Nonepileptic Seizures Research Articles

Induction of seizures due to cortical hyperexcitability during a podiatric physical examination in an epileptic patient: A case report

Epilepsy is a neurological disorder affecting the central nervous system and is characterized by recurrent and unprovoked seizures. Seizures often occur due to cortical hyperexcitability because of inappropriate sensory, cognitive, and reflex stimuli. Epilepsy has numerous etiologies, each related to an underlying central nervous system dysfunction. Focal seizures are limited to a single cerebral hemisphere, whereas general seizures involve both hemispheres. Literature review has shown the use of transcranial magnetic stimulation for inciting epileptic seizures, as well as the use of a tuning fork to elicit non-epileptic seizures (NES). However, minimal research exists demonstrating the use of a 128-Hz tuning fork to induce epileptic seizures. Clinical symptoms of psychogenic non-epileptic seizures (PNES) and epileptic seizures are very similar to the untrained eye and without the assistance of an EEG, one cannot distinguish the two. We report a case in which a 71-year-old female experienced symptoms consistent with an “aura” or onset of a seizure when subjected to an examination of vibratory sensation to the left medial malleolus during a general podiatric examination. The patient’s past medical history includes partial symptomatic epilepsy with complex partial seizures in addition to NES. The authors agree that it is imperative to practice with caution when conducting a general podiatric examination on a patient who is predisposed to epileptic activity, as the threshold for an induction of a seizure may be lowered.

Cardiac ECG-based tools to distinguish epileptic vs. psychogenic non-epileptic seizures

Cardiac ECG-based tools to distinguish epileptic vs. psychogenic non-epileptic seizures

Effect of Emotional Valence on Working Memory of Psychogenic Non-Epileptic Seizures (PNES) Patients

Background The present study investigated how emotional valence influenced the working memory of patients with psychogenic non-epileptic seizures (PNES) as compared to healthy individuals. Methods Emotional-N-Back task (E-N-back task) was administered to 15 PNES patients and equal number of healthy individuals. A 2 × 3 one-way analysis of variance (ANOVA) was used. Correct detection (accuracy) and reaction (RT) time were recorded as behavioral performance measures. Results The ANOVA result of correct detection (accuracy) measure revealed significant difference in the performance of patients with PNES as compared with healthy individual, F (2, 48) = 17.08, p = 0.001. However, on the measure of reaction time (RT), both groups performed equally and there was no significant difference, F (2, 48) = 1.13, p = 0.33. Also the results of present study showed that patients with PNES are quicker in identifying unpleasant picture stimuli, which is evident from their mean comparison: unpleasant ( M = 65.55, SD = 15.66), pleasant ( M = 58.22, SD = 20.03), and neutral ( M = 45.11, SD = 23.13). Conclusion Conclusively, the finding of the present study shows a significant effect of emotional valence on working memory of patients with PNES on the measure of correct detection (accuracy), but not for second measure, i.e., reaction time this clearly reveals that patients with PNES are poor at emotional–cognitive integration, specifically at working memory level.

Continuous Electroencephalogram Evaluation of Paroxysmal Events in Critically Ill Patients: Diagnostic Yield and Impact on Clinical Decision Making.

Continuous electroencephalogram (cEEG) monitoring has been widely used in the intensive care unit (ICU) for the evaluation of patients in the ICU with altered consciousness to detect nonconvulsive seizures. We investigated the yield of cEEG when used to evaluate paroxysmal events in patients in the ICU and assessed the predictors of a diagnostic findings. The clinical impact of cEEG was also evaluated in this study. We identified patients in the ICU who underwent cEEG monitoring (> 6h) to evaluate paroxysmal events between January 1, 2018, and December 31, 2019. We extracted patient demographics, medical history, neurological examination, brain imaging results, and the description of the paroxysmal events that necessitated the monitoring. We dichotomized the cEEG studies into those that captured habitual nonepileptic events or revealed epileptiform discharges (ictal or interictal), i.e., those considered to be of positive diagnostic yield (Y +), and those studies that did not show those findings (negative diagnostic yield,Y -). We also assessed the clinical impact of cEEG by documenting changes in administered antiseizure medication (ASM) before and after the cEEG. We identified 159 recordings that were obtained for the indication of paroxysmal events, of which abnormal movements constituted the majority (n = 123). For the remaining events (n = 36), descriptions included gaze deviations, speech changes, and sensory changes. Twenty-nine percent (46 of 159) of the recordings were Y + , including the presence of ictal or interictal epileptiform discharges (n = 33), and captured habitual nonepileptic events (n = 13). A history of epilepsy was the only predictor of the study outcome. Detection of abnormal findings occurred within 6h of the recording in most patients (30 of 46, 65%). Overall, cEEG studies led to 49 (31%) changes in ASM administration. The changes included dosage increases or initiation of ASM in patients with epileptiform discharges (n = 28) and reduction or elimination of ASM in patients with either habitual nonepileptic events (n = 5) or Y - cEEG studies (n = 16). Continuous electroencephalogram monitoring is valuable in evaluating paroxysmal events, with a diagnostic yield of 29% in critically ill patients. A history of epilepsy predicts diagnostic studies. Both Y + and Y - cEEG studies may directly impact clinical decisions by leading to ASMs changes.

Factors associated with comorbid epilepsy in patients with psychogenic nonepileptic seizures: A large cohort study

ObjectiveComorbid epilepsy and psychogenic nonepileptic seizures (PNES) occur in 12–22% of cases and the diagnosis of both simultaneous disorders is challenging. We aimed to identify baseline characteristics that may help distinguish patients with PNES-only from those with comorbid epilepsy. MethodsWe performed a longitudinal cohort study on those patients diagnosed with PNES in our epilepsy monitoring unit (EMU) between May 2001 and February 2011, prospectively followed up until September 2016. Patients were classified into PNES-only, PNES + possible or probable epilepsy, and PNES + definite epilepsy based on the clinical, vEEG, and neuroimaging data. Demographic and basal clinical data were obtained from chart review. Multiple regression models were performed to identify significant predictors of PNES + definite epilepsy, excluding patients with only possible or probable epilepsy for this specific analysis. ResultsOne-hundred and ninety four patients with PNES-only, 30 with PNES + possible or probable epilepsy and 47 with PNES + definite epilepsy were included. 73.8% were female and the mean age at EMU admission was 37.4 ± standard deviation 13.5 years.Patients with PNES + definite epilepsy most likely had never worked, had history of febrile seizures, structural brain lesions, developmental disabilities, and maximum reported seizure duration between 0.5 and 2 min.Patients with PNES-only were on fewer anti-seizure medications (ASM), reported more frequently an initial minor head trauma, seizures longer than 10 min, and a higher number of neurological and medical illnesses – being migraine (18.1%), other types of headaches (18.5%), and asthma (15.5%) the most prevalent ones. All p < 0.05.On the hierarchical regression analysis, history of febrile seizures, developmental disabilities, brain lesions, longest reported seizure duration between 0.5 and 2 min, and lack of neurological comorbidity, remained as significant predictors of PNES + epilepsy. The model's performance of a 5-fold cross-validation analysis showed an overall accuracy of 84.7% to classify patients correctly. ConclusionsSome demographic and clinical characteristics may support the presence of comorbid epilepsy in patients with PNES, being unemployment, the presence of brain lesions, developmental disabilities, history of febrile seizures, seizure duration and lack of comorbid headaches the most relevant ones.

Clinical utility of a video/audio-based epilepsy monitoring system Nelli

ObjectiveThe aim of this study was to evaluate the clinical utility of a semi-automated hybrid video/audio-based epilepsy monitoring system (Nelli®) in a home setting. MethodsIn this retrospective study, 104 consecutive patients underwent Nelli-registration for an average of 29 days at their home. The seizure-related data obtained from the registration were assessed to investigate the utility of the Nelli-registration regarding clinical decision-making. ResultsOf 104 patients, Nelli® hybrid system was able to recognize clinically relevant events in 83 (80%) patients: epileptic seizures in 67 (65%) and nonepileptic events in 16 (15%). A total of 2767 epileptic seizures of different seizure types were captured and identified. These seizures included not only tonic-clonic seizures but also other complex or simple motor seizures.For the outcomes regarding clinical decision-making, a need for a new therapeutic intervention was recognized in 54 (51.9%) patients based on the number and severity of seizures captured by Nelli-registration. In 12 (11.5%) patients, the need to change the treatment plan was excluded because no evidence of suspected epileptic seizures was found. Nelli-registration aided in confirming the therapeutic efficacy of modifications of antiseizure medications (ASMs) or neuromodulation therapies in 13 (12.5%) patients. Nelli-registration enabled to determine the change in seizure classification and facilitated to reach clear diagnostic conclusions in 11 (10.6%) patients. In 14 (13.5%) patients, there was no change in clinical outcome, as Nelli-registration was unable to infer any clinical decision either due to inconclusive results or lack of typical events.Seizures detected during Nelli-registration aided in decision-making for therapeutic interventions in 71 (68%) patients. Altogether, 44 (42%) patients had adjustment of ASMs, and in 9 (9%) patients, Nelli-registrations led to the change in the settings of vagus nerve stimulation (VNS) or deep brain stimulation (DBS) treatment. Additionally, 18 (17%) patients were referred to presurgical evaluation or established a baseline seizure frequency before surgical implantation for neuromodulation treatment with VNS or DBS, while 33 (32%) patients had no change in therapy. Nine patients (8.7%) were referred to video-EEG monitoring (VEM), as Nelli-recorded events highlighted the need for presurgical evaluation in 6 patients or further diagnostic evaluation in 3 patients. ConclusionThis study confirms the clinical utility of the video/audio monitoring system Nelli® in home settings. Home monitoring with Nelli® hybrid system provides a new alternative for the assessment of frequency and type of epileptic seizures as well as for a recognition of nonepileptic events. Thus, Nelli-registration can facilitate the optimization of seizure monitoring and management in clinical practice, complementing existing methods such as VEM and ambulatory EEG recordings.

Staring Spells: How to Distinguish Epileptic Seizures from Nonepileptic Staring.

To determine the nature of staring spells and factors distinguishing epileptic from nonepileptic staring spells, we studied the clinical and demographic features of children with staring spells referred to a regional new-onset seizure clinic. Our retrospective chart review encompassed 2818 consecutive patients evaluated in the new-onset seizure clinic between September 22, 2015, and March 19, 2018. We identified 121 patients with newly presenting staring spells. Sixty-two of 121 (51%) children were diagnosed with nonepileptic staring spells and 59 (49%) with epileptic seizures (24 with absence epilepsy, 35 with focal epilepsy). Patients with nonepileptic staring spells were younger (4.8 vs 7.1 years, P = .001) and more likely to have developmental delay (P = .005) than the seizure group. There was an 8.9-month delay on average from the onset of staring spells to the new-onset seizure clinic visit. The emergency department was a referral source for 80% (28/35) of focal seizures. In children with focal seizures, the staring spells typically lasted >1minute (29/35, 83%), whereas only 19 of 62 (31%) of children with nonepileptic staring spells had events lasting this long (P = .04). All children had a routine electroencephalography (EEG) on the day of new-onset seizure clinic visit. EEG was diagnostic in 100% (24/24) of absence seizures and 51% (18/35) of focal seizures. In children presenting with staring spells, the differential diagnosis of epileptic staring spells vs nonepileptic staring spells can be made by history and routine EEG. Staring was as likely to be epileptic as nonepileptic spells. Younger children with developmental delay were more likely to have nonepileptic events. Our simple approach based on event duration, postictal symptoms, and EEG allowed identification of epileptic staring on first visit to new-onset seizure clinic but requires validation in future prospective studies including long-term video EEG monitoring and follow-up.

Increased suicide attempt risk in people with epilepsy in the presence of concurrent psychogenic nonepileptic seizures

ObjectivesTo test the hypothesis that people with concurrent diagnosis of epilepsy and psychogenic nonepileptic seizures (PNES) are at increased risk of attempting suicide as compared to people with epilepsy or...

Family Functioning in Psychogenic Nonepileptic Seizures: Qualitative Study

Abstract Background: Psychogenic nonepileptic seizures (PNES) are understood as epileptic presentations without a neurological basis. PNES has underlying psychological stressors that manifest physiologically. However, family functioning has been poorly studied despite its potential to be one of the major stressors. Few studies on family functioning have focused on differences between PNES and epileptic seizures than an in-depth inquiry into family functioning in PNES. Methods: Patients diagnosed with PNES by a psychiatrist or neurologist through home videos were chosen to participate in the study. Participants had at least one seizure in the previous week before the interview, and those who had physical disabilities or comorbid epilepsy were excluded from the study. In-depth interviews were developed and conducted. Determined data was analyzed through latent thematic analysis. Results: Based on the determined data, nine themes were identified. They included interaction and attachment, communication, structure and system, distressful family factors, expressed emotions, cultural aspects, maladaptive coping, adaptive coping, and negative emotional experience. Approach avoidance and hints of ending relationships were the types of communication among PNES patients, attachment has been inconclusive, transgenerational trauma, disengaged boundaries, coalition, and maladaptive triangles are prevalent among families of PNES patients. Over-involvement and hostility are the expressed emotions that were found. Both maladaptive and adaptive coping strategies are found among PNES patients. Finally, superstitions and beliefs in possession exist among families of PNES patients. Conclusion: Family dysfunction is prevalent among families of PNES patients, and hence, family-based interventions are necessary.

Treatment of Psychogenic Nonepileptic Seizures.

Psychogenic nonepileptic seizures (PNES) are the most common Functional Neurological Disorder/Conversion Disorder subtype. Significant advances have been made related to diagnosis, neurobiology, and treatment. In this review, we summarize updates in diagnosis and management over the past 3years. Although evidence is mixed for the treatment of PNES, psychotherapeutic modalities remain a powerful instrument to empower patients and reduce seizures. A multidisciplinary, holistic approach is beneficial. While seizure freedom in all patients may not be the achieved endpoint in this chronic, paroxysmal disorder, quality of life can be improved with treatment. Additional treatment modalities and further research are needed for patients who are refractory to current treatment. Evidence-based therapies exist for PNES, and recent findings represent an increased understanding of the clinical and neurophysiologic aspects of PNES.

The Importance of Long-Term Video Electroencephalography Monitoring in the Differential Diagnosis of Epilepsy in Children.

Objective: Epilepsy is a condition in which abnormal, recurring, and excessive neuronal discharges caused by many different disorders in the central nervous system are observed. The rate of detecting epileptiform activity in the first interictal electroencephalography (EEG) of patients with epilepsy is around 40%, even when routine activation methods are applied. Video recordings simultaneously with EEG recordings enable the establishment of correlations between abnormalities.Patients and methods: The long-term video-EEG monitoring (VEM) reports and images of 87 patients hospitalized in the video EEG service in the Pediatric Neurology Clinic of İnönü University between 2016 and 2020 were retrospectively analyzed in this study. Demographic information of the patients, such as age, gender, diagnosis/history, and length of hospital stay, was analyzed.Results: A total of 87 patients were included in the study. Of the patients, 54 (62.1%) were male and 33 (37.9%) were female. The mean age was 107.57 ± 64.40 months. While 10 (11.5%) patients followed up with non-epileptic paroxysmal events (NEPE) were taking antiepileptic drugs (AEDs), AED treatments were discontinued after VEM. The diagnosis of 18 (20.69%) patients changed after VEM. The medications of 27 (31%) patients who took AEDs before VEM were discontinued after VEM. During VEM, sleep movement, psychogenic seizures, infantile masturbation, and tic disorder were observed in 19 (41.3%), 17 (36.9%), three (6.5%), and three (6.5%) patients, respectively.Conclusion: In conclusion, VEM is the gold standard diagnostic method used to distinguish between epilepsy and NEPEs. After VEM, the clinical diagnosis of patients can change, and unnecessary drug administration may be prevented. Psychogenic nonepileptic seizures and NEPEs are common in the pediatric population; however, they are often overlooked.

Low Serum Pyridoxine Levels Worsen Seizure Control in Adult Epilepsy Patients.

Background: Vitamin B6 (pyridoxine) is an important cofactor in the process by which glutamic acid decarboxylase (GAD) converts the excitatory, pro-epileptogenic neurotransmitter, glutamate, into the inhibitory, anti-epileptogenic neurotransmitter, gamma-aminobutyric acid (GABA). This concept has been established in infants with pyridoxine-dependent epilepsy as well as adult patients with other epilepsy subtypes who presented with medication-resistant status epilepticus, with both patient groups experiencing cessation of seizure activity following pyridoxine administration. Given our knowledge of the role of vitamin B6 in the conversion of glutamate to GABA, its effect on seizure control in infants with specific epilepsy subtypes, reports of adult-onset seizures associated with vitamin B6 deficiency, and vitamin B6’s role in terminating status epilepticus in adult patients with other types of epilepsy, we suspect that low vitamin B6 levels in adult epilepsy patients may correlate with poor seizure control across all epilepsy subtypes. This study seeks to determine whether there is a relationship between pyridoxine levels and the level of seizure control in adults with epilepsy, regardless of their seizure type.Methods: After obtaining institutional review board approval, we prospectively enrolled 32 patients (age range: 25-57 years) with epilepsy who presented to our clinic. Patients who did not meet the study criteria or who were diagnosed with psychogenic non-epileptic seizures (PNES) were excluded from the study (n = 2). Patients were classified as well-controlled (WC) or poorly controlled (PC) based on the absence or presence of a seizure within the last three months, respectively. After classification as WC or PC, pyridoxine serum levels and anti-seizure medication (ASM) levels were drawn in that clinic visit, following patient consent. All patients were contacted regarding pyridoxine and serum ASM levels, and patients that were found to be deficient in pyridoxine were treated with appropriate supplementation. At the end of the recruitment period, we performed analyses to determine if there was a statistically significant relationship between PC status and serum pyridoxine levels.Results: Of 32 patients, two patients were diagnosed with psychogenic non-epileptic events and were subsequently excluded. Of 30 patients, 10 had PC epilepsy. Median (interquartile range) serum B6 levels were 35.8 (26.8-54.2) in patients with WC epilepsy and 17.5 (10.1-41.3) in patients with PC epilepsy (P = 0.11). In the PC group, 6/10 (60%) of the patients demonstrated low serum pyridoxine compared to 3/20 (15%) in the WC group (P = 0.03).Conclusion: There was a statistically significant relationship between serum pyridoxine levels and seizure control. If appropriate, pyridoxine supplementation should be considered, especially in critically ill adult patients with refractory or PC seizures despite good adherence to ASMs.

A Case Study of Psychogenic Non-Epileptic Seizures in a patient with Dependent Personality Disorder

IntroductionPsychogenic Nonepileptic Seizures (PNES) refer to the dissociative condition which resembles seizures but does not involve epileptic synchronous cortical activity (Huff, 2021). 20% of people visiting epilepsy clinics have PNES (Huff, 2021). Depression, anxiety, and personality disorders predispose towards PNES (Ekanayake, 2018).ObjectivesTo present a case of PNES in a patient with dependent personality disorder (DPD) and to discuss the sociocultural aspects.MethodsA case study.ResultsA 23-years old, married female presented with 20 days history of episodes of ‘falling down, rolling on ground, and involuntary movements of her head.’ The episodes typically lasted from 20-25 minutes. During the episodes, patient closed her eyes but remained conscious and expressed her distress with gestures, and tearfulness was also observed. Her condition improved when she was offered water. The clinical picture of these episodes evolved with time. Her EEG and serum prolactin levels following the episodes were normal. Accordingly, a diagnosis of PNES was made. No acute stressor was present. The patient also fulfilled the criteria of Dependent Personality Disorder (DPD) (American Psychiatric Association, 2013). During communication with the patient, it appeared that the patient and her attendants perceived the train of questioning as investigational rather than therapeutic. Efforts were made towards a more empathetic understanding of their point of view, and the tailoring of long-term management in accordance with their sociocultural context.ConclusionsThe socio-cultural context is important in the management of PNES and a sensitive, and collaborative approach is recommended. Assessment of personality should be considered in patients presenting with PNES.DisclosureNo significant relationships.

Paraneoplastic Limbic Encephalitis Case Report In A Patient With Suspected Conversion Disorder

Introduction. Autoimmune encephalitis is a difficult-to-recognize, complex disease that can present with various neuropsychiatric symptoms. N-methyl-D-aspartate receptor (NMDA-r) and anti-leucine-rich glioma-inactivated 1 protein (LGI-1) subtypes of autoimmune encephalitis may present with psychiatric symptoms.ObjectivesWe would like to present an autoimmune encephalitis case that can be confused with conversion disorder.MethodsA 54-year-old, female patient started to have forgetfulness ten months ago, and convulsions started five months ago. The patient had disorganized behaviors and contractions in the extremities. Diffusion MRI and brain CT images were normal. The patient had low blood sodium level. In the follow-up, her orientation was impaired and she could hardly make eye contact. As the patient’s contractions were evaluated as conversion in the first stage, 50mg/day sertraline was added to the treatment.ResultsAfter cranial MRI and EEG recordings were completed, the patient was referred to the neurology department due to the suspicion of autoimmune encephalitis. In the cerebrospinal fluid examination anti-LGI-1 and anti-yo antibodies were positive. Thereupon, IV pulse steroid was given. After that her orientation and disorganized behavior improved. Then, the patient was referred to oncology department.ConclusionsLimbic encephalitis may manifest as sleep disorders, short-term memory loss, conversion disorder, disorganized behaviors, slurred speech, non-epileptic seizures, sensory and motor defects. Delay in diagnosis may worsen the prognosis of possible malignancy. It should be kept in mind that the patient with a suspected conversion disorder may have limbic encephalitis.DisclosureNo significant relationships.

A review on interventions for psychogenic nonepileptic seizures: which treatments improve outcome?

Introduction Psychogenic nonepileptic seizures (PNES), the most common conversion disorder, are episodic alterations in behaviour that resemble epileptic seizures without its characteristic EEG changes. PNES presumably reflect a physical manifestation of underlying psychological distress and can be as disabling as epilepsy. Standardized treatment approaches for PNES care are lacking.ObjectivesOur aim is to review the literature for therapeutic interventions in PNES.MethodsA literature search was conducted in PubMed/MEDLINE database for randomized controlled trials (RCTs) examining the effect(s) of specific intervention(s) in patients with PNES. Search terms were “psychogenic-nonepileptic-seizures” and selection was based on the abstracts of all the studies retrieved. Priority outcome was frequency of PNES.ResultsWe identified 8 eligible RCTs. Samples ranged from 19 to 82 patients. Follow-up periods varied from 6 weeks to 18 months. Regarding reduction of PNES frequency, several interventions were effective: motivational interviewing combined with psychotherapy; cognitive behavioural therapy informed psychotherapy (CBT-ip); combination of CBT-ip and sertraline; immediate withdrawal of antiepileptic drugs after PNES diagnosis; a standardized diagnostic approach associated with psychiatric inpatient consultation. Treatment with sertraline alone and brief educational interventions didn’t reduce PNES frequency significantly. Beside PNES rate reduction, most interventions conveyed some type of benefit such as improvement in quality of life, mood or functionality.ConclusionsThe majority of the beneficial interventions included a structured communicational approach and/or psychotherapeutic treatment. Our analysis highlights the importance of a multidisciplinary strategy that includes psychotherapy. Further studies with larger samples and longer follow-up periods are needed to robustly inform evidence-based treatment for PNES.DisclosureNo significant relationships.

Epileptic Seizures or not, that is the question: a case report

IntroductionPsychogenic nonepileptic seizures (PNES) consist of paroxysmal changes in responsiveness, movements, or behaviour that superficially resemble epileptic seizures.ObjectivesPresentation of a clinical case of a PNES in a patient with a diagnose of secondary epilepsy, illustrating the relevance of an adequate evaluation, differential diagnosis, and intervention.MethodsDescription of the clinical case, with brief literature review and discussion. A search was conducted on PubMed and other databases, using the MeSH terms “nonepileptic seizure”, and “epileptic seizure”.ResultsWe report the case of a 45-year-old female patient, brought to the emergency department because of tonic axial and limb nonsynchronous movements, closed eyes, long duration, with immediate awareness, no desaturation, tongue bite, facial flushing, dyspnoea or sphincter incontinency. She was medicated with clonazepam 1 mg and levetiracetam 1000 mg ev. TC-CE had no acute alteration. Bloodwork had no other major alteration except valproic acid below therapeutic levels (her usual medication, along with other antiepileptic drugs, antidepressant and antipsychotic). The antecedents of the patient: mild intellectual disability and an accidental traumatic brain injury in infancy, with secondary epilepsy. She was transferred to Psychiatry department. No electroencephalogram (EEG) was realized, because she had a recent one confirming PNES, and many other emergency observations with the diagnosis of PNES.ConclusionsThis clinical case showcases the diagnostic difficulties that clinicians face when there is an overlap in symptoms, emphasizing the need to combine patient history, witness reports, clinician observations, and ictal and interictal EEG to help distinguish these different clinical identities.DisclosureNo significant relationships.

Hysteria in neurology: a diagnostic approach to conversive disorder

IntroductionConversion disorder (a term that describes what was previously called hysteria) refers to motor or sensory symptoms, or both, that resemble a neurological disease, but that do not originate from or cannot be explained by a known physical disease.ObjectivesTo find reliable tools that can guide the difficult diagnosis of conversion disorder.MethodsBibliographic reviewResults The exact prevalence of the disorder is unknown. It is estimated that approximately 5% of referrals to neurology are for this disorder. Approximately one third of patients referred to the neurologist have symptoms that cannot be explained by an organic disease. Involuntary movements are the most common motor manifestations of the conversive syndrome, being tremor one of the most frequent manifestations. The first differential diagnosis of conversion disorder is neurological disease. It is currently not necessary for the diagnosis to assess whether or not the symptoms are produced intentionally, as the assessment of conscious intentionality is unreliable. The neurological examination is the fundamental tool for the diagnostic approach, being even more enlightening than the complementary tests. Hoover’s sign, Babinski’s combined leg flexion, plantar flexion of the ankle, tremor and its distraction and synchronisation manoeuvres, as well as the clinical differences between epileptic seizures and non-epileptic seizures of psychogenic origin, are some of the reliable tools for a correct diagnosis.ConclusionsThe diagnosis of the disease should be one of exclusion. There must be clinical data showing clear evidence of incompatibility with a neurological disease and conversion symptoms do not correspond to known physiological mechanisms and anatomical pathways.DisclosureNo significant relationships.

Combining Trauma Script Exposure With rTMS to Reduce Symptoms of Post-Traumatic Stress Disorder: Randomized Controlled Trial

BackgroundInnovative therapeutic interventions for post-traumatic stress disorder (PTSD) are required. We opted to facilitate fear extinction by combining trauma script exposure with repetitive transcranial magnetic stimulation (rTMS) to reduce symptoms of PTSD. ObjectiveThe efficacy and safety of 10 Hz rTMS of the right dorsolateral prefrontal cortex simultaneously with exposure to personal traumatic narrative were studied in patients with PTSD. Materials and MethodsThis trial was a single-center randomized controlled trial (NCT02584894). Patients were randomly assigned 1:1 to receive eight daily sessions of 110% of motor threshold high frequency (HF) 10 Hz rTMS (110% HF rTMS) or 70% low frequency (LF) 1 Hz rTMS (70% LF rTMS) with trauma script exposure in both groups. Severity of PTSD, depression, and anxiety were assessed before and after study treatment (one month, three months) by an assessor masked to the trial group assignment. The primary outcome was the severity of PTSD assessed by the Clinician Administered PTSD Scale (CAPS). We used mixed linear regression models for statistical comparisons. ResultsThirty-eight patients (65.8% females) were randomly assigned to 110% HF rTMS (n = 18, 31.3 ± 10.0 years, 13 females) or 70% LF rTMS (n = 20, 33.5 ± 11.1 years, 12 females). From baseline to three months, mean CAPS scores decreased by 51% in the 110% HF rTMS group (from 83.7 ± 14.4 to 41.8 ± 31.9) and by 36.9% in the 70% LF rTMS group (from 81.8 ± 15.6 to 51.6 ± 23.7), but with no significant difference in improvement (time by treatment interaction −3.61 [95% confidence interval (CI), −9.70 to 2.47]; p = 0.24; effect size 0.53). One serious adverse event occurred during the study (psychogenic nonepileptic seizure). ConclusionWe found no evidence of difference in clinical improvement or remission rates between the 110% HF and 70% LF stimulation. These findings may reflect the importance of exposure procedure and that larger number of participants is needed.

Automated seizure detection with noninvasive wearable devices: A systematic review and meta-analysis.

ObjectiveThis study was undertaken to review the reported performance of noninvasive wearable devices in detecting epileptic seizures and psychogenic nonepileptic seizures (PNES).MethodsWe conducted a systematic review and meta‐analysis of studies reported up to November 15, 2021. We included studies that used video‐electroencephalographic (EEG) monitoring as the gold standard to determine the sensitivity and false alarm rate (FAR) of noninvasive wearables for automated seizure detection.ResultsTwenty‐eight studies met the criteria for the systematic review, of which 23 were eligible for meta‐analysis. These studies (1269 patients in total, median recording time = 52.9 h per patient) investigated devices for tonic–clonic seizures using wrist‐worn and/or ankle‐worn devices to measure three‐dimensional accelerometry (15 studies), and/or wearable surface devices to measure electromyography (eight studies). The mean sensitivity for detecting tonic–clonic seizures was .91 (95% confidence interval [CI] = .85–.96, I 2 = 83.8%); sensitivity was similar between the wrist‐worn (.93) and surface devices (.90). The overall FAR was 2.1/24 h (95% CI = 1.7–2.6, I 2 = 99.7%); FAR was higher in wrist‐worn (2.5/24 h) than in wearable surface devices (.96/24 h). Three of the 23 studies also detected PNES; the mean sensitivity and FAR from these studies were 62.9% and .79/24 h, respectively. Four studies detected both focal and tonic–clonic seizures, and one study detected focal seizures only; the sensitivities ranged from 31.1% to 93.1% in these studies.SignificanceReported noninvasive wearable devices had high sensitivity but relatively high FARs in detecting tonic–clonic seizures during limited recording time in a video‐EEG setting. Future studies should focus on reducing FAR, detection of other seizure types and PNES, and longer recording in the community.

“It’s hard!”: Adolescents’ experience attending school with psychogenic nonepileptic seizures

Adolescents with psychogenic nonepileptic seizures (PNES) face many challenges in the school setting. Researchers have identified school stressors as potential predisposing, precipitating, and perpetuating factors for PNES. However, few researchers have explored the perspectives of adolescents with PNES regarding their experiences of attending school, where they spend much of their time. Therefore, this qualitative study employed content analysis to explore the experience of attending school as an adolescent with PNES. Ten adolescents (100% female, 80% White) were interviewed. With an overwhelming response of “It’s hard!” from respondents, five themes regarding the school experience emerged: stress, bullying, accusations of “faking” seizure events, feeling left out because of the condition, and school-management of PNES. Underlying these themes were expressions of the need for increased understanding from and collaboration among peers, as well as the need for increased understanding from families, healthcare providers, and school personnel including school nurses. Study findings should inform future adolescent PNES research, practice decisions made by healthcare providers in the health and education sectors, education of healthcare and school professionals, and policy development and implementation.