Trauma and non-epileptic seizures: patients need care

ALTHOUGH childhood trauma has long been linked to neurological disorders such as psychogenic non-epileptic seizures (PNES), a recent study found that trauma severity is also a key factor in diagnosis.

A study from Melbourne, recently published on preprint server MedRxiv, found that patients with PNES reported a higher frequency of childhood trauma than patients with epilepsy. The authors also found that the severity of trauma, rather than the presence or absence of trauma, should be considered when diagnosing PNES. (The research has not yet been peer-reviewed and should not be used to guide clinical practice.)

“Our findings that patients who experienced more severe childhood trauma are at higher risk for PNES, regardless of trauma subtypes, support the concept that rather than a specific type of childhood trauma being predictive of ‘subsequent diagnosis of PNES, subjective childhood trauma of any type patients at higher risk of diagnosis of PNES than epilepsy in a linear fashion,’ wrote the authors, led by Tianren Yang of the Melbourne School of Psychological Sciences.

According to Dr Adith Mohan of UNSW Sydney (not the study’s author), the subjective impact of trauma on an individual is an important practice point for clinicians.

“You can have two people with seemingly similar traumatic experiences. But the individual who has a higher level of trauma severity is more vulnerable than one who does not based on the results of this study. This serves to highlight individual differences between people in terms of the impact of a traumatic event,” he said.

One of the study’s authors, Associate Professor Charles Malpas of the University of Melbourne, said it aimed to find out whether particular types of childhood trauma put patients at increased risk.

“We ended up looking at five different types of childhood trauma, including neglect and abuse, separating those two and then looking at sexual abuse separately,” he said. Preview+.

They thought that abuse might pay more in patients with PNES rather than neglect alone. And based on their clinical experience, they believed that a history of sexual abuse would be strongly represented in the PNES group.

“I think the surprising thing is that we found no evidence that any particular type of trauma was reported more in the PNES group. We thought we were seeing an interesting profile. But instead, what we saw , is that all kinds of trauma were seen to occur more frequently in childhood in the PNES groups. This was unexpected,” he said.

Etiology of PNES

PNES is a subtype of functional neurological disorder (FND), a collection of neurological symptoms that cannot be explained by disease or anatomic abnormalities.

According to Dr. Mohan, the seizures can resemble epilepsy.

“An epileptic seizure represents a seizure phenomenon related to abnormal electrical discharges in the brain,” he explained.

“If you have someone who has a non-epileptic seizure, you are essentially describing someone who has a seizure-like event upon presentation, although those events are not caused by epileptic discharges in the brain,” did he declare.

The mechanisms behind these seizure-like events are not yet fully understood; however, there is a consistent link to traumatic events.

“About 90% of people with PNES report having experienced traumatic events in their lifetime, compared to 74.9% in the general population and 85% in epilepsy patients,” Yang and colleagues wrote.

Why this link occurs has yet to be worked out.

“It could be that there are fundamental brain changes that occur in people who have suffered childhood trauma that do not occur in others. One of the issues is that these brain changes are also a risk for organic epilepsy,” explained Associate Professor Malpas.

Diagnose PNES

Diagnosing PNES can be difficult. There is an average of 7 to 16 years of delay in diagnosis after seizure onset and often patients are misdiagnosed with epilepsy (here and here).

In the article by Yang and colleagues, data was collected from two cohorts: a retrospective cohort (203 people) and a prospective cohort (209).

Each cohort was monitored by video electroencephalogram (EEG) and completed the Childhood Trauma Questionnaire as part of their clinical practice. All patients were evaluated by a multidisciplinary team of neurologists, neuroradiologists, neuropsychiatrists and neuropsychologists to reach a consensus diagnosis.

Video EEG is considered the gold standard for diagnosis, but access is difficult for many.

“A video EEG is when someone comes in for an extended period of EEG monitoring where EEG electrodes are attached,” Dr. Mohan explained.

“In an ideal scenario, they would have the seizure-like event and you would confirm that the event was not accompanied by epileptic discharges in the brain. This confirms that the event is not epileptic. Obviously there is has problems accessing this kind of survey It depends on where the patient is and who they are seeing.

Most EEG video monitoring units are found in large hospitals in major centers.

Treat PNS

Once a patient has been diagnosed with PNES, it is important that they are informed appropriately.

“We worked a lot on that to make sure it’s not like ‘you don’t have epilepsy, you pretend, let’s go’. The normal approach is to tell them ‘it’s a good news, you don’t have organ-level brain impairment,” said Associate Professor Malpas.

However, an explanation is in order.

“We talk about things like the connection between mind and body, and how psychological conditions can manifest physically. And that will often bring up the discussion about trauma. for patients,” he said.

There are several treatment options for patients and it is often a multidisciplinary approach depending on the person’s symptoms.

“It’s about having a psychological intervention and an adapted paramedical health intervention in a broad sense; have the involvement of an occupational therapist, a physiotherapist and a psychologist and meet the specific needs of the patient, including their social and functional needs,” explained Dr. Mohan.

According to Associate Professor Malpas, patients are often reluctant to consult a psychiatrist. Often a neurologist is not suitable because they specialize in physical disorders of the brain.

“We are very lucky with neuropsychologists who fall somewhere in between. Patients are often quite willing to see these specialists and these specialists are trained in this area,” he said.

Another factor to consider is comorbid conditions.

“A number of patients may have a history of trauma and have other psychiatric illnesses that affect them. This is really where medication comes in. The use of medication is aimed at treating comorbidity. If someone is in pain, you manage their pain, if someone is in depression, you manage their depression,” Dr. Mohan said.

A previous study found that patients with PNES had a standardized mortality rate 2.5 times higher than that of the general population. This highlights the importance of proper diagnosis and early intervention.

“We’re in a phase right now where we’re taking PNES a lot more seriously as a condition. People are saying, ‘well, they’re just crazy, it’s all in their head,'” said Associate Professor Malpas.

“No. This is actually a serious thing, and these patients need care.

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