Psychiatric outcome of epilepsy surgery in patients with psychosis and temporal lobe drug-resistant epilepsy: A prospective case series

ObjectivesTemporal lobe resistant epilepsy has been associated with a high incidence of psychotic disorders; however, there are many controversies; while some patients get better after surgery from their psychiatric condition, others develop psychosis or de novo depression. The aim of this study was to determine the psychiatric and seizure outcome after epilepsy surgery in patients with a previous history of psychoses.MethodsSurgical candidates with temporal lobe drug-resistant epilepsy and a positive history of psychosis diagnosed during the presurgical psychiatric assessment were included. A two-year prospective follow-up was determined after surgery. The DSM-IV Structural Interview, GAF (global assessment of functionality, DSM-IV), Ictal Classification for psychoses, and Engel's classification were used. The Student t test and chi-square–Fisher tests were used.ResultsDuring 2000–2010, 89 patients were admitted to the epilepsy surgery program, 14 patients (15.7%) presented psychoses and were included in this series. After surgery, six patients (43%) did not develop any psychiatric complications, three patients (21%) with chronic interictal psychosis continued with no exacerbation, three patients (21%) developed acute and transient psychotic symptoms, and two patients (14%) developed de novo depression. Seizure outcome was Engel class I-II in 10 patients (71%). Total GAF scores were higher after surgery in patients found to be in Engel class I–II (p < 0.05).ConclusionsPatients with comorbid psychosis and temporal lobe drug-resistant epilepsy may benefit from epilepsy surgery under close psychiatric supervision.     

Outcomes of resective surgery in children and adolescents with focal lesional epilepsy: The experience of a tertiary epilepsy center

ObjectiveThis study aimed to investigate the efficacy of resective surgery in children with focal lesional epilepsy by evaluating the predictive value of pre- and postsurgical factors in terms of seizure freedom.MethodsThis study included 61 children aged between 2 and 18 years who were admitted to the pediatric video-EEG unit for presurgical workup. Each patient was evaluated with a detailed history, video-EEG, neuroimaging, and postsurgical outcomes according to Engel classification to predict postsurgical seizure freedom. All the possible factors including history, etiology, presurgical evaluation, surgical procedures, and postsurgical results were analyzed for their predictive value for postoperative seizure freedom.ResultsOf the 61 patients, 75% were diagnosed as having temporal lobe epilepsy (TLE), and 25% were diagnosed with extra-TLE. Two years after the surgery, 78.6% were seizure-free, of which 89% had TLE, and 50% had extra-TLE (p < 0.05). Patients were more likely to have a favorable outcome for seizure freedom if they had rare seizure frequency, focal EEG findings, and focal seizures; had a temporal epileptogenic zone; or had TLE and hippocampal sclerosis. On the other hand, patients were more likely to have unfavorable results for seizure freedom if they had younger age of seizure onset, frequent seizures before the surgery, a frontal or multilobar epileptogenic zone, secondarily generalized seizures, extra-TLE with frontal lobe surgery, or focal cortical dysplasia.SignificanceResective surgery is one of the most effective treatment methods in children with intractable epilepsy. A history of young age of seizure onset, frequent seizures before surgery, secondarily generalized seizures, a multilobar epileptogenic zone, frontal lobe surgery, and focal cortical dysplasia (FCD) are the most important predictive factors indicating that a patient would continue having seizures after surgery. On the other hand, focal seizure semiologies, temporal lobe localization, and hippocampal sclerosis indicate that a patient would have better results in terms of seizure freedom.     

Outcome of psychogenic nonepileptic seizures (PNES) in children: A 2-year follow-up study

ObjectiveThe objective of this study was to determine the outcome of psychogenic nonepileptic seizures (PNES) in children seen at a level 4 epilepsy center.MethodsWe retrospectively analyzed patients under the age of 18 years who were diagnosed with PNES based on evaluation in the epilepsy monitoring unit and had a follow-up of at least 2 years postdiagnosis. Remission of events was noted at 6 months, 12 months, and 24 months of follow-up, and patient and disease variables affecting outcome were studied.ResultsNinety patients met inclusion criteria (58 females; mean age: 14.03 ± 3.3 years). Thirty-two out of ninety (36%) patients had early (within 6 months) and sustained remission (until 2 years of follow-up) of their events (“favorable outcome”), while 30/90 patients (33%) never achieved remission during the study period (“unfavorable outcome”). The factors that were associated with “unfavorable outcome” included the presence of comorbid epilepsy [12/30 (40%) vs 0/32, p < 0.0001] and prolonged duration of symptoms before establishment of the diagnosis (median 365 days vs 60 days, p < 0.0001). Patient's age, gender, frequency of events, the presence of major psychosocial stressors, and comorbid psychiatric conditions had no significant impact on the disease outcome.ConclusionsAbout a third of children with PNES achieve early and sustained remission of symptoms, while another third continue to manifest seizure-like events until at least two years after the diagnosis. The presence of comorbid epilepsy and prolonged duration of PNES are associated with a poor two-year outcome. Early suspicion and diagnosis of PNES, especially in patients with epilepsy, is essential.     

Impact of psychogenic nonepileptic seizures on epilepsy presurgical investigation and surgical outcomes

IntroductionWe sought to determine the percentage of patients undergoing presurgical assessment that had both psychogenic nonepileptic seizures (PNESs) and epileptic seizures (ESs) captured within our telemetry unit and how this affected progression to surgery and describe eventual outcomes in patients with a history of mixed PNESs/ESs who underwent surgery.Material and methodsTo determine what happened to patients who had PNESs recorded during a presurgical workup, we reviewed the records of 725 patients admitted to our telemetry unit for presurgical assessment between 2007 and 2013 and identified those with PNESs and ESs recorded.To determine outcomes postsurgery in operated patients who had mixed PNESs/ESs, we also reviewed the records of 519 patients who had had epilepsy surgery between 1999 and 2012 and identified those within this group who also had PNESs prior to surgery.ResultsNineteen of the 725 patients had PNESs captured during their presurgical telemetry along with ESs captured on either this or a previous study. Four of these patients were ultimately offered surgery. Nine of the 519 patients with a history of PNESs underwent epilepsy surgery. At 1 to 5 years of follow-up (mean: 4.1 years) of those nine patients, five were still having ESs and three patients had worsening or new-onset PNESs. At the last follow-up, four had had a worthwhile improvement.DiscussionThis study suggests that recent outcomes for people with mixed PNESs/ESs are not as promising as previously described and that PNESs should remain a relative contraindication for surgery.     

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.     

The effect of seizures on working memory and executive functioning performance

The aim of this study was to assess whether duration of seizure disorder and lifetime seizure load are associated with deficits in higher cognitive functions in patients with temporal lobe epilepsy (TLE) (N = 207) or psychogenic nonepileptic seizures (PNES) (N = 216). Multivariate regression analyses revealed that age at onset, duration, and group assignment were significant predictors of neuropsychological performance (all P ? 0.02), with group having a moderating relationship. Univariate analyses revealed different patterns of predictor effects on cognitive functioning within each diagnostic group. An impairment index was calculated for each individual, and univariate analyses revealed that age at TLE but not PNES onset was the only significant predictor of impairment (b = –0.005, P < 0.001). The results suggest that earlier age at seizure onset, longer duration, and higher lifetime seizure frequency affect cognitive functioning in both the TLE and PNES groups, but differently within each group. These results have implications for early diagnosis and intervention in both groups.     

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.     

Changes in psychiatric comorbidity during early postsurgical period in patients operated for medically refractory epilepsy—A MINI-based follow-up study

PurposeThe purpose of this study was to assess axis-I DSM-IV psychiatric disorders in patients at baseline and 3 months after surgery for medically refractory temporal lobe epilepsy.MethodThe Mini International Neuropsychiatric Interview (MINI) and Quality of Life in Epilepsy Inventory-10 (QOLIE-10) were evaluated before and 3 months after surgery in 50 consecutive patients (21 females, 29 males) with medically refractory temporal lobe epilepsy (persistent seizures > 2/month, despite treatment with ≥ 2 appropriate drugs in adequate doses for ≥ 2 years) who underwent surgery [anterior temporal lobectomy with amygdalo-hippocampectomy (for mesial temporal sclerosis in 40), electrocorticography-guided lesionectomy (for other lesions in 10)].ResultsTwenty-six patients (52%) had an axis-I psychiatric disorder [26% depressive disorder, 28% anxiety disorder] at baseline, while 30 (60%) patients had an axis-I psychiatric disorder [28% depressive disorder, 28% anxiety disorder] at 3 months after surgery. Twenty percent developed a new psychiatric disorder, while 12% showed improvement postsurgery. Mean QOLIE-10 scores improved from 23.78 to 17.80 [24 (48%) patients showed ≥ 5-point improvement]. Thirty-four (68%) patients had no seizure, 6 (12%) had non-disabling seizures, while 2 (4%) had disabling seizures after surgery. High frequency of seizures prior to surgery (p < 0.038) and seizure occurrence after surgery (p < 0.055) predicted the presence of psychiatric disorders after surgery. No clinical characteristic could predict development of new psychiatric disorder after surgery.ConclusionPsychiatric dysfunction in the early postsurgery period is seen in nearly half of patients undergoing surgery for temporal lobe epilepsy, is mild in nature, and does not adversely affect quality of life but may cause significant clinical problems when it arises de novo postsurgery.     

Postsurgical outcome in patients with olfactory auras and drug-resistant epilepsy

ObjectivesWe investigated the clinical features associated with olfactory auras in patients with drug-resistant epilepsy and also hypothesized that this type of aura may predict worse postsurgical outcome in patients with drug-resistant temporal lobe epilepsy (TLE).MethodsIn this retrospective analysis, data from all patients with drug-resistant epilepsy who underwent epilepsy surgery were reviewed. Patients were prospectively registered in a database from 1986 through 2016. We assessed outcome in the first 5 years after surgery to produce a Kaplan–Meier estimate of seizure recurrence. Post-surgical outcome was classified into two groups; 1) seizure-free, with or without auras; or 2) relapse of complex partial or secondarily generalized seizures. We also investigated the clinical features of patients with TLE and olfactory auras compared with those without olfactory auras.ResultsWe studied 1186 patients. Thirty-seven patients (3.1%) reported olfactory auras with their seizures. Thirty-two patients had temporal lobe surgery. Intracranial video-EEG recording was performed in four patients. Three patients with lateral temporal neocortical seizures reported olfactory auras with their seizures; two of them were seizure-free after surgery. There were no significant clinical differences between patients with TLE and olfactory auras compared with those without. Seizure outcome after surgery was not significantly different between these two groups (p = 0.3; Cox–Mantel test).ConclusionThe rarity of olfactory auras makes it difficult to propose new diagnostic and treatment strategies. A multicenter approach, which can enroll more patients, is needed to devise better therapies for patients with drug-resistant epilepsy and this symptom.     

Number of patient-reported allergies helps distinguish epilepsy from psychogenic nonepileptic seizures

Psychogenic nonepileptic seizures (PNES) are relatively common, accounting for 5–40% of visits to tertiary epilepsy centers. Inpatient video-electroencephalogram (vEEG) monitoring is the gold standard for diagnosis, but additional positive predictive tools are necessary given vEEG's relatively scarce availability. In this study, we investigated if the number of patient-reported allergies distinguishes between PNES and epilepsy. Excessive allergy-reporting, like PNES, may reflect somatization. Using electronic medical records, ICD-9 codes, and text-identification algorithms to search EEG reports, we identified 905 cases of confirmed PNES and 5187 controls with epilepsy but no PNES. Patients with PNES averaged more self-reported allergies than patients with epilepsy alone (1.93 vs. 1.00, p < 0.001). Compared to those with no allergies, each additional allergy linearly increased the percentage of patients with PNES by 2.98% (R² = 0.71) such that with ≥ 12 allergies, 12/28 patients (42.8%) had PNES compared to 349/3368 (11.6%) of the population with no allergies (odds ratio = 6.49). This relationship remained unchanged with logistic regression analysis. We conclude that long allergy lists may help identify patients with PNES. We hypothesize that a tendency to inaccurately self-report allergies reflects a maladaptive externalization of psychologic distress and that a similar mechanism may be responsible for PNES in some patients with somatic symptom disorder.     

Postdiagnosis neurological care for patients with psychogenic nonepileptic spells (PNES)

ObjectiveThis study investigated continuity of neurological care for patients discharged from the epilepsy monitoring unit (EMU) with a diagnosis of psychogenic nonepileptic spells (PNES). Because PNES are seizure-like episodes that cannot be explained by abnormal electrical brain activity, they are challenging for patients to understand and accept. Consequently, after diagnosis, patients commonly fail to start recommended psychotherapy and instead pursue redundant medical care. As consistent relationships with healthcare providers may help, we instituted standard follow-up for patients diagnosed with PNES.MethodsWe performed a retrospective observational cohort study of adults diagnosed with PNES in our EMU. In November 2013, we began routine scheduling of postdischarge follow-up neurology appointments. We compared preintervention (November 2010–October 2013) and postintervention (November 2013–May 2016) cohorts with regard to clinic attendance, understanding the diagnosis, compliance with recommendations, and event frequency.ResultsWe identified 55 patients in the preintervention cohort and 123 patients in the postintervention cohort. We successfully implemented the intended practice changes; more patients had follow-up scheduled by discharge (preintervention 2% vs. postintervention 36%, p < 0.001), time to follow-up decreased (46 days vs. 29, p = 0.001), and providers more consistently queried understanding of diagnosis (38% vs. 67%, p = 0.03). Explicit planning for continued care did not produce the anticipated patient–provider relationships, as follow-up in clinic was low (38% vs. 37%). For patients who attended clinic, the intervention did not improve establishment of psychiatric care, compliance with medication recommendations, understanding of diagnosis, or event frequency. The odds of reduced event frequency were nonsignificantly increased with understanding the diagnosis (OR 3.75, p = 0.14). Recommending antiepileptic drug (AED) discontinuation was associated with increased odds of event freedom (OR 6.91, p < 0.01).SignificanceScheduling follow-up for patients diagnosed with PNES did not facilitate ongoing patient–provider relationships due to poor clinic attendance. As follow-up is unreliable, the inpatient visit is a critical window of opportunity for intervention.     

Postsurgical outcome in patients with auditory auras and drug-resistant epilepsy

PurposeWe assessed whether patients with auditory auras have similar outcomes after epilepsy surgery as patients without auditory auras, and hypothesized that patients with non-dominant hemisphere foci might fare better after temporal lobe surgery than patients with dominant resections.MethodsIn this retrospective study, outcome after temporal resection was assessed for patients with drug-resistant epilepsy. Preoperative demographic data, clinical data, and surgical outcome were prospectively registered in a database from 1986 through 2016. Seizure outcome was classified as either seizure-free or relapsed.ResultsData were available in 1186 patients. Forty five patients (3.8%) reported auditory auras; 42 patients (93%) had temporal lobe epilepsy (TLE), and three patients (7%) had extratemporal epilepsy. Since most patients with auditory auras had TLE and in order to have comparable groups, we selected 41 patients with auditory auras and compared them with patients without auditory auras who had temporal lobe resections (767 patients). There were no significant demographic or clinical differences between TLE patients with auditory auras and those without. Patients who had auditory auras were more likely to relapse after temporal lobe surgery than those without (p = 0.03). Among patients who had auditory auras and temporal lobe surgery, side of surgery was not related to postoperative outcome (p = 0.3).ConclusionAuditory auras are rare among patients with drug-resistant TLE. The presence of an auditory aura in a patient with drug-resistant TLE carries a worse prognosis for a postoperative seizure free outcome and this is not related to the side of surgery.     

Healthcare resource utilization after medium-term residential assessment for epilepsy and psychogenic nonepileptic seizures

IntroductionEpilepsy and epilepsy mimics may lead to high healthcare resource utilization (HRU) including diagnostic resources. The William Quarrier Scottish Epilepsy Centre (SEC) provides medium-term residential assessment (MTRA; average length of stay: 28 days) and treatment for complex presentations of epilepsy and related conditions (principally psychogenic nonepileptic seizures, PNES). We studied the effect of MTRA on HRU in a defined health board area in Scotland.MethodsA retrospective audit of individuals admitted to the SEC from a defined health board area using SEC and health board medical records. Neurological HRU assessed included emergency department visits, hospital admissions, outpatient clinic appointments, and brain imaging prior to and post-MTRA. Healthcare resource utilization was also compared with individuals referred but not admitted to the SEC because of individual circumstances and choice.ResultsSeventy-three individuals (51 female, average age: 37.51; 22 men, average age: 43.72) were identified from three years of admissions (1st April 2010 to 31st March 2013). Final diagnosis was epilepsy (ES), 32; ES and psychogenic nonepileptic seizures (ES + PNES), 17; and PNES alone, 24. Twenty-two individuals were identified as a comparison group (8 men, 14 women; average age: 37.21 and 43.90, respectively).Total average contacts per patient per year (CPY) was significantly different pre- and post-MTRA (4.16 vs. 1.32; t(72) = 6.11, p < .0001, d = .72).Comparison of HRU in the first year of baseline and last full year of follow-up showed a post-MTRA reduction in HRU for PNES of 92.28%, for ES of 46.81%, and for ES + PNES of 28.3%.During the course of follow-up, PNES CPY continued to drop (1.13 first year vs. 0.10 at 3 years post-MTRA). For individuals with epilepsy (with or without PNES), HRU use dropped significantly in the year after admission, and these gains remained stable (total first vs. third postdischarge CPY, 1.74 vs. 1.29).The participants in the comparison group, who were not admitted, had no comparable drop across the study period and were using significantly more resources at each follow-up point than those in the admitted group (F (1, 48) = 44.45, p < .01, η_p² = .49).ConclusionMedium-term residential assessment is associated with sustained reduction in HRU especially in patients with PNES. Overall HRU reduction was 68.27% following admission (d = .72). This suggests benefit from the MTRA model for people with complex presentations.     

Deconstructing stigma in psychogenic nonepileptic seizures: An exploratory study

Psychogenic nonepileptic seizures (PNES) are classified as a mental disorder, the manifestations of which superficially resemble epileptic seizures.There is a notable lack of in-depth qualitative or quantitative studies investigating the stigma attached to PNES. The current study is an exploratory analysis into the nature of perceived stigma in those with PNES when compared with individuals with epilepsy. Individuals with epilepsy (n = 78) and PNES (n = 47) were recruited from a United Kingdom hospital or membership-led organizations for individuals living with seizures. Participants were asked to complete a series of questionnaires investigating health-related quality-of-life components (NEWQOL-6D), anxiety (GAD-7), depression (NDDI-E), seizure frequency and severity (LSSS-3), and illness perception (B-IPQ). Perceived stigma was measured using one question taken from the NEWQOL-6D. Individuals with PNES reported a greater level of perceived stigma than those with epilepsy (p = 0.04). Our results indicate that the risk of experiencing perceived stigma in PNES was 42% higher than the risk in epilepsy. In epilepsy, but not PNES, perceived stigma was significantly associated with seizure frequency, anxiety, depression, and many of the sequelae of the condition. In both conditions, self-control was associated with stigma (rho ≥ 0.34, p ≤ 0.01). This study was exploratory, and so definitive conclusions cannot be made; however, our findings suggest that the majority (87.2%) of individuals with PNES reported experiencing some degree of perceived stigma, the risk of which is greater than that in epilepsy. Further research is needed into the prevalence, nature, and consequences of stigma in PNES.     

Review of systems questionnaire helps differentiate psychogenic nonepileptic seizures from epilepsy

We investigated the utility of a very brief review of system (ROS) questionnaire in differentiating psychogenic nonepileptic seizures (PNES) from epilepsy. In this retrospective study, we investigated all patients with PNES admitted to Jefferson Comprehensive Epilepsy Center from October 2013 through April 2015. Patients with a confirmed diagnosis of PNES or epilepsy based on video-EEG monitoring were included. These were matched with respect to age and sex. All patients had a brief ROS questionnaire in their electronic charts. The questionnaire included 10 general yes/no questions about the presence or absence of any abnormality in body systems. Thirty patients with PNES and 30 patients with epilepsy were investigated. The mean of ROS responses for the presence of any abnormality (±standard deviation) for the PNES group was 2.43 (±1.33) and for the epilepsy group was 1.50 (±0.94) (p = 0.01). Cut-off point of three positive ROS was able to differentiate these two conditions from each another (p = 0.01; OR: 6, 95% confidence interval: 1.48–24.29). Presence of multiple complaints in the ROS questionnaire argues in favor of PNES compared with epilepsy. This brief and easy to apply ROS questionnaire may be used as a valuable ancillary tool to differentiate PNES from epilepsy during the initial screening visit. This may help prevent the delay in making the diagnosis.     

Medically unexplained symptoms in patients with PNES: Do they explain poor employment outcome in patients with good seizure outcomes?

BackgroundMany patients with psychogenic nonepileptic seizures (PNES) have other medically unexplained symptoms (MUS). In order to assess their long-term contribution to ill-health and unemployment, we recorded MUS, employment, healthcare utilization, and seizure outcomes in a cohort of patients with PNES.MethodsWe had complete computerized healthcare records and employment information in 120 patients with PNES, 5–10 years postdiagnosis. We analyzed these data to assess the contribution of MUS to ill-health and to determine whether MUS could explain differences among seizure, employment, and healthcare utilization outcomes in PNES.ResultsAt 5–10 years, 41/120 patients (34.2%) were attending primary or secondary care for seizures, 42/120 patients (35.0%) had MUS other than PNES, and 36/120 patients (30.0%) were employed. Unemployment was predicted by age at presentation (OR: 0.90 (0.86–0.94), p < 0.001), presenting to primary or secondary care with seizures (OR: 0.16 (0.05–0.52), p = 0.003), and contact with psychiatric services at 5–10 years (OR: 0.16 (0.05–0.58), p = 0.005). No outcome measures were predicted by additional MUS, though MUS themselves were predicted by psychiatric contact (OR: 2.27 (1.01–5.01), p = 0.048).ConclusionsOur data suggest that MUS do not contribute independently to unemployment in the population with PNES, whereas psychiatric morbidity appears to do so. Nonetheless, MUS and psychiatric morbidity persist in the long term in a substantial minority of patients with PNES. We found no evidence that seizures in patients whose PNES have resolved are replaced with other MUS.