Management of psychogenic non-epileptic seizures: a multidisciplinary approach.

The International League against Epilepsy (ILAE) proposed a diagnostic scheme for psychogenic non-epileptic seizure (PNES). The debate on ethical aspects of the diagnostic procedures is ongoing, the treatment is not standardized and management might differ according to age group. The objective was to reach an expert and stakeholder consensus on PNES management. A board comprising adult and child neurologists, neuropsychologists, psychiatrists, pharmacologists, experts in forensic medicine and bioethics as well as patients' representatives was formed. The board chose five main topics regarding PNES: diagnosis; ethical issues; psychiatric comorbidities; psychological treatment; and pharmacological treatment. After a systematic review of the literature, the board met in a consensus conference in Catanzaro (Italy). Further consultations using a model of Delphi panel were held. The global level of evidence for all topics was low. Even though most questions were formulated separately for children/adolescents and adults, no major age-related differences emerged. The board established that the approach to PNES diagnosis should comply with ILAE recommendations. Seizure induction was considered ethical, preferring the least invasive techniques. The board recommended looking carefully for mood disturbances, personality disorders and psychic trauma in persons with PNES and considering cognitive-behavioural therapy as a first-line psychological approach and pharmacological treatment to manage comorbid conditions, namely anxiety and depression. Psychogenic non-epileptic seizure management should be multidisciplinary. High-quality long-term studies are needed to standardize PNES management.

Psychiatric disorders in patients suffering from an acute cerebrovascular accident or traumatic injury, and their effects on rehabilitation: an observational study.

BACKGROUND: The presence of a post-traumatic psychiatric disorder in patients with acute injuries may have adverse effects on outcomes. AIM: In this study our aims were: (1) to assess the frequency of psychiatric disorders after a cerebrovascular accident or traumatic injury requiring rehabilitation; (2) to examine whether there was any correlation between psychiatric disorders and patients' baseline demographic and clinical variables. DESIGN: The study consisted of two phases: the first was cross-sectional and the second prospective with a 12-month follow-up. The period of recruitment was two years. The results of the first phase are presented here. SETTING: The study sample consisted of a consecutive series of patients admitted to hospital because of an acute cerebrovascular accident or a traumatic injury and referred for a rehabilitation program. Two inpatient Rehabilitation Hospitals were involved in the study. POPULATION: The sample consisted of 230 consecutive patients with a recent cerebrovascular accident or trauma included in a rehabilitation program. METHODS: The sample included: 89 men (39%) and 141 women (61%) aged 20-97 years. Psychiatric disorders and motor disabilities were assessed through psychiatric interview and the mini-international neuropsychiatric interview plus (MINI Plus) and, respectively, with the functional independent measure (FIM). In case of post-traumatic stress disorder (PTSD), severity was assessed through the Davidson's Trauma scale. Psychiatric disorders were correlated to demographic and clinical variables through univariate and multivariate analyses, the latter with logistic regression models. RESULTS: The most frequent entry diagnoses were traumatic fracture (41.3%) and stroke (37.0%). Ninety-three patients (40.4%) had one or more psychiatric disturbances at study entry, the commonest being depression (56 cases, 24.7%) and anxiety (23 cases, 10.0%). PTSD was present in 8 cases (3.5%). A history of psychiatric disorder was reported by 55 patients (24.2%) Compared to the rest of the study population, these subjects had more psychopathologic complaints (P<0.001). Mean total FIM score was 54.4 (SD=17.8) and 61.2 (SD=19.6) in patients with and without psychopathology (P<0.01) Independent predictors of psychopathology included past psychiatric history, lower total FIM scores, and limb amputation. Depression was predicted by history of psychiatric disorders and lack of partner. CONCLUSION: History of psychiatric disorders is the most relevant factor associated with psychopathology in patients with an acute cerebrovascular accident or traumatic injury, followed by lower total FIM scores, and type of pathologic event. CLINICAL REHABILITATION IMPACT: The presence of psychiatric disorders may potentially influence the rehabilitation process and outcomes; thus their recognition and management are key factors during a rehabilitation program.

Clinical and genetic evaluation of a family showing both autism and epilepsy.

Autism is a strong genetic disorder, with an estimated heritability greater than 90%. Nonetheless, its specific genetic aetiology remains largely unknown. Autism is associated with epilepsy in early childhood and epilepsy occurs in 10-30% of individuals with autism. Here we report the case of a woman affected by a severe epileptic disorder with an onset at 14 years old. She is affected by a cryptogenetic focal epilepsy with complex partial (psychomotor) and secondarily generalized tonic-clonic seizures, which are drug resistant. The woman is married to a healthy man and has six children: two girls are healthy, a girl and two boys are affected by autism while one boy shows partial seizures. The three children with autism show moderate mental retardation and an EEG with no epileptiform alterations. The child with epileptic seizures shows an asymmetric EEG that is not necessarily pathological. In this family, no chromosomal rearrangements were detected by means of classical cytogenetic analyses. The presence of FRAXA alterations and of microdeletions of the 15q11-q13 chromosome region were also excluded. A genome-wide linkage analysis using microsatellite markers revealed several chromosome regions as possible susceptibility loci.

Epidemiologic survey of epilepsy among Army draftees in Lombardy, Italy.

We conducted an epidemiological survey of epilepsy among males born in 1967 who were called for selection for military service from the Lombardy region in northern Italy. Of 54,520 subjects, 258 had active epilepsy (prevalence, 0.47%). Idiopathic partial epilepsy was most common (29.1%), and generalized idiopathic and/or symptomatic epilepsy was least common (3.8%). In the year preceding the interview, 66.9% of the subjects had been free of generalized tonic-clonic seizures, 57.6% had been free of minor seizures, and 36.9% were seizure-free. Case histories revealed a background of febrile convulsions in 18.9% of subjects, status epilepticus in 11.3%, and a family history of epilepsy in 18.9%. Physical and mental development was normal in 75.5% of the subjects. Education level of subjects was lower than a control group, and the unemployment rate was the same as the local rate.

Intractable epilepsies. An open trial with Clobazam.

Clobazam was used as an added treatment in 28 patients with intractable epilepsies: 26 subjects had associated handicaps. A good response was observed during the first two-three months of Clobazam treatment: the reduction in seizure frequency of 73% for partial seizures and 62% for GTCs. A tolerance to Clobazam treatment was observed after the third month of treatment: at the end of the sixth month, the seizure frequency was reduced to 36% for partial seizures and 39% for GTCs. Out of 28 patients 4 were seizure free at the end of the sixth month; we have not found any specific characteristic in these patients. The AA. suggest the possibility of an intermittent use of Clobazam for this type of patients.

Carbamazepine, phenytoin and phenobarbital in drug-resistant partial epilepsies.

96 monotherapies with carbamazepine, phenytoin, phenobarbital and primidone were assessed in 42 patients with partial epilepsy. Those whose seizure frequency was reduced by 75% or more were considered to have improved. In 54 comparisons of monotherapies significant improvement in seizure frequency was achieved in only 16.7% of cases. Nonresponding patients showed practically no change across all comparisons according to the Fischer test.

PB:PRM ratio in patients with epilepsy treated with primidone.

Phenobarbitone (PB) and primidone (PRM) plasma concentrations were measured in 88 patients of both sexes with different types of epilepsy and treated with PRM, alone or in association with carbamazepine (CBZ), phenytoin (PHT), ethosuximide (ESM) or valproic acid (VPA). A correlation was observed between the dose and the levels of both PRM and PB. Plasma PB:PRM ratio was high variable, especially interindividually. These changes seemed to be linked to age and particularly to pharmacological associations. In fact, PB:PRM ratio was increased with CBZ, ESM, VPA and PHT respectively. Moreover, a correlation was observed between the PB:PRM ratio and PHT plasma levels. The possibility of monitoring PB and PRM plasma levels during long-term treatment with PRM is discussed.

Therapeutic plasma levels of some anticonvulsants in focal epilepsy in relation to computerized axial tomography.

The authors investigated 37 patients with established focal epilepsy in terms of the antiepileptic drug (AED) blood levels needed to achieve control or significant abatement of seizures; then they examined the patients by computerized axial tomography (CAT) and grouped them according as they did or did not show evidence of an organic food lesion of the brain. Statistical elaboration of the data revealed that CAT-positive patients required significantly higher mean AED blood levels for clinical effectiveness than did CAT-negative patients; also, single drugs failed to produce control at any plasma level, necessitating recourse to multidrug regimes, significantly more often in the CAT-positive than in the CAT-negative patient group. In the discussion the authors examine the possible reasons for the observed difference of therapeutic responses.