Mortality in patients with psychogenic non-epileptic seizures a population-based cohort study.

OBJECTIVES: To compare mortality, comorbidities and causes of death in people with psychogenic non-epileptic seizures (PNES), epilepsy and the general population. METHODS: Using linkage of multiple Swedish national registers, we identified individuals with incident diagnosis of PNES, epilepsy and conversion disorder with motor symptoms or deficits, and 10 controls for each. Main outcome was all-cause mortality. Causes of death were categorised into non-natural (eg, suicide, injuries) and natural. Conditional Cox regression models were used to estimate HRs and 95% CIs for mortality. HRs were adjusted for socioeconomic factors and psychiatric comorbidities. RESULTS: Included were 885 individuals with PNES, 50 663 with epilepsy and 1057 with conversion disorder and motor symptoms or deficits. We found 32 (3.6%) deaths among individuals with PNES, compared with 46 (0.5%) deaths in controls, giving an adjusted HR of 5.5 (95% CI 2.8 to 10.8). Patients with epilepsy had a 6.7 times higher risk of death (95% CI 6.4 to 7.0) compared with individuals without epilepsy. The association between conversion disorder with motor symptoms or deficits was non-significant after adjusting for psychiatric comorbidities. PNES carried a higher risk of natural (HR 8.1, 95% CI 4.0 to 16.4) and non-natural causes of death (HR 15.3, 95% CI 3.0 to 78.6). Suicide ranked high in patients with PNES (18.8%) and conversion disorder with motor symptoms and deficits. The association between PNES diagnosis and all-cause mortality varied with age and time since diagnosis. CONCLUSION: Like epilepsy, PNES carries a higher than expected risk of both natural and non-natural causes of death. The high proportion of suicides requires further investigation.

Improved ictal assessment performance in the epilepsy monitoring unit via standardization.

OBJECTIVE: To determine whether the standardization and implementation of an ictal testing protocol in the Epilepsy Monitoring Unit (EMU) leads to improvements in ictal testing performance. METHODS: Ictal assessments completed in the EMU from a single center were retrospectively reviewed over a two-month period. Each assessment was evaluated to determine whether 8 high-yield aspects of the ictal assessment were performed. Following observation of performance, a standardized ictal testing protocol was developed based on a root cause analysis and review of consensus guidelines. This protocol was disseminated to staff in conjunction with an annual epilepsy education seminar. Ictal assessment performance was re-assessed during the subsequent two months (short-term follow-up) and again during a five- to seven-month period (long-term follow-up) beyond the initial intervention. For sub-group analysis, event characteristics (event type, time of assessment) and patient characteristics (age, gender) were also evaluated and analyzed in relation to ictal testing performance. RESULTS: All eight individual ictal testing elements were more likely to be assessed in short-term and long-term follow-up periods when compared to pre-intervention assessments. The cumulative difference in ictal testing was 20.4% (95% CI 3.7-37.2, p = 0.02) greater for the short-term period and 16.7% (95% CI -0.3% to 33.8%, p = 0.05) greater in the long-term period when compared to baseline testing. CONCLUSIONS: Utilization of a standardized ictal testing battery in conjunction with staff education leads to an objective improvement in ictal assessment performance. Further research is warranted to assess the replicability of our findings.

Self-reporting versus clinical scrutiny: the value of adding questionnaires to the routine evaluation of seizure disorders. An exploratory study on the differential diagnosis between epilepsy and psychogenic nonepileptic seizures.

Questionnaires or symptom lists have proved effective for differentiating epileptic seizures (ES) from psychogenic nonepileptic seizures (PNES). However, monitoring the events, corroborated by medical history gathered by experts, remains the gold standard. We directly compared symptoms and characteristic of the events self-reported by patients/eyewitnesses (Questionnaire A/B) with the information contained in the clinical charts of 50 patients with undefined diagnosis undergoing long-term monitoring. Data extracted from medical records were reformatted to fit the questionnaires' templates (A1/B1) for comparison. Quantitatively, self-reported information was considerably greater and more complete. Calculating sensitivity (SE) and specificity (SP) of all variables in the group with confirmed diagnosis, we identified those above the preset thresholds with the potential to discriminate between ES and PNES. Eight predictive variables were common to both methods: head injury, physical/emotional abuse, chronic fatigue (A); talked out of seizures, eyes closed, apnea, and collapsing (B). Eleven predictive variables were specific to direct questioning: preictal headache, bright light, feeling overwhelmed, heart racing, tingling and numbness, postictal trouble speaking, physical pain, history of gastro-esophageal reflux disease (GERD), self-inflicted injuries (A); on/off shaking, and side-to-side head movements (B). Thirteen predictive variables were generated by chart review: sleep deprivation, strong emotions/anxiety, preictal headache (warning), nausea/vomiting, history of PNES, cholecystectomy, depression, medications for behavioral problems (A1), sudden start/sudden stop of shaking, both sides shaking, falling during the seizure, feeling confused and disoriented postictally (B1). CONCLUSION: Self-reporting and clinical scrutiny are complementary. Structured questionnaires increase the range of predictive variables and should be utilized routinely to facilitate clinicians' quest for the correct diagnosis.

Antiepileptic drug discontinuation by people with epilepsy in the general population.

OBJECTIVE: Rate, reasons, and predictors of antiepileptic drug (AED) discontinuation were investigated in a well-defined cohort of people with epilepsy to verify efficacy and tolerability of treatment up to 20 years from treatment initiation. METHODS: The history of AED usage in children and adults with epilepsy registered with 123 family physicians in an area of Northern Italy between 2000 and 2008 was recorded. Cumulative probabilities of AED withdrawal for specific reasons were estimated using cumulative incidence functions. The probabilities of withdrawing for terminal remission, and of achieving sustained remission while still on treatment, were also evaluated. The roles of sex, age at diagnosis, seizure types, duration at diagnosis, and syndrome were assessed with hazard ratios and 95% confidence intervals. RESULTS: Seven hundred thirty-one of 747 individuals were treated with one or more AEDs during the disease course. The three commonest drugs were valproate, carbamazepine, and phenobarbital. Reported reasons for AED withdrawal were, in decreasing order, terminal remission, ineffectiveness, and adverse events. The probability of withdrawing the first AED for terminal remission was 1.0% at 1 year and increased to 20.0% at 20 years. Corresponding rates were 2.9% and 12.6% for ineffectiveness and 0.5% and 3.3% for adverse events. Reasons for withdrawal varied with individuals' age, sex, disease characteristics, and drugs. SIGNIFICANCE: The initial AED given was retained in the majority of cases. Terminal remission, lack of efficacy, and adverse effects were, in decreasing order, the commonest reasons for AED discontinuation. Withdrawal could be predicted by age at diagnosis, sex, and clinical characteristics and varies among drugs.

The semiology of psychogenic nonepileptic seizures revisited: Can video alone predict the diagnosis? Preliminary data from a prospective feasibility study.

OBJECTIVE: To investigate if, when, and to what extent visual information contained in a video-recorded event allows experienced epileptologists to predict the diagnosis of psychogenic nonepileptic seizures (PNES) without the aid of electroencephalography (EEG). METHODS: Five neurologists actively practicing in epilepsy centers in Italy and the United States were asked to review 23 videos capturing representative events of 21 unselected consecutive patients admitted for long-term video-EEG monitoring (VEM). Four raters were blind to EEG and clinical information; one rater was not. They were requested to (1) rate the videos for quality and content; (2) choose among four diagnoses: (a) epileptic seizures (ES); (b) PNES; (c) Other nonepileptic seizures (NES; (syncope, movement disorder, migraine, etc.); (d) "Cannot Say"; and (3) explain in their own words the main reasons leading to the diagnosis of choice. RESULTS: All raters predicted the diagnosis correctly in 7 of 23 videos (all ES or PNES) (30.4%), whereas all raters failed in 5 of 23 cases (three Other NES, one PNES, one Cannot Say) (21.7%). The conditions that facilitate, and those that interfere with, a confident diagnosis were predictable. Degree of accuracy among raters was not uniform and was consistently better in three raters. Two among the four blind raters were as accurate as the rater who was not blinded. Interrater agreement was "moderate" (k = 0.52) for the overall group; "moderate" for ES (k = 0.53); "substantial" for PNES (k = 0.63); "fair" for Other NES (k = 0.21)-similar to the results obtained in a previous study evaluating the reliability of combined video-EEG. SIGNIFICANCE: In about one third of cases, a confident diagnosis of PNES/ES can be established on clinical grounds based on video data alone. Our results benefit all affected patients, particularly those with no access to video-EEG monitoring units.

A population-based study of active and drug-resistant epilepsies in Northern Italy.

Drug-resistant epilepsy (DRE) is defined by the International League Against Epilepsy as a failure of adequate trials of two tolerated, appropriately chosen, and used antiepileptic drugs to achieve sustained seizure freedom. Our aim was to calculate the following: (1) the prevalence of active epilepsy and DRE in a well-defined population of Northern Italy and (2) the proportion of incident cases developing DRE. The study population (146,506; year 2008) resided in the province of Lecco, Northern Italy. The medical records of 123 general practitioners were reviewed to identify patients with epilepsy, diagnosed by a neurologist during the period 2000-2008. The point prevalence of active epilepsy and DRE was calculated on December 31, 2008. A total of 747 prevalent patients with epilepsy, 684 patients with active epilepsy, and 342 incident cases were identified. The frequency of DRE was 15.6% (107/684) of all active epilepsies and 10.5% (36/342) of incident cases. The point prevalence was 0.73 per 1000. The standardized prevalence of DRE was 0.7 per 1000 (Italian population) and 0.8 per 1000 (world population). Our data indicate that 1/6 patients with active epilepsy in the general population has DRE, and 1/10 patients with newly diagnosed epilepsy will develop DRE within nine years from the diagnosis.

Metaphoric language in the differential diagnosis of epilepsy and psychogenic non-epileptic seizures: Time to move forward.

Conversation analysis (CA) to identify metaphoric language (ML) has been proposed as a tool for the differential diagnosis of epileptic (ES) and psychogenic nonepileptic seizures (PNES). However, the clinical relevance of metaphoric conceptualizations is not clearly defined. The current study aims to investigate the ML utilized by individuals with ES and PNES in a pulled multi-country sample. Two blinded researchers examined the transcripts and videos of 54 interviews of individuals (n = 29, Italy; n = 11, USA; n = 14, Russia) with ES and PNES, identifying the patient-seizure relationship representative of the patient's internal experience. The diagnoses were based on video-EEG. Metaphors were classified as "Space/place", "External force", "Voluntary action", and "Other". A total of 175 metaphors were identified. No differences between individuals with ES and PNES were found in metaphoric occurrence (χ2 (1, N = 54) = 0.07; p = 0.74). No differences were identified when comparing the types of metaphors utilized by participants with ES and those with PNES. Patients with PNES and ES did not demonstrate differences in terms of occurrence and categories in ML. Therefore, researchers and clinicians should carefully consider the use of metaphor conceptualizations for diagnostic purposes.

Acceptance of epilepsy surgery in the pediatric age - what the parents think and what the doctors can do.

Epilepsy surgery (ES) in pediatrics is safe and effective but can be underutilized. Possible barriers could be parental resistance and doctor inertia. We surveyed 138 parents of pediatric patients with epilepsy and found that 25.2% were opposed to this treatment. However, upon completing the questionnaire that contained factual information about ES, 50.4% of the responders stated that they had become more favorable vs. 3.3% more contrary and 46.3% unchanged. Parents of prepubescent patients were most receptive (p=0.0343) and more likely to shift to a more favorable attitude. Thus, pediatric neurologists should not hesitate to discuss ES as soon as indicated, providing all necessary information to increase acceptance. However, among 60 child neurologists surveyed, 60% did not fully comply with guidelines or follow accepted standards of practice, indicating that they may not be apt to provide proper parental guidance. We conclude that education of both practicing neurologists and parents is needed to facilitate the process.

Heart rate and autonomic biomarkers distinguish convulsive epileptic vs. functional or dissociative seizures.

OBJECTIVE: 20-40% of individuals whose seizures are not controlled by anti-seizure medications exhibit manifestations comparable to epileptic seizures (ES), but there are no EEG correlates. These events are called functional or dissociative seizures (FDS). Due to limited access to EEG-monitoring and inconclusive results, we aimed to develop an alternative diagnostic tool that distinguishes ES vs. FDS. We evaluated the temporal evolution of ECG-based measures of autonomic function (heart rate variability, HRV) to determine whether they distinguish ES vs. FDS. METHODS: The prospective study includes patients admitted to the University of Rochester Epilepsy Monitoring Unit. Participants are 18-65 years old, without therapies or co-morbidities associated with altered autonomics. A habitual ES or FDS is recorded during admission. HRV analysis is performed to evaluate the temporal changes in autonomic function during the peri­ictal period (150-minutes each pre-/post-ictal). We determined if autonomic measures distinguish ES vs. FDS. RESULTS: The study includes 53 ES and 46 FDS. Temporal evolution of HR and autonomics significantly differ surrounding ES vs. FDS. The pre-to-post-ictal change (delta) in HR differs surrounding ES vs. FDS, stratified for convulsive and non-convulsive events. Post-ictal HR, total autonomic (SDNN & Total Power), vagal (RMSSD & HF), and baroreflex (LF) function differ for convulsive ES vs. convulsive FDS. HR distinguishes non-convulsive ES vs. non-convulsive FDS with ROC>0.7, sensitivity>70%, but specificity<50%. HR-delta and post-ictal HR, SDNN, RMSSD, LF, HF, and Total Power each distinguish convulsive ES vs. convulsive FDS (ROC, 0.83-0.98). Models with HR-delta and post-ictal HR provide the highest diagnostic accuracy for convulsive ES vs. convulsive FDS: 92% sensitivity, 94% specificity, ROC 0.99). SIGNIFICANCE: HR and HRV measures accurately distinguish convulsive, but not non-convulsive, events (ES vs. FDS). Results establish the framework for future studies to apply this diagnostic tool to more heterogeneous populations, and on out-of-hospital recordings, particularly for populations without access to epilepsy monitoring units.

Barriers toward epilepsy surgery. A survey among practicing neurologists.

PURPOSE: Guidelines for refractory epilepsy recommend timely referral of potential surgical candidates to an epilepsy center for evaluation. However, this approach is seldom a priority for treating neurologists, possibly because of inertia of previous practice and personal attitudes, leading to a buildup of psychosocial disabilities and increased risk of morbidity and mortality. The aim of this study was to assess knowledge and attitudes toward epilepsy surgery among practicing neurologists and identify the barriers that delay the treatment. METHODS: We surveyed 183 Italian adult and child neurologists with an ad hoc questionnaire exploring physicians' willingness to refer patients for epilepsy surgery when such treatment may be indicated. Thirteen of 14 questions had graded answers ranging from 1 (unfavorable to surgery) to 10 (favorable). We compared the overall scores and per-question scores of the neurologists versus a group of academic and clinical leaders in the field. KEY FINDINGS: The neurologists gave responses characterized by extreme variability (i.e., wide response interquartile range) around intermediate scores. Experts had higher and less variable scores favoring surgery. The two groups differed significantly on issues such as how long to pursue pharmacologic treatment and information about indications and outcome of surgery. Multivariate analysis indicated that neurologists' attitudes correlated with the number of patients referred for surgery (p < 0.01) and the geographical region where specialty was attained (p < 0.01). Other variables such as years in practice, number of patients treated for epilepsy, or type of specialty had no predictive value on physicians' behavior. SIGNIFICANCE: The majority of Italian neurologists have highly variable attitudes toward epilepsy surgery, reflecting ambivalence and uncertainty toward this type of treatment. About two thirds of responders are nonaligned with the opinion leaders, mainly due to differences in handling pharmacologic treatment and information regarding epilepsy surgery, which affect their attitudes and ultimately patient management. Strategies that may solve the lack of agreement include reinforcing the concept of pharmacoresistance and associated risks, as opposed to the safety and potential benefits of surgery, the use of epilepsy quality measures during follow-up, and the adoption of structured referral sheets and greater involvement of patients in decision making. These measures should facilitate the referral of potential candidates for surgical evaluation and improve overall quality of care.

Acceptance of epilepsy surgery among adults with epilepsy--what do patients think?

Physician inertia is usually blamed for the underutilization of epilepsy surgery (ES) at the cost of increased patient disability and risk of mortality. Investigations on selected groups of patients with intractable TLE and minorities suggested that patient beliefs may also limit access to ES. To assess acceptance of ES among "mainstream" patients, we distributed an ad hoc questionnaire to 228 adults attending epilepsy clinics and found widespread fears and misconceptions leading to unfavorable perception of ES, irrespective of diagnosis, seizure type, and degree of intractability. Moreover, while a group firmly rejected ES, the majority became more favorable when given further information about modality, rationale, and expected outcome of ES. Attitude changes correlated with patient's social profile. Neurologists are responsible for providing all pertinent information to potential surgical candidates as soon as indicated. Therefore, an untimely or inadequate intervention of the treating physician constitutes an additional barrier to optimal utilization of ES.

Early surgical therapy for drug-resistant temporal lobe epilepsy: a randomized trial.

CONTEXT: Despite reported success, surgery for pharmacoresistant seizures is often seen as a last resort. Patients are typically referred for surgery after 20 years of seizures, often too late to avoid significant disability and premature death. OBJECTIVE: We sought to determine whether surgery soon after failure of 2 antiepileptic drug (AED) trials is superior to continued medical management in controlling seizures and improving quality of life (QOL). DESIGN, SETTING, AND PARTICIPANTS: The Early Randomized Surgical Epilepsy Trial (ERSET) is a multicenter, controlled, parallel-group clinical trial performed at 16 US epilepsy surgery centers. The 38 participants (18 men and 20 women; aged ≥12 years) had mesial temporal lobe epilepsy (MTLE) and disabling seizues for no more than 2 consecutive years following adequate trials of 2 brand-name AEDs. Eligibility for anteromesial temporal resection (AMTR) was based on a standardized presurgical evaluation protocol. Participants were randomized to continued AED treatment or AMTR 2003-2007, and observed for 2 years. Planned enrollment was 200, but the trial was halted prematurely due to slow accrual. INTERVENTION: Receipt of continued AED treatment (n = 23) or a standardized AMTR plus AED treatment (n = 15). In the medical group, 7 participants underwent AMTR prior to the end of follow-up and 1 participant in the surgical group never received surgery. MAIN OUTCOME MEASURES: The primary outcome variable was freedom from disabling seizures during year 2 of follow-up. Secondary outcome variables were health-related QOL (measured primarily by the 2-year change in the Quality of Life in Epilepsy 89 [QOLIE-89] overall T-score), cognitive function, and social adaptation. RESULTS: Zero of 23 participants in the medical group and 11 of 15 in the surgical group were seizure free during year 2 of follow-up (odds ratio = ∞; 95% CI, 11.8 to ∞; P < .001). In an intention-to-treat analysis, the mean improvement in QOLIE-89 overall T-score was higher in the surgical group than in the medical group but this difference was not statistically significant (12.6 vs 4.0 points; treatment effect = 8.5; 95% CI, -1.0 to 18.1; P = .08). When data obtained after surgery from participants in the medical group were excluded, the effect of surgery on QOL was significant (12.8 vs 2.8 points; treatment effect = 9.9; 95% CI, 2.2 to 17.7; P = .01). Memory decline (assessed using the Rey Auditory Verbal Learning Test) occurred in 4 participants (36%) after surgery, consistent with rates seen in the literature; but the sample was too small to permit definitive conclusions about treatment group differences in cognitive outcomes. Adverse events included a transient neurologic deficit attributed to a magnetic resonance imaging-identified postoperative stroke in a participant who had surgery and 3 cases of status epilepticus in the medical group. CONCLUSIONS: Among patients with newly intractable disabling MTLE, resective surgery plus AED treatment resulted in a lower probability of seizures during year 2 of follow-up than continued AED treatment alone. Given the premature termination of the trial, the results should be interpreted with appropriate caution. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00040326.

Psychodynamic interpretation of linguistic findings in patients with epileptic and psychogenic non-epileptic seizures: the role of metaphors.

This work points out the main differences in the semantic expressions used by patients with psychogenic non-epileptic seizures (PNES) and epileptic seizures (ES). In reference to the body as a phenomenological entity, in ES the concept of the body-object prevails while in PNES the body, with all its life attributes, predominates. In description of seizures and in similitudes and metaphors used, ES patients focus on the description of the attack, trying to close the "gap" with a big effort, while patients with PNES concentrate on the context and on the presence of bystanders. Patients with PNES are unable to describe their own attack, since this it is not at the core of their distress, but rather the manifestation of something else, which is hiding the extreme anguish associated with experiences of the past that cannot be revealed (expressed). In the case of ES, instead, the ability to talk and the willingness to elaborate on the emotions become useful tools for facing the disease, an entity perhaps unsurmountable but at least manageable, to the benefit of everyone. In general, we can say that the experience of a disease (real or symbolic) deserves constant attention because it gives us the opportunity not only to probe the depth of the emotional experiences but also the psychic structure of the individual in front of us. A cure would not be a cure without considering such fundamental elements. It would become a sterile exercise of prescribing medications without paying attention to the person, which is the best way of preserving dignity in a state of illness.

Design considerations for a multicenter randomized controlled trial of early surgery for mesial temporal lobe epilepsy.

PURPOSE: To describe the trial design for the multicenter Early Randomized Surgical Epilepsy Trial (ERSET). Patients with pharmacoresistant epilepsy are generally referred for surgical treatment an average of two decades after onset of seizures, often too late to avoid irreversible disability. ERSET was designed to assess the safety and efficacy of early surgical intervention compared to continued pharmacotherapy. METHODS: ERSET is a randomized controlled, parallel group clinical trial with blinded outcome adjudication. Participants are patients with mesial temporal lobe epilepsy (MTLE) older than the age of 12 who have had pharmacoresistant seizures for not >2 years and are determined by detailed evaluation to be surgical candidates prior to randomization. The primary outcome measure is seizure freedom in the second year of a 2-year follow-up period. Health-related quality of life (HRQOL), neurocognitive function, ancillary outcomes, and adverse events were also measured. RESULTS: Significant methodologic problems addressed by the study design included the following: recruitment of participants early in the course of epilepsy; establishment of operational definitions for "pharmacoresistant" and "early"; and standardization of diagnostic testing, medical treatment, and surgical interventions across multiple centers. DISCUSSION: Rigorous trial designs to assess surgical interventions in epilepsy are necessary to provide evidence to guide treatment. This article is the first of a series; trial results will be reported in subsequent publications.

Self-Report questionnaires for the diagnosis of psychogenic non-epileptic seizures in clinical practice. A comprehensive review of the available instruments.

We searched Medline from 1946 to 2019 for reports exploring differences between PNES and other comparable paroxysmal events using clinical instruments, few of which focused on the differential diagnosis using broad-based questionnaires covering multiple aspects of this condition. The majority investigated single items to highlight specific differences, either qualitative or quantitative, between groups and to elucidate some of the pathogenetic mechanisms of PNES. We selected all variables that proved to be useful for differentiating PNES from other types of paroxysmal events and classified them by category, by instrument utilized and method of investigation. This body of data will constitute the basis for assembling a new set of evidence-based questionnaires for patients and eyewitnesses to facilitate the differential diagnosis of these disorders, especially in resource-poor clinical settings. This will require a skillful translation of the content of each selected variable into clear and intuitive questions, appropriate for lay responders. Predictive variables found by more than one investigator, especially if using different approaches, have greater diagnostic weight and should be prominent in future questionnaires. However, even variables so far found to be predictive by one investigator will deserve consideration. Once the preliminary text of the questionnaires is consolidated, the instrument will need extensive testing and validation in large prospective studies before becoming available for clinical use in its definitive format.

History of violence/maltreatment and psychogenic non-epileptic seizures.

PURPOSE: To study the association of earlier violence/maltreatment with the occurrence of PNES in a nationwide population sample. METHODS: This is a nested case-control study performed using Swedish nationwide registers. Cases were all individuals born in Sweden between 1941 and 2009 with incident PNES between 2001 and 2013 while resident in Sweden according to the Swedish Patient Register. For each case, 10 controls, alive and PNES-free at time of PNES diagnosis of the matched case, were randomly selected from the Swedish Total Population Register, matched on age and sex. To test the specificity of the association, we conducted two similar analyses for epilepsy and dissociative disorder with motor symptoms or deficit, as comparators to PNES. Registers were examined in search of all coded diagnoses of child maltreatment or violence episodes before the index date among the cases and controls. RESULTS: 885 patients received a first diagnosis of PNES. 7.6 % of cases had a history of violence/maltreatment, compared to 1.1 % of controls, giving a crude OR of 7.9 (95 % CI: 3.7-11.0). The ORs decreased but remained significant after adjustment for socio-economic factors (OR = 6.3, 95 % CI: 4.4-9.0) and psychiatric comorbidities (OR = 5.2, 95 % CI: 3.5-7.9). The association was also evident for epilepsy and dissociative disorder, although of lower magnitude. CONCLUSION: Patients with PNES have a history of violence/maltreatment more frequently than the rest of the population. This association can be influenced by socio-economic factors and the presence of concurrent psychiatric disturbances.