Ictal consciousness in epilepsy and nonepileptic attack disorder

Exploration of subjective experiences during seizures may enhance knowledge of the differing natures of epilepsy and nonepileptic attack disorder (NEAD). We performed a quantitative evaluation of both the general level of awareness and the specific contents of consciousness during seizures using the Ictal Consciousness Inventory (ICI). Ninety-five adult outpatients attending general neuropsychiatry and epilepsy clinics with established diagnoses of either epilepsy (n = 66) or NEAD (n = 29) completed one ICI for each witnessed seizure recalled. Patients with a dubious/dual diagnosis were excluded. ICI Level (ICI-L) and ICI Content (ICI-L) scores were calculated for the 167 questionnaires generated by patients with epilepsy (n = 119, of which 58 from patients with temporal lobe epilepsy, 14 frontal lobe epilepsy, and 47 idiopathic 30 generalized epilepsy) and patients with NEAD (n = 48). Mann-Whitney U tests revealed statistically significant higher ICI-L and ICI-C scores for patients with NEAD (both P = 0.01). Subjective reports of consciousness experiences varied between epilepsy and NEAD, with patients with NEAD reporting significantly greater levels of general awareness/responsiveness and more vivid subjective experiences during attacks. The ICI is proposed as a potentially useful self-report instrument to supplement clinical and instrumental tests for the differential diagnosis of epilepsy and NEAD.     

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.     

The economic cost of nonepileptic attack disorder in Ireland

The present study endeavored to calculate a conservative estimate of both incidence- and prevalence-based costs of nonepileptic attack disorder (NEAD) in Ireland by applying previously identified prevalence figures to Irish population figures. Variables related to the economic cost of NEAD were identified based on a retrospective chart review of patients diagnosed with NEAD at Beaumont Hospital, Dublin. The annual cost per patient of undiagnosed NEAD was calculated as €20,995.30. The combined cost of diagnosis and psychological treatment of NEAD was estimated at €8728. Although it is difficult to determine precise economic costings, early diagnosis and intervention would result in a significant economic saving to the exchequer, a reduction in hospital waiting-list times, and a better prognosis for patients.     

Multimodular psychotherapy intervention for nonepileptic attack disorder: An individualized pragmatic approach

Nonepileptic attack disorder (NEAD) is a highly distressing and costly condition commonly seen in specialist epilepsy clinics. Consistently effective treatments for NEAD remain elusive, and findings from research indicate that there is no one form of psychological therapy that will be effective in such a heterogeneous group of patients. In this paper, we propose a multimodular approach to psychological therapy in NEAD, which allows the clinician to tailor an individualized management program for the patient appropriate to his/her needs.     

Illness perceptions among cardiac patients: relation to depressive symptomatology and sex

OBJECTIVE: This study examined cardiovascular disease (CVD) illness perceptions and how they relate to depressive symptomatology among women and men. METHODS: Acute coronary syndrome (ACS) patients at two hospitals were approached, and 661 consented to participate (504 men, 157 women; 75% response rate). Participants completed a survey including the Hospital Anxiety and Depression Scale (HADS) and Illness Perception Questionnaire (IPQ). RESULTS: Women perceived a significantly more chronic course (P<.001) and more cyclical episodes (P<.05) than men did, while men perceived greater personal control (P<.001) and treatability (P<.05) than women did. Participants perceived diet, heredity, and stress as the greatest CVD causes. For women (F=5.49, P<.001), greater depressive symptomatology was significantly related to younger age (P<.05), lower activity status (P<.001), and perceiving a chronic time course (P<.01). For men (F=7.68, P<.001), greater depressive symptomatology was significantly related to being non-white (P<.05), lower activity status (P<.001), less exercise behavior (P=.01), and three illness perceptions, namely, perceiving a chronic course (P<.05), greater consequences (P<.001), and lower treatability (P<.05). CONCLUSION: Women, compared with men, are more likely to attribute CVD to causes beyond their control and to perceive CVD as a chronic, untreatable condition. Illness perceptions were related to depressive symptomatology, which suggests that interventions to reframe these perceptions may be warranted to improve emotional health in the context of CVD.     

The role of outpatient ambulatory electroencephalography in the diagnosis and management of adults with epilepsy or nonepileptic attack disorder: A systematic literature review

Electroencephalography (EEG) is an established diagnostic tool with important implications for the clinical management of patients with epilepsy or nonepileptic attack disorder. Different types of long-term EEG recording strategies have been developed over the last decades, including the widespread use of ambulatory electroencephalography (AEEG), which holds great potential in terms of both clinical usefulness and cost-effectiveness. In this paper, we present the results of a systematic review of the scientific literature on the use of AEEG in the diagnosis of epilepsy and nonepileptic attacks in adult patients. Taken together, our findings confirmed that AEEG is a useful diagnostic tool in patients with equivocal findings on routine EEG studies and influences management decisions in the majority of studies. There is evidence that AEEG is also more likely to capture events than sleep-deprived EEG; however, there are currently insufficient data available to compare the diagnostic utility of modern AEEG technology with inpatient video-telemetry. Further research on the combined use of AEEG and home-video recording is, therefore, warranted.     

Illness perceptions and adherence in bipolar disorder: An exploratory study

BackgroundAccording to the Self-Regulation Model, illness perceptions influence an individual's coping (such as the taking of treatment) and emotional response to their illness. Emerging research suggests that this model could be used to explore illness perceptions in mental health. The aim of this exploratory study is, firstly, to measure and describe illness perception in French patients with a bipolar diagnosis and, secondly, to explore associations between illness perceptions and adherence in this population.MethodThirty-eight French patients with bipolar disorder completed the Illness Perception Questionnaire for Schizophrenia (except the identity dimension). We measured medication adherence with the Medication Adherence Rating Scale.ResultsOur results showed that patients with high perceptions concerning treatment control, low perceptions of negative emotions of their mental illness, low perception of consequences and high comprehension of their disorder had a better adherence.ConclusionsIllness perceptions can provide a framework for understanding adherence in bipolar disorder, and the findings could have important clinical and research implications.     

Illness perceptions determine psychological distress and quality of life in youngsters with epilepsy

The aim of this cross-sectional study was to explore the extent to which gender, epilepsy severity, and self-regulation concepts (illness perceptions, autonomous treatment regulation, perceived autonomy support by parents) predict psychological distress and quality of life (QoL) in young patients with epilepsy. Structured interviews were conducted in 100 patients (M_age = 13.9, SD = 2.21, 41% girls), and data were analyzed by means of multiple hierarchical regression analyses. Seizures of most patients (91%) were well controlled by antiepileptics, 3% of the patients had infrequent seizures, and seizures in 6% were pharmacoresistant. At a multivariate level, it appeared that youngsters with epilepsy who expect that their disease will last for a long time, who believe that they have less personal control over their illness, and who expect the illness to have a high emotional impact reported higher levels of distress. In addition, a better QoL was reported by youngsters who believed that treatment did not control their illness and who thought that their epilepsy would not affect them emotionally. Findings indicate the importance of illness perceptions, and it is suggested that they should be targeted in future interventions in youngsters with epilepsy.     

Abulia: a delphi survey of British neurologists and psychiatrists.

Abulia is the relatively uncommon yet debilitating lack of spontaneous, goal-directed behaviour that is seen predominantly with lesions of the basal ganglia and the frontal lobes. We sought to confirm the existence of abulia as an entity recognized by clinicians, to generate a set of items characteristic of the condition, and to see how clinicians differentiate between overlapping disorders. The Delphi technique was used to survey consultant neurologists and psychiatrists at three hospitals in London. The study consisted of two phases: semi- structured interviews of a small group of neurologists and psychiatrists, followed by a survey of a larger group of consultants using postal questionnaires. Both neurologists and psychiatrists recognized abulia to be a distinct clinical entity but its status as a syndrome was unclear. Features such as difficulty in initiating and sustaining spontaneous movements and reduction in emotional responsiveness, spontaneous speech, and social interaction were identified as being characteristic of abulia. The information generated by this study may help to develop a working classification for disorders of diminished drive and motivation, and instruments for clinical assessment and decision making.     

Panic attack symptoms differentiate patients with epilepsy from those with psychogenic nonepileptic spells (PNES)

Psychogenic nonepileptic spells (PNES) are frequently challenging to differentiate from epileptic seizures. The experience of panic attack symptoms during an event may assist in distinguishing PNES from seizures secondary to epilepsy. A retrospective analysis of 354 patients diagnosed with PNES (N = 224) or with epilepsy (N = 130) investigated the thirteen Diagnostic and Statistical Manual—IV-Text Revision panic attack criteria endorsed by the two groups. We found a statistically higher mean number of symptoms reported by patients with PNES compared with those with epilepsy. In addition, the majority of the panic attack symptoms including heart palpitations, sweating, shortness of breath, choking feeling, chest discomfort, dizziness/unsteadiness, derealization or depersonalization, fear of dying, paresthesias, and chills or hot flashes were significantly more frequent in those with PNES. As patients with PNES frequently have poor clinical outcomes, treatment addressing the anxiety symptomatology may be beneficial.     

Illness perceptions mediate the relationship between depression and quality of life in patients with epilepsy

The current study examined whether negative illness perceptions help explain the link between depression and quality of life. Seventy patients with epilepsy completed standardized self‐report questionnaires measuring depression, illness perception, and quality of life (QOL). Illness perception statistically mediated the relationship between depression and QOL (Indirect effect (CI; confidence interval) = ?.72, lower limit = ?1.7, upper limit = ?.22, p < .05). Results held with and without adjusting for potential confounding variables (age, sex, ethnicity, income, and seizure frequency) and when operationalizing depression as a continuous variable that indexed severity of symptoms or as a dichotomous variable that indexed criteria consistent with a diagnosis of major depressive disorder. This study is the first to suggest that illness perceptions may be a useful target in screening and intervention approaches in order to improve QOL among low‐income, racially/ethnically diverse patients with epilepsy.     

A comparative study of trauma and posttraumatic stress disorder prevalence in epilepsy patients and psychogenic nonepileptic seizure patients

PURPOSE: This study tests the hypothesis that trauma histories, including histories of physical and sexual abuse, and posttraumatic stress disorder (PTSD) are more prevalent in psychogenic non-epileptic seizure (NES) patients than in epilepsy patients. METHODS: Thirty-five inpatients with intractable seizures were evaluated for trauma history and PTSD. After these assessments, patients were diagnosed as having either epileptic or nonepileptic seizures through EEG monitoring. RESULTS: NES diagnosis correlated with PTSD and total number of lifetime traumas, adult traumas, and abuse traumas. Contrary to previous hypotheses, reported childhood sexual abuse (CSA) did not correlate significantly with NES diagnosis. However, CSA predicted PTSD in a discriminant analysis. CONCLUSIONS: We found evidence for the hypothesized relations between trauma, abuse, PTSD, and NES diagnosis. However, elevated levels in both seizure-disorder groups suggest that routine assessment for abuse, trauma, and PTSD might facilitate medical care and treatment for all intractable seizure patients.     

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.     

The influence of German speaking psychiatrists and neurologists in Northamerica and England (author's transl)]

The influence of German speaking psychiatrists has been quite remarkable in many countries. The German-Swiss Adolf Meyer placed the emphasis of his "psychobiological" school on psychodynamics a fact which opened the way for psychoanalysis. Those who had been invited to the Cnited States prior to 1933 like Franz Alexander and Sandor Rado, were followed by a great number of immigrants mostly from Vienna and Berlin. Representatives of nonanalytical psychiatry were the genetic psychiatrist Franz Kallmann and pioneers of somatic treatments like Sakel and Meduna. Prominent among neurologists coming from Germany to the United States were Kurt Goldstein, Hauptmann, Hans Strauss and Wartenberg. In England Mayer-Gross and Erich Guttmann exerted great influence. It seems that especially in Psychiatry the effort of so many representatives of our specialty in other countries has helped to promote international exchanges which formerly were missing.     

Psychiatric comorbidity in psychogenic nonepileptic seizures compared with epilepsy

ObjectivesPsychogenic nonepileptic seizures (PNESs) are closely linked with psychological distress, but their etiology is not well-understood. We reviewed psychiatric comorbidity in PNESs and epileptic seizures (ESs) with an aim to assist understanding, diagnosis, and management of PNESs.MethodsA search of Web of Science, MEDLINE (PubMed), PsycINFO, and Scopus identified 32 relevant studies on the prevalence of psychiatric comorbidity in PNESs. We used meta-analysis to compare psychiatric comorbidity between PNESs and ESs.ResultsSamples with PNESs had high rates of psychiatric comorbidity overall (53–100%), notably including posttraumatic stress disorder (PTSD), depression, and personality and anxiety disorders. Compared with ESs, samples with PNESs had more psychiatric comorbidity overall (RR: 1.30, 95% CI: 1.14–1.48, p < 0.0001) with significantly elevated risks found for PTSD, personality disorder, and anxiety but not depression.ConclusionsPsychiatric disorders are more common in PNESs than ESs. Because of methodological limitations of available studies, causality cannot be established; prospective longitudinal designs are required.     

Carbamazepine-induced nonepileptic myoclonus in a child with benign epilepsy

Myoclonic jerks involving the proximal limb musculature and tic-like movements (sniffing, coughing, or sighing) were observed in an 11-year-old boy with benign occipital epilepsy treated with carbamazepine (CBZ). The involuntary movements disappeared a few days after withdrawal of CBZ and reappeared with CBZ reintroduction. Plasma CBZ levels were always within the therapeutic range. Polygraphic studies failed to show any electroencephalogram (EEG) changes during myoclonic jerks. Appearance of nonepileptic myoclonus in epileptic children treated with CBZ should be carefully evaluated to prevent worsening of the clinical picture. The coexistence of other involuntary movements (tics) could suggest the correct diagnosis.     

Teaching Chinese psychiatrists to make reliable dissociative disorder diagnoses

The aim of the study was to assess the outcome of an educational effort by two North American experts in dissociative disorders to teach Chinese psychiatrists to make reliable dissociative disorder diagnoses. In the final phase of the educational effort, 569 patients at Shanghai Mental Health Center completed the Chinese version of the Dissociative Experiences Scale (DES). Patients were then randomly selected in different proportions according to their DES scores: 96 selected patients were then assessed with the Dissociative Disorders Interview Schedule (DDIS) and clinical diagnostic interviews based on DSM-IV criteria. According to the clinical diagnostic interviews, 28 (4.9%) patients were diagnosed as having dissociative disorders. Agreement between the American experts and Chinese psychiatrists for presence or absence of a dissociative disorder was 0.75 using Cohen's kappa. Dissociative disorders can be diagnosed in China with good inter-rater reliability. The authors describe the steps taken to achieve this outcome.