Nonconvulsive psychogenic attacks investigated for temporal lobe epilepsy

Slater and Roth recognize the occasional diagnostic problem due to the “overlap between the symptomatology of temporal lobe epilepsy and neurotic disturbance…”¹ Harper and Roth² compared the clinical features of patients with phobic anxiety-depersonalization syndrome with temporal lobe epileptics and found that the psychogenic group had significantly more family histories of neurosis, childhood and adult phobias, anxiety and depressive syndromes, hypochondriacal symptoms, and personality traits of immaturity and dependence. This study examined this subject using rating scales.     

Frequency of attacks in patients with psychogenic non-epileptic seizures

Aims. The aim of this study was to investigate the frequency of attacks (psychogenic seizures) in patients with psychogenic non-epileptic seizures (PNES) and to characterize factors potentially associated with attack frequency. Methods. In this retrospective study, all patients with PNES, who were studied at Shiraz Comprehensive Epilepsy Center at Shiraz University of Medical Sciences, Iran, from 2008 until 2018, were reviewed. We categorized the attack frequency in the patients as (1) daily; (2) weekly; and (3) frequency of less than one per week. Results. Three hundred and ten patients were studied. Attack frequency in patients was 34 ± 67 per month. One hundred and eleven patients (36%) had daily attacks, 93 (30%) had weekly attacks, and 106 (34%) had less than weekly attacks. Sixty-five patients (21%) reported having more than one attack per day. Demographic variables, attack-related variables, PNES associated factors, and use of AEDs were not significantly associated with attack frequency in the patients. Conclusion. We observed that two thirds of the patients with PNES had frequent daily or weekly attacks. The findings of our study could be helpful in designing future clinical trials. First, attack frequency is an unbiased outcome measure in the design of such studies. Second, it is easily measurable using attack calendars; we suggest that attack frequency be assessed daily using daily attack calendars. Finally, it is very easy to recruit patients with PNES for clinical trials (with regards to their attack frequency) since many of them have frequent attacks.     

De novo psychogenic nonepileptic attacks after adult epilepsy surgery: An underestimated entity

We retrospectively assessed all patients in a large cohort of patients with epilepsy surgery at the National Hospital for Neurology and Neurosurgery (NHNN) over 12 years, to identify patients with postoperative psychogenic nonepileptic attacks (PNEA). Twenty‐nine patients (23 women) were identified of a total of 790 patients, a frequency of 3.7%. Female gender and presurgical psychiatric diagnosis, other than psychosis, were significant risk factors for PNEA development. In female patients with a preoperative psychiatric diagnosis the chance of developing PNEA after epilepsy surgery was 8.5%. PNEA developed between 2 weeks and 10 years after epilepsy surgery, independently of outcome of epileptic seizures. In most cases, PNEA differed from the present or past epileptic seizures, and motor symptoms were the most common manifestations. Seizures after epilepsy surgery should be carefully evaluated. Physicians should consider the possibility of PNEA, especially in female patients with preoperative psychiatric comorbidity developing “atypical” seizures with motor manifestations postoperatively, even many years after epilepsy surgery.     

Functional anatomical study of psychogenic amnesia

Psychogenic amnesia is characterized by an inability to recall information already stored in the patient's memory. It is usually related to a stressful or traumatic event that cannot be explained by manifest brain damage. To examine the underlying functional disturbance of brain areas in this condition, we performed a positron emission tomography (PET) activation study on a psychogenic amnesic patient and on 12 normal control subjects. A task requiring explicit retrograde memory of faces was compared with a control task. To assess functional modifications associated with the processes of recovery, a second PET study was performed on the patient 12 months after onset. During the task, activation of the right anterior medial temporal region including the amygdala was increased in the psychogenic amnesic patient. Activation of the bilateral hippocampal regions increased only in the control subjects. During recovery, the right anterior medial temporal region became less active while the right hippocampal region became more active. Activation levels also differed in the anterior cingulate cortex, prefrontal cortex and some other cortical regions between control subjects and the patient. These findings suggest that the changes in these limbic and limbic-cortical functions are related to symptoms of the psychogenic amnesia.     

The effective and ethical use of voluntary induction of psychogenic drop attacks in a patient with idiopathic generalized epilepsy

A woman known to have never fully controlled idiopathic generalized epilepsy presented at 47 years of age with a new onset of drop attacks. After clinical investigations, including prolonged video/EEG telemetry, tilt-table testing, and multiple sleep latency tests, the etiology of her drop attacks remained elusive. Subsequently we were able to demonstrate that her drop attacks may be provoked by her voluntary recollection of memories of past sexual abuse. This case study highlights the need to consider psychological factors when evaluating otherwise unexplained drop attacks. In addition, we propose a seizure-provoking technique that may be used both effectively and ethically in the diagnosis of psychogenic drop attacks as well as nonepileptic seizures.     

Transcranial magnetic stimulation for psychogenic tremor - a pilot study

Psychogenic tremor is the most common psychogenic movement disorder. Its prognosis is widely held to be poor and strongly depends on the patient's insight into the psychogenicity of the syndrome. The clinical value of transcranial magnetic stimulation (TMS) for (i) establishing the diagnosis with a high level of certainty, (ii) modulating symptom severity and (iii) facilitating patients' insight into psychogenicity was tested in 11 patients with psychogenic tremor of the upper limb. After explaining the psychogenic origin of the syndrome and providing a neurobiological model, 30 TMS pulses were applied over the hand area of the primary motor cortex contralateral to the affected hand(s) at a rate of 0.2 Hz. 15 pulses were administered at intensities of 120 % and 140 % of the resting motor threshold, respectively. Kinematic motion analysis was used to document the effectiveness of the TMS procedure. All patients met the diagnostic criteria of conversion disorder. Time elapsed since symptom onset was on average 48 to 57 months. Tremor affected both hands in 8 patients, one patient had additional head tremor. The TMS procedure caused a significant reduction of tremor frequency and thus established the diagnosis of documented psychogenic tremor according to the criteria proposed by Fahn and Williams (1988) in each patient. The duration of symptom relief was transient in 7 patients, 4 patients had lasting symptom relief. The present pilot study demonstrates that TMS is a helpful tool to (i) establish the diagnosis of psychogenic hand tremor with a high level of certainty, (ii) reduce tremor intensity and (iii) facilitate the patient's insight into the psychogenic origin of the syndrome as a prerequisite to obtain adherence to psychotherapy.     

Acute myelitis after asthma attacks with onset after puberty

A poliomyelitis-like illness after asthma attacks has been found and is called asthmatic amyotrophy (Hopkins' syndrome). All of the previously reported cases were under 13 years of age. Three patients are described who developed acute myelitis after asthma attacks at 15, 22, and 73 years of age. All of them showed acute flaccid monoparesis, and needle EMG disclosed denervation potentials in the relevant muscles. In addition, in the two adult patients the sensory or pyramidal tracts were involved, and evoked potential studies confirmed an involvement of the pyramidal tracts in one of them. This 22 year old patient showed a second episode of monoparesis in the other limb after another asthma attack. All three patients had no significant changes in their antiviral antibody titres, whereas every patient had hyperIgEaemia and allergen specific IgE. These findings suggest that asthmatic amyotrophy can develop after puberty and that patients who develop this disease in adulthood seem to show both a widespread involvement of the spinal cord and a more varied course.     

The tendency to have psychogenic non-epileptic attacks out of camera view during long-term video-EEG monitoring.

The aim of this study was to compare out of camera view seizure occurrence rates between psychogenic non-epileptic and epileptic seizures during long-term video-EEG monitoring. From 1996 to 2001, 208 adult patients were monitored in 212 sessions, and 196 patients were included in the study. Depending on video-EEG recordings and witnessed accounts, 18 of the patients had no seizures recorded, 160 had epileptic seizures and 18 had psychogenic non-epileptic seizures, four of whom had psychogenic non-epileptic seizures plus true epileptic seizures. Six hundred and ninety two seizures were recorded; 634 of them were epileptic seizures and 58 of them, psychogenic non-epileptic ones. Out of camera attack occurrence was significantly higher in patients with psychogenic non-epileptic attacks compared with epileptic ones (chi-square with Yates correction = 19.75, df = 1, P< 0.001).     

The relation of psychogenic excoriation with psychiatric disorders: a comparative study

Psychogenic excoriation (PE), characterized by excessive scratching or picking of the skin, is not yet recognized as a symptom of a distinct DSM-IV disorder. It is a chronic disorder with a high rate of psychiatric comorbidity. The purpose of this study was to compare patients diagnosed with PE and patients with another dermatological disease in terms of comorbid psychiatric disorders. Thirty-one consecutive subjects were recruited from an outpatient dermatology clinic. The control group was composed of 31 patients with chronic urticaria. All subjects were interviewed using the Structured Clinical Interview for DSM-III-R (SCID-I), Beck Depression Inventory (BDI), Hamilton Anxiety Rating Scale (HARS), and Yale-Brown Obsession and Compulsion Scale (Y-BOCS) and also completed a semistructured questionnaire. Current major depressive syndrome was the most common psychiatric disorder in the PE group. There was a statistically significant difference between the two groups in terms of current major depressive syndrome (PE group 58.1%, control group 6.5%, P<.01). In the PE group, 45.2% of subjects were diagnosed with obsessive compulsive disorder (OCD), while the rate of OCD was only 3.7% in the control group (P <.01). The PE group scored significantly higher on the BDI, HARS, and Y-BOCS. The results of this study point to the close relationship of PE to depression and OCD.     

心因性非痫性发作误诊临床探讨

目的 通过分析心因性非痫性发作与癫痫性发作患者的发作诱因、临床表现,脑电图、颅脑MRI等相关指标的差异,以减少误诊.方法 采用回顾性分析法对18例确诊为心因性非痫性发作患者的临床资料进行分析,并与随机抽取的50例癫痫患者的临床资料进行比较.结果 18例患者发作的诱因多与环境刺激及情绪变化有关;发作频繁,清醒期发作;发作期EEG较相似,表现为在大量的肌电伪迹、动作伪迹间可见正常枕区背景节律,或表现为全部正常节律,无癫痫样放电.MRI未见与发作相关颅脑改变;心理疏导联合相关药物可减轻发作.与癫痫在以上方面表现均有明显差异.结论 心因性非痫性的发作是由多种心理因素相互作用所致,临床医师应根据病史、临床表现、发作期脑电图特点、药物反应等综合分析进行确诊,避免误诊.     

A feasibility study of a brief psycho-educational intervention for psychogenic nonepileptic seizures

PurposeWe have previously reported that one in six patients stops experiencing psychogenic nonepileptic seizures (PNES) following our communication protocol. This prospective multicentre study describes a psycho-educational intervention for PNES building on the initial communication of the diagnosis and examines the feasibility of its delivery by healthcare professionals with minimal experience in psychological therapies.MethodThree healthcare professionals with minimal training in psychological therapies took part in a one-day training course. 20 participants attended for a four-session manualised psycho-educational intervention delivered at three different clinical neuroscience centres. Participants completed self-report measures prior to the intervention at baseline (n = 29) and seven months after diagnosis (n = 13) measures included seizure frequency, health related quality of life, healthcare utilisation, activity levels, symptom attributions and levels of functioning. Therapy sessions were audiorecorded and manual adherence assessed.ResultsOf 29 patients enrolled into the study, 20 started and 13 completed the intervention and provided follow-up information. At follow-up, 4/13 of patients had achieved complete seizure control and a further 3/13 reported a greater than 50% improvement in seizure frequency. After training, epilepsy nurses and assistant psychologists demonstrated sufficient adherence to the manualised psycho-educational intervention in 80% of sessions.ConclusionThe delivery of our brief manualised psycho-educational intervention for PNES by health professionals with minimal training in psychological treatment was feasible. The intervention was associated with higher rates of PNES cessation than those observed in our previous studies describing the short-term outcome of the communication of the diagnosis alone. An RCT of the intervention is justified but a significant proportion of drop-outs will have to be anticipated.