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Nonepileptic attack disorder (NEAD) is a medical condition commonly seen in neuropsychiatry services, often as a differential diagnosis of other neuropsychiatric conditions. Recommendations by the International League Against Epilepsy (ILAE) Nonepileptic Seizures Task Force propose a four-level hierarchical approach to the diagnosis of NEAD, based on history, witnessed event, and electroencephalographic (EEG) investigation. We set out to provide the first description of the diagnostic levels of patients with NEAD at a specialist neuropsychiatry clinic. Comprehensive clinical data from 148 consecutive patients with NEAD attending the specialist Neuropsychiatry Clinic run by a single Consultant in Behavioral Neurology were retrospectively reviewed. Patients with NEAD were primarily referred to neuropsychiatry by Consultant Neurologists (n = 94; 63.5%). The majority of patients were female (n = 108; 73.0%), with a disease duration of 7.9 years (standard deviation: 10.4). Anxiety was the most common comorbidity (n = 43; 26.7%). Categorization of patients according to the ILAE Nonepileptic Seizures Task Force criteria was mainly based on clinical features and EEG findings, as only 7 (4.7%) patients had attacks witnessed by a specialist. The largest diagnostic categories were 'possible' (n = 54; 36.5%) and 'clinically established' (n = 40; 27.0%), followed by 'documented' (n = 12; 8.1%) and 'probable' (n = 5; 3.4%). In 125 patients (84.4%), EEGs were performed. Selective serotonin reuptake inhibitors were the most frequently prescribed psychotropic medications (n = 48; 32.4%); 89 patients (60.1%) received behavioral therapy. There were no differences in pharmacological or behavioral management strategies across the patients categorized under different diagnostic levels. Patients with NEAD seen within neuropsychiatry settings are mainly assigned 'possible' and 'clinically established' levels of diagnostic certainty. Difficulty in capturing typical clinical events witnessed by an experienced clinician while on video-EEG can limit the clinical application of the 'documented' diagnostic level. If appropriate, active interventions can be implemented irrespective of diagnostic levels to minimize delays in the neuropsychiatric care pathways., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to declare. The research presented in this article was awarded the Poster Prize at the 12th European Congress on Epileptology (Prague, 11–15 September 2016)., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Dissociative experiences are commonly reported by patients with non-epileptic attack disorder (NEAD). This cross-sectional study examined the prevalence and characteristics of dissociative experiences in patients with NEAD and assessed their association with health-related quality of life (HRQoL). Fifty-three patients diagnosed with NEAD were consecutively recruited (70.0% female, mean age=42 years, 22.0% with comorbid epilepsy) from a specialist neuropsychiatric clinic. Our sample reported high levels of dissociative experiences, with 36.7% of patients scoring ≥30 on the Dissociative Experiences Scale (DES). Significant negative correlations were found between total DES scores and HRQoL, as measured by the QOLIE-31 questionnaire (r=-0.64, p<0.001). This association remained significant when accounting for symptoms of depression and anxiety, other psychiatric comorbidities, and attack frequency and severity. These findings suggest a high prevalence of dissociative experiences in this patient population, highlighting the importance of routinely screening patients for dissociative symptoms and their impact on patients' lives., (Copyright © 2012 Elsevier Inc. All rights reserved.)

A wide range of controversial definitions and dynamic components surround the multi-dimensional concept of consciousness, with important reflections on the phenomenological description of ictal states relevant to epileptic seizures. The inadequacies of terminology, the insufficient emphasis on the subjective nature of consciousness, as well as the intrinsic limitations of the simple versus complex dichotomy for partial seizures, are to be considered in view of a modern definition of consciousness. In this paper, we review the difficulties encountered by clinicians in assessing the ictal conscious state in patients with epilepsy, and illustrate how a more sophisticated bi-dimensional model of consciousness can prove a valuable conceptual tool for the clinical assessment of ictal consciousness and the categorization of seizures., (Copyright © 2011 Elsevier Inc. All rights reserved.)

The assessment of ictal consciousness has been the landmark criterion for the differentiation between simple and complex partial seizures over the last three decades. After review of the historical development of the concept of "complex partial seizure," the difficulties surrounding the simple versus complex dichotomy are addressed from theoretical, phenomenological, and neurophysiological standpoints. With respect to consciousness, careful analysis of ictal semiology shows that both the general level of vigilance and the specific contents of the conscious state can be selectively involved during partial seizures. Moreover, recent neuroimaging findings, coupled with classic electrophysiological studies, suggest that the neural substrate of ictal alterations of consciousness is twofold: focal hyperactivity in the limbic structures generates the complex psychic phenomena responsible for the altered contents of consciousness, and secondary disruption of the network involving the thalamus and the frontoparietal association cortices affects the level of awareness. These data, along with the localization information they provide, should be taken into account in the formulation of new criteria for the classification of seizures with focal onset., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Exploration of subjective experiences during seizures may enhance knowledge of the differing natures of epilepsy and nonepileptic attack disorder (NEAD). We performed a quantitative evaluation of both the general level of awareness and the specific contents of consciousness during seizures using the Ictal Consciousness Inventory (ICI). Ninety-five adult outpatients attending general neuropsychiatry and epilepsy clinics with established diagnoses of either epilepsy (n = 66) or NEAD (n = 29) completed one ICI for each witnessed seizure recalled. Patients with a dubious/dual diagnosis were excluded. ICI Level (ICI-L) and ICI Content (ICI-L) scores were calculated for the 167 questionnaires generated by patients with epilepsy (n = 119, of which 58 from patients with temporal lobe epilepsy, 14 frontal lobe epilepsy, and 47 idiopathic 30 generalized epilepsy) and patients with NEAD (n = 48). Mann-Whitney U tests revealed statistically significant higher ICI-L and ICI-C scores for patients with NEAD (both P = 0.01). Subjective reports of consciousness experiences varied between epilepsy and NEAD, with patients with NEAD reporting significantly greater levels of general awareness/responsiveness and more vivid subjective experiences during attacks. The ICI is proposed as a potentially useful self-report instrument to supplement clinical and instrumental tests for the differential diagnosis of epilepsy and NEAD., (Copyright © 2010 Elsevier Inc. All rights reserved.)