Trauma and non-epileptic seizures: patients need care

ALTHOUGH childhood trauma has long been linked with neurological disorders such as psychogenic non-epileptic seizures (PNES), a recent study has found the severity of trauma is also a key factor in diagnosis.

A Melbourne study, recently published on pre-print server MedRxiv, found patients with PNES reported greater frequency of childhood trauma than patients with epilepsy. The authors also found that trauma severity, rather than the presence or absence of trauma, should be examined when diagnosing PNES . (The research has yet to be peer-reviewed and should not be used to guide clinical practice.)

“Our findings that patients who experienced more severe childhood trauma are at higher risk of PNES regardless of the trauma subtypes, is supportive of the concept that rather than a specific childhood trauma type being predictive of later PNES diagnosis, subjective childhood trauma of any kind places patients at higher risk of PNES diagnosis than epilepsy in a linear fashion,” wrote the authors, led by Tianren Yang from the Melbourne School of Psychological Sciences.

According to Dr Adith Mohan from the UNSW Sydney (not a study author), the subjective impact of trauma on an individual is an important practice point for clinicians.

“You can have two individuals with seemingly similar traumatic experiences. But the individual that has a greater level of trauma severity is more vulnerable than the one that doesn’t on the basis of the findings from this study. That serves to highlight the individual differences between people in terms of the impact of a traumatic event,” he said.

One of the study authors, Associate Professor Charles Malpas from the University of Melbourne, said they were aiming to find out whether particular kinds of childhood trauma placed patients at increased risk.

“We ended up looking at five different kinds of childhood trauma, including neglect and abuse, separating those two out and then also looking at sexual abuse separately,” he told InSight+.

They thought that abuse may report higher in the patients with PNES rather than neglect alone. And based on their clinical experience, they thought a history of sexual abuse would be highly represented in the PNES group.

“I think the surprising thing was we didn’t find evidence that one particular kind of trauma was reported more in the PNES group. We thought we’d see an interesting profile. But instead, what we saw was all kinds of trauma were rated as occurring more frequently in childhood in the PNES groups. That was unexpected,” he said.

Aetiology of PNES

PNES is a subtype of functional neurological disorder (FND), a collection of neurological symptoms that can’t be explained by a disease or anatomical abnormalities.

According to Dr Mohan, the seizures can resemble epilepsy.

“An epileptic seizure represents a seizure phenomenon that relates to abnormal electrical discharges in the brain,” he explained.

“If you have somebody that has a non-epileptic seizure, you’re essentially describing somebody that has a seizure-like event at presentation, though these events are not driven by epileptic discharges in the brain,” he said.

The mechanisms that cause these seizure-like events are yet to be fully understood; however, there is a consistent link with traumatic events.

“Approximately 90% of people with PNES report having experienced traumatic events across their lifetime compared to 74.9% in the general population and 85% in epilepsy patients,” Yang and colleagues wrote.

There still needs to be more work on why that link occurs.

“It could be that there are fundamental brain changes that occur in people who experienced childhood trauma that don’t occur in others. One of the problems is that those brain changes are actually a risk for organic epilepsy as well,” Associate Professor Malpas explained.

Diagnosing PNES

Diagnosing PNES can be difficult. There is an average of 7–16 years delay in diagnosis after seizure onset and often patients are misdiagnosed with epilepsy (here and here).

In the article by Yang and colleagues, data were collected from two cohorts: a retrospective cohort (203 people) and a prospective cohort (209).

Each cohort were monitored via video electroencephalogram (EEG) and completed the Childhood Trauma Questionnaire as part of their clinical practice. All patients were assessed by a multidisciplinary team of neurologists, neuroradiologists, neuropsychiatrists and neuropsychologists to reach a consensus diagnosis.

Video EEG is considered the diagnosis gold standard, but access is difficult for many.

“A video EEG is when someone comes in for a prolonged period of EEG monitoring where they have EEG electrodes attached,” Dr Mohan explained.

“In an ideal scenario, they would have the seizure-like event and you would confirm that the event wasn’t accompanied by epileptic discharges in the brain. That confirms that the event is non-epileptic. Obviously, there are issues with access to that sort of investigation. It depends on where the patient is and who they see”

Most video EEG monitoring units are in large hospitals in major centres.

Treating PNES

Once a patient has been diagnosed with PNES, it’s important they’re given the news appropriately.

“We have put a lot of work into that to make sure it’s not like ‘you don’t have epilepsy, you’re faking, off you go’. The normal approach is we break it to them as ‘this is good news, you don’t have an organ level brain impairment,’” Associate Professor Malpas said.

However, then an explanation is needed.

“We talk about things like the connection between the mind and the body, and how psychological conditions can manifest physically. And that quite often will bring up the trauma discussion. That’s often when things click for patients,” he said.

There are several therapeutic options for patients and often it’s a multidisciplinary approach depending on the person’s symptoms.

“It is about having psychological intervention and tailored allied health intervention broadly; having the involvement of an occupational therapist, physiotherapist and psychologist and addressing the patient’s specific needs, including their social and functional needs,” Dr Mohan explained.

According to Associate Professor Malpas, patients are often reluctant to see a psychiatrist. Often a neurologist isn’t appropriate as they specialise in physical disorders of the brain.

“We have a lot of luck with neuropsychologists that sit somewhere in between. Patients are often quite willing to go to those specialists and those specialists are trained in this area,” he said.

Another factor to consider is comorbid conditions.

“A number of patients may have trauma histories and have other psychiatric illnesses that affect them. That’s really where medication comes into it. The use of medication is to address comorbidity. If someone has pain, then you manage their pain, if somebody has depression, you manage their depression,” Dr Mohan said.

A previous study found that patients with PNES have a standardised mortality ratio that is 2.5 times higher than the general population. This emphasises the importance of a proper diagnosis and early intervention.

“We’re in a phase at the moment where we’re taking PNES much more seriously as a condition. People say, ‘well, they’re just crazy, it’s all in their head’,” said Associate Professor Malpas.

“No. This is actually a serious thing, and these patients need care.”

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