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Psychogenic nonepileptic seizures (PNES) are classified as a mental disorder, the manifestations of which superficially resemble epileptic seizures. There is a notable lack of in-depth qualitative or quantitative studies investigating the stigma attached to PNES. The current study is an exploratory analysis into the nature of perceived stigma in those with PNES when compared with individuals with epilepsy. Individuals with epilepsy (n=78) and PNES (n=47) were recruited from a United Kingdom hospital or membership-led organizations for individuals living with seizures. Participants were asked to complete a series of questionnaires investigating health-related quality-of-life components (NEWQOL-6D), anxiety (GAD-7), depression (NDDI-E), seizure frequency and severity (LSSS-3), and illness perception (B-IPQ). Perceived stigma was measured using one question taken from the NEWQOL-6D. Individuals with PNES reported a greater level of perceived stigma than those with epilepsy (p=0.04). Our results indicate that the risk of experiencing perceived stigma in PNES was 42% higher than the risk in epilepsy. In epilepsy, but not PNES, perceived stigma was significantly associated with seizure frequency, anxiety, depression, and many of the sequelae of the condition. In both conditions, self-control was associated with stigma (rho≥0.34, p≤0.01). This study was exploratory, and so definitive conclusions cannot be made; however, our findings suggest that the majority (87.2%) of individuals with PNES reported experiencing some degree of perceived stigma, the risk of which is greater than that in epilepsy. Further research is needed into the prevalence, nature, and consequences of stigma in PNES.

Introduction An uncomplicated, self-limiting epileptic seizure in a patient with an established diagnosis of epilepsy usually requires only first aid, but in the UK it is estimated that 75% of these patients are transported to hospital and many are discharged without review or follow-up with an epilepsy specialist. Alternative care pathways (ACP) have the potential to reduce unnecessary conveyance to hospital and to improve rates of epilepsy specialist follow-up, and thereby increase the quality and cost effectiveness of care. Methods A service evaluation of a new ACP in a regional ambulance service in the United Kingdom. The ACP allowed paramedics to refer eligible patients to an epilepsy specialist nurse service. Results The ambulance service managed 3,964 suspected seizure incidents in the study period (1 July 2015 – 31 May 2016) of which 22.5% (891 /3,964) were potentially eligible for the ACP. 9.8% (87/891) of the potentially eligible incidents were referred. The 87 incidents were generated by 74 individual patients. 97.3% (71/73) patients were contacted within the target time of 5 days, the average time taken for each phone call was 10 minutes and the average additional work load generated by each call was 10 minutes. There was a positive outcome in 55% (48/87) of incidents. Conclusions An ACP for people after a suspected seizure has the potential to safely reduce rates of transport to hospital and to improve care for people with epilepsy. However, paramedics in our study used the ACP for only a small proportion of those patients who were potentially eligible. Further research is required to develop tools to support paramedics to confidently identify patients that are suitable for management without transport to hospital.

Between 2009 and 2012 there were 26 epilepsy-related deaths in the UK of women who were pregnant or in the first post-partum year. The number of pregnancy-related deaths in women with epilepsy (WWE) has been increasing. Expert assessment suggests that most epilepsy-related deaths in pregnancy were preventable and attributable to poor seizure control. While prevention of seizures during pregnancy is important, a balance must be struck between seizure control and the teratogenic potential of antiepileptic drugs (AEDs). A range of professional guidance on the management of epilepsy in pregnancy has previously been issued, but little attention has been paid to how optimal care can be delivered to WWE by a range of healthcare professionals. We summarise the findings of a multidisciplinary meeting with representation from a wide group of professional bodies. This focussed on the implementation of optimal pregnancy epilepsy care aiming to reduce mortality of epilepsy in mothers and reduce morbidity in babies exposed to AEDs in utero. We identify in particular -What stage to intervene - Golden Moments of opportunities for improving outcomes -Which Key Groups have a role in making change -When - 2020 vision of what these improvements aim to achieve. -How to monitor the success in this field We believe that the service improvement ideas developed for the UK may provide a template for similar initiatives in other countries.

ObjectivesPatients with functional memory disorder (FMD) report significant memory failures in everyday life. Differentiating these patients from those with memory difficulties due to early stage neurodegenerative conditions is clinically challenging. The current study explored whether distinctive neuropsychological profiles could be established, suitable to differentiate patients with FMD from healthy individuals and those experiencing amnestic mild cognitive impairment (a-MCI).MethodsPatients with a clinical diagnosis of FMD were compared with patients with a-MCI, and healthy matched controls on several tests assessing different cognitive functions. Patients with clinically established mood disorders were excluded. Patients with FMD and a-MCI were broadly comparable on the level of their subjective memory complaints as assessed by clinical interview.ResultsThe neuropsychological profile of the FMD patients, although they expressed subjective memory and attention concerns during their clinical interview was distinct from patients with a-MCI on tests of memory [semantic fluency, age of acquisition (AoA) analysis of semantic fluency, verbal and non-verbal memory]. FMD patients did not differ significantly from healthy controls, but their scores on the letter fluency and digit cancellation tasks were not significantly different from those of the a-MCI patients indicating a possible sub-threshold deficit on these tasks.ConclusionWhilst subjective complaints are common within the FMD population, no objective impairment could be detected, even on a sensitive battery of tasks designed to detect subtle deficits caused by an early neurodegenerative brain disease. This study indicates that FMD patients can be successfully differentiated from patients with neurodegenerative memory decline by characterising their neuropsychological profile.

BACKGROUND: The early diagnosis of dementia is of great clinical and social importance. A recent study using the qualitative methodology of conversation analysis (CA) demonstrated that language and communication problems are evident during interactions between patients and neurologists, and that interactional observations can be used to differentiate between cognitive difficulties due to neurodegenerative disorders (ND) or functional memory disorders (FMD). OBJECTIVE: This study explores whether the differential diagnostic analysis of doctor-patient interactions in a memory clinic can be automated. METHODS: Verbatim transcripts of conversations between neurologists and patients initially presenting with memory problems to a specialist clinic were produced manually (15 with FMD, and 15 with ND). A range of automatically detectable features focusing on acoustic, lexical, semantic, and visual information contained in the transcripts were defined aiming to replicate the diagnostic qualitative observations. The features were used to train a set of five machine learning classifiers to distinguish between ND and FMD. RESULTS: The mean rate of correct classification between ND and FMD was 93% ranging from 97% by the Perceptron classifier to 90% by the Random Forest classifier.Using only the ten best features, the mean correct classification score increased to 95%. CONCLUSION: This pilot study provides proof-of-principle that a machine learning approach to analyzing transcripts of interactions between neurologists and patients describing memory problems can distinguish people with neurodegenerative dementia from people with FMD.

Purpose\ud Patients with epilepsy and those with psychogenic non-epileptic seizures (PNES) experience high levels of stress and stress is one of the most frequently self-identified seizure precipitants. Although stress is a multifaceted phenomenon, few studies have systematically examined its different components in patients with seizures. The aim of this study was therefore to describe diurnal patterns of psychological and physiological measures of stress in patients with epilepsy and patients with PNES, and explore their relationships to each other in order to improve our understanding of the mechanisms underlying stress and seizure occurrence in these patients.\ud \ud Method\ud A range of stress markers including self-reported stress, salivary cortisol, and heart rate variability (HRV) were explored in adult patients with refractory epilepsy (N = 22) and those with PNES (N = 23) undergoing three- to five-day video-telemetry.\ud \ud Results\ud A diurnal pattern was observed in the physiological measures, characterized by higher levels of physiological arousal in the mornings and lower levels at night in both patients with epilepsy and PNES. The physiological measures (cortisol and HRV) were associated with each other in patients with epilepsy; no close relationship was found with self-reported stress in either of the two patient groups.\ud \ud Conclusion\ud The findings contribute to and expand on previous studies of the patterns of stress in patients with seizures. The results also indicate a discrepancy between patients' physiological responses and their subjective stress perceptions, suggesting that simple self-reports cannot be used as a proxy of physiological arousal in patients with seizures and stress. Stress in these patient groups should be studied using a combination of complementary measures.\ud \ud

OBJECTIVES: Psychopathology levels are elevated in patients with psychogenic non-epileptic seizures (PNES) and those with epilepsy. However, patients with PNES report higher rates of trauma and neglect, poorer health-related quality of life (HRQoL), and an increased prevalence of insecure attachment. We examined to what extent attachment style and relationship quality with their main informal carer impact on levels of HRQoL, depression, and anxiety in patients with PNES versus those with epilepsy. METHOD: Consecutive patients with PNES (N=23) and epilepsy (N=72) completed questionnaires about attachment style, quality of their relationship with their main informal carer, seizure severity, HRQoL, depression, and anxiety. RESULTS: Patients with PNES reported higher levels of anxiety and depression and lower HRQoL than those with epilepsy. PNES: No significant correlations were found with HRQoL but depression correlated positively with attachment avoidance, attachment anxiety, and relationship conflict. Anxiety correlated positively with attachment avoidance, attachment anxiety, and relationship conflict, and negatively with relationship depth and support. Epilepsy: HRQoL correlated negatively with seizure severity, depression, anxiety, attachment avoidance, and attachment anxiety. Depression correlated positively with attachment avoidance, attachment anxiety, and relationship conflict. Anxiety correlated positively with seizure severity, attachment avoidance, and attachment anxiety. Correlations between measures of relationship quality and anxiety were stronger in patients with PNES versus those with epilepsy (zs=2.66 to 2.97, ps

Purpose\ud Self-compassion has been associated with a set of adaptive coping strategies, which in turn explain better adjustment in individuals with chronic illnesses such as inflammatory bowel disease and arthritis. The aim of this study was to investigate whether self-compassion is associated with adjustment in people with epilepsy (PWE) and people with psychogenic nonepileptic seizures (PWPNES). Adjustment was measured via coping efficacy, quality of life (QoL), anxiety, and depression.\ud \ud Method\ud A cross-sectional questionnaire design was employed. People with epilepsy (N = 74), PWPNES (N = 46), and controls (N = 89), recruited from outpatient seizure clinics and online, completed questionnaires about their self-compassion, coping efficacy, QoL, anxiety, and depression levels.\ud \ud Results\ud Overall, self-compassion was associated with adjustment in PWE and PWPNES. Self-compassion was negatively related to anxiety and depression in PWE, PWPNES, and controls and positively related to coping efficacy in PWE and PWPNES. Self-compassion was also positively related to QoL in PWE and controls; however, this relationship was not significant in PWPNES.\ud \ud Conclusion\ud Self-compassion is associated with better adjustment in PWE and PWPNES. Implications of these findings for psychotherapeutic interventions for individuals with seizure disorders and future research are discussed.

Background Generic or even disease-specific quality of life measures are unlikely to be equally responsive to different epilepsy treatment modalities, such as pharmacotherapy, surgery, or psychotherapy. The purpose of the present study was to summarize the development of a patient-reported outcome measure (PROM) designed to be particularly sensitive to change mediated by psychotherapeutic interventions in people with seizures. Methods The development of this instrument involved seven steps: (1) Development of a candidate item set based on the outcome of previous qualitative research, (2) initial quantitative–descriptive study yielding an assessment of content validity by clinical experts, (3) qualitative–descriptive posttherapy cognitive debriefing interviews with patients with epileptic and/or nonepileptic seizures (NES), (4) English translation, (5) elicitation of qualitative feedback from international experts, (6) assessment of internal consistency and correlation with similar previously validated generic and epilepsy-specific measures in a pilot study, and (7) final expert content validity rating. Results (1) The candidate item set comprised 29 stem items; five of which were followed by a follow-up (FU) item that refers to the statement of the stem item. (2) Eight clinical experts assessed content validity. Informed by rating and experts' qualitative comments, 15 items remained unchanged, eleven underwent substantial revisions, three were excluded, and six added. (3) Cognitive debriefing interviews were conducted with 14 patients with epilepsy and/or NES. Based on the interviewees' feedback, 29 of 32 items remained unchanged, two were excluded, one reworded, and four added. (4) The forwards–backwards English translation prompted substantial revision of two items because the verbatim back translation of the corresponding English items was conceptually more convincing than the original German wording. (5) The international experts identified problems with item comprehensibility/clarity of four stem and three FU items that were subsequently reworded. Ten items were added to incorporate their qualitative feedback resulting in a total of 44 items. (6) Thirty-one patients with epilepsy participated in the pilot study. The overall internal consistency of the self- E fficacy, A ssertiveness, S ocial support, self-awareness, and h E lpful thinking in people with seizures (EASE) was very good (α = 0.92). Analysis at item-level revealed problems with inverted and self-evident items. Based on this analysis, three items were eliminated and two items were revised (one FU item was turned into a stem item) resulting in a total of 42 items. (7) The second content validity rating showed final item-content validity indices (I-CVIs) between 0.38 and 1 and an excellent mean CVI of 0.92 at scale level (S-CVI/ave). Fourteen stem items were substantially revised by incorporating the experts' qualitative feedback, three items with low I-CVIs were excluded, and one item was added. The final questionnaire consisted of 40 stem items; eight of which include at least one FU item. Conclusion Based on these results, the EASE is valid in terms of content, internally consistent, clear, and acceptable to patients with seizures. The measure has now been developed to the stage at which the validity and reliability as well as the psychometric properties and factorial structure of the new instrument can be assessed in larger patient groups in a prospective clinical study.

OBJECTIVE:Functional movement and seizure disorders are still widely misunderstood and receive little public and academic attention. This is in stark contrast to their high prevalence and levels of associated disability. In an exploratory observational study, the authors examined whether the relative lack of media coverage of functional neurological disorders is in part due to misidentification in "human interest" news stories. METHODS:Thirteen recent news stories from high-impact English-language media outlets that portrayed patients with complex symptoms either attributed to other diagnoses or presented as medical mysteries were identified using online keyword searches. All selected news stories contained video or still images displaying relevant symptoms. Cases were categorized into movement disorders or seizure disorders and were then independently assessed by 10 respective expert raters. For each category, one story of a patient whose symptoms were due to a well-recognized neurological disease was also included. Both the diagnostic category and the respective confidence level were reported by each rater for each case. The interrater agreement was calculated for each group of disorders. RESULTS:The raters confirmed almost unanimously that all presented news stories except the negative control cases portrayed misidentified functional movement or seizure disorders. The interrater agreement and average diagnostic confidence were high. CONCLUSIONS:Functional neurological disorders are often wrongly considered a rare medical curiosity of the past. However, these findings suggest that, while they are largely absent from public discourse, they often appear in the news incognito, hiding in plain sight. The publisher's final version of this work can be found at https://doi.org/10.1176/appi.neuropsych.19010025. Deposited by shareyourpaper.org and openaccessbutton.org. We've taken reasonable steps to ensure this content doesn't violate copyright. However, if you think it does you can request a takedown by emailing help@openaccessbutton.org.

Aims Exploration of the relationship between negative life experiences and patients with Functional Neurological Disorder (FND), by analysing patient and non-clinical group responses to a new questionnaire called the Lifespan of Negative Experiences Scale (LiNES). LiNES was designed to examine predisposing vulnerabilities and perpetuating factors in individuals with FND by retrospectively assessing experiences of interpersonal trauma, affect and relationship insecurity at three developmental stages – childhood, adolescence and adulthood. Methods LiNES, CATS (measure of childhood abuse and trauma), RSQ (measure of relationship insecurity) and PANAS (measure of affect) questionnaires were administrated to 71 individuals with FND. Analyses were conducted to assess the reliability of the LiNES, explore correlations between different psychological domains within the FND group and to test whether LiNES scores predicted FND group membership. In addition, FND patients’ responses where compared to 270 matched healthy controls. Results The LiNES subscales had high internal consistency and correlated with CATS, RSQ and PANAS. Levels of interpersonal trauma were higher in FND patients than controls during childhood, adolescence and adulthood. High levels of negative affect were found in FND patients in adulthood compared to controls but no significant differences were found between FND patients and controls in relationship insecurity at any developmental stage. On the RSQ, FND patients had higher anxious and avoidant relationship styles. LiNES trauma scores at each developmental stage predicted FND status with over 80% accuracy. Additionally, FND patients self-reported more symptoms (SDQ-20) and a higher prevalence of comorbid conditions compared to controls. Conclusions The LiNES is a new brief retrospective measure of negative life experiences. Although psychological factors may not be necessary to the diagnosis of FND, they are substantially more common in FND patients compared to controls. In particular, a history of interpersonal trauma seems to play an important role in those with FND. These factors therefore are likely to play a pathophysiological role in many patients and their recognition is important for treatment. This study provides new insights into the association between the timing of negative experiences and the subsequent effect on an individual. Furthermore, the results support the use of LiNES as a valid screening tool in the clinical setting in patients presenting with functional symptoms with diagnostic and therapeutic implications.

Professor Reuber joined the Univ of Sheffield in 2005. He also works at the Royal Hallamshire Hospital and the Chesterfield Royal Hospital as an Honorary Consultant Neurologist. His clinical work focuses on the treatment of patients with epilepsy and other seizure disorders. He leads the Epilepsy Research Group in the Academic Neurology Unit and is the Epilepsy Research Theme Lead in the Clinical Neuroscience Directorate at Sheffield Teaching Hospitals. He is chair of the Neurosciences Local Priority Group of the Comprehensive Local Research Network and represents South Yorkshire on the National Speciality Group for Nervous System Disorders. He completed his undergraduate medical education in Cologne, Germany, and Nottingham. He pursued neurological training in Leeds, and at the Department of Epileptology of the University of Bonn, Germany. Dissociative seizures are experiential and behavioural responses to internal or external triggers. They superficially resemble epileptic seizures in terms of their subjective and objective manifestations. Although they are theoretically distinct from epileptic seizures in which seizure manifestations are related to hypersynchronous and excessive discharges in the brain, there is a complex relationship between epileptic and dissociative seizures, which extends beyond the (clinically extremely important) problem of misdiagnosis. While epilepsy is more closely associated with clinically detectable structural or biochemical abnormalities than dissociative seizures, the sort of experiential factors which are widely recognized as predisposing individuals to the development of dissociative seizures (such as trauma and neglect in early life) also increase the risk of developing epilepsy. The similar (albeit not identical) developmental background of patients with epilepsy on the one hand and dissociative seizures on the other is reflected by similar (but not identical) psychiatric comorbidity profiles. More specifically, epileptic seizures are a risk factor for the development of dissociative seizures, may precipitate or trigger dissociative seizures, and comorbid epilepsy may contribute to the perpetuation of dissociative seizures disorders. My talk will provide some food for thought about two seizure disorders often associated with high levels of disability which are theoretically different but which - in practice - have much in common. References Kutlubaev MA, et al. Dual diagnosis of epilepsy and psychogenic nonepileptic seizures: Systematic review and meta-analysis of frequency, correlates, and outcomes. Epilepsy and Behav 2018;89:70–78. Brown RJ, Reuber M. Psychological and psychiatric aspects of psychogenic non-epileptic seizures (PNES): A systematic review. Clin Psychol Rev 2016;45:157–182. Brown RJ, Reuber M. Towards an integrative theory of psychogenic non-epileptic seizures (PNES). Clin Psychol Rev 2016;47:55–70. Reuber M & Brown RJ. Understanding psychogenic nonepileptic seizures-Phenomenology, semiology and the Integrative Cognitive Model. Seizure 2017;44:199–205. Brown RJ, Baroni G et al. Variables associated with co-existing epileptic and psychogenic nonepileptic seizures: a systematic review. Seizure 2016;37:35–40.

Objectives/Aims Self-report studies of alexithymic traits in individuals with Functional Neurological Symptom Disorder (FND), suggest that emotion dysregulation in this population is characterised by an impaired ability to detect and identify their own emotions (identification impairments).1 This regulatory deficit might be particularly problematic for a patient group with an increased incidence of stressful life events relative to healthy controls,2 for whom the ability to regulate emotions might therefore be more crucial. Examining sensitivity to changes in physiological cues associated with emotional experience (interoception) is a way of assessing one aspect of participants’ capacity to identify their own emotions. However, no studies have yet experimentally investigated how stress might interact with interoception in this population. Therefore, the aim of this study was to investigate patients’ interoceptive sensitivity both at baseline and under stress. Methods Twenty-six patients with FND and twenty-seven healthy controls performed the Heartbeat Detection Task (HBDT) pre- and post- stress-induction with the Cold Pressor Test. The HBDT is a behavioural paradigm, measuring participants’ sensitivity to a physiological cue associated with emotional experience - the heartbeat. Participants also completed a self-report measure of emotion dysregulation (The Emotional Processing Scale-25) which includes a subscale capturing ‘a detached experience of one’s emotions due to poor emotional insight’, and a measure of Major Depressive symptomology (The PHQ-9). Results Relative to healthy controls, patients with FND performed more poorly on the HBDT both at baseline and following stress-induction (p=0.032). Patients also reported greater impairments across all domains of the EPS-25 and higher scores on the PHQ-9 than healthy controls (both p Conclusions Impaired HBDT performance suggests that patients with FND lack sensitivity to their heartbeat, both under ‘normal’ conditions and following stress-induction. Physiological cues (like the heartbeat) are an important source of interoceptive information for emotional experience, for example during stress. Our findings therefore represent a form of identification impairment that may contribute to stress-vulnerability in this population. Raised levels of self- reported ‘impoverished emotional experience’ corroborate the suggestion that patients with FND have difficulty identifying and understanding their emotions. These findings have direct implications for understanding and treating emotion dysregulation in FND. References Williams IA, Levita L, Reuber M. Emotion dysregulation in patients with psychogenic nonepileptic seizures: A systematic review based on the extended process model. Epilepsy & Behavior. 2018;86:37–48. Ludwig L, Pasman JA, Nicholson T, Aybek S, David AS, Tuck S, et al. Stressful life events and maltreatment in conversion (functional neurological) disorder: systematic review and meta-analysis of case-control studies. The Lancet Psychiatry. 2018;5(4):307–20.

The ageing population has caused a marked increased in the number of people with cognitive decline linked with dementia. Thus, current diagnostic services are overstretched, and there is an urgent need for automating parts of the assessment process. In previous work, we demonstrated how a stratification tool built around an Intelligent Virtual Agent (IVA) eliciting a conversation by asking memory-probing questions, was able to accurately distinguish between people with a neuro-degenerative disorder (ND) and a functional memory disorder (FMD). In this paper, we extend the number of diagnostic classes to include healthy elderly controls (HCs) as well as people with mild cognitive impairment (MCI). We also investigate whether the IVA may be used for administering more standard cognitive tests, like the verbal fluency tests. A four-way classifier trained on an extended feature set achieved 48% accuracy, which improved to 62% by using just the 22 most significant features (ROC-AUC: 82%).

To describe prevalence and relevance of Post-Traumatic Stress Disorder (PTSD) symptoms in Functional Neurological Symptom Disorder (FNSD) and explore differences in PTSD symptom scores between subgroups with Psychogenic Non-Epileptic Seizures (PNES) or other FNSD.This cross-sectional study evaluated data from 430 consecutive patients referred to a specialist psychotherapy service (69.3% female, 56% with PNES/44% with other FNSD). We analysed self-reported symptoms of Post-Traumatic Stress Disorder (PTSD Civilian Checklist, PCLC), depression (PHQ-9), anxiety (GAD-7), physical symptoms (PHQ-15), social functioning (WSAS), and health related quality of life (SF-36). Relationships between PTSD scores, diagnosis and other measures were examined. Independent associations of PTSD scores were identified using multilinear regression.Symptom scores likely to indicate clinical PTSD were reported by 60.7% of patients with no difference between PNES and FNSD subgroups. Those potentially symptomatic of PTSD were less likely to be living with a partner OR 2.95 (95% CI 1.83-4.04), or to be in employment OR 2.23 (95% CI 1.46-3.41) than less symptomatic patients. There were higher levels of anxiety (r = 0.62), depression (r = 0.63) and somatic symptoms (r = 0.45) and lower quality of life scores (r = 0.48) in patients with high PTSD symptom scores (p .0001 for all comparisons). Anxiety, depression and somatic symptoms made independent contributions to the variance of PTSD symptoms.There is a high prevalence of PTSD symptoms in patient with FNSD regardless of whether they have PNES. Trauma and PTSD symptoms are negatively correlated with quality of life. Self-report instruments for anxiety, depression and somatic symptoms may predict the presence of PTSD.

Purpose Many patients with epilepsy or psychogenic nonepileptic seizures (PNES) experience high levels of stress. Although psychological interventions have been developed for seizure disorders, few patients can currently access them. We aimed to assess the acceptability and feasibility of a self-help intervention targeting stress in patients with seizures, and to provide preliminary evidence for its effectiveness. Method Patients were recruited from outpatient neurology clinics and randomized to an immediate intervention group (n = 39), who received the intervention at baseline, or a delayed intervention group (n = 43), who received the intervention one-month postbaseline. Participants completed self-report questionnaires measuring stress (Smith Stress Symptom Inventory [SSSI]), anxiety (Generalized Anxiety Disorder 7-item Scale [GAD-7]), depression (Neurological Disorders Depression Inventory for Epilepsy [NDDI-E]), quality of life (European Quality of Life – 5 Dimensions [EQ-5D]), and seizure severity and frequency (Liverpool Seizure Severity Scale [LSSS-3]) at baseline, and at one- and two-month follow-up. Participants also provided telephone feedback. The intervention consisted of a self-help stress management workbook based on an integrative stress model framework. Results Although the rate of participants failing to return follow-up information at two months was approximately 50%, those who completed the trial found the intervention acceptable; with the majority rating it as helpful (63.6%) and that they would recommend it to others with seizures (88.1%). A significant reduction in self-reported stress (P = .01) with a medium effect size (dz = 0.51) was observed one-month postintervention. There were no significant changes in any other measures. Conclusion The intervention was perceived to be acceptable, safe, and helpful by participants. It could be a useful complementary treatment option for reducing stress experienced by patients living with seizure disorders. Further evaluation in a larger trial is warranted.

Background Seizure disorders affect not only the individual living with seizures, but also those caring for them. Carer–patient relationships may be influenced by, and have an influence on, some aspects of living with seizure disorders — with potentially different interactions seen in epilepsy and psychogenic nonepileptic seizures (PNES). Objectives We studied the influence of patient and carer attachment style and relationship quality on carer wellbeing and psychological distress, and explored whether these associations differ between carers for people with epilepsy and for those with PNES. Methods Consecutive adult patients with epilepsy (N = 66) and PNES (N = 16) and their primary informal carers completed questionnaires about relationship quality, attachment style, and psychopathological symptom burden. We used correlation analysis to identify associations between relationship quality, attachment style, and carer depression, anxiety, and wellbeing; and to explore differences in these associations between carers for people with epilepsy and for those with PNES. Results Overall, 25.3% of carers for people with epilepsy or PNES had scores above the clinical cutoff for depression and 39.6% for anxiety; significantly more carers for people with PNES reported clinically significant depression (47.1% vs. 20.0%), but there was no difference in anxiety rates likely to be of clinical relevance. Correlations differed significantly between carers for people with epilepsy and for those with PNES in terms of patient quality of life and carer anxiety (rE = − 0.577, rPNES = − 0.025); seizure severity and carer depression (rE = 0.248, rPNES = − 0.333) and mental wellbeing (rE = − 0.356, rPNES = 0.264); patient depression and carer anxiety (rE = 0.387, rPNES = − 0.266); and patient anxious attachment and carer anxiety (rE = 0.382, rPNES = 0.155). Significance Clinically evident levels of psychological distress are prevalent among carers for people with epilepsy and PNES. Clinical and relationship variables affect carer quality of life differently depending on whether care is provided for individuals with epilepsy or PNES.

Objective Diagnostic screening for functional neurological disorders (FNDs) continues to pose a challenge. Simple symptom counts fail clearly to discriminate patients with FND but there is increasing recognition of ‘positive’ features which are useful diagnostically during face-to-face assessments. A self-completed questionnaire evaluating specific features of FNDs would be useful for screening purposes in clinical and research settings. Methods The Edinburgh Neurosymptoms Questionnaire (ENS) is a 30-item survey of presence and nature of: blackouts, weakness, hemisensory syndrome, memory problems, tremor, pain, fatigue, globus, multiple medical problems, and operations constructed via literature review and expert consensus. We conducted a pilot of the ENS on new general neurology clinic attendees at a large regional neuroscience centre. Patients were grouped according to consultant neurologist impression as having symptoms that were ‘Not at all’, ’Somewhat’, ’Largely’ or ’Completely’ due to a functional disorder. Results Blackouts, weakness and memory questions provided reasonable diagnostic utility (AUROC = 0.94, 0.71, 0.74 respectively) in single symptom analysis. All other symptoms lacked discriminating features. A multivariate linear model with all symptoms predicted functional classification with moderate diagnostic utility (AUROC = 0.83), specificity of 0.97, sensitivity of 0.47. Pain and blackout scores provided the most accurate predictor of functional classification. Conclusion The ENS questionnaire provides some utility in differentiating patients presenting with functional blackouts but failed to provide diagnostic value in other types of FND, highlighting the limitations of this self-report tool.

Purpose: We investigated neurologists’ experience of participating in the large CODES trial involving around 900 adults with dissociative seizures which subsequently evaluated the effectiveness of tailored cognitive behavioural therapy (CBT) plus standardised medical care versus standardised medical care alone in 368 patients with dissociative seizures.Method: We asked all neurologists referring patients with dissociative seizures to the CODES study to complete a 43-item online survey. This examined neurologists’ (i) demographics, (ii) knowledge of dissociative seizures before and after their involvement in the CODES trial, (iii) clinical practice before, during and since their involvement, and (iv) their experience of the CODES trial. Results: Forty-three (51%) neurologists completed the questionnaire. Only about half of neurologists could make referrals to psychological intervention specific for dissociative seizures before and after the trial. One-third of doctors reported having changed their referral practice following their involvement. The majority (>69%) agreed that patient satisfaction with different aspects of the trial was very high, and 83.7% thought that it was easy to recruit patients for the study. Over 90% agreed they would like the treatment pathway to continue. Respondents found different elements of the trial useful, in particular, the patient factsheet booklet (98%), diagnosis communication advice (93%) and the CBT package (93%).Conclusions: Neurologists participating in CODES generally found it easy to recruit patients and perceived patient satisfaction as very high. However, 46.5% of neurologists could not offer psychotherapy once the trial had finished; suggesting that problems with lack of access to psychological treatment for dissociative seizures persist.

The expansion of new forms of public media, including social media, exposes clinicians to more illness experiences/narratives than ever before and increases the range of ways to interact with the people depicted. Existing professional regulations and ethics codes offer very limited guidance for such situations. We discuss the ethics of responding to such scenarios through presenting three cases of clinicians encountering television or social media stories involving potential unmet healthcare needs. We offer a structured framework for health workers to think through their responses to such situations, based around four key questions for the clinician to deliberate upon: who is vulnerable to harm; what can be done; who is best placed to do it; and what could go wrong? We illustrate the application of this framework to our three cases.

Psychogenic nonepileptic seizures (PNES) continue to represent a serious diagnostic challenge. The diagnostic difficulties are enhanced by the fact that a proportion of patients have a combination of epilepsy and PNES. Epilepsy can act as a predisposing, precipitating, perpetuating, or trigger factor for PNES development, with female patients predominating except in particular subpopulations, such as pediatric patients, those with intellectual disability or elderly patients. Trauma/sexual abuse is a less important etiological factor in patients with epilepsy and PNES while almost all patients with PNES having at least one current and recognizable additional psychiatric illness. There are many superficial similarities between the manifestations of PNES and epileptic seizures. Video EEG can help with this task, but additional diagnostic methods, such as careful and repeated history-taking during follow-up and home video recordings, have to be employed. The treatment strategy includes reducing antiepileptic drug (AED) toxicity, avoiding or withdrawing AEDs with negative psychotropic effects, and psychotherapeutic interventions, leading to relatively encouraging short-term outcomes and a poorer prognosis in the longer-term.

Purpose Stereotactic radiosurgery (SRS) may be an alternative to anterior temporal lobectomy (ATL) for mesial temporal lobe epilepsy (MTLE). Visual field defects (VFD) occur in 9–100% of patients following open surgery for MTLE. Postoperative VFD after minimally invasive versus open surgery may differ. Methods This prospective trial randomized patients with unilateral hippocampal sclerosis and concordant video-EEG findings to SRS versus ATL. Humphries perimetry was obtained at 24 m after surgery. VFD ratios (VFDR = proportion of missing homonymous hemifield with 0 = no VFD, 0.5 = complete superior quadrantanopsia) quantified VFD. Regressions of VFDR were evaluated against treatment arm and covariates. MRI evaluated effects of volume changes on VFDR. The relationships of VFDR with seizure remission and driving status 3 years after surgery were evaluated. Results No patients reported visual changes or had abnormal bedside examinations, but 49 of 54 (91%) of patients experienced VFD on formal perimetry. Neither incidence nor severity of VFDR differed significantly by treatment arm. VFDR severity was not associated with seizure remission or driving status. Conclusion The nature of VFD was consistent with lesions of the optic radiations. Effective surgery (defined by seizure remission) of the mesial temporal lobe results in about a 90% incidence of typical VFD regardless of method.

Objective Psychogenic nonepileptic seizures (PNES) are one of the most common differential diagnoses of epilepsy. This study provides an overview of diagnostic and treatment services for patients with PNES across Latin America. Methods In 2017–2018, clinicians practicing in Latin America with responsibilities for patients with PNES were contacted to respond to a survey regarding the management of this disorder developed by the International League Against Epilepsy (ILAE) PNES Task Force. Results Three hundred and sixty responses from 17 Latin American countries were analyzed. Most respondents were neurologists (81%) under 40 years of age (61%). Fifty-seven percent of professionals stated that they personally diagnose PNES, but only 33% stated that they provide follow-up, and only 20% that they recommend treatment. Many participants (54%) characterized themselves as either unfamiliar with the diagnosis or inexperienced in arranging treatment. Most respondents reported having access to brain magnetic resonance imaging (MRI; 88%) and routine electroencephalogram (EEG; 71%), 64% have the access to video-EEG longer than 8 h, and 54% of professionals performed video-EEG to confirm PNES diagnoses. Although cognitive–behavioral therapy was recognized as the treatment of choice (by 82% of respondents), there was little access to it (60%). In contrast, a high proportion of respondents reported using antidepressant (67%), antiseizure (57%), and antipsychotic medications (54%) as treatments for PNES. Significance This study reveals several deficiencies in the diagnosis and treatment of patients with PNES in Latin America. The barriers are reinforced by lack of knowledge among the specialists and poor healthcare system support. There is inadequate access to prolonged video-EEG and psychotherapy. An inappropriate use of antiseizure medicines seems commonplace, and there are low follow-up rates by neurologists after the diagnosis. Multidisciplinary guidelines are required to improve the approach of patients with PNES.

Purpose This is a narrative systematic synthesis of qualitative research investigating patients⿿ accounts of living with psychogenic nonepileptic seizures (PNES). Qualitative methodologies allow patients to share lived experiences in their own words. The examination of patients⿿ own accounts is likely to offer revealing insights into a poorly understood, heterogeneous disorder. Methods We identified 21 separate studies about PNES published after 1996 and based on analyses of patients⿿ own words. Papers were synthesised inductively and deductively using an iterative approach. Results Five key themes emerged from the synthesis of studies capturing accounts from over 220 patients, reflecting experiences of seizure events, diagnosis, treatment and management, emotional events, and impact on daily life. Patients with PNES discussed the phenomenology of their seizures differently from those with epilepsy. PNES were experientially heterogeneous. Many patients shared a sense of uncertainty surrounding PNES, often resisting psychological explanations. Negative experiences with healthcare professionals were common. Patients seeking validation of their experiences often reported feeling ignored or doubted. Many reported past or current stressful events. Some demonstrated insight into their methods of emotional processing. PNES were described as a significant burden associated with financial and psychosocial losses. Conclusions Qualitative studies have produced helpful insights into patients⿿ experiences of living with PNES, but many patient groups (men, young people, elderly, non-Western patients) are underrepresented in studies carried out to date. Research capturing these patient groups and using new methods of data collection and qualitative analysis could help to deepen our understanding of this disorder.

Rationale The aim of this study was to add to our understanding of the impact of psychoeducation on patients' acceptance of the diagnosis of psychogenic nonepileptic seizures (PNESs), the frequency of their seizures, and their quality of life. The study also aimed to evaluate the effectiveness of brief manualized psychoeducation interventions for PNESs, delivered by a more diverse range of clinicians and in a wider range of treatment settings. Method The final sample consisted of 25 patients diagnosed with PNESs by a neurologist specializing in the treatment of seizure disorder and referred to the psychotherapy service. The study included patients from four centers, using a manualized psychoeducation intervention delivered over 4 sessions by specialist epilepsy nurses and assistant psychologists. All patients completed self-measure questionnaires for Seizure Frequency, Impaired Functioning (WSAS), Psychological Distress (CORE-OM), Illness Perception (BIPQ), Health-Related Quality of Life: general (ED-QOL) and epilepsy-specific (NewQOL-6D), Symptom Attribution, and patient's perception of usefulness and relevance of the intervention. All measures were collected at baseline and after the completion of the fourth session. Results All measures improved from baseline to postintervention, but this improvement was only significant for CORE-OM (p

Psychogenic Nonepileptic Seizures (PNES) superficially resemble epileptic seizures but are thoughtto have a psychological rather than epileptic basis. Patients with PNES vary widely in terms ofbackground, personality profiles, comorbidities, response to treatment and outcomes. Previousaccounts interpreting these seizures as the activation of dissociated material, a physical manifestationof emotional distress, hard-wired reflex responses, or learned behaviours cannot explain key featuresof the phenomenon. Drawing on a brief review of the literature on etiology, correlates andphenomenology of PNES, this paper integrates existing approaches and data within a novelexplanatory framework that applies to all PNES patients with subjectively involuntary seizures.Following the Integrative Cognitive Model of medically unexplained symptoms, we suggest that thecentral feature of all PNES is the automatic activation of a mental representation of seizures (the“seizure scaffold”) in the context of a high level inhibitory processing dysfunction. This often arisesin response to elevated autonomic arousal, and may disrupt the individual‟s awareness of distressingmaterial, but can become divorced from abnormal autonomic and emotional activity. This modelaccounts both for existing findings and the heterogeneity of patients with PNES, whilst leading to anumber of novel hypotheses against which it can be evaluated.

There are many areas in medicine in which the diagnosis poses significant difficulties and depends essentially on the clinician’s ability to take and interpret the patient’s history. The differential diagnosis of transient loss of consciousness (TLOC) is one such example, in particular the distinction between epilepsy and ‘psychogenic’ non-epileptic seizures (NES) is often difficult. A correct diagnosis is crucial because it determines the choice of treatment. Diagnosis is typically reliant on patients’ (and witnesses’) descriptions; however, conventional methods of history-taking focusing on the factual content of these descriptions are associated with relatively high rates of diagnostic errors. The use of linguistic methods (particularly conversation analysis) in research settings has demonstrated that these approaches can provide hints likely to be useful in the differentiation of epileptic and non-epileptic seizures. This paper explores to what extent (and under which conditions) the findings of these previous studies could be transposed from a research into a routine clinical setting.

Psychogenic non-epileptic seizures (PNES) are common in neurological settings and often associated with considerable distress and disability. The psychological mechanisms underlying PNES are poorly understood and there is a lack of well-established, evidence-based treatments. This paper advances our understanding of PNES by providing a comprehensive systematic review of the evidence pertaining to the main theoretical models of this phenomenon. Methodological quality appraisal and effect size calculation were conducted on one hundred forty empirical studies on the following aspects of PNES: life adversity, dissociation, anxiety, suggestibility, attentional dysfunction, family/relationship problems, insecure attachment, defence mechanisms, somatization/conversion, coping, emotion regulation, alexithymia, emotional processing, symptom modelling, learning and expectancy. Although most of the studies were only of low to moderate quality, some findings are sufficiently consistent to warrant tentative conclusions: (i) physical symptom reporting is elevated in patients with PNES; (ii) trait dissociation and exposure to traumatic events are common but not inevitable correlates of PNES; (iii) there is a mismatch between subjective reports of anxiety and physical arousal during PNES; and (iv) inconsistent findings in this area are likely to be attributable to the heterogeneity of patients with PNES. Empirical, theoretical and clinical implications are discussed.

Purpose To derive clinically useful information about the efficacy and tolerability of adjunctive treatment with perampanel for refractory epilepsy in an outpatient setting. Method We pooled retrospective casenotes data of adult patients with refractory epilepsy prescribed perampanel from 18 hospitals throughout UK and Ireland. Results Three hundred and ten patients were included (mean age 40.9 [SD=12.0], 50% women, 27.7% with learning disability). The mean duration of epilepsy was 26.7 years (range 2–67 years, SD=13.5) and 91.9% were taking two or more anti-epileptic drugs at the time of perampanel initiation. Mean retention was 6.9 months (range 1 day–22.3 months, SD=4.5). The retention was 86% at 3 months, 71% at 6 months, 47.6% at 12 months and 27% at 18 months. At final follow-up a >50% reduction in seizure frequency was reached in 57.5% of tonic–clonic seizures, 57.4% of complex partial seizures and 43.8% of simple partial seizures. Eleven patients (3.5%) became seizure free. Two hundred and nine patients (67.4%) experienced adverse effects and of these 67% withdrew treatment due to their effects. The most common were sedation, behaviour/mood disturbance, dizziness, and unsteadiness. Conclusion Perampanel appears a safe and effective antiepileptic drug when used as adjunctive therapy in patients with uncontrolled partial epilepsy (including those with learning disability), although few patients achieved complete seizure control. Long-term retention was slightly lower than reported rates for other anti-epileptic drugs, potentially due to the highly refractory population. Monitoring for adverse effects on energy levels, mood and behaviour is recommended.

Question design during history-taking has clear implications for patients' ability to share their concerns in general and their seizure experiences in particular. Studies have shown that unusually open questions at the start of the consultation enable patients to display interactional and linguistic markers which may help with the otherwise challenging differentiation of epileptic from nonepileptic seizures (NES). In this study, we compared the problem presentation approach taken by trainee neurologists in outpatient encounters with new patients before and after a one-day conversation analytic training intervention in which doctors were taught to adopt an open format of question design and recognize diagnostically relevant linguistic features. We audio/video-recorded clinical encounters between ten doctors, their patients, and accompanying persons; transcribed the interactions; and carried out quantitative and qualitative analyses. We studied 39 encounters before and 55 after the intervention. Following the intervention, doctors were significantly more likely to use nondirective approaches to soliciting patient accounts of their presenting complaints that invited the patient to describe their problems from their own point of view and gave them better opportunity to determine the initial agenda of the encounter. The time to first interruption by the doctor increased (from 52 to 116 s, p

Objectives/AimsWe used our automated cognitive assessment tool to explore whether responses to questions probing recent and remote memory could aid in distinguishing between patients with early neurodegenerative disorders and those with Functional Cognitive Disorders (FCD).Hypotheses: pwFCD would have no significant differences in pause to speech ratio and measures of linguistic complexity compared to healthy controls. pwFCD would have significant differences in pause to speech ratio and measures of linguistic complexity compared to pwMCI and pwAD.MethodsWe recruited 15 participants with FCD, MCI and AD each as well as 15 healthy controls. Participants answered 12 questions posed by the ‘Digital Doctor’. Automatic processing of the audio-recorded answers involved automatic speech recognition including detecting length of pauses. Two questions probe recent memory, exploring knowledge of current affairs. Two probe remote memory, asking for autobiographical details.We analysed the data using: Pause to speech time ratio. Moving average type token ratio (MATTR): An automated measure of vocabulary richness. Computerised propositional idea density rater (CPIDR): An automated measure of propositional idea density.ResultsThere was a significant difference in the pause to speech ratio for recent memory questions for HC versus AD (P=0.0012) and MCI (pConclusionsThis study rejects both hypotheses. However, the data supports the application of linguistic measures to recent and remote memory questions in distinguishing those with MCI & AD from HC’s. Further work will investigate the utility of incorporating additional measures of lexical and grammatical complexity (word frequency, sentence structure). Longitudinal study will provide insights into which features may predict stability in FCD and HC’s and progression from MCI to AD, supporting the system’s promise as a monitoring tool.

Purpose This multicenter service evaluation explores the efficacy and tolerability of brivaracetam (BRV) in an unselected, consecutive population in ‘real-life’ clinical settings. Method We retrospectively collected data from patient records at 11 UK hospitals and epilepsy centers. Consecutive patients prescribed BRV with at least 3 months of follow-up (FU) were included. Apart from reporting effectiveness and tolerability of BRV across the whole cohort, we compared treatment outcomes depending on previous levetiracetam use (LEV + versus LEV −), comorbid learning disability (LD + versus LD −), and epilepsy syndrome (focal versus generalized epilepsy). Results Two hundred and ninety patients (46% male, median age: 38 years, range: 15 to 77) with ≥ 3 months of FU were included. The median duration of BRV exposure was 12 months (range: 1 day to 72 months). Overall BRV retention was 71.1%. While 56.1% of patients improved in terms of seizure frequency category (daily, weekly, monthly, yearly seizures), 23.1% did not improve on this measure and 20.8% deteriorated. In terms of seizure frequency, 21% of patients experienced a ≥ 50% reduction, with 7.0% of all patients becoming seizure-free. Treatment-emergent adverse events (AEs) were reported by 107 (36.9%) patients, but there were no serious AEs. The commonest AEs were sedation/fatigue (18.3%), mood changes (9.0%), and irritability/aggression (4.8%). There were no significant differences in drug retention, seizure frequency outcomes, or AEs between the LEV + and LEV − subgroups, or between patients with generalized or focal epilepsies. Although 15.5% of patients in the LD + group achieved a ≥ 50% reduction, this rate was lower than in the LD − group. Conclusions This ‘real-life’ evaluation suggests that reductions in seizure frequency can be achieved with BRV in patients with highly refractory epilepsy. Brivaracetam may be a useful treatment option in patients who have previously failed to respond to or tolerate LEV, those with LD, or (off-label) those with generalized epilepsies.

Previous work on interactions in the memory clinic has shown that conversation analysis can be used to differentiate neurodegenerative dementia from functional memory disorder. Based on this work, a screening system was developed that uses a computerised ‘talking head’ (intelligent virtual agent) and a combination of automatic speech recognition and conversation analysis-informed programming. This system can reliably differentiate patients with functional memory disorder from those with neurodegenerative dementia by analysing the way they respond to questions from either a human doctor or the intelligent virtual agent. However, much of this computerised analysis has relied on simplistic, nonlinguistic phonetic features such as the length of pauses between talk by the two parties. To gain confidence in automation of the stratification procedure, this paper investigates whether the patients’ responses to questions asked by the intelligent virtual agent are qualitatively similar to those given in response to a doctor. All the participants in this study have a clear functional memory disorder or neurodegenerative dementia diagnosis. Analyses of patients’ responses to the intelligent virtual agent showed similar, diagnostically relevant sequential features to those found in responses to doctors’ questions. However, since the intelligent virtual agent’s questions are invariant, its use results in more consistent responses across people – regardless of diagnosis – which facilitates automatic speech recognition and makes it easier for a machine to learn patterns. Our analysis also shows why doctors do not always ask the same question in the exact same way to different patients. This sensitivity and adaptation to nuances of conversation may be interactionally helpful; for instance, altering a question may make it easier for patients to understand. While we demonstrate that some of what is said in such interactions is bound to be constructed collaboratively between doctor and patient, doctors could consider ensuring that certain, particularly important and/or relevant questions are asked in as invariant a form as possible to be better able to identify diagnostically relevant differences in patients’ responses.

IntroductionReferrals to specialist memory clinics have increased out of proportion to the incidence of dementia. Time and financial pressures are consequently exerted on a service striving to deliver high quality care. We have developed a fully automated ‘Digital Doctor’ with the aim of providing pre-clinic risk stratification and ongoing monitoring for patients with memory concerns.MethodsWe recruited 15 participants with Functional Memory Disorder (FMD), Mild Cognitive Impairment (MCI) and Alzheimer’s disease each as well as 15 healthy controls. Participants answered 12 questions posed by the ‘Digital Doctor’. Audio and visual data is analysed using diarization and automatic speech recognition tools and machine learning classifiers.ResultsThe ‘Digital Doctor’ can distinguish between neuro-degenerative dementia and FMD with an accuracy of 95%. We will have results of a 4-way classification accuracy (HC, FMD, MCI & AD) at time of conference.DiscussionWe demonstrate the potential value of the ‘Digital Doctor’ as a stratification and triage tool. Accuracy will be improved with greater number of users and inclusion of fluency and picture description data. Patients at low risk could avoid the burden of a clinic appointment, whilst patients with higher risk could benefit from a more streamlined service.

Purpose This study is based on a narrative analysis of individuals' written accounts of living with epilepsy (n = 29) or psychogenic non-epileptic seizures (n = 20, PNES). Narrative analysis looks at both the content and structure of the personal account. We used a form of narrative analysis that allowed us to identify common story lines, otherwise known as narrative typologies, potentially characteristic of these patient groups. Different narrative typologies were described and compared between writers with the two conditions. Methods As part of a therapeutic writing intervention for individuals living with a seizure disorder, participants were asked to write for at least 20 min about their very deepest thoughts and feelings about their condition. Results Five narrative typologies emerged: 1. ‘Losses from Illness' – stories were dominated by events individuals could no longer do, authors appeared more disabled reporting greater frequency of seizures and lower health-related quality of life. 2 .‘Feeling Lost' – participants appeared to be in search of something and expressed uncertainty. 3 .‘Tackling Adversity' – individuals strove to not let their condition stop them from living their life. 4 .‘Overcoming Challenges' – stories reflected that the condition must be battled and fought with. 5 .‘A Normal Life' – individuals had demonstrated that they are managing to live with their condition. Conclusions While the ‘Tackling Adversity' typology was preferentially used by writers with epilepsy, the ‘Feeling Lost' typology was chosen more commonly by those with PNES. People with epilepsy narrate their disorder differently from those with PNES, suggesting that they have different life and illness experiences.

Psychogenic non-epileptic seizures (PNES) are often viewed as manifestations of altered motor and sensory function resulting from psychological responses to adverse experiences. Yet many patients and non-expert healthcare professionals find it difficult to understand how severe disturbances in normal neurological functioning can solely result from underlying psychological mechanisms to the exclusion of other physical causes. Perhaps importantly, recent advances using neuroimaging techniques point to possible structural and functional correlates in PNES. In an attempt to further our understanding of the neurobiological correlates of this condition, we compared the brain scans of 20 patients with PNES (14 females, mean age 41.05, range 19-62) and 20 age- and gender-matched healthy controls (14 females, mean age 40.65, range 21-61) to investigate group differences for cortical thickness and gyrification patterns using FreeSurfer. Compared to controls, patients with PNES showed cortical thickness increases in motor, sensory and occipital areas as well as cortical thickness decreases in temporal and frontal brain regions. In addition, we observed age-related changes in cortical thickness in the right lateral occipital area in PNES. However, contrary to our prediction that atypical gyrification may be present, we did not find any evidence of abnormalities on a measure thought to reflect prenatal and early childhood cortical development and organization. Nor did we find significant correlations between cortical thickness results and clinical features. These findings partly corroborate, but also differ from previous morphometric studies in PNES. These inconsistencies likely reflect the aetiology and phenomenological heterogeneity of PNES.

Importance: Functional neurological disorders (FND) are common sources of disability in medicine. Patients have often been misdiagnosed, correctly diagnosed after lengthy delays, and/or subjected to poorly delivered diagnoses that prevent diagnostic understanding and lead to inappropriate treatments, iatrogenic harm, unnecessary and costly evaluations, and poor outcomes. Observations: Functional Neurological Symptom Disorder/Conversion Disorder was adopted by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, replacing the term psychogenic with functional and removing the criterion of psychological stress as a prerequisite for FND. A diagnosis can now be made in an inclusionary manner by identifying neurological signs that are specific to FNDs without reliance on presence or absence of psychological stressors or suggestive historical clues. The new model highlights a wider range of past sensitizing events, such as physical trauma, medical illness, or physiological/psychophysiological events. In this model, strong ideas and expectations about these events correlate with abnormal predictions of sensory data and body-focused attention. Neurobiological abnormalities include hypoactivation of the supplementary motor area and relative disconnection with areas that select or inhibit movements and are associated with a sense of agency. Promising evidence has accumulated for the benefit of specific physical rehabilitation and psychological interventions alone or in combination, but clinical trial evidence remains limited. Conclusions and Relevance: Functional neurological disorders are a neglected but potentially reversible source of disability. Further research is needed to determine the dose and duration of various interventions, the value of combination treatments and multidisciplinary therapy, and the therapeutic modality best suited for each patient.

We investigated the feasibility, acceptability and preliminary effectiveness of a writing intervention for individuals with epilepsy or psychogenic nonepileptic seizures.Individuals were randomised to write about potentially 'therapeutic' topics (n = 43) or about their daily events (n = 25). Participants were asked to write on four separate occasions for at least 20 min. Repeated-measures analysis of variance was used to investigate change in measures of health-related quality of life (NEWQoL-6D), depression (NDDI-E), anxiety (GAD-7) and illness perception (B-IPQ) from baseline to one and three-month follow-ups. Qualitative and quantitative data taken from a Writing Task Questionnaire was analysed between the two conditions.Recruitment was acceptable with 52% of those randomised completing the full writing intervention. In both conditions, participants wrote for longer than 20 min suggesting those who completed the study engaged well with the procedure. Greater benefits were observed in the 'therapeutic' condition (p 0.05), which was associated with an improvement in health-related quality of life at one-month follow-up (p = 0.02). No differences were found in the other measures.A writing intervention is acceptable in this population. Self-reported benefits were modest, suggesting therapeutic writing may be more suitable as a supplement to other therapies rather than a stand-alone therapeutic intervention.

Given the significant impact that psychosocial factors and epilepsy treatments can have on the health-related quality of life (HRQOL) of individuals with epilepsy and their families, there is great clinical interest in the role of psychological evaluation and treatments to improve HRQOL and comorbidities. Therefore, the International League Against Epilepsy (ILAE) charged the Psychology Task Force with the development of recommendations for clinical care based on evaluation of the evidence from their recent Cochrane review of psychological treatments in individuals with epilepsy. The literature search for a recent Cochrane review of randomized controlled trials investigating psychological treatments for individuals with epilepsy constitutes the key source of evidence for this article. To provide practical guidance to service providers, we provide ratings on study research designs based on (1) the American Academy of Neurology's Level of Evidence system and (2) the Grading of Recommendations, Assessment, Development, and Evaluation system. This paper is the culmination of an international collaboration process involving pediatric and adult psychologists, neurologists, psychiatrists, and neuropsychiatrists. The process and conclusions were reviewed and approved by the ILAE Executive Committee. The strongest evidence for psychological interventions was identified for the most common mental health problems, including depression, neurocognitive disturbances, and medication adherence. Psychological interventions targeting the enhancement of HRQOL and adherence and a decrease in comorbidity symptoms (anxiety, depression) should be incorporated into comprehensive epilepsy care. There is a range of psychological strategies (ie, cognitive behavioral therapy and mindfulness-based therapies) that show promise for improving the lives of persons with epilepsy, and clinical recommendations are provided to assist epilepsy health care providers in treating the comorbidities and challenges associated with epilepsy and its treatments.

Psychological treatment is recommended for depression and anxiety in those with epilepsy. This review used standardised criteria to evaluate, for the first time, the clinical relevance of any symptom change these treatments afford patients. Databases were searched until March 2017 for relevant trials in adults. Trial quality was assessed and trial authors asked for individual participants’ pre-treatment and post-treatment distress data. Jacobson’s methodology determined the proportion in the different trial arms demonstrating reliable symptom change on primary and secondary outcome measures and its direction. Search yielded 580 unique articles; only eight eligible trials were identified. Individual participant data for five trials—which included 398 (85%) of the 470 participants randomised by the trials—were received. The treatments evaluated lasted ~7 hours and all incorporated cognitive-behavioural therapy (CBT). Depression was the primary outcome in all; anxiety a secondary outcome in one. On average, post-treatment assessments occurred 12 weeks following randomisation; 2 weeks after treatment had finished. There were some limitations in how trials were conducted, but overall trial quality was ‘good’. Pooled risk difference indicated likelihood of reliable improvement in depression symptoms was significantly higher for those randomised to CBT. The extent of gain was though low—the depressive symptoms of most participants (66.9%) receiving CBT were ‘unchanged’ and 2.7% ‘reliably deteriorated’. Only 30.4% made a ‘reliable improvement. This compares with 10.2% of participants in the control arms who ‘reliably improved’ without intervention. The effect of the treatments on secondary outcome measures, including anxiety, was also low. Existing CBT treatments appear to have limited benefit for depression symptoms in epilepsy. Almost 70% of people with epilepsy do not reliably improve following CBT. Only a limited number of trials have though been conducted in this area and there remains a need for large, well-conducted trials.

Background Transient loss of consciousness (TLOC) is a common presentation in primary care. Over 90% of these are due to epileptic seizures (ES), syncope, or psychogenic non-epileptic seizures (PNES). Misdiagnosis rates are as high as 30%. Methods Systematic review of inter-ictal clinical criteria to aid differential diagnosis of TLOC. We searched Medline, EMBASE, CINAHL and PsycInfo databases, as well as relevant grey literature depositories and citations of relevant reviews and guidelines for studies giving sensitivity and specificity of inter-ictal clinical characteristics used to differentiate between causes of TLOC. Two independent reviewers selected studies for inclusion and performed critical appraisal of included articles. We performed a narrative synthesis of included studies. Results Of 1023 results, 16 papers were included. Two compared syncope, ES, and PNES; all others compared ES and PNES. All were at significant risk of bias in at least one domain. 6 studied patient symptoms, 6 medical and social history, 3 witness reports and 1 examination findings. No individual criterion differentiated between diagnoses with high sensitivity and specificity. Conclusions There is a lack of validated diagnostic criteria to help clinicians assessing patients in primary or emergency care settings to discriminate between common causes of TLOC. Performance may be improved by combining sets of criteria in a clinical decision rule, but no such rule has been validated prospectively against gold-standard diagnostic criteria.

Purpose\ud \ud \ud Phenytoin is an effective anticonvulsant for focal epilepsy. Its use can be associated with long-term adverse effects including cerebellar ataxia. Whilst phenytoin is toxic to Purkinje cells in vitro; the clinical and radiological phenotype and mechanism of cerebellar degeneration in vivo remain unclear. We describe the prevalence, clinical and radiological characteristics of phenytoin-related ataxia.\ud \ud \ud \ud Methods\ud \ud \ud Patients with epilepsy receiving treatment with phenytoin were recruited from the Epilepsy clinics at Royal Hallamshire Hospital, Sheffield, UK. Neurological examination was performed on all patients after recruitment. Patients were categorised into those with and without ataxia. We determined the severity of ataxia clinically (SARA score) and the pattern of cerebellar involvement by neuroimaging (MRI volumetry and MR spectroscopy).\ud \ud \ud \ud Results\ud \ud \ud Forty-seven patients were recruited. Median duration of epilepsy was 24 years, median duration of phenytoin treatment was 15 years and current median phenytoin daily dose was 325 mg. Fifty-five percent of patients complained of poor balance. Clinical evidence of ataxia was seen in 40% patients. Gait, stance and heel-shin slide were the predominant features of cerebellar dysfunction. MRI demonstrated structural, volumetric and functional deficits of the cerebellum. Only one patient with ataxia had phenytoin levels above the normal range.\ud \ud \ud \ud Conclusions\ud \ud \ud Cerebellar ataxia is present in 40% of patients with epilepsy and chronic exposure to phenytoin. Patients on long-term phenytoin have reduced cerebellar volume even if they have no clinical evidence of ataxia. Evidence of structural deficits on imaging suggests a predilection for vermian involvement.

Objective To compare stereotactic radiosurgery (SRS) versus anterior temporal lobectomy (ATL) for patients with pharmacoresistant unilateral mesial temporal lobe epilepsy (MTLE). Methods This randomized, single-blinded, controlled trial recruited adults eligible for open surgery among 14 centers in the USA, UK, and India. Treatment was either SRS at 24 Gy to the 50% isodose targeting mesial structures, or standardized ATL. Outcomes were seizure remission (absence of disabling seizures between 25 and 36 months), verbal memory (VM), and quality of life (QOL) at 36-month follow-up. Results A total of 58 patients (31 in SRS, 27 in ATL) were treated. Sixteen (52%) SRS and 21 (78%) ATL patients achieved seizure remission (difference between ATL and SRS = 26%, upper 1-sided 95% confidence interval = 46%, P value at the 15% noninferiority margin = .82). Mean VM changes from baseline for 21 English-speaking, dominant-hemisphere patients did not differ between groups; consistent worsening occurred in 36% of SRS and 57% of ATL patients. QOL improved with seizure remission. Adverse events were anticipated cerebral edema and related symptoms for some SRS patients, and cerebritis, subdural hematoma, and others for ATL patients. Significance These data suggest that ATL has an advantage over SRS in terms of proportion of seizure remission, and both SRS and ATL appear to have effectiveness and reasonable safety as treatments for MTLE. SRS is an alternative to ATL for patients with contraindications for or with reluctance to undergo open surgery.