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Aim: Psychogenic nonepileptic seizures (PNES) or functional seizures are universal phenomena. However, data on their epidemiology is limited. The aim of the current study was to review the literature on the epidemiology of PNES and to provide analytical estimates of its incidence and prevalence based on the direct data that are available from previous studies on PNES., Methods: The methods of this work had two parts: (1) MEDLINE, PsycINFO, and Scopus from inception to 19 October 2019 were systematically searched. (2) The analytical study of the incidence and prevalence of PNES was performed, based on the following data from previous studies: incidence of PNES, duration of PNES before making a diagnosis, outcome and mortality of PNES., Results: The search strategy yielded five articles; three were on the incidence and two on the prevalence. In the analytical part of the study, the incidence of PNES was calculated to be 3.1 (95% Confidence Interval: 1.1-5.1) per 100,000 population per year. The calculated prevalence rate of PNES in 2019 was 108.5 (95% Confidence Interval: 39.2-177.8) per 100,000 population, in the USA., Conclusion: While, the generalizability of these calculated incidence and prevalence rates to other places in the world is limited, they give us a reasonable hint that PNES is a common condition and the prevalence is much more than that it was thought before.Supplemental data for this article is available online at https://doi.org/10.1080/00207454.2021.1942870.

Video-encephalographic (vEEG) seizure recordings make essential contributions to the differentiation of epilepsy and psychogenic nonepileptic seizures (PNES). The yield of vEEG examinations can be increased through suggestive seizure manipulation (SSM) (ie, activation/provocation/cessation procedures), but its use has raised ethical concerns. In preparation for guidelines on the investigation of patients with PNES, the ILAE PNES Task Force carried out an international survey to investigate practices of and opinions about SSM. An online questionnaire was developed by the ILAE PNES Task Force. Questions were asked at clinical unit or individual respondent level. All ILAE chapters were encouraged to send questionnaires to their members. The survey was open from July 1, 2019, to August 31, 2019. A total of 487 clinicians from 411 units across 94 countries responded. Some form of SSM was used in 296/411 units (72.0%). Over 90% reported the use of verbal suggestion, over 80% the use of activation procedures also capable of eliciting epileptic activity (hyperventilation or photic stimulation). Only 26.3% of units used techniques specifically intended to provoke PNES (eg, saline injection). Fewer than 10% of units had established protocols for SSM, only 20% of units required written patient consent, in 12.2% of units patients received explicitly false information to provoke seizures. Clinicians using SSM tended to perceive no ethical problems, whereas those not using SSM were likely to have ethical concerns about these methods. We conclude that the use of invasive nocebo techniques intended to provoke PNES in diagnostic settings has declined, but SSM is commonly combined with activation procedures also capable of eliciting epileptic activity. While research suggests that openness about the use of PNES-specific nocebo techniques does not reduce diagnostic yield, very few units have suggestion protocols or seek patient consent. This could be addressed through establishing consensus guidance for the practice of SSM., (© 2021 The Authors. Epilepsia Open published by Wiley Periodicals LLC on behalf of International League Against Epilepsy.)

Objective: We investigated the association between the glucocorticoid receptor (GR) gene, also known as the nuclear receptor subfamily 3, group C, member 1 (NR3C1), rs41423247 polymorphism, and functional seizures (psychogenic nonepileptic seizures/attacks) in a case–control study. We hypothesized that the tested polymorphism has significant associations with functional seizures (psychogenic nonepileptic seizures/attacks) independent from comorbid depression. Methods: Seventy patients with functional seizures (psychogenic nonepileptic seizures/attacks), 70 with major depressive disorder (MDD), and 70 healthy controls (HCs) were studied. Their DNAs were analyzed for NR3C1 rs41423247 polymorphism. Results: Genotype and allele frequencies of rs41423247 were different between the three groups. G allele carriers were more frequent in patients with functional seizures (psychogenic nonepileptic seizures/attacks) and those with MDD compared to HCs (p = 0.0001). However no significant difference was observed with respect to allele distributions between functional seizures (psychogenic nonepileptic seizures/attacks) and MDD groups (p = 0.391). CC genotype was less often associated with functional seizures (psychogenic nonepileptic seizures/attacks) versus HC: Codominant model; p = 0.001, OR = 0.11, 95% CI = 0.05–0.24, and −2loglilkelihood = 231.7. In comparison between functional seizures (psychogenic nonepileptic seizures/attacks) group and other (MDD + HC) groups, we observed a significant association between CG genotype and functional seizures (psychogenic nonepileptic seizures/attacks) (Codominant model; p = 0.001, OR = 5.63, 95% CI = 2.60–12.40 and −2loglikelihood = 245.99). Significance: Patients with functional seizures (psychogenic nonepileptic seizures/attacks) and those with MDD were significantly more often G allele carriers in rs41423247 compared with HCs. We observed a significant association between CG genotype and functional seizures (psychogenic nonepileptic seizures/attacks). However, we could not exclude the possibility of confounding effects of depression. Future genetic studies of patients with functional seizures (psychogenic nonepileptic seizures/attacks) should include a comparison group with depression in addition to a comparison group of HCs. [ABSTRACT FROM AUTHOR]

Objective: Ictal injuries have long been considered typical signs of epileptic seizures. However, studies have shown that patients with functional seizures (FS)—also named psychogenic nonepileptic seizures—can also present these signs, misleading physicians and delaying a correct diagnosis. This systematic review aimed to assess the prevalence of injuries from FS. Methods: A literature search was performed in PubMed, Embase, LILACS (Latin American and Caribbean Health Sciences Literature), Scopus, Web of Science, PsycINFO, Google Scholar, OpenGrey, and ProQuest. Observational studies were included. The risk of bias was assessed using the Joanna Briggs Institute (JBI) checklist for studies reporting prevalence data. RStudio was used for meta‐analyses. Cumulative evidence was evaluated according to Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria. Results: From the 2607 identified records, 41 studies were included in the qualitative synthesis, and 28 were included in meta‐analyses. A meta‐analysis of 13 studies, including 1673 individuals, resulted in an overall lifetime prevalence of injuries due to FS per person of 25% (95% confidence interval [CI] = 19%–32%, I2 = 88%). Considering a limited period (video‐electroencephalographic [VEEG] monitoring days), a meta‐analysis of 13 studies, including 848 individuals, resulted in an injury prevalence due to FS per person of.7% (95% CI = 0%–3%, I2 = 73%). Also, a meta‐analysis of eight studies, including 1000 individuals, resulted in a prevalence of injuries per FS of.1% (95% CI = 0%–.98%, I2 = 49%). The certainty in cumulative evidence assessed by GRADE was rated "very low" for lifetime prevalence of injuries per person, "low" for prevalence per person during VEEG monitoring, and "moderate" for prevalence per number of FS. Significance: Overall pooled lifetime prevalence of injuries due to FS per person was 25%. In comparison, the prevalence of injuries per person during VEEG monitoring and per functional seizure was.7% and.1%, respectively. [Correction added on 07 October 2023, after first online publication: In the preceding sentence, 'consecutively' was corrected to 'respectively'.] The evidence of the occurrence of injuries due to FS breaks the paradigm that epileptic seizures can cause injuries but FS cannot. [ABSTRACT FROM AUTHOR]

Background: Evidence on the genetics of functional seizures is scarce, and the purpose of the current scoping systematic review is to examine the existing evidence and propose how to advance the field. Methods: Web of science and MEDLINE were searched, from their initiation until May 2023. The following key words were used: functional neurological disorder(s), psychogenic neurological disorder(s), functional movement disorder(s), psychogenic movement disorder(s), functional seizures(s), psychogenic seizure(s), nonepileptic seizure(s), dissociative seizure(s), or psychogenic nonepileptic seizure(s), AND, gene, genetic(s), polymorphism, genome, epigenetics, copy number variant, copy number variation(s), whole exome sequencing, or next-generation sequencing. Results: We identified three original studies. In one study, the authors observed that six (5.9%) patients with functional seizures carried pathogenic/likely pathogenic variants. In another study, the authors observed that, in functional seizures, there was a significant correlation with genes that are over-represented in adrenergic, serotonergic, oxytocin, opioid, and GABA receptor signaling pathways. In the third study, the authors observed that patients with functional seizures, as well as patients with depression, had significantly different genotypes in FKBP5 single nucleotide polymorphisms compared with controls. Conclusion: Future genetic investigations of patients with functional seizures would increase our understanding of the pathophysiological and neurobiological problems underlying this common neuropsychological stress-associated condition. [ABSTRACT FROM AUTHOR]

Objective: We investigated medical comorbidities in patients with functional seizures (FS) and those with epilepsy (idiopathic generalized epilepsies [IGEs] or temporal lobe epilepsy [TLE]). We hypothesized that the nature of medical comorbidities differs between these three groups. This might be helpful to postulate on the pathophysiology of FS. Materials and Methods: In a retrospective study, all adult patients with a diagnosis of IGE, TLE, or FS were recruited at the outpatient epilepsy clinic at Shiraz University of Medical Sciences, Iran, from 2008 until 2020. The three groups of patients were matched with regard to their age. Age, sex, and medical comorbidities were registered routinely for all patients at the time of the first visit. Results: Nine hundred and sixty-six patients were studied (254 patients with IGE, 467 persons with TLE, and 245 individuals with FS). The groups differed significantly with regard to having medical comorbidities. The most striking difference was comorbid thyroid disorders; this was more common among patients with FS. The diagnosis of FS was independently significantly associated with thyroid disorder comorbidity (odds ratio: 2.77, 95% confidence interval: 1.06-7.23; P = 0.038). Conclusion: Thyroid disorders are significantly associated with FS. We can make the following suggestions to advance the field: a. It is necessary to reproduce this observation in larger multicenter studies; b. We recommend to evaluate thyroid function in all patients with FS; c. It might be helpful to design clinical trials to investigate whether correction of any clinical or subclinical thyroid disorders changes the treatment outcome in patients with FS. [ABSTRACT FROM AUTHOR]

This article discusses the potential role of cannabidiol (CBD) in the treatment of functional seizures, also known as psychogenic nonepileptic seizures or attacks. The author references previous studies that suggest FKBP5 single-nucleotide polymorphisms may play a role in these seizures and that FKBP5 blockade could be a treatment option for stress-associated disorders. The author also highlights a recent study that identifies CBD as an antagonist of FKBP5 and suggests that this discovery could open up new avenues for future research. Currently, psychotherapy is considered the best treatment option for functional seizures, but there is a need for more effective therapeutic options. [Extracted from the article]

Background Sleep and seizures can affect each other in different ways. Meanwhile, sleep disorders are among the most frequent complaints of patients with epileptic and non-epileptic seizures, with various health outcomes. Objective This study aimed to investigate the psychological symptoms and clinical indicators in patients with/without sleepiness with epileptic/non-epileptic seizures. Methods The present study was a fundamental and descriptive (causal-comparative) research. The study population included all patients with epileptic seizures (temporal and generalized) and non-epileptic psychogenic seizures in Shiraz City, Iran. A total of 68 patients (in two groups with sleepiness and without sleepiness) were selected by the purposive sampling method. The study data were collected using the clinical and demographic inventory, Stanford sleepiness scale, Beck depression and anxiety inventory, perceived stress, mood disorder, bipolar spectrum diagnostic scale, global assessment of the severity of epilepsy, and global assessment of disability-related directly to seizures. The obtained data were analyzed by univariate analysis of covariance, Fisher exact test, and Mann–Whitney U test. Results Analyses showed that patients with seizures who had sleepiness reported higher levels of depression, anxiety, and stress than patients without sleepiness (P<0.05). Also, patients with sleepiness suffer more than their counterparts from the symptoms of bipolar disorder I and II and assess the severity of disease and disability resulting from seizures as worse (P<0.05). Conclusion Sleepiness in patients with epileptic and non-epileptic seizures is associated with increased psychological symptoms and disease severity [ABSTRACT FROM AUTHOR]

• Interactions between genetic factors and sexual trauma may hypothetically contribute to the risk of functional seizures. • Sexual trauma may lead to structural and functional changes in the brain. • These changes may hypothetically predispose patients to functional seizures later in life. The relationship between functional seizures (FS) and sexual trauma has received attention in many previous studies. However, the mechanisms underlying this relationship have not been elucidated yet. The purpose of this narrative review is to explore and speculate on the underpinning neurobiological mechanisms for the association and link between sexual trauma and functional seizures. While existence of a causal relationship between a history of sexual trauma and functional seizures is plausible, it should be viewed and treated as a hypothesis. In explaining this hypothesis, we can speculate that interactions between genetic factors and a history of sexual trauma may contribute to the risk of experiencing functional seizures. Childhood sexual trauma may lead to structural and functional connectivity changes in the brain and dysregulation of the biological stress systems, particularly in women. These neurobiological changes speculatively may predispose patients to functional seizures later in life. Importantly, a history of sexual trauma has many other implications beyond the predisposition towards FS. [ABSTRACT FROM AUTHOR]

Purpose: We investigated medical comorbidities in patients with psychogenic non-epileptic seizures (PNES). We hypothesized that these patients commonly have significant medical comorbidities. Methods: In this retrospective study, all patients with PNES, who were diagnosed at Shiraz Comprehensive Epilepsy Center, Iran, from 2008 until 2019, were investigated. Age, gender, age at seizure onset, seizure semiology, and characteristics, known medical (organic) comorbidities reported by the patients and video-electroencephalography recordings of all patients were registered routinely. Results: During the study period, 272 patients with PNES-only had the inclusion criteria and were studied. Sixty-five patients (24%) reported having a medical (organic) comorbidity. The most commonly reported medical comorbidity was thyroid disorder. Age at onset (OR: 1.058; 95% CI: 1.026–1.090; p = 0.0001), duration of disease before the diagnosis (OR: 1.071; 95% CI: 1.025–1.119; p = 0.002), and sex (female) (OR: 1.97; 95% CI: 1.016–3.834; p = 0.04) were significantly associated with having medical comorbidities. Conclusion: While we did not have a control group to provide the number and type of medical problems that are expected in the general population, and therefore our results should be interpreted with caution, we had some intriguing observations. About one quarter of patients with PNES reported having medical comorbidities. The exact nature of the relationship between medical illnesses and PNES is not clear; however, hypothetically they could have a complex relationship. This study provides valuable information on the frequency and nature of medical comorbidities in patients with PNES and opens new horizons for future research. [ABSTRACT FROM AUTHOR]

The aim of this multicenter international cross-cultural study was to compare clinical variables in a large sample of people with adult-onset psychogenic nonepileptic seizures (PNES). In this retrospective study, we evaluated persons with documented PNES, who were older than 16 years of age at the onset, from four countries (i.e., Iran, Brazil, Venezuela, and Argentina) regarding their age, gender, PNES semiology, and possible predisposing factors. We included 389 patients (244 from Iran, 66 from Brazil, 51 from Venezuela, and 28 from Argentina). Age at diagnosis was 32 ± 9 years (range: 17–64 years), and age at the onset of seizures was 27 ± 8 years (range: 17–49 years). There was a female predominance in all countries. The demographic characteristics and factors associated with PNES were similar among the countries. However, there were significant semiological differences among the countries. This study corroborates the notion that PNES share more similarities than differences cross-culturally and across international borders. However, the background determined by cultural, ethnic, and religious differences may influence the semiology of PNES. Further cross-cultural studies involving more than two continents may advance our understanding of PNES. • We included 389 patients (244 from Iran, 66 from Brazil, 51 from Venezuela, and 28 from Argentina). • There was a female predominance in all countries. • The demographic characteristics and factors associated with PNES were similar among the countries. • However, there were significant semiological differences among the countries. [ABSTRACT FROM AUTHOR]

There is a predominance of female gender among patients with psychogenic nonepileptic seizures (PNES). Reasons for this preponderance are not entirely explained in the literature yet. The evidence shows that there exist sex-dependent intrinsic functional connectivity differences in brain areas responsible for emotional and cognitive processing. As a consequence, women and men may differ in vulnerability to physical or emotional trauma. An abnormal connectivity between brain areas involved in emotional processing, cognitive integration systems, motor and premotor regions and/or other related regions may explain the ictal events seen in patients with PNES. The intrinsic brain connectivity differences between men and women may be one reason for the predominance of female gender among patients with PNES. In addition, some early life experiences associated with PNES (e.g., childhood sexual abuse) are more prevalent among female gender. These lifetime experiences affect and alter brain connectivity in women differently compared with men and more often predispose female gender to psychopathology. These neurobiological, social and vulnerability differences may explain why PNES is predominantly seen in female gender. [ABSTRACT FROM AUTHOR]

• 1003 physicians from different regions of the world participated in the study. • Both neurologists and psychiatrists identified "seizures" as their preferred term. • The most preferred modifiers for "seizures" were "psychogenic" and "functional". • Most participants considered FS more difficult to treat compared to epilepsy. • Psychotherapy was considered the first treatment option for patients with FS. We conducted an observational study to investigate the opinions of neurologists and psychiatrists all around the world who are taking care of patients with seizures [epilepsy and functional seizures (FS)]. Practicing neurologists and psychiatrists from around the world were invited to participate in an online survey. On 29th September 2022, an e-mail including a questionnaire was sent to the members of the International Research in Epilepsy (IR-Epil) Consortium. The study was closed on 1st March 2023. The survey, conducted in English, included questions about physicians' opinions about FS and anonymously collected data. In total, 1003 physicians from different regions of the world participated in the study. Both neurologists and psychiatrists identified "seizures" as their preferred term. Overall, the most preferred modifiers for "seizures" were "psychogenic" followed by "functional" by both groups. Most participants (57.9%) considered FS more difficult to treat compared to epilepsy. Both psychological and biological problems were considered as the underlying cause of FS by 61% of the respondents. Psychotherapy was considered the first treatment option for patients with FS (79.9%). Our study represents the first large-scale attempt of investigating physicianś attitudes and opinions about a condition that is both frequent and clinically important. It shows that there is a broad spectrum of terms used by physicians to refer to FS. It also suggests that the biopsychosocial model has gained its status as a widely used framework to interpret and inform clinical practice on the management of patients. [ABSTRACT FROM AUTHOR]

Abstract Purpose We compared various clinical characteristics of psychogenic nonepileptic seizures (PNES) between young patients from Iran, Saudi Arabia, and Canada, three nations with significantly different socioeconomic and demographic characteristics. This international cross-cultural comparative study may advance our knowledge and understanding of PNES in children and adolescents across the cultures and borders. Methods In this retrospective study, we investigated all patients 16 years of age or younger, with PNES admitted to the epilepsy monitoring units at one center in Iran, one center in Saudi Arabia, and one center in Canada. Age, gender, age at seizure onset, seizure semiology, seizure frequency, factors potentially predisposing to PNES, and video-electroencephalography (EEG) recording of all patients were registered routinely and compared between the nations. Results Fifty-one patients were studied (22 from Iran, 14 from Saudi Arabia, and 15 from Canada). Age at the diagnosis was 13.4 ± 2.2 years (range: 8–16 years), and age at the onset of seizures was 12.3 ± 2.7 years (range: 5–16 years). Demographic and clinical characteristics of and associated factors in the patients among the three nations were not significantly different. Twenty-six (51%) patients were taking antiepileptic drugs at the time of diagnosis; the difference was not statistically significant between the nations (13 patients in Iran, 6 in Saudi Arabia, and 7 patients in Canada; P = 0.5). Conclusion Young patients with PNES across borders and between cultures share more similarities than differences with regard to their demographic and clinical characteristics. Highlights • Fifty-one patients were studied (22 from Iran, 14 from Saudi Arabia, and 15 from Canada). • Age at the onset of seizures was 12.3 ± 2.7 years (range: 5–16 years). • Characteristics of and associated factors in the patients among the three nations were not significantly different. • Young patients with PNES across borders and between cultures share more similarities than differences. [ABSTRACT FROM AUTHOR]

Abstract Purpose The aim of this study was to investigate the frequency of antiepileptic drug (AED) use in patients with psychogenic nonepileptic seizures (PNES) and to characterize the patients' historical risk factors that may be associated with such a practice. Methods In this retrospective database study, all patients with PNES, who were investigated at Shiraz Comprehensive Epilepsy Center at Shiraz University of Medical Sciences, from 2008 to 2018, were studied. Patients with concomitant epilepsy or abnormal Electroencephalogram (EEG) were not included. Results Two hundred and seventy patients had the inclusion criteria; 162 patients (60%) were taking AEDs, and 108 (40%) were not taking any AEDs at the time of the diagnosis. Reporting auras (odds ratio: 0.5; 95% confidence interval (CI): 0.301–0.952; p = 0.03), having ictal or postictal urinary incontinence (odds ratio: 3.86; 95% CI: 1.36–10.94; p = 0.01), reporting a dysfunctional family (odds ratio: 1.75; 95% CI: 1.002–3.072; p = 0.04), and a longer duration of the condition before the diagnosis (odds ratio: 1.057; 95% CI: 1.005–1.112; p = 0.03) were significantly associated with AED use; 63.7% of the cases were correctly predicted by the model that was generated by regression analysis (p = 0.0001). Conclusions Patients with PNES are at great risk of receiving unnecessary AEDs, and some patients' historical factors (e.g., urine incontinence) have a strong association with this practice. Highlights • 162 patients (60%) were taking AEDs, and 108 (40%) were not taking any AEDs at the time of the diagnosis. • Reporting auras (odds ratio: 0.5; 95% CI: 0.301–0.952; p = 0.03) was associated with AED use. • Having ictal or postictal urinary incontinence (odds ratio: 3.86; 95% CI: 1.36–10.94; p = 0.01) was a risk factor. • Reporting a dysfunctional family (odds ratio: 1.75; 95% CI: 1.002–3.072; p = 0.04) was a risk factor. • A longer duration of the condition before the diagnosis (odds ratio: 1.057; 95% CI: 1.005–1.112; p = 0.03) was a risk factor. [ABSTRACT FROM AUTHOR]

Objectives We investigated the prevalence of post-epilepsy surgery psychogenic nonepileptic seizures ( PNES) in patients with drug-resistant epilepsy and the possible influence of risk factors on these seizures. Methods In this retrospective study, we examined data from all patients with a clinical diagnosis of drug-resistant epilepsy who underwent epilepsy surgery at Graduate Hospital and the Jefferson Comprehensive Epilepsy Center between 1986 and 2016. Postsurgical outcome was identified for up to 15 years after surgery. Diagnosis of PNES was verified in the epilepsy monitoring unit with video-electroencephalography ( EEG) ictal recording. Potential associated factors were assessed by comparing patients with or without postoperative PNES. Results A total of 1,105 patients were studied; 697 patients had postoperative seizures, and, of these, 27 patients (3.9%) had documented PNES after surgery. A full-scale intelligence quotient ( IQ) <80 was significantly associated with post-epilepsy surgery PNES (odds ratio [OR] 2.89, p = 0.007, 95% confidence interval [CI] 1.33-6.29). A history of a preoperative psychiatric diagnosis was also significantly associated with post-epilepsy surgery PNES (OR 4.67, p = 0.0001, 95% CI 2.01-10.82). Other factors were not significantly associated with post-epilepsy surgery PNES. Significance Post-epilepsy surgery PNES should be considered when patients report recurrent seizures after epilepsy surgery. Although these seizures probably occur relatively infrequently, attention to factors such as appearance of new ictal behaviors, a preoperative history of a psychiatric disorder, and a low full-scale IQ should raise suspicion and lead to appropriate diagnostic measures. [ABSTRACT FROM AUTHOR]

We critically review the existing literature about the epidemiology (i.e., diagnosis, occurrence, age, gender, comorbidity with epilepsy, associated factors, prognosis, mortality, and cost) of psychogenic nonepileptic seizures (PNES) and provide suggestions for future research. Psychogenic nonepileptic seizures are commonly diagnosed at epilepsy centers. The diagnosis of PNES relies on a multidisciplinary evaluation and is usually based on different combinations of data. Recording a seizure, while under video-EEG monitoring, is the most reliable diagnostic test. However, not all patients present with seizures while under video-EEG monitoring. Furthermore, not all epileptic seizures produce visible changes in the scalp EEG. The incidence of PNES was estimated to be 1.4–4.9/100,000/year in three previous studies, and the prevalence was calculated to be between 2 to 33 per 100,000 in one study, making it a significant neuropsychiatric condition. However, there remains a scarcity of data about the epidemiology of PNES, and extant studies that assessed the epidemiological characteristics of PNES have significant limitations. For example, inconsistencies with regard to the age of patients studied and lack of standardization of the diagnostic criteria are some of the significant limitations among studies. In conclusion, PNES merit further epidemiological and pathophysiological investigation. A more precise definition and clear guidance on standards for the diagnosis might influence the direction of future research. Well-designed prospective population-based studies to clarify the epidemiology of PNES in various parts of the world, including an evaluation of the predisposing, precipitating, and perpetuating factors in cross-cultural comparisons is required. [ABSTRACT FROM AUTHOR]

Purpose We compared the semiology of psychogenic nonepileptic seizures (PNES) between patients from the USA and Brazil. This international cross-cultural comparative study may expand understanding of PNES across the borders. Methods We retrospectively investigated all patients with PNES admitted to one epilepsy center in the USA and one in Brazil. We classified their seizures into four classes: generalized motor, akinetic, focal motor, and subjective symptoms. All patients were interviewed by an epileptologist in both countries and were administered psychological assessment measures, including questions about PNES risk factors. For the statistical analyses, we compared patients from the two nations. Results Eighty-nine patients (49 from the USA and 40 from Brazil) were studied. Patients from the two countries were not significantly different with regard to sex and age, but patients from Brazil had earlier age at onset (26 years vs. 34 years; P = 0.004) and a significantly greater delay in diagnosis (9.9 years vs. 5.6 years; P = 0.001). Some characteristics of PNES were different between the two groups; patients from the USA had generally more seizure types and more often reported subjective seizures (55% in the USA vs. 10% in Brazil; P = 0.0001). Clinical and historical characteristics of the patients were not significantly different. Conclusion Delay in diagnosis of PNES may represent a major factor in resource-limited countries. Large multicenter cross-cultural studies may reveal subtle but significant cross-cultural differences with respect to the semiological, clinical, and historical aspects of PNES; however, patients with PNES share more similarities than differences. [ABSTRACT FROM AUTHOR]

Purpose The aim of the current post hoc study was to investigate factors associated with delay in diagnosis of adult patients with psychogenic nonepileptic seizures (PNES). Methods We retrospectively investigated all patients with PNES admitted to the epilepsy-monitoring unit at the Jefferson Comprehensive Epilepsy Center from 2012 through 2016. We identified the median time to diagnosis of PNES and divided the patients into two groups. We studied factors associated with delay in diagnosis of PNES. Results In all, 49 patients (39 women and 10 men) were studied. Mean age at the time of admission was 40 ± 16 years and at the onset of the seizures was 34 ± 16 years. Disease duration was 5.6 ± 8.2 years. The median for time to diagnosis was 3 years. Patients with early diagnosis (before 3 years after seizure onset) (21 patients) and patients with late diagnosis (delay of 3 years or more from onset) (28 patients) were compared. Only history of head trauma had significant association with the delay in diagnosis: 2 of 19 patients (7%) with an early diagnosis and 11 of 28 patients (39%) with a late diagnosis reported head trauma (P = 0.02). Conclusion Delay in diagnosis of PNES is common, and some factors (e.g., history of head trauma) may contribute to this delay. It is important that physicians involved in the management of seizures appreciate the importance of making an early and definitive diagnosis of PNES. [ABSTRACT FROM AUTHOR]

Purpose To describe a series of patients with ictal coughing to estimate its occurrence and characterize the clinical features and differential diagnoses. Methods We retrospectively reviewed all the long-term video-EEG reports from Jefferson Comprehensive Epilepsy Center over a 7-year period (2010–2016) for the occurrence of the term “cough” in the text body. All the extracted reports were reviewed and patients with at least one documented ictal coughing at the epilepsy monitoring unit (EMU) were included in the study. Results During the study period, 2487 patients were investigated at our EMU. Seven patients (0.28%) had at least one documented seizure accompanied by coughing. Four patients (0.16%) had epilepsy and three patients (0.12%) had psychogenic nonepileptic seizures (PNES). All patients with epilepsy had focal onset epilepsy; ictal coughing was not associated with any particular localization or lateralization. Conclusion We add to the literature on ictal coughing by providing additional information on its differential diagnosis and clinical features. Ictal coughing is a rare finding among patients evaluated at the EMUs. The differential diagnoses for ictal coughing include epilepsy and PNES. Epileptic ictal coughing is a rare semiological finding in patients with epilepsy and when present, it is invariably associated with focal epilepsy. [ABSTRACT FROM AUTHOR]

We investigated the utility of a very brief review of system (ROS) questionnaire in differentiating psychogenic nonepileptic seizures (PNES) from epilepsy. In this retrospective study, we investigated all patients with PNES admitted to Jefferson Comprehensive Epilepsy Center from October 2013 through April 2015. Patients with a confirmed diagnosis of PNES or epilepsy based on video-EEG monitoring were included. These were matched with respect to age and sex. All patients had a brief ROS questionnaire in their electronic charts. The questionnaire included 10 general yes/no questions about the presence or absence of any abnormality in body systems. Thirty patients with PNES and 30 patients with epilepsy were investigated. The mean of ROS responses for the presence of any abnormality (±standard deviation) for the PNES group was 2.43 (±1.33) and for the epilepsy group was 1.50 (±0.94) ( p = 0.01). Cut-off point of three positive ROS was able to differentiate these two conditions from each another ( p = 0.01; OR: 6, 95% confidence interval: 1.48–24.29). Presence of multiple complaints in the ROS questionnaire argues in favor of PNES compared with epilepsy. This brief and easy to apply ROS questionnaire may be used as a valuable ancillary tool to differentiate PNES from epilepsy during the initial screening visit. This may help prevent the delay in making the diagnosis. [ABSTRACT FROM AUTHOR]

Purpose We classified patients with psychogenic nonepileptic seizures (PNESs) according to a newly proposed classification system. Then, we investigated the demographic and clinical differences between various classes of the patients. Methods We retrospectively investigated all patients with PNESs admitted to the Jefferson Comprehensive Epilepsy Center from 2012 through 2016. We classified the patients into four distinct classes: patients with generalized motor seizures, patients with akinetic seizures, patients with focal motor seizures, and patients with seizures with subjective symptoms. All patients were interviewed by a neuropsychologist and were administered psychological assessment measures, including questions about PNES risk factors. For the statistical analyses, we compared patients who had generalized motor seizures with patients who had nonmotor seizures. Results Sixty-three patients were studied. Thirty-five (55.6%) patients had generalized motor seizures, 14 (22.2%) had seizures with subjective symptoms, 12 (19%) had akinetic seizures, and two (3.2%) patients had focal motor seizures. Patients with generalized motor seizures (35 patients) demonstrated a trend for later age at onset (p = 0.06), more frequently had a history of substance abuse (p = 0.001), and more often had loss of responsiveness with their seizures (p = 0.04) compared with patients who had nonmotor seizures (26 patients). Conclusion The recently proposed PNES classification system is useful and practical. This proposed classification of PNESs may address proper diagnosis and provide standardization across future studies. This may also potentially shed light on the etiologic understanding and management of various classes of patients affected with PNESs. [ABSTRACT FROM AUTHOR]

Purpose Ictal verbal help-seeking has never been systematically studied before. In this study, we evaluated a series of patients with ictal verbal help-seeking to characterize its frequency and underlying etiology. Methods We retrospectively reviewed all the long-term video-EEG reports from Jefferson Comprehensive Epilepsy Center over a 12-year period (2004–2015) for the occurrence of the term “help” in the text body. All the extracted reports were reviewed and patients with at least one episode of documented ictal verbal help-seeking in epilepsy monitoring unit (EMU) were studied. For each patient, the data were reviewed from the electronic medical records, EMU report, and neuroimaging records. Results During the study period, 5133 patients were investigated in our EMU. Twelve patients (0.23%) had at least one episode of documented ictal verbal help-seeking. Nine patients (six women and three men) had epilepsy and three patients (two women and one man) had psychogenic nonepileptic seizures (PNES). Seven out of nine patients with epilepsy had temporal lobe epilepsy; six patients had right temporal lobe epilepsy. Conclusion Ictal verbal help-seeking is a rare finding among patients evaluated in epilepsy monitoring units. Ictal verbal help-seeking may suggest that seizures arise in or propagate to the right temporal lobe. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this study was to describe a series of patients with ictal crying to estimate its occurrence and characterize the clinical features and the underlying etiology. Methods We retrospectively reviewed all the long-term video-EEG reports from Jefferson Comprehensive Epilepsy Center over a 12-year period (2004–2015) for the occurrence of the terms “cry” or “sob” or “weep” in the text body. All the extracted reports were reviewed, and patients with at least one episode of documented ictal crying at the epilepsy monitoring unit (EMU) were included in the study. Results During the study period, 5133 patients were investigated at our EMU. Thirty-two patients (0.6%) had at least one documented seizure accompanied by crying. Twenty-seven patients (26 women and one man) had psychogenic nonepileptic seizures (PNES), and five patients (0.1%) had epilepsy. Among patients with epileptic ictal crying, four patients had focal epilepsy (two had definite, and two had probable frontal lobe epilepsy), while one patient had Lennox–Gastaut syndrome. Conclusion Ictal crying is a rare finding among patients evaluated at the EMUs. The most common underlying etiology for ictal crying is PNES. However, ictal crying is not a specific sign for PNES. Epileptic ictal crying is often a rare type of partial seizure in patients with focal epilepsy. Dacrystic seizures do not provide clinical value in predicting localization of the epileptogenic zone. [ABSTRACT FROM AUTHOR]

Purpose: We have utilized different methods in machine learning (ML) to develop the best algorithm to differentiate comorbid functional seizures (FS) and epilepsy from those who have pure FS.Methods: This was a retrospective study of an electronic database of patients with seizures. All patients with a diagnosis of FS (with or without comorbid epilepsy) were studied at the outpatient epilepsy clinic at Shiraz University of Medical Sciences, Shiraz, Iran, from 2008 until 2021. We arbitrarily selected 14 features that are important in making the diagnosis of patients with seizures and also are easily obtainable during history taking. Pytorch and Scikit-learn packages were used to construct various models including random forest classifier, decision tree classifier, support vector classifier, k-nearest neighbor, and TabNet classifier.Results: Three hundred and two patients had FS (82.5%), while 64 patients had FS and comorbid epilepsy (17.5%). The "TabNet classifier" could provide the best sensitivity (90%) and specificity (74%) measures (accuracy of 76%) to help differentiate patients with FS from those with FS and comorbid epilepsy.Conclusion: These satisfactory differentiating measures suggest that the current algorithm could be used in clinical practice to help with the difficult task of distinguishing patients with FS from those with FS and comorbid epilepsy. Based on the results of the current study, we have developed an Application (SeiDx). This App is freely accessible at the following address: https://drive.google.com/file/d/1rAgBXKNPW9bmUCDioaGHHzLBQgzZ-HZ2/view. This App should be validated in a prospective assessment. [ABSTRACT FROM AUTHOR]

Objective: We investigated whether the COVID-19 pandemic has affected the clinical characteristics of patients with functional seizure (FS) (at the time of diagnosis).Methods: In a retrospective study of a prospectively developed and maintained database, all patients diagnosed with FS before and during the COVID-19 pandemic were studied at the outpatient epilepsy clinic at Shiraz University of Medical Sciences, Shiraz, Iran, from December 2008 until February 2021.Results: Three hundred and eighty-eight patients were studied. Three hundred and sixty-four patients (94%) were diagnosed before and 24 persons (6%) during the pandemic. Patients diagnosed during the COVID-19 pandemic less frequently had generalized motor seizures [odds ratio (OR): 0.30, 95% confidence interval (CI): 0.12-0.77; p = 0.012] and had higher seizure frequencies (OR: 1.00, 95% CI: 1.00-1.01; p = 0.044). Functional seizures were inversely associated with the education level as a trend during the COVID-19 pandemic (OR: 0.36, 95% CI: 0.13-1.01; p = 0.052).Conclusion: The COVID-19 pandemic has affected the characteristics of patients with FS (at the time of diagnosis). Larger and multi-center studies are needed to investigate the links and associations between the COVID-19 pandemic and characteristics of FS. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: The purpose of this study was to determine if patients with episodes of prolonged psychogenic nonepileptic seizures or pseudostatus are different from those with psychogenic nonepileptic seizures (PNESs) without prolonged attacks regarding their demographic and clinical characteristics and factors potentially predisposing to PNESs. Methods: In this prospective study, all patients with a clinical diagnosis of PNESs (based on ictal recordings) were recruited at the outpatient epilepsy clinic at Shiraz University of Medical Sciences from 2008 through 2013. The epileptologist interviewed all the patients. We compared the demographic and clinical characteristics of patients with PNES-status with those with PNES-only. Results: Two hundred and eleven patients were studied. Forty-nine patients (23.2%) reported episodes of PNES-status, and 162 patients (76.8%) did not report PNES-status. There were no significant differences between these two groups of patients regarding the demographic and clinical characteristics and factors potentially predisposing to PNESs. Conclusion: Psychogenic nonepileptic seizure status (PNES-status) is relatively common among patients with PNESs. It seems that patients with PNES-status are not different from those with PNES-only, at least regarding the demographic and clinical characteristics and factors potentially predisposing to PNESs. [Copyright &y& Elsevier]

• 1174 patients were studied. • The rates of ictal injury did not differ significantly between the groups. • Tongue injury was more frequently reported by patients with TLE. The aim of the current study was to compare the risk and also the types of ictal injuries in three groups of people with seizures [i.e., IGE vs. TLE vs. FS]. This was a retrospective study. All patients with an electro-clinical diagnosis of IGE, TLE, or FS were recruited at the outpatient epilepsy clinic at Shiraz University of Medical Sciences, Shiraz, Iran, from 2008 until 2020. Age, sex, age at seizure onset, seizure type(s), and occurrence of ictal injury at any time since the onset of the seizures and its characteristics were registered routinely for all patients at the time of the first visit. One thousand and one hundred seventy-four patients were studied (481 patients with IGE, 402 people with TLE, and 291 persons with FS). While the groups differed in their demographic and clinical characteristics, the rates of ictal injury did not differ significantly between the groups. Tongue injury was more frequently reported by patients with TLE compared with that by people with IGE or FS. Other types/locations of ictal injury were more or less reported by all three groups of the patients. Ictal injuries may happen with more or less similar rates among people with epilepsy (IGE and TLE) and those with FS. Ictal injury (rate, type, or location) should not be used as a marker for any specific diagnosis among people with seizures. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: Psychogenic non-epileptic seizures (PNES) are more prevalent among women. We investigated the potential differences in demographic and clinical characteristics of PNES between women and men. Methods: In this prospective study, all patients with a clinical diagnosis of PNES (based on ictal recordings) were recruited at the outpatient epilepsy clinic at Shiraz University of Medical Sciences, from 2008 through 2012. The epileptologist interviewed all the patients. We compared the demographic and clinical characteristics and seizure semiology of PNES between women and men. Results: Two hundred and twenty-two patients were diagnosed as having PNES. One hundred and eighty-eight patients had video-EEG recordings available and included in the study. One hundred and twenty-nine (69%) were female and 59 (31%) were male. There were no significant differences between women and men with PNES with regard to demographic, clinical and semiological characteristics. Conclusion: We did not observe any significant demographic differences between women and men with PNES. Likewise, seizure characteristics and semiology were very similar in both genders. It appears that an Islamic lifestyle (in Iran) has little influence on the sex ratio and clinical manifestations of PNES compared with the Western studies. [Copyright &y& Elsevier]

We conducted a multicenter international cross-cultural comparative study to investigate clinical semiology and predisposing factors of functional seizures in a large cohort of patients living in different countries around the world. We hypothesized that semiology and predisposing factors of functional seizures differ between various world regions. We conducted this retrospective observational study in adults with functional seizures admitted to epilepsy centers in Iran, Qatar, USA, France, Georgia, Egypt, and United Arab Emirates (UAE). We assessed and compared the demographic and clinical seizure characteristics of these patients, according to the patients' reports and review of the ictal recordings during video-electroencephalogram (EEG) monitoring. Five hundred nine patients were included (270 from Iran, 74 from Qatar, 63 from France, 43 from the USA, 22 from Egypt, 20 from UAE, and 17 from Georgia). Although all major manifestations of functional seizures (e.g., aura, loss of responsiveness, generalized motor seizures, ictal injury) were seen in all world regions, seizure semiology differed significantly across countries. Auras, ictal urinary incontinence, and ictal injury were more commonly reported by the American patients than patients from other world regions, whereas loss of responsiveness and generalized motor seizures were more frequently observed in the Iranian and American patients than the European and Arab patients. Semiology of functional seizures seems to vary across various regions of the world; socioeconomic, cultural, ethnic, and religious differences may play an essential role in the modulation of functional seizures semiology across different nations and cultures. • We conducted a multicenter international cross-cultural comparative study of functional seizures. • Frequencies of the investigated clinical characteristics of the patients were different between the world regions. • Frequencies of the risk factors were different between the world regions. • Sociocultural background is probably an important determinant of functional seizures semiology. [ABSTRACT FROM AUTHOR]

Purpose: We investigated the rate of acceptance of functional seizures (FS) or psychogenic nonepileptic seizures (PNES) diagnosis in a cross-sectional study in a cohort from Iran. We hypothesized that the acceptance of FS diagnosis has association with clinical characteristics of the patients.Methods: In this cross-sectional study, all patients with FS, who were diagnosed at Shiraz Comprehensive Epilepsy Center, Iran, from 2008 until 2018, were investigated. In a phone call interview in February 2020, we obtained the following information: whether they have accepted the diagnosis that was delivered to them; what is their seizure outcome (seizure-free during the past 12 months or not).Results: 100 patients participated; at the time of the follow-up call, 74 (74%) patients expressed that they have accepted the diagnosis of FS. At the follow-up call, 48 patients (48%) were seizure-free and 52 patients (52%) were suffering from FS yet; 34 of seizure-free patients (71%) and 40 of those patients who still had seizures (77%) expressed that they have accepted the diagnosis of FS (p = .504; Fisher's exact test). Patients' characteristics and seizure semiology were not associated with the acceptance of the diagnosis of FS.Conclusion: That the majority of patients with FS accept their diagnosis if it is delivered to them appropriately, and demographic and clinical characteristics of the patients do not have associations with this. [ABSTRACT FROM AUTHOR]

• During the study period, 274 patients with PNES-only had the inclusion criteria and were studied. • Seventy-seven (28%) patients had a positive family history of seizures and 197 (72%) patients did not have such a history. • There were no demographic or clinical differences between these two groups. If a positive family history of seizures plays a significant role that contributes to the risk for developing psychogenic nonepileptic seizures (PNES) by means of model learning, one would expect that patients with PNES with a family history of seizures show a different semiology than those without such a history. We investigated whether the above hypothesis is valid. In this retrospective study, all patients with PNES, who were diagnosed at Shiraz Comprehensive Epilepsy Center at Shiraz University of Medical Sciences, Iran, from 2008 until 2019, were investigated. Demographic and clinical characteristics were compared between patients with a positive family history of seizures and those without such a history During the study period, 274 patients with PNES-only had the inclusion criteria. Seventy-seven (28%) patients had a positive family history of seizures and 197 (72%) patients did not have such a history. There were no significant demographic or clinical differences between the two groups. It seems that a positive family history of seizures and model learning does not play a significant role in the development of PNES. Investigators should explore other potentially significant contributors and risk factors for developing PNES in future studies. [ABSTRACT FROM AUTHOR]

The purpose of the study was to review the literature on the terminologies for psychogenic nonepileptic seizures (PNES) and make a proposal on the terminology of this condition. This proposal reflects the authors' own opinions. We systematically searched MEDLINE (accessed from PubMed) and EMBASE from inception to October 10, 2019 for articles written in English with a main focus on PNES (with or without discussion of other functional neurological disorders) and which either proposed or discussed the accuracy or appropriateness of PNES terminologies. The search strategy reported above yielded 757 articles; 30 articles were eventually included, which were generally of low quality. "Functional seizures" (FS) appeared to be an acceptable terminology to name this condition from the perspective of patients. In addition, FS is a term that is relatively popular with clinicians. From the available evidence, FS meets more of the criteria proposed for an acceptable label than other popular terms in the field. While the term FS is neutral with regard to etiology and pathology (particularly regarding whether psychological or not), other terms such as "dissociative", "conversion", or "psychogenic" seizures are not. In addition, FS can potentially facilitate multidisciplinary (physical and psychological) management more than other terms. Adopting a universally accepted terminology to describe this disorder could standardize our approach to the illness and facilitate communication between healthcare professionals, patients, their families, carers, and the wider public. • The search strategy reported above yielded 757 articles. • 30 articles were eventually included, which were generally of low quality. • "Functional seizures" (FS) appeared to be an acceptable terminology from the perspective of patients. • In addition, FS is a term that is relatively popular with clinicians. [ABSTRACT FROM AUTHOR]

Previous studies from a few countries have reported semiological differences in younger children compared with adolescents or adults with psychogenic nonepileptic seizures (PNESs). This study tested the hypothesis that semiological, demographic, and historical risk factors vary with different ages of PNES onset in a large cohort from different countries. In this retrospective study, we investigated patients consecutively referred for PNES, who were admitted to epilepsy monitoring units in Iran, Brazil, Venezuela, Canada, Argentina, and USA. Age, gender, age at seizure onset, seizure semiology, and factors predisposing to PNES (abuse, stressors) were documented according to routine diagnostic practices at each center. Participants were grouped according to their age at onset (i.e., childhood, adolescence, or adulthood). A total of 448 patients were studied. Female predominance was associated with adolescent- (85/122, 70%) and adult-onset (190/270, 70%) but not in childhood-onset PNES (28/56, 50%) (p = 0.011). Event frequency in the month preceding the diagnosis was higher in the childhood- [ x ¯ = 50, standard deviation (sd) = 82, p = 0.025] versus adolescent- (x ¯ = 24, sd = 36) or adult-onset groups (x ¯ = 29, sd = 61). Significant between-group differences were observed for generalized body movements (p = 0.0001) and ictal injury (p = 0.027), suggesting more severe ictal presentations in adult-onset PNES compared with younger ages. Adult-onset patients were also more likely to be taking an unnecessary antiepileptic medication (p = 0.010). While PNES may present at any age, there appear to be notable differences across the lifespan with respect to some of the clinical characteristics. Further international and cross-cultural studies may reveal other interesting characteristics of PNES. • We included 448 patients from 6 countries (Iran = 262, Brazil = 85, Venezuela = 43, Canada = 21, Argentina = 19, and USA = 18). • There was a female predominance in adolescent and adult-onset PNES but not in childhood-onset patients. • Frequency of PNES events was significantly higher in the childhood-onset versus adolescent and adult-onset patients. • Generalized body movements and ictal injury were more common in adult-onset PNES than younger onset age groups. • Unnecessary antiepileptic medication was more likely to be prescribed among adult-onset PNES patients. [ABSTRACT FROM AUTHOR]

The aim of this retrospective study was to scrutinize factors that are associated with a delay in making the diagnosis of psychogenic nonepileptic seizures (PNES). In this study, patients with PNES, who were investigated at Shiraz Comprehensive Epilepsy Center, Iran, from 2008 to 2019, were studied. We categorized the patients into the following: 1. those with a definite diagnosis of PNES in less than a year since the onset of their attacks; 2. those with a definite diagnosis of PNES later than 10 years since the onset of their attacks. During the study period, 330 patients were recorded. In 98 patients (30%), the diagnosis of PNES was made in less than a year since their seizure onset. In 67 patients (20%), the diagnosis of PNES was made later than 10 years since their seizure onset. Taking antiepileptic drugs (AEDs) (odds ratio (OR) = 6) and a history of ictal injury (OR = 3.6) had a positive association, and age at the onset (OR = 0.8) had an inverse association with a delay in receiving a definite diagnosis of PNES (p = 0.0001). Some demographic variables (i.e., early age at the onset of seizures), patients' clinical variables (i.e., severe seizure manifestations such as ictal injury), and finally, some physician-related variables (i.e., prescribing AEDs) have significant associations with a delay in making a definite diagnosis of PNES. • 330 patients were recorded. • In 98 patients (30%), the diagnosis of PNES was made in less than a year since their seizure onset. • In 67 patients (20%), the diagnosis of PNES was made later than 10 years since their seizure onset. • Taking AEDs and ictal injury had a positive and age at the onset had an inverse association with delayed diagnosis. [ABSTRACT FROM AUTHOR]

Objective The Middle Eastern country of Qatar opened its first epilepsy monitoring unit (EMU) in late 2015. This study compared demographic and clinical characteristics of patients with confirmed epilepsy to those of patients with confirmed psychogenic nonepileptic seizures (PNES). Methods Data were collected via retrospective chart review on 113 patients admitted for evaluation to the Qatar national health system EMU between November 2015 and May 2017. Results Seventy-one patients had a confirmed diagnosis (20 had PNES, 46 had epilepsy, 5 had both PNES and epilepsy). Evaluation in 33 patients was inconclusive, and 9 had other medical conditions. Patients with PNES were significantly more likely to be primary Arabic speakers (p = 0.003), and this difference was not explained by education or employment status. The most common referral request in patients with PNES was for recurrent/refractory seizures (p = 0.011), and there was a trend for patients with PNES to have more frequent seizures compared with patients with epilepsy (daily to several per week versus several times a month or less, p = 0.051). Depression was identified in 47% of patients with epilepsy and 65% of patients with PNES, and patients with PNES had higher mean depression scores on the PHQ-9 than patients with epilepsy (p = 0.014). Patients with PNES experienced significantly more fatigue (p = 0.021). Seventy percent of patients with PNES and 50% of patients with epilepsy reported sleep problems. Conclusions The characteristics of patients with epilepsy and PNES at the EMU in Qatar were generally similar to those found worldwide. Patients with PNES more often suffered from frequent depression, sleep problems, and fatigue than those with epilepsy, but these were significant concerns for both groups. [ABSTRACT FROM AUTHOR]