Psychogenic nonepileptic seizures in adults with epilepsy: a tertiary hospital-based study.

Objectives: Many studies describe and characterize psychogenic nonepileptic seizures (PNES) in high-income but few come from low/middle and low income countries.Design/methods: We aimed to determine the prevalence of PNES coexisted in adults with epilepsy and to characterize their semiology, comorbidities and predictors whether presented with epilepsy (n = 563) or alone (n = 73). Patients were recruited from a tertiary referral epilepsy clinic. Clinical suspicion and diagnosis were done by the neurologist based on histories and clinical cues. Psychiatric evaluation included structured psychiatric interviewing and assessment of symptoms of depression, anxiety and stress using Depression Anxiety Stress Scale (DASS 21).Results: The prevalence of PNES with epilepsy was 4.97% and diagnosed after a mean interval of 7.12yrs from onset of the first attack. Patients with PNES were predominantly females in their 2nd-3rd decades. Semiology of PNES included loss of consciousness, drop attacks, involuntary movements and speech arrest. Compared to patients with PNES coexisted with epilepsy, those with PNES alone were younger at presentation (p = 0.01) and age at onset (p = 0.002) and had frequent attacks (p = 0.001), psychosocial stressors and comorbid medical illnesses (p = 0.0001) and higher scores of depression, anxiety (p = 0.01) and stress (p = 0.001). In multivariate analysis, the significant predictors of high DASS scores with PNES were psychosocial stressors and comorbid medical conditions.Conclusions: The prevalence of PNES among adults with epilepsy is ∼5%. They are frequently misdiagnosed and treated as epilepsy. Specialist neurologists are more comfortable to diagnose patients with PNES. The multidisciplinary neurology and psychiatric assessments will help in the patient's therapeutic plan.

Evaluation of chronic idiopathic tinnitus and its psychosocial triggers.

BACKGROUND: The tinnitus susceptibility patterns in relation to different psychological and life stressors are unknown in different cultures. AIM: To determine the comorbid psychosocial factors and behaviors associated with tinnitus and the predictors for the increase in its severity. METHODS: Participants were 230 adults (males = 70; females = 160; mean age = 38.6 ± 3.3). They underwent audiograms, speech discrimination and masking testing, and neuropsychiatric evaluation. Measures used for assessment included tinnitus handicap inventory, depression anxiety stress scale 21 (DASS-21), perceived stress scale (PSS), and insomnia severity index (ISI). RESULTS: Patients had mean duration of tinnitus of 11.5 ± 2.5 mo. They had intact hearing perception at 250-8000 Hz and 95 (41.3%) had aggravation of tinnitus loudness by masking noise. Decompensated tinnitus was reported in 77% (n = 177). The majority had clinically significant insomnia (81.3%), somatic symptoms (75%) other than tinnitus and perceived moderate (46.1%) and high (44.3%) stress to tinnitus. The severe/extremely severe symptoms of depression, anxiety and stress were reported in 17.4%, 35.7% and 44.3%, respectively. Patients with decom-pensated type had significantly higher scores for ISI (P = 0.001) and DASS-21 (depression = 0.02, anxiety = 0.01, stress = 0.001) compared to those with compensated tinnitus. Psychiatric interviewing showed that 35.7% had non-specific anxiety disorder, 17.4% had major depression, and 19.6% fulfilled the criteria of somatization disorder. Multivariate analysis showed that the only independent predictors for tinnitus severity were the duration of tinnitus [odd ratios (OR) = 0.832, 95%CI: 0.640-1.158; P = 0.001] and PSS (OR = 0.835, 95%CI: 0.540-1.125; P = 0.001) scores. CONCLUSION: To the best of our knowledge, this is the first study in our culture to evaluate the causal relationship between psychological factors and tinnitus onset, severity and persistence. Tinnitus could be the earliest and dominant somatic symptom induced by life stressors and psychological vulnerabilities. Therefore, multidisciplinary consultation (psychologists, psychiatrists, and neurologists) is important to acknowledge among the audiologists and otolaryngologists who primarily consult patients.

Behavioral assessment of children and adolescents with Graves' disease: A prospective study.

Previous studies have identified frequent comorbid neuropsychiatric disorders and conditions in adults with thyrotoxicosis. These studies are scarce or even lacking in pediatric population. This work aimed to study the behavior of children and adolescents with Graves' disease (GD). This study included 35 children with GD (boys = 15; girls = 25; mean age: 11.45±1.50yrs) and 40 healthy children (boys = 20; girls = 20; mean age: 12.54±1.62yrs). Behavior was assessed using Child Behavior Checklist (CBCL). Children with GD were assessed during periods of thyroid hormone elevation (active disease) and normalized thyroid hormones (with anti-thyroid drugs or ATDs). Compared to healthy children, patients during periods of thyroid hormone elevation (74.29%) and normalized thyroid hormones (31.43%) had higher frequencies of behavioral abnormalities and scorings of total CBCL scale (P = 0.01; P = 0.04, respectively) and its subscales' [Anxious/Depressed (P = 0.02; P = 0.04), Withdrawn/Depressed (P = 0.03; P = 0.04) and Somatic Complaints (P = 0.03; P = 0.127) and Social (P = 0.01; P = 0.225), Thought (P = 0.01; P = 0.128) and Attention (P = 0.01; P = 0.01) problems], indicating internalizing and externalizing problems. The majority of patients had at least two different behavioral problems. Marked improvement was found during period of normalized thyroid hormones (P = 0.001). Correlation analyses showed significant associations between total CBCL scoring and age at onset (P = 0.01; P = 0.001) and lower concentrations of thyroid stimulating hormone (TSH) (P = 0.001; P = 0.04) and higher concentrations of free thyroxine (fT4) (P = 0.01; P = 0.02), triiodothyronine (fT3) (P = 0.01; P = 0.03) and thyrotropin receptor antibodies (TRAbs) (P = 0.001; P = 0.01) during periods of thyroid hormone elevation and normalized thyroid hormones, respectively. Multiple linear regression analysis showed that "at presentation" lower concentrations of TSH (P = 0.001; P = 0.03) and higher concentrations of fT4 (P = 0.001, P = 0.01), fT3 (P = 0.01; P = 0.06) and TRAbs (P = 0.001; P = 0.001) were predictors of behavioral problems during periods of active disease and normalized thyroid hormones. We conclude that GD is associated with higher frequencies and severities of anxiety, depression and inattention during periods of thyroid hormone elevation as well as normalized thyroid hormones with ATDs. Therefore, early diagnosis and optimizing management are required to improve children's social life.

Behavioral assessment of females with congenital adrenal hyperplasia.

PURPOSE: Patients with congenital adrenal hyperplasia (CAH) have an increased risk of psychological/psychiatric symptoms and disorders. This study aimed to assess the behavior of girls with CAH and its independent risk variables. METHODS: This cross-sectional study included 55 girls with CAH due to 21-hydroxylase deficiency (mean age 12.64 ± 1.52 years; salt-wasting (SW) form = 20, simple virilizing (SV) form = 35). Psychiatric interviewing and the Strength and Difficulties Questionnaire (SDQ) (parent-reporting questionnaires) were used to assess behavior. RESULTS: Compared to controls (n = 60), patients had a high total SDQ score (P = 0.001) and emotional, conduct, and hyperactivity-inattention symptoms, peer relationship problems (P = 0.001 for all), and prosocial behavior (p = 0.01) subscale scores, indicating externalizing and internalizing behavioral problems. Severe emotional symptoms and poor disease control were found with SW compared to the SV form. Multiple linear regression showed that bone age (BA) (ß = 0.331, t = 3.608; P = 0.001) and 17-OHP (ß = 0.408, t = 4.220; P = 0.001), testosterone (ß = 0.348, t = 3.220; P = 0.001), and androstenedione (ß = 0.238, t = 2.487; P = 0.015) levels were independently associated with behavioral problems. CONCLUSION: Females with CAH had frequent and severe behavioral symptoms. Excess androgenization, which was in part due to suboptimal steroid therapy, was the cause of the behavioral problems. Therefore, early optimization of CAH management should be stressed to prevent psychological consequences.

Sexual functions in women with focal epilepsy: Relationship to demographic, clinical, hormonal and psychological variables.

OBJECTIVES: Sexual dysfunctions [SDs] are common in women with epilepsy [WWE] but related studies were neglected in our locality. We aimed to determine the frequencies and severities of SDs and their clinical, hormonal and psychological determinants in WWE. PATIENTS AND METHODS: This study included 120 adults [mean age: 36.35 ± 2.89yrs] with temporal [63.33 %] and frontal [36.67 %] lobe epilepsies and treated with carbamazepine [CBZ] [n = 60] or oxcarbazepine [OXC] [n = 60] for mean duration of 18.63 ± 4.33yrs. Patients were assessed using Female Sexual Function Index [FSFI] questionnaire, Beck Depression Inventory [BDI-II] and Hamilton Anxiety Rating Scale [HAM-A]. Total testosterone, sex hormone binding globulin [SHBG] and free androgen index [FAI] were measured to assess endocrinal status. PATIENTS AND METHODS: This study included 120 adults [mean age: 36.35 ± 2.89yrs] with temporal [63.33 %] and frontal [36.67 %] lobe epilepsies and treated with carbamazepine [CBZ] [n = 60] or oxcarbazepine [OXC] [n = 60] for mean duration of 18.63 ± 4.33yrs. Patients were assessed using Female Sexual Function Index [FSFI] questionnaire, Beck Depression Inventory [BDI-II] and Hamilton Anxiety Rating Scale [HAM-A]. Total testosterone, sex hormone binding globulin [SHBG] and free androgen index [FAI] were measured to assess endocrinal status. RESULTS: The majority had occasional/rare frequency of seizures [76.67 %] and well controlled on antiepileptic drugs [AEDs] [81.67 %]. Compared to healthy women, WWE had lower total testosterone and FAI and higher SHBG levels. Compared to women on CBZ, those on OXC had lower frequency and well controlled seizures on medication [P = 0.0001 for both], higher testosterone [P = 0.01] and FAI [P = 0.001] and lower SHBG [P = 0.001] levels. Compared to controls, WWE had significantly higher frequencies and severities of SDs [total sexual function, desire, arousal, lubrication, orgasm, satisfaction and pain] and depression and anxiety symptoms. OXC therapy was associated with lower SDs [FSFI: P = 0.033] and anxiety symptoms [P = 0.025] compared to CBZ therapy. In multiple logistic regression analyses, determinants of SDs were the higher seizures frequency, increasing severities of depression and anxiety but not lower androgen levels or type of epilepsy or AEDs. CONCLUSIONS: Different aspects of SD and depression and anxiety symptoms were frequent in WWE. Determinants of SDs were the higher frequency of seizures and increasing severities of depression and anxiety. OXC had better control on seizures and thus lower frequencies and severities of SDs and depression and anxiety symptoms. Thus optimizing seizure control is important for psychological state and healthy sexual function in WWE.

Psychosis in adults with epilepsy and its relationship to demographic, clinical and treatment variables.

Objectives: Psychiatric symptoms and disorders are commonly reported with epilepsy. This study aimed to determine the prevalence of interictal psychosis (IIP) in adults with epilepsy and its risk predictors. Methods: The study included 710 patients (mean age: 36.40 years; age at onset: 13.58 years; duration of epilepsy: 22.80 years). All underwent neurological and psychiatric interviewing, electroencephalography and brain imaging. Results: IIP was reported in 20.65%, of them 50% had temporal lobe epilepsy with impaired awareness and/or to bilateral tonic clonic, 42.47% had frontal lobe epilepsy with impaired awareness and/or to bilateral tonic clonic and 7.53% had generalized tonic-clonic seizures. Compared to patients without psychosis, patients with psychosis were older at age of examination, had earlier age at onset, frequent seizures, longer duration of epilepsy and long-term antiepileptic drugs therapy and many relatives with epilepsy. Nearly 76.71% had history of postictal psychosis (PIP). The mean age of onset of IIP was 30.45 years and its mean duration was 3.84 months. Approximately 22% of patients with IIP had family history of psychosis. Patients developed IIP 10 years or more after epilepsy onset. Multivariate logistic regression analyses showed that predictors for IIP were the age at onset and duration of epilepsy, number of seizures, family history of epilepsy or psychosis, history of PIP and different types of epilepsy. Conclusion: IIP is not infrequent with chronic epilepsy regardless to its type. These findings emphasize the importance of optimizing patients' treatment and early recognition and management of IIP. Abbreviations: IIP: interictal psychosis; PIP: post-ictal psychosis; TLE: temporal lobe epilepsy; FLE: frontal lobe epilepsy; GTC: generalized tonic clonic; AEDs: antiepileptic drugs; CBZ: carbamazepine; VPA: valproate; LEV: levetiracetam; APDs: antipsychotic drugs.