Management of patients with nonepileptic attack disorder in the United Kingdom: a survey of health care professionals

Nonepileptic attack disorder (NEAD) is one of the commonest differential diagnoses of epilepsy. A number of approaches to the communication of this diagnosis and its treatment have been described; however, there are currently no evidence-based management pathways. This study captures the care currently received by patients with NEAD in the United Kingdom and Ireland. The findings are based on 130 responses to an Internet survey of clinicians from the United Kingdom and the Republic of Ireland (65.6% neurologists). The responses indicate that there is much variability in the approaches to diagnosis of NEAS and communication of the diagnosis to the patient. Although there is good access to diagnostic equipment, 30% of diagnoses are made on clinical grounds alone. While 93% of respondents endorsed psychological treatment as the treatment of choice, only 35% were able to refer all of their patients for this treatment and 15% were unable to refer any patients.     

Stretch syncope: reflex vasodepressor faints easily mistaken for epilepsy

The pathophysiology of stretch syncope is demonstrated through the clinical, electrophysiological, and hemodynamic findings in three patients. Fifty-seven attacks were captured by video/EEG monitoring. Simultaneous EEG, transcranial (middle cerebral artery) doppler, and continuous arterial pressure measurements were obtained for at least one typical attack of each patient. They all experienced a compulsion to precipitate their attacks. Episodes started with a stereotyped phase of stretching associated with neck torsion and breath holding, followed by a variable degree of loss of consciousness and asymmetric, recurrent facial and upper limb jerks in the more prolonged episodes. Significant sinus tachycardia coincided with the phase of stretching and was followed within 9-16 seconds by rhythmic generalized slow wave abnormalities on the EEG in attacks with impairment of consciousness. Transcranial doppler studies showed a dramatic drop in cerebral perfusion in the middle cerebral arteries during the episodes. The combination of the stereotyped semiology of the attacks, the pseudofocal myoclonic jerking, and the rhythmic generalized slow wave EEG abnormalities with the tachycardia make differential diagnosis from epilepsy challenging.     

Illness perceptions of health care workers in relation to epileptic and psychogenic nonepileptic seizures

Illness perceptions of health care professionals are likely to affect patient care. This study describes the illness perceptions of two groups of health care staff toward epilepsy and psychogenic nonepileptic seizures (PNES). Sixty-one health care professionals (30 emergency care [EC] and 31 neuroscience ward [NW] staff) who regularly see patients with seizures completed the adapted Illness Perception Questionnaire-Revised (IPQ-R) and the Symptom Attribution Question for epilepsy and PNES. Respondents reported a poorer understanding of PNES than of epilepsy (P<0.001), thought epilepsy was a more chronic condition (P=0.001/P<0.001) and that patients with PNES had more "personal control" of their seizures (P=0.014/P<0.001). Staff from both departments identified psychological causes as most important for PNES (P<0.001). EC staff also attributed PNES to behavioral issues or alcohol. The Illness Perception Questionnaire-Revised and Symptom Attribution Question demonstrated important differences in attitudes of health care staff toward epilepsy and PNES. The findings illustrate why some patients with PNES have traumatic encounters with health care professionals.     

Acceptability and effectiveness of a strategy for the communication of the diagnosis of psychogenic nonepileptic seizures

Purpose:   Communicating the diagnosis of psychogenic nonepileptic seizures (PNES) is a challenging task. This study was carried out to assess the acceptability and effectiveness of a new communication procedure consisting of a patient information leaflet and a communication strategy for neurologists.
Methods:   In a multicenter prospective study, 50 patients newly diagnosed with PNES were informed about the diagnosis by 10 different neurologists using the communication procedure. Follow-up data were gathered by telephone interview and completion of a questionnaire about symptom attributions (psychological/physical) and illness cognitions (Illness Perception Questionnaire-Revised, IPQ-R).
Results:   Ninety-four percent of patients found the leaflet easy to understand. Ninety-four percent stated their questions were answered by the doctor; 70% got what they wanted from the consultation; only 4% reported feeling angry during the consultation. Eighty-six percent of patients acknowledged that psychological factors were at least contributing to their seizures. On the IPQ-R, "emotional" causes for the seizures were endorsed more commonly than "nonemotional" causes (p < 0.001). After 3 months, 14% of patients were seizure-free and 63% reported a >50% reduction in seizure frequency.
Discussion:   We conclude that our procedure is acceptable and effectively communicates a psychological etiologic model for PNES.     

Integrated psychological care services within seizure settings: Key components and implementation factors among example services in four ILAE regions: A report by the ILAE Psychiatry Commission

Mental health comorbidities are prevalent and problematic in patients with seizures but often suboptimally managed. To address common gaps in care, the Integrated Mental Health Care Pathways Task Force of the International League Against Epilepsy (ILAE) Psychiatry Commission was tasked with providing education and guidance on the integration of mental health management (e.g., screening, referral, treatment) into routine seizure care. This report aims to describe a variety of established services in this area, with a specific focus on psychological care models. Services were identified by members of the ILAE Psychiatry Commission and authors of psychological intervention trials in epilepsy. A total of eight services met inclusion criteria and agreed to be showcased. They include three pediatric and five adult services located across four distinct ILAE regions (Europe, North America, Africa, Asia Oceania). The report describes the core operations, known outcomes, and implementation factors (i.e., barriers and facilitators) of these services. The report concludes with a set of practical tips for building successful psychological care services within seizure settings, including the importance of having local champions, clearly defining the scope of the service, and establishing sustainable funding models. The breadth of exemplars demonstrates how models tailored to the local environment and resources can be implemented. This report is an initial step to disseminate information regarding integrated mental health care within seizure care settings. Future work is needed to systematically examine both psychological and pharmacological care models and to further establish the evidence base in this area, especially around clinical impact, and cost-effectiveness.     

Comparison of heart rate variability parameters during complex partial seizures and psychogenic nonepileptic seizures

Purpose: Psychogenic nonepileptic seizures (PNES) superficially resemble epileptic seizures. Little is known about ictal autonomic nervous system (ANS) activity changes in epilepsy and PNES. This study compares ictal heart rate variability (HRV) parameters as a reflection of ANS tone in epileptic seizures and PNES, and explores differences between interictal and ictal ANS tone in both patient groups. Methods: Ictal HRV parameters were extracted from single‐lead electrocardiography (ECG) data collected during video–electroencephalography (EEG) recordings of 26 patients with medically refractory temporal lobe epilepsy and 24 age‐ and sex‐matched patients with PNES. One seizure per patient in a resting, wake, supine state was analyzed. Interictal ECG data were available for comparison from 14 patients in both groups. HRV parameters in time and frequency domains were analyzed (low frequency [LF], high frequency [HF], standard deviation of all consecutive normal R wave intervals [SDNN], square root of the mean of the sum of the squares of differences between adjacent normal R wave intervals [RMSSD]). CVI (cardiovagal index), CSI (cardiosympathetic index), and ApEn (approximate entropy) were calculated from Lorenz plots. Key Findings: There were significant differences between ictal HRV measures during epileptic and nonepileptic seizures in the time and frequency domains. CSI (p < 0.001) was higher in epileptic seizures. Time interval between two consecutive R waves in the ECG (RR interval) (p = 0.002), LF (p = 0.02), HF (p = 0.003), and RMSSD (p = 0.003) were significantly lower during epileptic seizures. Binary logistic regression yielded a significant model based on the differences in CSI classifying 88% of patients with epilepsy and 73% of patients with PNES correctly. The comparison between resting and ictal states in both seizure disorders revealed significant differences in RR interval (epilepsy p < 0.001, PNES p = 0.01), CSI (epilepsy p < 0.001, PNES p = 0.02), HF (epilepsy p = 0.002, PNES p = 0.03), and RMSSD (epilepsy p = 0.004, PNES p = 0.04). In patients with epilepsy there were also significant differences in ictal versus interictal mean values of ApEn (p = 0.03) and LF (p = 0.04). Although CSI was significantly higher, the other parameters were lower during the seizures. Stepwise binary regression in the 14 patients with epilepsy produced a significant model differentiating resting state from seizures in 100% of cases. The same statistical approach did not yield a significant model in the PNES group. Significance: Our results show greater ANS activation in epileptic seizures than in PNES. The biggest ictal HRV changes associated with epileptic seizures (CSI, HF, and RMSSD) reflect high sympathetic system activation and reduced vagal tone. The reduced ApEn also reflects a high sympathetic tone. The observed ictal alterations of HRV patterns may be a more specific marker of epileptic seizures than heart rate changes alone. These altered HRV patterns could be used to detect seizures and also to differentiate epileptic seizures from PNES. Larger studies are justified with intergroup and intragroup comparisons between ictal and resting states.     

Carcinogenicity and toxicity of malathion and malaoxon

Malathion and its oxygen analogue, malaoxon, are carcinogenic in Osborne-Mendel and Fischer-344 rats. Benign and malignant neoplasms at all sites were increased in Osborne-Mendel and Fischer-344 male and female rats ingesting malathion. Both Osborne-Mendel and Fischer-344 male rats were more susceptible than the female rats. The organ sites were not the same for Fischer-344 and Osborne-Mendel rats. Osborne-Mendel rats developed neoplasms of the endocrine organs, brain, and liver. Fischer-344 rats had neoplasms of the adrenal medulla, organs with squamous cells, lung, and hematopoietic system. Fischer-344 male rats given malathion were more susceptible to chronic renal disease, parathyroid hyperplasia, metastatic calcification, and atrophy of the testes than were Osborne-Mendel male rats. They also had ulcers of the forestomach. Chronic renal disease and atrophy of the testes affected the health of the animals and interfered with the development of neoplasms. Malathion increased the incidence of neoplasms of the liver in B6C3F1 male mice. Male mice also had atrophy of the testes. Benign and malignant neoplasms at all sites, and in the endocrine organs, were increased in Fischer-344 male and female rats ingesting malaoxon. Neoplasms were present in the adrenal medulla, organs with squamous cells, liver, and hematopoietic system. Both male and female Fischer-344 rats receiving malaoxon had chronic renal disease and the male rats had parathyroid hyperplasia and metastatic calcification.     

Chronic carcinogenesis studies of acrolein and related compounds

Acrolein and two of its more stable derivatives, the oxime and the diethylacetal, and the related allyl alcohol were given in drinking water to groups of 20 male and 20 female F344 rats at doses close to the maximum that could be tolerated by the animals, for most of their lifetime. Acetaldoxime served as a control for the hydroxylamine derivative of acrolein. Most of the tumors were common in untreated rats of this strain. Only adenomas of the adrenal cortex in females were more numerous than in untreated controls. Acrolein itself was too toxic to hamsters to conduct a carcinogenesis study. Acrolein oxime, acrolein diethylacetal and allyl alcohol were all quite toxic to hamsters, but 2 mg per week by gavage was tolerated by groups of 20 male Syrian hamsters. There was a small number of tumors of the pancreatic ducts and of the forestomach in the treated hamsters, but the incidence was not statistically significant.