Introduction/Objectives Comorbid/dual diagnosis (DD) epilepsy (ES) and functional seizures (FS) occur at a significant rate in adult populations but it is not known whether the underlying mechanism or aetiological models are similar to patients with FS alone. We conducted a systematic review of patients with dual diagnosis to understand more about underlying mechanisms and natural history, in comparison to patients with FS only. Methods The search strategy used the PRESS (Peer Review of Electronic Search Strategies) 2015 evidence-based checklist. We selected papers from MEDLINE, APA PsychInfo, and Google Scholar with search terms to identify primary research, on comorbid epilepsy and functional seizures confirmed by video EEG/telemetry, excluding people younger than 18 or over 75, and not including studies on populations with learning difficulties. Papers from the last 30 years were examined. Case reports were excluded. Papers were summarised by two authors and results corroborated. Results 116 papers (with 1854 participants) were included. Studies indicated patients with DD and FS were similar in the pre-ictal changes to heart-rate variability. Both showed similar degrees of suggestibility and similar semiology. Both had similar levels of, and features of, dissociation during FS. Studies identified differences in the psychiatric profile between these groups, and of symptom burden and comorbidities, especially somatovisceral disorders (e.g. irritable bowel, headache, gastro-oesophageal reflux, or pain) which were more common in patients with FS than patients with DD. Discussion/Conclusion Bayesian models of perception have been explored in functional conditions (Edwards, 2012), 1 suggesting functional symptoms emerge due to a disorder of bodily priors. Recent work on interoception seeks to characterise the contribution of these bodily afferent signals and explore a role of dysregulation in aetiology of FS and functional conditions in general. Our findings suggest that, in the lead up to and during events, patients with DD and FS both experience disordered interoception as indexed by the development of subjective bodily symptoms, and objective changes in autonomic tone (changes in heart-rate variability). Interictally, however, patients with a dual diagnosis are less likely to report other generalised functional symptoms, compared to those with FS alone. Our findings suggest potentially different underlying mechanisms within a Bayesian framework. In patients with FS alone there may be a generalised disorder of hyper-precise bodily priors, while in DD patients the primary problem may be one of excessive attention to bottom-up bodily afferent signals and phenomena linked to their epilepsy. Reference Mark J Edwards, Rick A Adams, Harriet Brown, Isabel Pareés, Karl J Friston. A Bayesian account of ‘hysteria’, Brain 2012; 135 (11): 3495–3512, https://doi.org/10.1093/brain/aws129
Modafinil is a non-amphetamine stimulant that is prescribed for narcolepsy-associated sleepiness as well as reported off-licence uses among university students looking to improve wakefulness and focus. There is limited information in the medical literature about supratherapeutic modafinil dosage, symptomatology and management of overdose. We report a case of a healthy 32-year-old man who was found unconscious, having vomited, with an empty modafinil blister strip. At the emergency department, he presented with reduced Glasgow Coma Scale and prolonged episodes of vomiting. This acute presentation was conservatively managed in the intensive care unit. Antibiotics were also given for a suspected aspiration pneumonia. CT of the head showed cerebral oedema and biochemistry investigations revealed hyponatraemia. Result aetiology was unclear, however, it has been theorised to be secondary to a sizeable modafinil overdose.
Background Patients with functional seizures (FS) can experience dissociation (depersonalisation) before their seizures. Depersonalisation reflects disembodiment, which may be related to changes in interoceptive processing. The heartbeat-evoked potential (HEP) is an electroencephalogram (EEG) marker of interoceptive processing. Aim To assess whether alterations in interoceptive processing indexed by HEP occur prior to FS and compare this with epileptic seizures (ES). Methods HEP amplitudes were calculated from EEG during video-EEG monitoring in 25 patients with FS and 19 patients with ES, and were compared between interictal and preictal states. HEP amplitude difference was calculated as preictal HEP amplitude minus interictal HEP amplitude. A receiver operating characteristic (ROC) curve analysis was used to evaluate the diagnostic performance of HEP amplitude difference in discriminating FS from ES. Results The FS group demonstrated a significant reduction in HEP amplitude between interictal and preictal states at F8 (effect size rB=0.612, false discovery rate (FDR)-corrected q=0.030) and C4 (rB=0.600, FDR-corrected q=0.035). No differences in HEP amplitude were found between states in the ES group. Between diagnostic groups, HEP amplitude difference differed between the FS and ES groups at F8 (rB=0.423, FDR-corrected q=0.085) and C4 (rB=0.457, FDR-corrected q=0.085). Using HEP amplitude difference at frontal and central electrodes plus sex, we found that the ROC curve demonstrated an area under the curve of 0.893, with sensitivity=0.840 and specificity=0.842. Conclusion Our data support the notion that aberrant interoception occurs prior to FS. Changes in HEP amplitude may reflect a neurophysiological biomarker of FS and may have diagnostic utility in differentiating FS and ES.
We analysed general symptom burden in patients with psychogenic nonepileptic seizures (PNES). A comparison was made between those who accept and those who do not accept the diagnosis of PNES (Thaller, Hyland, Kandasamy, & Sadler, 2016).
Method
A questionnaire-based pilot study of newly diagnosed psychogenic nonepileptic seizure patients was carried out. PNES diagnosis had to be confirmed by video electroencephalograph. The questionnaire was a 59-item general symptom questionnaire, with frequency (scores) ranging from never (0) to every day (5). Next, we performed blinded assessment of the patient9s acceptance of diagnosis.
Results
We collected data on 13 patients over the five month period. Eight accepted the diagnosis, and five did not. Diagnosis acceptance correlated with a significantly lower overall symptom score (p<0.001) and significantly lower symptom scores in seven symptom subscales – of which there were 10 in total.
Conclusion
Symptom burden and distribution of psychogenic nonepileptic seizure patients differs between those accepting, versus those not accepting diagnosis. The complexity of additional symptoms may contribute to poorer outcomes in those that do not accept the psychogenic nonepileptic seizure diagnosis. The next step would be to collect similar data on a larger number of these patients.
Objectives Twitter may provide a platform for clinicians and allied health professionals to publicise Functional Neurological Disorder (FND) and Non-Epileptic Attack Disorder (NEAD), and also provides a platform for patients and their communities to discuss the disorders. The prevalence and sentiment of discussions of these disorders have not been reported before now. We wrote a program to collect and analyse ‘Tweets’ about the subjects in their sentiment, connectivity and content. Methods Preliminary searches and graph analyses identified the most relevant search terms. Tweets were collected automatically, along with available metadata. Sentiment analysis was performed using natural language processing with valence aware dictionary analysis, allowing automatic interpretation of text including idioms and ‘emojis’. Results 13347 tweets were collected, with tweets not in English having been excluded from the analysis. The analysis showed a majority positive sentiment in the tweets. The most negative discourse was related to search terms: ‘Medically Unexplained Symptoms’ and ‘Psychosomatic’. Engagement with charities and tweets aiming to promote awareness of the disorders in question were common. Most frequent links to posts about FND were synonyms for the disorder, along with NEAD and charities and awareness movements. For NEAD, the most common links made were with FND, awareness campaigns, synonyms for NEAD, and Chronic Fatigue Syndrome. Conclusions FND and NEAD have active communities on Twitter. These include both health professionals, patients and lay advocates. The overall sentiment is positive (p<0.05), but with some negativity from sceptical patients and some who are disappointed with their care, and with more negativity associated with certain search terms. (For example, more negative sentiment in tweets about ‘Medically Unexplained Symptoms’ compared to ones about ‘Functional Neurological Disorder’, p<0.0005). Public discourse analysis on websites such as Twitter may prove fruitful for monitoring patient understanding, trends in patient acceptance of diagnosis and factors contributing to these.
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