De Novo Psychogenic Nonepileptic Seizures After Epilepsy Surgery

Summary: Purpose: The occurrence of de novo nonepileptic seizures (NES) after epilepsy surgery have been reported only twice in the literature (one article and one abstract).
Methods: We report three patients whose de novo NES were documented by video-EEG telemetry after epilepsy surgery. These patients were drawn from a sample of 166 consecutive patients who underwent epilepsy surgery at our center between 1989 and 1996.
Results: Two patients became seizure free after surgery, and one had significant improvement of her seizures. The interval between the date of surgery and the development of the symptoms was variable (8, 10, and 47 months, respectively). The clinical phenomena of NES differed from those of the epileptic seizures preceding surgery. Their diagnosis had not been suspected in two patients before the diagnostic video-EEG monitoring study. After the diagnosis of NES, spells stopped in two patients and recurred rarely in one.
Conclusions: We conclude that de novo NES appears to occur rarely after epilepsy surgery. Given that the possibility of NES was suspected in only one patient, its incidence after surgery may be higher than so far reported. Physicians should therefore consider NES in the differential diagnosis of recurrent seizures after a seizure-free period after epilepsy surgery.     

Psychogenic Seizures

Summary: Psychogenic seizures occur in a heterogeneous population and are varied in their expression and etiology. Patients with psychogenic seizures form a significant percentage of patients presenting with "epilepsy"-especially the group intractable to treatment. Intensive neurodiagnostic monitoring of ictal events and the classification of patients into clinically useful subgroups are important tools in approaching this disorder.     

Weeping During Psychogenic Nonepileptic Seizures

Ictal weeping may help distinguish psychogenic nonepileptic seizures (PNES) from epileptic seizures. However, the prevalence of weeping during PNES or epileptic seizures is unknown. We reviewed videotapes of recorded events in 84 consecutive patients with PNES or epilepsy. Weeping was observed during 14% of PNES in 31% of patients with PNES. Ictal weeping was not observed in any epileptic seizures occurring in 48 patients. The differences were highly significant. One patient with epileptic seizures originating in the right temporal lobe wept soon after the end of a seizure. Depression was not more common in PNES patients with than without ictal weeping. Weeping during an apparent seizure strongly argues that the event is not epileptic.     

Factors Distinguishing Families of Patients with Psychogenic Seizures from Families of Patients with Epilepsy

Summary: Purpose: Psychogenic seizures (PS) (emotionally based nonelectrical seizures) have been explained by psychodynamics and trauma. However, the family health literature suggests that somatization, of which psychogenic seizures are a form, may run in families and be determined by family patterns of response to distress. This study compared families of patients with PS and those of patients with epilepsy on variables of distress (anxiety and depression) and somatization.
Methods: Eighteen patients (9 with PS and 9 with epilepsy) matched for age and education, and their families answered the Health Status Questionnaire (HSQ), the Weinberger Adjustment Inventory (WAI), the Family Emotional Involvement and Criticism Scale (FEICS), Barsky's Somatization Symptom Inventory (SS), and the Dissociation Experience Scale (DES). Family members' scores were averaged to obtain "family scores."
Results: Patients with PS and those with epilepsy did not differ in any of the measures. However, families of patients with PS reported more health problems, distress, and criticism than did families of patients with epilepsy (p < 0.05). Families of patients with PS had increased criticism and somatic problem scores comparable to those of both types of patients.
Conclusions: Although epilepsy causes patients physical and emotional problems, their families are relatively healthy. In contrast, families of patients with PS are more troubled and may unwittingly contribute to PS through family distress, criticism, and tendencies to somatize.     

Clinical Features and Prognosis of Nonepileptic Seizures in a Developing Country

PURPOSE: To determine the predictive value of clinical features and medical history in patients with nonepileptic seizures (NESs). METHODS: One hundred sixty-one consecutive ictal video-EEGs were reviewed, and 17 patients with 41 NESs identified. NES diagnosis was defined as paroxysmal behavioral changes suggestive of epileptic seizures recorded during video-EEC without any electrographic ictal activity. Clinical features, age, sex, coexisting epilepsy, associated psychiatric disorder, social and economic factors, delay in reaching the diagnosis of NES, previous treatment, and correlation with outcome on follow-up were examined. RESULTS: The study population included 70% female patients with a mean age of 33 years. Mean duration of NESs before diagnosis was 9 years. Forty-one percent had coexisting epilepsy. The most frequent NES clinical features were tonic-clonic mimicking movements and fear/anxiety/hyperventilation. The most common psychiatric diagnosis was conversion disorder and dependent and borderline personality disorder. Seventy-three percent of patients with pure NESs received antiepileptic drugs (AEDs), and 63.5% of this group received new AEDs. Fifty-nine percent of the patients received psychological/psychiatric therapy. At follow-up, 23.5% were free of NESs. CONCLUSIONS: All seizure-free patients had two good prognostic factors: having an independent lifestyle and the acceptance of the nonepileptic nature of the episodes. Video-EEG monitoring continues to be the diagnostic method to ensure accurate seizure classification. Establishing adequate health care programs to facilitate access to new technology in public hospitals as well as the implementation of continuous education programs for general practitioners and neurologists could eventually improve the diagnosis and treatment of patients with NESs.     

Self-Injury and Incontinence in Psychogenic Seizures

Summary: Two patients who incurred significant injuries during psychogenic seizures prompted us to do a telephone survey of self-injury and incontinence in 102 consecutive patients diagnosed with psychogenic seizures by EEG-closed-circuit TV (EEG-CCTV) monitoring. Seventy-three patients (or a close family member or friend) were reached by telephone and responded to our survey. During typical attacks of psychogenic seizures, 40% reported injuries, 44% reporting tongue biting, and 44% reported urinary incontinence. Suicide attempts were reported by 32% and were more common in those with self-injury and urinary incontinence. We compared the results of patients with psychogenic seizures with those of 30 patients with refractory epilepsy documented by ictal recordings, using a similar telephone survey. Injuries of all types were more commonly reported by epilepsy patients. Burn injuries were reported only by patients with epilepsy. Suicide attempts were more commonly reported by the psychogenic seizure group. Self-injury and incontinence are commonly reported by psychogenic seizure patients. In view of their significant association with suicide attempts, they may indicate an underlying depression.     

Developmental Background and Outcome in Patients with Nonepileptic Versus Epileptic Seizures: A Controlled Study

Summary: Purpose: This study was designed to evaluate the relevance of developmental emotional stress factors, which are considered to influence emotional functioning, as contributing factors in the development of psychogenic symptoms.
Methods: Ten patients with nonepileptic seizures (non-ESs)(frequently referred to as psychogenic seizures), in whom diagnosis had been confirmed by a placebo-infusion test (PT), and 10 control patients with complex partial seizures (ESs) were evaluated with regard to developmental background by using structured in-depth interviews performed by a single interviewer blinded to the diagnosis. In addition, outcome assessment in the non-ES group after PT was done.
Results: There were no significant differences between groups in developmental psychosocial stress or in any single developmental stress factor. Six months after PT, the outcome was favorable in patients with non-ES: six were seizure free, and two had a considerable reduction in frequency of seizures.
Conclusions: Our research indicates the following: (a) a high incidence of developmental stress factors and functional disturbances may be found in patients with non-ESs and ESs; (b) assessment of developmental emotional stress and functional disturbances as a basis for validating the diagonsis of non-ES should be treated with caution; (c) use of PT followed by supportive information about the nonepileptic origin of the attacks may have a positive therapeutic effect or help to introduce psychotherapeutic treatment.     

A Comprehensive Profile of Clinical, Psychiatric, and Psychosocial Characteristics of Patients with Psychogenic Nonepileptic Seizures

PURPOSE: To attain a comprehensive profile of clinical, psychiatric and psychosocial characteristics of patients with psychogenic nonepileptic seizures (NESs), and to assess the relation of these factors to NES outcome. METHODS: We administered a telephone-based structured questionnaire to 56 patients with NESs (16 male and 40 female patients; mean age, 35 years) at a mean follow-up time of 18 months after making the diagnosis of NES. RESULTS: Mean age of NES onset was 28 years with a mean duration of 8 years. Episodes resolved in 29 (51.8%) cases, decreased in 24 (42.9%), persisted unchanged in two (3.6%), and increased in frequency in one (1.8%). Thirty (53.6%) patients, including 13 (44.8%) of patients whose NESs resolved, were rehospitalized for NESs or for other symptoms. Twenty-nine (51.8%) had significant depressive symptoms, 22 (39.3%) had suicidal ideation, and 11 (19.6%) attempted suicide [including 6 (21%) of the patients whose NESs resolved]. Believing the NES diagnosis was associated with resolution or improvement of NES frequency (p<0.029), whereas anger in response to receiving the diagnosis did not predict a poorer outcome. Patients' perceptions of having good health (p<0.02) and good occupational functioning (p<0.04) were highly correlated with NES resolution. Only patients whose episodes resolved were employed at the time of follow-up. CONCLUSIONS: At a mean of 1.5 years, NES outcome was poor, with resolution in only half the group and with frequent rehospitalizations after NES diagnosis, even among patients whose NES resolved. Depressive symptoms, suicidal ideation, and suicide attempts were common. Believing the NES diagnosis and patient perceptions of having good health and good occupational functioning correlated well with NES resolution.     

Psychogenic Nonepileptic Seizures: Diagnosis,Management, and Bioethics

BackgroundThe diagnosis and management of psychogenic nonepileptic seizures (PNES) is often challenging and fraught with discord and disagreement between patients, parents, and physicians. Furthermore, there are ethical challenges when making the diagnosis, communicating this information, and instituting management.MethodsWe reviewed the current body of knowledge regarding the characteristic differences between epileptic seizures and PNES, and the high incidence of psychiatric comorbidities. An ethical analysis was made of diagnosis and management based on ethical principles, virtue ethics, and the social contract that health professionals have with patients.ResultsKey distinctions between PNES and epilepsy lie in both patient and seizure characteristics. Long duration, eye closure, asynchronous movements, frequent recurrence in the same context, intra-ictal awareness, and lack of post ictal state are useful in helping establish the diagnosis. Psychiatric comorbidities, history of abuse, cognitive impairment, and multiple non specific somatic complaints are some salient patient features that should increase suspicion for the diagnosis of PNES. However, definitive diagnosis rests on capturing the events on video EEG.ConclusionEffective diagnosis and management of PNES requires the use of video EEG and an early collaborative approach between pediatricians, neurologists, psychiatrists, nursing staff, and other professional colleagues. Ethical questions that may arise should be addressed with the virtues of competence, courage, compassion, prudence, and honesty; and the principles of respect beneficence, and the avoidance of unnecessary harm.     

Dissociation in Epilepsy and Conversion Nonepileptic Seizures

Summary: Purpose: We examined the dimensionality of the item content of the Dissociative Experiences Scale (DES) in relation to the clinical diagnosis of conversion nonepileptic seizures (C-NES) versus complex partial epilepsy (CPE).
Methods : The DES was administered to a sex- and agematched sample of 132 patients with C-NES and 169 with CPE and was factor analyzed with principal components analysis (PCA) with varimax rotation.
Results : The mean total DES score was 15.1 in the C-NES group and 12.7 in the CPE group (p = 0.079). The factors obtained by PCA differentiated the CPE and C-NES groups more strongly than did the total DES score. The factor accounting for the most variance, interpreted as "depersonalizationderealization," was significantly greater in C-NES than CPE (p = 0.005). An "absorption-imaginative involvement" factor, which included some of the clinical features of posttraumatic stress disorder was elevated only in subjects reporting histories of childhood abuse (p = 0.001) regardless of the diagnosis of CPE or C-NES. An "amnestic" factor appearing to represent memory problems related to neurologic impairment showed a trend toward elevation in CPE (p = 0.056) and may have confounded the CPE versus C-NES distinction using total DES scores.
Conclusions : The DES has separate underlying dimensions that appear to relate distinctively to depersonalization and derealization, childhood trauma, and neurologic impairment. The heterogeneous item content of the DES is a potential confound that should be appreciated when this instrument is used to study dissociation in neuropsychiatric populations.     

Factors Affecting the Outcome of MMPI and Neuropsychological Assessments of Psychogenic and Epileptic Seizure Patients

The literature reveals conflicting information regarding the extent to which psychogenic seizure patients have emotional disorders and neuropsychological deficits as compared with patients with epileptic seizures. Among groups matched for numbers of subjects, age, sex, and years of education, we observed that patients who had solely psychogenic seizures with either a major component of affectual expression or relatively minor motor activity were more disturbed emotionally than epileptic patients with partial seizures. In contrast, the personality characteristics of psychogenic seizure patients whose attacks had either little affectual display or prominent motor expression could not be distinguished from those of epileptic patients with convulsive generalized seizures. Closely matched groups of patients with solely psychogenic seizures, partial seizures, or generalized seizures did not differ in neuropsychological performance. However, psychogenic seizure patients performed much better on neuropsychological measures than a less-well-educated, but otherwise matched group of patients with generalized epileptic seizures.     

转换障碍伴类似癫痫发作误诊1例

本文目的是为心因性假性癫痫发作（PNES）的早期诊断、鉴别及治疗提供参考。PNES是转换障碍最常见临床表现之一,常于患者情绪激动或受暗示时突然发病,表现类似癫痫发作,但并无大脑异常的癫痫样放电活动。本案例报道了一例中年女性多次出现类似癫痫发作,结合病史及辅助检查诊断为“转换障碍-心因性假性癫痫发作”,经对症治疗后病情好转。     

Incidence of Psychogenic Seizures in Adults: A Population-Based Study in Iceland

Summary: Purpose: We wished to determine the incidence of psychogenic nonepileptic (NES) seizures in a population-based study.
Methods: Cases were identified through review of the results of all long-term video-EEG studies made in Iceland during the study period.
Results: The incidence of NES was 1.4 in 100,000 person-years of observation. Age-specific incidence was highest in the youngest age group (age 15–24 years) and decreased thereafter. A strong female preponderance was observed.
Conclusions: The incidence of NES is equal to almost 4% of that reported for epilepsy from Iceland for persons aged ≥15 years. For people aged 15–24 years, the incidence of NES is equal to −5% of the incidence of epilepsy. Half the patients also had epilepsy.     

Psychogenic Seizures in Old Age: A Case Report

Psychogenic seizures are unusual after age 60 years, A 73-year-old woman had onset of psychogenic seizures at age 69 years. Five to six attacks occurred each month, usually at night, characterized by an initial subjective sensation and headache followed by generalized stiffening and shaking. Continuous EEG-closed circuit television (EEG-CCTV) monitoring clearly showed these episodes to be nonepileptic. Discontinuation of antiepileptic drugs (AEDs) did not increase the frequency or severity of attacks. Epileptiform discharges were not recorded during the awake, drowsy, or sleeping states. Psychiatric evaluation identified significant turmoil in the patient's life and a history of childhood sexual and physical abuse. Psychogenic seizures may begin in old age and should be considered in the differential diagnosis of intractable seizures in the elderly. Predominantly nocturnal occurrence should not exclude the diagnosis.     

Effects of Sleep and Sleep Stage on Epileptic and Nonepileptic Seizures

Summary: Purpose: Previous studies of patients with epilepsy and animal models of epilepsy suggest that sleep increases the frequency, duration, and secondary generalization of seizures. This information is, however, incomplete.
Methods: We retrospectively examined video-EEG monitoring reports from our comprehensive epilepsy center. We recorded seizure type, site of onset (for partial seizures), sleep state at onset, and whether partial seizures secondarily generalized. Seizures arising from sleep were then reviewed to determine sleep state.
Results: We analyzed 1,116 seizures in 188 patients. Thirty-five percent of complex partial seizures (CPSs) starting during sleep underwent secondary generalization compared with 18% in wakefulness (p < 0.0001). Frontal lobe CPSs secondarily generalized at equal rates during sleep (22%) and wakefulness (20%), but temporal lobe CPSs generalized much more frequently during sleep (45%) than in wakefulness (19%; p < 0,0001). Frontal lobe seizures were more likely to occur during sleep (37%) than were temporal lobe seizures (26%; p = 0.0068). CPSs were more frequent in stages 1 and 2 and occurred rarely during REM. Seizures starting during slow-wave sleep were significantly longer than seizures starting during wakefulness or stage 2 sleep. Psychogenic nonepileptic seizures (PNESs) were rare between midnight and 6 a.m. and never occurred during sleep.
Conclusions: Sleep has a pronounced effect on secondary generalization of partial seizures, especially those of temporal lobe origin. Frontal lobe seizures occur more often during sleep than do temporal lobe seizures, and occurrence during sleep helps to distinguish PNESs from CPSs.     

Abuse,Not Financial Incentive,Predicts Non-Credible Cognitive Performance in Patients With Psychogenic Non-Epileptic Seizures

Participants with psychogenic non-epileptic seizures (PNES) who fail symptom validity testing (SVT) perform worse on neuropsychological testing than those who do not, consistent with results found in participants with different clinical presentations (e.g., mild traumatic brain injury). However, little is known about how variables typically associated with SVT failure in other populations (e.g., the presence of financial incentives, exaggerated report of psychopathology) correlate with SVT failure in participants with PNES. Likewise the relationship between SVT failure and reported abuse, one of the most frequently described demographic characteristics of the PNES population, has not been examined. We found that failure on the Word Memory Test (WMT) in 91 participants with PNES was strongly associated with reported abuse but, contrary to expectations, was not associated with the presence of financial incentives or severity of reported psychopathology. These results indicate that the factors driving WMT failure may differ significantly in participants with PNES in ways that are potentially clinically relevant.