Psychogenic Seizures Research Articles

'Positive' inter-ictal clinical signs of functional neurological disorders are found in patients with functional dissociative seizures.

Prior studies highlighted the high diagnostic specificity (ranging from 92% to 100%) of clinical signs observed in functional neurological disorders (FNDs). However, these signs are rarely looked for by epileptologists when trying to distinguish between functional dissociative seizure (FDS) and epileptic seizure. The aim of this study was to determine the prevalence of inter-ictal clinical signs of FND in a cohort of patients with probable FDS. The secondary objective was to compare the prevalence of inter-ictal FND clinical signs in FDS patients with age- and gender-matched epileptic patients without FDS. Patients diagnosed with FDS seen at two tertiary care centres and epileptic outpatients were included in the study. Each patient underwent a physical examination, searching for inter-ictal clinical signs of FND. In the FDS group, 79% of patients presented at least one sign of FND, compared to 16.6% of patients with epilepsy (p < 0.001). Moreover, 66.6% of FDS patients presented three or more FND signs, whereas only 4.1% of epileptic patients did (p < 0.001). The median number of FND clinical signs in the FDS group was four (SD 1.7; 5.5). Using the threshold of three signs or more, the specificity of detecting three or more FND signs was 83.3%, with a sensitivity of 79.2%. Inter-ictal clinical signs of FND are present in patients with FDS and should be looked for during neurological examination.

Personality disorders in individuals with functional seizures: a systematic review.

https://www.crd.york.ac.uk/PROSPEROFILES/509286_STRATEGY_20240203.pdf, identifier CRD42024509286.

Functional seizures and their mimics: a retrospective service review of cases from a tertiary video telemetry database

ObjectiveIdentify the proportion of patients referred with putative functional seizures (FS) that were subsequently re-diagnosed as epileptic seizures (ES), or an alternative diagnosis, following video telemetry EEG (VTEEG). In addition,...

Elevated plasma neurofilament light and glial fibrillary acidic protein in epilepsy versus nonepileptic seizures and nonepileptic disorders.

Research suggests that recurrent seizures may lead to neuronal injury. Neurofilament light chain protein (NfL) and glial fibrillary acidic protein (GFAP) levels increase in cerebrospinal fluid and blood in response to neuroaxonal damage, and they have been hypothesized as potential biomarkers for epilepsy. We examined plasma NfL and GFAP levels and their diagnostic utility in differentiating patients with epilepsy from those with psychogenic nonepileptic seizures (PNES) and other nonepileptic disorders. We recruited consecutive adults admitted for video-electroencephalographic monitoring and formal neuropsychiatric assessment. NfL and GFAP levels were quantified and compared between different patient groups and an age-matched reference cohort (n = 1926) and correlated with clinical variables in patients with epilepsy. A total of 138 patients were included, of whom 104 were diagnosed with epilepsy, 22 with PNES, and 12 with other conditions. Plasma NfL and GFAP levels were elevated in patients with epilepsy compared to PNES, adjusted for age and sex (NfL p = .04, GFAP p = .04). A high proportion of patients with epilepsy (20%) had NfL levels above the 95th age-matched percentile compared to the reference cohort (5%). NfL levels above the 95th percentile of the reference cohort had a 95% positive predictive value for epilepsy. Patients with epilepsy who had NfL levels above the 95th percentile were younger than those with lower levels (37.5 vs. 43.8 years, p = .03). An elevated NfL or GFAP level in an individual patient may support an underlying epilepsy diagnosis, particularly in younger adults, and cautions against a diagnosis of PNES alone. Further examination of the association between NfL and GFAP levels and specific epilepsy subtypes or seizure characteristics may provide valuable insights into disease heterogeneity and contribute to the refinement of diagnosis, understanding pathophysiological mechanisms, and formulating treatment approaches.

From Request To Result: The Clinical Significance of EEG in a Tertiary Hospital in Turkey

Objective: This study aimed to assess the clinical and demographic profiles of patients undergoing electroencephalography (EEG) over one year, evaluate EEG's impact on patient management, and ascertain the appropriateness of EEG requests. Methods: A retrospective analysis was conducted in the neurophysiology department at XXX University Faculty of Medicine over 12 months from October 2022 to October 2023. The study included the EEG request to the neurophysiology department; pediatrics and the cases that had artifacts or technical issues were excluded. Age, gender, imaging characteristics, EEG findings, and the reasons for EEG requests were recorded. The contribution of EEG to patient management was analyzed. Results: The study included 1217 patients with a mean age of 34.4±16.5 years, ranging from 18 to 90 years. Of these, 656 were female and 561 male. A history of epilepsy was reported in 821 patients. Neurology outpatient clinics, inpatient wards, and intensive care units requested the majority of EEGs. Epilepsy, presyncope/syncope, and psychogenic non-epileptic seizures (PNES) were the top reasons for EEG requests. Among the newly diagnosed epilepsy patients, 13 showed abnormal EEG results. The study identified MRI abnormalities in 202 patients, with a 27% concordance between EEG and MRI findings. EEG significantly influenced patient management in 577 cases (46.5%), demonstrating its crucial role in clinical decision-making. Conclusion: EEG's diagnostic value, particularly in epilepsy and complex neurological conditions, remains unique. Advocating suiting EEG requests and increasing physician knowledge of seizures can optimize patient care and resource use.

Dissimilar Changes in Serum Cortisol after Epileptic and Psychogenic Non-Epileptic Seizures: A Promising Biomarker in the Differential Diagnosis of Paroxysmal Events?

The hypothalamic-pituitary-adrenal axis is known to be involved in the pathogenesis of epilepsy and psychiatric disorders. Epileptic seizures (ESs) and psychogenic non-epileptic seizures (PNESs) are frequently differentially misdiagnosed. This study aimed to evaluate changes in serum cortisol and prolactin levels after ESs and PNESs as possible differential diagnostic biomarkers. Patients over 18 years with ESs (n = 29) and PNESs with motor manifestations (n = 45), captured on video-EEG monitoring, were included. Serum cortisol and prolactin levels as well as hemograms were assessed in blood samples taken at admission, during the first hour after the seizure, and after 6, 12, and 24 h. Cortisol and prolactine response were evident in the ES group (but not the PNES group) as an acute significant increase within the first hour after seizure. The occurrence of seizures in patients with ESs and PNESs demonstrated different circadian patterns. ROC analysis confirmed the accuracy of discrimination between paroxysmal events based on cortisol response: the AUC equals 0.865, with a prediction accuracy at the cutoff point of 376.5 nmol/L 0.811 (sensitivity 86.7%, specificity 72.4%). Thus, assessments of acute serum cortisol response to a paroxysmal event may be regarded as a simple, fast, and minimally invasive laboratory test contributing to differential diagnosis of ESs and PNESs.

Psychogenic non-epileptic seizures in individuals with intellectual disability/borderline cognitive function: Characterization through a comparison study

PurposeWe set out to characterize psychogenic non-epileptic seizures (PNES) in individuals with either intellectual disability (ID) or borderline intellectual function (BIF) in comparison to those with normal cognitive function. We aimed to identify differences between the two groups to improve clinical management protocols. MethodsWe conducted a retrospective, observational, single-center study. The medical records of individuals (aged ≥ 14 years) diagnosed with PNES, confirmed through video-electroencephalography (vEEG) at a specialized epilepsy center between January 2008 and December 2021, were reviewed. We restricted our study to individuals who underwent comprehensive neuropsychological evaluations. Furthermore, demographic, clinical, and neuropsychological data with potential prognostic indicators, alongside the reevaluation of vEEG recordings were studied. We compared two study groups based on intelligence quotient (IQ): individuals without ID (IQ≥85; n = 25) and those with either mild ID or BIF (n = 25). ResultsNo statistically significant clinical differences were observed between the two groups. Individuals with mild ID/BIF didn't show a longer diagnostic delay, and the prescription of inappropriate antiseizure medications (ASMs) was comparable in both cohorts. Most individuals with mild ID/BIF were treated with behavioral psychotherapeutic approaches with similar outcomes in both subgroups. ConclusionsIndividuals with mild ID/BIF and PNES don't differ in clinical management. Demographic and clinical data, as well as semiology, were comparable to those of individuals with normal cognitive function. Cognitive behavioral therapy (CBT) appears to be an effective treatment approach for individuals with and without mild ID/BIF. Further studies are needed to validate and ascertain their possible applicability in individuals with moderate/severe ID.

Altered fronto-limbic-motor response to stress differs between functional and epileptic seizures in a TBI model

Background and ObjectivesPsychogenic nonepileptic (functional) seizures (FS) clinically resemble epileptic seizures (ES) with both often preceded by traumatic brain injury (TBI). FS and ES emergence and occurrence after TBI may be linked to aberrant neurobehavioral stress responses. We hypothesized that neural activity signatures in response to a psychosocial stress task would differ between TBI + FS and TBI + ES after controlling for TBI status (TBI-only). MethodsIn the current multicenter study, participants were recruited prospectively from Rhode Island Hospital, Providence Rhode Island Veterans Administration Medical Center, and the University of Alabama at Birmingham Medical Center. Previous diagnoses of TBI, ES, and FS were verified based on data collected from participants, medical chart and record review, and, where indicated, results of EEG and/or video-EEG confirmatory diagnosis. TBI + ES (N = 21) and TBI + FS (N = 21) were matched for age and sex and combined into an initial group (TBI + SZ; N = 42). A TBI-only group (N = 42) was age and sex matched to the TBI with seizures (TBI + SZ) group. All participants completed an fMRI control math task (CMT) and stress math task (SMT) based on the Montreal Imaging Stress Task (MIST). ResultsThe TBI + SZ group (n = 24 female) did not differ in mood or anxiety severity compared to TBI-only group (n = 24 female). However, TBI + FS group (n = 11 female) reported greater severity of these symptoms compared to TBI + ES (n = 13 female). The linear mixed effects analysis identified neural responses that differed between TBI-only and TBI + SZ during math performance within the left premotor cortex and during auditory feedback within bilateral prefrontal cortex and hippocampus/amygdala regions. Additionally, neural responses differed between TBI + ES and TBI + FS during math performance within the right dorsolateral prefrontal cortex and bilateral amygdala during auditory feedback within the supplementary motor area. All tests comparing neural stress responses to psychiatric symptom severity failed to reach significance. DiscussionControlling for TBI and seizure status, these findings implicate specific nodes within frontal, limbic, and sensorimotor networks that may maintain functional neurological symptoms and possibly distinguish FS from ES. This study provides class II evidence of differences in neural responses to psychosocial stress between ES and FS after TBI.

Investigating psychobiological causes and mechanisms in functional seizures and functional motor symptoms: Study protocol.

Advances have been made in understanding the aetiology of functional neurological disorder (FND); however, its pathophysiological mechanisms have not been definitively demonstrated. Evidence suggests interacting roles for altered emotional processing and interoception, elevated autonomic arousal, and dissociation, but there is limited evidence demonstrating their causal influence on specific FND symptoms. Our superordinate aim is to elucidate potentially shared and distinct aetiological factors and mechanisms in two common FND subtypes, functional seizures (FS) and functional motor symptoms (FMS). This study has a multimodal, mixed between- and within-groups design. The target sample is 50 individuals with FS, 50 with FMS, 50 clinical controls (anxiety/depression), and 50 healthy controls. Potential aetiological factors (e.g., adverse life events, physical/mental health symptoms, dissociative tendencies, interoceptive insight/sensibility) will be assessed with a detailed medical history interview and self-report questionnaires. A laboratory session will include a neurocognitive battery, psychophysiological testing, cardiac interoception and time estimation tasks and an isometric handgrip task. A subsample will undergo magnetic resonance imaging, including structural, resting-state and task-based scans combined with psychophysiological recording. Remote monitoring with ecological momentary assessment and wearables will measure variability in FND symptoms and their potential predictors/correlates for ≥2 weeks in patients' daily lives. Longitudinal follow-ups at 3, 6, and 12-months will monitor longer-term outcomes in the clinical groups. This study employs multimodal research methods to rigorously examine several putative mechanisms in FND, at subjective/experiential, behavioural, and physiological levels. The study will test causal hypotheses about the role of altered emotional processing, autonomic arousal, dissociation and interoception in the initiation or exacerbation of FND symptoms, directly comparing these processes in FS and FMS to healthy and clinical controls. This is the first study of its kind, with potential to reveal important targets for prevention and treatment of FND in future.

A comparison of patients with epileptic seizures (ES) versus those with psychogenic non-epileptic seizures (PNES) on measures of alexithymia, mood, and anxiety

ObjectiveTo compare persons with epilepsy (PWE) to those with psychogenic non-epileptic seizures (PNES) on measures of depression, anxiety, and alexithymia subscales (i.e., difficulty identifying emotions, difficulty describing emotions, and external-oriented thinking). Material and methodsIn this retrospective study, 235 epilepsy patients and 90 patients with PNES were evaluated between 2012 and 2020 at the Northeast Regional Epilepsy Group. These patients had completed the Toronto Alexithymia Scale (TAS-20), The Center for Epidemiologic Studies - Depression Scale (CES-D) and The State-Trait Anxiety Inventory (STAI). Background information was collected regarding work/student/disability status at the time of the evaluation history of psychiatric diagnosis; psychological trauma; and involvement in psychotherapy either at the time of the evaluation or prior. ResultsSignificant differences between PWEs and those with PNES were found not only in historical data (e.g., Psychiatric History, History of Trauma, and History of Therapy) (p < .001) but also on measures of Depression (p = .002) and Anxiety (p < .001). ANOVA analysis also revealed significant differences in the distribution of the TAS-Total score, TAS-Describing emotions, and TAS-Identifying emotions. Using logistic regression (stepwise model) the optimal set of predictors for a differential diagnosis of epilepsy and PNES was combination of TAS-Identifying emotions score, history of psychological trauma, and history of therapy. The accuracy of the prediction was determined to be 80.2 %. ConclusionsAlthough higher alexithymia rates are present in PNES and PWEs, clinicians may find a combination of TAS-Identifying Emotion score, history of trauma, and history of psychotherapy useful in supporting a differential diagnosis. Also, a subgroup may exist among those with PNES with high levels of alexithymia, depression, and anxiety that may require a different treatment approach focused on addressing difficulties in identifying and describing their emotions and their other symptomatology.

Current research on the neuropsychology of dissociative seizures

ZusammenfassungDissoziative Anfälle sind komplexe und oftmals nicht ausreichend verstandene Symptome an der Grenze von körperlichen zu psychischen Phänomenen. Dies ist sowohl im Kinder- und Jugend- als auch im Erwachsenenbereich ein Problem, da ohne ein ausreichendes Krankheitsverständnis Diagnosevermittlung und Therapieplanung oft unbefriedigend verlaufen. In diesem narrativen Review wird eine Übersicht über aktuelle Forschungsergebnisse zur Neuropsychologie dissoziativer Anfälle gegeben. Dabei werden sowohl klinische als auch grundlagenwissenschaftliche Aspekte betrachtet und jeweils für den Kinder- und Jugend- sowie den Erwachsenenbereich beleuchtet. In der aktuellen Grundlagenforschung zu dissoziativen Anfällen wird v. a. die Rolle von Emotionen, Arousal-Zuständen und der Wahrnehmung von Körpersignalen untersucht. Dabei werden neben Fragebogen- und Verhaltensstudien auch experimentelle neurowissenschaftliche Methoden genutzt. In diesem Beitrag wird zudem ein aktueller, integrierender Ansatz für die Rolle von Emotionen vorgestellt. Aus der Übersicht zur Neuropsychologie dissoziativer Anfälle lassen sich neben Aspekten des Krankheitsverständnisses auch Hinweise auf Therapieansätze ableiten. Zudem wird in dieser Forschung die physische Realität des Psychischen deutlich.

Heartbeat evoked potentials and autonomic arousal during dissociative seizures: insights from electrophysiology and neuroimaging

IntroductionDissociative seizures often occur in the context of dysregulated affective arousal and entail dissociative symptoms such as a disintegration of bodily awareness. However, the interplay between affective arousal and changes...

A Case Study of Comorbid Psychogenic Non-Epileptic Seizures and Epileptic Seizures in an Adolescent Female with Depression

Among patients with Psychogenic Non-Epileptic Seizures (PNES), about 10% to 30% have epilepsy, which brings some difficulties in diagnosis. Usually, psychogenic non-epileptic seizures and epileptic seizures occur independently at different points in time, and their performance is similar, but rarely seizures can occur several times in a row. This paper reports a case of adolescent depression in our hospital, who experienced psychogenic non-epileptic seizures followed by epileptic seizures.

A Systematic Review of Studies of Attitudes and Beliefs of Healthcare Professionals Towards Non-Epileptic Attack Disorder (NEAD)

A Systematic Review of Studies of Attitudes and Beliefs of Healthcare Professionals Towards Non-Epileptic Attack Disorder (NEAD)

A comparison between two validated screening tools to diagnose psychogenic non-epileptic seizures (PNES): The PNES-DSQ and the SS-PNES

A comparison between two validated screening tools to diagnose psychogenic non-epileptic seizures (PNES): The PNES-DSQ and the SS-PNES

Comparative study of perceived invalidating environment and stress coping strategies between patients with drug resistant epilepsy and functional dissociative seizures

Background and objectivesWe investigated perceived invalidating environment during childhood and stress-coping strategies in patients with; functional dissociative seizures (FDS, n=26), drug-resistant epilepsy patients with no psychiatric comorbidity (DREnc, n=23), and drug-resistant epilepsy patients with psychiatric comorbidity (DREpc, n=34). Design/MethodsWe performed a cross-sectional study. Patients underwent Video Electroencephalography to confirm the diagnosis and completed a psychiatric assessment supported by clinical instruments. Invalidating environment and stress coping were studied through the ICES and CAE questionaries, respectively. A series of multinomial logistic regression analyses were performed with the explored variables. ResultsThe maternal negative response model predicted a higher probability of FDS condition. A chaotic family type increased the likelihood of DREpc instead of FDS. DREpc and FDS patients displayed many different behaviors to cope with stress other than trying to solve the problem, the most used strategy in the DREnc group. Parental invalidation was higher in DREpc than in FDS. ConclusionsOur results deepen the data provided by previous studies indicating that multiple variables of biosocial origin have significant effects on these groups of patients. The presence of an invalidating environment may predict FDS but also the presence of psychiatric disorders among DRE. Psychotherapeutic strategies to enhance these variables might be necessary for this population.

P.003 Outcome of psychogenic nonepileptic seizures following diagnosis in the epilepsy monitoring unit

Background: study patients with PNES’ outcome after their diagnosis in the EMU. Methods: Comparative analyses were carried out on several variables before and after diagnosis: number of participants with daily PNES, number of visits to the emergency department, number of participants who took ASMs or psychotropic drugs, and employment status. Results: 61/103 patients (79% female) participated. The median age at PNES onset was 35 years. 62% were receiving ASMs and 40% psychotropic drugs. The mean stay at the EMU was five days. PNES diagnosis was explained to almost all patients (97%) by the end of their EMU stay and was well accepted by most (89%). When contacted, 46% of participants no longer had PNES; 32% mentioned that their PNES had ceased immediately upon communication of the diagnosis. Fewer patients had daily seizures after the diagnosis. Similarly, the median number of emergency department visits was significantly lower. Only 17 patients consulted their general practitioner and 20 a neurologist after a PNES attack. The use of ASMs was also significantly reduced from 70% to 33%, with only one still taking an ASM for its antiseizure properties. Conclusions: significant reductions in PNES frequency, health care utilization and ASM use.

Estimating the likelihood of epilepsy from clinically noncontributory electroencephalograms using computational analysis: A retrospective, multisite case-control study.

This study was undertaken to validate a set of candidate biomarkers of seizure susceptibility in a retrospective, multisite case-control study, and to determine the robustness of these biomarkers derived from routinely collected electroencephalography (EEG) within a large cohort (both epilepsy and common alternative conditions such as nonepileptic attack disorder). The database consisted of 814 EEG recordings from 648 subjects, collected from eight National Health Service sites across the UK. Clinically noncontributory EEG recordings were identified by an experienced clinical scientist (N = 281; 152 alternative conditions, 129 epilepsy). Eight computational markers (spectral [n = 2], network-based [n = 4], and model-based [n = 2]) were calculated within each recording. Ensemble-based classifiers were developed using a two-tier cross-validation approach. We used standard regression methods to assess whether potential confounding variables (e.g., age, gender, treatment status, comorbidity) impacted model performance. We found levels of balanced accuracy of 68% across the cohort with clinically noncontributory normal EEGs (sensitivity =61%, specificity =75%, positive predictive value =55%, negative predictive value =79%, diagnostic odds ratio =4.64, area under receiver operated characteristics curve =.72). Group level analysis found no evidence suggesting any of the potential confounding variables significantly impacted the overall performance. These results provide evidence that the set of biomarkers could provide additional value to clinical decision-making, providing the foundation for a decision support tool that could reduce diagnostic delay and misdiagnosis rates. Future work should therefore assess the change in diagnostic yield and time to diagnosis when utilizing these biomarkers in carefully designed prospective studies.

Inpatient treatment of people with psychogenic non-epileptic seizures in epilepsy centers? A critical statement

Inpatient treatment of people with psychogenic non-epileptic seizures in epilepsy centers? A critical statement

Personality disorders in people with epilepsy: a review.

Epileptologists and psychiatrists have long observed a correlation between epilepsy and personality disorders (PDs) in their clinical practice. We conducted a comprehensive PubMed search looking for evidence on PDs in people with epilepsy (PwE). Out of over 600 results obtained without applying any time restriction, we selected only relevant studies (both analytical and descriptive) limited to English, Italian, French and Spanish languages, with a specific focus on PDs, rather than traits or symptoms, thus narrowing our search down to 23 eligible studies. PDs have been investigated in focal epilepsy (predominantly temporal lobe epilepsy - TLE), juvenile myoclonic epilepsy (JME) and psychogenic non-epileptic seizures (PNES), with heterogeneous methodology. Prevalence rates of PDs in focal epilepsy ranged from 18 to 42% in surgical candidates or post-surgical individuals, with Cluster C personality disorders or related traits and symptoms being most common. In JME, prevalence rates ranged from 8 to 23%, with no strong correlation with any specific PDs subtype. In PNES, prevalence rates ranged from 30 to 60%, with a notable association with Cluster B personality disorders, particularly borderline personality disorder. The presence of a PD in PwE, irrespective of subtype, complicates treatment management. However, substantial gaps of knowledge exist concerning the neurobiological substrate, effects of antiseizure medications and epilepsy surgery on concomitant PDs, all of which are indeed potential paths for future research.