Non-Epileptic Seizures and Other Functional Neurological Symptoms: Predisposing, Precipitating, and Perpetuating Factors

Reuber, Markus; Howlett, Stephanie; Khan, Ajjaz; Grünewald, Richard A.

doi:10.1176/appi.psy.48.3.230

Cited by 166 publications

(121 citation statements)

References 46 publications

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“…Fifth, there are other potential predictors of outcome that we did not measure. For example, recently published studies of symptom outcome have included a wider range of patient illness beliefs (Frostholm et al 2007 ;Foster et al 2008), whereas others have highlighted the role of duration of symptoms, patient personality, or changes in personal relationships, family problems and social circumstances in predicting outcome (Craig et al 1994 ;Crimlisk et al 1998 ;Reuber et al 2007b), none of which we measured. Sixth, we measured the outcome with a global self-rated measure of improvement.…”

Section: Discussionmentioning

confidence: 99%

Neurology out-patients with symptoms unexplained by disease: illness beliefs and financial benefits predict 1-year outcome

et al. 2009

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Background. Patients whose symptoms are ' unexplained by disease ' often have a poor symptomatic outcome after specialist consultation, but we know little about which patient factors predict this. We therefore aimed to determine predictors of poor subjective outcome for new neurology out-patients with symptoms unexplained by disease 1 year after the initial consultation.Method. The Scottish Neurological Symptom Study was a 1-year prospective cohort study of patients referred to secondary care National Health Service neurology clinics in Scotland (UK). Patients were included if the neurologist rated their symptoms as ' not at all ' or only ' somewhat explained ' by organic disease. Patient-rated change in health was rated on a five-point Clinical Global Improvement (CGI) scale (' much better ' to ' much worse ') 1 year later.Results. The 12-month outcome data were available on 716 of 1144 patients (63 %). Poor outcome on the CGI (' unchanged ', ' worse ' or ' much worse ') was reported by 482 (67 %) out of 716 patients. The only strong independent baseline predictors were patients' beliefs [expectation of non-recovery (odds ratio [OR] 2.04, 95 % confidence interval [CI] 1.40-2.96), non-attribution of symptoms to psychological factors (OR 2.22, 95 % CI 1.51-3.26)] and the receipt of illness-related financial benefits (OR 2.30,. Together, these factors predicted 13 % of the variance in outcome.Conclusions. Of the patients, two-thirds had a poor outcome at 1 year. Illness beliefs and financial benefits are more useful in predicting poor outcome than the number of symptoms, disability and distress.

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Section: Discussionmentioning

confidence: 99%

Neurology out-patients with symptoms unexplained by disease: illness beliefs and financial benefits predict 1-year outcome

et al. 2009

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“…The evidence points to a chronic inadequate family environment and a history of abuse as the two major psychosocial factors. 10 Treatment is generally supportive with explanation, reassurance, and physical therapy. 11 Behaviour therapy, cognitive therapy, and psychoeducation are recommended with the aim of promoting acceptance of the psychiatric etiology.…”

Section: Discussionmentioning

confidence: 99%

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confidence: 99%

Conversion Disorder after Surgery in a Brain Tumour Patient

Khu

Ali

Bernstein

2010

Can. j. neurol. sci.

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We describe a case of conversion disorder in a young lady who had just been operated on for a glioma. CASE REPORTA 31-year-old lady presented two years ago with seizures manifesting as jerking of her right arm and leg. Neurological examination revealed no focal deficits. Brain imaging revealed the presence of a small lesion in her left mesial posterior frontal lobe, just anterior to the motor strip ( Figure 1). The appearance was compatible with a low grade glioma. There was no perilesional edema, enhancement, or mass effect. She was treated with anti-epileptic medications with good control of her seizures. The brain tumour was managed conservatively with regular clinical and imaging follow-up.The patient remained well and asymptomatic, but her most recent magnetic resonance imaging (MRI) showed an increase in the size of the tumour (Figure 2). Awake craniotomy with cortical mapping for tumour excision was recommended and performed. Mapping over the motor cortex was positive, in that the right leg became weak when that area of cortex was stimulated. Corticotomy was made anterior to the motor cortex and aggressive subtotal resection of the tumour was achieved leaving behind a small cuff posteriorly, adjacent to the motor strip. As is our usual protocol, the patient was sedated after the mapping was performed, precluding continuous testing during tumour resection.Immediately post-operatively, the patient could not move her right leg. Motor examination was 5/5 for all limbs except for the right lower extremity which was 0/5 in all muscle groups. There was no sensory deficit. The patient had hyperreflexia bilaterally but no Babinski. She was noted to have a positive Hoover's sign, with palpable downward force of the right leg while raising the unaffected left limb. The patient's pattern of leg weakness exhibited some inconsistencies: despite a motor strength of 0/5, she was able to bear weight on her right leg and walk with support within two days. In addition, throughout the patient's hospital stay, she showed little concern about and seemed to be indifferent to her condition.Various investigations were carried out. Computed tomogram four hours after surgery and MRI 40 hours post-operatively both revealed the resection cavity in the left posterior frontal area anterior to the precentral gyrus, and a small amount of residual tumour between the surgical site and the motor strip (Figure 3). There was no hemorrhage, increase in the perilesional edema, or mass effect. Neurophysiologic studies such as nerve conduction velocity, electromyography, and motor evoked potentials done two weeks after surgery confirmed no organic brain pathology. BRIEF COMMUNICATIONSSteroids were started but there was no improvement in the patient's leg weakness. Our considerations during this time were supplementary motor cortex syndrome versus conversion disorder. Upon probing further into the patient's history, it was found that she is married with a three-year-old son. She is a high school graduate and is unemployed. She has no previous med...

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“…Sexual abuse was considered at one point as one of the main causes of PNES. However, sexual abuse is only reported by a minority of patients with PNES (about 30% of women and 5% of men), and over the past 10 years there has been a shift towards a more non-specific but possibly more nuanced view of the role of trauma in PNES, with sexual abuse conceptualised as a marker of more severe emotional and physical neglect, rather than a specific cause in itself (Reuber 2007;Bakvis 2009b). …”

Section: Past Traumatic Experiencementioning

confidence: 99%

“…Stressful or traumatic life events prior to the start of PNES can be identified in the majority of patients Reuber 2007). A wide variety of psychological and physical stressors have been reported as possible precipitating factors.…”

Section: Precipitating Factorsmentioning

confidence: 99%

Psychogenic non-epileptic seizures: aetiology, diagnosis and management

Oto¹,

Reuber²

2014

Adv. psychiatr. treat

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SummaryPsychogenic non-epileptic seizures (PNES) have a significant impact on most patients in terms of distress, disability, loss of income and iatrogenic harm. Three-quarters of patients with PNES are initially misdiagnosed and treated for epilepsy. Misdiagnosis exposes patients to multiple iatrogenic harms and prevents them from accessing psychological treatment. In most cases, the patient's history (and witness accounts) should alert clinicians to the likely diagnosis of PNES. Since this diagnosis may be resisted by patients and may involve ‘un-diagnosing’ epilepsy, video-electroencephalogram recording of typical seizures is often helpful. The underlying causes of PNES are diverse: a model combining predisposing, precipitating and perpetuating factors is a useful way of conceptualising their aetiology. The initial step of treatment should be to limit iatrogenic harm. There is some evidence for the effectiveness of psychotherapy.

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Non-Epileptic Seizures and Other Functional Neurological Symptoms: Predisposing, Precipitating, and Perpetuating Factors

Cited by 166 publications

References 46 publications

Neurology out-patients with symptoms unexplained by disease: illness beliefs and financial benefits predict 1-year outcome

Neurology out-patients with symptoms unexplained by disease: illness beliefs and financial benefits predict 1-year outcome

Conversion Disorder after Surgery in a Brain Tumour Patient

Psychogenic non-epileptic seizures: aetiology, diagnosis and management

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