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Objective Psychogenic nonepileptic seizures (PNES) are associated with high alexithymia, social cognition problems and low quality of life (QoL). Theory of Mind (ToM) has been studied in several conditions as a significant predictor of QoL. We aimed to assess the relationship between ToM abilities, alexithymia and subjective QoL in PNES patients and compare with generalised epilepsy (ES) patients and healthy controls. Method Patients with PNES (n = 28), ES (n = 28) and healthy volunteers (n = 28) were evaluated for alexithymia and quality of life (QoL) with Toronto Alexithymia Scale-20 (TAS-20) and Short Form-36 (SF-36). Reading the Mind in the Eyes test was used for assessment of affective ToM and Hinting Task and Strange Stories tests for cognitive ToM abilities. Results Analyses revealed lower SF-36 scores and poorer ToM performance in the PNES group compared to healthy group and poorer cognitive ToM performance than ES group. Cognitive ToM performance was inversely correlated with TAS-20 “difficulty identifying feelings” subscale and “physical functioning” subscale of SF-36 in the PNES group. Conclusion These results are consistent with previous research on PNES and other somatoform disorders and suggest that PNES is associated with impaired ToM task performance. ToM task performance might be related to specific aspects of alexithymia and QoL.

Objectives The aim of the current study was to compare the frequency of significant head injuries in three groups of people with seizures [idiopathic generalized epilepsies (IGE) vs. temporal lobe epilepsy (TLE) vs. functional seizures (FS)]. Methods This was a retrospective study. All patients with a diagnosis of IGE, TLE, or FS were recruited at the outpatient epilepsy clinic at Shiraz University of Medical Sciences, Shiraz, Iran, from 2008 until 2020. Results One thousand and four hundred ninety-two patients were studied (559 patients with IGE, 646 people with TLE, and 287 persons with FS). Overall, 77 (5.2%) individuals of the studied people reported experiencing severe head injuries before the onset of their seizures [9 patients (1.6%) with IGE, 56 people (8.7%) with TLE, and 12 persons (4.2%) with FS; p = 0.0001]. Compared to people with IGE, the odds ratio of having a premorbid history of severe head injury in the FS group was 2.67 [95% Confidence Interval (CI): 1.11–6.40; p = 0.0280]. Compared to people with TLE, the odds ratio of having a premorbid history of severe head injury in the FS group was 0.46 (95% CI: 0.24–0.87; p = 0.0170). Conclusion Severe head injury is significantly associated with FS. However, since head injury is also a significant risk factor for focal epilepsies, it may be necessary to ascertain the diagnosis of post-traumatic seizures by obtaing a detailed clinical history and also by performing video-EEG monitoring in order to adopt an appropriate treatment strategy in these patients.

To compare auras between three groups of people with seizures [i.e., Idiopathic generalized epilepsies (IGE) vs. Temporal lobe epilepsy (TLE) vs. Functional seizures (FS)].All patients, 10 years of age or older, with a diagnosis of IGE, TLE, or FS were prospectively registered in an electronic database and retrospectively studied at the outpatient epilepsy clinic at Shiraz University of Medical Sciences, Shiraz, Iran, from 2008 until 2020.One thousand and three hundred ninety-one patients were studied (480 with IGE, 617 with TLE, and 294 with FS). Among patients with TLE, 63.5% of individuals reported auras; this figure was 68% in the FS and 12.7% in the IGE groups (p0.00001). Odds ratio of having auras in the TLE group compared with the IGE group was 11.96 (95% CI: 8.73-16.39; p = 0.0001). Odds ratio of having auras in the TLE group compared with the FS group was 0.81 (95% CI: 0.61-1.10; p = 0.1840). Odds ratio of having auras in the FS group compared with the IGE group was 14.61 (95% CI: 10.15-21.02; p = 0.0001). The following auras were more frequent among patients with TLE: emotional, cognitive, epigastric, and olfactory/gustatory. The following auras were more frequent among patients with FS: headache and dizziness/vertigo.Auras are not specific to focal epilepsies. Future studies should investigate auras in large cohorts of patients with focal or generalized epilepsies and also those with FS to determine the exact clinical value of each aura.

Purpose The purpose of this study was to investigate the sensitivity and specificity of a standardized placebo protocol using a moist swab pad application in children and adolescents with psychogenic seizures vs epileptic seizures. Methods We retrospectively reviewed clinical data and video-EEG monitoring records with the standardized placebo protocol of 408 patients. Video -EEG diagnosis with PNES-consistent semiology was made in the context of clinical data by a two-certified epileptologist. Results of induction of psychogenic seizure by moist swab pad application were analyzed in 158 patients with PNES. A control group was composed of 74 patients with epilepsy in which induction was performed. Results Sensitivity of placebo test for the diagnosis of PNES was 81.1%, specificity 79.8%, positive predictive value 89.6% and negative predictive value 66.3%. Conclusion The placebo technique with a moist swab can be regarded as helpful in triggering a psychogenic episode in children and adolescents.

Purpose The average delay from first seizure to diagnosis of psychogenic non-epileptic seizures (PNES) is over 7 years. The reason for this delay is not well understood. We hypothesized that a perceived decrease in seizure frequency after starting an anti-seizure medication (ASM) may contribute to longer delays, but the frequency of such a response has not been well established. Methods Time from onset to diagnosis, medication history and associated seizure frequency was acquired from the medical records of 297 consecutive patients with PNES diagnosed using video-electroencephalographic monitoring. Exponential regression was used to model the effect of medication trials and response on diagnostic delay. Results Mean diagnostic delay was 8.4 years (min 1 day, max 52 years). The robust average diagnostic delay was 2.8 years (95% CI: 2.2–3.5 years) based on an exponential model as 10 to the mean of log 10 delay. Each ASM trial increased the robust average delay exponentially by at least one third of a year (Wald t =3.6, p =0.004). Response to ASM trials did not significantly change diagnostic delay (Wald t =−0.9, p =0.38). Conclusion Although a response to ASMs was observed commonly in these patients with PNES, the presence of a response was not associated with longer time until definitive diagnosis. Instead, the number of ASMs tried was associated with a longer delay until diagnosis, suggesting that ASM trials were continued despite lack of response. These data support the guideline that patients with seizures should be referred to epilepsy care centers after failure of two medication trials.

Purpose Although most neuroscientists and physicians would argue against Cartesian dualism, Descartes's version of the psyche/soma divide, which has been controversial since he proposed it in the seventeenth century, continues to haunt contemporary neurological diagnoses through terms such as functional , organic , and psychogenic . Drawing on my own experiences as a person with medically unexplained seizures, I ask what this language actually means if all human experience has an organic basis. Methods Close reading of a textbook chapter on psychogenic seizures. Results I expose the author's unreflective embrace of psyche and soma as distinct entities, his inherent bias against illnesses labeled psychogenic, and the implicit sexism of his position. I further argue that even when a patient's symptoms are not alleviated, heightened self-consciousness and narrative framing can strengthen his or her sense of agency and have therapeutic benefits. Conclusion The ethical treatment of patients requires a respect for their stories.

Purpose The aim of this meta-analysis is to evaluate and synthesize the available evidence from the previous 20 years regarding the utility of psychological interventions in the management of psychogenic non-epileptic seizures (PNES). Method Studies were retrieved from MEDLINE via OvidSP and PsychINFO. Selection criteria included controlled and before-after non-controlled studies including case series, using seizure frequency as an outcome measurement. Studies were required to assess one or more types of psychological intervention for the treatment of PNES in adults. Data from 13 eligible studies was pooled to examine the effectiveness of psychological interventions in treating PNES on two primary outcomes: seizure reduction of 50% or more and seizure freedom. A meta-analysis was conducted with data extracted from 228 participants with PNES. Results Interventions reviewed in the analysis included CBT, psychodynamic therapy, paradoxical intention therapy, mindfulness and psychoeducation and eclectic interventions. Meta-analysis synthesized data from 13 studies with a total of 228 participants with PNES, of varied gender and age. Results showed 47% of people with PNES are seizure free upon completion of a psychological intervention. Additional meta-analysis synthesized data from 10 studies with a total of 137 participants with PNES. This analysis found 82% of people with PNES who complete psychological treatment experience a reduction in seizures of at least 50%. Conclusion The studies identified for this analysis were diverse in nature and quality. The findings highlight the potential for psychological interventions as a favorable alternative to the current lack of treatment options offered to people with PNES.

Understanding stress and coping among individuals with psychogenic nonepileptic seizures (PNES) may have important treatment implications. 40 patients with PNES, 20 with epilepsy (EPIL), and 40 healthy control (HC) participants reported the frequency of various stressful life events (both positive and negative) and appraised the distress these events induced. They also described their habitual coping behaviors. PNES patients reported no more frequent stressful life events than EPIL patients or HC. In addition, the stressors they experienced are not objectively more severe. However, they reported more severe distress due to negative life events, especially in the domains of work, social functioning, legal matters, and health. PNES patients also engaged in less planning and active coping than HC. Neither of these two coping behaviors was associated with distress ratings. The PNES group did not engage in more denial than either group. However, greater denial among PNES patients was associated with greater perceived distress. Coping in PNES is characterized by elevated levels of perceived distress and fewer action strategies than are normally employed to reduce the impact of a stressor. These findings may inform cognitive behavioral therapy of PNES patients.

Purpose (1) To evaluate autonomic nervous system (ANS) functions during both interictal and postictal periods in a group of cases with nonepileptic psychogenic seizures (NEPS) and a group of epileptic patients to determine whether they have autonomic dysfunction. (2) If a significant difference can be established between epileptic and NEPS groups, to determine whether ANS tests can be used as a clinical helper in the differentiation between epileptic seizures (ES) and NEPS. Methods ANS functions (sympathetic skin response and R–R interval variation) were measured during both interictal and postictal periods in 25 patients who had NEPS and 30 patients who had primary generalized tonic–clonic seizures (GTCS) and partial seizures with secondary GTCS, as well as once in the healthy control group. Results When the patient group with NEPS both in the interictal and postictal period was compared with the control group, functions of both sympathetic and parasympathetic systems were found normal. This finding implies that patients with NEPS have normal ANS functions. A comparison of the epileptic patient group in the interictal and postictal periods with the control group revealed that the former had dysfunctions in both the sympathetic and parasympathetic systems. When patients with NEPS were compared with the ES, the measurements in sympathetic and parasympathetic nervous system functions during the interictal and postictal periods in the ES group were significantly different than those of the NEPS group. Conclusion This finding indicates that measurements of ANS functions may be helpful in differentiating between ES and NEPS.

Background: There are numerous terms to describe seizure-like episodes not explained by disease—for example pseudoseizures, psychogenic seizures and non-epileptic attack disorder. Debates about which is best to use tend to centre around theoretical arguments and not scientific evaluation. In this study we examine the meanings of these labels for patients, which have the least potential to offend, and consequently to provide a more positive basis for further management. Methods and results: We interviewed 102 consecutive general neurology outpatients who were asked to consider a scenario that they were being given a diagnosis by a doctor after experiencing a blackout with normal tests. We investigated 10 different diagnoses for blackouts with six different connotations. Three of these connotations—‘putting it on', ‘mad' and ‘imagining symptoms'—were used to derive an overall ‘offence score'. Using this score some labels were highly offensive, e.g. ‘symptoms all in the mind' (89%) and ‘hysterical seizures' (48%). There were no significant differences between the labels ‘pseudoseizures', ‘psychogenic seizures' and ‘non-epileptic attack disorder'. ‘Stress-related seizures' and ‘functional seizures' were significantly less offensive than these three diagnoses and were equivalent to ‘tonic–clonic' and ‘grand mal'. Conclusions: Many labels for seizures unexplained by disease are potentially offensive to patients. The search for labels that accurately describe the phenomenon, can be used by patients, doctors and researchers and enhance trust and recovery is worthwhile and amenable to scientific study.

A follow-up study was performed in 33 patients with proven (ictal EEG-CCTV) psychogenic, non-epilptic seizures (PNES). These patients received a questionnaire to evaluate seizures, treatment and rehabilitation. The response group consisted of 21 females (80% response) and seven males (100% response). Follow-up after diagnosis varied from 23–67 months. Seven patients (25%) reported that seizures had ceased and of the patients not seizure-free seven did report a seizure-free period after diagnosis of an average 6.7 months. Eight patients were on antiepileptic drugs again. Of 13 patients referred for psychotherapy, who also did receive treatment, six became free of seizures and seven did not. Of seven patients also referred, but who did not receive psychotherapy, all continued to have seizures. On a self-rating scale to compare "overall function" at the time of diagnosis and follow-up, 75% considered themselves to have "improved", but no improvement could be detected in psychosocial functioning.

The economic burden of epilepsy is well recognized. However, empirical investigation establishing costs associated with the diagnosis and treatment of non-epileptic psychogenic seizures (NEPS) is lacking. We studied 20 patients with video/EEG monitoring-confirmed NEPS to determine the effect of definitive diagnosis and treatment on medical costs and utilization. A medical resource utilization questionnaire and inpatient medical chart review were employed to calculate utilization information. Medication usage, outpatient visits, emergency room admissions, and diagnostic testing over a 6-month pre-diagnosis and a 6- month post-diagnosis period were compared. There was an 84% average reduction in total seizure-related medical charges in the 6 months following NEPS diagnosis. Average diagnostic testing charges declined 76%, average medication charges decreased 69%, outpatient clinic visits declined 80%, and emergency room visits reduced by 97%. A majority of patients obtaining a definitive inpatient video/EEG-seizure-monitoring-confirmed NEPS diagnosis experience substantial reductions in health care utilization and dollar costs.

The clinical characteristics, psychosocial background, neuropsychological testing, clinical and social outcome were analysed in 93 adults with psychogenic seizures (PS). Thirteen (14%) were males and 80 (86%) were females. Mean age was 31.7 years (range 16 to 55 years). Lack of responsiveness associated with motor activity was the most common finding. Neuropsychological testing done in 46 cases revealed hysteroid traits and coping mechanisms and depression to be the most prevalent underlying problems. History of sexual abuse was evident in 10 (10.7%) cases. Social impact analysis revealed that of 62 patients who were working at the onset of PS, 34 were not working at the time of the diagnosis of PS. In 25 cases, PS were the reason for not working. After a mean follow-up of 60.7 months done in 63 patients, 16 (25.4%) patients were seizure-free. There were no obvious significant predictors of poor prognosis.

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.(ABSTRACT TRUNCATED AT 250 WORDS)

The prevalence of psychogenic non-epileptic seizures is difficult to estimate. We propose an estimate based on a calculation. We used the following data, which are known or have been estimated, and are generally accepted. A prevalence of epilepsy of 0.5–1%; a proportion of intractable epilepsy of 20–30%; a percentage of these referred to epilepsy centers of 20–50%; and a percentage of patients referred to epilepsy centers that are psychogenic non-epileptic seizures: 10–20%. Using the low estimates, the prevalence of psychogenic non-epileptic seizures would be 1/50 000. Using the high estimates, the prevalence of psychogenic non-epileptic seizures would be 1/3000. The prevalence of psychogenic non-epileptic seizures is somewhere between 1/50 000 and 1/3000, or 2 to 33 per 100 000, making it a significant neurologic condition.

We describe two patients with psychogenic seizures of rare semiology. Both patients (a 23-year-old man and a 26-year-old woman) attended the emergency department because status epilepticus with myoclonic seizures had been diagnosed. Seizures were documented with video-electroencephalography. Semiology of seizures were brief myoclonia of both arms resulting in a short elevation of both arms without impairment of consciousness. Ictal EEG registration was without abnormal finding. Psychiatric diagnostic assessment suggested a dissociative disorder and mild depression, respectively. During psychiatric treatment seizures occurred only rarely within a 3–5 months follow-up. One should be aware that juvenile myoclonic epilepsy may be mimicked by psychogenic seizures

Rationale: The study aim was to assess patients' understanding of and reaction to a diagnosis of non-epileptic attack disorder and to explore whether these factors contribute to outcome. Method: Eighty-four patients diagnosed with non-epileptic attack disorder participated in the study. Participants answered questions about their seizures and understanding and reaction to the diagnosis. Data were collected by semi-structured telephone interview. Questionnaires were sent to the patients' general practitioners (GPs) to gather information regarding the patient's seizure status, prescription of anti-epileptic drugs and opinion regarding the diagnosis. Results: At the time of follow-up, a third of participants reported being seizure free. A total of 63% did not have a good understanding of the diagnosis, most were unclear about the precipitating factors and the most common reaction to the diagnosis was confusion. Many reported a negative impact of NES on everyday life. Sixty-five percent reported receiving psychological follow-up but the number of sessions attended was few (median 2). There was evidence that the reaction to the diagnosis contributed to the outcome in particular an angry outcome was associated with a poor prognosis. Ten GPs did not agree with the diagnosis. Conclusion: Patients understanding and reactions to a diagnosis of non-epileptic attacks are important factors that should contribute to the development of more tailored treatment approaches.

Background: There are numerous terms to describe seizure-like episodes not explained by disease—for example pseudoseizures, psychogenic seizures and non-epileptic attack disorder. Debates about which is best to use tend to centre around theoretical arguments and not scientific evaluation. In this study we examine the meanings of these labels for patients, which have the least potential to offend, and consequently to provide a more positive basis for further management.Methods and results: We interviewed 102 consecutive general neurology outpatients who were asked to consider a scenario that they were being given a diagnosis by a doctor after experiencing a blackout with normal tests. We investigated 10 different diagnoses for blackouts with six different connotations. Three of these connotations—‘putting it on’, ‘mad’ and ‘imagining symptoms’—were used to derive an overall ‘offence score’. Using this score some labels were highly offensive, e.g. ‘symptoms all in the mind’ (89%) and ‘hysterical seizures’ (48%). There were no significant differences between the labels ‘pseudoseizures’, ‘psychogenic seizures’ and ‘non-epileptic attack disorder’. ‘Stress-related seizures’ and ‘functional seizures’ were significantly less offensive than these three diagnoses and were equivalent to ‘tonic–clonic’ and ‘grand mal’.Conclusions: Many labels for seizures unexplained by disease are potentially offensive to patients. The search for labels that accurately describe the phenomenon, can be used by patients, doctors and researchers and enhance trust and recovery is worthwhile and amenable to scientific study.

Patients with psychogenic nonepileptic seizures (PNESs) or pseudoseizures are known to have psychiatric comorbidities. In the present retrospective analysis, we examined the sociodemographics, clinical characteristics, and psychiatric diagnoses of patients with PNESs. Our aim is to demonstrate the contribution of the consulting psychiatrists to the presumed psychiatric diagnoses of the neurologists. We used data from long-term video EEG monitoring (LVEM) performed at a specialized epilepsy center in Turkey. The study group comprised 67 patients (mean age: 30years, 75% female) diagnosed with PNESs following LVEM of approximately 5 days’ duration. Two hundred thirty-three episodes were recorded. Most of the patients experienced a PNES on the first day. All of the patients were taking antiepileptic drugs (AEDs) at the time of admission; 56.7% were taking antidepressant (AD) drugs. All of the PNES patients were diagnosed with conversion disorder by both the neurologists and the psychiatrists. Most of the PNES patients were using multiple AEDs. Cooperation between neurologists and psychiatrists and ongoing education for both neurologists and psychiatrists about PNES are needed in appropriate diagnosing and management of patients with PNES.