Psychogenic Seizures Research Articles

Diagnostic Value of Intermittent Photic Stimulation Among Adult Patients in a Tertiary Referral Epilepsy Center: A Retrospective Study.

Photosensitivity is a phenomenon that may be elicited by standardized intermittent photic stimulation during EEG recording and is detected more frequently in children and adolescents. Nevertheless, at our Epilepsy Center, we routinely assess photosensitivity in all newly referred adult patients. In this investigation, we sought to address the diagnostic yield under the prerequisites described. We reanalyzed all routine EEG recordings among referrals to the department of adults during the first six months of 2019, including a simultaneous video that is always coregistered in our center. The prevalence of abnormal findings during photic stimulation was assessed. Intermittent photic stimulation was performed on 344 patients. Photoparoxysmal response were detected in five subjects (1.5%). All patients were female. Four patients were diagnosed with idiopathic generalized epilepsy, and one with Doose syndrome. Photomyogenic responses were recorded in 1.1% and only in patients with psychogenic nonepileptic seizures. In two subjects with psychogenic nonepileptic seizures, the typical seizure was provoked by intermittent photic stimulation (8.7% of all subjects with psychogenic nonepileptic seizures in this cohort). Photoparoxysmal response was not detected in any subject with focal epilepsy, syncope, or other nonepileptic paroxysmal events. In every case of photoparoxysmal responses, increased photosensitivity had already been reported before recording. In our study, photoparoxysmal responses was a rare phenomenon among adults with a preponderance of females and idiopathic generalized epilepsies. Intermittent photic stimulation may be helpful in provoking typical psychogenic nonepileptic seizures and thus abbreviate the diagnostic process. Provided a careful history, routine intermittent photic stimulation in adults with epilepsy does not appear to be mandatory.

Can immature granulocyte (IG), an inflammatory marker, be used in the differential diagnosis of epilepsy and non-epileptic psychogenic seizure?

Can immature granulocyte (IG), an inflammatory marker, be used in the differential diagnosis of epilepsy and non-epileptic psychogenic seizure?

The Yield of Ambulatory Video-EEG: Predictors of Successful Event Capture.

The purpose of this study was to assess the likelihood of capturing a patient's typical event in question on ambulatory video-EEG monitoring (AVEM) based on certain baseline patient or event characteristics. We retrospectively reviewed 300 studies that resulted between June 2021 and August 2022 ordered by adult epileptologists. Patients were included in event analysis if the study was ordered for the purpose of capturing an event (and excluded for all other purposes). A total of 149 studies were included in event analysis. Sixty-eight patients (46%) had their typical events captured on AVEM. Diagnosis was an epileptic seizure in 17 patients (25%), psychogenic nonepileptic seizure in 7 (10%), and other nonepileptic events in 44 (65%). Regarding event frequency, for patients who on average had daily events, 84% had events captured, which corresponds to a significantly increased odds ratio (OR 17.90, 95% CI 7.55-42.44, p < 0.001). For those who had events <1 per week to ≥1 per month, only 9% had events captured (OR 0.06, 95% CI 0.02-0.19, p < 0.001). No patients who had events less frequently than once per month had a diagnostic AVEM. Regarding the number of antiseizure medications (ASMs), the odds ratio was increased for those not on ASMs (OR 2.65, 95% CI 1.17 -6.03, p = 0.02) and decreased for those on 1 ASM (OR 0.28, 95% CI 0.13 -0.60, p = 0.001). There was no statistical significance based on event type (motor vs nonmotor), prior seizure diagnosis, history of psychiatric comorbidity, or presence of a focal brain lesion. Certain baseline characteristics can increase or decrease the pretest probability of capturing a typical event on AVEM, particularly the frequency of events and number of ASMs. This can be useful information for clinicians before ordering a study so that resources can be properly allocated.

Prevalence of ictal injuries in functional (psychogenic nonepileptic) seizures: A systematic review and meta-analysis.

Ictal injuries have long been considered typical signs of epileptic seizures. However, studies have shown that patients with functional seizures (FS)-also named psychogenic nonepileptic seizures-can also present these signs, misleading physicians and delaying a correct diagnosis. This systematic review aimed to assess the prevalence of injuries from FS. A literature search was performed in PubMed, Embase, LILACS (Latin American and Caribbean Health Sciences Literature), Scopus, Web of Science, PsycINFO, Google Scholar, OpenGrey, and ProQuest. Observational studies were included. The risk of bias was assessed using the Joanna Briggs Institute (JBI) checklist for studies reporting prevalence data. RStudio was used for meta-analyses. Cumulative evidence was evaluated according to Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria. From the 2607 identified records, 41 studies were included in the qualitative synthesis, and 28 were included in meta-analyses. A meta-analysis of 13 studies, including 1673 individuals, resulted in an overall lifetime prevalence of injuries due to FS per person of 25% (95% confidence interval [CI] = 19%-32%, I2 = 88%). Considering a limited period (video-electroencephalographic [VEEG] monitoring days), a meta-analysis of 13 studies, including 848 individuals, resulted in an injury prevalence due to FS per person of .7% (95% CI = 0%-3%, I2 = 73%). Also, a meta-analysis of eight studies, including 1000 individuals, resulted in a prevalence of injuries per FS of .1% (95% CI = 0%-.98%, I2 = 49%). The certainty in cumulative evidence assessed by GRADE was rated "very low" for lifetime prevalence of injuries per person, "low" for prevalence per person during VEEG monitoring, and "moderate" for prevalence per number of FS. Overall pooled lifetime prevalence of injuries due to FS per person was 25%. In comparison, the prevalence of injuries per person during VEEG monitoring and per functional seizure was .7% and .1%, respectively. [Correction added on 07 October 2023, after first online publication: In the preceding sentence, 'consecutively' was corrected to 'respectively'.] The evidence of the occurrence of injuries due to FS breaks the paradigm that epileptic seizures can cause injuries but FS cannot.

Narrative Medicine: A Communication Therapy for the Communication Disorder of Psychogenic Non-Epileptic Seizures (PNES)

Narrative Medicine: A Communication Therapy for the Communication Disorder of Psychogenic Non-Epileptic Seizures (PNES)

Can a single dose of psilocybin improve cognitive control in functional dissociative seizures?

Dissociative symptoms can occur in prevalent psychiatric illnesses, and they are particularly frequent in Functional Neurological Disorders which belong to Dissociative Disorders in international classifications. Although the pathophysiology of these disorders remains partially unknown, it has been related to the impairment of cognitive control abilities. Evidence suggest that psilocybin is likely to enhance cognitive control, but no clinical trial has evaluated the value of psilocybin in Dissociative Disorders. We believe that functional/dissociative seizures (previously named psychogenic non-epileptic seizures) constitute a good model for studying the effect of therapeutic interventions on dissociative phenomena. To investigate the effect of psilocybin on cerebral networks, we propose to focus on the circuits associated with cognitive control and their interactions with the processing of emotional information by quantifying changes in the activity of the cognitive control network assessed with functional brain MRI during an emotional Go-No Go task.

P09.04.B PNES IN BRAIN TUMOR PATIENTS : AN UNEXPECTED CHALLENGE

Abstract BACKGROUND Epileptic seizures (ES) are common in brain tumor patients. The phenomenon of psychogenic non-epileptic seizures (PNES) amongst those patients has not been well described. PNES Phenomenology could be similar to ES, however, epileptogenic activity on electro-encephalogram (EEG) is absent. The diagnosis of PNES can be challenging in brain tumor patients since both types of seizures can present with similar symptoms and might occur together. Risk factors for the development of PNES include a history of negative events in childhood, exposure to trauma, history of psychiatric illness and chronic pain, and substance abuse. Diagnosing PNES is important for delivering the appropriate treatment, and preventing the toxic influence of unneeded treatment and procedures. MATERIAL AND METHODS The Electronic files of patients with ES and PNES were evaluated, in A retrospective analysis from the database of the Neuro-Oncology unit at Sheba Medical-Center. RESULTS 4 patients with brain tumor related epilepsy and PNES were identified: a female 22 years old with right frontal IDH1 mutated non 1p/19q deleted glioma WHO2, a 44 years old male with right frontal IDH1 mutated 1p/19q deleted glioma WHO2, a 48 years old female with left temporo-insular IDH1 mutated non 1p/19q deleted glioma WHO2 and a 65 years old female with multiple radiation induced meningiomas. Seizures semiology were compatible with the lesions. The first two patients had recent stress factors, and the last two suffered severe diagnosis-related anxiety. All patients presented initially with ES and developed PNES subsequently. They were treated with 2-4 Anti-Epileptic drugs(AED’s). They were referred to EEG video monitoring due to worsening seizures frequency despite increasing the AED’s and no evidence of tumor progression at that time. All patients had clinical seizures which did not have any epileptiform activity correlation on Video-EEG. Hence, PNES was diagnosed. Three patients underwent psychological treatment and two patients received medical therapy for underlying psychological factors contributing to PNES. Seizure frequency and number of AED's decreased in all patients. CONCLUSION In patients with brain tumors the diagnosis of PNES can be challenging but should be considered in patients with increased seizures frequency regardless of stable imaging and absence of any other provocative factors. Video EEG is pivotal for PNES diagnosis. Psychological consulting and treatment are recommended in PNES cases. Correct diagnosis and treatment will contribute to the patient's quality of life.

Development and validation of a peripheral cell ratio and lactate score for differentiating status epilepticus from prolonged psychogenic nonepileptic seizures.

Differentiating status epilepticus (SE) from prolonged psychogenic nonepileptic seizures (pPNES) can be difficult clinically. We aimed to define the utility of peripheral cell counts, cell ratios, and lactate levels in distinguishing SE from pPNES. Retrospective two-center study investigating the sensitivity and specificity of acute (≤12 h of event offset) peripheral cell counts, cell ratios (neutrophil-lymphocyte ratio, neutrophil-monocyte ratio, monocyte-lymphocyte ratio, platelet-lymphocyte ratio, systemic immune-inflammatory index [SII], systemic inflammatory response index [SIRI]), and lactate levels in differentiating SE from pPNES. Patients were identified from two tertiary hospitals, with one forming the development cohort and the other the validation cohort. Using generalized additive models to generate biomarker vs time curves, optimal blood collection times were defined for set parameters. Three diagnostic scores combining neutrophil count, SII, or SIRI with lactate levels were developed and validated in separate cohorts. For the development cohort, 1262 seizure-like events were reviewed and 79 SE and 44 pPNES events were included. For the validation cohort, 241 events were reviewed and 20 SE and 11 pPNES events were included. Individually, the biomarkers generally had low sensitivity and reasonable specificity for differentiating SE from pPNES, with the neutrophil count, SIRI, and SII performing best with sensitivities of 0.65-0.84, specificities of 0.64-0.89, and ROC AUCs of 0.78-0.79. Lactate levels peaked at 60 min, while cell counts and ratios peaked after 240 min. Combining early peaking lactate levels and later peaking neutrophil count, SIRI or SII resulted in three scores that improved predictive potential with sensitivities of between 0.75 and 0.79, specificities between 0.93 and 1.00, and ROC AUCs of 0.89-0.91. Lactate levels peak early post-SE, whereas cell counts and ratios do so later. The differing post-event time profiles of lactate levels vs neutrophil count, SIRI, and SII allow incorporation into three separate scores which can assist in differentiating SE from pPNES.

Depression, anxiety, stress, and suicide risk in patients with functional seizures vs. those with epilepsy.

We aimed to investigate the rates of positive screening for depression, anxiety, stress, and suicide risk in adults with seizures [i.e., well-matched groups of patients with focal epilepsy vs. idiopathic generalized epilepsy (IGE) vs. functional seizures (FS)]. This was a cross sectional study. Patients, 19-55 years of age, with a diagnosis of IGE, focal epilepsy or FS were investigated at the outpatient epilepsy clinic at Shiraz University of Medical Sciences, Shiraz, Iran, from September 2022 until January 2023 and during their follow-up visits. We used the validated Farsi version of DASS-21 (Depression-Anxiety-Stress Scale) to investigate and screen for depression, anxiety, and stress in these patients. We also used the Beck Scale for Suicide Ideation (BSSI). Forty patients with focal epilepsy, 40 persons with IGE, and 40 individuals with FS were included. Depression and anxiety were more prevalent among patients with FS compared with those with epilepsy. The rate of stress among patients with FS was not significantly different compared with that in patients with epilepsy. The suicide risks were not significantly different between the groups either. Patients with FS are at high risk for psychiatric comorbidities that is comparable or even worse than that in patients with epilepsy. Specific validated scales to screen for psychiatric comorbidities and suicide risk should be integral components of the evaluation and treatment of all patients with seizures.

Heart rate and autonomic biomarkers distinguish convulsive epileptic vs. functional or dissociative seizures

Objective20–40% of individuals whose seizures are not controlled by anti-seizure medications exhibit manifestations comparable to epileptic seizures (ES), but there are no EEG correlates. These events are called functional or dissociative seizures (FDS). Due to limited access to EEG-monitoring and inconclusive results, we aimed to develop an alternative diagnostic tool that distinguishes ES vs. FDS. We evaluated the temporal evolution of ECG-based measures of autonomic function (heart rate variability, HRV) to determine whether they distinguish ES vs. FDS. MethodsThe prospective study includes patients admitted to the University of Rochester Epilepsy Monitoring Unit. Participants are 18–65 years old, without therapies or co-morbidities associated with altered autonomics. A habitual ES or FDS is recorded during admission. HRV analysis is performed to evaluate the temporal changes in autonomic function during the peri‑ictal period (150-minutes each pre-/post-ictal). We determined if autonomic measures distinguish ES vs. FDS. ResultsThe study includes 53 ES and 46 FDS. Temporal evolution of HR and autonomics significantly differ surrounding ES vs. FDS. The pre-to-post-ictal change (delta) in HR differs surrounding ES vs. FDS, stratified for convulsive and non-convulsive events. Post-ictal HR, total autonomic (SDNN & Total Power), vagal (RMSSD & HF), and baroreflex (LF) function differ for convulsive ES vs. convulsive FDS. HR distinguishes non-convulsive ES vs. non-convulsive FDS with ROC>0.7, sensitivity>70%, but specificity<50%. HR-delta and post-ictal HR, SDNN, RMSSD, LF, HF, and Total Power each distinguish convulsive ES vs. convulsive FDS (ROC, 0.83–0.98). Models with HR-delta and post-ictal HR provide the highest diagnostic accuracy for convulsive ES vs. convulsive FDS: 92% sensitivity, 94% specificity, ROC 0.99). SignificanceHR and HRV measures accurately distinguish convulsive, but not non-convulsive, events (ES vs. FDS). Results establish the framework for future studies to apply this diagnostic tool to more heterogeneous populations, and on out-of-hospital recordings, particularly for populations without access to epilepsy monitoring units.

Ictal crying in epileptic seizures and psychogenic nonepileptic seizures: What are the hints to differentiate them?

ObjectivesIctal crying (IC) is a quite rare semiological manifestation of epileptic seizures (ESs) and it has been mostly reported in psychogenic nonepileptic seizures (PNESs). However, labeling IC as a pathognomonic sign of PNES can be harmful. We first aimed to investigate IC frequency in ES and PNES and highlight the differences of IC between ES and PNES. Secondly, we aimed to analyze etiology, detailed semiology, treatment options, and outcome of patients with IC in ES in more detail. MethodsWe retrospectively screened all video-EEG monitoring unit reports from Hacettepe University Hospitals’ Epilepsy Center over a 20-year period (1996–2017) for the diagnosis of IC. We included the patients with IC who had at least one documented seizure. Patients who had IC with both facial expression and vocalization compatible with crying with or without weeping and subjective feeling of sadness, were included in the study. We classified patients with IC as ES and PNES. Demographic, historical, clinical, neuroimaging, electrophysiological parameters, video-EEG data, treatment options, and prognosis of all patients were recorded. Demographic, clinical, and video-EEG data were compared between ES and PNES. ResultsDuring the study period, 1983 patients were investigated. Six patients (all female) with ES and 37 patients (33 female) with PNES were identified. When we compared patients with PNES and ES with IC, the number of ASMs taken and duration of disease were significantly higher in patients with ES than PNES. Longer duration of seizure, longer duration of crying component, late onset of crying component in seizure, early responsiveness after seizure, not occurring during sleep, accompanied by eye closure and weeping, were found significantly higher in patients with PNES. Besides, if we analyze ES group in more detail, all had medical treatment refractory focal epilepsy and two of them whose IC was seen as an early semiological manifestation of their seizures had good outcome after nondominant anterior temporal lobectomy (ATL)+amygdalohippocampectomy (AH). However, three patients had various cortical lesions apart from temporal lobe on MRI and one patient had focal epilepsy with frontal lobe semiology with negative MRI. ConclusionAlthough the most common etiology for IC is PNES and it is rarely seen in ES, it can be harmful to label ictal crying as a pathognomonic sign for PNES. We proposed that there are some semiological differences in terms of IC between PNES and ES. These differences may help to distinguish IC in PNES and ES in daily practice. Moreover, it can be speculated that nondominant temporal lobe involvement may be associated with IC in ES.

Classification of Epileptic and Psychogenic Nonepileptic Seizures via Time-Frequency Features of EEG Data.

The majority of psychogenic nonepileptic seizures (PNESs) are brought on by psychogenic causes, but because their symptoms resemble those of epilepsy, they are frequently misdiagnosed. Although EEG signals are normal in PNES cases, electroencephalography (EEG) recordings alone are not sufficient to identify the illness. Hence, accurate diagnosis and effective treatment depend on long-term video EEG data and a complete patient history. Video EEG setup, however, is more expensive than using standard EEG equipment. To distinguish PNES signals from conventional epileptic seizure (ES) signals, it is crucial to develop methods solely based on EEG recordings. The proposed study presents a technique utilizing short-term EEG data for the classification of inter-PNES, PNES, and ES segments using time-frequency methods such as the Continuous Wavelet transform (CWT), Short-Time Fourier transform (STFT), CWT-based synchrosqueezed transform (WSST), and STFT-based SST (FSST), which provide high-resolution time-frequency representations (TFRs). TFRs of EEG segments are utilized to generate 13 joint TF (J-TF)-based features, four gray-level co-occurrence matrix (GLCM)-based features, and 16 higher-order joint TF moment (HOJ-Mom)-based features. These features are then employed in the classification procedure. Both three-class (inter-PNES versus PNES versus ES: ACC: 80.9%, SEN: 81.8%, and PRE: 84.7%) and two-class (Inter-PNES versus PNES: ACC: 88.2%, SEN: 87.2%, and PRE: 86.1%; PNES versus ES: ACC: 98.5%, SEN: 99.3%, and PRE: 98.9%) classification algorithms performed well, according to the experimental results. The STFT and FSST strategies surpass the CWT and WSST strategies in terms of classification accuracy, sensitivity, and precision. Moreover, the J-TF-based feature sets often perform better than the other two.

Genetics of Functional Seizures; A Scoping Systematic Review.

Evidence on the genetics of functional seizures is scarce, and the purpose of the current scoping systematic review is to examine the existing evidence and propose how to advance the field. Web of science and MEDLINE were searched, from their initiation until May 2023. The following key words were used: functional neurological disorder(s), psychogenic neurological disorder(s), functional movement disorder(s), psychogenic movement disorder(s), functional seizures(s), psychogenic seizure(s), nonepileptic seizure(s), dissociative seizure(s), or psychogenic nonepileptic seizure(s), AND, gene, genetic(s), polymorphism, genome, epigenetics, copy number variant, copy number variation(s), whole exome sequencing, or next-generation sequencing. We identified three original studies. In one study, the authors observed that six (5.9%) patients with functional seizures carried pathogenic/likely pathogenic variants. In another study, the authors observed that, in functional seizures, there was a significant correlation with genes that are over-represented in adrenergic, serotonergic, oxytocin, opioid, and GABA receptor signaling pathways. In the third study, the authors observed that patients with functional seizures, as well as patients with depression, had significantly different genotypes in FKBP5 single nucleotide polymorphisms compared with controls. Future genetic investigations of patients with functional seizures would increase our understanding of the pathophysiological and neurobiological problems underlying this common neuropsychological stress-associated condition.

Pediatric psychogenic non-epileptic seizures: A retrospective observational cohort study at a quaternary center

BackgroundPsychogenic non-epileptic seizures (PNES) represent a common functional disorder in the pediatric population. We aimed to characterize pediatric PNES by describing their clinical characteristics, PNES semiologies, and healthcare pathway towards and after diagnosis. Material and MethodsThis was a retrospective, observational chart review of pediatric patients aged 6 to 18 years admitted between December 2020 and December 2021 for spell classification or suspected PNES. Psychogenic non-epileptic seizure diagnosis was made by the capture of a typical event on video electroencephalogram (vEEG). We used descriptive statistics to summarize demographic and clinical characteristics. ResultsWe included 26 patients (18 females, 69.2%) with a mean age (SD) of 13.9 (2.5) years. Pre-morbid neurologic and psychiatric conditions included: epilepsy (23.1%), migraine (46.2%), mild traumatic brain injury (26.9%), anxiety (57.7%), ADHD (34.6%), and depression (30.8%). Six patients (23.1%) had a prior diagnosis of PNES. 14 patients (53.8%) presented with convulsive, and 6 (23.1%) each with non-convulsive and mixed PNES.Patients were seen by a range of providers prior to diagnosis including ED providers (50%), neurologists (53.8%), pediatricians (34.6%), and psychology/psychiatry (11.5%). Emergency department evaluation occurred for 13 patients (50%) on 15 occasions, and six (23.1%) were admitted to the hospital. The median (p25-p75) time from PNES onset to presentation and diagnosis at our institution was 3.5 (1.5–6.2) and 4.1 (3–7) months, respectively.A total of 33 events from the 26 patients were captured on vEEG. The most frequent semiologies in our cohort were rhythmic motor (27.3%) followed by equal frequency (18.2%) of complex motor and dialeptic. Eighteen patients (69.2%) were followed after the PNES diagnosis, for a median (p25-p75) of 17.3 months (6.3–21) with variable outcome. ConclusionPediatric PNES has female predominance and often presents with comorbid psychosocial stressors and psychiatric conditions. High clinical suspicion and early recognition are crucial to decrease healthcare utilization and establish timely diagnosis and treatment.

Attention deficit hyperactivity disorder in patients with seizures: Functional seizures vs. epilepsy

BackgroundWe investigated the rates of positive screening for attention deficit-hyperactivity disorder (ADHD) in adults with seizures [i.e., focal epilepsy vs. idiopathic generalized epilepsy (IGE) vs. functional seizures (FS)]. We hypothesized that the rates of positive screening for ADHD are different between these three groups of patients. MethodsThis was a cross sectional study. Patients, 19 to 55 years of age, with a diagnosis of IGE, focal epilepsy or FS were investigated at the outpatient epilepsy clinic at Shiraz University of Medical Sciences, Shiraz, Iran, from September 2022 until January 2023 and during their follow-up visits. We used the validated Persian version of Adult ADHD Self-Report Scale (ASRS v1.1)15 to investigate and screen for ADHD in these patients. ResultsForty patients with focal epilepsy, 40 with IGE, and 40 with FS were included. Attention deficit-hyperactivity disorder (ADHD) screening was positive in 35% of patients with FS, in 30% of those with focal epilepsy (compared with FS, p = 0.633), and in 10% of patients with IGE (compared with FS, p = 0.007). ConclusionAdult patients with functional seizures and those with focal epilepsy are at a high risk of self-reporting experiences that could be characteristic of ADHD. Screening tools [e.g., Adult ADHD Self-Report Scale (ASRS v1.1)] are useful to help clinicians address seizure comorbidities such as ADHD. However, a clinical diagnosis of ADHD should be ascertained in a patient with positive screening.

Treatment Provided in Children and Adolescents with Functional Seizures-A Danish Nationwide Cohort.

Functional seizures (FS) are episodes of paroxysmal involuntary movements and altered consciousness without the typical changes in the electroencephalography as with epilepsy. A multidisciplinary approach is the golden standard in the treatment of FS. This study examined the cross-sectoral collaboration and treatment modalities provided to children and adolescents after a diagnosis of FS. A Danish nationwide cohort, consisting of 334 children and adolescents, aged 5-17 years, with a validated diagnosis of FS during the period 2004-2014 was studied. Medical record data were collected from diagnosing hospital departments. Management and treatment modalities from the time of diagnosis up to three months after diagnosis were explored. The most used treatment modalities were psychoeducation (n = 289, 86.5%) and follow-up in outpatient care (n = 192, 70.6%). A cross-sectoral collaboration was initiated for a third of cases (n = 98, 29.3%). The most commonly provided treatment combination consisted of psychoeducation, follow-up in outpatient care and psychotherapy; however, only a few patients received this specific combination (n = 14, 4.2%). The treatment applied was individualized and consisted of varying use of treatment modalities. Initiatives to curate clinical guidelines and implement a multidisciplinary treatment approach should be further explored to improve treatment for this young group of patients.

Psychiatric and psychological assessment of Spanish patients with drug-resistant epilepsy and psychogenic nonepileptic seizures (PNES) with no response to previous treatments

ObjectivePsychogenic nonepileptic seizures (PNES) are common imitators of epileptic seizures. Refractoriness to antiseizure medication hinders the differential diagnosis between ES and PNES, carrying deleterious consequences in patients with PNES. Psychiatric and psychological characteristics may assist in the differential diagnosis between drug-resistant epilepsy (DRE) and PNES. Nevertheless, current comprehensive psychiatric and psychological descriptive studies on both patient groups are scarce and with several study limitations. This study provides a comprehensive psychiatric and psychological characterization of Spanish patients with DRE and PNES. MethodA cross-sectional and comparative study was completed with 104 patients with DRE and 21 with PNES. Psychiatric and psychological characteristics were assessed with the HADS, SCL-90-R, NEO-FFI-R, PDQ-4+, COPE, and QOLIE-31 tests. Parametric and non-parametric tests were used, and regression models were fit to further explore factors affecting patients' life quality. ResultsPatients with PNES had greater levels of somatization and extraversion and were associated with benzodiazepine intake. Patients with DRE showed greater narcissistic personality disorder symptoms than those with PNES. In patients with DRE, difficulty in performing basic needs-related tasks and greater psychological distress severity and seizure frequency were associated with poorer life quality. In contrast, being a woman, having a psychiatric disorder history, and greater psychiatric symptoms’ intensity were associated with poorer life quality in patients with PNES. ConclusionPatients with DRE and PNES share similar psychiatric and psychological characteristics, with only very few being significantly different.

Functional Seizure Clinics: A Proposed Financially Viable Solution to the Neurologist Supply and Demand Mismatch.

Projections from recent studies suggest that by 2025, there will not be enough neurologists to meet the demand in 41 states. In this study, we investigate the financial impact and improved access to care for persons with epilepsy that is possible by implementing a multidisciplinary treatment clinic for persons with functional seizures (FS), previously referred to as psychogenic nonepileptic seizures, thus separating those patients out of an epilepsy clinic. This observational retrospective study used real-time data of 156 patients referred to an FS clinic integrated into a tertiary care epilepsy center to simulate its effect on epilepsy division access and finances. Access was measured using simulations of the number of return patient visits (RPVs) and new patient visits (NPVs) of patients with FS to a dedicated epilepsy clinic, based on survey results inquiring about the standard of care without the FS clinic. Finances were simulated using the resultant access multiplied by respective wRVU and reimbursement per CPT code. Treatment of 156 patients with FS in a multidisciplinary FS clinic resulted in 343 newly opened NPVs, reimbursement of $102,000, and 1,200 wRVUs in our dedicated epilepsy clinic. There were 686 RPVs, $103,000 in reimbursement, and 1,320 wRVUs. Relative to the total number of NPVs with epilepsy clinic epileptologists, 343 NPVs represent a biennial 15.5% increase in available new patient visit slots. Our findings describe the financial viability of integrating a treatment clinic for persons with FS by directing them to FS-specialized treatment and thereby increasing access for patients with probable epilepsy to the dedicated epilepsy clinic. This study provides a potential solution to the national mismatch in the supply and demand of neurologists and an initial framework to use for those who wish to establish or integrate FS services in their institution.

Overall comorbidities in functional neurological disorder: A narrative review

IntroductionThe importance to assess and include the frequent comorbidities in the personalised care management plan of patients with functional neurological disorders (FND) has arisen through the years. FND patients are not only complaining from motor and/or sensory symptoms. They also report some non-specific symptoms that participate to the burden of FND. In this narrative review, we aim to better describe these comorbidities in terms of prevalence, clinical characteristics and their variability depending on the subtype of FND. MethodsThe literature was searched for on Medline and PubMed. The search was narrowed to articles between 2000 and 2022. ResultsFatigue is the most common symptom reported in relation to FND (from 47 to 93%), followed by cognitive symptoms (from 80 to 85%). Psychiatric disorders are reported in 40 to 100% FND patients, depending on the FND subtype (functional motor disorder [FMD], functional dissociative seizures [FDS]…) but also on the type of psychiatric disorder (anxiety disorders being the most frequent, followed by mood disorders and neurodevelopmental disorders). Stress factors such as childhood trauma exposure (emotional neglect and physical abuse predominantly) have also been identified in up to 75% of FND patients, along with maladaptive coping strategies. Organic disorders are commonly reported in FND, such as neurological disorders (including epilepsy in FDS [20%] and FMD in Parkinson's Disease [7%]). Somatic symptom disorders including chronic pain syndromes are frequently associated to FND (about 50%). To be noted, recent data also suggest a high comorbidity between FND and hypermobile Ehlers Danlos Syndrome (about 55%). ConclusionPut together, this narrative review highlights the high burden of FND patients, not only due to somatosensory alterations but also by considering the frequent comorbidities reported. Thus, such comorbidities must be taken into consideration when defining the FND personalised care management strategy for the patients.

Principles for delivering improved care of people with functional seizures: Closing the treatment gap.

Patients diagnosed with functional (psychogenic nonepileptic) seizures have similar or greater levels of disability, morbidity and mortality than people with epilepsy, but there are far fewer treatment services. In contrast to epilepsy, the current understanding of pathophysiological mechanisms and the development of evidence-based treatments for functional seizures is rudimentary. This leads to high direct healthcare costs and high indirect costs to the patient, family and wider society. There are many patient, clinician and system-level barriers to improving outcomes for functional seizures. At a patient level, these include the heterogeneity of symptoms, diagnostic uncertainty, family factors and difficulty in perceiving psychological aspects of illness and potential benefits of treatment. Clinician-level barriers include sub-specialism, poor knowledge, skills and attitudes and stigma. System-level barriers include the siloed nature of healthcare, the high prevalence of functional seizures and funding models relying on individual medical practitioners. Through the examination of international examples and expert recommendations, several themes emerge that may address some of these barriers. These include (1) stepped care with low-level, brief generalised interventions, proceeding to higher level, extended and individualised treatments; (2) active triage of complexity, acuity and treatment readiness; (3) integrated interdisciplinary teams that individualise formulation, triage, and treatment planning and (4) shared care with primary, emergency and community providers and secondary consultation. Consideration of the application of these principles to the Australian and New Zealand context is proposed as a significant opportunity to meet an urgent need.