepsy and as a result Todd9s paresis. The literature search was not very useful in finding the right answer.

Non-epileptic seizures: patients’ understanding and reaction to the diagnosis and impact on outcome

Rationale: The study aim was to assess patients’ understanding of and reaction to a diagnosis of non-epileptic attack disorder and to explore whether these factors contribute to outcome. Method: Eighty-four patients diagnosed with non-epileptic attack disorder participated in the study. Participants answered questions about their seizures and understanding and reaction to the diagnosis. Data were collected by semi-structured telephone interview. Questionnaires were sent to the patients’ general practitioners (GPs) to gather information regarding the patient’s seizure status, prescription of anti-epileptic drugs and opinion regarding the diagnosis. Results: At the time of follow-up, a third of participants reported being seizure free. A total of 63% did not have a good understanding of the diagnosis, most were unclear about the precipitating factors and the most common reaction to the diagnosis was confusion. Many reported a negative impact of NES on everyday life. Sixty-five percent reported receiving psychological follow-up but the number of sessions attended was few (median 2). There was evidence that the reaction to the diagnosis contributed to the outcome in particular an angry outcome was associated with a poor prognosis. Ten GPs did not agree with the diagnosis. Conclusion: Patients understanding and reactions to a diagnosis of non-epileptic attacks are important factors that should contribute to the development of more tailored treatment approaches.