Original articleNeuropsychological and psychiatric correlates of intractable pseudoseizures☆,☆☆
Abstract
Psychogenic seizures can mimic convulsive epilepsy and with repetitive attacks, iatrogenic complications from aggressive treatment of status epilepticus can occur. We studied neuropsychiatric features of 20 patients in whom psychogenic seizures were intractable and at times continuous.
Nineteen of 20 patients seen were female, and all but one were under 40 years of age. All had convulsive attacks resistant to various medications, normal neurological examinations, and negative imaging studies and electroencephalograms (EEGs). Sixteen had previous evidence of epilepsy and the other four had epileptic relatives. Seizures were atypically prolonged, included back arching and pelvic thrusting, and persisted despite intravenous diazepam and therapeutic phenytoin and phenobarbital levels. Seizures terminated spontaneously in five, were stopped by suggestion in four, and persisted until respiratory arrest or elective intubation in 11.
Ten patients had conversion disorder, six borderline or mixed personality disorder and four mental retardation. Fifteen had had some precipitating stressor and the remainder had histories of exhibiting attention-seeking behaviour. Nine of 10 patients with conversion disorder had ‘conversion V’ Minnesota Multiphasic Personality Inventory (MMPI) profiles, while personality disorder patients had elevation of several psychopathological scales. Patients with conversion disorder gradually improved with anticonvulsant discontinuation, while retarded individuals were helped by behaviour modification, situational change or neuroleptics. Personality disorder patients continued to have attacks and eventually discontinued follow-up.
Clinical evidence of non-epileptic seizures includes clinical atypicality and long duration, exacerbation by medications and frequent attacks despite normal examination and studies. Such patients often have clinical evidence of mental subnormality, conversion disorder or personality disorder, and can be found to have psychopathology and evidence of cognitive impairment, either focal or general, by neuropsychological testing.
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Cited by (58)
Functional status (FSt) describes the phenomenon of prolonged non-epileptic attacks that may be misidentified as Status Epilepticus (SE). The early differentiation between epileptic and functional status is crucial in order to avoid unnecessarily invasive and costly medical escalation in the latter group, including the hazards of overmedication, intubation and intensive care admission. The authors conducted a literature review of available studies describing cases of functional status to extract the common aspects of FSt seizure semiology, investigations used to differentiate from SE, and guidance for managing FSt. A search was carried out using Medline, Embase and PsychInfo databases and 3909 papers were extracted for review. 30 papers were found relevant for inclusion, describing 260 cases of FSt. FSt was found to occur more commonly in younger, female patients with a family history of epilepsy, co-morbid psychiatric diagnosis and following a recent traumatic event. Common clinical features of FSt during and after, the events were identified. While video-EEG remains the gold standard investigation for differentiating FSt from SE, many of the included studies considered the utility of other investigation modalities including serum markers and neuroimaging. One key shortcoming identified within the literature reviewed was a lack of well-defined guidance on the acute management of FSt. We offer an A-F step management plan for the immediate and longer term assessment and treatment of FSt.
What do we know about non-epileptic seizures in adults with intellectual disability: A narrative review
2021, SeizureCitation Excerpt :This is further impacted by a lack of available data investigating population-based cohorts. However, the rates of comorbid ID reported in cross-sectional samples of adults with PNES have varied from 0[22] to 45.8%[23]; with a median rate of 9.4% across eleven studies[12,13,19,20,22-29]. This wide range is not surprising, given that comorbidity rates of PNES and ID are likely to depend on many factors, including the reference population and how patients were investigated (both for ID and PNES).
Psychogenic non-epileptic seizures (PNES) superficially resemble epileptic seizures, but are not associated with abnormal electrical activity in the brain. PNES are a heterogeneous entity and while there is increasing interest in the characterisation of PNES sub-groups, little is known about individuals with PNES who have an intellectual disability (ID). ID is a lifelong condition characterised by significant limitations in cognitive, social and practical skills. ID (commonly with comorbid epilepsy) has been identified as a risk factor for developing PNES. However, people with ID are often excluded from research in PNES. This has unfortunately resulted in a lack of evidence to help inform practice and policy for this population. This narrative review synthesises the currently available evidence in terms of the epidemiology, demographic and clinical profile of adults with PNES and ID. There is a particular focus on demographics, aetiological factors, PNES characteristics, diagnosis and treatment of the condition in this population. Throughout this article, we critique the existing evidence, discuss implications for clinical practice and highlight the need for further research and enquiry. What emerges from the evidence is that, even within the sub-group of those with ID, PNES are a heterogeneous condition. Individuals with ID and PNES are likely to present with diverse and complex needs requiring multidisciplinary care. This review is aimed at the broad range of healthcare professionals who may encounter this group. We hope that it will stimulate further discussion and research initiatives.
From epileptic hysteria to psychogenic non epileptic seizure: Continuity or discontinuity for contemporary psychiatry?
2021, European Journal of Trauma and DissociationIn the wake of Charcot, the École de la Salpêtrière became passionate about major crises or hysterical attacks: at the time, hysteria was not just about this great crisis, even if it represented an ideal heuristic model for a patient presentation that left a lasting impression on people's minds. The great attack is a framework for the study of hystero-epilepsy that opens the way to psychopathological explanation. The heirs of the Salpêtrière School's knowledge protesters each boast of imposing a universal model of hysteria seen from the perspective of its causes. If Babinski considers hysteria to be a purely psychogenic mechanism, it is of the subconscious mind or self-suggestion, the subject abandoning himself to his symptom. Unlike pithiatism, Freud and Breuer understand crisis as the cleavage of the content of consciousness that testifies to the return of a forgotten traumatic memory. These questions, partly eclipsed by modern psychiatry, are resurfacing with the description of a new clinical entity: the nonepileptic psychogenic seizure.
Non-epileptic psychogenic seizures (PNES) can be defined as paroxysmal manifestations clinically suggestive of epileptic seizures but related to unconscious psychogenic processes. Clinical diagnosis is particularly difficult. Most patients with PNES incorrectly use anticonvulsant therapy, which is ineffective and has frequent side effects. To establish a diagnosis that discriminates between PNES and epilepsy, the electroencephalographic recording coupled with a video recording is the paraclinical examination of choice. The treatment of PNESs is complex: despite a diagnosis made by the patient and joint follow-up by a specialized team of neurologists and psychiatrists, the prognosis remains uncertain.
We sought a phenomenal continuity between a major hysterical attack, hystero-epilepsy and a non-epileptic psychogenic seizure. From one time to another, the diagnosis of epileptic seizures is a diagnosis of clinical and paraclinical elimination. A reference to hysteria is found over time, currently confusing into dissociative and somatoform disorders. Consistent with ancient theories, the psychotraumatic dimension of the epileptoid phenomenon is found in recent epidemiological studies.
Since hysteria was not just about major attacks, the entity called PNES is a group of clinical manifestations with heterogeneous etiologies. Some research teams consider PNESs to be the result of non-epileptic, normal electroencephalogram neuronal hyperexcitability. Other authors have adopted the etiological hypothesis of recurrent dissociative disorders and equivalent to a particular form of post-traumatic stress disorder.
Psychological and psychiatric aspects of psychogenic non-epileptic seizures (PNES): A systematic review
2016, Clinical Psychology ReviewPsychogenic non-epileptic seizures (PNES) are common in neurological settings and often associated with considerable distress and disability. The psychological mechanisms underlying PNES are poorly understood and there is a lack of well-established, evidence-based treatments. This paper advances our understanding of PNES by providing a comprehensive systematic review of the evidence pertaining to the main theoretical models of this phenomenon. Methodological quality appraisal and effect size calculation were conducted on one hundred forty empirical studies on the following aspects of PNES: life adversity, dissociation, anxiety, suggestibility, attentional dysfunction, family/relationship problems, insecure attachment, defence mechanisms, somatization/conversion, coping, emotion regulation, alexithymia, emotional processing, symptom modelling, learning and expectancy. Although most of the studies were only of low to moderate quality, some findings are sufficiently consistent to warrant tentative conclusions: (i) physical symptom reporting is elevated in patients with PNES; (ii) trait dissociation and exposure to traumatic events are common but not inevitable correlates of PNES; (iii) there is a mismatch between subjective reports of anxiety and physical arousal during PNES; and (iv) inconsistent findings in this area are likely to be attributable to the heterogeneity of patients with PNES. Empirical, theoretical and clinical implications are discussed.
A necessary evolution of the definition of conversion
2014, Evolution PsychiatriqueDans notre monde où la technique s’impose, les troubles psychiques sont scrutés par les explorations modernes de génétique, de biologie, de neurophysiologie et d’imagerie cérébrale fonctionnelle. La conversion ne se voit plus simplement sur le corps, elle s’entrevoit également dans les images qui rendent compte du fonctionnement cérébral.
Les éléments d’investigations biologiques et radiologiques modernes discutent-ils les conceptions psychopathologiques classiques de la conversion au point d’en offrir une nouvelle définition ?
Les études neuroscientifiques récemment publiées ont permis de revisiter d’un regard critique nos classiques conceptions de la conversion hystérique.
Freud avait eu l’intelligence de différencier conversion et simulation comme deux cadres nosologiques non superposables : la neurobiologie a confirmé scientifiquement l’intervention de mécanismes cérébraux distincts. Freud avait eu le mérite de définir la conversion grâce à une stratégie diagnostique positive psychopathologique et non pas en se contentant d’une simple élimination de l’organicité : avec la même éthique positive, les techniques d’imagerie permettent d’établir un distinguo subtil entre maladies somatiques et troubles conversifs. D’autre part, la possibilité d’une détermination mnésique psychotraumatique à l’origine des accès conversifs a trouvé un écho grâce à des études très récentes qui ont objectivé, dans la physiopathologie conversive, l’intervention de structures cérébrales impliquées dans les mémorations émotionnelles. Enfin, les travaux de recherche s’intéressant aux mécanismes neurofonctionnels déterminant les troubles dissociatifs et conversifs confirment leur proche parenté.
Les études de neuro-imagerie les plus récentes valident l’hypothèse d’un support biologique aux phénomènes conversifs. Si ces nouvelles données devraient nous inciter à redéfinir la conversion, c’est aussi la définition du signifiant « psychogène » qui a évolué du fait des progrès techniques appliqués à la neuro-imagerie. Toute manifestation psychique ou somatique ne proviendrait-elle pas, également, d’une origine neuronale ?
Ce que nous démontrent ces études est que la science peut permettre de valider ou de préciser certains de nos paradigmes classiques de psychopathologie.
Technology is omnipresent in our world today and mental disorders are examined using modern genetic, biological, neurophysiological and functional brain imaging exploratory techniques. Conversion is not just external, it can also be glimpsed at in images that look at brain functioning.
Do modern biological and radiological investigation elements discuss classic psychopathological conceptions of conversion and hence offer a new definition?
Recently published neuroscientific studies have re-evaluated our traditional ideas of hysterical conversion with a critical eye.
Freud had the intelligence of differentiating conversion and simulation as two nosological frameworks that could not be superimposed: neurobiology scientifically confirmed the intervention of distinct brain mechanisms. Freud had the merit of defining conversion using a positive psychopathological diagnostic strategy, and not just by simply eliminating the organicity: with the same positive ethics, a distinction between somatic illnesses and conversive disorders can be established with imaging techniques. Furthermore, the possibility of conversive attacks caused by a psychotraumatic mnemic determination has found an echo in very recent studies which have objectified, in the conversive physiopathology, the intervention of cerebral structures involved in emotional memories. Finally, research looking at neurofunctional mechanisms that determine dissociative and conversive disorders confirm their close relationship.
The most recent neuroimaging studies validate the hypothesis of a biological carrier of conversive phenomena. If this new data should incite us to redefine conversion, it is also the definition of the signifier “psychogenic” which has evolved due to the advances in neuroimaging techniques. Is any psychological or somatic manifestation not also of neuronal and signified origin?
These studies show that science can validate or specify some of our classical psychopathological paradigms.
Emotional dysregulation, alexithymia, and attachment in psychogenic nonepileptic seizures
2013, Epilepsy and BehaviorPsychogenic nonepileptic seizures (PNESs) are poorly understood and difficult to treat. Research and theory suggest that problems with recognizing, acknowledging, and regulating emotional states (i.e., emotional dysregulation) may contribute to the development and maintenance of PNESs. However, there is a lack of well-controlled studies using dedicated measures of emotional regulation with patients with PNESs. The current study sought to address this gap.
Forty-three patients with PNESs and 24 with epilepsy completed a postal survey comprising measures of emotional dysregulation (Difficulties in Emotion Regulation Scale), alexithymia (Toronto Alexithymia Scale), attachment (Relationship Scales Questionnaire), and psychopathology (Generalized Anxiety Disorder-7; Patient Health Questionnaire-9; Somatoform Dissociation Questionnaire-20). Cluster analysis was used to identify possible subgroups of patients with PNESs characterized by distinct patterns of emotional dysregulation.
Two clusters of patients with PNESs were identified. The first (n = 11) was characterized by higher levels of psychopathology, somatization, alexithymia, and difficulties with most aspects of emotional regulation (including identifying, accepting, and describing feelings, accessing adaptive regulatory strategies, performing goal-directed behaviors, and controlling feelings and actions) compared with the group with epilepsy. The second (n = 32) was characterized by relatively high somatization and depression scores but comparatively normal levels of alexithymia and emotional regulation.
The findings suggest that patients with PNESs can be divided into at least two meaningful subgroups characterized by distinct psychological profiles, only one of which is characterized by significant problems with emotional dysregulation. Further research is needed to determine whether the relatively normal emotional dysregulation and high somatization scores of some patients with PNESs are due to emotional avoidance or more basic problems with perceptual and behavioral control.
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Presented in part at the 44th Annual Meeting, American Epilepsy Society, San Diego, California, 12th November, 1990.
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Supported in part by the Denman Fund for Epilepsy Research, The Ohio State University.