Psychological trauma, somatization, dissociation, and psychiatric comorbidities in patients with psychogenic nonepileptic seizures compared with those in patients with intractable partial epilepsy.

OBJECTIVE: The objective of this study was to compare patients with intractable epilepsy with patients with psychogenic nonepileptic seizures (PNES) on the presence of psychological traumas, clinical factors, and psychological measures of somatization and dissociation. BACKGROUND: Several studies have reported a high prevalence of psychological trauma in patients with PNES, while less have examined the prevalence of psychological trauma in patients with epilepsy and compared both groups. Reports have been somewhat divergent with some describing significantly higher prevalence in physical abuse, others, in emotional abuse/neglect, and others, in sexual abuse in patients with PNES compared with those in patients with epilepsy. METHODS: This is a retrospective study of 96 patients (61 women, 35 men) with intractable epilepsy (2009 to 2017) and 161 patients (107 women, 54 men) with PNES (2008 to 2018). Demographic and clinical (psychological trauma, depression, anxiety, seizure frequency, and number of antiepileptic drugs) data were collected. The Trauma Symptom Inventory II and the Minnesota Multiphasic Personality Inventory 2RF were administered. RESULTS: Patients with PNES differed significantly from those with intractable epilepsy on sexual trauma (χ2 (5df, N = 257) =9.787, p < .002) and "other" trauma (χ2 (5df, N = 257) = 17.9076, p < .000). On psychological measures, there was a significant difference on Somatization scores in patients with PNES (M = 59.63, SD = 11.47) and patients with intractable epilepsy (M = 53.98, SD = 11.31); t(173) = 2.8396, p = .0051, but no difference was noted on a measure of Dissociation. Subsequent principal components analysis revealed that the first 3 principal components (sexual, physical, and other trauma) explained 74.19% of the variability, and that one principal component (dissociation, somatization, demoralization) explained 61.57% of the variability. However, after adjusting for the effects of covariates, only the presence of trauma discriminated between epilepsy and PNES. CONCLUSIONS: Patients with PNES diagnoses differed from those with epilepsy on a Somatization scale but not on Dissociation or Intrusive Experiences and exhibited significantly higher rates of sexual and "other" trauma compared with those with intractable epilepsy. However, subsequent analyses revealed that a history of psychological trauma was the only condition found to discriminate between patients with PNES and those with epilepsy. These findings suggest that during initial workup and diagnosis, when patients report a history of psychological trauma (sexual or otherwise) a psychogenic nonepileptic etiology should be strongly considered in the differential diagnosis.

Are there gender differences in those diagnosed with psychogenic nonepileptic seizures?

OBJECTIVE: The objective of the study was to determine whether male and female populations of patients with psychogenic nonepileptic seizures (PNES) differ, in terms of demographic, social/clinical, and etiological factors as well as psychological measures. BACKGROUND: Psychogenic nonepileptic seizures are overrepresented by females; therefore, information about PNES in males is limited. Only a handful of studies have examined PNES and gender, and of those, one was a literature review and with the exception of two, most have had small sample sizes. Of the existing literature, differences in abuse type, psychiatric diagnoses, and psychometric results have been observed in the two genders. METHODS: This is a retrospective study of 51 consecutive males and 97 consecutive females with video-electroencephalogram (video-EEG) confirmed diagnosis of PNES. Patients were examined on demographics (age, education, working status), clinical (seizure frequency, trauma type: sexual, nonsexual, age of first trauma), and psychometric measures. The latter included the State Trait Anger Expression Inventory-2 (STAXI-2), Trauma Symptom Inventory-2 (TSI-2), the Coping Inventory for Stressful Situations (CISS), and the Quality of Life Inventory in Epilepsy-31 (QOLIE-31). RESULTS: Women reported experiencing significantly more sexual traumas (p=0.007) than men. Women also endorsed significantly higher levels of dissociation (p=0.012) and sexual disturbances (p=0.46). In contrast, men reported significantly greater use of avoidance (p=0.001) as a stress coping strategy and higher levels of depression (p=0.006). CONCLUSIONS: Gender differences were identified with males reporting a significantly higher use of avoidance (cognitive and behavioral avoidance of stress) and depressive symptoms. Women exhibited significantly higher rates of sexual trauma compared with male counterparts. Consequently, women also had significantly higher rates of trauma symptomatology (dissociation and sexual disturbances) which are often observed in those who have been traumatized sexually. These gender distinctions may support different first-line treatment approaches (e.g., trauma-focused; more traditional cognitive behavioral therapy) depending on the most prominent symptomatology.

Test-retest reliability of cortical language mapping in a patient with refractory focal epilepsy: 11 years later.

Electrical stimulation mapping (ESM) is considered the gold standard for identification of essential language cortex and is especially important in patients for whom classic language landmarks are less useful because of reorganization in response to epileptogenic or neoplastic cortex. However, little is known regarding the reliability of the procedure, particularly over extended time intervals. The authors present the case of a young man with refractory left temporal lobe epilepsy in the setting of a low-grade left temporal tumor who had undergone intraoperative language mapping at age 14 years and repeat mapping at age 25. Results from both the initial ESM and the repeat ESM 11 years later revealed a positive auditory description naming site in the same location on the superior temporal gyrus, at the anterior aspect of the tumor. This case provides support for the reliability of ESM and underscores intraindividual reliability in the location of language cortex over a prolonged period.

Performance on Standard Indexes of Effort Among Patients with Dementia.

Assessment of response validity is an integral part of neuropsychological practice. Although many studies have demonstrated the efficacy of stand alone and embedded effort measures in a variety of medical and compensation-seeking contexts, much less is known about the robustness of these measures in elderly populations, particularly in patients with dementia. Although older adults may be viewed as less likely to intentionally feign symptoms for an external gain, there are a variety of other factors that could result in suboptimal effort, including fatigue, lack of interest or cooperation in the testing process, or failure to fully appreciate the implications of the assessment on treatment care and outcome. The current study examined the clinical utility of several stand alone and embedded effort measures including the Repeatable Battery for the Assessment of Neuropsychological Status Effort Index, Trail-Making Test Ratio, Rey 15-Item Test, and the Test of Memory Malingering in a sample of patients with dementia. Results found that the majority of effort indexes demonstrated unacceptably high false-positive error rates with specificity levels as high as 83%. These findings demonstrate the need for caution in interpreting effort measure performance in dementia samples due to the fact that despite their best effort, many patients with dementia fail effort measures and are at risk for being misclassified.

Survey results regarding use of the Boston Naming Test: Houston, we have a problem.

Members of the National Academy of Neuropsychology were surveyed in 2005 to assess then current practices regarding Boston Naming Test (BNT) administration, interpretation, and reporting procedures. Nearly half of 445 respondents followed discontinuation rules that differed from instructions published with the test, and nearly 10% did not administer items in reverse order to achieve the required 8 consecutive item basal. Of further concern, between 40% and 55% of respondents indicated that they did not interpret BNT scores in light of linguistic and ethnic background, and over 25% reported that they did not consider educational level. Despite the fact that non-normal distribution of BNT test scores renders use of percentiles misleading, nearly 60% of respondents endorsed using percentiles when reporting BNT data. The implications of these results are discussed, and recommendations are provided.

Examination of various WMS-III logical memory scores in the assessment of response bias.

The assessment of response validity during neuropsychological evaluation is an integral part of the testing process. Research has increasingly focused on the use of "embedded" effort measures (derived from standard neuropsychological tasks) because they do not require additional administration time and are less likely to be identified as effort indicators by test takers because of their primary focus as measures of cognitive function. The current study examined the clinical utility of various WMS-III Logical Memory scores in detecting response bias, as well as the Rarely Missed Index, an embedded effort indicator derived from the WMS-III Logical Memory Delayed Recognition subtest. The Rarely Missed Index cut-off only identified 24.1% of 63 non-credible participants (at >/=90% specificity in 125 credible patients), and cut-offs for other Logical Memory variables were in fact found to be more sensitive to non-credible performance. A new indicator, consisting of the weighted combination of the two most sensitive Logical Memory subtest scores (Logical Memory II raw score and Logical Memory Delayed Recognition raw score), was associated with 53% to 60% sensitivity, and thus may be an effective adjunct when utilized in conjunction with other validated effort indicators and collateral information in identifying non-credible performance.