Kenneth Perrine

Stress coping strategies in patients with psychogenic non-epileptic seizures and how they relate to trauma symptoms, alexithymia, anger and mood

PURPOSE The purpose of the present study was to assess stress coping strategies employed by patients with psychogenic non-epileptic seizures (PNES) and determine whether these approaches were associated with other psychopathological features. Ineffective stress coping strategies can have a variety of unhealthy consequences fueling psychopathology just as psychopathology can also have an impact on stress coping. Because of this, the study of stress coping has the potential to inform our understanding of the PNES condition and underscore a potential target for psychological treatment. METHODS Eighty-two consecutive patients with PNES were studied using the Coping Inventory for Stressful Situations (CISS). The CISS is a self-rating coping strategies scale that has three main subscales (Task-Oriented, Emotion-Focused, and Avoidance-Oriented). Other psychological variables that were thought to potentially influence the chosen coping mechanisms including alexithymia, symptoms of post-traumatic stress disorder, anger expression and select scales from the Minnesota Multiphasic Personality Inventory 2-RF (MMPI 2-RF) were also evaluated. RESULTS Fifty patients (60.9%) endorsed using at least one coping strategy that was 1.5 standard deviations or more away from the normal adult mean. Over 30% of the participants endorsed using elevated Emotion-Focused coping strategies (T score ≥ 65), and just over 25% endorsed underusing Task-Oriented coping strategies (T score ≤ 35). Elevations in avoidance strategies were endorsed by only 15.9% of the respondents. ANOVA comparing T scores between the coping strategies was significant (F=13.4, p=.0001) with a significantly lower Task-Oriented strategy than Emotion-Focused (p=.001) and Avoidance (p=.005) strategies. Patients with high scores of Emotion-Focused coping strategies also had significantly high scores on diverse psychopathology factors including elevations on depressive mood, intrusive experiences, anger state, and general anger scores. In contrast, those who used Task-Oriented strategies and who used Avoidance-Focused strategies had less psychopathology including low positive emotion scores (RC2). CONCLUSION Nearly one-third of patients with PNES tended to use the less effective Emotion-Oriented coping strategies and one fourth reported underusing the more effective Task-focused strategies. Substantial differences were noted between coping strategies with a significantly lower Task-Oriented strategy than Emotion-Focused and Avoidance strategies. In addition, high Emotion-Focused coping was seen in patients with underlying psychological symptoms that were not observed in other coping strategies. This information supports the relevance of assessing stress coping in patients with PNES because it allows the identification of useful behavioral targets for the psychotherapist.

Prevalence of alexithymia in patients with psychogenic non-epileptic seizures and epileptic seizures and predictors in psychogenic non-epileptic seizures

OBJECTIVE The first objective of this study was to determine the prevalence rate of alexithymia (dysregulation and unawareness of emotion) in patients with psychogenic non-epileptic seizures (PNESs) and epileptic seizures (ESs). The second objective was to identify the predictors of alexithymia in patients with PNESs. METHODS We studied 66 consecutive patients with PNESs and 35 patients with ESs with the Toronto Alexithymia Scale-20. The prevalence of alexithymia was determined in both groups. In order to identify the risk factors of alexithymia in PNES, the Trauma Symptom Inventory-II (TSI-II), the MMPI 2-RF, a clinical history, and demographic variables were studied. RESULTS Our study revealed a prevalence of alexithymia in PNES and ES of 36.9% and 28.6%, respectively (not a significant difference). Upon examining the group with PNES, we found a significant correlation between alexithymia and Anxious Arousal (r=.497, p<.000), Intrusive Experiences (r=.541, p<.000), Dissociation (r=.421, p<.001), and Defensive Avoidance (r=.444, p<.000) from the TSI-II. Minnesota Multiphasic Personality Inventory-2-RF RCd (r=.512, p<.000), RC1 (r=.346, p<.017), RC2 (r=.355, p<.017), RC3 (r=.467, p<.001), and EID (r=.567, p<.000) also correlated significantly with alexithymia. However, stepwise regression analysis only retained Intrusive Experiences and Defensive Avoidance from the TSI-II and the cynicism RC3 scale from the MMPI 2-RF. CONCLUSION Symptoms of psychological trauma and cynicism in patients diagnosed with PNESs were associated with alexithymia. These findings are encouraging, as they assist in better understanding the condition and in treatment design for this subset of patients.

The value of intraoperative electrocorticography in surgical decision making for temporal lobe epilepsy with normal MRI

Purpose:  We hypothesized that acute intraoperative electrocorticography (ECoG) might identify a subset of patients with magnetic resonance imaging (MRI)–negative temporal lobe epilepsy (TLE) who could proceed directly to standard anteromesial resection (SAMR), obviating the need for chronic electrode implantation to guide resection.

The effects of lacosamide on cognition, quality-of-life measures, and quality of life in patients with refractory partial epilepsy

OBJECTIVE The objective of this study was to examine cognitive and quality-of-life measures/quality of life outcomes with adjunctive lacosamide therapy in patients with treatment-resistant partial epilepsy. METHODS This was a prospective, open-label, nonblinded, adjunctive therapy test-retest (within subjects) study of patients with treatment-resistant partial epilepsy in which outcome (cognitive functioning and mood/quality of life) was measured in the same subject before and after adjunctive lacosamide administration for 24weeks. The cognitive assessment included the following: Controlled Oral Word Association Test, Buschke Selective Reminding Test, Brief Visuospatial Memory Test-Revised, Stroop Color Word Test, Symbol Digit Modalities Test, Digit Span, Digit Cancellation, and Trails A and B. The quality-of-life measures/quality-of-life assessment included the following: Beck Depression Inventory-II, Profile of Mood States, and Quality of Life Inventory-89. Lacosamide was started at 100mg (50mg twice daily) and could be titrated as needed up to 400mg/day (200mg twice daily). Baseline concomitant AEDs were kept constant. Composite scores were calculated for a pre-post difference score for the cognitive and mood/quality-of-life measures separately and used in regression analyses to correct for the effects of age, education, seizure frequency, seizure severity, dose of lacosamide, and number of AEDs at baseline. RESULTS Thirty-four patients were enrolled (13 males, 21 females). Mean age was 38.8±2.43years. Mean seizure frequency decreased significantly from 2.0±2.55 seizures per week at baseline to 1.02±1.72 seizures per week at posttreatment (t=4.59, p<.0001) with a 50% responder rate seen in 18 patients (52.9%). No significant differences were found on the composite scores of the cognitive or the mood/quality-of-life measures after 6months of lacosamide. SIGNIFICANCE Lacosamide appeared to have low risks of significant changes in cognition or mood/quality of life. In addition, the present study supports prior studies that have proven lacosamide as an effective adjunctive therapy for the treatment of resistant partial epilepsy.

Cognitive differences between patients who have psychogenic nonepileptic seizures (PNESs) and posttraumatic stress disorder (PTSD) and patients who have PNESs without PTSD

OBJECTIVES The objective of this study was to examine cognitive and clinical differences among three groups of patients diagnosed with psychogenic nonepileptic seizures (PNESs): those with posttraumatic stress disorder (PTSD), those with a history of trauma but no PTSD, and those without a history of trauma. METHODS Seventeen patients who were confirmed to have PTSD based on the Trauma Symptom Inventory-2 (TSI-2) and clinical interview were compared with 29 patients without PTSD who had experienced trauma and 17 patients who denied experiencing trauma. We analyzed demographic data, psychiatric information, trauma characteristics, and neuropsychological variables in these groups. RESULTS Our study revealed that patients with PNESs with comorbid PTSD performed significantly worse on episodic verbal memory (narrative memory); had greater self-reported Total, Verbal, and Visual Memory impairments; and had higher substance abuse history and use of psychopharmacological agents compared with patients without PTSD regardless of a history of trauma. CONCLUSION The present study showed that patients with PNESs diagnosed with PTSD exhibited memory functions that were significantly different from those in patients with PNESs who do not carry a diagnosis of PTSD (regardless of history of trauma). Furthermore, these specific cognitive findings in narrative memory are consistent with those reported in patients with PTSD alone. The present findings contribute to further identifying discrete intragroup differences within PNESs. Identifying a specific psychopathological subgroup such as PTSD will allow clinicians to accurately select treatment.

The Current Status of Research on Chronic Traumatic Encephalopathy

Chronic traumatic encephalopathy (CTE) evolved from the term dementia pugilistica describing the dementia found in many boxers to its current use in describing the dementia and depression sometimes found in athletes subjected to multiple concussions or subconcussive blows to the head. Concurrently, the neuropathology evolved to specify a unique type of tauopathy found in perivascular spaces at the depth of sulci and other features not typically seen in neurodegenerative tauopathies. Four stages of CTE have been proposed, with 4 corresponding clinical syndromes of traumatic encephalopathy syndrome. However, it remains unclear whether this is a syndrome unique to repetitive head trauma, especially in contact sports, because the epidemiology has been difficult to establish. In particular, research to date has had a denominator problem in not establishing the total number of potential cases at risk for developing CTE. The current review examines the evidence to date for these syndromes and contributing or complicating factors affecting the neuropathology, neuroimaging, and clinical presentations associated with them.

Depression and quality of life in Spanish-speaking immigrant persons with epilepsy compared with those in English-speaking US-born persons with epilepsy.

OBJECTIVE This study aimed to examine levels of depression and quality of life in Spanish-speaking (less acculturated) immigrants with epilepsy compared with those in English-speaking US-born persons with epilepsy (PWEs). METHODS The study included 85 PWEs - 38 Spanish-speaking immigrants with epilepsy and 47 US-born PWEs. All patients underwent video-EEG monitoring and completed depression and quality-of-life inventories in their dominant language (Spanish/English). Chart review of clinical epilepsy variables was conducted by an epileptologist. RESULTS Our study revealed that depression scores were significantly higher in Hispanic PWEs (21.65±14.6) than in US-born PWEs (14.50±10.2) (t (64.02)=-2.3, two-sided p=.025). Marital status, medical insurance, antidepressant use, seizure frequency, and number of antiepileptic drugs (AEDs) were tested as covariates in the ANCOVA framework and were not statistically significant at the 0.05 significance level. Fewer Hispanics were prescribed antidepressant medications (13.15% for Hispanics and 40.42% for US-born, χ(2) (1,85) 7.71, p=.005) and had access to comprehensive health insurance coverage (χ(2) (1,85)=13.70, p=0.000). Hispanic patients were also found to be receiving significantly less AEDs compared with their US-born peers (t (83, 85)=2.33, p=.02). Although quality of life was diminished in both groups, Seizure Worry was worse for Hispanics after accounting for potential effects of marital status, medical insurance, use of antidepressants, seizure frequency, and number of antiepileptic drugs (AEDs) ((1, 83), F=7.607, p=0.007). SIGNIFICANCE The present study is the first of its kind to examine depression and quality of life in Spanish-speaking US immigrants with epilepsy. Spanish-speaking immigrants with epilepsy have been identified as a group at risk. They demonstrated higher depression scores and more Seizure Worry independent of epilepsy and demographic characteristics compared with their US-born peers. The Hispanic group was receiving less treatment for depression, was taking less AEDs, and had less access to comprehensive health coverage compared with non-Hispanics.

Predictive value of Spanish neuropsychological testing for laterality in patients with epilepsy

In presurgical treatment planning for patients with epilepsy, neuropsychological testing assists in lateralization of the seizure focus. Previous research with English speakers has shown that patients with left hemisphere (LH) onsets versus right hemisphere (RH) onsets perform worse on naming and other verbal skills tests, but similar findings with Hispanic patients are limited. Thirty-nine Spanish-speaking patients were administered a comprehensive battery of neuropsychological tests in Spanish. LH-onset patients performed significantly worse than RH-onset patients on verbal comprehension (P=0.006), visual matching (P=0.047), the Ponton-Satz Boston Naming Test (P=0.001), and the dominant hand trial of the Grooved Pegboard Test (P=0.012). A stepwise regression model to predict seizure laterality from these tests was significant (F=12.10, P=0.001), but only the Ponton-Satz Boston Naming Test was retained. This comprehensive battery of neuropsychological tests in Spanish proved useful in predicting lateralization in patients with partial epilepsy.

A Pediatrician’s Guide to Concussion Management

Concussions are one of the most common injury-related diagnoses in childhood and account for 65 % of adolescent emergency department visits. It is important for the pediatrician to understand the mechanisms of concussion, the expected time course of concussion resolution, and the circumstances involved in post-concussion syndrome recognized as symptoms beyond the typical remission period of several weeks. Pediatricians should also be cognizant of the special considerations in the pediatric population, especially among adolescent athletes. This chapter provides the necessary background for understanding the mechanisms and resolution pattern of concussion and also provides a comprehensive review of specific factors required in a history taken in an office visit for a child with a concussion. We will review aspects of the physical and neurologic exam specific to concussion, how to give feedback and make rational recommendations for the recovery period, how to manage persisting post-concussion syndrome, and when to make a referral to a specialist. Several case examples are provided to help the clinician understand the diversity of presentations and management of pediatric concussion.