Which psychogenic nonepileptic seizure (PNES) patients are more likely to be treated with anti-seizure medications?

BACKGROUND: The average time for psychogenic nonepileptic seizures (PNES) diagnosis is about 7.5 years. Many patients receive inadequate treatment and sometimes even life-threatening treatments such as tracheal intubation during this time. PURPOSE: To determine the risk factors for misdiagnosis of PNES as Epilepsy. METHODS: The medical records of patients who underwent video-electroencephalogram (EEG) monitoring were reviewed retrospectively. Patients who had PNES without epileptic seizures (ES) were included in this study. Baseline personal and monitoring characteristics were collected. The patients were then divided into two groups based on their therapeutic status. Patients in the treatment group were again divided into two groups based on the number of anti-seizure medications (ASM) they were treated with. RESULTS: Fifty-seven patients diagnosed with PNES were included in this study. Thirty-seven patients were under treatment, and 20 patients were not under treatment at the time of monitoring. Motor seizures, abnormal interictal EEG patterns, and pathological brain imaging findings were more frequent among patients in the treatment group (p<0.05). Patients with motor seizures were more likely to be treated with multiple ASM than patients with only dialeptic nonmotor seizures (p<0.05). Lastly, patients in the treatment group were monitored longer and had fewer seizures during monitoring (p<0.05). CONCLUSION: PNES patients with abnormal EEG patterns and pathological brain imaging findings are more likely to be treated with ASM. The pure dialeptic nature of seizures is less likely to be misdiagnosed as ES. In addition, patients with such seizures are less likely to be treated with multiple treatment lines.

Estimated Frequency of Psychodermatologic Conditions in Alberta, Canada.

BACKGROUND: Psychodermatologic disorders are difficult to identify and treat. Knowledge about the prevalence of these conditions in dermatological practice in Canada is scarce. This hampers our ability to address potential gaps and establish optimal care pathways. OBJECTIVES: To provide an estimate of the frequencies of psychodermatologic conditions in dermatological practice in Alberta, Canada. METHODS: Two administrative provincial databases were used to estimate the prevalence of potential psychodermatological conditions in Alberta from 2014 to 2018. Province-wide dermatology claims data were examined to extract relevant International Classification of Disease codes as available. Claims were linked with pharmacy dispensation data to identify patients who received at least 1 psychoactive medication within 90 days of the dermatology claim. RESULTS: Of 243 963 patients identified, 28.6% had received at least 1 psychotropic medication (mean age: 47.9 years; 67.5% female). Rates of concurrent psychotropic medications were highest for pruritus and related conditions (46.7%), followed by urticaria (44.5%) and hyperhidrosis (32.8%). Among patients with psychotropic medications, rates of antidepressants were highest (56.3%), followed by anxiolytics (37.1%). Across billing codes, besides hyperhidrosis (71.2%), diseases of hair (61.4%) and psoriasis (59.1%) had the highest rates of antidepressant dispensations. Patients with atopic dermatitis had the highest rates for anxiolytic prescriptions (54.3%). CONCLUSION: In a 5-year window, more than a quarter of the identified dermatology patients in Alberta received at least 1 psychotropic medication, pointing to high rates of potential psychodermatologic conditions and/or concurrent mental health issues in dermatology. Diagnostic and care pathways should include a multidisciplinary approach to better identify and treat these conditions.

Use of psychiatric drugs in Dermatology.

Patients with psychocutaneous disorders often refuse psychiatric intervention in their first consultations, leaving initial management to the dermatologist. The use of psychotropic agents in dermatological practice, represented by antidepressants, antipsychotics, anxiolytics, and mood stabilizers, should be indicated so that patients receive the most suitable treatment rapidly. It is important for dermatologists to be familiar with the most commonly used drugs for the best management of psychiatric symptoms associated with dermatoses, as well as to manage dermatologic symptoms triggered by psychiatric disorders.

Use of psychiatric drugs in Dermatology

Abstract Patients with psychocutaneous disorders often refuse psychiatric intervention in their first consultations, leaving initial management to the dermatologist. The use of psychotropic agents in dermatological practice, represented by antidepressants, antipsychotics, anxiolytics, and mood stabilizers, should be indicated so that patients receive the most suitable treatment rapidly. It is important for dermatologists to be familiar with the most commonly used drugs for the best management of psychiatric symptoms associated with dermatoses, as well as to manage dermatologic symptoms triggered by psychiatric disorders.

Provocative induction of psychogenic nonepileptic seizures: Noninferiority of an induction technique without versus with placebo.

We aim to demonstrate, in a sufficiently powered and standardized study, that the success rate of inducing psychogenic nonepileptic seizures (PNES) without placebo (saline infusion) is noninferior to induction with placebo. The clinical data of 170 consecutive patients with suspected PNES who underwent induction with placebo from January 21, 2009 to March 31, 2013 were pair-matched with 170 consecutive patients with suspected PNES who underwent the same induction technique but without addition of placebo from April 1, 2013 to February 7, 2018 at the same center. The success rates of induction were 79.4% (135/170) without placebo and 73.5% (125/170) with placebo. The difference of these two proportions was 5.9%, with two-sided 95% confidence interval ranging from -3.6% to 15.2%, indicating a non-statistically significant difference. The lower bound of the 95% confidence interval (-3.6%) was above the noninferiority margin (δ = -5%), hence inferring noninferiority of induction without versus with placebo. The greater cumulative induction experiences of the clinician performer (influencing the manner/presentation of induction) may supplant the potential advantage from addition of placebo (the means utilized). Among experienced performers, provocative induction without placebo should be the preferred diagnostic approach, given more ethically acceptable transparency and the noninferior success rate when compared to the same induction technique with placebo.

Recent developments on synthesis and biological activities of γ-carboline.

γ-Carboline alkaloids are a family of natural and synthetic agents that have diverse bioactivities including antiviral, antibacterial, antifungal, antiparasitic, antitumor, anti-inflammatory, neuropharmacological activities and so on. They constitute an important class of pharmacologically active scaffolds that exhibit biological activity via diverse mechanisms. This review provides an update on the recent developments (2010-2017) in the synthesis and biological activities of these compounds. In cases where sufficient information is available, the mechanism and the structure-activity relationship (SAR) of biological activity are presented, and based on our expertise in the field and careful analysis of the recent literature, for the potential of γ-carboline alkaloids as medicinal drugs is proposed.

The effect of long-term melatonin supplementation on psychosomatic disorders in postmenopausal women.

Different psychosomatic disorders are observed in postmenopausal women. The decrease of estrogen production is believed to be the main cause of their severity. It is nowadays evident that the decreased melatonin release in women at this age who suffer from postmenopausal disorders might also contribute to the severity of the symptoms. The aim of the study was to evaluate the effect of melatonin supplementation on female hormones release and the alteration in climacteric symptoms. The study included 60 postmenopausal women, aged 51 - 64 years, who were randomly allotted into two equal groups. Group I was recommended placebo (2 x 1 tablet) and Group II - melatonin (3 mg in the morning and 5 mg at bedtime) for 12 months. Serum levels of 17ß-estradiol, follicle-stimulating hormone (FSH), melatonin and urinary 6-sulfatoxymelatonin (aMT6s) excretion as well as Kupperman Index (KI) and body mass index (BMI) were determined before the start and at 12 months after placebo or melatonin administration. In Group I only the value of KI slightly decreased (28.4 ± 2.9 versus 25.6 ± 3.8 points, P = 0,0619). In Group II - KI decreased from 29.1 ± 2.9 to 19.7 ± 3.1 points (P < 0.001) and BMI from 30.9 ± 2.9 to 28.1 ± 2.3 kg/m2 (P < 0.05). Melatonin supplementation failed to change significantly the serum concentration of female reproductive hormones 17ß-estradiol and FSH. We conclude that melatonin supplementation therapy exerts a positive effect on psychosomatic symptoms in postmenopausal women and can be recommended as the useful adjuvant therapeutic option in treatment of these disorders.

Utilization of brain imaging in evaluating patients with psychogenic nonepileptic spells.

BACKGROUND: Psychogenic nonepileptic spells (PNES) are paroxysmal movements or sensory events that resemble epileptic seizures but lack corresponding ictal electrographic changes. A confirmed diagnosis of PNES is only accomplished via video electroencephalogram (vEEG) monitoring. Prior to diagnosis, patients are often assessed with neurodiagnostic imaging and their conditions treated with anticonvulsant medications, both of which are of limited clinical value and contribute to the higher cost of care. In this study, we assessed the relationship between the semiological features of PNES, medication regimen, or psychiatric comorbidities and the frequency of referrals for brain imaging tests prior to diagnosis of PNES. METHODS: This is a retrospective chart review of 224 adult patients diagnosed as having PNES at a level 4 epilepsy care center from 2012 to 2017. Patients with coexisting epilepsy were excluded. The 882 segments of vEEG records were reviewed for semiology of spells, and patients were categorized into one of seven distinct phenotypic classes according to the accepted clinical classification. The frequency of neurodiagnostic tests completed for each patient prior to vEEG was correlated with PNES phenotype and other clinical characteristics. RESULTS: There were 68 (30%) males and 156 (70%) females diagnosed as having PNES with a median age of 36 years. Seventy-four percent of patients were receiving one or several anticonvulsant medications, and 67% of patients were treated with psychotropic medications other than benzodiazepines. The most prevalent PNES events were characterized by semirhythmic small amplitude movements in the extremities (class 2; 34%) followed by those resembling tonic-clonic seizures (class 4; 28%). Neurodiagnostic imaging tests including computed tomography (CT) and magnetic resonance imaging (MRI) of the brain were performed at least once in 60% of patients and 4 times or more in 11% prior to vEEG. There was a significant association between the frequency of neurodiagnostic tests and the PNES phenotype (p = 0.02). Specifically, patients with sensory changes (class 6) had more imaging tests than those with primitive gesturing and truncal posturing (classes 1 and 5, respectively). Additionally, patients diagnosed with 3 or more psychiatric disorders underwent significantly more neurodiagnostic tests relative to patients diagnosed with two or fewer psychiatric disorders (p = 0.03). Furthermore, patients whose conditions were treated with anticonvulsant medications tended to undergo more imaging scans prior to vEEG as compared with the patients whose conditions were not being treated with anticonvulsants. CONCLUSIONS: These findings suggest that the frequency of brain imaging obtained prior to the definitive diagnosis of PNES is influenced by semiology of spells and the psychiatric health of patients. Patients who demonstrate minimal paroxysmal movements in the settings of multiple psychiatric comorbidities represent a particularly challenging patient phenotype which is linked to more frequent referrals for brain imaging. These patients should be promptly referred for vEEG to improve diagnostic accuracy and prevent treatment with anticonvulsants as well as referrals for serial neurodiagnostic tests.

Risk factors for psychological and psychosomatic symptoms among children with malignancies.

AIM: With increasing survival rates in paediatric malignancies, the quality-of-life of children during hospitalisation should be given more attention. We aimed to identify factors associated with psychological and psychosomatic symptoms (PPS) that required medication among children hospitalised for treatment of malignancies. METHODS: We retrospectively analysed data of 190 patients aged 2-18 years old. They were diagnosed with malignant diseases and admitted for treatment at St. Luke's International Hospital between 2003 and 2013. Patients were considered as having PPS if they were prescribed psychotropic agents during hospitalisation. RESULTS: Of the 190 patients, 56 (30%) were prescribed psychotropic agents for PPS. Types of PPS included insomnia in 21 (38%), anxiety in 11 (20%), and others conditions (psychogenetic nausea, agitation, delirium, depression). The most prescribed psychotropic agents were etizolam for 34 cases (61%), followed by diazepam and risperidone. The multivariable analyses confirmed statistically significant independent associations for haematopoietic stem cell transplantation (HSCT) (odds ratio (OR), 5.21; 95% confidence interval (CI), 1.77-15.35), older age (12-18 years vs. 2-5 years, OR, 3.74; 95% CI, 1.04-10.00), and opioid use (OR, 7.15; 95% CI, 2.36-21.69). CONCLUSIONS: Older age at admission, undergoing HSCT, and those given opioids were found to be risk factors for PPS among children with malignancies. Appropriate preventive measures against PPS may be warranted for patients with these risk factors.

[Pharmaceutical care for patients of the third age in pharmacy organizations as a significant aspect of social gerontology].

There are questions in the article that study mutual relations of patients of elderly and senile age with pharmaceutical experts. It was revealed that pharmacy organizations are an important element in the life of patients of the third age and noted the high role of the pharmaceutical specialist in their social environment. The article shows the need to focus on the psychosomatic features of elderly patients with proper pharmaceutical counseling and professional communication. It was noted that interaction of patients of the third age with pharmaceutical specialists and their confidence in them has high importance.

Literature Review: Herbal Medicine Treatment after Large-Scale Disasters.

Large-scale natural disasters, such as earthquakes, tsunamis, volcanic eruptions, and typhoons, occur worldwide. After the Great East Japan earthquake and tsunami, our medical support operation's experiences suggested that traditional medicine might be useful for treating the various symptoms of the survivors. However, little information is available regarding herbal medicine treatment in such situations. Considering that further disasters will occur, we performed a literature review and summarized the traditional medicine approaches for treatment after large-scale disasters. We searched PubMed and Cochrane Library for articles written in English, and Ichushi for those written in Japanese. Articles published before 31 March 2016 were included. Keywords "disaster" and "herbal medicine" were used in our search. Among studies involving herbal medicine after a disaster, we found two randomized controlled trials investigating post-traumatic stress disorder (PTSD), three retrospective investigations of trauma or common diseases, and seven case series or case reports of dizziness, pain, and psychosomatic symptoms. In conclusion, herbal medicine has been used to treat trauma, PTSD, and other symptoms after disasters. However, few articles have been published, likely due to the difficulty in designing high quality studies in such situations. Further study will be needed to clarify the usefulness of herbal medicine after disasters.

Cluster reduction in patients in a pilot treatment trial for psychogenic nonepileptic seizures.

INTRODUCTION: The present study examined seizure clusters as a primary outcome in patients receiving treatment for PNES. Cluster reduction is examined longitudinally using frequency threshold and statistical definitions of seizure cluster for patients. Possible risk factors for clustering will be examined along with clustering as a risk factor for poorer secondary outcomes. METHODS: Participants were from a pilot randomized treatment trial for PNES where they received cognitive behavioral therapy-informed psychotherapy (CBT-ip), sertraline, combination therapy, or treatment as usual. Seizure data are from patients' seizure dairies. RESULTS: Cluster reduction was observed for those receiving CBT-ip or combination treatment using all definitions of daily clusters and weekly clusters. No risk factors of clustering were observed. Those who were identified as having clusters during the trial had poorer secondary outcomes on several measures at baseline relative to those who were not identified as having clusters. DISCUSSION: This is the first study known to the authors to not only examined seizure clusters as a primary outcome for those with PNES, but also the first study to suggest that CBT-ip and combination therapy may be effective in reducing the frequency of clusters.

A preliminary investigation of sleep quality in functional neurological disorders: Poor sleep appears common, and is associated with functional impairment.

PURPOSE: Functional neurological disorders (FND) are disabling conditions for which there are few empirically-supported treatments. Disturbed sleep appears to be part of the FND context; however, the clinical importance of sleep disturbance (extent, characteristics and impact) remains largely unknown. We described sleep quality in two samples, and investigated the relationship between sleep and FND-related functional impairment. METHODS: We included a sample recruited online via patient charities (N=205) and a consecutive clinical sample (N=20). Participants completed validated measures of sleep quality and sleep characteristics (e.g. total sleep time, sleep efficiency), mood, and FND-related functional impairment. RESULTS: Poor sleep was common in both samples (89% in the clinical range), which was characterised by low sleep efficiency (M=65.40%) and low total sleep time (M=6.05h). In regression analysis, sleep quality was negatively associated with FND-related functional impairment, accounting for 16% of the variance and remaining significant after the introduction of mood variables. CONCLUSIONS: These preliminary analyses suggest that subjective sleep disturbance (low efficiency, short sleep) is common in FND. Sleep quality was negatively associated with the functional impairment attributed to FND, independent of depression. Therefore, sleep disturbance may be a clinically important feature of FND.

Use of neurotransmitter regulators in functional gastrointestinal disorders based on symptom analysis.

It has been a great challenge for gastroenterologists to cope with functional gastrointestinal disorders (FGIDs) in clinical practice due to the contemporary increase in stressful events. A growing body of evidence has shown that neuroregulators such as anti-anxiety agents and antidepressants function well on FGIDs, particularly in cases that are refractory to classical gastrointestinal (GI) medications. Among these central-acting agents, small individualized doses of tricyclic antidepressants and selective serotonin reuptake inhibitors are usually recommended as a complement to routine GI management. When these drugs are chosen to treat FGIDs, both their central effects and the modulation of peripheral neurotransmitters should be taken into consideration. In this article we recommend strategies for choosing drugs based on an analysis of psychosomatic GI symptoms. The variety and dosage of the neurotransmitter regulators are also discussed.

Psychosomatic patients in integrated care: Which treatment mediators do we have to focus on?

The field of psychosomatics has gained increasing significance; it has been struggling to establish its position as either an independent discipline or a subdomain of specific areas such as internal medicine or psychiatry. However, the rise of psychosomatic syndromes and disease patterns as well as an increase of specific integrated psychosomatic wards is a clear indication for the growing importance of interdisciplinary approaches to psychosomatic disorders. The study presents data from an 8-week inpatient treatment at a psychosomatic facility and investigates whether patients improved in their subjective symptom experience. A complex treatment approach, ranging from pharmacological treatment and group and individual psychotherapy to physiotherapy and ergotherapy was integrated into this intervention. In essence, containment of intrapsychic aggression derivatives played a central role in the treatment of psychosomatic symptoms. A significant factor contributing to a successful treatment is the doctor-patient relationship. All these factors were investigated in the present study.

The role of placebo in the diagnosis and treatment of functional neurologic disorders.

Placebo therapy can produce meaningful, clinical relief for a variety of conditions. While placebos are not without their ethically fraught history, they continue to be used, largely covertly, even today. Because the prognosis for psychogenic disorders is often poor and recovery may be highly dependent on the patient's belief in the diagnosis and treatment regimen, some physicians find placebo therapy for psychogenic disorders compelling, but also particularly contentious. Yet placebos also have a long tradition of being used for provocative diagnosis (wherein placebo is used to elicit and/or terminate the symptoms as a way of diagnosing symptoms as "psychogenic"). In this chapter we discuss cases describing placebo as therapy for psychogenic disorders and the challenges related to embedded Cartesian beliefs in Western medicine. The legitimate ethical reservations against placebo therapy, in general, have been related to assumptions about their "inertness" and a requirement for deception, both which are being refuted by emerging data. In this chapter, we also re-evaluate the concerns associated with placebo therapy for psychogenic disorders by asking, "Are we harming patients by withholding placebo treatment?"