Theory of mind abilities in patients with psychogenic nonepileptic seizures

BackgroundPsychogenic nonepileptic seizures (PNES) have been frequently linked to deficits in affect regulation and altered processing of emotionally salient information. However, less is known about how patients suffering from PNES actually process and interpret affective social stimuli. Thus, the present study aimed to investigate basal facial affect recognition as well as mind-reading skills in a sample of patients with PNES and matched control subjects.MethodsPatients with PNES (N = 15) and healthy controls (N = 15) completed self-report questionnaires that measured alexithymia and perceived stress vulnerability. Affect perception was tested using a series of computerized movies of models whose facial expressions slowly change from neutral to full-blown emotions (anger, fear, sadness, happiness, disgust, and surprise), allowing for a fine-grained assessment of facial emotion recognition impairments. Further, all participants were presented with the Movie for the Assessment of Social Cognition, a well-validated video-based test for the evaluation of subtle mind-reading deficits.ResultsData analyses revealed increased alexithymic traits and, impaired mentalizing skills in individuals with PNES, while basal facial expression recognition was not compromised.DiscussionThe present findings are the first to demonstrate that patients with PNES exhibit several deficits in reasoning about their own and other people's mental states. Patients with PNES may benefit from psychotherapeutic interventions that focus on disturbed affect regulation and aim to enhance emotional awareness.     

Diminished sensitivity and specificity at recognising facial emotional expressions of varying intensity underlie emotion-specific recognition deficits in autism spectrum disorders

BackgroundA plethora of research on facial emotion recognition in autism spectrum disorders (ASD) exists and reported deficits in ASD compared to controls, particularly for negative basic emotions. However, these studies have largely used static high intensity stimuli. The current study investigated facial emotion recognition across three levels of expression intensity from videos, looking at accuracy rates to investigate impairments in facial emotion recognition and error patterns (’confusions’) to explore potential underlying factors.MethodTwelve individuals with ASD (9 M/3F; M(age) = 17.3) and 12 matched controls (9 M/3F; M(age) = 16.9) completed a facial emotion recognition task including 9 emotion categories (anger, disgust, fear, sadness, surprise, happiness, contempt, embarrassment, pride) and neutral, each expressed by 12 encoders at low, intermediate, and high intensity.ResultsA facial emotion recognition deficit was found overall for the ASD group compared to controls, as well as deficits in recognising individual negative emotions at varying expression intensities. Compared to controls, the ASD group showed significantly more, albeit typical, confusions between emotion categories (at high intensity), and significantly more confusions of emotions as ‘neutral’ (at low intensity).ConclusionsThe facial emotion recognition deficits identified in ASD, particularly for negative emotions, are in line with previous studies using other types of stimuli. Error analysis showed that individuals with ASD had difficulties detecting emotional information in the face (sensitivity) at low intensity, and correctly identifying emotional information (specificity) at high intensity. These results suggest different underlying mechanisms for the facial emotion recognition deficits at low vs high expression intensity.     

Uncinate fasciculus connectivity in patients with psychogenic nonepileptic seizures: A preliminary diffusion tensor tractography study

The amygdala, hippocampus, and medial prefrontal cortex are limbic brain regions connected by the uncinate fasciculus (UF) and implicated in emotion regulation. The aim of this study was to assess the connectivity characteristics of the UF in patients with psychogenic nonepileptic seizures (PNES) and matched healthy controls. We hypothesized that white matter connectivity of the UF in patients with PNES would differ from that in healthy controls. Eight patients with PNES and eight age- and sex-matched healthy controls underwent 3T MRI and 32-direction diffusion tensor imaging (DTI). Computation of DTI indices including fractional anisotropy (FA) and diffusion tensor tractography was performed. Two regions of interest were defined to manually trace the UF in each hemisphere for each subject. Fractional anisotropy and the number of reconstructed streamlines for the left and right hemispheres of the UF and the degree of asymmetry for each measure were compared between groups. Correlations between UF measures and clinical variables were also performed. Patients with PNES exhibited a significantly greater number of UF streamlines in the right hemisphere tract than in the left hemisphere (p = 0.031), with such difference not observed in controls (p = 0.81). This was reflected in a significant group difference in the asymmetry index (AI) for the number of streamlines, with more rightward asymmetry in patients with PNES (p = 0.021). Average FA of the UF was similar between groups and between hemispheres for each group (all p > 0.05). Age at illness onset was correlated with the AI for FA (r = − 0.87; p = 0.0045). Previously observed differences in emotion processing between controls and patients with PNES may be related to the differences in the rightward asymmetry in the number of UF streamlines in patients with PNES. Age at PNES onset appears to also have a role in the FA asymmetry of the UF. This is the first study to investigate the structural connectivity in these regions involved in emotional regulation in patients with PNES; further research is necessary to clarify the complex relationships between clinical measures and DTI characteristics.     

Semiology of psychogenic nonepileptic seizures: An international cross-cultural study

PurposeWe compared the semiology of psychogenic nonepileptic seizures (PNES) between patients from the USA and Brazil. This international cross-cultural comparative study may expand understanding of PNES across the borders.MethodsWe retrospectively investigated all patients with PNES admitted to one epilepsy center in the USA and one in Brazil. We classified their seizures into four classes: generalized motor, akinetic, focal motor, and subjective symptoms. All patients were interviewed by an epileptologist in both countries and were administered psychological assessment measures, including questions about PNES risk factors. For the statistical analyses, we compared patients from the two nations.ResultsEighty-nine patients (49 from the USA and 40 from Brazil) were studied. Patients from the two countries were not significantly different with regard to sex and age, but patients from Brazil had earlier age at onset (26 years vs. 34 years; P = 0.004) and a significantly greater delay in diagnosis (9.9 years vs. 5.6 years; P = 0.001). Some characteristics of PNES were different between the two groups; patients from the USA had generally more seizure types and more often reported subjective seizures (55% in the USA vs. 10% in Brazil; P = 0.0001). Clinical and historical characteristics of the patients were not significantly different.ConclusionDelay in diagnosis of PNES may represent a major factor in resource-limited countries. Large multicenter cross-cultural studies may reveal subtle but significant cross-cultural differences with respect to the semiological, clinical, and historical aspects of PNES; however, patients with PNES share more similarities than differences.     

Attachment style,relationship quality,and psychological distress in patients with psychogenic non-epileptic seizures versus epilepsy

ObjectivesPsychopathology levels are elevated in patients with psychogenic non-epileptic seizures (PNES) and those with epilepsy. However, patients with PNES report higher rates of trauma and neglect, poorer health-related quality of life (HRQoL), and an increased prevalence of insecure attachment. We examined to what extent attachment style and relationship quality with their main informal carer impact on levels of HRQoL, depression, and anxiety in patients with PNES versus those with epilepsy.MethodConsecutive patients with PNES (N = 23) and epilepsy (N = 72) completed questionnaires about attachment style, quality of their relationship with their main informal carer, seizure severity, HRQoL, depression, and anxiety.ResultsPatients with PNES reported higher levels of anxiety and depression and lower HRQoL than those with epilepsy. PNES: No significant correlations were found with HRQoL but depression correlated positively with attachment avoidance, attachment anxiety, and relationship conflict. Anxiety correlated positively with attachment avoidance, attachment anxiety, and relationship conflict, and negatively with relationship depth and support. Epilepsy: HRQoL correlated negatively with seizure severity, depression, anxiety, attachment avoidance, and attachment anxiety. Depression correlated positively with attachment avoidance, attachment anxiety, and relationship conflict. Anxiety correlated positively with seizure severity, attachment avoidance, and attachment anxiety. Correlations between measures of relationship quality and anxiety were stronger in patients with PNES versus those with epilepsy (zs = 2.66 to 2.97, ps < 0.004). Attachment style and relationship quality explained larger amounts of variance in depression (45%) and anxiety (60%) in the patients with PNES than those with epilepsy (16% and 13%).SignificanceLevels of anxiety and depression were higher in patients with PNES than those with epilepsy. Interpersonal problems were much more closely associated with anxiety and depression in patients with PNES than those with epilepsy. The findings support the use of therapeutic interventions for PNES focusing on attachment and relationship issues.     

Prolonged exposure therapy for the treatment of patients diagnosed with psychogenic non-epileptic seizures (PNES) and post-traumatic stress disorder (PTSD)

ObjectiveAlthough there is general consensus that psychogenic non-epileptic seizures (PNES) are treated with psychotherapy, the effectiveness of most psychotherapeutic modalities remains understudied. In this treatment series of 16 patients dually diagnosed with PNES and post-traumatic stress disorder (PTSD), we evaluated the effect of prolonged exposure therapy (PE) on reduction of PNES. Secondary measures included Beck Depression Inventory (BDI-II) and Post-Traumatic Disorder Diagnostic Scale (PDS).MethodsSubjects diagnosed with video EEG-confirmed PNES and PTSD confirmed through neuropsychological testing and clinical interview were treated with traditional PE psychotherapy with certain modifications for the PNES. Treatment was conducted over the course of 12–15 weekly sessions. Seizure frequency was noted in each session by examining the patients' seizure logs, and mood and PTSD symptomatology was assessed at baseline and on the final session.ResultsEighteen subjects enrolled, and 16 (88.8%) completed the course of treatment. Thirteen of the 16 (81.25%) therapy completers reported no seizures by their final PE session, and the other three reported a decline in seizure frequency (Z = − 3.233, p = 0.001). Mean scores on scales of depression (M = − 13.56, SD = 12.27; t (15) = − 4.420, p < 0,001) and PTSD symptoms (M = − 17.1875, SD = 13.01; t (15) = − 5.281, p < 0.001) showed significant improvement from baseline to final session. Longitudinal seizure follow up in 14 patients revealed that gains made on the final session were maintained at follow-up (Z = − 1.069 p = 0.285).SignificanceProlonged exposure therapy for patients dually diagnosed with PNES and PTSD reduced the number of PNES and improved mood and post traumatic symptomatology. Follow-up revealed that gains made in seizure control on the last day of treatment were maintained over time.     

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.     

Diagnostic implications of review-of-systems questionnaires to differentiate epileptic seizures from psychogenic seizures

ObjectiveEarly and accurate diagnosis of patients with psychogenic nonepileptic seizures (PNES) leads to appropriate treatment and improves long-term seizure prognosis. However, this is complicated by the need to record seizures to make a definitive diagnosis. Suspicion for PNES can be raised through knowledge that patients with PNES have increased somatic sensitivity and report more positive complaints on review-of-systems questionnaires (RoSQs) than patients with epileptic seizures. If the responses on the RoSQ can differentiate PNES from other seizure types, then these forms could be an early screening tool.MethodsOur dataset included all patients admitted from January 2006 to June 2016 for video-electroencephalography at UCLA. RoSQs prior to May 2015 were acquired through retrospective chart review (n = 405), whereas RoSQs from subsequent patients were acquired prospectively (n = 190). Controlling for sex and number of comorbidities, we used binomial regression to compare the total number of symptoms and the frequency of specific symptoms between five mutually exclusive groups of patients: epileptic seizures (ES), PNES, physiologic nonepileptic seizure-like events (PSLE), mixed PNES plus ES, and inconclusive monitoring. To determine the diagnostic utility of RoSQs to differentiate PNES only from ES only, we used multivariate logistic regression, controlling for sex and the number of medical comorbidities.ResultsOn average, patients with PNES or mixed PNES and ES reported more than twice as many symptoms than patients with isolated ES or PSLE (p < 0.001). The prospective accuracy to differentiate PNES from ES was not significantly higher than naïve assumption that all patients had ES (76% vs 70%, p > 0.1).DiscussionThis analysis of RoSQs confirms that patients with PNES with and without comorbid ES report more symptoms on a population level than patients with epilepsy or PSLE. While these differences help describe the population of patients with PNES, the consistency of RoSQ responses was neither accurate nor specific enough to be used solely as an early screening tool for PNES. Our results suggest that the RoSQ may help differentiate PNES from ES only when, based on other information, the pre-test probability of PNES is at least 50%.     

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.     

Facial emotion recognition in psychiatrists and influences of their therapeutic identification on that ability

ObjectivesAlthough emotional cues like facial emotion expressions seem to be important in social interaction, there is no specific training about emotional cues for psychiatrists. Here, we aimed to investigate psychiatrists' ability of facial emotion recognition and relation with their clinical identification as psychotherapy–psychopharmacology oriented or being adult and childhood-adolescent psychiatrist.MethodsFacial Emotion Recognition Test was performed to 130 psychiatrists that were constructed by a set of photographs (happy, sad, fearful, angry, surprised, disgusted and neutral faces) from Ekman and Friesen's.ResultsPsychotherapy oriented adult psychiatrists were significantly better in recognizing sad facial emotion (p = .003) than psychopharmacologists while no significant differences were detected according to therapeutic orientation among child-adolescent psychiatrists (for each, p > .05). Adult psychiatrists were significantly better in recognizing fearful (p = .012) and disgusted (p = .003) facial emotions than child-adolescent psychiatrists while the latter were better in recognizing angry facial emotion (p = .008).ConclusionFor the first time, we have shown some differences on psychiatrists' facial emotion recognition ability according to therapeutic identification and being adult or child-adolescent psychiatrist. It would be valuable to investigate how these differences or training the ability of facial emotion recognition would affect the quality of patient–clinician interaction and treatment related outcomes.     

Autonomic nervous system functioning associated with psychogenic nonepileptic seizures: Analysis of heart rate variability

ObjectivePsychogenic nonepileptic seizures (PNESs) resemble epileptic seizures but originate from psychogenic rather than organic causes. Patients with PNESs are often unable or unwilling to reflect on underlying emotions. To gain more insight into the internal states of patients during PNES episodes, this study explored the time course of heart rate variability (HRV) measures, which provide information about autonomic nervous system functioning and arousal.MethodsHeart rate variability measures were extracted from double-lead electrocardiography data collected during 1–7 days of video-electroencephalography monitoring of 20 patients with PNESs, in whom a total number of 118 PNESs was recorded. Heart rate (HR) and HRV measures in time and frequency domains (standard deviation of average beat-to-beat intervals (SDANN), root mean square of successive differences (RMSSD), high-frequency (HF) power, low-frequency (LF) power, and very low-frequency (VLF) power) were averaged over consecutive five-minute intervals. Additionally, quantitative analyses of Poincaré plot parameters (SD1, SD2, and SD1/SD2 ratio) were performed.ResultsIn the five-minute interval before PNES, HR significantly (p < 0.05) increased (d = 2.5), whereas SDANN (d = − 0.03) and VLF power (d = − 0.05) significantly decreased. During PNES, significant increases in HF power (d = 0.0006), SD1 (d = 0.031), and SD2 (d = 0.016) were observed. In the five-minute interval immediately following PNES, SDANN (d = 0.046) and VLF power (d = 0.073) significantly increased, and HR (d = − 5.1) and SD1/SD2 ratio (d = − 0.14) decreased, compared to the interval preceding PNES.ConclusionThe results suggest that PNES episodes are preceded by increased sympathetic functioning, which is followed by an increase in parasympathetic functioning during and after PNES. Future research needs to identify the exact nature of the increased arousal that precedes PNES.     

Delay in diagnosis of psychogenic nonepileptic seizures in adults: A post hoc study

PurposeThe aim of the current post hoc study was to investigate factors associated with delay in diagnosis of adult patients with psychogenic nonepileptic seizures (PNES).MethodsWe retrospectively investigated all patients with PNES admitted to the epilepsy-monitoring unit at the Jefferson Comprehensive Epilepsy Center from 2012 through 2016. We identified the median time to diagnosis of PNES and divided the patients into two groups. We studied factors associated with delay in diagnosis of PNES.ResultsIn all, 49 patients (39 women and 10 men) were studied. Mean age at the time of admission was 40 ± 16 years and at the onset of the seizures was 34 ± 16 years. Disease duration was 5.6 ± 8.2 years. The median for time to diagnosis was 3 years. Patients with early diagnosis (before 3 years after seizure onset) (21 patients) and patients with late diagnosis (delay of 3 years or more from onset) (28 patients) were compared. Only history of head trauma had significant association with the delay in diagnosis: 2 of 19 patients (7%) with an early diagnosis and 11 of 28 patients (39%) with a late diagnosis reported head trauma (P = 0.02).ConclusionDelay in diagnosis of PNES is common, and some factors (e.g., history of head trauma) may contribute to this delay. It is important that physicians involved in the management of seizures appreciate the importance of making an early and definitive diagnosis of PNES.     

Predictors of health-related quality of life in patients with epilepsy and psychogenic nonepileptic seizures

Epilepsy and psychogenic nonepileptic seizures (PNES) are associated with reduced health-related quality of life (HRQoL). The present study investigated the profile, relationship, and predictive power of illness perceptions, psychological distress (depression and anxiety), seizure activity, and demographic factors on HRQoL in these patient groups. Patients with epilepsy (n = 62) and PNES (n = 45) were recruited from a United Kingdom hospital and from membership-led organizations for individuals living with seizures. Patients completed a series of self-report questionnaires assessing: anxiety (GAD-7), depression (NDDI-E), illness perceptions (B-IPQ), HRQoL (NEWQOL-6D), and seizure frequency and severity (LSSS-3). Correlational and hierarchical multiple regression analyses were conducted. Patients with epilepsy reported higher HRQoL and scored lower on measures of depression and anxiety. Patients with PNES perceived their condition as more threatening overall. In both conditions, HRQoL was negatively correlated with more severe illness perceptions and psychological distress. In epilepsy and PNES, psychological distress (epilepsy: 27%; PNES: 24.8%) and illness perceptions (epilepsy: 23.1%; PNES: 23.3%) accounted for the largest amount of variance in HRQoL. Clinical factors were found not to be significant predictors, while demographic factors predicted HRQoL in epilepsy (12.6%), but not in PNES. Our findings support the notion that psychological factors are a stronger predictor of HRQoL in epilepsy and PNES than condition-related and demographic variables. Prior research suggests that anxiety and depression are key predictors of HRQoL; this study demonstrates that the relationship between illness perceptions and HRQoL is similarly close. These findings highlight the importance of addressing patients' beliefs about their condition.     

Health care utilization following diagnosis of psychogenic nonepileptic seizures

ObjectivesThe long-term outcome of patients with psychogenic nonepileptic seizures (PNES) is of importance given the disabling symptoms and tendency to affect patients early in their productive years. Health care utilization (HCU) is an important outcome measure reflecting overall health status and costs. There is little information regarding long-term HCU following diagnosis of PNES.MethodsWe retrospectively reviewed records of Veterans diagnosed with PNES during epilepsy monitoring unit (EMU) evaluation. For the three-year period following diagnosis of PNES, we reviewed emergency department (ED) visits, hospitalizations, outpatient clinic visits, and radiology procedures. We compared the three years following PNES diagnosis with the three years preceding diagnosis. We also compared patients with PNES and patients with epileptic seizures (ES).ResultsEmergency department visits and hospitalizations were more frequent in patients with PNES compared with those in patients with ES (p = 0.01). There was no overall improvement in HCU during the three-year interval following diagnosis of PNES. A transient decrease during the year following diagnosis was not sustained over three-year follow-up. Pain complaints rather than seizures were the most common reason for presentation, whereas the opposite was true for patients with ES (p < 0.01). There was a sharp decrease in neurology outpatient visits (p < 0.001) and a decrease in primary care visits (p < 0.05) after PNES was diagnosed. Total outpatient visits were unchanged.ConclusionsOverall HCU did not improve during the three years following diagnosis of PNES, compared with three years preceding diagnosis. The results add to studies documenting poor seizure outcomes following diagnosis of PNES and underscore the need for more effective and comprehensive treatments, addressing comorbid symptoms.     

Psychopathological constellation in patients with PNES: A new hypothesis

Depression symptoms have often reported in patients with psychogenic nonepileptic seizures (PNES), although the underlying psychopathological symptomatology has been poorly understood. Our aim was to compare constellations of psychological and behavioral disturbance in PNES with respect to patients with mild-major depressive disorder (MDD), hypothesizing that the construct of depression might be different in the two groups.Ten patients with PNES and ten sex-/age-matched patients with mild-MDD newly-diagnosed, were enrolled in this study. A wide neuropsychiatric battery was employed including the following: symptoms checklist 90-R (SCL-90-R), Toronto alexithymia scale (TAS-20), Hamilton anxiety rating scale (HAMA), Beck depression inventory (BDI II), dissociative experiences scale (DES), traumatic experience checklist (TEC), somatoform dissociation questionnaire (SDQ-20), and temperament and character inventory-revised (TCI-R).No significant difference was detected in the large part of psychopathological examination including personality profile between the two groups. However, PNES showed high scores in alexithymia (p = 0.02); anxiety (p = 0.03), and somatoform symptomatology (p's < 0.03) with respect to patients with mild-MDD. Moreover, somatoform symptoms strongly correlated with depression scores in both groups, whereas alexithymia was influenced by high anxiety level only in the group with PNES. No significant relationship was found between traumatic experience (as measured by TEC) and construct of depression.Our proof-of-concept study suggests that patients with PNES are characterized by their inability to verbalize emotions when dealing with anxiety symptoms, therefore expressing them in a somatic dimension. Further researches, including the investigation of the relationship between anxiety status and emotional expression, are warranted to better understand the pathogenesis of PNES.     

Differential diagnosis of a paroxysmal neurological event: Do neurologists know how to clinically recognize it?

PurposeTo investigate ability to recognize paroxysmal neurological events (PNE) based on video-recorded events alone in a group of physicians treating prevalent neurological conditions.MethodsTotal of 12 patients' videos (6 epileptic seizures (ES), 4 psychogenic nonepileptic seizures (PNES), 2 other nonepileptic seizures (oNES)) were selected. Videos were displayed once to physicians blind to clinical data and final diagnosis. Physicians determined their clinical choice: ES, PNES, oNES, and I don't know (IDK). When ES was chosen, subjects determined type of ES: focal ES, secondary generalized tonic-clonic seizure (GTCS), primary GTCS, and IDK.ResultsIn total 145 physicians (62% female, mean age 46.2 ± 9 years) (neurologists 58.6%, neuropsychiatrists 25.5%, psychiatrists 5%, and neurology residents 10.3%) were enrolled. Physician's exposure to patients with epilepsy per week was diverse: ≤ 1 patient (43.7%); 1–7 patients (37.2%); > 7 patients (14.5%). Reported frequency of observation of PNE was as follows: frequent (21.4%), sometimes (47.6%); rarely (26.9%); never (2.1%). Majority of subjects were not EEG readers (60.7%). Median percentage (Mdn%) of correct answers (CA) was 75% (range 25–100). Predictor of better PNE recognition was higher frequency of clinical exposure to PNE (OR 1.65; CI95% 1.11–2.45; p = 0.013). Mdn% of ES CA was 83.3%, (range 33.3–100), and of PNES CA was 50% (range 0–100). Physicians were more accurate in ES than PNES identification (p < 0,001). Mdn% of type of ES CA was 50%, (range 0–100).ConclusionsWe demonstrate the need for education about clinical features of PNE across subgroups of physicians who deliver neurological service, with emphasis on PNES and ES type classification.     

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.