Psychogenic Nonepileptic Seizures Patients Research Articles

Prof M. Murugappan Poster Award

Background:Patients with psychogenic non epileptic seizures (PNES) tend to have more frequent and disabling seizures than those which true epilepsy and are often misdiagnosed as epilepsy due to lack of clear diagnostic criteria and variations in clinical semiology.Aims & Objectives:To understand the type of clinical manifestations seen in patients of PNES and the cultural beliefs regarding their symptoms.Material & Methods:71 patients who consented were enrolled in the study after institutional ethics committee approval. They were diagnosed by the neurologist to be having psychogenic seizures on the basis of their clinical presentation and a 2 hours VEEG recording which was normal. The details of the psychogenic seizure viz. clinical manifestation, duration of the episode, loss of consciousness, incontinence and injuries were recorded on a proforma. Patient’s history was taken in detail to understand areas of conflicts, interpersonal problems, discord or any other stressors. The cultural attributions of the patients were also recorded in open and closed ended questions.Results:Clinical manifestations included verbal unresponsiveness (74%), whole body rigidity (72%), upper limb (55%) and lower limb movements (39%), vocalisations and head movements in less than 25% and automatisms in only 6 patients. Pelvic thrusting as a manifestation was seen in only 1 patient. 38 patients attributed their symptoms to being possessed by God/ghost/evil spirit; 9 to black magic being done on them; 24 patients did not relate symptoms to religious beliefs. 62 patients had visited faith healers.Conclusions:This study is first of its kind which looks at the various clinical presentations of PNES patients in order to assess if there is any cultural basis for the symptoms.

Abstract- Poster

• Background:Patients with psychogenic non epileptic seizures (PNES) tend to have more frequent and disabling seizures than those which true epilepsy and are often misdiagnosed as epilepsy due to lack of clear diagnostic criteria and variations in clinical semiology.• Aims & Objectives:To understand the type of clinical manifestations seen in patients of PNES and the cultural beliefs regarding their symptoms.• Material & Methods:71 patients who consented were enrolled in the study after institutional ethics committee approval. They were diagnosed by the neurologist to be having psychogenic seizures on the basis of their clinical presentation and a 2 hours VEEG recording which was normal. The details of the psychogenic seizure viz. clinical manifestation, duration of the episode, loss of consciousness, incontinence and injuries were recorded on a proforma. Patient’s history was taken in detail to understand areas of conflicts, interpersonal problems, discord or any other stressors. The cultural attributions of the patients were also recorded in open and closed ended questions.• Results:Clinical manifestations included verbal unresponsiveness (74%), whole body rigidity (72%), upper limb (55%) and lower limb movements (39%), vocalisations and head movements in less than 25% and automatisms in only 6 patients. Pelvic thrusting as a manifestation was seen in only 1 patient. 38 patients attributed their symptoms to being possessed by God/ghost/evil spirit; 9 to black magic being done on them; 24 patients did not relate symptoms to religious beliefs. 62 patients had visited faith healers.Conclusions:• This study is first of its kind which looks at the various clinical presentations of PNES patients in order to assess if there is any cultural basis for the symptoms.

Clinical manifestations and cultural correlates of psychogenic nonepileptic seizure symptoms: An Indian perspective.

Patients with psychogenic nonepileptic seizures (PNES) tend to have more frequent and disabling seizures than those which true epilepsy and are often misdiagnosed as epilepsy due to lack of clear diagnostic criteria and variations in clinical semiology. This study was an attempt to improve the understanding and type of clinical manifestations seen in patients of PNES and the cultural beliefs regarding their symptoms. In this cross-sectional observational study, 71 patients diagnosed with PNES by neurologists on the basis of their clinical presentation and a two hours normal VEEG recording were enrolled in the study after ethics approval. The clinical manifestations of PNES were recorded in detail along with details of various cultural attributions of the patients to the symptoms which were recorded in open- and closed-ended questions. Clinical manifestations included verbal unresponsiveness (74%), whole body rigidity (72%), upper limb (55%) and lower limb movements (39%), vocalizations and head movements in less than 25%, and automatisms in only 6 patients. Pelvic thrusting as a manifestation was seen in only one patient. Thirty-eight patients attributed their symptoms to being possessed by God/ghost/evil spirit; nine to black magic being done on them; twenty-four patients did not relate symptoms to religious beliefs. Sixty-two patients had visited faith healers. This study is the first of its kind which looks at various clinical presentations of PNES patients in order to assess if there is any cultural basis for the symptoms.

Telepsychology May Improve Treatment Adherence in Patients with Psychogenic Nonepileptic Seizures

Introduction: Access to mental health care is a significant challenge in patients with psychogenic nonepileptic seizures (PNES). Telepsychology can curb the access barriers and improve adherence but the role of telepsychology in improving adherence has not been well investigated. The current study examines the utility of telepsychology during the COVID-19 pandemic and treatment adherence in PNES patients. Materials and Methods: Patients with PNES admitted to a 12-week counseling program were offered two visit types: telepsychology and in-office. Visit type, visit status, and demographic information were obtained from department database. Follow-up visits in 6 months were used to examine the effect of visit type on visit status. Adherence to treatment was measured by higher attendance of scheduled visits and less cancellation and no-show rates. Results: Two hundred fifty-seven (n) patients who scheduled virtual or telepsychology visits were included in the study. After adjusting for demographic variables, and accounting for repeated measures, telepsychology visits were significantly more likely to be attended (odds ratio [OR] = 2.40, 95% confidence interval [CI] = 1.69-3.41, p < 0.001) and were significantly less likely to be canceled (OR = 0.43, 95% CI = 0.29-0.64, p < 0.001). The regression model showed patients in the telepsychology visit group attended more than three times as many visits as in-office patients (incidence rate ratios = 3.16, 95% CI = 2.13-4.73, p < 0.001). Conclusions: Patients with PNES have logistical and psychological barriers that can impede their ability to attend counseling treatment. Receiving care remotely may have been associated with higher engagement with mental health treatment compared to having to travel to counseling clinics. Considering the symptom-related restrictions patients with PNES have and the barriers presented by the COVID-19 pandemic, telepsychology played a key role for continuation of mental health treatment.

Screening for Psychiatric Comorbidities and Psychotherapeutic Assessment in Inpatient Epilepsy Care: Preliminary Results of an Implementation Study.

Background: Anxiety and depression remain underdiagnosed in routine clinical practice in up to two thirds of epilepsy patients despite significant impact on medical and psychosocial outcome. Barriers to adequate mental health care for epilepsy and/or psychogenic non-epileptic seizures (PNES) include a lack of integrated mental health specialists and standardized procedures. This naturalistic study outlines the procedures and outcome of a recently established psychotherapeutic service.Methods: Routine screening included the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E, cut-off value > 13) and Generalized Anxiety Disorder scale (GAD-7, cut-off value > 5). Positively (above cut-off in at least one questionnaire) screened patients were seen for a standardized interview for mental health disorders and the development of a personalized treatment plan. PNES patients were seen irrespective of their screening score. Resources were provided to support self-help and access to psychotherapy. Patients were contacted 1 month after discharge to evaluate adherence to therapeutic recommendations.Results: 120 patients were screened. Overall, 56 of 77 positively screened patients (77%) were found to have a psychiatric diagnosis through standardized interview. More epilepsy patients with an anxiety disorder had previously been undiagnosed compared to those with a depressive episode (63% vs. 30%); 24 epilepsy patients (62%) with a psychiatric comorbidity and 10 PNES patients (59%) were not receiving any mental health care. At follow-up, 16/17 (94%) epilepsy patients and 7/7 PNES patients without prior psychiatric treatment were adhering to therapeutic recommendations.Conclusion: Integrating mental health specialists and establishing standardized screening and follow-up procedures improve adherence to mental health care recommendations in epilepsy and PNES patients.

Random-forest classification of psychogenic non-epileptic seizures and temporal lobe epilepsy

Psychogenic nonepileptic seizures (PNES) represent a multifactorial psychopathology, which makes diagnosis particularly challenging: PNES can be misdiagnosed as pharmaco-resistant temporal lobe epilepsy (TLE), and approximately 80% of subjects actually undergo anti-epileptic drug (AED) at the time of correct diagnosis. In this study, we used machine learning (ML) to differentiate PNES and TLE patients.

The Comparison Between Neuropsychological Features of Psychogenic Non-epileptic Seizures and Epileptic Seizures

Background: Both epileptic seizures (ES) and psychogenic non-epileptic seizures (PNES) are often associated with some degree of cognitive impairment. Video electroencephalography (EEG) monitoring is the gold standard for diagnosing PNES. This diagnostic procedure is costly and available in specific tertiary centers. Neuropsychological assessment can provide clues for the differential diagnosis of PNES and ES and help clarify the nature and etiology of these two disorders. Objectives: Therefore, this study aimed to compare the neuropsychological profiles of PNES and ES patients. Methods: In this analytical cross-sectional study, 30 patients with ES and 31 patients with PNES were compared by neuropsychiatric tests, such as the Wechsler Adult Intelligence scale (WAIS), Addenbrooke’s Cognitive examination (ACE), and California Verbal Learning test (CVLT). Results: There was a female predominance in the PNES group (female-to-male ratio = 4.16/1, P = 0.003). In the PNES group, 77.4% of the patients had a psychiatric disorder versus 66.7% of the patients in the ES group; however, the difference was not statistically significant (P = 0.34). The mean score of total intelligence was higher in the PNES group (84.77 ± 16.94), compared to the ES group (83.63 ± 10.04); however, the difference was not significant (P = 0.75). Based on the mean subscale scores, the digit symbol score (WAIS-IV subscale) and memory score (ACE subscale) were significantly higher in the PNES group compared to the ES group (P = 0.037 and 0.032, respectively). Conclusions: This study showed that neuropsychological assessments might not differentiate ES from non-epileptic seizures.

Psychiatric disorders, depression and quality of life in patients with psychogenic non-epileptic seizures and drug resistant epilepsy living in Argentina

ObjectivesPsychiatric disorders are frequently found in both patients with PNES and DRE, making the differential diagnosis even more complex. The aim of this study was to analyze and compare psychiatric aspects and the quality of life in patients with psychogenic non-epileptic seizures (PNES) and drug resistant epilepsy (DRE). MethodsPatients admitted to video-electroencephalograpy (VEEG) unit with confirmed PNES and DRE were included. Demographical characteristics, psychiatric diagnosis according to SCID I and II of DSM IV, pharmacological treatment, general functioning measured with GAF (Global assessment of functionality), quality of life (QoL) using QlesQSF (Quality of Life Enjoyment and Satisfaction Questionnaire Short Form) and depression severity using BDI II (Beck depression inventory), were compared between the groups. Non-parametric tests, chi square test, and logistic regression were used for statistical analysis. Results148 patients consecutively admitted to VEEG were included (DRE n = 97; PNES n = 51). Somatization disorder (RR: 13.02, 95% CI: 1.23–137.39, p = 0.03) and a history of trauma (RR: 8.66, 95% CI: 3.21–23.31, p = 0.001) were associated with PNES. The QlesQ score and the GAF score were lower with a higher prevalence of suicide attempts in the PNES group (p < 0.01). A negative correlation was observed between the severity of depression and the quality of life (DRE r = - 0.28, p = 0.013; PNES r = - 0.59, p = 0.001). ConclusionsHigher psychiatric comorbidity with poorer QoL were found in PNES patients compared to DRE. However, depression comorbidity negatively affected the QoL in both groups. Future studies based on illness perception will be orientated to complete this analysis.

Psychogenic nonepileptic seizures: The effect of accurate diagnosis on cognition

ObjectiveMuch remains to be elucidated about the cognitive profile of patients with psychogenic nonepileptic seizures (PNES) and about how this changes over time and compares to that of patients with epilepsy. The aim of this study was to study the neuropsychological profile of patients with PNES and an age-matched group of patients with temporal lobe epilepsy (TLE) during admission to a video electroencephalography monitoring unit (VEMU) and 1 year after discharge. MethodsPatients diagnosed with PNES or TLE at a VEMU were prospectively recruited. Neuropsychological, demographic, clinical, and treatment variables were collected at baseline and 1 year. To minimize multiple comparisons, scores from different cognitive tests were computed for attention and psychomotor speed, verbal memory, visual memory, language, and executive function. A global cognitive impairment index (GCII) was also created. Post hoc analyses were conducted to identify clinical variables that might mediate the differences observed in cognition over time between the groups. These included seizure frequency, number of antiseizure medication (ASM), number of psychotropic drugs, depression, and quality of life. ResultsWe studied 24 patients with PNES and 24 patients with TLE. The groups performed similarly in the baseline neuropsychological tests. There was a significant time (baseline to 1-year follow-up) by group (PNES vs TLE) interaction for the GCII (p = 0.006), language (p = 0.04), and executive function (p = 0.013), with PNES patients showing improvement and TLE patients remaining stable. The time by group interaction for attention and psychomotor speed showed a trend toward significance (p = 0.056), Reduction in number of ASM was associated with improved cognition in PNES patients at 1 year. ConclusionPNES patients showed improved cognition at 1 year of follow-up, particularly in language and executive functions. This finding shows the potential benefits of an early, accurate diagnosis, which range from improved cognition to better management.

Adverse events related to antiepileptic drugs

ObjectiveAdverse events (AEs) related to antiepileptic drugs (AEDs) may interfere with adequate dosing and patient adherence, leading to suboptimal seizure control, and relatedly, increased injuries, hospitalizations, and mortality. This study investigated the clinicodemographic factors associated with AEs related to AEDs as reported by the Liverpool Adverse Events Profile (LAEP), and explored the ability of LAEP to discriminate between epilepsy and psychogenic nonepileptic seizures (PNES). We hypothesized that female sex, mood disorders, AED-polytherapy, duration, and severity of epilepsy are associated with increased endorsement of AEs related to AEDs, and that endorsement of AEs related to AEDs would significantly differ between epilepsy and PNES patients. MethodsWe prospectively enrolled adult patients admitted to two inpatient video-electroencephalogram monitoring units. Clinicodemographic variables and psychometric measures of depression, anxiety, and cognitive function were recorded. Patient-reported AE endorsement was obtained using the LAEP, which was reduced to four latent domains using exploratory structural equation modeling. General linear models identified variables associated with each domain. Logistic regression determined the ability of LAEP scores to differentiate between epilepsy and PNES. Results311 patients met inclusion criteria. Mean age was 38 years and 56% of patients were female. Network analysis demonstrated strong relationships between depression and anxiety with physical, sleep, psychiatric, and dermatological AE endorsement. Depression, female sex, and AED polytherapy were associated with greater AE endorsement. Epilepsy, compared to PNES, was associated with lower AE endorsement. Fewer prescribed AEDs and greater reported physical AE endorsement were associated with PNES diagnosis. SignificanceThere is a strong relationship between patient-reported AEs and psychiatric symptomatology. Those with PNES paradoxically endorse greater physical AEs despite receiving fewer AEDs. Patients who endorse AEs in clinical practice should be screened for comorbid depression or anxiety and treated accordingly.

Clinical differences between patients with psychogenic nonepileptic seizures and functional motor disorder

ObjectivesWhy a patient might present with psychogenic nonepileptic seizures (PNES) as opposed to another functional neurological symptom is unknown. A recent review suggested that patients with PNES and functional motor disorders (FMD) differ on demographic and clinical factors of potential aetiological and mechanistic significance, arguing they might represent different disorders, though direct comparisons are limited. We sought to determine whether these factors differed in patients presenting with FMD and PNES at our clinic, as well as whether preceding medical complaints would differ between the two, particularly those affecting the limbs or head. MethodsA retrospective chart review of all presentations with FMD or PNES patients to a functional neurology clinic, collecting demographic and clinical data, including medical and surgical history. ResultsFifty-six patients with FMD and 52 with PNES were included. Significantly more patients with FMD had functional somatic syndromes (46% vs 27%, p = 0.036) and preceding medical events that affected their limbs than patients with PNES (34% vs 14%, p = 0.013); significantly more patients with PNES had dissociative symptoms (31% vs 4%, p < 0.001) and lifetime suicidal ideation (56% vs 32%, p = 0.013). SignificanceThese results highlight the substantial comorbidities affecting FMD and PNES, but find clinical differences between the two groups that may be of aetiological or mechanistic significance.

A South African review of routinely-collected health data of psychogenic nonepileptic seizure patients referred to psychiatrists in Johannesburg

Patients with psychogenic nonepileptic seizures (PNES) are often referred to psychiatrists for treatment of functional neurological symptom disorder (FNSD). However, not all patients with FNSD have an identified psychiatric comorbidity [1].The aim of this observational study was to characterize the clinical and psychiatric features of patients with PNES from Johannesburg, South Africa, where a high frequency of PNES has been reported [2], and compare these findings to other reports. We hypothesized that patient outcomes regarding treatment adherence and episode frequency would improve when treated within a closed multidisciplinary team. The data included a retrospective record review of patients diagnosed with PNES from an epilepsy monitoring unit and referred for psychiatric assessment and treatment between November 2013 and July 2017.Fifty-nine cases met the criteria for the study. There were 7 male and 52 female participants, aged between 14 and 72 years (M = 33.76, SD = 13.88). The most frequently reported comorbid symptoms were anxiety (90%); dissociative symptoms (51%); headaches (76%) and gastrointestinal symptoms (36%). Important patient characteristics included past substance abuse (76%); impaired attachment (86%); past trauma (69%) and sexual trauma (29%). Generalized anxiety disorder (76%), major depressive disorder (64%) and PTSD (22%) were the most prevalent psychiatric diagnoses. After receiving psychiatric treatment, 47% of patients experienced a decrease in the frequency of episodes, while 86% became aware of the precipitants of their episodes.Psychiatric data can valuably inform current theories of PNES management. This study contributes to the understanding of comorbid, aetiological, and prognostic factors that are crucial to refining coherent models that will guide practice.

Differentiating psychogenic nonepileptic seizures from epileptic seizures: An observational study of patients undergoing video-electroencephalography (VEEG) in Australia

Video-electroencephalography (VEEG) is an invaluable tool for the differentiation of psychogenic nonepileptic seizures (PNES) from epileptic seizures (ES). This paper (i) evaluates the demographics of patients undergoing VEEGs at the Princess Alexandra Hospital from July 1 2017 to July 1 2019 and identifies those subsequently diagnosed with PNES, (ii) determines the delay in PNES diagnosis and proportion of PNES patients on antiepileptic drugs (AEDs) prior to a VEEG, and (iii) determines the proportion of PNES patients who subsequently ceased their AEDs.Of the 94 patients in the study group, 51 were female and 43 were male. In total, 22 (23%) of VEEGs were consistent with epilepsy (ES), 25 (26%), with PNES, 5 (5%) mixed (PNES and ES), 5 (5%) with other types of events, and 37 were nondiagnostic. Two patients with non-diagnostic VEEGs were subsequently treated as PNES at the treating clinician’s discretion. Regarding AEDs, 62 of the patients were on at least one agent at the time of VEEG recording. The mean durations of AED therapy and diagnostic delay for patients subsequently diagnosed with PNES were six years and seven years, respectively. Of these, the majority had their AEDs subsequently weaned/ceased.This study highlights the value of VEEG in diagnostic differentiation of epileptic from nonepileptic events, thereby preventing unnecessary AED therapy for patients with PNES. The results are consistent with previous studies in the literature evaluating VEEG clinical outcomes.

Psychosocial long-term outcome in patients with psychogenic non-epileptic seizures

PurposeTo evaluate psychosocial long-term outcome in patients diagnosed with psychogenic nonepileptic seizures (PNES) and to predict outcome of PNES, economic status, and quality of life (QoL) at follow-up. MethodsPatients diagnosed with PNES in the video-EEG-monitoring unit at our Epilepsy center between 2002–2016 were contacted by phone 1–16 years after communicating the diagnosis. Patients underwent a structured interview asking for current PNES status, psychosocial situation (economic status, marital status, setting of living, driving), depression, and QoL. ResultsOf 70 PNES patients without comorbid epilepsy (age: 41.1 ± 13.5 years; 74 % female, follow-up: 5.2 ± 4.2 years), 23 patients (33 %) reported to be free of PNES during the last 12 months. Patients with cessation of PNES were younger at PNES onset (p < .01) and diagnosis (p < .01) and had a higher education (p < .05). At follow-up, the proportion of economically active patients only increased in individuals with cessation of PNES (p < .001) while an increased number of patients with persisting PNES relied on governmental support (p < .001). Cessation of PNES was associated with better mood (p < .01) and QoL (p < .001). In multiple regression models, cessation of PNES was only predicted by younger age at onset, while good economic outcome was determined by younger age and good economic status at diagnosis and cessation of PNES at follow-up. Good QoL at follow-up was predicted by low depressive symptoms, freedom of PNES, and economic activity at follow-up. ConclusionLong-term outcome in patients with PNES remains to be poor and the majority of patients continue to have PNES. Cessation of PNES was associated with good economic outcome, mood, and QoL.

The impact of sexual abuse on psychopathology of patients with psychogenic nonepileptic seizures.

In the present study, we evaluated if the presence of sexual abuse in the clinical history of patients with psychogenic non-epileptic seizures (PNES) is associated with a different psychopathological profile. In a consecutive population of 63 PNES patients, we compared two demographically and clinically matched groups of patients with (no. 15) and without (no. 48) a history of sexual abuse using a comprehensive psychopathological assessment (Beck Depression Inventory, Hamilton Anxiety Rating Scale, Dissociative Experience Scale, Somatoform Dissociation Questionnaire, and Toronto Alexithymia Scale). We found that the group of patients reporting sexual abuse is characterized by higher scores on Dissociative Experience Scale (p = 0.003) and Beck Depression Inventory (p = 0.001) with respect to the other group. No significant statistical differences in Hamilton Anxiety Rating Scale (p = 0.103), Toronto Alexithymia Scale (p = 0.137), and Somatoform Dissociation Questionnaire (p = 0.486) were captured. Moreover, we found that the negative effect on dissociate symptoms was also hampered by the increasing of seizure frequency. This study reinforces the importance of traumatic screening in the clinical spectrum of PNES in order to implement and improve specific therapeutic strategies.

Heart Rate Variability Parameters During Psychogenic Non-epileptic Seizures: Comparison Between Patients With Pure PNES and Comorbid Epilepsy.

Introduction: Psychogenic non-epileptic seizures (PNES) may resemble epileptic seizures. There are few data about ictal ANS activity alterations induced by PNES in patients with pure PNES (pPNES) compared to PNES with comorbid epilepsy (PNES/ES). We aimed to compare heart rate variability (HRV) parameters and hence autonomic regulation in PNES in epileptic and non-epileptic patients.Methods: We obtained HRV data from video-electroencephalography recordings in 22 patients presenting PNES (11 pPNES and 11 PNES/ES) in awake, and supine states. We calculated HRV parameters in both time and frequency domains including low frequency (LF) power, high frequency power (HF), LF/HF ratio, square root of the mean of the sum of the squares of differences between adjacent R wave intervals (RMSSD) and the standard deviation of all consecutive R wave intervals (SDNN). We also evaluated approximate entropy (ApEn), cardiosympathetic index (CSI), and cardiovagal index (CVI). Four conditions were considered: basal condition (BAS), before PNES (PRE), during PNES (ICT) and after PNES (POST).Results: HRV analysis showed significantly higher ICT LF and LF/HF ratio vs. each condition. We also found higher POST HF vs. PRE and BAS, lower RRI in ICT vs. each condition and PRE vs. BAS. POST RMSSD was significantly higher compared to all other states. ICT CSI was significantly higher compared to all other states, whereas CSI was significantly lower in POST vs. PRE and PRE CVI lower than ICT and higher in POST vs. BAS and PRE. Also, ICT ApEn was lower than in all other states. Higher LF in pPNES vs. PNES/ES was also evident when compared across groups.Significance: A few studies examined HRV alterations in PNES, reporting high sympathetic tone (although less evident than in epileptic seizures). Our data suggest a sympathetic overdrive before and during PNES followed by a post-PNES increase in vagal tone. A sympathovagal imbalance was more evident in pPNES as compared to PNES/ES.

Skin conductance response and emotional response in women with psychogenic non-epileptic seizures

PurposeRecent etiopathogenic models place emotional dysregulation at the core of psychogenic nonepileptic seizure (PNES). Our purpose was to assess physiological, cognitive, and behavioral emotional responses of PNES patients. MethodsThis study compared three types of emotional responses to visual emotional stimuli between 34 female PNES group and 34 matched healthy controls: physiological response measured by skin conductance response (SCR) (rate, amplitude and latency) and heart rate deceleration; cognitive response measured by valence and arousal elicited by the images; and behavioural response measured by latency of ratings. The groups were characterized on psychiatric comorbidities, traumatic history, alexithymia, and dissociation. ResultsCompared to controls, PNES group displayed lower SCR for all images (p = 0.038), shorter amplitude of heart rate deceleration (p = 0.024) and faster arousal rating for all images (p = 0.019), but no difference on cognitive rating of images. Within-groups analyses showed only in PNES subjects increased rate (+19.35%, p = 0.046) SCR for negative stimuli with strong arousal compared to negative with low arousal. PNES physiological response (SCR and heart rate deceleration) was negatively correlated to dissociation tendency (r=-0.48, p = 0.0083) and alexithymia (r=-0.44, p = 0.012)). For cognitive response, no correlation was found. ConclusionThese results are in favour of a lower physiological emotional response but with an over-reactivity at behavioral level contrasting with similar cognitive assessment. For strong aversive stimuli, PNES might present a trend to overreact at physiological and behavioural levels. Our results suggest that dissociation and difficulty in describing feelings are associated with an altered physiological response in PNES women only.

Adherence to mental health care and caregiver-patient relationship after diagnosis of psychogenic non-epileptic seizures: Longitudinal follow-up study

PurposeThis study aimed to describe the quality of adherence to mental health care follow-up and the mental health caregiver-patient relationship after diagnosis of psychogenic non-epileptic seizures (PNES). MethodsWe conducted an ancillary study of a multicenter prospective study. Patients (n = 108) received a standardized diagnostic explanation of PNES following video-EEG. They were referred to their community mental health centers or to a private psychiatrist/psychologist, who received written information about PNES and the study. Data collected about adherence to care (follow-up started or not, consensual and those who withdrew non-consensually, ongoing follow-up) were cross-tabulated from patients and care structures by telephone at 6, 12, 18 and 24 months after diagnosis. At M24, we collected reasons for stopping follow-up by phone using a predefined 9-item questionnaire. We also assessed the perception of the caregiver-patient relationship among patients who started follow-up and their mental health caregivers with a simple questionnaire based on five dimensions: feeling comfortable, continuity of care, content of therapy sessions, effectiveness of therapy sessions, and the patient's overall assessment of the follow-up. ResultsFrom M6 to M24, ongoing follow-up decreased from 64.8 to 25.8%, while the “not following initial recommandations” group of patients (those who never started follow-up and those who withdrew non-consensually) increased from 35.2 to 64.9%. We found two main reasons for stopping follow-up: lack of interest and feeling better. Adherent patients had an overall more positive view of their therapy than caregivers. ConclusionOnly a third of PNES patients adhered to a mental health care program and felt comfortable in the caregiver-patient relationship. Solutions need to be found to help patients understand the interest of follow-up therapy and help mental health caregivers improve their feeling of competence.

The role of Orexin-A levels in epileptic seizure

BackgroundThe aim of this study is to determine the usefulness of Orexin-A levels in differentiating between epileptic seizures and psychogenic non-epileptic seizures in patients presenting to the emergency service with epileptic seizure-type symptoms. MethodsA total of 80 individuals were included in this study, including 59 who presented to the emergency service within the first four hours of having been diagnosed with generalized tonic-clonic seizures (39 with epileptic seizures (ES) and 20 with pseudoseizures (PNES) and 21 controls. Orexin-A levels were measured in venous blood samples. ResultsThe mean Orexin-A levels were 5.16 ng/mL in the control group, 7.17 ng/mL in the PNES group, and 11.08 ng/mL in the ES group (Table 1). The mean Orexin-A level of the ES group was significantly different from both the control group and the PNES group (Table 1, p < 0.001); the difference between the control group and the PNES group was not significant (p > 0.05). ConclusionsResults of this study suggest that blood Orexin-A may be an effective biomarker in the differential diagnosis of epileptic seizures/psychogenic non-epileptic seizures in patients presenting to the emergency service with an epileptic seizure-type clinical picture.

EEG-based classification of epilepsy and PNES: EEG microstate and functional brain network features

Epilepsy and psychogenic non-epileptic seizures (PNES) often show over-lap in symptoms, especially at an early disease stage. During a PNES, the electrical activity of the brain remains normal but in case of an epileptic seizure the brain will show epileptiform discharges on the electroencephalogram (EEG). In many cases an accurate diagnosis can only be achieved after a long-term video monitoring combined with EEG recording which is quite expensive and time-consuming. In this paper using short-term EEG data, the classification of epilepsy and PNES subjects is analyzed based on signal, functional network and EEG microstate features. Our results showed that the beta-band is the most useful EEG frequency sub-band as it performs best for classifying subjects. Also the results depicted that when the coverage feature of the EEG microstate analysis is calculated in beta-band, the classification shows fairly high accuracy and precision. Hence, the beta-band and the coverage are the most important features for classification of epilepsy and PNES patients.