Nonepileptic Seizures Research Articles

N°247 – Resting-state brain connectivity differences between epileptic and non-epileptic first events

N°247 – Resting-state brain connectivity differences between epileptic and non-epileptic first events

A systems biology approach for discovering the cellular and molecular aspects of psychogenic non-epileptic seizure.

Psychogenic non-epileptic seizure (PNES) is the most common non-epileptic disorder in patients referring to epilepsy centers. Contrary to common beliefs about the disease's harmlessness, the death rate of PNES patients is similar to drug-resistant epilepsy. Meanwhile, the molecular pathomechanism of PNES is unknown with very limited related research. Thus, the aim of this in silico study was to find different proteins and hormones associated with PNES via a systems biology approach. Different bioinformatics databases and literature review were used to find proteins associated with PNES. The protein-hormone interaction network of PNES was constructed to discover its most influential compartments. The pathways associated with PNES pathomechanism were found by enrichment analysis of the identified proteins. Besides, the relationship between PNES-related molecules and psychiatric diseases was discovered, and the brain regions that could express altered levels of blood proteins were discovered. Eight genes and three hormones were found associated with PNES through the review process. Proopiomelanocortin (POMC), neuropeptide Y (NPY), cortisol, norepinephrine, and brain-derived neurotrophic factor (BDNF) were identified to have a high impact on the disease pathogenesis network. Moreover, activation of Janus kinase-signaling transducer and activator of transcription (JAK-STAT) and JAK, as well as signaling of growth hormone receptor, phosphatidylinositol 3-kinase /protein kinase B (PI3K/AKT), and neurotrophin were found associated with PNES molecular mechanism. Several psychiatric diseases such as depression, schizophrenia, and alcohol-related disorders were shown to be associated with PNES predominantly through signaling molecules. This study was the first to gather the biochemicals associated with PNES. Multiple components and pathways and several psychiatric diseases associated with PNES, and some brain regions that could be altered during PNES were suggested, which should be confirmed in further studies. Altogether, these findings could be used in future molecular research on PNES patients.

Epileptiform activity influences theta-burst induced LTP in the adult hippocampus: a role for synaptic lipid raft disruption in early metaplasticity?

Non-epileptic seizures are identified as a common epileptogenic trigger. Early metaplasticity following seizures may contribute to epileptogenesis by abnormally altering synaptic strength and homeostatic plasticity. We now studied how in vitro epileptiform activity (EA) triggers early changes in CA1 long-term potentiation (LTP) induced by theta-burst stimulation (TBS) in rat hippocampal slices and the involvement of lipid rafts in these early metaplasticity events. Two forms of EA were induced: (1) interictal-like EA evoked by Mg2+ withdrawal and K+ elevation to 6 mM in the superfusion medium or (2) ictal-like EA induced by bicuculline (10 μM). Both EA patterns induced and LTP-like effect on CA1 synaptic transmission prior to LTP induction. LTP induced 30 min post EA was impaired, an effect more pronounced after ictal-like EA. LTP recovered to control levels 60 min post interictal-like EA but was still impaired 60 min after ictal-like EA. The synaptic molecular events underlying this altered LTP were investigated 30 min post EA in synaptosomes isolated from these slices. EA enhanced AMPA GluA1 Ser831 phosphorylation but decreased Ser845 phosphorylation and the GluA1/GluA2 ratio. Flotillin-1 and caveolin-1 were markedly decreased concomitantly with a marked increase in gephyrin levels and a less prominent increase in PSD-95. Altogether, EA differentially influences hippocampal CA1 LTP thorough regulation of GluA1/GluA2 levels and AMPA GluA1 phosphorylation suggesting that altered LTP post-seizures is a relevant target for antiepileptogenic therapies. In addition, this metaplasticity is also associated with marked alterations in classic and synaptic lipid raft markers, suggesting these may also constitute promising targets in epileptogenesis prevention.

Bilateral tonic seizures vs. bilateral tonic events in critically ill patients: differences in semiology

PurposeOur primary aim was to analyze bilateral epileptic tonic seizures (ETS) and bilateral non-epileptic tonic events (NTE) in critically ill patients. Our secondary aim was to analyze ETS per their epileptogenic zone. MethodsWe performed a retrospective analysis of clinical signs in patients with bilateral ETS and NTE. Two authors independently reviewed 34 videos of ETS in 34 patients and 15 videos of NTEs in 15 patients. Initial screening and review was performed in an unblinded manner. Subsequently, the semiology was characterized independently and blindly by a co-author. Statistical analysis was conducted using Bonferroni correction and two-tailed Fischer exact test. Positive predictive value (PPV) was calculated for all signs. Cluster analysis of signs with a PPV >80% was performed to evaluate co-occurring semiological features in the two groups. ResultsCompared to patients with ETS, those with NTEs more frequently had predominant involvement of proximal upper extremities (UE) (67% vs. 21%), internal rotation of UE (67% vs. 3%), adduction of UE (80% vs. 6%) and bilateral elbow extension (80% vs. 6%). In contrast, those with ETS more frequently had abduction of UE (82% vs 0%), elevation of UE (91% vs. 33%), open eyelids (74% vs. 20%), and involvement of both proximal and distal UE (79% vs. 27%). In addition, seizures that remained symmetrical throughout were more likely to have a generalized onset than focal (38% vs. 6%), p = 0.032, PPV 86%. ConclusionsA careful analysis of semiology can often help differentiate between ETS and NTE in the ICU. The combination of eyelids open, upper extremity abduction, and elevation reached a PPV of 100% for ETS. The combination of bilateral arms extension, internal rotation, and adduction reached a PPV of 90.9% for NTE.

Dostoevsky, The Brothers Karamazov, and Epilepsy.

Fyodor Mikhailovich Dostoevsky was a brilliant nineteenth-century Russian novelist who had a seizure disorder that influenced his life and his creativity.His novels explore issues of love, faith, doubt, morality and reflect his personal experience with epilepsy. He was a keen observer of familial psychodynamics. The Brothers Karamazov (1880)was Dostoyevsky's longest and last novel, completed just a few months before his death from a pulmonary hemorrhage, most likely related to his life-long habit of cigarette smoking.In this novel, he explores the subtility of interpersonal relationships and the psychopathology within the Karamazov family and how one of the three brothers, Smerdyakov, uses psychogenic non-epileptic seizures as an alibi to get away with the perfect crime of patricide.

Adolescents' Perceptions of Functional Seizure Self-Management Strategies, Facilitators, and Barriers in the School Environment.

Adolescents with functional (psychogenic nonepileptic) seizures encounter many struggles within the school environment, including stress, bullying, stigmatization, and accusations of faking seizure events. Mental health nurses and school personnel are poised to support school-based self-management; unfortunately, to date, no evidence exists to detail effective school-based self-management strategies for adolescents with functional seizures. Therefore, in the current qualitative study, we examined adolescents' functional seizure self-management, perceived effectiveness, and facilitators and barriers using semi-structured interviews analyzed using content analysis. We interviewed 10 adolescent females aged 12 to 19 years. Themes of proactive (prior to seizure warning symptoms) and reactive (after seizure warning symptoms) self-management, involving protection, perseverance, and progress monitoring, emerged. Adolescents perceived proactive strategies as primarily effective, whereas reactive strategies were less effective. Adolescents identified school nurses and personnel, family, and peers as facilitators and barriers to self-management. Mental health nurses are positioned to provide care, co-create plans, and advocate for adolescents with functional seizures in collaboration with school nurses and personnel. [Journal of Psychosocial Nursing and Mental Health Services, 61(10), 19-27.].

Neuropsychological profile and drug treatment response in Idiopathic Generalized Epilepsy

PurposeThe endophenotype of Idiopathic Generalized Epilepsies (IGE) comprises distinct neuropsychological deficits compared to normal controls. It is unknown if the severity of features of the endophenotype correlates with resistance to anti-seizure medication. Therefore, we here studied the association of neuropsychological profiles with treatment response. MethodsWe evaluated 106 Danish patients aged ≥18 and diagnosed with IGE using a neuropsychological test battery comprising tests for executive dysfunction, visual attention, episodic memory, and verbal comprehension. Tests were complemented by the Purdue Pegboard test. Patients with suspected ongoing psychogenic non-epileptic seizures were excluded. ResultsAt testing, 72 patients were seizure free, and 34 patients had recent seizures despite anti-seizure medication. As compared to age corrected Danish normative values, IGE patients showed significant impairments in semantic fluency and performed significantly worse in the Purdue Pegboard test. The vocabulary subtest of the WAIS-IV suggested lower verbal comprehension in IGE patients. We found no signs of memory impairment. Comparisons between results of the test battery, drug resistance, and the different IGE subsyndromes revealed consistent null-associations in various predefined and exploratory univariate and multivariate analyses. ConclusionWe here found and confirmed the distinct neuropsychological profile comprising impaired executive functions, reduced psychomotor speed, and normal memory previously described in juvenile myoclonic epilepsy. This profile was, however, not restricted to juvenile myoclonic epilepsy but equally affected all IGE patients. The neuropsychological deficits were not significantly associated with drug treatment outcome.

Stroke, Seizures, and State of the Union: How Neurologic Ailments of FLOTUS Changed the Course of World Affairs (P4-3.003)

<h3>Objective:</h3> Describe the impact of stroke and seizure disorders of the First Ladies of the United States (FLOTUS) on the President of the United States (POTUS), and world affairs. <h3>Background:</h3> The FLOTUS has had significant influence on politics and society throughout history. Many First Ladies have been involved with the campaign trail, served as advisors for their husband, and led their own social initiatives. However, many of these influential women were impacted by strokes and seizures. Considering the importance of the FLOTUS in affecting politics and history, a proper examination of the effect of their neurologic conditions on the nation is critical for historians and neurologists alike. <h3>Design/Methods:</h3> An analysis of historical literature was done to determine which First Ladies have suffered from seizure and stroke. The first ten google hits for each FLOTUS were reviewed for evidence of either disorder. An analysis of the scientific literature was then completed using PubMed and Google Scholar to help describe reasonable diagnoses and etiologies. Finally, books and government websites were used to further analyze historical timelines and propose potential ways that their conditions may have impacted national and world politics. <h3>Results:</h3> There have been 54 FLOTUS, 43 official and 11 acting FLOTUS. 10 have had neurologic ailments, six of which have been stroke or seizure. FLOTUS have had both epileptic and nonepileptic seizures and strokes have ranged from middle cerebral artery to internal capsular stroke. Their conditions often affected how they performed as first lady and the public’s impression of the President, which led to substantial changes in the White House and world affairs. <h3>Conclusions:</h3> The neurologic health of the First Ladies had significant effects on American and World History. Their conditions affected White House precedents, decisions made by the President, and expectations of women in society and politics. <b>Disclosure:</b> Ms. Heide has nothing to disclose. Dr. Etienne has nothing to disclose.

Facial Emotion Processing Changes in Functional Seizures after Neurobehavioral Therapy (P12-8.008)

<h3>Objective:</h3> To prospectively investigate effects of neurobehavioral therapy (NBT) on fMRI emotion processing in adults with psychogenic non-epileptic (functional) seizures (FS). <h3>Background:</h3> NBT reduces FS frequency and affects emotion processing in people with FS. We hypothesized that changes in FS frequency, mood symptoms and overall functioning with NBT would be associated with changes in emotion processing. <h3>Design/Methods:</h3> Adults with FS after traumatic brain injury (TBI+FS; n=47) underwent a 12-sessions of NBT. TBI+FS and TBI-only controls (n=57) completed two fMRIs and assessments of depression (BDI-II), anxiety (BAI), and Global Assessment of Functioning (GAF) about 12 weeks apart (V1; V2). Subjects performed the emotion faces task (EFT) during fMRI where they viewed happy, sad, fearful and neutral faces. Linear mixed effects assessed group-by-time interactions on emotion response (corrected p&lt;0.05), fMRI signal was extracted, and correlations performed (Bonferroni-corrected p&lt;0.0125). <h3>Results:</h3> 53% of TBI+FS were seizure-free following NBT. There were significant group-by-time interactions (V1-to-V2 increases in TBI+FS and decreases in TBI-only) for fMRI response within right middle frontal gyrus (RMFG) to happy, sad, and fearful faces, and right inferior frontal gyrus (RIFG) to fearful faces. In combined sample, there were negative correlations between V2-V1 BDI-II changes and RMFG response changes to happy (rho=−0.30, p=0.003) and sad faces (rho=−0.27, p=0.008), and positive correlations between V2-V1 GAF changes and RMFG response changes to happy (rho=0.34, p&lt;0.001) and sad faces (rho=0.31, p=0.001), and RIFG response changes to fearful faces (rho=0.26, p=0.008). There were non-significant trends in TBI+FS for relationship between percent FS reduction and RMFG response changes to happy (rho=−0.24, p=0.106) and sad faces (rho=−0.24, p=0.109). <h3>Conclusions:</h3> We observed strong relationships in the combined group between behavioral changes and fMRI changes. The observed seizure reduction was not correlated with imaging changes suggesting that factors other than seizure reduction may be driving post-NBT changes in facial emotion processing. <b>Disclosure:</b> Dr. Szaflarski has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for UCB Pharma. Dr. Szaflarski has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for SK Life Sciences. Dr. Szaflarski has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for LivaNova Inc. Dr. Szaflarski has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Serina Therapeutics. Dr. Szaflarski has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for GW Biosciences. An immediate family member of Dr. Szaflarski has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for GW Biosciences. Dr. Szaflarski has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Elsevier. Dr. Szaflarski has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for Law Firm. Dr. Szaflarski has stock in AdCel Biopharma, LLC. Dr. Szaflarski has stock in iFovea. An immediate family member of Dr. Allendorfer has received personal compensation for serving as an employee of Northport Health Services, LLC. Dr. Allendorfer has received personal compensation in the range of $100,000-$499,999 for serving as a Consultant for Liva Nova, Inc. The institution of Dr. Allendorfer has received research support from National Institutes of Health. Dr. Allendorfer has a non-compensated relationship as a Grants Reviewer with American Epilepsy Society that is relevant to AAN interests or activities. Dr. Goodman has nothing to disclose. Rodolphe Nenert, 4770 has nothing to disclose. Dr. Gaston has received personal compensation in the range of $500-$4,999 for serving as a Consultant for GW Biosciences. Dr. Perry Grayson has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Jazz Pharmaceuticals . The institution of Dr. Perry Grayson has received research support from Department of Defense . The institution of Dr. Philip has received research support from NIH, DoD, VA. Stephen Correia has received research support from Alzheimer’s Association/National Institute on Aging. Stephen Correia has received research support from NIMH. Dr. LaFrance has received personal compensation in the range of $10,000-$49,999 for serving as an Expert Witness for medico-legal work.. The institution of Dr. LaFrance has received research support from Department of Defense. Dr. LaFrance has received publishing royalties from a publication relating to health care. Dr. LaFrance has received publishing royalties from a publication relating to health care.

Child Neurology Residency Survey of Psychogenic Nonepileptic Seizure Education (P2-2.004)

<h3>Objective:</h3> To assess the learning needs of pediatric neurology resident trainees and program directors (PD) on the education of psychogenic nonepileptic seizures (PNES) during training. <h3>Background:</h3> PNES proves difficult to differentiate from epileptic seizures (ES) even for neurologists who see these conditions frequently, given overlapping semiologic findings between the two diagnoses. Previous studies have shown trainees, including neurology trainees, are not very accurate in differentiating PNES from ES. Neurologists often find the communication of PNES difficult. Despite these challenges, most programs do not have a formal curriculum for teaching PNES and there are no ABPN standards for residency curricula in this topic. <h3>Design/Methods:</h3> Two unique surveys were designed, one for child neurology trainees and one for PDs. Questions were designed to assess trainees’ abilities, current education received, and desired teaching. Similarly, PDs’ level of confidence in trainee management of PNES was assessed, as well as specific preferences for a standardized curriculum. <h3>Results:</h3> Sixty-five trainees out of approximately 202 and 21 PDs and associate PDs have responded to the survey. About one-third of trainees report neutral to low levels of confidence and 36.9% report neutral to low levels of knowledge in caring for PNES patients. Trainees reported that directing PNES patients to appropriate management was the most challenging aspect of care, followed by communicating the diagnosis, with 60.0% and 46.1% reporting difficulty, respectively. Trainees report preferring to learn about this topic through reading material and simulation. One-fifth of PDs feel their current PNES education is not sufficient and 52.4% of PDs would incorporate a standardized curriculum, with remaining PDs reporting willingness depending on the required time. <h3>Conclusions:</h3> Areas of needed training and desired teaching format were identified based on trainee responses. PDs desire a standardized curriculum and would incorporate one into their programs. Findings of this study will be utilized to create a national curriculum. <b>Disclosure:</b> The institution of Dr. Albert has received research support from Nationwide Children’s Hospital, Division of Neurology, Internal Research Grant. Dr. Freedman has nothing to disclose. Dr. Talai has nothing to disclose.

Epilepsia Partialis Continua Presenting as Hypoxemic Respiratory Failure (P9-1.004)

<h3>Objective:</h3> An unusual case of a patient with epilepsia partialis continua (EPC) who presented with abdominal spasm and hypoxemic respiratory failure necessitating intubation. <h3>Background:</h3> EPC, also known as focal motor status epilepticus, is a is a rare, recurrent, focal seizure disorder that has a wide range of clinical presentation. EPC usually manifests with treatment-resistant seizures with retained awareness and unilateral motor symptoms. The differential diagnosis of the underlying causes of EPC is broad, including structural etiologies such as malignancy, focal cortical dysplasia, and ischemic stroke, and metabolic disorders such as non-ketotic hyperglycemia. <h3>Design/Methods:</h3> <h3>Case Presentation:</h3> Our patient is a 23-year-old woman with a history of a steroid responsive encephalitis complicated by focal aware and focal impaired awareness seizures as well as psychogenic non-epileptic seizures. She presented to a regional emergency department three times over a 48 hours period for episodes of abdominal spasms that spread through all of her limbs equally and occurred very briefly every two to three minutes. She was told each time that her episodes were nonepileptic. <h3>Results:</h3> Upon transfer to our center, she continued to have frequent episodes of diaphragmatic spasm without EEG correlate until she developed respiratory failure and altered mental status. She was intubated and placed on continuous EEG. After a paralytic trial, she was found to have focal electrographic seizures with bilateral (left &gt; right) parasaggital, sharp rhythmic, alpha activity evolving to theta activity. <h3>Conclusions:</h3> EPC is frequently silent on EEG. This patient had a rare form of abdominal and diaphragmatic epilepsy with preserved awareness that ultimately progressed to respiratory failure. The ictal nature of her symptoms only became apparent on EEG after administration of paralytics. In patients with abdominal spasm, it is important to consider ictal causes that may not be electrographically evident. <b>Disclosure:</b> Dr. O’Connor has nothing to disclose. Dr. Stulberg has nothing to disclose. Dr. Johnson has nothing to disclose. The institution of Dr. Peters has received research support from NIH.

Development of De novo Functional Seizures after Epilepsy Surgery (S35.010)

<h3>Objective:</h3> The purpose of this evaluation was to identify the frequency and risk factors of de novo FS in patient after epilepsy surgery. <h3>Background:</h3> Functional seizures (FS) (also known as psychogenic non-epileptic seizures (PNES) or dissociative seizures) are seizures that mimic an epileptic seizure but have no associated epileptogenic EEG changes and are thought to have a psychological basis. Epilepsy surgery can be an effective means of treatment for patients with drug refractory seizures, but it is important to understand the complications that can arise from surgery. <h3>Design/Methods:</h3> The surgical data based showed 1116 patients who underwent epilepsy surgery from 1998 to 2022. The clinic notes were reviewed and identified 37 patients who developed de novo FS post-surgery. They were characterised by their age, sex, age of surgery, duration of epilepsy before surgery, pre-operative psychiatric co-morbidities, type/site of surgery, and post-operative complications <h3>Results:</h3> 37 patients were identified (30F, 7M). The mean age at the time of surgery was 36.2 (17–52 years). 31 patients had documented post-operative de novo FS. 16 patients had a documented pre-operative psychiatric diagnosis. 10 patients developed immediate post-operative complications and de novo FS an average of 9.8 months after surgery. 4 patients with no past psychiatric issues developed psychosis following immediate post-operative complications. Patient with no immediate post-operative complications with or without pre-operative psychiatric diagnosis developed de novo FS on average of 29.4 months after epilepsy surgery <h3>Conclusions:</h3> 1) The rate of development of de novo FS after epilepsy surgery is low (2.77%). 2) The patients who have de novo FS after surgery have high rates of pre-operative psychiatric diagnoses (43.2 %), are predominantly female (81.1%) , and have immediate post-op complications (27%). 3) Immediate post-operative complications can result in new functional seizures developing less a year after surgery <b>Disclosure:</b> Dr. Manoj has nothing to disclose. Dr. Yogarajah has received personal compensation in the range of $500-$4,999 for serving as an Expert Witness for MEWA. Dr. Yogarajah has received personal compensation in the range of $500-$4,999 for serving as an Expert Witness for Forensic Access. Dr. Yogarajah has received personal compensation in the range of $500-$4,999 for serving as an Expert Witness for Eopinex. The institution of Dr. Yogarajah has received research support from MRC. Dr. Yogarajah has received publishing royalties from a publication relating to health care. Dr. Huda has nothing to disclose. Ms. De Tisi has nothing to disclose. John Duncan has nothing to disclose.

A Randomised Controlled Trial on the Effect of Viewing the Event in Psychogenic non epileptic Events (S44.010)

<h3>Objective:</h3> To study the effect of viewing one’s event on psychological status in psychogenic non-epileptic events (PNEE) <h3>Background:</h3> PNEEs are bodily complaints due to unconscious mental conflict and the thoughts of which alters the psychological status adversely. Thus, when this sensitive diagnosis is delivered along with one’s own event, a better understanding of the illness brings harmony to internal milieu when coupled with psychotherapy. <h3>Design/Methods:</h3> This is a single centre prospective randomised controlled trial where patients diagnosed with PNEE in our epilepsy monitoring unit were randomised into intervention and control arm. Both the groups were given standard psychotherapy while the recorded event was shown to intervention arm alone. Event frequency and baseline psychological status using standard questionnaires (HADS and QOLIE - 31) was recorded at baseline and compared during follow up at 12 weeks. Paired t test was used to compare the results. <h3>Results:</h3> A total of 65 patients (31 intervention/34 control) were included in the study with similar baseline characteristics. The mean baseline per-week event frequency was 9.93 (16.7) and 11.78 (25.3) in intervention and control group respectively, which had fallen to 2.58 (4.65), p=0.731 and 1.58 (3.04), p=0.313 during 12 week follow up. HADS anxiety and depression scores improved significantly in both the groups while among QOLIE 31 components, seizure worry (p=0.008), overall quality of life (p&lt;0.001) and emotional well being (p&lt;0.003) in intervention arm. However, control arm had improvement in overall quality of life (p=0.003) and social effects (p=0.016) components. <h3>Conclusions:</h3> Event viewing, in addition to psychotherapy improves psychological status in PNEE especially with regard to seizure worry and emotional well being perhaps by improving self - acceptance of the diagnosis and increasing the engagement and adherence to psychotherapy. <b>Disclosure:</b> Dr. Priya has nothing to disclose. Dr. Radhakrishnan has nothing to disclose.

Responsive neurostimulation device use in patients with epilepsy and psychogenic non-epileptic events. Case report and Healthcare expenditure analysis related to neuromodulation therapy in Epilepsy patients (P5-1.005)

Responsive neurostimulation device use in patients with epilepsy and psychogenic non-epileptic events. Case report and Healthcare expenditure analysis related to neuromodulation therapy in Epilepsy patients (P5-1.005)

Cognitive behavioural therapy for psychogenic nonepileptic seizures (PNES) in an adult with a learning disability: A case study

AbstractBackgroundPsychogenic nonepileptic seizures (PNES) are attacks that often look like epileptic seizures (ES). Unlike ES, PNES are not triggered by underlying neurological factors. PNES are relatively rare in the general population; however, their prevalence in people with learning disabilities is much higher—up to 10%. Individuals with PNES and learning disabilities often have psychiatric comorbidities, such as anxiety disorders, depression and posttraumatic stress disorder. There are currently no treatment guidelines for PNES in people with or without learning disabilities. However, talking therapies, such as cognitive‐behavioural therapy (CBT), are recommended. This study explores the effectiveness of CBT for the treatment of PNES in a woman (Susan) with PNES and learning disabilities.MethodsWe used a single‐case experimental design (SCED) to investigate the effectiveness of CBT intervention. Specifically, the withdrawal (also known as ABA) design was applied. The patient's average PNES frequency, as well as idiosyncratic mood measure and standardised outcome measures for people with learning disabilities (Glasgow Anxiety Scale for People with an Intellectual Disability and Mini‐Maslow Assessment of Needs Scale‐Learning Disabilities), were used to assess the effectiveness of treatment.FindingsResults show that Susan's monthly PNES frequency reduced from phase A1 (assessment phase) to phase B (treatment phase), and this persisted to the follow‐up phase (phase A2). However, the reduction was not statistically significant. The intervention was associated with improvements in Susan's mood, anxiety and quality of life. Reduction of Susan's anxiety was clinically significant.ConclusionsThis SCED study demonstrates that CBT might be associated with reduction of PNES frequency and improvements in general functioning in people with PNES and learning disabilities; however, further research, especially around confounding variables is needed.

Seizures in eating disorders.

To complete a descriptive study of seizure etiology in a large population of eating disorder (ED) patients and to better understand whether malnutrition itself, in those with EDs, is associated with seizure development. In this retrospective study, 75 patients with documented seizures met inclusion criteria from a total of 1664 charts. Prevalence of seizures in this ED cohort was found to be 4.5%, with 29.3% of individuals experiencing seizures due to psychogenic nonepileptic seizures (PNES). Other common causes of seizures included substance abuse/withdrawal (18.7%), primary seizure disorder (12%), and electrolyte abnormalities/hypoglycemia (10.7%). Three patients (4%) also developed their seizures presumably due to Wernicke's encephalopathy (WE). Several etiologies of seizures are reported from this large sample of ED patients, and this is also the first study to report on a possible association of WE as a cause of seizures in ED patients. The contribution of WE and malnutrition toward the development of seizures in this population remains to be determined, and future studies should also seek to better understand the inter-relationship between malnutrition and the other variables discussed in this article, such as hypomagnesemia, toward seizure development. The medical complications of EDs are myriad but seizures have not historically been considered one of those direct complications of malnutrition. The findings of this retrospective study suggest that seizure development may be a direct and indirect complication associated with EDs. The presentation of Wernicke's encephalopathy, which can also be associated with development of seizures, requires further investigation in those with EDs.

Non-epileptic paroxysmal events at pediatric video-electroencephalography monitoring unit over a 15-year period

ObjectiveNon-epileptic paroxysmal events (NEPEs) are common in pediatric patients and may be misdiagnosed as epileptic seizures. We aimed to study the distribution of NEPEs across age groups and with different comorbidities, and to correlate the patients' presenting symptoms with their final diagnosis after video-EEG. MethodsWe retrospectively analyzed video-EEG recordings of children aged one month to 18 years who were admitted between March 2005 and March 2020. Patients who experienced any NEPE while under video-EEG monitorization were evaluated in this study. Subjects with concomitant epilepsy were also included. The patients were first divided into 14 groups according to the basic characteristics of symptoms they reported at admission. The events captured on video-EEG were then classified into six NEPE categories based on the nature of the events. These groups were compared according to video-EEG results. ResultsWe retrospectively evaluated 1338 records of 1173 patients. The final diagnosis was non-epileptic paroxysmal event in 226 (19.3%) of 1173 patients. The mean age of the patients was 105.4 ± 64.4 months at the time of the monitoring. The presenting symptoms were motor in 149/226 (65.9%) patients, with jerking being the most common (n = 40, 17.7%). Based on video-EEG, the most common NEPE was psychogenic non-epileptic seizures (PNES) (n = 66, 29.2%), and the most common PNES subtype was major motor movements (n = 19/66, 28.8%). Movement disorders (n = 46, 20.4%) were the second most common NEPE and the most common NEPE (n = 21/60, 35%) in children with developmental delay (n = 60). Other common NEPEs were physiological motor movements during sleep (n = 33, 14.6%), normal behavioral events (n = 31, 13.7%), and sleep disorders (n = 15, 6.6%). Almost half of the patients had a prior diagnosis of epilepsy (n = 105, 46.5%). Following the diagnosis of NEPE, antiseizure medication (ASM) was discontinued in 56 (24.8%) patients. ConclusionNon-epileptiform paroxysmal events can be difficult to distinguish from epileptic seizures in children, especially in patients with developmental delay, epilepsy, abnormal interictal EEG, or abnormal MRI findings. Correct diagnosis of NEPEs by video-EEG prevents unnecessary ASM exposure in children and guides appropriate management of NEPEs.

Erupted compound odontoma in patient with epileptic seizures - a case report

Erupted odontomas are rarely found in the oral cavity. To the best of our knowledge there are only a few cases reported of compound erupted odontoma. Also, different pathological conditions have been related to odontoma’s aetiology. This article describes a case report with review of a 17-year-old girl in investigation of Dravet syndrome, psychogenic nonepileptic seizures and psychotic disorder in whom it was identified an enamel-like tissue exposed in gingiva. The size of the lesion was around 2 mm and it was located between the right permanent mandibular lateral incisor and canine teeth. Periapical radiography revealed a radiopaque image of irregular tooth-like structures, suggesting the presence of an erupted compound odontoma. The lesion was surgically removed under infiltrative anesthesia and without the need for a flap. Four small tooth-like structures were removed, and the specimens were sent for histopathological analysis, confirming the hypothesis of compound odontoma. The procedure went without complications nor need of patient sedation. Twenty days after the surgery, there was satisfactory healing of the operated region’s tissue. Odontoma’s aetiology is not very well established yet, so it is unknown whether eventual epileptic seizures that occur during the period of dental formation and thus increase patient risk for accidental dental injuries could favor the development of these lesions.

Risk factors for drug-resistant epilepsy in adult patients

IntroductionDrug-resistant epilepsy occurs in about 30% of epilepsy patients. It has been suggested that etiology or seizure type would increase the risk of pharmacoresistance. This study aims to compare the characteristics of patients with drug-sensitive epilepsy with patients with drug-resistant epilepsy to identify risk factors. Patient and methodsA multicentric cohort study was conducted between 2019 and 2022. We included patients >18 years-old with epilepsy but excluded psychogenic non-epileptic seizures and less than 2 years of follow-up. ResultsWe included 128 patients, of whom 46 had drug-resistance epilepsy, and 82 responding to medication. Both groups showed similar characteristics. Febrile seizures (OR: 7.25), focal epilepsy (OR: 2.4), focal seizures with loss of consciousness (OR: 2.36), structural etiology (OR: 2.2) and abnormal MRI (OR: 4.6) were significant risk factors for drug-resistance epilepsy. ConclusionFollowing other studies, we observed that factors such as epilepsy type, seizure type, structural etiology, abnormal MRI, and febrile seizure increased the risk for drug-resistance epilepsy, in our population.

Neuropsychiatric profile in average intelligent individuals with coexisting epilepsy and psychogenic non-epileptic seizures.

Global neuropsychological impairments with intellectual disability (ID) seem to play a major role in the occurrence of psychogenic non-epileptic seizures (PNES) in epilepsy. Conversely, the pathophysiology underlying PNES combined with epilepsy without ID remains elusive. We investigated the neuropsychiatric profile in 26 average intelligent subjects (15 women, mean age: 40.04 ± 13.53 years) with temporal lobe epilepsy (TLE) plus PNES (TLE + PNES), compared with 28 with TLE and 22 with PNES alone, matched for age and sex. All subjects underwent neuropsychiatric assessment, including Beck Depression Inventory-2 (BDI-2), State-Trait Anxiety Inventory (STAI), Dissociative Experiences Scale (DES), Toronto Alexithymia Scale (TAS-20), Traumatic Experience Checklist (TEC), and cognitive evaluation. TLE + PNES and PNES groups shared a similar psychiatric profile with higher levels of depression (BDI-2, P < 0.001), anxiety (STAI-S, P < 0.001; STAI-T, P < 0.001), dissociation (DES, P < 0.001), and alexithymia (TAS, P=0.005) scales than the TLE group. Nonetheless, like individuals with TLE, patients with TLE + PNES had a lower rate of a potentially traumatizing event than PNES. The very low rate of potentially traumatizing event in subjects with TLE + PNES leads us to hypothesize that epilepsy itself may be the psychophysiological distress that contributed to PNES. A psychopathological assessment in subjects with epilepsy is crucial to identify those more likely to develop PNES.