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

PURPOSE: The aim of the current post hoc study was to investigate factors associated with delay in diagnosis of adult patients with psychogenic nonepileptic seizures (PNES). METHODS: We 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. RESULTS: In all, 49 patients (39 women and 10 men) were studied. Mean age at the time of admission was 40±16years and at the onset of the seizures was 34±16years. Disease duration was 5.6±8.2years. The median for time to diagnosis was 3years. Patients with early diagnosis (before 3years after seizure onset) (21 patients) and patients with late diagnosis (delay of 3years 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). CONCLUSION: Delay 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.

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

PURPOSE: We 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. METHODS: We 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. RESULTS: Eighty-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 (26years vs. 34years; P=0.004) and a significantly greater delay in diagnosis (9.9years vs. 5.6years; 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. CONCLUSION: Delay 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.

How variable are psychogenic nonepileptic seizures? A retrospective semiological study.

PURPOSE: To classify patients with psychogenic nonepileptic seizures (PNES) according to a recently proposed classification system and investigate the variability of PNES semiology. METHODS: We retrospectively investigated all patients with PNES admitted at the Jefferson Comprehensive Epilepsy Center from 2012 through 2016. We classified their seizures after retrospectively reviewing their recorded videos during their video-EEG monitoring admission and investigated the seizure variability. We extracted all the clinical data from their medical records. We also studied factors potentially associated with seizure variability. RESULTS: Forty nine patients were studied and 220 seizures were reviewed and classified. Mean number of seizures per patient was 4.5. Twenty seven (55%) patients had subjective seizures, 26 (53%) had generalized motor, 14 (29%) had akinetic and five (10%) had focal motor seizures. Twenty eight (57%) patients had only one seizure class, while 19 (39%) patients had two different seizure classes and two (4%) patients had three seizure classes. Among 28 patients with one seizure class, 14 (50%) patients had variable semiologies from one seizure to the other. Hence, 71.5% of the patients showed either inter- or intra-class variability, whereas seizures were stereotypical in 28.5%. No demographic or clinical factors were significantly associated with variability of PNES semiology. CONCLUSION: Neither the stereotypy nor the variability of PNES can or should be used as a marker of the disease and to differentiate PNES from epilepsy. The variability of the episodes of PNES does not hinder an appropriate classification of these seizures.

Semiological classification of psychogenic nonepileptic seizures.

PURPOSE: We classified patients with psychogenic nonepileptic seizures (PNESs) according to a newly proposed classification system. Then, we investigated the demographic and clinical differences between various classes of the patients. METHODS: We retrospectively investigated all patients with PNESs admitted to the Jefferson Comprehensive Epilepsy Center from 2012 through 2016. We classified the patients into four distinct classes: patients with generalized motor seizures, patients with akinetic seizures, patients with focal motor seizures, and patients with seizures with subjective symptoms. All patients were interviewed by a neuropsychologist and were administered psychological assessment measures, including questions about PNES risk factors. For the statistical analyses, we compared patients who had generalized motor seizures with patients who had nonmotor seizures. RESULTS: Sixty-three patients were studied. Thirty-five (55.6%) patients had generalized motor seizures, 14 (22.2%) had seizures with subjective symptoms, 12 (19%) had akinetic seizures, and two (3.2%) patients had focal motor seizures. Patients with generalized motor seizures (35 patients) demonstrated a trend for later age at onset (p=0.06), more frequently had a history of substance abuse (p=0.001), and more often had loss of responsiveness with their seizures (p=0.04) compared with patients who had nonmotor seizures (26 patients). CONCLUSION: The recently proposed PNES classification system is useful and practical. This proposed classification of PNESs may address proper diagnosis and provide standardization across future studies. This may also potentially shed light on the etiologic understanding and management of various classes of patients affected with PNESs.

Post-epilepsy surgery psychogenic nonepileptic seizures.

OBJECTIVES: We investigated the prevalence of post-epilepsy surgery psychogenic nonepileptic seizures (PNES) in patients with drug-resistant epilepsy and the possible influence of risk factors on these seizures. METHODS: In this retrospective study, we examined data from all patients with a clinical diagnosis of drug-resistant epilepsy who underwent epilepsy surgery at Graduate Hospital and the Jefferson Comprehensive Epilepsy Center between 1986 and 2016. Postsurgical outcome was identified for up to 15 years after surgery. Diagnosis of PNES was verified in the epilepsy monitoring unit with video-electroencephalography (EEG) ictal recording. Potential associated factors were assessed by comparing patients with or without postoperative PNES. RESULTS: A total of 1,105 patients were studied; 697 patients had postoperative seizures, and, of these, 27 patients (3.9%) had documented PNES after surgery. A full-scale intelligence quotient (IQ) <80 was significantly associated with post-epilepsy surgery PNES (odds ratio [OR] 2.89, p = 0.007, 95% confidence interval [CI] 1.33-6.29). A history of a preoperative psychiatric diagnosis was also significantly associated with post-epilepsy surgery PNES (OR 4.67, p = 0.0001, 95% CI 2.01-10.82). Other factors were not significantly associated with post-epilepsy surgery PNES. SIGNIFICANCE: Post-epilepsy surgery PNES should be considered when patients report recurrent seizures after epilepsy surgery. Although these seizures probably occur relatively infrequently, attention to factors such as appearance of new ictal behaviors, a preoperative history of a psychiatric disorder, and a low full-scale IQ should raise suspicion and lead to appropriate diagnostic measures.

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.

Medial prefrontal cortex hyperactivation during social exclusion in borderline personality disorder.

Frontal systems dysfunction and abandonment fears represent central features of borderline personality disorder (BPD). BPD subjects (n=10) and matched non-psychiatric comparison subjects (n=10) completed a social-cognitive task with two confederates instructed to either include or exclude subjects from a circumscribed interaction. Evoked cerebral blood oxygenation in frontal cortex was measured using 16-channel functional near infrared spectroscopy. BPD subjects showed left medial prefrontal cortex hyperactivation during social exclusion suggesting potential dysfunction of frontolimbic circuitry.

The neurocognitive effects of 5 day anesthetic ketamine for the treatment of refractory complex regional pain syndrome.

BACKGROUND: Complex regional pain syndrome I (CRPS) is characterized by severe neuropathic pain that exceeds the severity of an injury and is refractory to traditional treatments. Recent experimental interventions include ketamine infusion therapy. OBJECTIVE: We sought to evaluate the physical, neurocognitive, and emotional effects of extended treatment with anesthetic doses of ketamine in refractory CRPS I patients. METHODS: Nine patients (eight females) received a neuropsychological evaluation pre- and 6 weeks post-treatment that evaluated intellectual and academic abilities, executive functioning/processing speed, attention, learning and memory, and motor functioning. Mood/affect and personality were also evaluated and patients completed an extensive pain questionnaire. RESULTS: There was a marked reduction in the report of both acute and overall pain after treatment. Brief attention and processing speed improved significantly post-treatment, whereas all other cognitive domains remained stable, with the exception of a mild decline in motor strength. CONCLUSIONS: Findings suggest that, at least at a 6-week follow up: (1) deep ketamine therapy is effective for relief of pain CRPS I and (2) there were no adverse cognitive effects of extended treatment with deep ketamine infusion. No definitive conclusions could be drawn about the relationship between mood and personality factors and the presence of CRPS I.