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Summary: Introduction: It is estimated that up to 25% of patients referred to specialised epilepsy centers suffer from psychogenic non-epileptic seizures (PNES). The prognosis is unfavourable and there are no generally accepted treatment protocols. Method: In this study, the effect of an uncontrolled, prospective inpatient treatment program for PNES patients is evaluated. The treatment is multidisciplinary and based on cognitive behavioural principles. Seizure control, general psychopathology, anxiety, depression, coping, dissociation and health related quality of life are evaluated. Twenty-two patients participated in the study of which 16 patients were followed 6 months after treatment. Results: After follow-up, 81% of patients had a seizure reduction of over 50%, and half of them became seizure-free. Measures of anxiety, depression and dissociation tended to normalize, coping was more adequate and health related quality of life was increased slightly. In the period between the end of treatment and follow-up the most positive effects are maintained and even strengthened. Patients who became seizure-free at follow-up improved more on the psychological outcome measures than patients with continuing seizures. Conclusion: The outcome suggests effectiveness of the treatment. PNES patients may profit from a comprehensive, multidisciplinary treatment program following cognitive behavioural principles. Seizure cessation appears to be an important factor in the improvement of psychological functioning. [Copyright &y& Elsevier]

Although psychogenic nonepileptic seizures (PNES) are considered a stress-induced paroxysmal disintegration of cognitive functions, it remains unknown whether stress indeed impairs cognitive integrative functions, such as working memory (WM), in patients with PNES. An N-back task with emotional distracters (angry, happy, and neutral faces) was administered at baseline and after stress induction (Cold Pressor Test) to 19 patients with PNES and 20 matched healthy controls. At baseline, patients displayed increased WM interference for the facial distracters. After stress induction, group differences generalized to the no-distracter condition. Within patients, high cortisol stress responses were associated with larger stress-induced WM impairments in the no-distracter condition. These findings demonstrate that patients' cognitive integrative functions are impaired by social distracters and stress induction. Moreover, the stress- and cortisol-related generalization of the relative WM impairments offers a promising experimental model for the characteristic paroxysmal disintegration of attentional and mnemonic functions in patients with PNES associated with stress., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Purpose: Several studies have indicated that psychogenic nonepileptic seizures (PNES) are associated with psychological trauma, but only a few studies have examined the associations with neurobiologic stress systems, such as the hypothalamus-pituitary-adrenal (HPA) axis and its end-product cortisol. We tested several relevant HPA-axis functions in patients with PNES and related them to trauma history., Methods: Cortisol awakening curve, basal diurnal cortisol, and negative cortisol feedback (using a 1 mg dexamethasone suppression test) were examined in 18 patients with PNES and 19 matched healthy controls (HCs) using saliva cortisol sampling on two consecutive days at 19 time points. Concomitant sympathetic nervous system (SNS) activity was assessed by analyzing saliva alpha-amylase (sAA)., Results: Patients with PNES showed significantly increased basal diurnal cortisol levels compared to HCs. This effect was driven mainly by patients reporting sexual trauma who showed a trend toward higher cortisol levels as compared to patients without a sexual trauma report. Importantly, the increased basal diurnal cortisol levels in patients were not explained by depression, medication, or smoking, or by current seizures or group differences in SNS activity., Discussion: This is the first study showing that basal hypercortisolism in patients with PNES is independent of the acute occurrence of seizures. In addition, basal hypercortisolism was more pronounced in traumatized patients with PNES as compared to nontraumatized patients with PNES. These findings suggest that HPA-axis activity provides a significant neurobiologic marker for PNES.

Previous studies have provided evidence for a vigilant attentional bias toward threat stimuli and increased basal diurnal cortisol levels in patients with psychogenic nonepileptic seizures (PNES). Because cortisol levels may be predictive of threat vigilance, we reanalyzed previous data on threat vigilance in 19 unmedicated patients with PNES and found a positive correlation between baseline cortisol levels and attentional bias scores for threat stimuli (r=0.49, P=0.035). There was no such relationship in healthy matched controls (n=20) or in patients with epileptic seizures (n=17). These findings provide the first evidence linking an endocrine stress marker to increased threat sensitivity in PNES and support new integrated psychoneurobiological models of PNES.

Purpose: Psychogenic nonepileptic seizures (PNES) have long been considered as paroxysmal dissociative symptoms characterized by an alteration of attentional functions caused by severe stress or trauma. Although interpersonal trauma is common in PNES, the proposed relation between trauma and attentional functions remains under explored. We examined the attentional processing of social threat in PNES in relation to interpersonal trauma and acute psychological stress., Methods: A masked emotional Stroop test, comparing color-naming latencies for backwardly masked angry, neutral, and happy faces, was administered to 19 unmedicated patients with PNES and 20 matched healthy controls, at baseline and in a stress condition. Stress was induced by means of the Trier Social Stress Test and physiologic stress parameters, such as heart rate variability (HRV) and cortisol, were measured throughout the experiment., Results: No group differences related to the acute stress induction were found. Compared to controls, however, patients displayed a positive attentional bias for masked angry faces at baseline, which was correlated to self-reported sexual trauma. Moreover, patients showed lower HRV at baseline and during recovery., Discussion: These findings are suggestive of a state of hypervigilance in patients with PNES. The relation with self-reported trauma, moreover, offers the first evidence linking psychological risk factors to altered information processing in PNES.

Background: Animal and human studies have found that prior stressful events can result in an altered reactivity in the HPA axis. The aim of the present study was to investigate the role of adverse events in childhood on cortisol reactivity to psychosocial stress in young healthy subjects (n=80)., Methods: Salivary cortisol levels were measured before, during and after exposure to a psychosocial stress task in healthy men and women with high (n=33) and low (n=47) exposure to adverse childhood events., Results: A significant blunted cortisol response was found in individuals with a history of adverse events compared to individuals with no adverse life events, with no differences in baseline cortisol levels. This finding appeared to be primarily driven by men. The groups did not differ on any other physiological or subjective stress measure, including heart rate, blood pressure, and subjective tension., Conclusions: These findings suggest that, at least in healthy young males, adverse childhood events are associated with changes in HPA-axis functioning. Longitudinal studies are needed to investigate whether the blunted cortisol response is a risk factor in the etiology of psychiatric disorders or rather reflects resiliency with regard to the development of psychopathology.

The purpose of the present study was to investigate the effects of social stress and stress-induced cortisol on the preconscious selective attention to social threat. Twenty healthy participants were administered a masked emotional Stroop task (comparing color-naming latencies for angry, neutral and happy faces) in conditions of rest and social stress. Stress was induced by means of the Trier social stress test. Based on the stress-induced increase in cortisol levels, participants were allocated post hoc (median-split) to a high and low responders group. In contrast to low responders, high responders showed a negative or avoidant attentional bias to threat (i.e. shorter latencies for angry than neutral faces) in the rest condition. Most importantly, although low responders became avoidant, the high responders became vigilant to the angry faces after stress induction. There were no such effects for happy faces. Our findings are in line with previous studies in both animals and humans, that associate high glucocorticoid stress-responsiveness with diminished avoidance and prolonged freezing reactions during stress.