CPCP: Psychogenic Non-Epileptic Seizures by the Medical Students

Karl Loth M3

Karl Loth M3

Aeen Asghar M3

Aeen Asghar M3

Another very interesting Clinical Problems in Consultation Psychiatry (CPCP) presentation coming your way by 3rd year medical students Aeen Asghar and Karl Loth. Aeen is going into surgery and Karl is still thinking about what he’ll specialize in.

The controversial status of Psychogenic Non-Epileptic Seizures (PNES) starts with the name, which has evolved over many years. Terms like pseudoseizures and hysterical seizures, as the students mention, are out because they are invalidating to the patients.

A couple of observations I’d like to point out have to do with balancing the both/and nature of epilepsy and PNES. Figures vary about the extent of comorbidity of epilepsy with PNES, anywhere from 3.6% to 58% in one review [1]. The point is that they can occur together and keeping that in mind is essential to patient-centered, safe management.

The other point is that there’s hope for recovery even though a significant proportion of patients struggle over the long term toward healing. At least in my view, one of the more exciting new developments is a study involving the use of mindfulness-based interventions [2].

And here’s the active link from slide 3 to “The Truth about Psychogenic Nonepileptic Seizures.”

 Extra References and see below for slides:

1. Hoepner, R., et al. (2014). “Distinguishing between patients with pure psychogenic nonepileptic seizures and those with comorbid epilepsy by means of clinical data.” Epilepsy & Behavior 35(0): 54-58.
Patients with psychogenic nonepileptic seizures (PNESs) often have additional epileptic seizures (ESs). Distinguishing between those with ESs and those without ESs is difficult but mandatory. We hypothesize that these two patient groups differ in clinical data, which might be useful for establishing diagnosis. All patients with PNESs (n = 114) from the Bethel Epilepsy Centre treated between 1/11/2010 and 1/11/2011 were included. Thirty-six percent had additional epilepsy. In contrast, 84 of the 114 patients with PNESs took antiepileptic drugs (AEDs) (AED treatment: patients with PNESs = 44/73, patients with PNESs + ESs = 40/41), most of them (65.5%) as polytherapy. Significant differences between both groups were as follows: patients with PNESs were older at disease onset, had a shorter duration from onset to inpatient visit, were less frequently on AEDs, were less frequently on antiepileptic polytherapy, and had a normal EEG compared with patients with PNESs + ESs. Multivariate stepwise logistic regression revealed age at seizure onset, number of AEDs, and difference between number of AEDs and psychiatric drugs as significant predictors of patients with ESs in PNESs (Nagelkerke’s r2 = 0.59). Therefore, clinical data proved to be useful in the diagnostic process. http://www.sciencedirect.com/science/article/pii/S1525505014001231

2. Baslet, G., et al. (2014). “Treatment of Psychogenic Nonepileptic Seizures: Updated Review and Findings From a Mindfulness-Based Intervention Case Series.” Clinical EEG and Neuroscience.
Psychogenic nonepileptic seizures (PNES) were first described in the medical literature in the 19th century, as seizure-like attacks not related to an identified central nervous system lesion, and are currently classified as a conversion disorder, according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). While a universally accepted and unifying etiological model does not yet exist, several risk factors have been identified. Management of PNES should be based on interdisciplinary collaboration, targeting modifiable risk factors. The first treatment phase in PNES is patient engagement, which is challenging given the demonstrated low rates of treatment retention. Acute interventions constitute the next phase in treatment, and most research studies focus on short-term evidence-based interventions. Randomized controlled pilot trials support cognitive–behavioral therapy. Other psychotherapeutic and psychopharmacological interventions have been less well-studied using controlled and uncontrolled trials. Within the discussion of acute interventions, we present a preliminary evaluation for feasibility of a mindfulness-based psychotherapy protocol in a very small sample of PNES patients. We demonstrated in 6 subjects that this intervention is feasible in real-life clinical scenarios and warrants further investigation in larger scale studies. The final treatment phase is long-term follow-up. Long-term outcome studies in PNES show that a significant proportion of patients remains symptomatic and experiences continued impairments in quality of life and functionality. We believe that PNES should be understood as a disease that requires different types of intervention during the various phases of treatment. http://eeg.sagepub.com/content/early/2014/12/01/1550059414557025.long


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