Psychological factors in the genesis and management of nonepileptic seizures: clinical observations

Nonepileptic seizures (NES) are frequently thought to have a "psychogenic" basis. Two 6-month group psychotherapy programs were provided for patients diagnosed as having NES [eight patients were treated during the first program, seven during the second (N=15)] to explore the potential role of psychological factors in the genesis of NES and to determine if psychotherapeutic interventions reduced the frequency of NES. Of the 15 patients, 9 (60%) completed at least 58% of the treatment sessions. Of those 9 patients, 6 (66%) reported a decline in "seizure frequency." One reported an increase (11%). Self-reported frequency highly correlated with paranoid ideation. Dissociative phenomena were common as was a history of sexual abuse. Each patient reported being in an adult situation that they found unacceptable or intolerable. None perceived a solution to their situation. Reports by health care providers that their seizures were not "real" (i.e., true epilepsy) restimulated feelings associated with their not being believed when they reported being sexually abused as children. The psychological genesis of NES in this sample of patients appears rooted in the recurrent experience of being in abusive or exploited relationships for which they perceived no solution.     

What is the Significance of Subjective Events Recorded During Long-Term EEG Video Monitoring?

Summary: Purpose : Purely subjective events, identified as "seizures" by patients but not accompanied by any clinical or EEG changes, commonly occur during evaluation of patients for intractable epilepsy. We wished to determine the significance of such events.
Methods : We analyzed the frequency of subjective episodes in 379 adults who underwent EEG video monitoring as part of their evaluation for intractable epilepsy and the relationship of these experiences to epileptic and psychogenic nonepileptic (NES) seizures. We examined the results of tests of mental ability and of emotional, psychosocial, and quality of life (QOL) adjustment to determine if individuals with subjective events alone could be distinguished from those with epileptic seizures only, NES only, or no events, by these measures.
Results : We noted subjective events in 39% (147 of 379) of the patients. Of patients with subjective episodes, 52% also had epileptic seizures, 7% had NES, 1% had both epileptic seizures and NES, and 40% had subjective events alone. As a group, patients with subjective events alone were slightly more intelligent and less impaired neuropsychologically than people in the other groups, hut they performed more poorly on several important measures of adjustment.
Conclusions : The identification of persons with purely subjective episodes apart from all other episodes is important both phenomenologically and from a practical viewpoint.     

The value of provocation methods in patients suspected of having non-epileptic seizures.

Non-epileptic seizures (NES) are reported in 18-23% of patients referred to comprehensive epilepsy centres. Non-epileptic seizures may also be present in 5-20% of the patients who are diagnosed as having refractory seizures. Because of their prevalence, financial and psychosocial outcomes cannot be ignored and accurate diagnosis is of the utmost importance. Various methods of seizure induction have been developed with the aim of differentiating epileptic from non-epileptic seizures. However, recording the attacks by video-EEG monitoring is the gold standard. In our outpatient EEG laboratory we try to induce seizures with verbal suggestion or IV saline infusion in patients who are referred by a clinician with the diagnosis of probable non-epileptic seizures. In this study we investigated the results of 72 patients who were referred between January 1992-June 1996. Non-epileptic seizures were observed in 52 (72.2%) patients. Thirteen of these patients still had risk factors for epilepsy. We could not decide whether all of their previous attacks were non-epileptic because 10-30% of the patients with NES also have epileptic seizures. For a more accurate diagnosis it was decided that these 13 patients, together with the 20 patients who did not have seizures with induction, needed video-EEG monitoring. Thirty-nine patients who had NES and no risk factors for epilepsy were thought to have pure non-epileptic seizures. We claim that not all patients suspected of having NES need long-term video-EEG monitoring and almost half (54.2%) of the cases can be eliminated by seizure induction with some provocative techniques.     

Provocation of Nonepileptic Seizures by Suggestion in a General Seizure Population

Summary: Nonepileptic seizures (NES) are common and are often diagnosed at epilepsy centers by video-EEG recording of both spontaneous and suggestion-induced episodes, but no study has evaluated provocative testing in a general seizure population. We studied consecutive patients with a tentative diagnosis of epilepsy using saline provocation during video–EEG recording, suggesting that this could produce a typical seizure. Of 52 patients, 40% had no response, 23% had responses unlike their seizures, and 37% had typical episodes (positive test). Patients whose usual episodes resembled complex partial seizures (CPS) were more likely to have NES than were patients with a history of generalized tonic-clonic seizures (GTC). Of patients with positive provocations, the primary physician predicted NES in 68% of cases. This preliminary study suggests that NES are frequent in a general neurology setting, and that saline provocation is a sensitive method of identifying NES.     

Postictal symptoms help distinguish patients with epileptic seizures from those with non-epileptic seizures.

The aim of the study was to assess whether post-ictal symptoms can help distinguish patients who have epileptic seizures from those with non-epileptic seizures (NES). We reviewed the spontaneous responses to the question 'What symptoms do you have after a seizure?' in 16 patients with epileptic seizures (predominantly focal with secondary generalization or generalized tonic-clonic) and 23 NES patients. Six of the 16 patients (38%) vs. only one of 23 NES patients (4.3%) noted post-ictal headache (P = 0.008). Nine epilepsy patients (56%) vs. three NES patients (13%) reported post-ictal fatigue (P = 0.004). Confusion or other symptoms did not distinguish epilepsy patients from those with NES. All epilepsy patients had at least one post-ictal symptom while 12 NES patients (52%) had none (P = 0.001). Therefore, patients evaluated for epileptic vs. non-epileptic seizures who have post-ictal fatigue or headache, are more likely to have epileptic seizures. Patients with a diagnosis of NES who note post-ictal fatigue or headache should be investigated further.     

Seizure anticipation by patients with focal and generalized epilepsy: a multicentre assessment of premonitory symptoms

PURPOSE: To assess subjective seizure anticipation in patients with focal and generalized epilepsy. METHODS: Five hundred consecutively recruited out-patients (251 male, 249 female, mean age 38.1 year) from three German tertiary epilepsy referral centres filled out questionnaires regarding subjective anticipation of seizures by at least 30 min and to timing and semiologic characteristics of their premonitory symptoms versus those of ictal phenomena. Patients were not regarded as having prodromi if the semiology of symptoms reported long before a seizure was identical to auras. RESULTS: 6.2% of patients reported that they were able to anticipate seizures. Premonitory symptoms were classified as stereotyped in all but one patient. An intraindividual semiologic analysis showed that the majority of these patients had symptoms, which were distinct from ictal experiences during auras. Seizure anticipation was reported both by patients with focal and idiopathic generalized epilepsy. The median estimated time interval between occurrence of premonitory symptoms and seizure onset was 90 min. CONCLUSIONS: This study gives evidence that both patients with focal and idiopathic generalized epilepsy may subjectively anticipate the occurrence of epileptic seizures. Premonitory symptoms are distinct from auras in terms of semiology and time of occurrence. The lower percentage of patients regarded as having premonitory symptoms as compared to some earlier reports may be related to stricter criteria and to the exclusion of auras, which could directly evolve into seizures, and other ictal events. Premonitory symptoms occur at similar periods prior to seizures as anticipatory EEG-changes have been reported using methods from time series analysis.     

Subjective and objective characteristics of altered consciousness during epileptic seizures

BackgroundConscious states are inner states and processes of awareness. These states are by definition subjective.MethodsWe analyzed subjective and objective characteristics of alteration of consciousness (AOC) during epileptic seizures, including its involvement in both the level of awareness and subjective content of consciousness. We evaluated AOC using the Consciousness Seizure Scale, the Ictal Consciousness Inventory, and a new structured survey developed by our group: the Seizure Perception Survey, which incorporates patients' subjective experiences before and after they watch a video-electroencephalographic recording of their own seizure.ResultsWe included 35 patients (105 seizures) with drug-resistant epilepsy. Most seizures caused profound AOC. The content of consciousness was lower during temporal seizures with profound AOC. We uncovered a correlation between the subjective perception and objective duration of a seizure using the Seizure Perception Survey regarding memory; the patients had a better recall of ictal onset during wakefulness regardless of the epileptogenic zone, laterality, or magnitude of AOC. Nonetheless, the recovery of memory at the end of a seizure took more time in patients who showed greater AOC, less vivid content of consciousness, or a longer seizure. For 85% of the patients, this was the first time they were able to view their own seizures. The majority of the patients requested to view them again because this procedure allowed them to compare the recordings with their own memories and emotions during a seizure and to verify the real duration of the seizure.DiscussionAlteration of consciousness is one of the most dramatic clinical manifestations of epilepsy. Usually, practitioners or relatives assume that the patients with AOC may not have any knowledge on their seizures. In this study, however, we found that most patients with AOC had a fairly accurate perception of the duration of a seizure and retained their memory of ictal onset. In contrast, for the majority of the patients, watching their own seizure was an extremely positive experience, and most patients stated that they were surprised as well as glad to view what really happened, without expressing negative opinions. Inclusion of subjective characteristics of AOC into the analysis yielded complete assessment of various dimensions of consciousness and therefore allowed us to gain a more detailed understanding of consciousness.     

Lateralizing value of postictal automatisms in temporal lobe epilepsy

PURPOSE: To describe clinical characteristics and lateralizing value of postictal automatisms in patients with temporal lobe epilepsy (TLE). METHODS: One hundred and ninety-three videotaped seizures of 55 consecutive patients with refractory TLE and postoperatively seizure-free outcome were analyzed. Ictal as well as postictal (manual, oral and speech) automatisms were monitored. RESULTS: Thirty-four (62%) of the 55 patients showed PA at least once during their seizures. Postictal automatism was observed in 70 (36%) attacks as manual (21%), oral (13%) or speech (9%) automatisms. Fifteen seizures contained a combination of two different postictal automatisms. The presence of postictal oral automatisms did not lateralize the seizure onset zone (p=0.834). Speech automatisms (repetitive verbal behavior) occurred more frequently after left-sided seizures (p=0.002). Postictal unilateral manual automatism showed no lateralizing value occurring by the ipsilateral hand in 10 and the contralateral upper limb in 6 seizures (p=0.454). CONCLUSION: : Postictal automatism is a relatively frequent phenomenon in TLE. Postictal speech automatism lateralizes the seizure onset zone to the left hemisphere. Our observation can help the presurgical evaluation of TLE because verbal perseveration frequently occurs spontaneously, even in seizures without appropriate postictal language testing.     

Temporal relationship between awakening and seizure onset in nocturnal partial seizures

Clinical awakening can be seen just before or after seizure onsets. In this study we determined the time between onset of seizures and awakening in patients with frontal lobe epilepsy (FLE) and temporal lobe epilepsy (TLE). Sixty-eight patients who underwent video-EEG monitoring with simultaneous PSG were retrospectively examined. TLE or FLE patients having seizures during sleep were included. Seizure onset and awakening onset were marked according to clinical and electrophysiological features. The duration between awakening and seizure onset was compared in patients with TLE and FLE. Twenty-five patients who had been diagnosed with TLE (17) or FLE (8) had a total of 75 seizures during sleep. All seizures except one, occurred during NREM sleep in both TLE and FLE patients. The seizure onsets were before awakening in 49 seizures (FLE: 20, TLE: 29) and the awakening preceded the seizure onsets in 12 seizures (FLE: 3, TLE: 9). The duration between seizure onset and the awakening was shorter in FLE, either in seizures with preceding awakening or not (p=0.014, p=0.015). Awakening was mostly seen after onset of seizures rather than before, especially in TLE. But in patients with FLE the duration between seizure onset and awakening was shorter. The localization of epileptic activity may play a role for the timing of awakening mechanisms during nocturnal partial seizures.     

The Effect of Menopause and Perimenopause on the Course of Epilepsy

PURPOSE: The purpose of this study was to obtain preliminary information about the effect of menopause and perimenopause on the course of epilepsy, and to determine whether seizure type, use of hormone-replacement therapy (HRT), or a history of catamenial seizure pattern would influence this course. METHODS: We performed a questionnaire study of women with epilepsy currently in menopause and perimenopause, requesting information regarding the course of their epilepsy and treatment. Statistical analysis was performed by using Pearson chi2 with 95% confidence limits. RESULTS: Forty-two menopausal women (ages 41-86 years) responded. Twelve subjects reported no change in seizures at menopause, 17 reported a decrease in seizure frequency, and 13 reported an increase. Sixteen (38%) took synthetic HRT. Sixteen (38%) additional subjects (having some overlap with the HRT group) reported having a catamenial seizure pattern before menopause. HRT was significantly associated with an increase in seizures during perimenopause (p = 0.001). A history of catamenial seizure pattern was significantly associated with a decrease in seizures at menopause (p = 0.013). Thirty-nine perimenopausal women (ages 38-55 years) responded. Nine subjects reported no change in seizures at perimenopause, five reported a decrease in seizure frequency, and 25 reported an increase. Eight (15%) subjects took synthetic HRT, and 28 (72%) reported having a catamenial seizure pattern before menopause. HRT had no significant effect on seizures; however, a history of catamenial seizure pattern was significantly associated with an increase in seizures at perimenopause (p = 0.02). CONCLUSIONS: These pilot data suggest that synthetic HRT may be associated with an increase in seizure frequency in menopausal women with epilepsy. A catamenial seizure pattern may be associated with seizure decrease during menopause but with an increase during perimenopause.     

Auditory event-related potentials (P300) in the identification of psychogenic nonepileptic seizures

The feasibility and conceivable value of postictal event-related potential (ERP) recordings were studied in patients with nonepileptic seizures (NES) admitted for long-term video/EEG monitoring. Ten patients with NES underwent preictal (on hospital admission) and postictal (< or =6 hours after seizure) ERP recordings of an auditory oddball paradigm. Additionally, 10 temporal lobe epilepsy (TLE) patients with partial seizures and secondary generalization underwent preictal, postictal (< 6 hours after seizures), and interictal (7-48 hours after seizure) ERP recordings. We recently reported that ERPs recorded in TLE patients with partial epilepsy undergo a temporary change postictally, while returning to their preictal state during interictal recordings. In the current study intraclass correlations, transformed into z scores, are used to determine test-retest validity of repeated ERP recordings. An independent sample t test with z scores for the comparison of preictal and postictal recordings showed that ERP activation differed between NES and TLE patients (P=0.009). More specifically, ERP recordings in the preictal and postictal states were similar in NES patients, but dissimilar in TLE patients. On the other hand, this dissimilarity in ERPs disappeared when comparing z scores for the preictal and postictal recordings in NES patients with z scores for the preictal and interictal recordings in TLE patients. This further supports the notion that identical waveforms during preictal and postictal recordings in NES patients reflect nonepileptic seizure activity. The current findings suggest that postictal ERP recordings are useful in the diagnosis of NES and differentiate TLE from NES.     

Transient hyperammonemia in seizures: a prospective study

Purpose: To investigate the incidence and duration of transient hyperammonemia in seizures and to verify the significant confounders related to transient hyperammonemia in seizures. Methods: One hundred twenty‐one noncirrhotic adult patients with seizures admitted to the emergency department were enrolled in the study. Laboratory examination was performed, including plasma ammonia level assessment. In addition, the basic parameters, underlying systemic diseases, and seizure‐related conditions were assessed. The patients were classified into a group with hyperammonemia on arrival and a group without, in order to compare seizure‐related adverse events that occurred during a 9‐month period. Key Findings: The incidence of hyperammonemia in patients with seizures was 67.77%. Plasma ammonia levels in patients with generalized tonic–clonic (GTC) seizures were significantly higher than those in patients in the non‐GTC seizure group (median 174.5 vs. 47 μg/dl; proportion 76.5% vs. 21.1%; p < 0.001). Median plasma ammonia levels decreased spontaneously from 250 to 54 μg/dl (p < 0.00001) in an average interval of 466.79 min. GTC seizures (p < 0.0001), male gender (p < 0.0001), bicarbonate (p < 0.0001), diabetes (p = 0.0139), and alcohol‐related seizures (p = 0.0002) were significant factors associated with hyperammonemia on arrival. No significant differences related to admission rates or mortalities were found between the two groups. Significance: The presence of transient hyperammonemia in patients with seizures is significantly related to GTC seizures, male gender, bicarbonate, diabetes, and alcohol‐related seizures. The appropriate period to study ammonia levels following a seizure event is within 8 h. Because these phenomena are self‐limited, ammonia‐lowering management are not necessary. Hyperammonemia on arrival is not necessarily related to adverse outcomes.     

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.     

Improved prediction of nonepileptic seizures with combined MMPI and EEG measures

PURPOSE: Nonepileptic seizures (NESs) are frequently mistaken for epileptic seizures (ESs). Improved detection of patients with NESs could lead to more appropriate treatment and medical cost savings. Previous studies have shown the MMPI/MMPI-2 to be a useful predictor of NES. We hypothesized that combining the MMPI-2 with a physiologic predictor of epilepsy (routine EEG; rEEG) would result in enhanced prediction of NES. METHODS: Consecutive patients undergoing CCTV-EEG monitoring underwent rEEG evaluation and completed an MMPI-2. Patients were subsequently classified as having epilepsy (n = 91) or NESs (n = 76) by using standardized criteria. Logistic regression was used to predict seizure type classification. RESULTS: Overall classification accuracy was 74% for rEEG, 71% for MMPI-2 Hs scale, and 77% for MMPI-2 Hy scale. The model that best predicted diagnosis included rEEG, MMPI-2, and number of years since the first spell, resulting in an overall classification accuracy of 86%. CONCLUSIONS: The high accuracy achieved by the model suggests that it may be useful for screening candidates for diagnostic telemetry.     

Intentional seizure interruption may decrease the seizure frequency in drug-resistant temporal lobe epilepsy.

We investigated the nature of preictal subjective phenomena and whether they had any effect on the seizure frequency in 95 adult patients with medial temporal lobe epilepsy. Seventy-three (77%) patients indicated that they experienced seizure-provoking factors. Ten patients (11%) had prodromas independent of auras, while auras occurred in 89%. Forty-four patients (46%) reported that that they had tried to stop their seizures in the presence of prodroma or aura and this action had resulted in success at least once. Twenty-one patients (22%) regularly tried to stop their seizures because this effort was often successful according to their interpretation. Patients who reported that they could frequently inhibit their seizures had 1.8 +/- 1.6 seizures/month, a significantly lower mean seizure frequency than those 74 patients who did not do it regularly (4.6 +/- 4.8 seizures/month, P<0.001). Patients who reported regular experience in inhibiting intentionally their seizures more often had affective (P=0.05) and vertiginous auras (P<0.01) as well as isolated auras (P<0.05). Patients who experienced provoking factors showed the same seizure frequency as those who did not. Our results suggest that intentional seizure inhibition had an impact on the severity of drug-resistant epilepsy.     

Predicting seizure frequency after epilepsy surgery

OBJECTIVE: To identify clinical features related to seizure frequency after epilepsy surgery in patients with recurrent seizures. BACKGROUND: No studies have examined the differences between patients who have rare seizures and patients who experience frequent seizures after epilepsy surgery. Since seizure frequency correlates with morbidity and quality of life, it is desirable to know which preoperative clinical features predict postoperative seizure frequency. METHODS: Patients with recurrent seizures were placed in two categories: rare postoperative seizures (< or =2 per year) and frequent postoperative seizures (> or =12 per year) using seizure frequency in the second postoperative year. Variables included preoperative seizure frequency, age of first risk, age at first seizure, epilepsy duration, age at surgery, history of febrile convulsions, tonic-clonic seizures, status epilepticus, or family history, IQ, magnetic resonance imaging (MRI), and positron emission tomography (PET). Variables were analyzed using non-parametric tests to assess relationship to postoperative seizure frequency. RESULTS: Of 475 patients who had epilepsy surgery, 111 had rare or frequent seizures in the second postoperative year. After anterior temporal lobectomy (ATL), age of first risk< or =5 years and presence of mesial temporal sclerosis on MRI were associated with rare seizures (66% of patients), whereas lack of these risk factors was associated with frequent seizures (75% of patients) (p<0.03). For non-ATL operations, preoperative seizure frequency of > or =20 seizures per month was associated with frequent postoperative seizures (p=0.03). No other variables influenced outcome. CONCLUSIONS: Some preoperative clinical features correlate with postoperative seizure frequency in patients with recurrent seizures after epilepsy surgery. This has implications for the surgical decision making process and early postoperative management.     

A follow-up survey on seizures induced by animated cartoon TV program "Pocket Monster"

PURPOSE: To identify the short-term outcome of patients who had seizures while watching an animated cartoon TV program, "Pocket Monster," on December 16, 1997. METHODS: One and three years after the incident, questionnaires were sent to physicians of each patient about seizure recurrence, EEGs, and medication. RESULTS: Among 103 patients in whom epileptic seizures occurred during the TV program and information on the outcomes was available, 25 (24%) patients had a history of unprovoked seizures before the incident (Epilepsy Group), and 78 (76%) did not (Non-Epilepsy Group). Twenty-three (22%) patients were reported to have seizures after the incident, and 15 of them had visually induced seizures. Patients of the Epilepsy Group had more seizure recurrence than did those of the Non-Epilepsy Group (56% vs. 9%; p < 0.0001), either for unprovoked (44% vs. 4%; p < 0.0001) or visually induced seizures (28% vs. 9%; p < 0.05). Of nine patients of the Non-Epilepsy Group who had seizures after the incident, only three developed recurrent unprovoked seizures. In the Non-Epilepsy Group, no difference was found in seizure recurrence between patients in whom valproate (VPA) was prescribed immediately after the incident and in those without medication (one of five (20%) vs. seven of 73 (10%); p > 0.05). EEG was performed at least once in 98 patients after the incident. Photoparoxysmal response (PPR) was present in 45 (46%) patients, and spontaneous epileptiform discharges, in 49 (50%). PPR did not have any correlation with recurrence of seizures, neither spontaneous nor visually induced seizures, whereas spontaneous epileptiform discharges showed a good correlation with seizure recurrence (34% vs. 8%; p < 0.01), including visually induced seizures (24% vs. 2%; p < 0.01). CONCLUSIONS: Short-term outcomes showed that 70 (68%) of 103 patients who had a seizure during the incident had no seizures before and during < or = 3 years of follow-up.