Death of a loved one: A potential risk factor for onset of functional seizures.

Functional seizures (FS) are a symptom of Functional Neurological Disorder (FND), the second most common neurological diagnosis made worldwide. Childhood trauma is associated with the development of FS, but more research is needed to truly understand the effects of trauma on FS onset. A sample of 256 responses by adults with FS to the Childhood Traumatic Events Scale were analyzed using a Cox proportional hazard model. When investigating each unique childhood traumatic exposure and its associated self-reported severity together, experiencing death of a loved one and experiencing violence were significantly associated with FS onset, suggesting reduced time from trauma exposure to first FS. Death of a loved one in childhood is often overlooked as an influential risk factor for future development of serious mental illnesses such as FS. In this study we show death of a loved one in childhood should be considered as an influential traumatic experience and recommend FND researchers examine its prevalence in patient histories and the potential effects on attachment-related processes and clinical treatment formulations. We recommend future studies incorporate loss of a loved one during childhood (before age 18) in both quantitative and qualitative assessments of persons with FND.

The Financial Burden of Functional Neurological Disorders.

PURPOSE OF REVIEW: Functional neurological disorder (FND) is a common and severely debilitating condition lacking clinical ownership, existing between neurology and psychiatry. This article reports the findings of recent research investigating the economic costs of FND diagnosis and management. We define what the costs are, why they exist, and suggest actionable steps to reduce them. RECENT FINDINGS: The financial burden of FND exists across the globe characterized by high healthcare utilization resulting in exorbitant direct and indirect costs for the patient, healthcare system, and society. Inadequate medical education and stigmatization of the disorder prolong the time to diagnosis, during which cyclical utilization of inpatient and emergency department services drive up costs. Despite being cost-effective, lack of accessible treatment compounds the issue, leaving patients without a reliable exit. Recent findings support an increased awareness and the need for a cultural shift to overcome the financial burden associated with this underserved population.

Functional Seizure Clinics: A Proposed Financially Viable Solution to the Neurologist Supply and Demand Mismatch.

Background and Objectives: Projections from recent studies suggest that by 2025, there will not be enough neurologists to meet the demand in 41 states. In this study, we investigate the financial impact and improved access to care for persons with epilepsy that is possible by implementing a multidisciplinary treatment clinic for persons with functional seizures (FS), previously referred to as psychogenic nonepileptic seizures, thus separating those patients out of an epilepsy clinic. Methods: This observational retrospective study used real-time data of 156 patients referred to an FS clinic integrated into a tertiary care epilepsy center to simulate its effect on epilepsy division access and finances. Access was measured using simulations of the number of return patient visits (RPVs) and new patient visits (NPVs) of patients with FS to a dedicated epilepsy clinic, based on survey results inquiring about the standard of care without the FS clinic. Finances were simulated using the resultant access multiplied by respective wRVU and reimbursement per CPT code. Results: Treatment of 156 patients with FS in a multidisciplinary FS clinic resulted in 343 newly opened NPVs, reimbursement of $102,000, and 1,200 wRVUs in our dedicated epilepsy clinic. There were 686 RPVs, $103,000 in reimbursement, and 1,320 wRVUs. Relative to the total number of NPVs with epilepsy clinic epileptologists, 343 NPVs represent a biennial 15.5% increase in available new patient visit slots. Discussion: Our findings describe the financial viability of integrating a treatment clinic for persons with FS by directing them to FS-specialized treatment and thereby increasing access for patients with probable epilepsy to the dedicated epilepsy clinic. This study provides a potential solution to the national mismatch in the supply and demand of neurologists and an initial framework to use for those who wish to establish or integrate FS services in their institution.

Exploring the influence of telehealth on patient engagement with a multidisciplinary Non-Epileptic Seizure (NES) Clinic during the COVID-19 pandemic.

The ILAE task force has identified a gap in treatment access for patients with nonepileptic seizures (NES) [1]. Access to multidisciplinary treatment clinics for adults with NES is limited with only 18 institutions delivering care across the United States [2]. Patient engagement has been low in the University of Colorado, NES Clinic treatment program despite our clinic's status as the only clinic of its kind in the mountain west. We analyzed patient factors of those who engaged in treatment before and after COVID-19 regulations were imposed and found a 23.6% increase in treatment engagement using telehealth. Those who engaged using telehealth were more likely to be of white race, of non-Hispanic ethnicity, publicly insured, employed, have a Charlson Comorbidity Index (CCI) of zero, a daily seizure rate of 0-1, did not have suicidal ideation or attempts, and live greater than 25 miles from the NES clinic. Delivering NES treatment via telehealth reduced the logistical and psychological barriers to initiating recovery and with a severe lack of accessible treatments for patients with NES, barrier reduction is necessary. This study describes patient factors that result in higher engagement with NES treatment using telehealth and emphasizes the importance of telehealth utilization to improve access to available treatment.

Assessing the hidden burden of psychiatric disease in patients with nonepileptic seizures.

Nonepileptic seizures are commonly associated with psychiatric comorbidities, and specifically PTSD. Despite increased prevalence of psychiatric disease noted on referral of patients to our dedicated clinic for nonepileptic seizures, we found even higher rates of comorbid psychiatric disease or significant symptomatology after our initial clinic intakes, whereby patients are formally evaluated by a behavioral health provider, in addition to an epileptologist. After intake, an additional 21% of patients were identified as having PTSD or significant trauma-related symptoms, an additional 7% of patients were identified with significant anxiety or panic-related symptoms, and an additional 11% of patients were identified with significant depressive symptoms. While highly effective treatment of nonepileptic seizures remains elusive, well-developed treatment paradigms with proven efficacy exist for depression, anxiety, and PTSD. Eliciting these psychiatric comorbidities and pursuing targeted treatments, especially for those patients that do not have easy access to providers with dedicated expertise in the management of nonepileptic seizures, may be a more easily scalable and implementable treatment modality for these patients.

Electrographic seizure monitoring with a novel, wireless, single-channel EEG sensor.

OBJECTIVE: Recording seizures using personal seizure diaries can be challenging during everyday life and many seizures are missed or mis-reported. People living with epilepsy could benefit by having a more accurate and objective wearable EEG system for counting seizures that can be used outside of the hospital. The objective of this study was to (1) determine which seizure types can be electrographically recorded from the scalp below the hairline, (2) determine epileptologists' ability to identify electrographic seizures from single-channels extracted from full-montage wired-EEG, and (3) determine epileptologists' ability to identify electrographic seizures from Epilog, a wireless single-channel EEG sensor. METHODS: Epilog sensors were worn concurrently during epilepsy monitoring unit (EMU) monitoring. During standard-of-care review, epileptologists were asked if the electrographic portion of the seizure was visible on single channels of wired electrodes at locations proximal to Epilog sensors, and if focal-onset, which electrode was closest to the focus. From these locations, single channels of EEG extracted from wired full-montage EEG and the proximal Epilog sensor were presented to 3 blinded epileptologists along with markers for when known seizures occurred (taken from the standard-of-care review). Control segments at inter-ictal times were included as control. The epileptologists were asked whether a seizure event was visible in the single channel EEG record at or near the marker. RESULTS: A total of 75 seizures were recorded from 22 of 40 adults that wore Epilog during their visit to the EMU. Epileptologists were able to visualize known seizure activity on at least one of the wired electrodes proximal to Epilog sensors for all seizure events. Epileptologists accurately identified seizures in 71% of Epilog recordings and 84% of single-channel wired recordings and were 92% accurate identifying seizures with Epilog when those seizures ended in a clinical convulsion compared to those that did not (>55%). CONCLUSIONS: Epileptologists are able to visualize seizure activity on single-channels of EEG at locations where Epilog sensors are easily placed on the scalp below hairline. Manual review of seizure annotations can be done quickly and accurately (>70% TP and >98% PPV) on single-channel EEG data. Reviewing single-channel EEG is more accurate than what has been reported in the literature on self-reporting seizures in seizure diaries, the current standard of care for seizure counting outside of the EMU. SIGNIFICANCE: Wearable EEG will be important for seizure monitoring outside of the hospital. Epileptologists can accurately identify seizures in single-channel EEG, better than patient self-reporting in diaries based on the literature. Automated or semi-automated seizure detection on single channels of EEG could be used in the future to objectively count seizures to complement the standard of care outside of the EMU without the overt burden upon epileptologist review.

Pediatric and adult epileptologist perspectives and experiences of pediatric to adult epilepsy care transition: "Saying goodbye and opening a door."

We aimed to describe perspectives of transition and transfer of adolescents and young adults with childhood-onset epilepsy from pediatric to adult care from the viewpoints of both pediatric and adult epileptologists. Telephone semi-structured interviews with pediatric (n = 15) and adult (n = 11) epileptologists at leading U.S. epilepsy centers were used to collect data about the transition process. Interviews were audio-recorded, transcribed, systematically coded using thematic analysis by two independent researchers, and subsequently checked for agreement during regular meetings. Participants were on average 46 years old (SD = 7.4), 50% male, 91% Non-Hispanic and 85% Caucasian; all had completed a formal epilepsy or clinical neurophysiology fellowship (mean = 11 years since terminal training) and were employed at a comprehensive epilepsy center. Three interrelated themes regarding epileptologists' perspectives of epilepsy transition and transfer of care were evident: (1) the process is unnatural and disruptive, (2) clinicians make the best of challenges, and (3) the epilepsy transition process includes a spectrum of broad needs some of which are unique to epilepsy care while others are common to other chronic diseases. Despite challenges, epilepsy clinicians spontaneously expressed stress, empathy, and commitment to providing the best possible care.

Validation of a predictive calculator to distinguish between patients presenting with dissociative versus epileptic seizures.

Dissociative seizures (also known as psychogenic nonepileptic seizures) are a common functional neurological disorder that can be difficult to distinguish from epileptic seizures. Patients with dissociative seizures provide diagnostic challenges, leading to delays in care, inappropriate care, and significant healthcare utilization and associated costs. The dissociative seizure likelihood score (DSLS) was developed by Kerr and colleagues at UCLA to distinguish between patients with epileptic seizures and dissociative seizures based on clinical and medication history as well as features of seizure semiology. We validated this calculator at the University of Colorado, which is a Level 4 National Association of Epilepsy Center. The DSLS accurately predicted the diagnosis in 81% of patients, despite local variability in the factors associated with epileptic versus dissociative seizures between the two populations. The DSLS can be a useful tool to assist with history taking and may have important utility for clinical decision making with these difficult to distinguish patient populations.

Sex Effects on Coping, Dissociation, and PTSD in Patients With Non-epileptic Seizures.

PURPOSE OF REVIEW: Sex differences in non-epileptic seizures (NES) are of interest, as the diagnosis is more frequent in women than men (3:1 ratio). This paper reviews clinical findings regarding sex differences in NES through selective literature review and compares coping measures between women and men in our NES clinic. RECENT FINDINGS: Some distinguishing clinical features of NES in women and men are reported in the literature. However, we found few sex differences in demographics and coping. In our population, avoidance and dissociation were strongly related to one another and significantly related to co-occurring PTSD diagnosis, which was seen in over 50% in both sexes. Our findings confirm a high prevalence of PTSD in patients with NES, suggesting that comorbid PTSD may override sex differences in accounting for use of avoidant and dissociative coping. These findings raise the possibility that NES may, at times, represent an extreme variant in dysfunctional coping in patients with PTSD.

The feasibility of a multidisciplinary group therapy clinic for the treatment of nonepileptic seizures.

A high percentage of patients presenting to epilepsy centers have a functional neurological disorder with apparent seizures, ultimately diagnosed as nonepileptic seizures (NES). Meta-analyses suggest that psychological treatment is required, but this treatment is not reliably available, resulting in reentry of these patients to neurology clinics and urgent care settings, reducing access for these services to patients with epilepsy and resulting in inadequate psychological care for patients with NES. A sustainable, group therapy-focused treatment clinic for patients with NES was developed as a combined effort between the departments of neurology and psychiatry at the University of Colorado Hospital, consisting of a full psychiatric evaluation, a five-week psychoeducational group, a 12-week psychodynamic therapy group, individual therapy, medication management, and family assessment. One hundred and six patients were treated in this clinic between July 2016 and October 2018. Patient retention after referral for treatment was 89/136 (65.4%), and group therapy adherence was 89/106 (84.0%). Healthcare utilization, used as a proxy to demonstrate worth, decreased during and after treatment. Analysis of the 106 treated patients elucidates other clinical characteristics of this population, including psychiatric comorbidities and specific medication classes at time of NES diagnosis. We conclude that this clinic model is feasible for recruiting, retaining, and engaging patients in appropriate treatment for their NES.