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Functional neurological disorder (FND) is a common diagnosis of varied neuropsychiatric symptoms presenting to pediatric healthcare settings, including primary, urgent and subspecialty care. A key diagnostic shift appearing in the DSM-V is that FND is no longer a diagnosis of exclusion; rather, a rule-in diagnosis based on suggestive elements of symptom presentation. This article reviews diagnostic criteria, clarifying features, risks, and prognostic factors. This is the first in a series of six articles on FND and will introduce an FND case that will be examined in each subsequent article in the context of their more specific subject matter. [ABSTRACT FROM AUTHOR]

• Components and modalities of psychoeducation interventions vary widely. • Methods and quality of evaluation vary between studies. • There are indications that psychoeducation has benefits as an intervention in its own right. • Psychoeducation likely best placed as part of a stepped care model. Cognitive behavioural therapy (CBT) and other psychological approaches have a growing evidence base for treating Non-Epileptic Seizures (NES). However, communication about the diagnosis can be difficult for clinicians and is not always well received. It is thought that Psychoeducation about NES may improve engagement with treatment such as CBT and may contribute to reductions in the frequency of seizures and improvements in health related quality of life. However, psychoeducational components of treatment are often not evaluated in isolation meaning the specific benefit to patients is not currently well understood. The researchers aimed to examine the outcomes associated with psychoeducational interventions and the content of these programmes for NES. A scoping review was undertaken across four databases with seventeen eligible studies identified which were charted to analyse the data. Findings revealed that components and modalities of interventions varied as did methods of evaluating the interventions. A number of different outcome measures were used and not all studies reported the significance of findings. Results across studies were inconsistent; however, there was a general trend across the studies of symptom reduction and improvement in mental health. Findings illustrate that psychoeducation has potential benefits as an intervention in its own right. However, it may be best placed as a second step in a stepped care model, between initial diagnosis and further psychological treatment. The present literature needs replication and more robust studies for more certain conclusions to be drawn. [ABSTRACT FROM AUTHOR]

Background: Research has demonstrated that implementation of Nocebo Hypothesis Cognitive Behavioural Therapy (NH-CBT) achieved full symptom remission in 93% of people with Functional Neurological Symptoms Disorder (FNSD), most of them exhibiting motor symptoms. The basis for NH-CBT is consistent with a predictive coding aetiological model of FNSD. This idea is transparently shared with people with FNSD in the form of telling them that their symptoms are caused by a nocebo effect, usually followed by some physical activity that aims to change the person's belief about their body. Aims: To demonstrate that a version of NH-CBT can also be effective in eliminating or reducing non-epileptic seizures (assumed to be a sub-type of FNSD). Method: A consecutive case series design was employed. Participants were treated with NH-CBT over a 12-week period. The primary outcome measure was seizure frequency. Numerous secondary measures were employed, as well as a brief qualitative interview to explore participants' subjective experience of treatment. Results: Seven out of the 10 participants became seizure free at least 2 weeks before their post-treatment assessment, and all stayed seizure-free for at least 5 months. Six of those seven remained seizure free at 6-month follow-up. There were large positive effect sizes for the majority of secondary measures assessed. Conclusions: This case series provides evidence of feasibility and likely utility of NH-CBT in reducing the frequency of non-epileptic seizures. [ABSTRACT FROM AUTHOR]

Objectives: We report routinely collected outcome data from an 8-week outpatient rehabilitative therapy program. The aims of the intervention were to (1) reduce symptom severity and (2) improve functional mobility in adults with functional neurological disorder (FND). Methods: The program delivered individual physiotherapy, cognitive behavioral therapy (CBT) and self-management sessions, group physiotherapy, and psychoeducation. Outcome measures included the Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI-II), Work and Social Adjustment Scale (WSAS), 10-Meter Walk Test (10MWT), Timed Up and Go (TUG), and Berg Balance Scale (BBS). Data were analyzed retrospectively in accordance with routine service evaluation. Wilcoxon signed-rank tests assessed changes in outcomes between weeks 1 and 8 for all patients completing treatment (n = 45). For patients who attended the 3-month follow-up (n = 31), Friedman's ANOVA assessed overall change in outcomes over time. Post hoc Wilcoxon signed-rank tests compared pairs of time-points (Weeks 1, 8, and 3-month follow-up). Results: Analyses of patients completing the program revealed significant improvements in scores between week 1 and week 8. Excluding the BBS, there were statistically significant improvements in all outcomes between weeks 1 and 8 and between weeks 1 and 3-month follow-up. Discussion: This outpatient therapy program provided effective treatment for FND. Patients reported reduced anxiety, depression, and functional impairment, as well as improved performance on most physiotherapy measures. [ABSTRACT FROM AUTHOR]

Contextual events are recognized to affect seizure-like behaviors, yet there is limited research on procedures assessing contextual control. This study aimed to examine the utilization of a brief experimental precursor functional analysis within a clinical team assessment. Furthermore, the study explored if telehealth supervision could guide a parent administered replication of the functional analysis. The participants were a young female with Rett syndrome and a history of epilepsy as well as non-epileptic seizures and her mother. The functional analysis procedures consisted of the systematic alternations of contextual conditions that were hypothesized to either prevent or evoke seizure-like behaviors. The primary outcome measure was the occurrence of behavioral precursors that were identified to consequently signal subsequent seizure-like behaviors. In addition, procedure fidelity and interobserver agreement data were obtained alongside parent rating of the procedure’s social validity. The clinical functional analysis clearly suggested that the seizure-like behaviors served the function of access to attention and preferred activities. A parent administered functional analysis replicated clinical functional analysis findings. The parent’s fidelity to procedures was high and scores in social validity were excellent. The results show that functional analysis procedures could provide essential information in assessment of non-epileptic seizures. Strengths and limitations are discussed.

• A review was undertaken of an Australia-wide ambulatory video-EEG monitoring service. • Patients were in view of camera for 94.90% of events, and 84.89% of studies had all events on camera. • 84.42% of events from wakefulness were reported, compared to 54.27% from sleep. Recording electrographic and behavioral information during epileptic and other paroxysmal events is important during video electroencephalography (EEG) monitoring. This study was undertaken to measure the event capture rate of an home service operating across Australia using a shoulder-worn EEG device and telescopic pole-mounted camera. Neurologist reports were accessed retrospectively. Studies with confirmed events were identified and assessed for event capture by recording modality, whether events were reported or discovered, and physiological state. 6,265 studies were identified, of which 2,788 (44.50%) had events. A total of 15,691 events were captured, of which 77.89% were reported. The EEG amplifier was active for 99.83% of events. The patient was in view of the camera for 94.90% of events. 84.89% of studies had all events on camera, and 2.65% had zero events on camera (mean = 93.66%, median = 100.00%). 84.42% of events from wakefulness were reported, compared to 54.27% from sleep. Event capture was similar to previously reported rates from home studies, with higher capture rates on video. Most patients have all events captured on camera. Home monitoring is capable of high rates of event capture, and the use of wide-angle cameras allows for all events to be captured in the majority of studies. [ABSTRACT FROM AUTHOR]

Rationale: The aim of this study was to evaluate the effectiveness of a three-hour psychoeducation group in improving understanding of non-epileptic seizures (NES), health outcomes and quality of life in young people with NES.Background: Multi-session psychoeducational groups for adults with NES have reported improved psychosocial functioning and reduced NES compared to those who do not receive psychoeducational interventions. To date there have been no studies in young people examining the effects of a single session of psychoeducation.Method: 15 young people with NES and their families attended a psychoeducation group within a specialist hospital following a multidisciplinary assessment. The group's effectiveness was evaluated in terms of perceptions of seizure controllability, seizure severity, the management of the condition and health-related quality of life measures.Results: A significant decrease in accident and emergency (A&E) visits and ambulance call outs was observed following the psychoeducation group. Young people additionally reported increased knowledge of NES and ability to cope with the condition which was maintained at 6-week follow-up. Significant reduction in NES occurrence or quality of life was not observed.Conclusion: Significant reduction in A&E attendance and ambulance use was found following group psychoeducation and improvements in psychosocial functioning and knowledge about NES. Group psychoeducation has the potential to increase child and parental understanding of NES and reduce inappropriate healthcare usage. [ABSTRACT FROM AUTHOR]

• 35% of all cases of non-epileptic seizures (NES) were considered refractory. • A clear precipitant and psychosocial adversity were associated with poor outcome. • Unemployment at the time of diagnosis was a poor prognostic factor. This incidence of non-epileptic seizures (NES) is estimated at 1–35 per 100,000 population. While many patients achieve remission, a significant fraction of patients have a poor prognosis despite optimal interventions. This study reports on the characteristics of patients with refractory NES diagnosed and treated at a comprehensive epilepsy centre. A retrospective review of admissions to the Epilepsy Monitoring Unit identified patients diagnosed with NES over a 6-year period. Patients with refractory NES were identified through review of medical files. A diagnosis of refractory NES was assigned when patients experienced ongoing NES at least 1 year after diagnostic video-EEG monitoring. Data pertaining to predisposing, precipitating and perpetuating factors was collected on all patients and a comparative analysis was conducted between refractory and non-refractory cases. 66 patients with NES were identified, 35% were deemed refractory. There was no significant difference amongst predisposing factors between the groups. Psychosocial adversity and a clear precipitant proximate to the onset of NES were significantly more common in the refractory cohort. Unemployment at time of diagnosis was a significant perpetuating factor associated with poor outcome. This study provides insight into the features associated with refractory NES and may serve to improve prognostication and management in this disabling condition. [ABSTRACT FROM AUTHOR]

PurposeThe average delay from first seizure to diagnosis of psychogenic non-epileptic seizures (PNES) is over 7 years. The reason for this delay is not well understood. We hypothesized that a perceived decrease in seizure frequency after starting an anti-seizure medication (ASM) may contribute to longer delays, but the frequency of such a response has not been well established.MethodsTime from onset to diagnosis, medication history and associated seizure frequency was acquired from the medical records of 297 consecutive patients with PNES diagnosed using video-electroencephalographic monitoring. Exponential regression was used to model the effect of medication trials and response on diagnostic delay.ResultsMean diagnostic delay was 8.4 years (min 1 day, max 52 years). The robust average diagnostic delay was 2.8 years (95% CI: 2.2-3.5 years) based on an exponential model as 10 to the mean of log10 delay. Each ASM trial increased the robust average delay exponentially by at least one third of a year (Wald t=3.6, p=0.004). Response to ASM trials did not significantly change diagnostic delay (Wald t=-0.9, p=0.38).ConclusionAlthough a response to ASMs was observed commonly in these patients with PNES, the presence of a response was not associated with longer time until definitive diagnosis. Instead, the number of ASMs tried was associated with a longer delay until diagnosis, suggesting that ASM trials were continued despite lack of response. These data support the guideline that patients with seizures should be referred to epilepsy care centers after failure of two medication trials.

Amongst the most important conditions in the differential diagnosis of epilepsy is the one that manifests as paroxysms of altered behaviour, awareness, sensation or sense of bodily control in ways that often resemble epileptic seizures, but without the abnormal excessive or synchronous electrical activity in the brain that defines these. Despite this importance, there remains little agreement - and frequent debate - on what to call this condition, known inter alia as psychogenic non-epileptic seizures (PNES), dissociative seizures (DS), functional seizures (FS), non-epileptic attack disorder (NEAD), pseudoseizures, conversion disorder with seizures, and by many other labels besides. This choice of terminology is not merely academic - it affects patients' response to and understanding of their diagnosis, and their ability to navigate health care systems.This paper summarises two recent discussions hosted by the American Epilepsy Society and Functional Neurological Disorders Society on the naming of this condition. These discussions are conceptualised as the initial step of an exploration of whether it might be possible to build consensus for a new diagnostic label. [ABSTRACT FROM AUTHOR]

Background: Non-epileptic seizures (NES) fall under the category of medically unexplained symptoms (MUS). Patients are often misdiagnosed with epilepsy because convulsions and unconsciousness experienced in NES mirror symptoms of epileptic tonic-clonic seizures. Our current understanding is that these physiological symptoms of NES are caused purely by psychological distress. There is a lack of research that has explored the possible neuropsychological causes that trigger and maintain convulsions and unconsciousness. Aims: This article proposes a neuropsychological explanation of how convulsions and unconsciousness occur and maintain in patients with NES. Methods: Analysis of current research literature into NES is used to generate a neuropsychological perspective into the causes of NES, focusing on symptoms of convulsions and unconsciousness. Conclusions: This article argues the need for more neuropsychological research to be conducted into NES which can contribute to improving our understanding and treatment of NES. [ABSTRACT FROM AUTHOR]

Background: Dissociative (non-epileptic) seizures are potentially treatable by psychotherapeutic interventions; however, the evidence for this is limited. Objectives: To evaluate the clinical effectiveness and cost-effectiveness of dissociative seizure-specific cognitive–behavioural therapy for adults with dissociative seizures. Design: This was a pragmatic, multicentre, parallel-arm, mixed-methods randomised controlled trial. Setting: This took place in 27 UK-based neurology/epilepsy services, 17 liaison psychiatry/neuropsychiatry services and 18 cognitive–behavioural therapy services. Participants: Adults with dissociative seizures in the previous 8 weeks and no epileptic seizures in the previous year and meeting other eligibility criteria were recruited to a screening phase from neurology/epilepsy services between October 2014 and February 2017. After psychiatric assessment around 3 months later, eligible and interested participants were randomised between January 2015 and May 2017. Interventions: Standardised medical care consisted of input from neurologists and psychiatrists who were given guidance regarding diagnosis delivery and management; they provided patients with information booklets. The intervention consisted of 12 dissociative seizure-specific cognitive–behavioural therapy 1-hour sessions (plus one booster session) that were delivered by trained therapists, in addition to standardised medical care. Main outcome measures: The primary outcome was monthly seizure frequency at 12 months post randomisation. The secondary outcomes were aspects of seizure occurrence, quality of life, mood, anxiety, distress, symptoms, psychosocial functioning, clinical global change, satisfaction with treatment, quality-adjusted life-years, costs and cost-effectiveness. Results: In total, 698 patients were screened and 368 were randomised (standardised medical care alone, n = 182; and cognitive–behavioural therapy plus standardised medical care, n = 186). Primary outcome data were obtained for 85% of participants. An intention-to-treat analysis with multivariate imputation by chained equations revealed no significant between-group difference in dissociative seizure frequency at 12 months [standardised medical care: median of seven dissociative seizures (interquartile range 1–35 dissociative seizures); cognitive–behavioural therapy and standardised medical care: median of four dissociative seizures (interquartile range 0–20 dissociative seizures); incidence rate ratio 0.78, 95% confidence interval 0.56 to 1.09; p = 0.144]. Of the 16 secondary outcomes analysed, nine were significantly better in the arm receiving cognitive–behavioural therapy at a p-value

There are no well-validated treatments for functional seizures. While specialist psychotherapy is usually recommended, the evidence for its benefit is qualified, and it can be difficult to obtain. Given the association between hyperventilation and functional seizures we explored an alternative modality, breathing control training, in a multi-site open label pilot trial. Participants with functional seizures over the age of 16 received an hour of breathing training from a respiratory physiotherapist, with a half-hour booster session a month later. Seizure frequency and Nijmegen scores (a measure of hyperventilation) were reported at baseline and follow-up, 3–4 months later. Eighteen subjects were recruited, and 10 completed follow-up. Seven of these 10 had improved seizure frequency, and 3 did not (Wilcoxon signed rank test, p = 0.09), with seizure frequency correlating with Nijmegen score (Spearman's rank correlation = 0.75, p = 0.034). The intervention was well tolerated, with no adverse events reported. These preliminary results support a potentially new approach to treating functional seizures that should prove cost-effective and acceptable, though require confirmation by a randomised controlled trial. [ABSTRACT FROM AUTHOR]

• We tested common questions to distinguish epilepsy from seizure mimics. • The overall model we created was sensitive and specific for epilepsy diagnosis. • This questionnaire could be used in most clinical settings by non-specialists. • This questionnaire could help inform future studies to improve epilepsy diagnosis. The aim of this study was to evaluate the diagnostic accuracy of common interview questions used to distinguish a diagnosis of epilepsy from seizure mimics including non-epileptic seizures (NES), migraine, and syncope. 200 outpatients were recruited with an established diagnosis of focal epilepsy (n = 50), NES (n = 50), migraine (n = 50), and syncope (n = 50). Patients completed an eight-item, yes-or-no online questionnaire about symptoms related to their events. Sensitivity and specificity were calculated. Using a weighted scoring for the questions alone with baseline characteristics, the overall questionnaire was tested for diagnostic accuracy. Of individual questions, the most sensitive one asked if events are sudden in onset (98 % sensitive for epilepsy (95 % CI: 89 %, 100 %)). The least sensitive question asked if events are stereotyped (46 % sensitive for epilepsy (95 % CI: 32 %, 60 %)). Overall, three of the eight questions showed an association with epilepsy as opposed to mimics. These included questions about "sudden onset" (OR 10.76, 95 % CI: (1.66, 449.21) p = 0.0047), "duration < 5 min" (OR 3.34, 95 % CI: (1.62, 6.89), p = 0.0008), and "duration not > 30 min" (OR 4.44, 95 % CI: (1.94, 11.05), p = <0.0001). When individual seizure mimics were compared to epilepsy, differences in responses were most notable between the epilepsy and migraine patients. Syncope and NES were most similar in responses to epilepsy. The overall weighted questionnaire incorporating patient age and sex produced an area under the ROC curve of 0.80 (95 % CI: 0.74, 0.87)). In this study, we examined the ability of common interview questions used by physicians to distinguish between epilepsy and prevalent epilepsy mimics, specifically NES, migraines, and syncope. Using a weighted scoring system for questions, and including age and sex, produced a sensitive and specific predictive model for the diagnosis of epilepsy. In contrast to many prior studies which evaluated either a large number of questions or used methods with difficult practical application, our study is unique in that we tested a small number of easy-to-understand "yes" or "no" questions that can be implemented in most clinical settings by non-specialists. [ABSTRACT FROM AUTHOR]

Background A large amount of literature surrounds the differences between dissociative neurological symptom disorder with non-epileptic seizures (DNSD-S) and epilepsy. Aims To explore the research gap on phenotypic differences between DNSD-S and other psychiatric disorders. Method We conducted a case–control study of 1860 patients (620 patients with DNSD-S and 1240 controls with other psychiatric disorders) seen at the South London and Maudsley Hospital NHS Trust between 2007 and 2019. Results Compared with the controls, the patients with DNSD-S were more likely to be female (76 v. 47%, P < 0.001), of White ethnicity (77 v. 60%, P < 0.001), married (34 v. 14%, P < 0.001) and living in areas of lower socioeconomic status (−3.79, 95% CI −2.62 to −4.96, P < 0.001). Two peaks for age at diagnosis were observed for DNSD-S: the early 20s and late 40s. After 31 years of age, men's chance of being diagnosed with DNSD-S increased from 19 to 28% (P = 0.009). People with DNSD-S presented more commonly with a history of a neurological episodic or paroxysmal disorder (OR = 12, 95% CI 7.82–20.26), another dissociative disorder (OR = 10, 95% CI 1.64– 65.95) or unclassified signs or symptoms (OR = 4, 95% CI 2.61–6.43). Neither anxiety, depression nor other somatoform disorders predicted subsequent diagnosis of DNSD-S, and controls had a larger proportion of preceding psychiatric diagnoses than patients with DNSD-S (65 v. 49%, P < 0.001). Conclusions This is the first study comparing demographic and phenotypic correlates of patients with DNSD-S against a large cohort of psychiatric patients. These data will inform development and drive service needs in psychiatry for people with DNSD-S.

Patients struggling with functional seizures represent a significant issue for institutions across the country. Fortunately, they often respond to regular Cognitive Behavioral oriented psychotherapy. This patient population tends to be underserved, and it is the hope that my experience in their treatment will alleviate this problem. My approach to therapy is largely self taught, and based on observation, trial and error, and over ten years of experience. My approach begins with the introduction of behavioural interventions, and as treatment progresses, I begin to rely on talk therapy aimed at the introduction of cognitive interventions. Treatment begins with an analysis of their episodes followed by interventions aimed at symptom reduction. Longer term goals include the management of co occurring mental health concerns and systemic issues.

Contextual events are recognized to affect seizure-like behaviors, yet there is limited research on procedures assessing contextual control. This study aimed to examine the utilization of a brief experimental precursor functional analysis within a clinical team assessment. Furthermore, the study explored if telehealth supervision could guide a parent administered replication of the functional analysis. The participants were a young female with Rett syndrome and a history of epilepsy as well as non-epileptic seizures and her mother. The functional analysis procedures consisted of the systematic alternations of contextual conditions that were hypothesized to either prevent or evoke seizure-like behaviors. The primary outcome measure was the occurrence of behavioral precursors that were identified to consequently signal subsequent seizure-like behaviors. In addition, procedure fidelity and interobserver agreement data were obtained alongside parent rating of the procedure's social validity. The clinical functional analysis clearly suggested that the seizure-like behaviors served the function of access to attention and preferred activities. A parent administered functional analysis replicated clinical functional analysis findings. The parent's fidelity to procedures was high and scores in social validity were excellent. The results show that functional analysis procedures could provide essential information in assessment of non-epileptic seizures. Strengths and limitations are discussed., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: First author ’s work hours were funded by The Swedish National Center for Rett syndrome and related disorders. A public, non-profit, competence and research center within the Swedish health care system. Besides the statement above, none of the authors have any conflict of interest to disclose., (© 2024 The Authors. Published by Elsevier Inc.)

Our understanding about underlying mechanisms leading to Functional Neurological Disorders (FND) has changed in recent years. While in the past these disorders were presumed to be solely due to psychological issues we know now that their development is dependent on complex interactions between biological, psychological and social factors. We present an analysis of clinical presentations and psychological profiles of patients who were seen in our FND outpatient clinic over 3 years. We aim to review the prevalence of common symptoms in the patients seen within our clinic, and to identify any common psychological or psychiatric profiles that differentiated these symptom groups. This may help to elucidate underlying mechanisms leading to the development of functional symptoms and identify the predisposing, triggering and perpetuation factors.

Patients with epilepsy have their authorisation to drive restricted under detailed guidelines, but the rules for those with non-epileptic seizures are far less clear. We surveyed specialist clinicians in Australia and found little agreement as to whether such guidelines existed for non-epileptic seizures or what they might be. A number of possible interpretations of the Australian fitness to drive guidelines are explored, and these are often vague in themselves, as well as uncertain in their scope. This means clinicians making momentous driving decisions for their patients with non-epileptic seizures are doubly challenged, first in interpreting what guidelines exist, and second in what they mean. The International League Against Epilepsy proposed specific guidelines for driving with non-epileptic seizures, which reflect the range of presentations of non-epileptic seizures in a decision-making algorithm. We believe a specific algorithm such as this is essential in removing one level of uncertainty and responsibility for clinicians, and restoring equity for patients with non-epileptic seizures. [ABSTRACT FROM AUTHOR]

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Our understanding about underlying mechanisms leading to Functional Neurological Disorders (FND) has changed in recent years. While in the past these disorders were presumed to be solely due to psychological issues we know now that their development is dependent on complex interactions between biological, psychological and social factors. We present an analysis of clinical presentations and psychological profiles of patients who were seen in our FND outpatient clinic over 3 years. We aim to review the prevalence of common symptoms in the patients seen within our clinic, and to identify any common psychological or psychiatric profiles that differentiated these symptom groups. This may help to elucidate underlying mechanisms leading to the development of functional symptoms and identify the predisposing, triggering and perpetuation factors. [ABSTRACT FROM AUTHOR]

Objective: Evidence suggests that impairments in social cognition are associated with the occurrence of NES. Our aim was to investigate impairments in social cognition in the form of emotional and cognitive empathy in patients with NES compared to healthy controls.Methods: For this purpose, we recruited 41 patients with video-EEG secured NES and compared them to 41 healthy controls matched by age, gender and educational level. Emotional and cognitive empathy were assessed using the Multifaceted Empathy Task (MET) and the Read the Mind in the Eye Test (RMET). Self-assessment questionnaires were used to record psychopathology in both groups.Results: Patients with NES showed no differences in cognitive empathy compared to the healthy controls. Additionall, they seem to have less emotional empathy specifically towards positive emotions, compared to healthy controls.Discussion: Our results are an indication of possible emotional empathy abnormalities in patients with NES. Those deviations, if replicated in large sample sizes, could implicate, that interventions for patients with NES should focus on improving empathy skills. [ABSTRACT FROM AUTHOR]

Purpose: Non-epileptic seizures are paroxysmal events which to an observer resemble epileptic seizures. Proposed risk factors incorporate biopsychosocial aspects including factors in the affected individual. Unexpectedly high rates of autism spectrum disorder (ASD) occurred in the clinical population reported here. Although elevated levels of psychiatric co-morbidity are known to be present in patients with NES, ASD has only been previously described in a single case report.Methods: This case series captures rates of ASD in 59 children and young people who were referred to a specialist paediatric mental health service at Great Ormond Street Hospital, London, UK for assessment and treatment of non-epileptic seizures between 2012 and 2016.Results: 10/59 (16.9%) of the children and young people with non-epileptic seizures also had ASD, with 5/10 (50%) of these undiagnosed with ASD before referral. Children and young people with ASD were significantly more likely to have tics or attention-deficit hyperactivity disorder than those without ASD.Conclusion: ASD may be a common co-morbidity in non-epileptic seizures. Careful clinical assessment with consideration of ASD traits is therefore important in the non-epileptic seizures population. It is beneficial to diagnose ASD early as its presence is likely to require a modified approach to assessment and treatment of non-epileptic seizures. Study of the development of non-epileptic seizures in ASD may suggest hypotheses for the pathogenesis of non-epileptic seizures in the wider population. [ABSTRACT FROM AUTHOR]

Abstract Background Dissociative seizures (DSs), also called psychogenic non-epileptic seizures, are a distressing and disabling problem for many patients in neurological settings with high and often unnecessary economic costs. The COgnitive behavioural therapy versus standardised medical care for adults with Dissociative non-Epileptic Seizures (CODES) trial is an evaluation of a specifically tailored psychological intervention with the aims of reducing seizure frequency and severity and improving psychological well-being in adults with DS. The aim of this paper is to report in detail the quantitative and economic analysis plan for the CODES trial, as agreed by the trial steering committee. Methods The CODES trial is a multicentre, pragmatic, parallel group, randomised controlled trial performed to evaluate the clinical effectiveness and cost-effectiveness of 13 sessions of cognitive behavioural therapy (CBT) plus standardised medical care (SMC) compared with SMC alone for adult outpatients with DS. Discussion The objectives and design of the trial are summarised, and the aims and procedures of the planned analyses are illustrated. The proposed analysis plan addresses statistical considerations such as maintaining blinding, monitoring adherence with the protocol, describing aspects of treatment and dealing with missing data. The formal analysis approach for the primary and secondary outcomes is described, as are the descriptive statistics that will be reported. This paper provides transparency to the planned inferential analyses for the CODES trial prior to the extraction of outcome data. It also provides an update to the previously published trial protocol and guidance to those conducting similar trials. Trial registration ISRCTN registry ISRCTN05681227 (registered on 5 March 2014); ClinicalTrials.gov NCT02325544 (registered on 15 December 2014).

There is accumulating evidence that patients with functional neurological symptom disorder (FND) show activation of multiple components of the stress system—the hypothalamic–pituitary–adrenal axis, autonomic nervous system, and brain regions involved in arousal- and emotion-processing. This study aims to examine whether the immune-inflammatory component of the stress system is also activated. C-reactive protein (CRP) blood titre levels were measured in 79 children and adolescents with FND. CRP values ≥ 2 mg/L suggest low-grade inflammation. CRP values > 10 mg/L suggest a disease process. Sixty-six percent of subjects (n = 52) had CRP titres ≥ 2 mg/L. The upward shift in the distribution of CRP levels suggested low-grade inflammation (median CRP concentration was 4.60 mg/L, with 75th and 90th percentiles of 6.1 and 10.3 mg/L, respectively). Elevated CRP titres were not explained by sex, pubertal status, BMI, or medical factors. Confounder analyses suggested that history of maltreatment (χ2 = 2.802, df = 1, p = 0.094, φ = 0.190; β = 2.823, p = 0.04) and a diagnosis of anxiety (χ2 = 2.731, df = 1, p = 0.098, φ = 0.187; β = 4.520, p = 0.061) contributed to elevated CRP levels. Future research will need to identify the origins and locations of immune cell activation and the pathways and systems contributing to their activation and modulation. Because functional activity in neurons and glial cells—the brain's innate effector immune cells—is tightly coupled, our finding of elevated CRP titres suggests activation of the immune-inflammatory component of the brain's stress system. A more direct examination of inflammation-related molecules in the brain will help clarify the role of immune-inflammatory processes in FND. [ABSTRACT FROM AUTHOR]

In territories of medical uncertainty, clinical encounters are highly contentious. To uncover maintaining mechanisms behind persistent conflicts, we explore the interactional dynamics of clinical encounters fused with medical uncertainty. Based on a thematic qualitative analysis of experiential texts from 385 people living with medically unexplained physical symptoms in Norway, UK, Ireland, USA and Canada, we explore patients' main expectations, how these expectations are met, and how their expectations and experiences are socially constructed and structurally conditioned. Five fundamental expectations are identified: Health professionals ought to (1) acknowledge the lack of medical knowledge, and be frank, open and curious about it; (2) believe patient experiences and accept their condition as "real"; (3) avoid blaming patients for their ailment; (4) demonstrate compassion, understanding and respect; and (5) share decision-making power with patients. Our participants experience unfulfilled expectations in all five areas. Both experiences and unfulfilled expectations are influenced by structural factors transpiring from the modern Western biomedical paradigm, and from cultural norms and values of its surrounding society. Structural and cultural forces obstruct team-oriented collaboration based on congruent understandings, mutual trust and reciprocated respect. Without such contextualisation, the interactional dynamics between patients and health professionals in clinical consultations cannot be exposed. [ABSTRACT FROM AUTHOR]

Functional somatic symptoms (FSS) emerge when the stress system is activated in response to physical or emotional stress that is either chronic or especially intense. In such cases, the heightened state of physiological arousal and motor activation can be measured through biological markers. Our team have integrated the use of biological markers of body state – respiratory rate, heart rate (HR) and heart rate variability (HRV) measurements – as a way of helping families to understand how physical symptoms can signal activation of the body's stress systems. This study measured respiratory rates, HR and HRV in children and adolescents with FSS (and healthy controls) during baseline assessment to determine whether these biological markers were effective at differentiating patients with FSS. The study also implemented a biofeedback intervention during the assessment to determine whether patients with FSS were able to slow their respiratory rates and increase HRV. Patients with FSS had faster respiratory rates, faster HR, and lower HRV, suggesting activation of the autonomic nervous system coupled with activation of the respiratory motor system. Like controls, patients were able to slow their respiratory rates, but in contrast to controls, they were unable to increase their HRV. Our findings suggest that patients with FSS present in a state of physiological activation and struggle to regulate their body state. Patients with FSS are likely to need ongoing training and practice to regulate body state coupled with interventions that target regulatory capacity across multiple systems. [ABSTRACT FROM AUTHOR]

Altered interoception may be a pathophysiological mechanism in functional neurological disorder (FND). However, findings have been inconsistent across interoceptive dimensions in FND including functional motor symptoms (FMS) and seizures (FS). Here, individuals with FMS/FS (n = 17) and healthy controls (HC, n = 17) completed measures of interoceptive accuracy and insight (adapted heartbeat tracking task [HTT] with confidence ratings), a time estimation control task (TET) and the Multidimensional Assessment of Interoceptive Awareness–2 (MAIA-2) to assess interoceptive sensibility. The groups did not differ in interoceptive accuracy (p = 1.00, g = 0.00) or confidence (p =.99, g = 0.004), although the FMS/FS group displayed lower scores on the "Not-Distracting" (p <.001, g = 1.42) and "Trusting" (p =.005, g = 1.17) MAIA-2 subscales, relative to HCs. The groups did not differ in TET performance (p =.82, g = 0.08). There was a positive relationship between HTT accuracy and confidence (insight) in HCs (r =.61, p =.016) but not in FMS/FS (r = 0.11, p =.69). HTT confidence was positively correlated with MAIA-2 "Self-Regulation" (r = 0.77, p =.002) and negatively correlated with FND symptom severity (r = −0.84, p <.001) and impact (r = −0.86, p <.001) in FMS/FS. Impaired interoceptive accuracy may not be a core feature in FMS/FS, but reduced insight and altered sensibility may be relevant. Reduced certainty in self-evaluations of bodily experiences may contribute to the pathogenesis of FND symptoms. • Intact interoceptive accuracy in functional motor symptoms/seizures (FMS/FS). • Potentially reduced interoceptive insight in FMS/FS versus healthy controls (HC). • Lower levels of "Trusting" and "Not-Distracting" in FMS/FS compared to HC. • Elevated "Self-regulation" positively related to interoceptive confidence in FMS/FS. • Elevated symptom severity/impact negatively related to interoceptive confidence. [ABSTRACT FROM AUTHOR]

Functional neurologic disorder (FND) is commonly encountered across outpatient and inpatient medical settings. Given the potential for a high burden of disability in some patients and mounting evidence for the efficacy of FND-specific multidisciplinary treatment services, expanding clinical services for this population is a necessity. In this perspective article, we discuss considerations for creating FND services, including the types of services that exist, how to start, how to identify appropriate referrals, and how to develop and monitor individualized treatment plans. In addition, we discuss how this effort can be done sustainably - balancing patient needs with limited healthcare resources., (Copyright © 2023 Elsevier Inc. All rights reserved.)

People with dissociative seizures (DS) report a range of difficulties in emotional functioning and exhibit altered responding to emotional facial expressions in experimental tasks. We extended this research by investigating subjective and autonomic reactivity (ratings of emotional valence, arousal and skin conductance responses [SCRs]) to general emotional images in 39 people with DS relative to 42 healthy control participants, whilst controlling for anxiety, depression, cognitive functioning and, where relevant, medication use. It was predicted that greater subjective negativity and arousal and increased SCRs in response to the affective pictures would be observed in the DS group. The DS group as a whole did not differ from controls in their subjective responses of valence and arousal. However, SCR amplitudes were greater in ‘autonomic responders’ with DS relative to ‘autonomic responders’ in the control group. A positive correlation was also observed between SCRs for highly arousing negative pictures and self‐reported ictal autonomic arousal, in DS ‘autonomic responders’. In the DS subgroup of autonomic ‘non‐responders’, differences in subjective responses were observed for some conditions, compared to control ‘non‐responders’. The findings indicate unaffected subjective responses to emotional images in people with DS overall. However, within the group of people with DS, there may be subgroups characterized by differences in emotional responding. One subgroup (i.e., ‘autonomic responders’) exhibit heightened autonomic responses but intact subjective emotional experience, whilst another subgroup (i.e., ‘autonomic non‐responders’) seem to experience greater subjective negativity and arousal for some emotional stimuli, despite less frequent autonomic reactions. The current results suggest that therapeutic interventions targeting awareness and regulation of physiological arousal and subjective emotional experience could be of value in some people with this disorder. [ABSTRACT FROM AUTHOR]

Acute compression on the brainstem or acute increase in intracranial pressure may induce non-epileptic events varying from tonic seizures to axial rigidity with motor automatism, sometimes clearly characterized by decerebrate or decorticate paroxysmal posturing. The EEG correlate is characterized by diffuse asynchronous slow waves of variable amplitude. The mechanism behind such events, known as “cerebellar seizures or fits”, is linked to cerebellar herniation and brainstem compression and is not of cortical origin. Misrecognition of such entity may entail an incongruous therapeutic intervention in a life-threatening situation. We describe two emblematic paediatric cases of cerebellar fits caused by diffuse oedema and brainstem compression: a 10-year-old girl with acute disseminated encephalomyelitis (ADEM) and a 2-year-old girl with severe respiratory distress symptomatic of Fallot tetralogy. We also describe the EEG correlate recorded during the events. [ABSTRACT FROM AUTHOR]

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Psychogenic non-epileptic seizures (PNES) are a common problem in paediatric neurology and psychiatry that can best be understood as atypical responses to threat. Threats activate the body for action by mediating increases in arousal, respiration, and motor readiness. In previous studies, a range of cardiac, endocrine, brain-based, attention-bias, and behavioral measures have been used to demonstrate increases in arousal, vigilance, and motor readiness in patients with PNES. The current study uses respiratory measures to assess both the motor readiness of the respiratory system and the respiratory regulation of CO. Baseline respiratory rates during clinical assessment and arterial CO levels during the hyperventilation component of routine video electroencephalogram were documented in 60 children and adolescents referred for treatment of PNES and in 50 controls. Patients showed elevated baseline respiratory rates [ t(78) = 3.34, p = .001], with 36/52 (69%) of patients [vs. 11/28 (39%) controls] falling above the 75th percentile ( χ = 6.7343; df = 1; p = .009). Twenty-eight (47%) of patients [vs. 4/50 (8%) controls] showed a skewed hyperventilation-challenge profile-baseline PCO <36 mmHg, a trough PCO ≤ 20 mmHg, or a final PCO <36 mmHg after 15 min of recovery-signaling difficulties with CO regulation ( χ = 19.77; df = 1; p < .001). Children and adolescents with PNES present in a state of readiness-for-action characterized by high arousal coupled with activation of the respiratory motor system, increases in ventilation, and a hyperventilation-challenge profile shifted downward from homeostatic range. Breathing interventions that target arousal, decrease respiratory rate, and normalize ventilation and arterial CO may help patients shift brain-body state and avert PNES episodes. [ABSTRACT FROM AUTHOR]

Background: Dissociative seizures (DSs), also called psychogenic non-epileptic seizures, are a distressing and disabling problem for many patients in neurological settings with high and often unnecessary economic costs. The COgnitive behavioural therapy versus standardised medical care for adults with Dissociative non-Epileptic Seizures (CODES) trial is an evaluation of a specifically tailored psychological intervention with the aims of reducing seizure frequency and severity and improving psychological well-being in adults with DS. The aim of this paper is to report in detail the quantitative and economic analysis plan for the CODES trial, as agreed by the trial steering committee.Methods: The CODES trial is a multicentre, pragmatic, parallel group, randomised controlled trial performed to evaluate the clinical effectiveness and cost-effectiveness of 13 sessions of cognitive behavioural therapy (CBT) plus standardised medical care (SMC) compared with SMC alone for adult outpatients with DS.Discussion: The objectives and design of the trial are summarised, and the aims and procedures of the planned analyses are illustrated. The proposed analysis plan addresses statistical considerations such as maintaining blinding, monitoring adherence with the protocol, describing aspects of treatment and dealing with missing data. The formal analysis approach for the primary and secondary outcomes is described, as are the descriptive statistics that will be reported. This paper provides transparency to the planned inferential analyses for the CODES trial prior to the extraction of outcome data. It also provides an update to the previously published trial protocol and guidance to those conducting similar trials.Trial Registration: ISRCTN registry ISRCTN05681227 (registered on 5 March 2014); ClinicalTrials.gov NCT02325544 (registered on 15 December 2014). [ABSTRACT FROM AUTHOR]

Loss or reduction of awareness is common in neuropsychiatric disorders and culturally influenced dissociative phenomena but the underlying brain mechanisms are poorly understood. fMRI was combined with suggestions for automatic writing in 18 healthy highly hypnotically suggestible individuals in a within-subjects design to determine whether clinical alterations in awareness of thought and movement can be experimentally modelled and studied independently of illness. Subjective ratings of control, ownership, and awareness of thought and movement, and fMRI data were collected following suggestions for thought insertion and alien control of writing movement, with and without loss of awareness. Subjective ratings confirmed that suggestions were effective. At the neural level, our main findings indicated that loss of awareness for both thought and movement during automatic writing was associated with reduced activation in a predominantly left-sided posterior cortical network including BA 7 (superior parietal lobule and precuneus), and posterior cingulate cortex, involved in self-related processing and awareness of the body in space. Reduced activity in posterior parietal cortices may underlie specific clinical and cultural alterations in awareness of thought and movement. Clinically, these findings may assist development of imaging assessments for loss of awareness of psychological origin, and interventions such as neurofeedback. [ABSTRACT FROM AUTHOR]

Background: Seizures are common in dogs and can be caused by non-epileptic conditions or epilepsy. The clinical course of newly diagnosed epilepsy is sparsely documented. The objective of this study was to prospectively investigate causes for seizures (epileptic and non-epileptic) in a cohort of dogs with new-onset untreated seizures, and for those dogs with newly diagnosed epilepsy to investigate epilepsy type, seizure type and the course of disease over time, including the risk of seizure recurrence. Untreated client-owned dogs experiencing new-onset seizures were prospectively enrolled in a longitudinal observational study including clinical investigations and long-term monitoring at the Copenhagen University Hospital for Companion Animals. A baseline clinical assessment was followed by investigator/owner contact every eight weeks from inclusion to death or end of study. Inclusion of dogs was conducted from November 2010 to September 2012, and the study terminated in June 2014. Results: One hundred and six dogs were included in the study. Seventy-nine dogs (74.5%) were diagnosed with epilepsy: 61 dogs (77.2%) with idiopathic epilepsy, 13 dogs (16.5%) with structural epilepsy and five dogs (6.3%) with suspected structural epilepsy. A non-epileptic cause for seizures was identified in 13 dogs and suspected in 10 dogs. Four dogs in which no cause for seizures was identified experienced only one seizure during the study. In dogs with idiopathic epilepsy 60% had their second epileptic seizure within three months of seizure onset. Twenty-six dogs with idiopathic epilepsy (43%) completed the study without receiving antiepileptic treatment. The natural course of idiopathic epilepsy (uninfluenced by drugs) was illustrated by highly individual and fluctuating seizure patterns, including long periods of remission. Cluster seizures motivated early treatment. In a few dogs with a high seizure frequency owners declined treatment against the investigators advice. Conclusions: Epilepsy is the most likely diagnosis in dogs presenting with new-onset seizures. The course of idiopathic epilepsy is highly individual and might not necessarily require long-term treatment. This must be considered when advising owners about what to expect with regard to treatment and prognosis. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this meta-analysis is to evaluate and synthesize the available evidence from the previous 20 years regarding the utility of psychological interventions in the management of psychogenic non-epileptic seizures (PNES).Method: Studies were retrieved from MEDLINE via OvidSP and PsychINFO. Selection criteria included controlled and before-after non-controlled studies including case series, using seizure frequency as an outcome measurement. Studies were required to assess one or more types of psychological intervention for the treatment of PNES in adults. Data from 13 eligible studies was pooled to examine the effectiveness of psychological interventions in treating PNES on two primary outcomes: seizure reduction of 50% or more and seizure freedom. A meta-analysis was conducted with data extracted from 228 participants with PNES.Results: Interventions reviewed in the analysis included CBT, psychodynamic therapy, paradoxical intention therapy, mindfulness and psychoeducation and eclectic interventions. Meta-analysis synthesized data from 13 studies with a total of 228 participants with PNES, of varied gender and age. Results showed 47% of people with PNES are seizure free upon completion of a psychological intervention. Additional meta-analysis synthesized data from 10 studies with a total of 137 participants with PNES. This analysis found 82% of people with PNES who complete psychological treatment experience a reduction in seizures of at least 50%.Conclusion: The studies identified for this analysis were diverse in nature and quality. The findings highlight the potential for psychological interventions as a favorable alternative to the current lack of treatment options offered to people with PNES. [ABSTRACT FROM AUTHOR]

Children and adolescents with conversion disorders and their families are challenging to understand and challenging to treat. This study examined whether self-report instruments are a useful adjunct to family and individual assessment. A total of 57 children and adolescents diagnosed with conversion disorders and 57 sex- aged-matched controls, along with their parents, completed the Strength and Difficulties Questionnaire, Child Behaviour Checklist, Depression Anxiety and Stress Scales, Somatic and Psychological Health Report ( SPHERE), Brief Risk-Resilience Index for Screening, and the NEO-Five-Factor Inventory. The conversion disorder and control groups were compared on each questionnaire, and classified participants as 'cases' or not according to established clinical thresholds for each questionnaire. A discriminant analysis was used to examine which components of the SDQ, CBCL, DASS, SPHERE, BRISC, and NEO- FFI emerged as most useful in identifying the clinical characteristics of children with conversion disorders. The role of attachment strategy with regards to the utility of self-report measures was also examined. The SPHERE was the only self-report that our patient cohort were able to utilise to communicate their somatic and emotional discomfort and distress. Our results suggest that children and adolescents presenting with functional somatic symptoms represent a distinctive clinical population for which the 'psychological' focus of most currently available questionnaires is not useful for identifying the presence of somatic illness or of comorbid anxiety and depression, and that these measures - with the exception of the SPHERE - are not a useful adjunct to a family-based assessment. Therapeutic conversations that utilise language that asks about the state of the body - the body's response to stress, illness, pain, and injury - facilitate engagement and serve as the cornerstone of treatment. [ABSTRACT FROM AUTHOR]

One important, but underreported, phenomena in Tourette Syndrome (TS) is the occurrence of ‘tic attacks’. These episodes have been described at conferences as sudden bouts of tics and/or functional tic-like movements, lasting from 15 minutes to several hours. They have also been described by patients in on-line TS communities. To date, there are no reports of tic attacks in the literature. The aim of this article is to stimulate discussion and inform clinical practices by describing the clinical presentation of 12 children (mean age 11 years 3 months; sd=2 years 4 months) with TS and tic attacks, with a detailed case report for one case (JT, 13 years). These children commonly present acutely to casualty departments and undergo unnecessary medical investigations. Interestingly, all children reported co-morbid anxiety, with worries about the tics themselves and an increased internal focus of attention on tics once the attacks had started. In keeping with other children, JT reported a strong internal focus of attention, with a relationship between physiological sensations/tic urges, worries about having tic attacks and behavioural responses (e.g. body scanning, situational avoidance, other responses). In our experience the attacks reduce with psychological therapy, for example, JT attended 13 sessions of therapy that included metacognitive and attention training techniques, as well as cognitive behavioural strategies. Following treatment an improvement was seen across a range of measures assessing tics, mood, anxiety and quality of life. Thus, psychological techniques used to treat anxiety disorders are effective at supporting a reduction in tic attacks through modifying attention, worry processes and negative beliefs. It is hypothesised that an attentional style of threat monitoring, difficulties tolerating internal sensory urges, cognitive misattributions and maladaptive coping strategies contribute to the onset and maintenance of tic attacks. These cases provide support for the view that tic attacks are triggered and maintained by psychological factors, thereby challenging the view that tic attacks merely reflect extended bouts of tics. As such, we propose that the movements seen in tic attacks may resemble a combination of tics and functional neurological movements, with tic attacks reflecting episodes of panic and anxiety for individuals with TS.

Aim To explore psychic and psychological characteristics of patientssuffering from non- epileptic seizures and compare them with the patients suffering from epilepsy. Methods Using medical documentation 40 patients with non epileptic seizures were compared with 40 randomly selected epilepsy patients according to psychiatric and psychological report, and using psychotropic medications. Results Both psychiatric and psychological reports have shown that pathologic changes were more frequently found within the epilepsy group (n = 20 and n=7, respectively) than in non-epileptic fits group (n= 18 and n=4, respectively). Six patients had neurotic disorders within the epilepsy group, versus 3 within the non-epileptic fits group. Conversion disorders were more frequently foundwithin the non-epileptic group (n=6) as compared to epilepsy group (n=2). Disorders due to acute reaction to stress occurred in six patients in the non-epileptic fits group versus three patients in theepilepsy group. Cognitive disorders were found more frequently within the epilepsy group (n=6) as compared to the non-epilepticfits group (n=1). Vulnerable character, adolescence crisis, deficitof social abilities and indifference were more frequently foundwithin the non-epileptic fits group (n=3) in comparison with theepilepsy group (n=1). Conclusion Psychiatric and psychological reports are most important elements in the diagnostic of psychogenic non-epilepticseizures.

We present the case of a 10-year-old boy, Evan, where a knock to the head activated memories of past bullying, causing intense distress, activation of the body’s stress-regulation systems and recurrent hospital presentations with hyperventilation-induced non-epileptic seizures. We describe the initial assessment session that enabled Evan and his family to understand the context for Evan’s non-epileptic seizures, to engage with the therapeutic team and to collaborate in the implementation of a mind–body multimodal family-based intervention. Once the physical symptoms had been addressed therapeutically, we explored possible dangers within the family and school systems and we worked with Evan and his family to increase his ability to access comfort and protection from his parents. Our short hospital intervention highlighted the importance of ongoing therapeutic work with Evan and the family and laid the foundation stones for the next part of the family’s therapeutic journey. [ABSTRACT FROM AUTHOR]