Anxiety and avoidance in psychogenic nonepileptic seizures: The role of implicit and explicit anxiety

This study examined implicit and explicit anxiety in individuals with epilepsy and psychogenic nonepileptic seizures (PNESs) and explored whether these constructs were related to experiential avoidance and seizure frequency. Based on recent psychological models of PNESs, it was hypothesized that nonepileptic seizures would be associated with implicit and explicit anxiety and experiential avoidance. Explicit anxiety was measured by the State-Trait Anxiety Inventory; implicit anxiety was measured by an Implicit Relational Assessment Procedure; and experiential avoidance was measured with the Multidimensional Experiential Avoidance Questionnaire. Although both groups with epilepsy and PNESs scored similarly on implicit measures of anxiety, significant implicit–explicit anxiety discrepancies were only identified in patients with PNESs (p < .001). In the group with PNESs (but not in the group with epilepsy), explicit anxiety correlated with experiential avoidance (r = .63, p < .01) and frequency of seizures (r = .67, p < .01); implicit anxiety correlated with frequency of seizures only (r = .56, p < .01). Our findings demonstrate the role of implicit anxiety in PNESs and provide additional support for the contribution of explicit anxiety and experiential avoidance to this disorder.     

Long-term outcome of psychogenic nonepileptic seizures: The role of induction by suggestion

PurposeThe aims of our retrospective observational study were to evaluate the long-term outcome of PNESs after communication of the diagnosis and to define predictors of good outcome.MethodTwenty-seven consecutive patients with a certain diagnosis of psychogenic nonepileptic seizures (PNESs) were included in the study. Follow-up information was obtained from each participant through a questionnaire designed for the study. Regarding seizure frequency, the patients were asked to report how many seizures they had experienced on average every month before the communication of the diagnosis and after it.ResultsAfter the communication of the diagnosis, the median seizure frequency had dropped to 4 every month (p < 0.001). Seventeen participants (63%) were seizure-free at follow-up, and a further five (18.5%) showed a greater than 50% improvement in seizure frequency. Regarding the predictive value of clinical and sociodemographic variables for PNES global outcome, the factors gender, education, economic status, interval of time from onset, comorbidity with epilepsy, psychiatric history, mental retardation, psychological therapy, psychiatric therapy, and the presence of stressful and traumatic events were not related to prognosis; the only factor associated with a better outcome was the diagnosis made after the induction of PNESs by suggestion (p = 0.000, χ² = 4.654).ConclusionA substantial majority of our patients became seizure-free with communication of the diagnosis as the only intervention. The use of the induction by suggestion test was an important predictor of good outcome.     

Specific adverse effects of antiepileptic drugs — A true-to-life monotherapy study

BackgroundIn patients taking antiepileptic drugs (AEDs) for epilepsy, adverse effects (AEs) often lead to unfavorable quality of life, impaired adherence, and, eventually, discontinuation of pharmacological treatment. In a true-to-life sample of subjects from our academic epilepsy outpatient clinic, we aimed to identify predictors for overall high AE burden and for specific AEs focusing on patients on monotherapy.MethodsAll patients ≥ 16 years of age with epilepsy for ≥ 12 months were routinely asked to complete the Liverpool Adverse Event Profile (LAEP) just before their appointment. Demographic, epilepsy, and treatment variables were derived from our comprehensive outpatient database.ResultsOut of 841 patients, 438 (61% female, mean age: 44.7 ± 17.1 years) on monotherapy were included in this study. Levetiracetam (n = 151), lamotrigine (n = 167), valproic acid (n = 73), or controlled-release carbamazepine (n = 47) were the most commonly used antiepileptic drugs (AEDs). Independent predictors for general high AE burden (LAEP score ≥ 45) were duration of epilepsy, lack of 12-month seizure freedom, and partial epilepsy, but none of the four individual AEDs. The most frequent LAEP-defined specific AEs were sleepiness, difficulty concentrating, tiredness, and memory problems. The three most frequent independent predictors for each of the 19 AEs were lack of 12-month seizure freedom (13/19 AEs), individual AED (7/19 AEs), and partial epilepsy (6/19 AEs). Levetiracetam was independently associated with anger/aggression, nervousness/agitation, upset stomach, depression, and sleep disturbance; lamotrigine with nervousness/agitation, upset stomach, and difficulty concentrating; and valproic acid with upset stomach and shaky hands.ConclusionIndividual AEDs independently predicted some specific AEs, but not overall high AE burden. Our findings may help to characterize patients with epilepsy who are at high risk for specific AEs. Dose reduction or change to another AED may reduce LAEP score and potential nonadherence.     

Epilepsy may be the major risk factor of mental retardation in children with tuberous sclerosis: A retrospective cohort study

Mental retardation (MR) is one of the most common cognitive comorbidities in children with tuberous sclerosis, and there are enormous studies about its risk factors. The genetic difference and the severity of epilepsy are the two main factors, but their weight in the occurrence of MR is still unclear. Two hundred twenty-three patients with tuberous sclerosis who received intelligence assessment, genetic mutation analysis, and the epilepsy severity assessment were included in our study. Genotype–neurocognitive phenotype correlations and epilepsy–neurocognitive phenotype correlations were analyzed by binary logistic regression analysis. No statistical significant result was found on genotype–neurocognitive phenotype correlations, which contrasted the previous report. The prevalence of MR was 50.0% for the patients with tuberous sclerosis complex-1 (TSC1) mutation, 54.5% for TSC2 (p = 0.561), 54.7% for patients with protein-truncating (PT) and 50.0% for patients with nontruncating (NT) (p = 0.791), and 54.3% for patients with family history and 53.7% for patients without family history (p = 0.748). Statistical significant results were found on epilepsy–neurocognitive phenotype correlations, both on E-chess score (p = 0.01) and the occurrence of infantile spasms (p = 0.014), which was consistent to the previous study. For children with tuberous sclerosis, instead of genetic factors, epilepsy may play the main role for the presence of mental retardation. Patients with mental retardation tend to have earlier seizure attack, take more AEDs, have more seizure types, and have higher seizure frequency. Among the four cognitive functions in Denver II, social ability and language ability are more vulnerable to be influenced than fine and gross motor ability.     

Implicit and explicit self-esteem discrepancies in people with psychogenic nonepileptic seizures

PurposeSelf-esteem (SE), or one's sense of competence and worth, is reduced in many mental and physical disorders. Low SE is associated with perceived stigma and disability and poor treatment outcomes. The present study examined implicit and explicit SE (automatic and deliberate views about the self) in people with epilepsy and people with psychogenic nonepileptic seizures (PNESs). Discrepancies between implicit SE and explicit SE have been found to correlate with psychological distress in disorders often associated with PNESs but are relatively unexplored in PNESs. We hypothesized that, compared with epilepsy, PNESs would be associated with lower self-reported SE and greater discrepancies between implicit SE and explicit SE.MethodsThirty adults with PNESs, 25 adults with epilepsy, and 31 controls without a history of seizures were asked to complete the Rosenberg Self-esteem Scale as a measure of explicit SE and an Implicit Relational Assessment Procedure as a measure of implicit SE. The State–Trait Anxiety Inventory and Patient Health Questionnaire—15 (a somatic symptom inventory) were also administered.ResultsWe found significant group differences in explicit (p < 0.001) but not implicit SE. Patients with PNESs reported lower SE than the other groups. No group differences were found in implicit SE. Implicit–explicit SE discrepancies were larger in the group with PNESs than in the other groups (p < 0.001). Higher frequency of PNESs (but not epileptic seizures) was associated with lower explicit SE (r_s = − .83, p < 0.01) and greater SE discrepancies (i.e., lower explicit relative to implicit SE; r_s = .65, p < 0.01). These relationships remained significant when controlling for anxiety and somatization.ConclusionPatients with PNESs had lower explicit SE than those with epilepsy or healthy controls. In keeping with our expectations, there were greater discrepancies between implicit SE and explicit SE among patients with PNESs than in the other groups. Our results, including the strong relationship between PNES frequency, anxiety, and explicit–implicit SE discrepancies, support the interpretation that PNESs serve to reduce cognitive dissonance, perhaps protecting patients' implicit SE.     

Epilepsy monitoring unit length of stay

With an increasing focus on quality metrics, hospital length of stay (LOS) in the U.S. has garnered significant scrutiny. To help establish evidence-based benchmarks for epilepsy monitoring unit (EMU) metrics, we evaluated the impact of multiple variables on LOS through a retrospective analysis of 905 consecutive inpatient adult EMU admissions. The most common reasons for admission were event characterization (n = 494), medication adjustment (n = 189), and presurgical evaluation (n = 96). Presurgical evaluations experienced a longer average LOS (aLOS) of 7.1 days versus patients admitted for other indications (p < 0.001). Patients with symptomatic generalized epilepsy (n = 22) had a longer aLOS (6.9 days) than patients with other types of epilepsy/events (p < 0.001). Patients admitted on two or fewer antiepileptic drugs (AEDs) had a shorter aLOS than patients admitted on three or more AEDs (4.3 days vs 6.3 days, respectively; p < 0.001). A history of previous invasive epilepsy management was associated with a longer aLOS than those without (6.2 days vs 4.7 days, respectively; p < 0.0001). Epilepsy monitoring unit aLOS is influenced by admission indication, epilepsy classification, medication burden, and having had prior invasive management. Multiple variables should be considered when analyzing LOS EMU metrics, arguing against a “one size fits all” approach.     

Randomized-controlled trials of levetiracetam as an adjunctive therapy in epilepsy of multiple seizure types

This meta-analysis aimed to systematically collect and synthesize the current evidence regarding the efficacy and tolerability of levetiracetam (LEV) as an adjunctive therapy for adults and children suffering from idiopathic and secondary epilepsy of multiple seizure types. We selected randomized-controlled trials (RCT) of LEV as an adjunctive therapy in epilepsy according to predefined criteria. Outcome measures included a ⩾50% reduction in seizure frequency, seizure freedom, and adverse events. Thirteen RCT were analyzed. Results showed that the efficacy of adjunctive LEV was superior to placebo both in achieving ⩾50% reduction in seizure frequency (pooled odds ratio [OR] 3.36, 95% confidence interval [CI] 2.78–4.07, Z = 12.46; p < 0.00001) and seizure freedom (pooled OR 4.72, 95% CI 2.96–7.54, Z = 6.50; p < 0.00001). The heterogeneity was mild (chi-squared = 12.28, I² = 2% in ⩾50% reduction in seizure frequency, and chi-squared = 0.49, I² = 0% in seizure freedom). Subgroup analysis suggested similar effects across different dosages in adults. The incidence of adverse reactions was not significantly different between the LEV group and the placebo group. The adverse events of relatively high incidence in the LEV group included somnolence, agitation, dizziness, asthenia, and infection. Incidence of serious adverse reaction such as rash and white blood cells and platelets decreasing was quite low. Adjunctive therapy with LEV was superior to placebo in reducing the frequency of seizures in patients with partial and idiopathic generalized epilepsy with effect in both adults and children, and demonstrated good tolerance in patients with epilepsy.     

Effect of successful epilepsy surgery on subjective and objective sleep parameters – a prospective study

ObjectiveTo evaluate the effect of surgery on subjective and objective measures of sleep quality among patients with medically refractory focal epilepsy.MethodsIn a prospective cohort study, patients with medically refractory epilepsy undergoing epilepsy surgery were recruited. All patients were assessed seven days pre- and three months post-surgery in terms of history pertaining to epilepsy and sleep, Epworth sleepiness score (ESS), one week sleep log and over night polysomnography (PSG).ResultsAmong 17 patients (mean age 18, 11 males), seizure frequency had reduced (p = 0.04) and self reported sleep parameters had significantly improved (reduced total duration of night time sleep, regularity on one week sleep log and ESS (p < 0.05)) three months following epilepsy surgery. Patients with good surgical outcome (n = 12) showed reduced seizure frequency (p = 0.01) and reduced ESS with corresponding reduction in arousal index (AI) (p = 0.02) and increase in total sleep time (p = 0.03), postoperatively. Three patients in the good surgical outcome group showed reduction in apnea–hypopnea index (AHI) from more than five to less than five. There was no significant change either in seizure frequency, self reported clinical parameters or PSG parameters among patients with poor surgical outcome.ConclusionEpilepsy surgery improves subjective sleep parameters in patients with medically refractory epilepsy during the early post operative period. Successful epilepsy surgery may improve objective (PSG documented) sleep quality, sleep architecture and obstructive sleep apnea with resultant reduction in excessive daytime sleepiness.     

Impact of the chronic use of benzodiazepines prescribed for seizure control on the anxiety levels of patients with epilepsy

In a cross-sectional study, we evaluated the impact of the chronic use of benzodiazepines (BDZ) prescribed for seizure control on the anxiety levels of patients with temporal lobe epilepsy. We assessed the anxiety level of 99 patients with temporal lobe epilepsy with (n = 15) or without (n = 84) BDZ for seizure control, using the Beck Anxiety Inventory (BAI) or the Hamilton Anxiety Scale (HAMA). Independent risk factors for high anxiety levels were being a female patient (O.R. = 2.93; 95% C.I. = 1.05–8.16; p = 0.039), having uncontrolled seizures (O.R. = 4.49; 95% C.I. = 1.66–12.11; p = 0.003) and having a history of a psychiatric disorder (O.R. = 4.46; 95% C.I. = 1.63–12.21; p = 0.004). However, there were no statistically significant differences in anxiety levels between patients utilizing or not utilizing BDZ prescribed exclusively for seizure control. We concluded that in our study, patients with chronic use of BDZ prescribed exclusively for seizure control showed similar anxiety levels than patients who were not using this class of drug. Additional studies are needed to define better strategies for the treatment of anxiety disorders in epilepsy.     

Marijuana use in adults admitted to a Canadian epilepsy monitoring unit

ObjectivesEpidemiologic evidence supporting antiseizure properties of cannabis is limited and controversial. We determined the prevalence of marijuana use and its perceived effects in patients with and without epilepsy.MethodsInformation was collected over 14 months from consecutive adult patients admitted to an epilepsy monitoring unit using a 27-item anonymous questionnaire. Patients with cognitive impairment unable to understand the questions or give informed consent and readmissions were not recruited. Subjects were divided into 4 groups, those with epileptic seizures, those with psychogenic nonepileptic seizures (PNES), those with both epileptic and PNES, and those with other nonepileptic events. Patients with exclusively epileptic seizures were compared with those with exclusively PNES.ResultsFrom 310 patients, 18 undiagnosed cases were excluded leaving a cohort of 292 patients with median age 35 (range: 27–49) years; 57.2% female. Epilepsy was documented in 190 (65.1%), PNES in 64 (21.9%), and both types of seizures in 26 (8.9%). Median duration of seizure disorder was longer (2 [1–9] vs. 13 [5.7–25] years; p < 0.001) and seizure frequency lower (daily or weekly in 62.3% vs. 44.9%; p = 0.03) in patients with epilepsy compared with those in patients with PNES. Overall, 166 (57%) had tried marijuana, and 36.2% used it over the past year. Utilization was 57.1% in sole epilepsy and 64.1% in sole PNES, but daily use was more likely in epilepsy (59% vs. 33.3%). Estimated mean dose was 1 g/day. Marijuana use was associated with tobacco smoking (p < 0.001) but not alcohol use. Eight patients used other street drugs. Improvement in seizures was perceived by 84% in those with epilepsy and 72.7% in those with PNES. In the 2 groups, stress was decreased in 84.9% and 88%, sleep improved in 77.3% and 88%, and memory/concentration was better in 32% and 28%, respectively. Antiepileptic drug side effects were decreased in 53.2% of marijuana users. Perceived effect on epileptic seizures correlated with effect on stress (r = 0.35, p = 0.004). Adverse effects of marijuana were mild and reported in 30.7% but included possible seizure precipitation in 5 patients with epilepsy.SignificancePatients with uncontrolled epilepsy or nonepileptic events had a high rate of marijuana use with associated perceived improvements in seizure control, stress, sleep, and drug side effects. Stress reduction may contribute to the perceived impact of marijuana on seizures and nonepileptic events in adults.     

Is reoperation an option for patients with temporal lobe epilepsy after failure of surgery?

PurposeEpilepsy surgery is the most efficacious therapeutic modality for patients with medically refractory focal epilepsies, but surgical failures remain a challenge to the epilepsy treatment team. The aim of present study was to evaluate the postoperative outcome of patients who underwent reoperation after a failed epilepsy surgery on the temporal lobe.MethodsWe systematically analyzed the results of comprehensive preoperative evaluations before the first surgery, and before and after reoperation in 17 patients with drug resistant temporal lobe epilepsies.ResultsOverall, 13 of 17 patients (76.5%) improved after reoperation: five patients (29.4%) were completely seizure free after reoperation (median duration 60 months, range 12–72); six patients (35.3%) were seizure free at least 12 month before observation points (median duration 120.5 months, range 35–155) and two patients (11.8%) had a decrease in seizure frequency. Four patients (23.5%) remained unchanged with respect to seizure frequency and severity. There was no correlation between the improvement in seizure outcome after reoperation and other clinical data except of the history of traumatic brain injury (TBI). The patients who had no history of TBI improved after reoperation, compared to patients with TBI (p = 0.044). The postoperative seizure outcome of patients with incongruent Video-EEG results before the first surgery (p = 0.116) and before reoperation (p = 0.622) was not poorer compared to patients with congruent Video-EEG results.ConclusionsReoperation can considerably improve the operative outcome of the first failed epilepsy surgery in patients with drug resistant temporal lobe epilepsies. Epilepsy centres should be encouraged to report the results of failed epilepsy surgeries.     

Long-term seizure and psychosocial outcomes after resective surgery for intractable epilepsy

Resective surgery is considered an effective treatment for refractory localization-related epilepsy. Most studies have reported seizure and psychosocial outcomes of 2–5 years postsurgery and a few up to 10 years. Our study aimed to assess long-term (up to 15 years) postsurgical seizure and psychosocial outcomes at our epilepsy center. The Henry Ford Health System Corporate Data Store was accessed to identify patients who had undergone surgical resection for localization-related epilepsy from 1993 to 2011. Demographics including age at epilepsy onset and surgery, seizure frequency before surgery, and pathology were gathered from electronic medical records. Phone surveys were conducted from May 2012 to January 2013 to determine patients' current seizure frequency and psychosocial metrics including driving and employment status and use of antidepressants. Surgical outcomes were based on Engel's classification (classes I and II = favorable outcomes). McNemar's tests, chi-square tests, two sample t-tests, and Wilcoxon two sample tests were used to analyze the relationships of psychosocial and surgical outcomes with demographic and surgical characteristics. A total of 470 patients had resective epilepsy surgery, and of those, 50 (11%) had died since surgery. Of the remaining, 253 (60%) were contacted with mean follow-up of 10.6 ± 5.0 years (27% of patients had follow-up of 15 years or longer). Of the patients surveyed, 32% were seizure-free and 75% had a favorable outcome (classes I and II). Favorable outcomes had significant associations with temporal resection (78% temporal vs 58% extratemporal, p = 0.01) and when surgery was performed after scalp EEG only (85% vs 65%, p < 0.001). Most importantly, favorable and seizure-free outcome rates remained stable after surgery over long-term follow-up [i.e., < 5 years (77%, 41%), 5–10 years (67%, 29%), 10–15 years (78%, 38%), and > 15 years (78%, 26%)]. Compared to before surgery, patients at the time of the survey were more likely to be driving (51% vs 35%, p < 0.001) and using antidepressants (30% vs 22%, p = 0.013) but less likely to be working full-time (23% vs 42%, p < 0.001). A large majority of patients (92%) considered epilepsy surgery worthwhile regardless of the resection site, and this was associated with favorable outcomes (favorable = 98% vs unfavorable = 74%, p < 0.001). The findings suggest that resective epilepsy surgery yields favorable long-term postoperative seizure and psychosocial outcomes.     

Thoughts,emotions, and dissociative features differentiate patients with epilepsy from patients with psychogenic nonepileptic spells (PNESs)

Psychogenic nonepileptic spells (PNESs) are often very difficult to treat, which may be, in part, related to the limited information known about what a person experiences while having PNESs. For this retrospective study, thoughts, emotions, and dissociative features during a spell were evaluated in 351 patients diagnosed with PNESs (N = 223) or epilepsy (N = 128). We found that a statistically higher number of thoughts, emotions, and dissociative symptoms were endorsed by patients with PNESs versus patients with epilepsy. Patients with PNESs reported significantly more anxiety and frustration, but not depression, compared with those with epilepsy. Emotions and dissociations, but not thoughts, and a history of any type of abuse were endorsed significantly more often by patients with PNESs. Patients with PNESs are prone to having poor outcomes, and interventions focusing on their actual experiences may be helpful for treatment planning.     

Ambiguous results of an attempt to withdraw barbiturates in epilepsy patients with intellectual disability

Phenobarbital and primidone frequently have adverse effects on mental functions. Therefore, an attempt was made to taper barbiturates in 85 patients out of a resident population with epilepsy and intellectual disability who were selected according to clinical criteria. The objectives were to reduce the use of barbiturates, to improve the patients’ cognitive and psychological state, and to reduce polypharmacy while avoiding seizure exacerbation. Four months after complete withdrawal changes in seizure frequency were assessed as well as changes in cognitive abilities, psychological state and behaviour (using the clinical global impression scale). In 13 patients the tapering failed due to complications (seizure increase in 11 patients). In 72 patients the barbiturate was completely withdrawn (mean duration of tapering: 393 days). Cognitive improvement was achieved in 17 patients (23.6%), 5 patients (6.9%) deteriorated. Seizure frequency remained unchanged in 33 patients (45.8%), in another 15 patients (20.8%) the seizure frequency decreased. Reduction in polypharmacy was obtained in 61 patients (84.7%). In an overall judgement (clinical global impression scale) of cognitive abilities AND seizure control, 25 patients (34.7%) were improved. 31 patients (43.1%) remained unchanged while 12 patients deteriorated (4 patients: impossible to judge). For statistical analysis three outcome groups were defined: the improved group (N = 25), the unchanged group (N = 31), and the deteriorated/failed group (N = 25) consisting of the 12 deteriorated patients plus the 13 patients in whom tapering failed. Stepwise logistic regression revealed a history of an attempt to withdraw phenobarbital/primidone (p = 0.017; OR 3.8), age (p = 0.012) and seizure frequency (marginally significant: p = 0.097) as outcome predictors. Older age was associated with better outcome. A high seizure frequency before tapering was related to good outcome, while seizure freedom and a history of failed withdrawal were associated with deterioration/failure. Outcome did not depend on duration of barbiturate therapy, dosage or serum concentration, co-medication, reduction rate, degree of intellectual disability, or epilepsy syndrome. In summary, the number of barbiturate medications has been considerably reduced, but the principal aim of the project, to relieve patients from assumed barbiturate side effects, has been achieved only in one out of four patients.     

Byproducts of protein,lipid and DNA oxidative damage and antioxidant enzyme activities in seizure

PurposeTo get more insight into molecular mechanisms underlying oxidative stress and its role in different types of seizure, in this study, oxidative byproducts of proteins, lipids and DNA, as well as, antioxidant enzyme activities were studied in adult patients with epilepsy.MethodsStudy was performed in 60 patients with epilepsy and in 25 healthy controls. Plasma protein reactive carbonyl derivatives (RCD) and protein thiol groups (P-SH), byproducts of oxidative protein damage, as well as antioxidant enzyme activities, superoxide dismutase (SOD) and glutathione peroxidase (GPX) were studied spectrophotometrically. Urinary 8-epi-prostaglandin F_2α (8-epi-PGF_2α) and 8-hydroxy-2′-deoxyguanosine (8-OHdG), representative byproducts of lipid and DNA oxidative damage, respectively, were determined by enzyme immunoassay.ResultsRCD levels were significantly increased (p = 0.001), while P-SH content was decreased in patients with first seizure (p = 0.052) compared to controls, independently of the seizure type. Urinary 8-epi-PGF_2α and 8-OHdG were significantly increased in patients with epilepsy (p = 0.001 and p = 0.001). Rise in 8-epi-PGF_2α was more pronounced in patients with generalized tonic–clonic seizure (GTCS) compared to those with partial seizure (PS). Both SOD and GPX activity were significantly increased in epileptic patients compared to controls (p = 0.001 and p = 0.001), but only SOD activity was significantly higher in patients with GTCS than in those with PS.ConclusionsData on enhanced protein, lipid and DNA oxidation, together with upregulated antioxidant enzyme activities, confirm the existence of systemic oxidative stress in patients with epilepsy. It might be speculated that post-translational modification to existing functional proteins, particularly alterations to ion channels, might be at least partially responsible for acute early changes in neuronal networks.     

Distinguishing between patients with pure psychogenic nonepileptic seizures and those with comorbid epilepsy by means of clinical data

Patients with psychogenic nonepileptic seizures (PNESs) often have additional epileptic seizures (ESs). Distinguishing between those with ESs and those without ESs is difficult but mandatory. We hypothesize that these two patient groups differ in clinical data, which might be useful for establishing diagnosis. All patients with PNESs (n = 114) from the Bethel Epilepsy Centre treated between 1/11/2010 and 1/11/2011 were included. Thirty-six percent had additional epilepsy. In contrast, 84 of the 114 patients with PNESs took antiepileptic drugs (AEDs) (AED treatment: patients with PNESs = 44/73, patients with PNESs + ESs = 40/41), most of them (65.5%) as polytherapy. Significant differences between both groups were as follows: patients with PNESs were older at disease onset, had a shorter duration from onset to inpatient visit, were less frequently on AEDs, were less frequently on antiepileptic polytherapy, and had a normal EEG compared with patients with PNESs + ESs. Multivariate stepwise logistic regression revealed age at seizure onset, number of AEDs, and difference between number of AEDs and psychiatric drugs as significant predictors of patients with ESs in PNESs (Nagelkerke's r² = 0.59). Therefore, clinical data proved to be useful in the diagnostic process.     

Predictors of quality of life and their interrelations in Korean people with epilepsy: A MEPSY study

PurposePeople with epilepsy (PWE) are more likely to have impaired quality of life (QOL) than the general population. We studied predictors of QOL and their interrelations in Korean PWE.MethodsSubjects who consecutively visited outpatient clinics in four tertiary hospitals and one secondary care hospital were enrolled. These subjects completed the Korean version of the Neurological Disorders Depression Inventory for Epilepsy (K-NDDI-E), the Generalized Anxiety Disorder-7 (GAD-7), the Quality of Life in Epilepsy-10 (QOLIE-10), and the Korean version of Liverpool Adverse Event Profile (K-LAEP). We evaluated the predictors of QOL by multiple regression analyses and verified the interrelations between the variables using a structural equation model.ResultsA total of 702 PWE were eligible for the study. The strongest predictor of the overall QOLIE-10 score was the K-LAEP score (β = −0.375, p < 0.001), followed by the K-NDDI-E score (β = −0.316, p < 0.001), seizure control (β = −0.152, p < 0.001), household income (β = −0.375, p < 0.001), and GAD-7 score (β = −0.119, p = 0.005). These variables explained 68.7% of the variance in the overall QOLIE-31 score. Depression and seizure control had a bidirectional relationship and exerted direct effects on QOL. These factors also exerted indirect effects on QOL by provoking adverse effects of AEDs. Anxiety did not have a direct effect on QOL; it had only indirect effect through the adverse effects of AEDs.ConclusionDepression, anxiety, seizure control, and adverse effects of AEDs have complex interrelations that determine the QOL of PWE.     

Effects of seizure severity and seizure freedom on the health-related quality of life of an African population of people with epilepsy

PurposeThis study aimed at determining the effects of seizure severity and seizure freedom on health-related quality of life (HRQOL) of people with epilepsy (PWE) in the presence of perceived stigma in a sub-Saharan African culture.MethodsHealth-related quality of life was assessed using QOLIE-31 in 93 consecutive adults (56 males and 37 females) with epilepsy. They were stratified into seizure-free, low–moderate seizure severity, and high seizure severity groups based on the seizure type and the number of seizures in the previous 6 months. Other illness variables and sociodemographic variables were also obtained. A 3-item perceived stigma scale was administered. A modified QOLIE-31 (excluding the epilepsy-specific items) was given to 102 age- and sex-matched healthy controls.ResultsThere was moderate negative correlation between seizure severity and mean total HRQOL score as well as scores on the Seizure Worry (p = .000), Overall Quality of Life (p = .000), and Social Function (p = .001) subscales of QOLIE-31. Overall, the healthy control subjects had a higher mean HRQOL score compared with the PWE put together (71.0 + 11.1 vs 64.2 ± 13.6, p = .001). However, there was no difference in the mean HRQOL score between the seizure-free individuals and the healthy controls (p = .270). Seizure severity was associated with HRQOL independent of perceived stigma on a multiple regression analysis.ConclusionThis study provides evidence that seizure severity relates to health-related quality of life in an inverse, graded manner and independent of perceived stigma. Seizure-free people with epilepsy can have quality of life comparable with healthy individuals.     

Association of primary care factors with hospital admissions for epilepsy in England, 2004–2010: National observational study

PurposeThere has been little research on the accessibility and quality of primary care services for epilepsy and emergency hospital admissions for epilepsy.MethodsWe examined time trends in admissions for epilepsy in England between 2004–2005 and 2010, and the association of admission rates with population and primary care factors. The units of analysis were the registered populations of 8622 general practices. We used negative binomial regression to model indicators from the Quality and Outcomes Framework, the UK's primary care pay for performance scheme, to measure the accessibility and quality of care for epilepsy, and supply of general practitioners, after adjustment for population factors.ResultsThe mean indirectly standardised admission rate decreased from 122.9 to 102.6 (−16.5%; P < 0.001) over the study period, while the mean percentage of patients seizure free increased from 65.3% to 74.9% (P < 0.001). In the multivariable analysis, a one unit increase in the percentage of seizure free adult patients on epilepsy drugs predicted a 0.20% decrease (IRR = 0.9980; 95% CI: 0.9974–0.9986) in admission rate. The percentage of patients who were able to book a GP appointment over two days ahead predicted a 0.12% decrease (IRR = 0.9988; 95% CI: 0.9982–0.9994). The deprivation score of practice populations (IRR = 1.0179; P < 0.001) and general practitioner supply (IRR = 1.0022; P < 0.001) were both positively associated with admission rates.ConclusionPatient access to primary care appointments and percentage of patients who have been recorded as seizure free for 12 months were associated with lower admission rates. However the effect sizes are small relative to that of population deprivation.     

Initial response to antiepileptic drugs in patients with newly diagnosed epilepsy

This study aimed to identify factors predicting the response to antiepileptic drugs in patients with newly diagnosed epilepsy. We prospectively studied 176 patients with newly diagnosed epilepsy. Patients were included if they had a history of two or more clinically definite unprovoked seizures, or had a definite epileptic focus on MRI or epileptiform discharges on electroencephalography if they had suffered only one seizure. The primary endpoint was seizure freedom during the initial 6 months of antiepileptic drug treatment. The secondary endpoint was the time to the first seizure during the maintenance period of antiepileptic drug treatment. A total of 100 patients were included, and seizure freedom for 6 months was achieved in 73 patients. The response to antiepileptic drugs was significantly lower in patients with early age at seizure onset (⩽16 versus >16 years old, odds ratio = 4; 95% confidence interval [CI] 1.5–12.9; relative risk = 1.4; 95% CI 1.1–1.8). In addition, the time to the first seizure during the maintenance period was significantly earlier in patients with age at seizure onset ⩽16 years compared with those with age at seizure onset >16 years on the Kaplan–Meier survival analysis (p = 0.011). Early age at seizure onset is an important factor influencing the response to antiepileptic drugs in patients with newly diagnosed epilepsy.