M. Oto

Early outcomes and predictors in 260 patients with psychogenic nonepileptic attacks

Objective: To determine short-term outcome and its predictors in patients with psychogenic nonepileptic attacks (PNEA). Methods: Retrospective cohort study of outcomes relating to attendance at follow-up, spells, use of emergency services, employment, and social security payments recorded at 6 and 12 months post diagnosis in 260 consecutive patients. Results: A total of 187 patients (71.9%) attended at least 1 follow-up visit, and 105 patients (40.4%) attended 2. A total of 71/187 patients (38.0%) were spell-free at last follow-up. In contrast, 35/187 patients (18.7%) had marked increase in spell frequency postdiagnosis. Delay to diagnosis had no relationship to outcome. Patients with anxiety or depression were 2.32 times less likely to become spell-free (p = 0.012), and patients drawing social security payments at baseline were 2.34 times less likely to become spell-free (p = 0.014), than patients without those factors. Men were 2.46 times more likely to become spell-free than women (p = 0.016). While 93/187 patients (49.7%) were using emergency medical services at baseline, only 29/187 (15.5%) were using them at follow-up (p < 0.001). This was independent of whether or not the patient became spell-free. Conclusion: A substantial minority of our patients became spell-free with communication of the diagnosis the only intervention. Previous psychiatric diagnoses, social security payments, and gender were important predictors of outcome. Most patients stopped using emergency services, irrespective of whether or not spells continued. Outcomes other than spell frequency may be important in patients with psychogenic nonepileptic attacks.

Outpatient video EEG recording in the diagnosis of non-epileptic seizures: a randomised controlled trial of simple suggestion techniques

Objective: To assess the yield of recorded habitual non-epileptic seizures during outpatient video EEG, using simple suggestion techniques based on hyperventilation and photic stimulation. Design: Randomised controlled trial of “suggestion” v “no suggestion” during outpatient video EEG recording. Setting: Regional epilepsy service (tertiary care; single centre). Participants: 30 patients (22 female, 8 male), aged over 16 years, with a probable clinical diagnosis of non-epileptic seizures; 15 were randomised to each group. Main outcome measures: Yield of habitual non-epileptic seizures recorded, and requirement for additional inpatient video EEG. Results: 10/15 patients had habitual non-epileptic seizures with suggestion; 5/15 had non-epileptic seizures with no suggestion (p = 0.058; NS); 8/9 patients with a history of previous events in medical settings had non-epileptic seizures recorded during study. Logistic regression analysis with an interaction clause showed a significant effect of suggestion in patients with a history of previous events in medical settings (p = 0.003). An additional inpatient video-EEG was avoided in 14 of the 30 patients (47%). Conclusions: Habitual non-epileptic seizures can be recorded reliably during short outpatient video EEG in selected patients. Simple (non-invasive) suggestion techniques increase the yield at least in the subgroup with a history of previous events in medical settings. Inpatient video EEG can be avoided in some patients.

Late onset psychogenic nonepileptic attacks

Objective: To investigate differences between groups of patients with early vs late onset psychogenic nonepileptic attacks (PNEA). Methods: The authors compared patients with onset of PNEA after age 55 years (n = 26) to patients whose onset of PNEA was before age 55 years (n = 241). The authors examined sociodemographic variables, factors potentially predisposing to PNEA, clinical semiology, and medical and psychiatric background. Results: Patients with late onset PNEA were more likely to be male (p = 0.029) (p values are quoted uncorrected for multiple comparisons). They were less likely to report antecedent sexual abuse (p = 0.008), and more likely to have severe physical health problems (p < 0.001) and to report health-related traumatic experiences (p < 0.0001). There were no clear differences in PNEA clinical semiology. There was a trend to better baseline mental health in the late onset group. Conclusions: The data suggest a distinct subgroup of patients with late onset psychogenic nonepileptic attacks, in whom psychological trauma related to poor physical health plays a prominent role.

Gender differences in psychogenic non-epileptic seizures

PURPOSE To determine whether male and female populations of patients with psychogenic non-epileptic seizures (PNES) are similar, in terms of demographic and social factors, aetiological factors, the clinical characteristics of events and path to diagnosis. METHODS Prospective study by semi-structured interview of 160 consecutive patients (117 female and 43 male) with video EEG confirmed diagnosis of PNES + epileptic seizures (ES). RESULTS Most parameters showed no significant differences. Males were, however, more likely to be unemployed (P = 0.028), and females were six times more likely to self-harm (P = 0.050), though the numbers were small in these categories. Men were more likely to attribute their PNES to a predisposing factor for epilepsy (P = 0.001), and women were over eight times more likely to report sexual abuse (P = 0.001). Event semiology was similar, but women were more likely to weep after events (P = 0.017). The carers and family of men with PNES were three times less likely to accept the diagnosis of PNES (P = 0.017). CONCLUSIONS Our samples showed few significant gender differences, suggesting that other male and female populations of patients with PNES are likely to be similar also. Some of the differences we found may give insight into causation of PNES.

Clinical differences between patients with nonepileptic seizures who report antecedent sexual abuse and those who do not

Purpose: To investigate clinical differences between patients with psychogenic nonepileptic seizures (PNES) who report antecedent sexual abuse, and patients who do not.

The safety of antiepileptic drug withdrawal in patients with non-epileptic seizures.

Background: To determine whether withdrawal of anticonvulsant drugs (AED) can be carried out safely in patients with non-epileptic seizures (NES). Methods: Prospective evaluation of safety and outcome in 78 patients with NES who satisfied a standardised set of criteria for excluding the diagnosis of coexisting or underlying epilepsy. Findings: The patients were taking from one to three AED. Sixty four patients were withdrawn as outpatients, 14 as inpatients. Five patients stopped their drugs abruptly, and two had AED restarted and had to be withdrawn again. Otherwise all patients adhered to withdrawal schedules. A new type of attack in addition to NES was seen in three patients (complex partial seizures in all three cases). NES frequency declined in the group as a whole over the period of the study (follow up 6–12 months) in all individuals except for eight patients in whom there was a transient increase. Fourteen patients reported new physical symptoms after withdrawal; however, no serious adverse events were reported. Conclusions: With appropriate diagnostic investigation and surveillance during follow up withdrawal of AED can be achieved safely in patients with NES.

Pseudosleep events in patients with psychogenic non-epileptic seizures: prevalence and associations

Objectives: To determine the prevalence and clinical associations of a history of events during sleep in patients with psychogenic non-epileptic seizures (PNES, pseudoseizures), and to compare the prevalence of a history of sleep events with that in poorly controlled epilepsy. Methods: Prospective study by semistructured interview of the history of event patterns and their clinical associations in 142 patients with video EEG confirmed PNES, and 100 patients with poorly controlled epilepsy. Results: 84/142 patients with PNES (59%) and 47/100 with epilepsy (47%) gave a history of events during sleep (p = 0.062). In patients with PNES, significant associations were found between a history of sleep events and: convulsive clinical semiology, antiepileptic drug treatment, fatigue, suicide attempts, mood disorder, and physical abuse. A particularly strong association with social security benefit was also found (odds ratio 4.0, p<0.001). Conclusions: The prevalence of a history of sleep events is similar in PNES and epilepsy, and is of no value in discriminating between the two, although a history of events occurring exclusively during sleep does suggest epileptic seizures. The clinical associations found indicate that a combination of psychopathological and external influences may be important in determining whether or not a patient with PNES gives a history of events during sleep.

Misdiagnosis of epilepsy in patients prescribed anticonvulsant drugs for other reasons

Doctors must be clear to patients and other doctors when prescribing anticonvulsants for conditions other than epilepsy

Mortality in a cohort of patients with psychogenic non-epileptic seizures

Some evidence suggests that psychogenic non-epileptic seizures (PNES) are associated with increased mortality. The authors obtained death certificate information in a cohort of 260 patients who presented with PNES between 1999 and 2004. The follow-up period averaged 7.92 years, during which 17 patients died, 12/17 were under the age of 75 years, giving a premature (<75 years) mortality rate of 0.58%, compared with a Scottish mortality rate for the 40–75 years age group of 0.41% per year. The main predictor of death was the patient age at presentation of PNES. There was no correlation with withdrawal of anticonvulsant medication, and death certificate information provided no evidence to suggest that the deaths were related to the seizure disorder. The population had a high mean deprivation rank, providing a possible explanation for a modest increase in premature death rate.