**Psychogenic Non-Epileptic Seizures in a Surgical Epilepsy Unit: Experience and a Comprehensive Review**

Lorena Vega-Zelaya, Marta Alvarez, Elena Ezquiaga, Jaime Nogeiras, María Toledo, Rafael G. Sola and Jesús Pastor

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/57439

#### **1. Introduction**

[75] Non-epileptic seizures: patients' understanding and reaction to the diagnosis and im‐ pact on outcome. Carton S, Thompson PJ, Duncan JS Seizure. 2003;12(5):287.

[76] Early outcomes and predictors in 260 patients with psychogenic nonepileptic attacks. McKenzie P, Oto M, Russell A, Pelosi A, Duncan R Neurology. 2010;74(1):64.

[77] Psychiatric and neurologic predictors of psychogenic pseudoseizure outcome. Kan‐ ner AM, Parra J, Frey M, Stebbins G, Pierre-Louis S, Iriarte J Neurology. 1999;53(5):

933.

192 Epilepsy Topics

Psychogenic non-epileptic seizures (PNES) are paroxysmal involuntary changes in behaviour, sensation, motor activity, cognitive processing or autonomic function that resemble epileptic seizures (ES). However, they have no electrophysiological correlate but instead possess a psychological origin [1, 2].

Historically known as hysteria seizures by Hippocrates and Aristotle, the French neurologist Jean-Martin Charcot recognised hysteria as a neurologically diagnosable condition. Many years after this recognition, Sigmund Freud reclassified hysteria as a psychiatric disorder.

Previously, PNES has been given various names, such as pseudoseizures, non-epileptic spells or psychogenic seizures. In general, this terminology involving the prefix 'pseudo-' has become out-dated as it implies that the seizures are not real and may suggest 'malingering'.

PNES have been commonly classified as dissociative or conversion disorders. However, PNES have also been considered to be very similar to other functional somatic symptoms and syndromes [3]. In the current and recently published DSM-V, PNES are classified as a "func‐ tional neurological symptom disorder". It appears that PNES are not a single entity and that a variety of clinical manifestations can occur. Furthermore, comorbid psychiatric disorders are common; thus, it is not surprising that a PNES diagnosis is difficult to achieve. PNES exist at the interface of neurology and psychiatry and as discussed below, constitute an important challenge in the practice of both medical specialties, because of their inherent diagnostic and therapeutic difficulties.

© 2014 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Misdiagnosis leads to iatrogenic effects of antiepileptic medication and aggressive or invasive procedures, such as intubations during emergency department visits [4]. After initial symptom onset, the average time to a formal PNES diagnosis is 7 to 9 years [2, 4, 5].

between July 2001 and July 2013. All patients underwent prolonged video-electroencephalog‐ raphy (vEEG) monitoring as part of the evaluation for surgical treatment [22, 23]. The evalu‐ ation also included psychiatric, psychological and clinical evaluations, scalp EEG, 1.5T magnetic resonance imaging (MRI) and interictal single photon emission-computed tomog‐ raphy (SPECT) with 99mTc-HmPAO. vEEG monitoring was conducted using 19 collodion-fixed scalp electrodes, according to the international 10-20 system. During vEEG recordings, antiepileptic drugs were progressively removed from the second to the fourth day of record‐ ings at a rate of approximately one-third of the dose per day. The digital EEGs (NeuroWorks, XLTEK®, Oakville, Canada) were sampled at 512 Hz and filtered at 0.5-70 Hz with a notch filter of 50 Hz. Accessory electrodes were used to monitor electromyography (EMG) at

Psychogenic Non-Epileptic Seizures in a Surgical Epilepsy Unit: Experience and a Comprehensive Review

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195

The following criteria were used to diagnose PNES: (1) at least one single typical clinical event captured on vEEG, (2) the EEG recording did not detect any concomitant ictal activity or postictal slowing, and (3) no evidence of any alternative neurological diagnosis (e.g., move‐ ment disorders) [3]. An epilepsy diagnosis was assigned according to the International League Against Epilepsy (ILAE) classification system [24]. The provocative protocol technique with placebo was utilised in cases where discordance was observed between the clinical and

We used induction techniques to support the diagnosis of PNES when considered useful [25]. The systematic steps in the provocative induction technique with placebo utilised in our

All patients received verbal information and signed an inform consent document stating the need for a test with a drug that could induce their seizures. The informed consent was accepted

The following cardiorespiratory parameters were monitored: EKG, respiratory rate, capillary

Two millilitres of a saline solution were intravenously injected. When a typical seizure

Diagnoses were determined according to the DSM-IV-TR criteria (Diagnostic and Statistical

All patients were evaluated with a non-structured clinical assessment interview according to

Bioelectrical brain function and behaviour was simultaneously monitored by vEEG.

appeared, a second 2-ml bolus of saline was administered to terminate the event.

Manual of Mental Disorders, fourth edition, text revision, Axis I Disorders).

the Protocol of Psychiatric Assessment for our Epilepsy Surgery Unit (Table 1).

different muscles in combination with an electrocardiogram (EKG).

Two neurophysiologists were present and monitored the entire study.

electrical findings.

**2.2. Induction techniques**

epilepsy unit were [26]:

Psychiatric assessment

by the Hospital's ethical committee.

saturation oxygen (SaO2) and blood pressure.

Video-electroencephalography (vEEG) monitoring is an indispensable tool for diagnosing PNES because it allows the simultaneous analysis of both clinical and ictal EEG findings. In some cases, provocative techniques aid in diagnosing PNES, and these are performed only when necessary and in approximately 30-50% of patients diagnosed with PNES [6]. These techniques are very useful in detecting the presence of suggestibility, which strongly supports a psychogenic mechanism.

Approximately 25-30% of epilepsy patients referred to tertiary epilepsy centres or specialised hospitals have PNES [7]. The incidence of PNES is approximately 4% of the total epilepsy incidence [8], and in fact, most patients misdiagnosed with epilepsy at epilepsy centres have PNES [9]. These patients are heavy users of emergency and nonemergency health care [10], and approximately three fourths receive inappropriate AED treatment before their diagnosis [11], which can produce adverse side effects, high costs to health care facilities, high medical utilisation rates and high personal and societal costs.

At present, PNES are considered symptoms of an underlying psychological or psychiatric disorder and are associated with impaired social function [12] and high disability [13, 14] that affect patient quality of life [15, 16]. Disability and quality of life may even be poorer than in epilepsy patients [12, 14, 17]. Additionally, PNES patients have been reported to be twice as likely to be unemployed as patients with epilepsy [12].

PNES seem to occur more frequently in women [18] but also may be more difficult to recognise in men [19]. Gender differences in clinical presentation have been reported, and males have shown higher seizure frequencies, more antiepileptic drug use, and a longer interval before PNES diagnosis [12]. Most patients experienced PNES onset at a young age, and approximately 10% of patients experienced PNES onset after the age of 60 [20].

Furthermore, patients from lower sociocultural classes are more likely to experience PNES [4]. A small number of clinical studies have observed differences in the cognitive profiles of patients with PNES versus patients with epilepsy [21].

A PNES diagnosis is a very common and important diagnosis in epilepsy units and is described as a common condition associated with epilepsy (PNES+ E). In this study, we attempted to depict and describe the characteristics of PNES patients and the difficulty of diagnosis in a national referral centre for epilepsy surgery. In light of the current literature, the physiopa‐ thological hypothesis, treatment and prognosis should be revised.

#### **2. Methods**

#### **2.1. Patients**

We retrospectively reviewed all patients with an intractable epilepsy diagnosis admitted to the National Referral Centre for Epilepsy Surgery at the Hospital Universitario de la Princesa between July 2001 and July 2013. All patients underwent prolonged video-electroencephalog‐ raphy (vEEG) monitoring as part of the evaluation for surgical treatment [22, 23]. The evalu‐ ation also included psychiatric, psychological and clinical evaluations, scalp EEG, 1.5T magnetic resonance imaging (MRI) and interictal single photon emission-computed tomog‐ raphy (SPECT) with 99mTc-HmPAO. vEEG monitoring was conducted using 19 collodion-fixed scalp electrodes, according to the international 10-20 system. During vEEG recordings, antiepileptic drugs were progressively removed from the second to the fourth day of record‐ ings at a rate of approximately one-third of the dose per day. The digital EEGs (NeuroWorks, XLTEK®, Oakville, Canada) were sampled at 512 Hz and filtered at 0.5-70 Hz with a notch filter of 50 Hz. Accessory electrodes were used to monitor electromyography (EMG) at different muscles in combination with an electrocardiogram (EKG).

The following criteria were used to diagnose PNES: (1) at least one single typical clinical event captured on vEEG, (2) the EEG recording did not detect any concomitant ictal activity or postictal slowing, and (3) no evidence of any alternative neurological diagnosis (e.g., move‐ ment disorders) [3]. An epilepsy diagnosis was assigned according to the International League Against Epilepsy (ILAE) classification system [24]. The provocative protocol technique with placebo was utilised in cases where discordance was observed between the clinical and electrical findings.

#### **2.2. Induction techniques**

Misdiagnosis leads to iatrogenic effects of antiepileptic medication and aggressive or invasive procedures, such as intubations during emergency department visits [4]. After initial symptom

Video-electroencephalography (vEEG) monitoring is an indispensable tool for diagnosing PNES because it allows the simultaneous analysis of both clinical and ictal EEG findings. In some cases, provocative techniques aid in diagnosing PNES, and these are performed only when necessary and in approximately 30-50% of patients diagnosed with PNES [6]. These techniques are very useful in detecting the presence of suggestibility, which strongly supports

Approximately 25-30% of epilepsy patients referred to tertiary epilepsy centres or specialised hospitals have PNES [7]. The incidence of PNES is approximately 4% of the total epilepsy incidence [8], and in fact, most patients misdiagnosed with epilepsy at epilepsy centres have PNES [9]. These patients are heavy users of emergency and nonemergency health care [10], and approximately three fourths receive inappropriate AED treatment before their diagnosis [11], which can produce adverse side effects, high costs to health care facilities, high medical

At present, PNES are considered symptoms of an underlying psychological or psychiatric disorder and are associated with impaired social function [12] and high disability [13, 14] that affect patient quality of life [15, 16]. Disability and quality of life may even be poorer than in epilepsy patients [12, 14, 17]. Additionally, PNES patients have been reported to be twice as

PNES seem to occur more frequently in women [18] but also may be more difficult to recognise in men [19]. Gender differences in clinical presentation have been reported, and males have shown higher seizure frequencies, more antiepileptic drug use, and a longer interval before PNES diagnosis [12]. Most patients experienced PNES onset at a young age, and approximately

Furthermore, patients from lower sociocultural classes are more likely to experience PNES [4]. A small number of clinical studies have observed differences in the cognitive profiles of

A PNES diagnosis is a very common and important diagnosis in epilepsy units and is described as a common condition associated with epilepsy (PNES+ E). In this study, we attempted to depict and describe the characteristics of PNES patients and the difficulty of diagnosis in a national referral centre for epilepsy surgery. In light of the current literature, the physiopa‐

We retrospectively reviewed all patients with an intractable epilepsy diagnosis admitted to the National Referral Centre for Epilepsy Surgery at the Hospital Universitario de la Princesa

onset, the average time to a formal PNES diagnosis is 7 to 9 years [2, 4, 5].

a psychogenic mechanism.

194 Epilepsy Topics

**2. Methods**

**2.1. Patients**

utilisation rates and high personal and societal costs.

likely to be unemployed as patients with epilepsy [12].

patients with PNES versus patients with epilepsy [21].

10% of patients experienced PNES onset after the age of 60 [20].

thological hypothesis, treatment and prognosis should be revised.

We used induction techniques to support the diagnosis of PNES when considered useful [25]. The systematic steps in the provocative induction technique with placebo utilised in our epilepsy unit were [26]:

All patients received verbal information and signed an inform consent document stating the need for a test with a drug that could induce their seizures. The informed consent was accepted by the Hospital's ethical committee.

Two neurophysiologists were present and monitored the entire study.

Bioelectrical brain function and behaviour was simultaneously monitored by vEEG.

The following cardiorespiratory parameters were monitored: EKG, respiratory rate, capillary saturation oxygen (SaO2) and blood pressure.

Two millilitres of a saline solution were intravenously injected. When a typical seizure appeared, a second 2-ml bolus of saline was administered to terminate the event.

#### Psychiatric assessment

Diagnoses were determined according to the DSM-IV-TR criteria (Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision, Axis I Disorders).

All patients were evaluated with a non-structured clinical assessment interview according to the Protocol of Psychiatric Assessment for our Epilepsy Surgery Unit (Table 1).

The psychiatric assessment of all patients included the following:

Mental health exploration to identify current psychiatric disorders.

History of psychiatric disorders.

Personality traits.

History of drug abuse and previous and current psychopharmacologic treatments, including benzodiazepines, antidepressants and antipsychotic drugs.

*<sup>c</sup>*( *<sup>f</sup>* )= <sup>1</sup> *<sup>p</sup>* ∑ *i*=1 *p*

Statistical comparisons between each channel before and during seizures were performed.

Psychogenic Non-Epileptic Seizures in a Surgical Epilepsy Unit: Experience and a Comprehensive Review

A total of 630 patients were included in this study. We classified the patients into 4 diagnostic

**•** Epilepsy: clinical and bioelectrical evidence of epileptic seizures were confirmed. We did not distinguish between partial and generalised epilepsy because that classification was

**•** No evidence of seizures: in these cases, the data suggested epilepsy (abnormal epileptiform activity in the vEEG), but no seizures occurred after a sufficient period of time without

**•** No evidence of epilepsy: no epileptiform activity or any clinical event was observed during

**•** PNES: at least one typical clinical event was captured on vEEG but without concomitant

We analysed the clinical features of PNES and epilepsy patients. The mean age of the PNES patients was 33,9 ± 1,7 years old, and the mean age of epileptic patients was 34,3 ± 0,5 years old (p < 0,05, Student's t test). The average age of seizure onset was 15,6 ± 2,0 years old for

PNES patients and 11,9 ± 0,4 years old for epilepsy patients (n.s., Student's t test).

The mean seizure frequency for epileptic and PNES patients is shown in Figure 1.

**n %**

Where *p* is the number of electrodes that were computed.

groups according to the following criteria (Table 2) [26]:

vEEG recordings that supported a PNES or epilepsy diagnosis.

epileptiform bioelectric characteristics or other justifiable organic causes.

Epilepsy 554 87,9 No evidence of seizures 23 3,7 No evidence of epilepsy 23 3,7 PNES 30 4,7

**3. Results**

**3.1. Patient classifications**

outside the scope of this work.

**Table 2.** Diagnostic classifications of patients.

medication (usually more than 2 weeks).

*Ci* (2)

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197

Previous abuse or childhood trauma.

A neuropsychological assessment including IQ, verbal and manipulative IQ, total, verbal and visual memory and executive function tests.

**Table 1.** Patient psychiatric assessment

#### **2.3. Statistical analysis**

Statistical comparisons between groups were performed using Student's t-test (two groups) or analysis of variance (more than two groups) for parametric samples. For non-parametric samples, the Mann-Whitney test (two groups) and the Kruskal-Wallis test (more than two groups) were used. The sample fit to a Gaussian distribution was assessed by the chi-square or Kolmogorov-Smirnov tests.

The SigmaStat 3.5 software (SigmaStat, Point Richmond, CA, USA) was used for the statistical analysis. The significance level was set at p < 0.05. The results are presented as the mean ± SEM, except where otherwise indicated.

For patients in whom differential diagnosis was especially difficult, a numerical analysis of EEG recordings was performed to differentiate between epilepsy and PNES by developing a custom program with Matlab R2008 software (MathWorks, Natic, USA).

Recordings of bioelectrical activity occurring prior to the seizure and during the epileptic event were exported as ASCII files for analysis. For every channel, a Butterworth digital filter from 0,5 to 70 Hz (notch filter, 48-52 Hz) was applied. Artefact free periods of 5 to 10 s were divided in *N* non-overlapping windows of 1024 points each, and no software was used to remove electrooculogram signals. We calculated the fast Fourier transform (FFT) for every channel (*Xi* ; i=1, 2,...19). The power spectrum (*Si* ; i=1, 2,...19) was divided into the EEG frequency bands delta (0.5-4 Hz), theta (4-8 Hz), alpha (8-13 Hz) and beta (13-30 Hz), and the total area under the curve was computed. (*Si,k*; *i=1, 2,...19; k=1, 2,...N*). Cross-spectra between channels *i* and *j* (*Sij*) were also calculated for all channel pairs. Coherence [27] for the frequency, f, and for every channel pair, *i* and *j*, is defined according to the following expression:

$$\mathcal{C}(f) = \frac{|\{\mathbb{S}\_{\vec{\imath}}(f)\}\_{\mathsf{N}}|^2}{\{\mathbb{S}\_{\vec{\imath}}(f)\}\_{\mathsf{N}}\{\mathbb{S}\_{\vec{\imath}}(f)\}\_{\mathsf{N}}} \tag{1}$$

Local coherence (*c*) was obtained from neighbouring channels according to the following expression [28]:

Psychogenic Non-Epileptic Seizures in a Surgical Epilepsy Unit: Experience and a Comprehensive Review http://dx.doi.org/10.5772/57439 197

$$\mathcal{L}\{f\} = \frac{1}{p} \sum\_{i=1}^{p} \mathbf{C}\_i \tag{2}$$

Where *p* is the number of electrodes that were computed.

Statistical comparisons between each channel before and during seizures were performed.

#### **3. Results**

The psychiatric assessment of all patients included the following: Mental health exploration to identify current psychiatric disorders.

History of drug abuse and previous and current psychopharmacologic treatments, including benzodiazepines,

A neuropsychological assessment including IQ, verbal and manipulative IQ, total, verbal and visual memory and

Statistical comparisons between groups were performed using Student's t-test (two groups) or analysis of variance (more than two groups) for parametric samples. For non-parametric samples, the Mann-Whitney test (two groups) and the Kruskal-Wallis test (more than two groups) were used. The sample fit to a Gaussian distribution was assessed by the chi-square

The SigmaStat 3.5 software (SigmaStat, Point Richmond, CA, USA) was used for the statistical analysis. The significance level was set at p < 0.05. The results are presented as the mean ± SEM,

For patients in whom differential diagnosis was especially difficult, a numerical analysis of EEG recordings was performed to differentiate between epilepsy and PNES by developing a

Recordings of bioelectrical activity occurring prior to the seizure and during the epileptic event were exported as ASCII files for analysis. For every channel, a Butterworth digital filter from 0,5 to 70 Hz (notch filter, 48-52 Hz) was applied. Artefact free periods of 5 to 10 s were divided in *N* non-overlapping windows of 1024 points each, and no software was used to remove electrooculogram signals. We calculated the fast Fourier transform (FFT) for every channel

delta (0.5-4 Hz), theta (4-8 Hz), alpha (8-13 Hz) and beta (13-30 Hz), and the total area under the curve was computed. (*Si,k*; *i=1, 2,...19; k=1, 2,...N*). Cross-spectra between channels *i* and *j* (*Sij*) were also calculated for all channel pairs. Coherence [27] for the frequency, f, and for every

( *<sup>f</sup>* ) *<sup>N</sup>* <sup>|</sup><sup>2</sup>

Local coherence (*c*) was obtained from neighbouring channels according to the following

( *f* ) *<sup>N</sup>*

; i=1, 2,...19) was divided into the EEG frequency bands

(1)

custom program with Matlab R2008 software (MathWorks, Natic, USA).

channel pair, *i* and *j*, is defined according to the following expression:

*<sup>C</sup>*( *<sup>f</sup>* )= <sup>|</sup> *Sij*

*Sii* ( *f* ) *<sup>N</sup> S jj*

History of psychiatric disorders.

antidepressants and antipsychotic drugs. Previous abuse or childhood trauma.

**Table 1.** Patient psychiatric assessment

or Kolmogorov-Smirnov tests.

except where otherwise indicated.

; i=1, 2,...19). The power spectrum (*Si*

Personality traits.

196 Epilepsy Topics

executive function tests.

**2.3. Statistical analysis**

(*Xi*

expression [28]:

#### **3.1. Patient classifications**

A total of 630 patients were included in this study. We classified the patients into 4 diagnostic groups according to the following criteria (Table 2) [26]:



**Table 2.** Diagnostic classifications of patients.

We analysed the clinical features of PNES and epilepsy patients. The mean age of the PNES patients was 33,9 ± 1,7 years old, and the mean age of epileptic patients was 34,3 ± 0,5 years old (p < 0,05, Student's t test). The average age of seizure onset was 15,6 ± 2,0 years old for PNES patients and 11,9 ± 0,4 years old for epilepsy patients (n.s., Student's t test).

The mean seizure frequency for epileptic and PNES patients is shown in Figure 1.

Percentage (%)

**Patient Number**

**Age (years)** **Age of Onset (years)**

7 47 9 Bi-T

<sup>13</sup> <sup>32</sup> <sup>3</sup> Irregular

16 35 30 L-T

17 49 35 R-MT

19 37 14 Bi-FT

<sup>24</sup> <sup>40</sup> <sup>23</sup> Irregular

**Table 3.** Characteristics of PNES patients.

matter.

perfusion

perfusion

<sup>30</sup> <sup>33</sup> <sup>20</sup> Bi-F R-F Hyper-intensities

**SPECT MRI vEEG Engel's**

Psychogenic Non-Epileptic Seizures in a Surgical Epilepsy Unit: Experience and a Comprehensive Review

Subcortical Hyperintensities

 37 8 L-T Normal GE \_ Yes/Yes No 19 16 Normal Normal \_ Yes/No DS 55 3 R-MT Normal Bi-T EA \_ Yes/Yes No 37 31 Normal Normal L-TLE II Anxiety 33 3 Bi-T Surgical changes Bi-T EA \_ Yes/Yes No

> R-F Encephalomalacia

14 49 26 R-MT R-MTS R-MTLE I Yes/Yes No 15 28 15 Normal Normal \_ DS

L-T anterior horn

R-T anterior horn increase

Bi-FP ischemic

 40 1 L-TM Normal G- EA \_ No 16 13 L-MT L-MTS \_ Yes/Yes No 33 14 R-MT Normal \_ No 41 27 L-FP Normal \_ No

> L Hippocampal dysplasia

> > WM

Bi, bilateral; DS, dissociative disorders; EA, epileptiform activity; F, frontal; FLE, frontal lobe epilepsy; FP, fronto-parietal; FT, fronto-temporal; GE, generalised epilepsy; L, left; MT, mesial temporal; MTLE, mesial temporal lobe epilepsy; MTS, mesial temporal sclerosis; PTSD, posttraumatic stress disorder; R, right; T, temporal; TLE, temporal lobe epilepsy; WM, white

 32 8 L-FT R-MTS L-FLE I Depression 38 29 R-MT Normal L-MTLE \_ No 35 2 L-MT L-MTS L-MTLE I Anxiety 48 23 R-MT Normal L-MTLE I Anxiety 27 1 R-MT R-MTS R-MTLE \_ No

18 41 28 L-T L-MTS L-T EA \_ Depression

**scale**

R-T AE \_ No

R-FLE Yes/Yes No

R-T EA \_ Depression

L-T EA \_ Anxiety

L-MTLE \_ Depression

increase \_ No

alterations \_ No

**Placebo/ Response**

http://dx.doi.org/10.5772/57439

**Psychiatric Disorder(s)** 199

**Figure 1.** Mean seizure frequency for PNES (filled bars) and epileptic patients (empty bars).

Females represented a greater percentage of PNES patients (20/30). In addition, 70% of PNES patients presented with comorbid epilepsy (PNES+E, 12/21) or epileptiform activity (PNES +EA, 9/21), which were verified by EEG recordings (Table 3). Nine of the 30 patients were diagnosed with PNES alone.


Psychogenic Non-Epileptic Seizures in a Surgical Epilepsy Unit: Experience and a Comprehensive Review http://dx.doi.org/10.5772/57439 199


**Table 3.** Characteristics of PNES patients.

Frequency

Females represented a greater percentage of PNES patients (20/30). In addition, 70% of PNES patients presented with comorbid epilepsy (PNES+E, 12/21) or epileptiform activity (PNES +EA, 9/21), which were verified by EEG recordings (Table 3). Nine of the 30 patients were

**SPECT MRI vEEG Engel's**

1 18 18 Normal Normal \_ PTSD 2 31 7 Normal Normal \_ DS 3 30 2 Bi-T Tuberose Sclerosis L-T AE \_ Yes/Yes DS

5 19 1 Bi-T Bi-TMS L-T AE \_ Yes/No No

is

**scale**

cavernomas L-TLME \_ Dysthymia

Petit mal

**Placebo/ Response**

Epilepsy \_ Anxiety

**Psychiatric Disorder(s)**

**Figure 1.** Mean seizure frequency for PNES (filled bars) and epileptic patients (empty bars).

Daily Weekly Monthly

PNES Epilepsy

Percentage (%)

**Patient Number** 0

diagnosed with PNES alone.

**Age of Onset (years)**

4 29 Bi-T Normal

<sup>6</sup> <sup>19</sup> <sup>16</sup> Bi-T Multiple

**Age (years)**

10

20

30

40

50

198 Epilepsy Topics

Bi, bilateral; DS, dissociative disorders; EA, epileptiform activity; F, frontal; FLE, frontal lobe epilepsy; FP, fronto-parietal; FT, fronto-temporal; GE, generalised epilepsy; L, left; MT, mesial temporal; MTLE, mesial temporal lobe epilepsy; MTS, mesial temporal sclerosis; PTSD, posttraumatic stress disorder; R, right; T, temporal; TLE, temporal lobe epilepsy; WM, white matter.

The semiology of PNES was highly stereotyped in each patient and mainly consisted of *convulsive* components or bizarre bilateral motor manifestations involving the upper or lower limbs. Other manifestations lacked motor events but involved sensory feelings or unrespon‐ siveness, although these stereotypies were less frequent.

Importantly, in the PNES+E group, structural abnormalities were evident in 11/12 neuroimag‐ ing studies. We also found that in patients diagnosed as PNES+EA, structural abnormalities associated with temporal lobe epilepsy were observed in 9 patients. Moreover, 3 patients presented with mesial temporal sclerosis in MRI studies.

When we assessed the PNES group with the same tests, we found that there were cerebral perfusion abnormalities on SPECT in 6/9 patients and that in 3/9 patients, MRI showed lesions sometimes associated with temporal lobe epilepsy (TLE).

In PNES+E patients, there were 8 cases of temporal lobe epilepsy, 2 cases of frontal lobe epilepsy, and 2 cases of generalised epilepsy. Also in this group, the following surgical interventions were utilised: temporal lobectomy (4 patients), and frontal lobectomy (1 patient) with an Engel's scale outcome of I in 4 and II in 1.

#### **3.2. Provocative techniques**

A provocative placebo technique was used to confirm a PNES diagnosis in 9 patients with an inconclusive diagnosis from vEEG monitoring. In 7 patients, the provocative test was positive for PNES, and in those cases, the patients experienced similar episodes to the previously recorded spontaneous episodes. However, a variable delay (of less than a minute) between saline administration and symptom onset was observed. The recorded bioelectric activity during the induced, as well as during spontaneous episodes, was completely normal, with visible muscle and movement artefacts. After a varying 30- to 60-second period after the episode started, we administered a second dose of saline after warning the patient that this drug would abort the crisis, which indeed occurred with a latency between 15 and 45 s. One example of this technique is shown in Figure 2.

episode and experienced no residual amnesia. The interictal EEG showed intense and very frequent irritative activity with a burst of epileptiform discharge in the left frontal area and a

**Figure 2.** A typical recording during the provocative induction test. The image corresponds to 25 s after a 2-ml saline injection. The patient (inset) experienced myoclonus of all four limbs. Two neurophysiologist (LV-Z and JP) were moni‐ toring the patient's response. The EEG recording showed no pathological activity, except for movement artefacts.

Psychogenic Non-Epileptic Seizures in a Surgical Epilepsy Unit: Experience and a Comprehensive Review

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201

True seizures were recorded during the spike-wave discharges, which were accompanied by an altered state of consciousness, mild to severe difficulty to speak and a clear delay in response

During the episodes, no clear evidence of any ictal pattern emerged. We conducted an induction test that proved positive, reproducing the previously described patient episodes

In addition to this type of seizure (of which the patient did not complain), the patient com‐ plained of severe and multi-day seizures of language emission and difficulties in understand‐ ing. The brain activity recorded during these episodes did not show a clear ictal pattern. Nevertheless, the recorded bioelectrical activity needed to be classified as a seizure or another disorder. To assess these recordings, we analysed the band coherence [*C(f)*] using to equation 1 and compared the basal and ictal activity using the *c(f)* equation. We hypothesised that a true seizure most likely increases the local coherence for any scallop region (Figure 5). However, as shown in Figure 5, the local coherence was not significantly modified from basal activity

generalised spike-wave complex (Figure 3).

during any of the recorded paroxysmal episodes.

to different orders (Figure 4).

(Figure 4).

Provocative induction was positive for PNES in 7 patients. However in the other two patients we did not obtain any response.

#### **3.3. Diagnostic challenges**

Prolonged vEEG monitoring provides a definitive PNES diagnosis in nearly all cases. How‐ ever, in some situations, a definitive PNES or epilepsy diagnosis can be difficult to obtain. Here, we describe a case in which the semiology and vEEG did not confirm that the episode was psychogenic in origin. Quantitative EEG (qEEG) had been used to assess the patient by both spectral and coherence methods while recording EEGs during basal conditions and episodes.

This patient, a 29 year old female, experienced seizure onset at 9 years old. The clinical symptomatology was described as an inability to emit and understand language, with feelings of sadness and fear. Moreover, the patient reported remaining conscious during the entire

The semiology of PNES was highly stereotyped in each patient and mainly consisted of *convulsive* components or bizarre bilateral motor manifestations involving the upper or lower limbs. Other manifestations lacked motor events but involved sensory feelings or unrespon‐

Importantly, in the PNES+E group, structural abnormalities were evident in 11/12 neuroimag‐ ing studies. We also found that in patients diagnosed as PNES+EA, structural abnormalities associated with temporal lobe epilepsy were observed in 9 patients. Moreover, 3 patients

When we assessed the PNES group with the same tests, we found that there were cerebral perfusion abnormalities on SPECT in 6/9 patients and that in 3/9 patients, MRI showed lesions

In PNES+E patients, there were 8 cases of temporal lobe epilepsy, 2 cases of frontal lobe epilepsy, and 2 cases of generalised epilepsy. Also in this group, the following surgical interventions were utilised: temporal lobectomy (4 patients), and frontal lobectomy (1 patient)

A provocative placebo technique was used to confirm a PNES diagnosis in 9 patients with an inconclusive diagnosis from vEEG monitoring. In 7 patients, the provocative test was positive for PNES, and in those cases, the patients experienced similar episodes to the previously recorded spontaneous episodes. However, a variable delay (of less than a minute) between saline administration and symptom onset was observed. The recorded bioelectric activity during the induced, as well as during spontaneous episodes, was completely normal, with visible muscle and movement artefacts. After a varying 30- to 60-second period after the episode started, we administered a second dose of saline after warning the patient that this drug would abort the crisis, which indeed occurred with a latency between 15 and 45 s. One

Provocative induction was positive for PNES in 7 patients. However in the other two patients

Prolonged vEEG monitoring provides a definitive PNES diagnosis in nearly all cases. How‐ ever, in some situations, a definitive PNES or epilepsy diagnosis can be difficult to obtain. Here, we describe a case in which the semiology and vEEG did not confirm that the episode was psychogenic in origin. Quantitative EEG (qEEG) had been used to assess the patient by both spectral and coherence methods while recording EEGs during basal conditions and

This patient, a 29 year old female, experienced seizure onset at 9 years old. The clinical symptomatology was described as an inability to emit and understand language, with feelings of sadness and fear. Moreover, the patient reported remaining conscious during the entire

siveness, although these stereotypies were less frequent.

presented with mesial temporal sclerosis in MRI studies.

sometimes associated with temporal lobe epilepsy (TLE).

with an Engel's scale outcome of I in 4 and II in 1.

example of this technique is shown in Figure 2.

we did not obtain any response.

**3.3. Diagnostic challenges**

episodes.

**3.2. Provocative techniques**

200 Epilepsy Topics

**Figure 2.** A typical recording during the provocative induction test. The image corresponds to 25 s after a 2-ml saline injection. The patient (inset) experienced myoclonus of all four limbs. Two neurophysiologist (LV-Z and JP) were moni‐ toring the patient's response. The EEG recording showed no pathological activity, except for movement artefacts.

episode and experienced no residual amnesia. The interictal EEG showed intense and very frequent irritative activity with a burst of epileptiform discharge in the left frontal area and a generalised spike-wave complex (Figure 3).

True seizures were recorded during the spike-wave discharges, which were accompanied by an altered state of consciousness, mild to severe difficulty to speak and a clear delay in response to different orders (Figure 4).

During the episodes, no clear evidence of any ictal pattern emerged. We conducted an induction test that proved positive, reproducing the previously described patient episodes (Figure 4).

In addition to this type of seizure (of which the patient did not complain), the patient com‐ plained of severe and multi-day seizures of language emission and difficulties in understand‐ ing. The brain activity recorded during these episodes did not show a clear ictal pattern. Nevertheless, the recorded bioelectrical activity needed to be classified as a seizure or another disorder. To assess these recordings, we analysed the band coherence [*C(f)*] using to equation 1 and compared the basal and ictal activity using the *c(f)* equation. We hypothesised that a true seizure most likely increases the local coherence for any scallop region (Figure 5). However, as shown in Figure 5, the local coherence was not significantly modified from basal activity during any of the recorded paroxysmal episodes.


 0.5 

Banda delta

Banda alfa

between basal (left) and *ictal* activity (right).

0

 0.5 

0

 0.5 

Banda theta

Banda beta

0

 0.5 

0

A B A B

Psychogenic Non-Epileptic Seizures in a Surgical Epilepsy Unit: Experience and a Comprehensive Review

**Figure 5.** Quantitative EEG recordings assess the presence of epilepsy. A) Recording during a *typical seizure*. The emp‐ ty arrow indicates when the patient pressed the patient-event button, which identifies the presence of a seizure. Dot‐ ted boxes indicate the basal (left) and *ictal* (right) periods selected for analysis. B) The EEG electrode schemes represent the 10-20 IS on the scalp. Local coherence was obtained using equation 2 for every electrode and every fre‐ quency band. Coherence is related to the diameter of each electrode, and no significant differences were observed

Furthermore, after placebo injection, an episode was recorded that was similar to the sponta‐

The rate of psychiatric comorbidities in PNES patients was 50%. Affective disorders were the most frequent psychiatric diagnosis (10/15), in particular, depression and anxiety disorders. Dissociative disorders were observed in 4 patients. Post-traumatic stress disorder was diagnosed in the remaining patient (Table 2). Interestingly, no differences were observed in

D T

neously recorded episode, and this reinforced a PNES diagnosis.

the psychiatric comorbidities between the PNES+ E and PNES patients.

**3.4. Psychiatric comorbidities and patient management**

(right).

Figure 6. Quantitative EEG recordings assess the presence of epilepsy. A) Recording during a *typical seizure*. The empty arrow indicates when the patient pressed the patient-event button, which identifies the presence of a seizure. Dotted boxes indicate the basal (left) and *ictal* (right) periods selected for analysis. B) The EEG electrode schemes represent the 10-20 IS on the scalp. Local coherence was obtained using equation 2 for every electrode and every frequency band. Coherence is related to the diameter of each electrode, and no significant differences were observed between basal (left) and *ictal* activity

 0.5 

Banda delta

Banda alfa

0

 0.5 

0

 0.5 

Banda theta

Banda beta

0

 0.5 

0

http://dx.doi.org/10.5772/57439

D T

Furthermore, after placebo injection, an episode was recorded that was similar to

the spontaneously recorded episode, and this reinforced a PNES diagnosis.

**Figure 3.** Wakeful interictal activity shows a burst of generalised spike-wave complexes.

consciousness. The patient was ordered to close her eyes (filled arrow), but the response was delayed by 6,4 s towards the end of the seizure. The HR (inset) increased from 72.8 ± 1.8 bpm before the burst to 83.7 ± 0.7 bpm during the episode (p < 0.05, ANOVA test by ranks) and returned to 78.8 ± 0.9 bpm after the episode (p < 0.05, ANOVA test). **Figure 4.** A burst of blunted spike-waves at 3 Hz shows a true alteration of consciousness. The patient was ordered to close her eyes (filled arrow), but the response was delayed by 6,4 s towards the end of the seizure. The HR (inset) in‐ creased from 72.8 ± 1.8 bpm before the burst to 83.7 ± 0.7 bpm during the episode (p < 0.05, ANOVA test by ranks) and returned to 78.8 ± 0.9 bpm after the episode (p < 0.05, ANOVA test).

complained of severe and multi-day seizures of language emission and difficulties in understanding. The brain activity recorded during these episodes did not show a clear ictal pattern. Nevertheless, the recorded bioelectrical activity needed to be classified as a seizure or another disorder. To assess these recordings, we analysed the band coherence [*C(f)*] using to equation 1 and compared the basal and ictal activity using the *c(f)* equation. We hypothesised that a true seizure most likely increases the local coherence for any scallop region (FIGURE 6). However, as shown in FIGURE 6, the local coherence was not significantly modified from basal activity during any of the recorded paroxysmal episodes.

Figure 4. A burst of blunted spike-waves at 3 Hz shows a true alteration of

In addition to this type of seizure (of which the patient did not complain), the patient

Figure 6. Quantitative EEG recordings assess the presence of epilepsy. A) Recording during a *typical seizure*. The empty arrow indicates when the patient pressed the patient-event button, which identifies the presence of a seizure. Dotted boxes indicate the basal (left) and *ictal* (right) periods selected for analysis. B) The EEG electrode schemes represent the 10-20 IS on the scalp. Local coherence was obtained using equation 2 for every electrode and every frequency band. Coherence is related to the diameter of each **Figure 5.** Quantitative EEG recordings assess the presence of epilepsy. A) Recording during a *typical seizure*. The emp‐ ty arrow indicates when the patient pressed the patient-event button, which identifies the presence of a seizure. Dot‐ ted boxes indicate the basal (left) and *ictal* (right) periods selected for analysis. B) The EEG electrode schemes represent the 10-20 IS on the scalp. Local coherence was obtained using equation 2 for every electrode and every fre‐ quency band. Coherence is related to the diameter of each electrode, and no significant differences were observed between basal (left) and *ictal* activity (right).

electrode, and no significant differences were observed between basal (left) and *ictal* activity (right). Furthermore, after placebo injection, an episode was recorded that was similar to the sponta‐ neously recorded episode, and this reinforced a PNES diagnosis.

Furthermore, after placebo injection, an episode was recorded that was similar to

#### the spontaneously recorded episode, and this reinforced a PNES diagnosis. **3.4. Psychiatric comorbidities and patient management**

**Figure 3.** Wakeful interictal activity shows a burst of generalised spike-wave complexes.

Figure 4. A burst of blunted spike-waves at 3 Hz shows a true alteration of

In addition to this type of seizure (of which the patient did not complain), the patient

consciousness. The patient was ordered to close her eyes (filled arrow), but the response was delayed by 6,4 s towards the end of the seizure. The HR (inset) increased from 72.8 ± 1.8 bpm before the burst to 83.7 ± 0.7 bpm during the episode (p < 0.05, ANOVA test by

**Figure 4.** A burst of blunted spike-waves at 3 Hz shows a true alteration of consciousness. The patient was ordered to close her eyes (filled arrow), but the response was delayed by 6,4 s towards the end of the seizure. The HR (inset) in‐ creased from 72.8 ± 1.8 bpm before the burst to 83.7 ± 0.7 bpm during the episode (p < 0.05, ANOVA test by ranks)

complained of severe and multi-day seizures of language emission and difficulties in understanding. The brain activity recorded during these episodes did not show a clear ictal pattern. Nevertheless, the recorded bioelectrical activity needed to be classified as a seizure or another disorder. To assess these recordings, we analysed the band coherence [*C(f)*] using to equation 1 and compared the basal and ictal activity using the *c(f)* equation. We hypothesised that a true seizure most likely increases the local coherence for any scallop region (FIGURE 6). However, as shown in FIGURE 6, the local coherence was not significantly modified from basal activity during any of the recorded paroxysmal episodes.

ranks) and returned to 78.8 ± 0.9 bpm after the episode (p < 0.05, ANOVA test).

and returned to 78.8 ± 0.9 bpm after the episode (p < 0.05, ANOVA test).

Epilepsy Topics

Y Axis

**Box Plot**

XData Basal\_3 Ictal\_3 Postictal\_3

> The rate of psychiatric comorbidities in PNES patients was 50%. Affective disorders were the most frequent psychiatric diagnosis (10/15), in particular, depression and anxiety disorders. Dissociative disorders were observed in 4 patients. Post-traumatic stress disorder was diagnosed in the remaining patient (Table 2). Interestingly, no differences were observed in the psychiatric comorbidities between the PNES+ E and PNES patients.

Our preliminary data have confirmed reports in the literature detailing the higher disability observed in PNES patients compared with epilepsy patients. To provide proper patient management, we applied a protocol of patient management to all patients in our unit to provide the appropriate care to PNES and PNES+E patients (Table 4). We have observed that PNES patients showed good family integration, and both patients and families have adapted to the disorder, even in an overprotective way.

**4. Discussion**

belong to the PNES group.

**4.1. Characteristics of patients with non-epileptic seizures of psychogenic origin**

other somatoform and dissociative disorders [30, 31, 32].

We have found that 4.8% of patients referred to our epilepsy centre for pre-surgical evaluation received a diagnosis of PNES. This percentage is lower than other published studies. However, PNES was the most frequent non-epileptic condition diagnosed in our epilepsy monitoring unit. Interestingly, in 90% of PNES+E patients, we discovered alterations in brain imaging studies, and also in more than half of the PNES-alone patients, we detected alterations in brain imaging studies. These findings have been previously described, and other researchers have found MRI changes in up to 60% of PNES+ E patients and up to 10% of PNES-alone patients [29]. If epileptiform activity is also considered as marker of brain abnormality, then the percentage of PNES patients in this study with evidence of physical or functional brain abnormalities was 55%. This percentage, though lower than in previously reported studies, reinforces the theory that physical brain disease may play a role in PNES development and in

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205

In this study, early diagnoses were complicated by concomitant epilepsy or epileptiform activity in 21 PNES patients; however, the semiology of the events helped differentiate PNES from epilepsy (closed eyes, non-rhythmic movements, awareness during the ictal phase and the ability of bystanders to modulate symptom intensity are more often observed in PNES). Nonetheless, no single observation provides a definitive PNES diagnosis, and no single semiological feature is shared by all PNES patients [33]. Moreover, eyewitness accounts of semiology may not be reliable in many cases. Usually, it is difficult for an experienced clinician to determine if an event is a true seizure or PNES, and generally, it is nearly impossible to rule out a diagnosis of epileptic seizures. The gold standard for ruling out epilepsy is vEEG telemetry that analyses typical seizures [34]. Observations of typical seizures combined with recorded brainwave activity lead to accurate diagnosis in up to 90% of cases [35]. In our study, 3,7% of patients did not receive a positive diagnosis because the bioelectric abnormalities or clinical manifestations typical of PNES were not observed. Thus, we could only conclude that the patient had no evidence of epilepsy, but it is possible that these patients might actually

The diagnosis of PNES is difficult to obtain. In fact, the absence of epileptiform activity in scalp recordings during the event is necessary, and evidence of this can be extremely difficult to obtain, because a true partial seizure may have no significant changes in scalp recordings. In these cases, it is necessary to perform a more complex brain activity analysis to reach a definite and clear diagnosis. As misdiagnosis can lead to devastating consequences, all efforts should be made to determine the appropriate diagnosis, and in these cases, provocative techniques aid in providing a definitive diagnosis. We used these techniques in 9 patients to confirm a PNES diagnosis, and they were positive for PNES in 7 patients. The observed clinical mani‐ festations were never associated with bioelectrical changes in the EEG recordings. The sensitivity to induction is unknown but estimated at 30% [25]. The key factors in PNES diagnoses are confirming that the habitual episode was indeed induced and always obtaining a simultaneous vEEG. If the recorded episode is not the habitual type typically recognised by


**Table 4.** Protocol of Patient Management at the National Referral Centre for Refractory Epilepsy

#### **4. Discussion**

Our preliminary data have confirmed reports in the literature detailing the higher disability observed in PNES patients compared with epilepsy patients. To provide proper patient management, we applied a protocol of patient management to all patients in our unit to provide the appropriate care to PNES and PNES+E patients (Table 4). We have observed that PNES patients showed good family integration, and both patients and families have adapted

to the disorder, even in an overprotective way.

or Neurosurgeon (if the patient has been referred for a neurosurgical evaluation)

Single Photon Emission Computed Tomography (SPECT) with 99Tc-HmPAO

Clinical decisions are determined in a regular multidisciplinary clinical meeting. When PNES are detected, a more complex psychiatric assessment protocol is initiated

The need to treat the disorder with psychiatric and psychotherapy approaches.

The need to treat the disorder with psychiatric and psychotherapy approaches.

The appropriate way to reduce neurological medications is supervised by a neurologist.

In patients with PNES, it is important to differentiate between PNES alone and PNES+E patients.

The psychogenic basis of the disorder, the diagnostic process and the likelihood of individualised psycho-

The patient receives a complete clinical report to facilitate treatment continuation in his/her health care district.

A close neurophysiological EEG survey is always recommended, which occurs during the progressive withdrawal from

Usually patients need to visit a neurologist and psychiatrist before completing care at his/her mental health centre. When patients suffer from PNES+E, a joint visit from a neurologist and a psychiatrist is used to inform to the patient

The patient is given a complete clinical report to facilitate mental health treatment in his/her health-care district. An individualised and thorough study of epilepsy is crucial to before deciding on surgery. In a small number of patients, epilepsy is detected during the vEEG, because of antiepileptic drug withdrawal; however, when AEDs are

The psychogenic basis of the disorder, the diagnostic process and the likelihood of individualised psychoetiopathogenic mechanisms of the disorder. The high disability associated with the disorder is also emphasised.

**Table 4.** Protocol of Patient Management at the National Referral Centre for Refractory Epilepsy

When patients suffer from PNES alone, a joint visit from a neurologist and psychiatrist are used to inform the patient

Neurologist refers patients to the Unit. **First Step**. All patients are assessed by a:

MRI (1.5 T) with an epilepsy protocol

**Second Step.** Ancillary tests and other specialists:

and if possible, the closest family member about:

and if possible, the closest family member about:

reintroduced, only the PNES are clinically significant.

The high disability associated with the disorder is also emphasised.

etiopathogenic mechanisms of the disorder.

Neurologist

204 Epilepsy Topics

Scalp EEG

Psychiatrist Neuropsychologist

antiepileptic drugs.

#### **4.1. Characteristics of patients with non-epileptic seizures of psychogenic origin**

We have found that 4.8% of patients referred to our epilepsy centre for pre-surgical evaluation received a diagnosis of PNES. This percentage is lower than other published studies. However, PNES was the most frequent non-epileptic condition diagnosed in our epilepsy monitoring unit. Interestingly, in 90% of PNES+E patients, we discovered alterations in brain imaging studies, and also in more than half of the PNES-alone patients, we detected alterations in brain imaging studies. These findings have been previously described, and other researchers have found MRI changes in up to 60% of PNES+ E patients and up to 10% of PNES-alone patients [29]. If epileptiform activity is also considered as marker of brain abnormality, then the percentage of PNES patients in this study with evidence of physical or functional brain abnormalities was 55%. This percentage, though lower than in previously reported studies, reinforces the theory that physical brain disease may play a role in PNES development and in other somatoform and dissociative disorders [30, 31, 32].

In this study, early diagnoses were complicated by concomitant epilepsy or epileptiform activity in 21 PNES patients; however, the semiology of the events helped differentiate PNES from epilepsy (closed eyes, non-rhythmic movements, awareness during the ictal phase and the ability of bystanders to modulate symptom intensity are more often observed in PNES). Nonetheless, no single observation provides a definitive PNES diagnosis, and no single semiological feature is shared by all PNES patients [33]. Moreover, eyewitness accounts of semiology may not be reliable in many cases. Usually, it is difficult for an experienced clinician to determine if an event is a true seizure or PNES, and generally, it is nearly impossible to rule out a diagnosis of epileptic seizures. The gold standard for ruling out epilepsy is vEEG telemetry that analyses typical seizures [34]. Observations of typical seizures combined with recorded brainwave activity lead to accurate diagnosis in up to 90% of cases [35]. In our study, 3,7% of patients did not receive a positive diagnosis because the bioelectric abnormalities or clinical manifestations typical of PNES were not observed. Thus, we could only conclude that the patient had no evidence of epilepsy, but it is possible that these patients might actually belong to the PNES group.

The diagnosis of PNES is difficult to obtain. In fact, the absence of epileptiform activity in scalp recordings during the event is necessary, and evidence of this can be extremely difficult to obtain, because a true partial seizure may have no significant changes in scalp recordings. In these cases, it is necessary to perform a more complex brain activity analysis to reach a definite and clear diagnosis. As misdiagnosis can lead to devastating consequences, all efforts should be made to determine the appropriate diagnosis, and in these cases, provocative techniques aid in providing a definitive diagnosis. We used these techniques in 9 patients to confirm a PNES diagnosis, and they were positive for PNES in 7 patients. The observed clinical mani‐ festations were never associated with bioelectrical changes in the EEG recordings. The sensitivity to induction is unknown but estimated at 30% [25]. The key factors in PNES diagnoses are confirming that the habitual episode was indeed induced and always obtaining a simultaneous vEEG. If the recorded episode is not the habitual type typically recognised by the patient and family, then a firm conclusion is unattainable, and most likely, the patient has different types of episodes. Another important issue is the awareness of the different types of seizures that can accompany a normal ictal EEG and which types cannot.

consistently correlated with significant differences in dissociative and conversion trait scores

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207

Somatic syndromes, such as fibromyalgia, chronic fatigue syndrome, chronic pain syndrome or tension headaches, and irritable bowel syndrome, have occurred at a higher frequency in PNES patients than in other patients with epilepsy [46, 47]. Other medical conditions, such as cancer, orthopaedic problems, and multiple surgeries, were also more frequent in the PNES

In PNES patients, this high prevalence of somatic syndromes could be related to a higher risk of manifesting psychic conflicts through somatic symptoms. In fact, PNES has been considered as a somatic symptom response to a wide range of negative events, including stress in

As we analysed the psychological evaluations from our study, we realised that the amount of information from the psychological profiles and psychopathological mechanisms warrants an extended discussion of both topics. Therefore, we will discuss the psychopathological mech‐

Most PNES patients met the criteria for a diagnosis of an axis II personality disorder (around 60%) [4, 5], but patients with ES also had an increased prevalence of personality disorders. The prevalence of personality disorders in ES patients 34.3%, which was significantly higher than

Nevertheless, some significant differences exist in the types of personality disorders diagnosed in the PNES and ES patients. In the ES group, the most common personality disorders were cluster C personality disorders (i.e., avoidant, dependent, and obsessive-compulsive disor‐ ders) [48, 49, 50], and in PNES patients, cluster B personality disorders were more common (i.e., antisocial, borderline, histrionic and narcissistic disorders) [49, 50, 51, 52, 53,]. The presence of personality disorders is associated with a poor prognosis, diminished quality of

When personality traits have been assessed and specialised instruments used, a general, complex, and diverse psychological profile has been obtained, as evaluated with both neurotic and psychotic scales [4, 54]. Thus, PNES personality profiles do not reveal a specific, unique

The MMPI has been the most widely used inventory to classify personality traits. The higher personality assessment scores have been in somatisation and externalisation; these patients have a strong preference for a medical explanation for their symptoms and tend to project the burden of their symptoms to their environment instead of a possible psychological explanation for their disorder [29, 55]. It is interesting to note that families of psychogenic seizure patients have also been found to be more prone to somatic problems and emotional distress than

matched controls with epilepsy [56], hypochondriasis and conversion traits [4, 57].

life, and increased resource use in both PNES and ES patients [3, 4, 48, 51].

as determined with the Minnesota Multiphasic Personality Inventory (MMPI) [4].

group than in the epilepsy group.

adulthood [38].

healthy controls.

syndrome [55].

**4.3. Psychological profile**

anisms separately in the next section.

Another confounding factor in diagnosing PNES is that both epileptic seizures and PNES may occur concomitantly.Upto a 40% of ourpatients experiencedPNES andepilepsy. Some authors estimated the prevalence ofthis comorbidity as ranging from 10% to 50% [36].In 5 patients with PNES+E,weperformedresective surgery.Thisdeterminationwasbasedonthe resultsofvEEG, psychological and psychiatric assessments that suggested the decrease or disappearance of epileptic seizures could increase patient quality of life. The outcome of these patients is good; 4 patients showed Engel's grade I and the remaining patient an Engel's grade II.

#### **4.2. Psychiatric diagnosis**

When considering psychiatric disorders, some authors have found no differences in the prevalence of current axis I disorders in patients with recent-onset PNES+E [37]. Nevertheless, in most studies, a high prevalence of psychiatric comorbidities has been found, and up to 90% of PNES patients met the criteria for another psychiatric disorder, axis I or axis II, according to the DSM criteria. Although a significant degree of psychopathology has been documented, there is an absence of a unique character substrate. Despite numerous studies that have linked PNES to a high prevalence of comorbid psychiatric conditions, we found a low percentage (40%) of the PNES patients exhibited these disorders. Furthermore, we did not observe differences in the psychiatric comorbid disorders of the PNES+E and PNES patient groups. However, we only detected dissociative disorder and post-traumatic stress disorder (PTSD) in the PNES-alone patients, but affective disorders were more common in the PNES+E group. Other studies have shown that approximately 60% of patients met the criteria for an affective episode [4, 5]. However, depressive symptoms are similar in PNES and epilepsy patients; thus, a negative affect could be the result of a chronic illness rather than uniquely related to PNES [38].

Other studies consider PNES as a heterogeneous entity, and to better understand it, different predisposing, precipitating and modulating factors must be considered. Patients with PNES usually present with a larger background of traumatic experiences than the general population [39], with values ranging from 84% [5, 40] to approximately 40%, in more recent studies [4, 38, 41]. These studies have shown a higher incidence of adverse childhood experiences and life events [42]. Previous trauma correlated with a high rate of psychiatric comorbidity and with strong dissociative mechanisms [43]. Additionally, a consistent history of psychiatric treat‐ ment, suicide attempts, borderline personality disorder or a history of abuse have been documented [44].

Regarding dissociative disorders, different but high prevalence rates of comorbid dissociative disorders have been reported, which range from 37% to 80% of cases [4, 5]. Not only clinically diagnosed dissociative disorders but dissociative experiences appear to be more frequent in PNES patients, as measured with the Dissociative Experience scale (DES). Patients with epilepsy and PNES scored significantly higher on the DES than patients with epilepsy without PNES and non-epileptic individuals [45]. Nevertheless, these diagnoses have not been consistently correlated with significant differences in dissociative and conversion trait scores as determined with the Minnesota Multiphasic Personality Inventory (MMPI) [4].

Somatic syndromes, such as fibromyalgia, chronic fatigue syndrome, chronic pain syndrome or tension headaches, and irritable bowel syndrome, have occurred at a higher frequency in PNES patients than in other patients with epilepsy [46, 47]. Other medical conditions, such as cancer, orthopaedic problems, and multiple surgeries, were also more frequent in the PNES group than in the epilepsy group.

In PNES patients, this high prevalence of somatic syndromes could be related to a higher risk of manifesting psychic conflicts through somatic symptoms. In fact, PNES has been considered as a somatic symptom response to a wide range of negative events, including stress in adulthood [38].

#### **4.3. Psychological profile**

the patient and family, then a firm conclusion is unattainable, and most likely, the patient has different types of episodes. Another important issue is the awareness of the different types of

Another confounding factor in diagnosing PNES is that both epileptic seizures and PNES may occur concomitantly.Upto a 40% of ourpatients experiencedPNES andepilepsy. Some authors estimated the prevalence ofthis comorbidity as ranging from 10% to 50% [36].In 5 patients with PNES+E,weperformedresective surgery.Thisdeterminationwasbasedonthe resultsofvEEG, psychological and psychiatric assessments that suggested the decrease or disappearance of epileptic seizures could increase patient quality of life. The outcome of these patients is good;

When considering psychiatric disorders, some authors have found no differences in the prevalence of current axis I disorders in patients with recent-onset PNES+E [37]. Nevertheless, in most studies, a high prevalence of psychiatric comorbidities has been found, and up to 90% of PNES patients met the criteria for another psychiatric disorder, axis I or axis II, according to the DSM criteria. Although a significant degree of psychopathology has been documented, there is an absence of a unique character substrate. Despite numerous studies that have linked PNES to a high prevalence of comorbid psychiatric conditions, we found a low percentage (40%) of the PNES patients exhibited these disorders. Furthermore, we did not observe differences in the psychiatric comorbid disorders of the PNES+E and PNES patient groups. However, we only detected dissociative disorder and post-traumatic stress disorder (PTSD) in the PNES-alone patients, but affective disorders were more common in the PNES+E group. Other studies have shown that approximately 60% of patients met the criteria for an affective episode [4, 5]. However, depressive symptoms are similar in PNES and epilepsy patients; thus, a negative affect could be the result of a chronic illness rather than uniquely related to PNES

Other studies consider PNES as a heterogeneous entity, and to better understand it, different predisposing, precipitating and modulating factors must be considered. Patients with PNES usually present with a larger background of traumatic experiences than the general population [39], with values ranging from 84% [5, 40] to approximately 40%, in more recent studies [4, 38, 41]. These studies have shown a higher incidence of adverse childhood experiences and life events [42]. Previous trauma correlated with a high rate of psychiatric comorbidity and with strong dissociative mechanisms [43]. Additionally, a consistent history of psychiatric treat‐ ment, suicide attempts, borderline personality disorder or a history of abuse have been

Regarding dissociative disorders, different but high prevalence rates of comorbid dissociative disorders have been reported, which range from 37% to 80% of cases [4, 5]. Not only clinically diagnosed dissociative disorders but dissociative experiences appear to be more frequent in PNES patients, as measured with the Dissociative Experience scale (DES). Patients with epilepsy and PNES scored significantly higher on the DES than patients with epilepsy without PNES and non-epileptic individuals [45]. Nevertheless, these diagnoses have not been

seizures that can accompany a normal ictal EEG and which types cannot.

4 patients showed Engel's grade I and the remaining patient an Engel's grade II.

**4.2. Psychiatric diagnosis**

206 Epilepsy Topics

[38].

documented [44].

As we analysed the psychological evaluations from our study, we realised that the amount of information from the psychological profiles and psychopathological mechanisms warrants an extended discussion of both topics. Therefore, we will discuss the psychopathological mech‐ anisms separately in the next section.

Most PNES patients met the criteria for a diagnosis of an axis II personality disorder (around 60%) [4, 5], but patients with ES also had an increased prevalence of personality disorders. The prevalence of personality disorders in ES patients 34.3%, which was significantly higher than healthy controls.

Nevertheless, some significant differences exist in the types of personality disorders diagnosed in the PNES and ES patients. In the ES group, the most common personality disorders were cluster C personality disorders (i.e., avoidant, dependent, and obsessive-compulsive disor‐ ders) [48, 49, 50], and in PNES patients, cluster B personality disorders were more common (i.e., antisocial, borderline, histrionic and narcissistic disorders) [49, 50, 51, 52, 53,]. The presence of personality disorders is associated with a poor prognosis, diminished quality of life, and increased resource use in both PNES and ES patients [3, 4, 48, 51].

When personality traits have been assessed and specialised instruments used, a general, complex, and diverse psychological profile has been obtained, as evaluated with both neurotic and psychotic scales [4, 54]. Thus, PNES personality profiles do not reveal a specific, unique syndrome [55].

The MMPI has been the most widely used inventory to classify personality traits. The higher personality assessment scores have been in somatisation and externalisation; these patients have a strong preference for a medical explanation for their symptoms and tend to project the burden of their symptoms to their environment instead of a possible psychological explanation for their disorder [29, 55]. It is interesting to note that families of psychogenic seizure patients have also been found to be more prone to somatic problems and emotional distress than matched controls with epilepsy [56], hypochondriasis and conversion traits [4, 57].

Dissociation scores have been widely studied and, on average, are higher in PNES patients but not significantly higher [7, 45, 58, 59]. Dissociative trait scores were higher in patients with a reported trauma [7].

**4.4. Etiopathogenic models of PNES**

esised to explain psychogenic seizures.

patients or patients with motor conversion disorders [67].

observed in almost any illness [67].

illness group and a borderline personality group.

level subgroup with daily life stress.

**4.5. PNES subtypes**

genic subgroups.

Thus, prolongation factors could explain the persistence of PNES over time.

increase PNES vulnerability.

The final symptomatic expression of PNES remains unclear. Some etiopathogenic theories that comprehensively address many factors have been previously reported and have been hypoth‐

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209

Bodde y cols [55] considered factors that predispose patients to psychosomatic symptoms and

Sexual abuse, other traumatic experiences, organic vulnerability (such as head trauma) and personality factors (emotional profile or neuropsychological functioning) increase PNES vulnerability. Stressful childhood events, including parental divorce and physical abuse [67], other childhood trauma and family dysfunction [68] also increase PNES vulnerability.

The observed personality traits have a tendency towards somatisation or dissociative experi‐ ences or reaction with somatic symptoms of psychological distress [7]. Alexithymia, cognitive inflexibility and hypervigilance have also been considered as PNES vulnerability factors [69]. Factors that shape patient perceptions could explain the presence of seizures and not other functional disorders, such as past epilepsy or having a close friend or relative with epileptic seizures. When examined, personally witnessing a seizure prior to their own attack occurs significantly more often in patients with PNES than in patients with epileptic seizures [67, 70]. Triggering factors, such as some psychological mechanisms or psychosocial events, might provoke seizure onset at specific moments. PNES patients report more events than epilepsy

The modulating factors, e.g., personality [3], patient coping style and secondary gain aspects, could also contribute. There are some criticisms of secondary gain, as this benefit can be

In general psychopathology, somatisation, alexithymia and difficulties with most aspects of emotional regulation could be the most important factors in the etiopathogenesis of PNES [71]. Considering all the etiopathogenic factors, some studies have proposed different etiopatho‐

Reuber and House [2] classified PNES into 3 groups based on the most prominent psychiatric comorbidity profiles: an anxiety-depressive group with depressive or anxiety symptoms, including panic and post-traumatic stress disorder (PTSD), a somatisation and abnormal

Bodde et al. [55] proposed 4 etiopathogenic groups: a psychotrauma subgroup, a high vulnerability somatisation subgroup (approximately 1/5 of patients), a sensitive personality subgroup (less than 1/5 of the patients) and a high vulnerability somatisation, low cognitive

Additionally, an anxious, practical and perfectionist attitude with difficulties tolerating ambiguity and a strong need to control have also been reported [55]. Another study described increased shyness [7], which has been related to antisocial behaviour and a high tendency to internally control emotions [55].

PNES has been associated with an alexithymic pattern and a lack of psychological awareness of the causes and consequences of their psychological dysfunction [55]. Although alexithymia appears to be elevated in PNES, it has also been elevated in epilepsy patients [38]. PNES has been significantly correlated with symptoms of anxiety, autonomic hyperarousal, dissociation and defensive avoidance, which are all characteristic of traumatic experiences. Thus, alexi‐ thymia has been hypothesised as a deficit that results from physiological and cognitive dysregulation following post-traumatic stress disorder [60].

Another personality trait of PNES patients is difficulty with coping strategies. Elevated levels of perceived distress and a lack of coping strategies, such as a passive and/or avoidant attitude to resolve psychological problems in other ways [3, 61, 62], make it difficult to employ strategies that would normally be used to reduce the impact of a stressor [63]. Some effective minimal coping strategies, such as emotion-focused coping strategies, are more frequently used than effective coping strategies, such as task-focused strategies [60]. These features lead to difficulties in emotional experiences to daily life situations, and diminished positive emotional behaviour has also been reported [64].

Two emotion dysregulation profiles have been described [65], a high level of emotion dysre‐ gulation associated with severe psychiatric symptomatology and impaired quality of life and low emotion dysregulation that is characterised by emotional unawareness or avoidance.

Some common personality traits as well as some clinical similarities have been documented between PNES and borderline personality disorder patients. Higher prevalence rates of sexual trauma, posttraumatic stress disorder, dissociative disorders, somatoform disorders, depres‐ sive disorders, anger problems, suicide attempts, emotional instability and hostile coping styles have been reported in both conditions [49, 50, 52, 66].

Some similarities in personality traits have also been found between PNES and patients with functional somatic symptoms disorders [55].

Although the *interpersonal relationships* of PNES patients in clinical practice appear to be deeply affected, their social functioning scores remain within normal limits [4]. These patients make instrumental use of the PNES, which may contribute to the perception of being well-adapted in their relationships. Patients with higher emotional dysfunction and higher abnormal personality traits have a lower quality of life [47].

#### **4.4. Etiopathogenic models of PNES**

Dissociation scores have been widely studied and, on average, are higher in PNES patients but not significantly higher [7, 45, 58, 59]. Dissociative trait scores were higher in patients with a

Additionally, an anxious, practical and perfectionist attitude with difficulties tolerating ambiguity and a strong need to control have also been reported [55]. Another study described increased shyness [7], which has been related to antisocial behaviour and a high tendency to

PNES has been associated with an alexithymic pattern and a lack of psychological awareness of the causes and consequences of their psychological dysfunction [55]. Although alexithymia appears to be elevated in PNES, it has also been elevated in epilepsy patients [38]. PNES has been significantly correlated with symptoms of anxiety, autonomic hyperarousal, dissociation and defensive avoidance, which are all characteristic of traumatic experiences. Thus, alexi‐ thymia has been hypothesised as a deficit that results from physiological and cognitive

Another personality trait of PNES patients is difficulty with coping strategies. Elevated levels of perceived distress and a lack of coping strategies, such as a passive and/or avoidant attitude to resolve psychological problems in other ways [3, 61, 62], make it difficult to employ strategies that would normally be used to reduce the impact of a stressor [63]. Some effective minimal coping strategies, such as emotion-focused coping strategies, are more frequently used than effective coping strategies, such as task-focused strategies [60]. These features lead to difficulties in emotional experiences to daily life situations, and diminished positive

Two emotion dysregulation profiles have been described [65], a high level of emotion dysre‐ gulation associated with severe psychiatric symptomatology and impaired quality of life and low emotion dysregulation that is characterised by emotional unawareness or avoidance.

Some common personality traits as well as some clinical similarities have been documented between PNES and borderline personality disorder patients. Higher prevalence rates of sexual trauma, posttraumatic stress disorder, dissociative disorders, somatoform disorders, depres‐ sive disorders, anger problems, suicide attempts, emotional instability and hostile coping

Some similarities in personality traits have also been found between PNES and patients with

Although the *interpersonal relationships* of PNES patients in clinical practice appear to be deeply affected, their social functioning scores remain within normal limits [4]. These patients make instrumental use of the PNES, which may contribute to the perception of being well-adapted in their relationships. Patients with higher emotional dysfunction and higher abnormal

reported trauma [7].

208 Epilepsy Topics

internally control emotions [55].

dysregulation following post-traumatic stress disorder [60].

emotional behaviour has also been reported [64].

styles have been reported in both conditions [49, 50, 52, 66].

functional somatic symptoms disorders [55].

personality traits have a lower quality of life [47].

The final symptomatic expression of PNES remains unclear. Some etiopathogenic theories that comprehensively address many factors have been previously reported and have been hypoth‐ esised to explain psychogenic seizures.

Bodde y cols [55] considered factors that predispose patients to psychosomatic symptoms and increase PNES vulnerability.

Sexual abuse, other traumatic experiences, organic vulnerability (such as head trauma) and personality factors (emotional profile or neuropsychological functioning) increase PNES vulnerability. Stressful childhood events, including parental divorce and physical abuse [67], other childhood trauma and family dysfunction [68] also increase PNES vulnerability.

The observed personality traits have a tendency towards somatisation or dissociative experi‐ ences or reaction with somatic symptoms of psychological distress [7]. Alexithymia, cognitive inflexibility and hypervigilance have also been considered as PNES vulnerability factors [69].

Factors that shape patient perceptions could explain the presence of seizures and not other functional disorders, such as past epilepsy or having a close friend or relative with epileptic seizures. When examined, personally witnessing a seizure prior to their own attack occurs significantly more often in patients with PNES than in patients with epileptic seizures [67, 70].

Triggering factors, such as some psychological mechanisms or psychosocial events, might provoke seizure onset at specific moments. PNES patients report more events than epilepsy patients or patients with motor conversion disorders [67].

Thus, prolongation factors could explain the persistence of PNES over time.

The modulating factors, e.g., personality [3], patient coping style and secondary gain aspects, could also contribute. There are some criticisms of secondary gain, as this benefit can be observed in almost any illness [67].

#### **4.5. PNES subtypes**

In general psychopathology, somatisation, alexithymia and difficulties with most aspects of emotional regulation could be the most important factors in the etiopathogenesis of PNES [71].

Considering all the etiopathogenic factors, some studies have proposed different etiopatho‐ genic subgroups.

Reuber and House [2] classified PNES into 3 groups based on the most prominent psychiatric comorbidity profiles: an anxiety-depressive group with depressive or anxiety symptoms, including panic and post-traumatic stress disorder (PTSD), a somatisation and abnormal illness group and a borderline personality group.

Bodde et al. [55] proposed 4 etiopathogenic groups: a psychotrauma subgroup, a high vulnerability somatisation subgroup (approximately 1/5 of patients), a sensitive personality subgroup (less than 1/5 of the patients) and a high vulnerability somatisation, low cognitive level subgroup with daily life stress.

Other authors proposed a more simplified, two-subgroup etiopathogenic classification scheme: a posttraumatic PNES group, characterised by psychogenic attacks that develop in response to acute or chronic traumatic experience exposure, and developmental PNES group, characterised by difficulties in coping with tasks and milestones on the individual's psycho‐ social development continuum [71].

All these difficulties in the diagnosis and treatment of PNES patients must be considered when deliberating over the most effective strategy to provide information about a PNES diagnosis

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A good therapeutic relationship between the neurologist and patient is crucial. One or several clinical interviews involving a neurologist, psychiatrist and patient that provide a multidisci‐

When presenting a PNES diagnosis, it is recommended to explain to patient and family the lack of ictal discharges during vEEG, the psychogenic nature of the attacks as a result of difficulties managing stressful or life situations, the acknowledgement that the attacks are real and out of the patient's control and the need for psychotherapeutic and/or psychiatric treat‐ ment to managing stressful situations and psychiatric comorbidities. Unless patients and families understand and accept the diagnosis, they typically will not comply with recommen‐

A neurologist will continue to provide care, monitoring the patient outcome, and progressively

If patients present with both PNES and epilepsy and antiepileptic drugs must be maintained, patients will need to be informed and must understand both the neurologic and psychiatric treatments. However, some controversy exists about the discontinuation of antiepileptic drugs in PNES patients without epilepsy. Antiepileptic drugs could provide therapeutic benefits on mood and impulsivity and for headache or pain prophylaxis. On the contrary, toxicity,

The treatment plan must be individually adjusted to each patient, depending on the psycho‐

For example, if difficulties in emotional reactions occur, some strategies, such as monitoring symptom triggers, re-interpreting physical sensations and increasing relaxation, could be

Most psychotherapy techniques, such as psychodynamic interpersonal psychotherapy, group psychodynamic psychotherapy and group psychoeducation, have been evaluated in uncon‐ trolled trials. These interventions all seem promising but require further investigation in larger

CBT is based on the conceptualisation of PNES as dissociative responses to arousal when a patient is confronted with stimuli or circumstances that the patient tends to avoid, consciously

plinary presentation of the diagnosis and treatment plan are highly recommended.

to patients previously considered neurologic patients.

dations and will not follow-up with a psychiatrist.

**4.6. Treatment**

effective in PNES patients [64].

scale samples and/or more rigorous methodology.

**4.8. Cognitive-Behavioural Therapy (CBT)**

**4.7. Psychotherapy**

or not.

decreasing antiepileptic drug doses when appropriate.

teratogenicity and medication expense need to be considered [78].

genic factors considered to underlie the psychopathology [7, 79, 80].

The importance of diagnosis presentation

The first step towards symptom improvement is presenting the diagnosis to the patient and when appropriate, to his or her family. Providing patients with a PNES diagnosis, appears to reduce PNES frequency in the months following diagnosis in at least one third of patients [69, 72, 73, 74, 75, 76].

A marked reduction in health care demand after PNES diagnosis has also been established by prospective follow-up studies [10, 69, 77]. However, long-term studies examining the decrease in PNES frequency shortly after diagnosis has not been maintained longitudinally when a diagnosis is the main and sole "intervention" [3, 58].

Effectively communicating the PNES diagnosis in an understandable and acceptable way to the patient and family is critical and is considered the first therapeutic step.

The process of explaining to the patients that their disease may be psychiatric instead of neurological must be cautiously and progressively handled [16]. Patients and family must be engaged in a treatment plan very different from the previous plan.

A significant patient and family resistance to a new and non-neurologic diagnosis requires the implementation of coordinated strategies by a neurologist and a psychiatrist to manage the best outcome for these patients. When a diagnosis is given to patients and families, some of patients have a sense of relief to know that the events are not epileptic and that they will be helped in identifying sources of stress and other emotional problems responsible for triggering their events [75]. However, most patients react negatively to the diagnosis of PNES. Frequently, they feel that doctors are communicating that the symptoms are not real but invented.

Many factors may contribute to this negative, even hostile, attitude towards a psychogenic basis of their crisis [46, 52]. Some personality trait factors, such as somatisation and external‐ isation traits, make diagnosis acceptance difficult. Patients and families show a tendency to seek medical responsibility for these symptoms and might be very reluctant to be referred for psychological or psychiatric treatment.

An indirect benefit obtained through this behavioural pattern may also help explain their resistance to change [4].

Another factor related to the initially hostile attitude of the patients is the risk of stigma, which is inherent to psychiatric disorders. Patients fear being viewed as malingerers or attention seekers [74], and also the not infrequent stigmatisation of the doctor, who only considers neurologic diseases real diseases, may transmit this bias that a psychogenic crisis is not a real disease to patients. These stigmatising views can lead patients to believe that they do not need attentive specialised and technical care but a psychiatric clinic for insane individuals.

All these difficulties in the diagnosis and treatment of PNES patients must be considered when deliberating over the most effective strategy to provide information about a PNES diagnosis to patients previously considered neurologic patients.

A good therapeutic relationship between the neurologist and patient is crucial. One or several clinical interviews involving a neurologist, psychiatrist and patient that provide a multidisci‐ plinary presentation of the diagnosis and treatment plan are highly recommended.

When presenting a PNES diagnosis, it is recommended to explain to patient and family the lack of ictal discharges during vEEG, the psychogenic nature of the attacks as a result of difficulties managing stressful or life situations, the acknowledgement that the attacks are real and out of the patient's control and the need for psychotherapeutic and/or psychiatric treat‐ ment to managing stressful situations and psychiatric comorbidities. Unless patients and families understand and accept the diagnosis, they typically will not comply with recommen‐ dations and will not follow-up with a psychiatrist.

A neurologist will continue to provide care, monitoring the patient outcome, and progressively decreasing antiepileptic drug doses when appropriate.

If patients present with both PNES and epilepsy and antiepileptic drugs must be maintained, patients will need to be informed and must understand both the neurologic and psychiatric treatments. However, some controversy exists about the discontinuation of antiepileptic drugs in PNES patients without epilepsy. Antiepileptic drugs could provide therapeutic benefits on mood and impulsivity and for headache or pain prophylaxis. On the contrary, toxicity, teratogenicity and medication expense need to be considered [78].

#### **4.6. Treatment**

Other authors proposed a more simplified, two-subgroup etiopathogenic classification scheme: a posttraumatic PNES group, characterised by psychogenic attacks that develop in response to acute or chronic traumatic experience exposure, and developmental PNES group, characterised by difficulties in coping with tasks and milestones on the individual's psycho‐

The first step towards symptom improvement is presenting the diagnosis to the patient and when appropriate, to his or her family. Providing patients with a PNES diagnosis, appears to reduce PNES frequency in the months following diagnosis in at least one third of patients [69,

A marked reduction in health care demand after PNES diagnosis has also been established by prospective follow-up studies [10, 69, 77]. However, long-term studies examining the decrease in PNES frequency shortly after diagnosis has not been maintained longitudinally when a

Effectively communicating the PNES diagnosis in an understandable and acceptable way to

The process of explaining to the patients that their disease may be psychiatric instead of neurological must be cautiously and progressively handled [16]. Patients and family must be

A significant patient and family resistance to a new and non-neurologic diagnosis requires the implementation of coordinated strategies by a neurologist and a psychiatrist to manage the best outcome for these patients. When a diagnosis is given to patients and families, some of patients have a sense of relief to know that the events are not epileptic and that they will be helped in identifying sources of stress and other emotional problems responsible for triggering their events [75]. However, most patients react negatively to the diagnosis of PNES. Frequently, they feel that doctors are communicating that the symptoms are not real but invented.

Many factors may contribute to this negative, even hostile, attitude towards a psychogenic basis of their crisis [46, 52]. Some personality trait factors, such as somatisation and external‐ isation traits, make diagnosis acceptance difficult. Patients and families show a tendency to seek medical responsibility for these symptoms and might be very reluctant to be referred for

An indirect benefit obtained through this behavioural pattern may also help explain their

Another factor related to the initially hostile attitude of the patients is the risk of stigma, which is inherent to psychiatric disorders. Patients fear being viewed as malingerers or attention seekers [74], and also the not infrequent stigmatisation of the doctor, who only considers neurologic diseases real diseases, may transmit this bias that a psychogenic crisis is not a real disease to patients. These stigmatising views can lead patients to believe that they do not need

attentive specialised and technical care but a psychiatric clinic for insane individuals.

the patient and family is critical and is considered the first therapeutic step.

engaged in a treatment plan very different from the previous plan.

social development continuum [71].

72, 73, 74, 75, 76].

210 Epilepsy Topics

The importance of diagnosis presentation

diagnosis is the main and sole "intervention" [3, 58].

psychological or psychiatric treatment.

resistance to change [4].

The treatment plan must be individually adjusted to each patient, depending on the psycho‐ genic factors considered to underlie the psychopathology [7, 79, 80].

For example, if difficulties in emotional reactions occur, some strategies, such as monitoring symptom triggers, re-interpreting physical sensations and increasing relaxation, could be effective in PNES patients [64].

#### **4.7. Psychotherapy**

Most psychotherapy techniques, such as psychodynamic interpersonal psychotherapy, group psychodynamic psychotherapy and group psychoeducation, have been evaluated in uncon‐ trolled trials. These interventions all seem promising but require further investigation in larger scale samples and/or more rigorous methodology.

#### **4.8. Cognitive-Behavioural Therapy (CBT)**

CBT is based on the conceptualisation of PNES as dissociative responses to arousal when a patient is confronted with stimuli or circumstances that the patient tends to avoid, consciously or not.

Patients with PNES tend to display significantly distorted somatic beliefs and develop dysfunctional, repetitive illness behaviour patterns with associated depressive affect as well as a sudden and time-limited disturbance in controlling cognitive, emotional, and/or behav‐ ioural functions [70, 79]. CBT is intended to modify distorted beliefs and change the perception of the limitations associated with PNES.

session topics. The substantial percentage of individuals whose seizures remitted following diagnosis supports the hypothesis that education about the disorder is an effective treatment. The results of a six-month psychotherapy group, with an open, uncontrolled design [84], have been published. Over a total of 24 sessions, the discussion of feelings related to past or present events relevant to PNES was encouraged. A decrease in seizure frequency was reported in six

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In another pilot study with a psychodynamic focus and psychoeducational structure, selfrelaxation with hypnosis was also used [85]. Dissociation was considered a defence mechanism that splits traumatic memories from consciousness because they are inconsistent with the patient's self-concept. The goal of therapy was to facilitate the patient's awareness of these patterns and to thus allow change. The development of assertive coping strategies instead of passive avoidant behaviour was emphasised. The study reported an overall decrease in seizure

Recently, another uncontrolled study with group psychotherapy has been published [86]. Psychoeducation and behavioural and psychoanalytic techniques were utilised. Nine patients completed 12 weeks of psychotherapy. In this therapy, families gathering four times for 1 h during the study provided a different treatment element. Families were not included in the therapeutic process and met just before the group sessions. Families were encouraged to ask questions and talk about seizures, and behavioural management strategies were advised. A sustainable decrease in seizure frequency, which lasted from the beginning of the therapy until the 12th month of follow-up, was observed. All patients showed a >50% reduction in seizure

This technique has been used in PNES and conversion disorder patients. In a randomised trial of PNES patients, Ataoglu et al. [87] tested inpatient paradoxical intention (PI) therapy versus oral outpatient benzodiazepine. PI therapy consisted of encouraging patients to intentionally engage in their unwanted conversion symptoms. This study did not focus on crisis frequency but on conversion symptoms. Both groups recorded significantly decreased anxiety scores by

Given the theoretical importance of dissociation in PNES aetiology, hypnosis would appear to offer a useful intervention for this patient population [72]. The effectiveness of hypnosis was evaluated in a prospective study [88] where 49 patients were randomly assigned to either a hypnosis-based 10-week session treatment for conversion disorder, motor type, or a wait list control group. Only two patients in this conversion disorder study had PNES. A significant improvement in the Motor Conversion Symptoms scale (VRMC) for the treatment group was

Other studies evaluated dissociation and hypnotisability in PNES patients and compared them with a nonclinical control group or epilepsy patients. In one study, PNES patients had higher

frequency and a significant improvement in different psychometric assessments.

of the nine PNES subjects (67%).

**4.10. Paradoxical intention therapy**

frequency.

the end of treatment.

**4.11. Hypnosis**

observed.

This therapy may be useful several symptom patterns: (a) acute anxiety/panic, (b) impaired affect regulation and interpersonal skills, (c) somatisation/conversion, (d) depression, (e) PTSD, and (f) reinforced behavioural patterns [80]. These classifications were based on the most effective psychotherapeutic interventions for each patient group.

CBT is the only psychotherapeutic PNES intervention that has been studied in a randomised, controlled pilot trial and is therefore the psychotherapeutic treatment with the highest level of efficacious evidence (Class III) in this population. Goldstein et al. [81] reported that in an open-label trial for patients with dissociative seizure, a 12-session CBT intervention was significantly more effective than standard medical care (SMC) for reducing seizure frequency in PNES patients. Psychotherapy focused on the following factors: engagement in treatment, reinforcement of independence, distraction, relaxation, refocusing techniques at the earliest signs of an event, graded exposure to avoided situations, cognitive restructuring, and relapse prevention. A tendency for this benefit to persist was maintained at the 6-month follow-up. There was also an overall improvement in self-rated social functioning of the CBT group compared with SMC.

Moreover, an uncontrolled CBT study where therapy was focused on addressing cognitive distortions and promoting behavioural changes has been published [82]. Some specific objectives of the psychotherapeutic sessions included the study of the individual's context, identification of moods, situations, and thoughts, training in healthy communication and support seeking, understanding central nervous system medications and seizures, conducting a functional behavioural analysis, developing relaxation techniques, examining external stressors and internal triggers, and preparing for life after completing the time-limited intervention. Patients reduced the number of PNES and improved quality of life, family functioning, and psychosocial functioning.

In summary, the data on CBT efficacy for PNES treatment are sparse but promising.

#### **4.9. Group therapy**

To date, several studies have reported the use of group therapy for PNES patients.

Zaroff et al. [83] evaluated the effectiveness of group psychotherapy based on psychodynamic theories and a psychoeducational session structure. All patients included in this open-label trial participated in a one-hour weekly group psychotherapy session for a total of 10 weeks. In each session, the following relevant PNES topics were discussed: PNES, anger, trauma and abuse, depression and anxiety, somatisation tendencies, quality of life, paths toward health, stress coping techniques and topic review. At the conclusion of the 10-week program, group psychotherapy continued in a less structured and more supportive format without specific session topics. The substantial percentage of individuals whose seizures remitted following diagnosis supports the hypothesis that education about the disorder is an effective treatment.

The results of a six-month psychotherapy group, with an open, uncontrolled design [84], have been published. Over a total of 24 sessions, the discussion of feelings related to past or present events relevant to PNES was encouraged. A decrease in seizure frequency was reported in six of the nine PNES subjects (67%).

In another pilot study with a psychodynamic focus and psychoeducational structure, selfrelaxation with hypnosis was also used [85]. Dissociation was considered a defence mechanism that splits traumatic memories from consciousness because they are inconsistent with the patient's self-concept. The goal of therapy was to facilitate the patient's awareness of these patterns and to thus allow change. The development of assertive coping strategies instead of passive avoidant behaviour was emphasised. The study reported an overall decrease in seizure frequency and a significant improvement in different psychometric assessments.

Recently, another uncontrolled study with group psychotherapy has been published [86]. Psychoeducation and behavioural and psychoanalytic techniques were utilised. Nine patients completed 12 weeks of psychotherapy. In this therapy, families gathering four times for 1 h during the study provided a different treatment element. Families were not included in the therapeutic process and met just before the group sessions. Families were encouraged to ask questions and talk about seizures, and behavioural management strategies were advised. A sustainable decrease in seizure frequency, which lasted from the beginning of the therapy until the 12th month of follow-up, was observed. All patients showed a >50% reduction in seizure frequency.

#### **4.10. Paradoxical intention therapy**

This technique has been used in PNES and conversion disorder patients. In a randomised trial of PNES patients, Ataoglu et al. [87] tested inpatient paradoxical intention (PI) therapy versus oral outpatient benzodiazepine. PI therapy consisted of encouraging patients to intentionally engage in their unwanted conversion symptoms. This study did not focus on crisis frequency but on conversion symptoms. Both groups recorded significantly decreased anxiety scores by the end of treatment.

#### **4.11. Hypnosis**

Patients with PNES tend to display significantly distorted somatic beliefs and develop dysfunctional, repetitive illness behaviour patterns with associated depressive affect as well as a sudden and time-limited disturbance in controlling cognitive, emotional, and/or behav‐ ioural functions [70, 79]. CBT is intended to modify distorted beliefs and change the perception

This therapy may be useful several symptom patterns: (a) acute anxiety/panic, (b) impaired affect regulation and interpersonal skills, (c) somatisation/conversion, (d) depression, (e) PTSD, and (f) reinforced behavioural patterns [80]. These classifications were based on the

CBT is the only psychotherapeutic PNES intervention that has been studied in a randomised, controlled pilot trial and is therefore the psychotherapeutic treatment with the highest level of efficacious evidence (Class III) in this population. Goldstein et al. [81] reported that in an open-label trial for patients with dissociative seizure, a 12-session CBT intervention was significantly more effective than standard medical care (SMC) for reducing seizure frequency in PNES patients. Psychotherapy focused on the following factors: engagement in treatment, reinforcement of independence, distraction, relaxation, refocusing techniques at the earliest signs of an event, graded exposure to avoided situations, cognitive restructuring, and relapse prevention. A tendency for this benefit to persist was maintained at the 6-month follow-up. There was also an overall improvement in self-rated social functioning of the CBT group

Moreover, an uncontrolled CBT study where therapy was focused on addressing cognitive distortions and promoting behavioural changes has been published [82]. Some specific objectives of the psychotherapeutic sessions included the study of the individual's context, identification of moods, situations, and thoughts, training in healthy communication and support seeking, understanding central nervous system medications and seizures, conducting a functional behavioural analysis, developing relaxation techniques, examining external stressors and internal triggers, and preparing for life after completing the time-limited intervention. Patients reduced the number of PNES and improved quality of life, family

In summary, the data on CBT efficacy for PNES treatment are sparse but promising.

To date, several studies have reported the use of group therapy for PNES patients.

Zaroff et al. [83] evaluated the effectiveness of group psychotherapy based on psychodynamic theories and a psychoeducational session structure. All patients included in this open-label trial participated in a one-hour weekly group psychotherapy session for a total of 10 weeks. In each session, the following relevant PNES topics were discussed: PNES, anger, trauma and abuse, depression and anxiety, somatisation tendencies, quality of life, paths toward health, stress coping techniques and topic review. At the conclusion of the 10-week program, group psychotherapy continued in a less structured and more supportive format without specific

most effective psychotherapeutic interventions for each patient group.

of the limitations associated with PNES.

212 Epilepsy Topics

compared with SMC.

**4.9. Group therapy**

functioning, and psychosocial functioning.

Given the theoretical importance of dissociation in PNES aetiology, hypnosis would appear to offer a useful intervention for this patient population [72]. The effectiveness of hypnosis was evaluated in a prospective study [88] where 49 patients were randomly assigned to either a hypnosis-based 10-week session treatment for conversion disorder, motor type, or a wait list control group. Only two patients in this conversion disorder study had PNES. A significant improvement in the Motor Conversion Symptoms scale (VRMC) for the treatment group was observed.

Other studies evaluated dissociation and hypnotisability in PNES patients and compared them with a nonclinical control group or epilepsy patients. In one study, PNES patients had higher levels of dissociation and hypnotisability as measured by the Dissociative Experience Scale (DES) [61]. Hypnotisability was also significantly higher for the PNES group compared with the control group, as other authors have previously reported [89].

assessment period. The particular comorbidities of the patients included in this study prevent the extrapolation of the results to the broader PNES population, but the combined prevalence of depressive and anxiety disorders among PNES patients that may reach up to two thirds of PNES patients should not be ignored [4]. An additional caution when interpreting these results is the lack of a placebo-arm, especially if we consider the documented initial decrease in seizure frequency consistently observed during the first months after PNES diagnosis [16, 73, 75, 76]. This factor could account for some of the event frequency reductions described in this study.

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Clinicians have often tried other pharmacological PNES treatments based on current knowl‐ edge of PNES-related disorders. As we have previously described, patients suffering from PNES share many underlying psychopathological characteristics with other conversion and somatoform disorders. These comorbidities may lead to the hypothesis that treatments demonstrating efficacy for these other disorders might also provide some benefit in PNES.

Evidence-based treatments for other conversion disorders have been documented in uncon‐ trolled trials. A retrospective study on patients with psychogenic paralysis showed that repetitive Transcranial Magnetic Stimulation (rTMS) over the motor cortex contralateral to the corresponding paralysis achieved improvement in 62 of 70 patients (89%), with total recovery

In an open-label, prospective study conducted on 23 patients diagnosed with chronic psycho‐ genic movement disorder (PMD), antidepressant medications (paroxetine, citalopram and venlafaxine) showed a reduction and even remission of psychogenic movements in the subgroup of patients in which the movements were not accompanied by other somatoform disorders, such as hypochondriasis or somatisation disorders [92]. Various classes of antide‐ pressants have also demonstrated a reduction in medically unexplained symptoms, including headache, fibromyalgia, functional gastrointestinal syndromes, idiopathic pain, tinnitus, and

In summary, no strong evidence exists to date that establishes the efficacy of any particular medication for the treatment of PNES. Despite this fact, preliminary studies suggest that sertraline and venlafaxine could be beneficial therapeutics. The data investigating treatments

PNES is one of the most frustrating clinical pathologies. Diagnosis is sometimes difficult and can take several years to reach a definitive PNES diagnosis. Moreover, treatment can be even more difficult. However, PNES is a severely debilitating illness for the patient, family and society; thus, we must continue to identify and improve patient quality-of-life. Nevertheless, a significant percentage of patients referred to epilepsy surgery units present with PNES, where the necessary assessments, such as vEEG, can provide a correct diagnosis; therefore, the

actual magnitude of PNES diagnoses may be larger than currently detectable.

observed in 53 patients (76%) [96].

for PNES-related disorders also support this hypothesis

chronic fatigue [97].

**5. Conclusions**

#### **4.12. Pharmacological treatment**

To date, the lack of a consistent neurobiological model explaining PNES physiopathology makes it considerably difficult to identify a specific and effective pharmacological treatment. Owing to a lack of large, controlled trials evaluating the efficacy of different treatment modalities, guidelines on how to treat this complex health problem do not exist [16, 79].

Nonetheless, under the premise that some of the factors that seem to be involved in PNES etiopathogenesis, such as depressive mood and anxiety, are associated with serotonergic neurotransmission alterations, selective serotonin reuptake inhibitors (SSRIs) have been investigated as potentially useful drugs. In addition to their established efficacy for treating depression and anxiety [90, 91], SSRIs have shown promise in trials for conversion or soma‐ toform disorders [92] and some personality disorders [93]. These disorders are frequently occurring comorbidities in PNES patients, which make SSRIs particularly attractive as a potential treatment.

LaFrance et al. conducted a randomised, double-blind, placebo-controlled clinical trial (which meets the criteria for Class II evidence) evaluating the efficacy of flexible-dose sertraline over 12 weeks at reducing PNES frequency and improving other symptom severity and psychoso‐ cial measures [94]. Patients were allowed to participate even with previous antidepressant use, except for monoamine oxidase inhibitors or sertraline at a 100 mg/day or higher dose, to maintain a constant dose of the concurrent antidepressants for the study duration. The sertraline group experienced a 45% decline in biweekly seizure rates over the 12-week course of the intervention from 22.24 to 12.18 (ratio, 0.55; 95% CI, 0.32-0.93; p = 0.03), while the control group showed an 8% increase from 13.38 to 14.38 (ratio, 1.08; 95% CI, 0.65-1.77; p = 0.78). However, the limited sample size (33 patients were included in the final analysis) implied this study was underpowered and unable to detect statistically significant differences between groups (RR, 0.51; 95% CI, 0.25-1.05; p = 0.29). There were no differences in secondary outcome measure changes between the groups (a series of scales assessing different psychiatric symptoms, functionality and quality of life-related measures). The evaluation of SSRIs in larger, randomised, controlled trials is therefore necessary to establish solid treatment guidelines.

Venlafaxine, a noradrenalin-serotonin reuptake inhibitor (NSRI), has also been evaluated as a potential psychopharmacological PNES treatment. An open-label, prospective, uncontrolled study evaluated the efficacy of flexible-dose venlafaxine on seizure frequency reduction and anxiety and depression disorder severity improvement [95]. All enrolled subjects had vEEGconfirmed PNES but also met the DSM-IV criteria for a unipolar depressive disorder and/or anxiety disorder. The 19 subjects who completed the 5-month follow-up experienced a statistically significant reduction in all symptom scales and monthly event frequency at the five-month assessment compared with the initial assessment; however, no differences were detected in the patient subgroup with more than ten events in the 15-day baseline pre-inclusion assessment period. The particular comorbidities of the patients included in this study prevent the extrapolation of the results to the broader PNES population, but the combined prevalence of depressive and anxiety disorders among PNES patients that may reach up to two thirds of PNES patients should not be ignored [4]. An additional caution when interpreting these results is the lack of a placebo-arm, especially if we consider the documented initial decrease in seizure frequency consistently observed during the first months after PNES diagnosis [16, 73, 75, 76]. This factor could account for some of the event frequency reductions described in this study.

Clinicians have often tried other pharmacological PNES treatments based on current knowl‐ edge of PNES-related disorders. As we have previously described, patients suffering from PNES share many underlying psychopathological characteristics with other conversion and somatoform disorders. These comorbidities may lead to the hypothesis that treatments demonstrating efficacy for these other disorders might also provide some benefit in PNES.

Evidence-based treatments for other conversion disorders have been documented in uncon‐ trolled trials. A retrospective study on patients with psychogenic paralysis showed that repetitive Transcranial Magnetic Stimulation (rTMS) over the motor cortex contralateral to the corresponding paralysis achieved improvement in 62 of 70 patients (89%), with total recovery observed in 53 patients (76%) [96].

In an open-label, prospective study conducted on 23 patients diagnosed with chronic psycho‐ genic movement disorder (PMD), antidepressant medications (paroxetine, citalopram and venlafaxine) showed a reduction and even remission of psychogenic movements in the subgroup of patients in which the movements were not accompanied by other somatoform disorders, such as hypochondriasis or somatisation disorders [92]. Various classes of antide‐ pressants have also demonstrated a reduction in medically unexplained symptoms, including headache, fibromyalgia, functional gastrointestinal syndromes, idiopathic pain, tinnitus, and chronic fatigue [97].

In summary, no strong evidence exists to date that establishes the efficacy of any particular medication for the treatment of PNES. Despite this fact, preliminary studies suggest that sertraline and venlafaxine could be beneficial therapeutics. The data investigating treatments for PNES-related disorders also support this hypothesis

#### **5. Conclusions**

levels of dissociation and hypnotisability as measured by the Dissociative Experience Scale (DES) [61]. Hypnotisability was also significantly higher for the PNES group compared with

To date, the lack of a consistent neurobiological model explaining PNES physiopathology makes it considerably difficult to identify a specific and effective pharmacological treatment. Owing to a lack of large, controlled trials evaluating the efficacy of different treatment modalities, guidelines on how to treat this complex health problem do not exist [16, 79].

Nonetheless, under the premise that some of the factors that seem to be involved in PNES etiopathogenesis, such as depressive mood and anxiety, are associated with serotonergic neurotransmission alterations, selective serotonin reuptake inhibitors (SSRIs) have been investigated as potentially useful drugs. In addition to their established efficacy for treating depression and anxiety [90, 91], SSRIs have shown promise in trials for conversion or soma‐ toform disorders [92] and some personality disorders [93]. These disorders are frequently occurring comorbidities in PNES patients, which make SSRIs particularly attractive as a

LaFrance et al. conducted a randomised, double-blind, placebo-controlled clinical trial (which meets the criteria for Class II evidence) evaluating the efficacy of flexible-dose sertraline over 12 weeks at reducing PNES frequency and improving other symptom severity and psychoso‐ cial measures [94]. Patients were allowed to participate even with previous antidepressant use, except for monoamine oxidase inhibitors or sertraline at a 100 mg/day or higher dose, to maintain a constant dose of the concurrent antidepressants for the study duration. The sertraline group experienced a 45% decline in biweekly seizure rates over the 12-week course of the intervention from 22.24 to 12.18 (ratio, 0.55; 95% CI, 0.32-0.93; p = 0.03), while the control group showed an 8% increase from 13.38 to 14.38 (ratio, 1.08; 95% CI, 0.65-1.77; p = 0.78). However, the limited sample size (33 patients were included in the final analysis) implied this study was underpowered and unable to detect statistically significant differences between groups (RR, 0.51; 95% CI, 0.25-1.05; p = 0.29). There were no differences in secondary outcome measure changes between the groups (a series of scales assessing different psychiatric symptoms, functionality and quality of life-related measures). The evaluation of SSRIs in larger, randomised, controlled trials is therefore necessary to establish solid treatment

Venlafaxine, a noradrenalin-serotonin reuptake inhibitor (NSRI), has also been evaluated as a potential psychopharmacological PNES treatment. An open-label, prospective, uncontrolled study evaluated the efficacy of flexible-dose venlafaxine on seizure frequency reduction and anxiety and depression disorder severity improvement [95]. All enrolled subjects had vEEGconfirmed PNES but also met the DSM-IV criteria for a unipolar depressive disorder and/or anxiety disorder. The 19 subjects who completed the 5-month follow-up experienced a statistically significant reduction in all symptom scales and monthly event frequency at the five-month assessment compared with the initial assessment; however, no differences were detected in the patient subgroup with more than ten events in the 15-day baseline pre-inclusion

the control group, as other authors have previously reported [89].

**4.12. Pharmacological treatment**

214 Epilepsy Topics

potential treatment.

guidelines.

PNES is one of the most frustrating clinical pathologies. Diagnosis is sometimes difficult and can take several years to reach a definitive PNES diagnosis. Moreover, treatment can be even more difficult. However, PNES is a severely debilitating illness for the patient, family and society; thus, we must continue to identify and improve patient quality-of-life. Nevertheless, a significant percentage of patients referred to epilepsy surgery units present with PNES, where the necessary assessments, such as vEEG, can provide a correct diagnosis; therefore, the actual magnitude of PNES diagnoses may be larger than currently detectable.

Hence, when assessing patients with epilepsy, the PNES pathology should be kept in mind and patients should be sent to a specialised unit, even under the minimal suspicion of PNES, to provide a correct diagnosis in a timely manner. These steps should minimise medication side-effects and consumption of health care resources and offer the patient the most efficacious treatment.

[3] Bodde NM, Brooks JL, Baker GA, Boon PA, Hendriksen JG, Mulder OG, Aldenkamp AP. Psychogenic non-epileptic seizures – definition, treatment and prognostic issues:

Psychogenic Non-Epileptic Seizures in a Surgical Epilepsy Unit: Experience and a Comprehensive Review

http://dx.doi.org/10.5772/57439

217

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[11] Reuber M. The etiology of psychogenic non-epileptic seizures: toward a biopsycho‐

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#### **Acknowledgements**

This work was supported by a grant from the Plan Nacional de Investigación Científica, Desarrollo e Innovación Tecnológica (I+D+I), Instituto de Salud Carlos III, Subdirección General de Evaluación y Fomento de la Investigación PI12/02839.

#### **Author details**

Lorena Vega-Zelaya1 , Marta Alvarez2 , Elena Ezquiaga2 , Jaime Nogeiras2 , María Toledo3 , Rafael G. Sola4 and Jesús Pastor1\*

\*Address all correspondence to: jesus.pastor@salud.madrid.org

1 Clinical Neurophysiology, National Referral Centre for Refractory Epilepsy, Hospital La Princesa, Madrid, Spain

2 Psychiatry, National Referral Centre for Refractory Epilepsy, Hospital La Princesa, Ma‐ drid, Spain

3 Neurology, National Referral Centre for Refractory Epilepsy, Hospital La Princesa, Ma‐ drid, Spain

4 Neurosurgery, National Referral Centre for Refractory Epilepsy, Hospital La Princesa, Ma‐ drid, Spain

#### **References**


[3] Bodde NM, Brooks JL, Baker GA, Boon PA, Hendriksen JG, Mulder OG, Aldenkamp AP. Psychogenic non-epileptic seizures – definition, treatment and prognostic issues: a critical review. Seizure 2009;18(8) 543–53.

Hence, when assessing patients with epilepsy, the PNES pathology should be kept in mind and patients should be sent to a specialised unit, even under the minimal suspicion of PNES, to provide a correct diagnosis in a timely manner. These steps should minimise medication side-effects and consumption of health care resources and offer the patient the most efficacious

This work was supported by a grant from the Plan Nacional de Investigación Científica, Desarrollo e Innovación Tecnológica (I+D+I), Instituto de Salud Carlos III, Subdirección

, Elena Ezquiaga2

1 Clinical Neurophysiology, National Referral Centre for Refractory Epilepsy, Hospital La

2 Psychiatry, National Referral Centre for Refractory Epilepsy, Hospital La Princesa, Ma‐

3 Neurology, National Referral Centre for Refractory Epilepsy, Hospital La Princesa, Ma‐

4 Neurosurgery, National Referral Centre for Refractory Epilepsy, Hospital La Princesa, Ma‐

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**Acknowledgements**

**Author details**

Lorena Vega-Zelaya1

Princesa, Madrid, Spain

Rafael G. Sola4

drid, Spain

drid, Spain

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[95] Pintor L, Baillés E, Matrai S, Carreño M, Donaire A, Boget T, Setoain X, Rumia J, Bar‐ galló N. Efficiency of venlafaxine in patients with psychogenic nonepileptic seizures and anxiety and/or depressive disorders. J Neuropsychiatry Clin Neurosci. 2010;22(4)

[96] Chastan N, Parain D. Psychogenic paralysis and recovery after motor cortex transcra‐

nial magnetic stimulation. Mov Disord. 2010;25(10) 1501-4.

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[84] Prigatano GP, Stonnington CM, Fisher RS. Psychological factors in the genesis and management of nonepileptic seizures: clinical observations. Epilepsy Behav. 2002;3(4) 343-349.

[70] Bautista RE, Gonzales-Salazar W, Ochoa JG. Expanding the theory of symptom mod‐ eling in patents with psychogenic nonepileptic seizures. Epilepsy Behav. 2008;13(2)

[71] Brown RJ, Bouska JF, Frow A, Kirkby A, Baker GA, Kemp S, Burness C, Reuber M. Emotional dysregulation, alexithymia, and attachment in psychogenic nonepileptic

[72] Walczak TS, Papacostas S, Williams DT, Scheuer ML, Lebowitz N, Notarfrancesco A. Outcome after diagnosis of psychogenic nonepileptic seizures. Epilepsia. 1995;36(11)

[73] Reuber M, Mitchell AJ, Howlett S, Elger CE. Measuring outcome in psychogenic non‐ epileptic seizures: how relevant is seizure remission? Epilepsia. 2005;46(11) 1788-95.

[74] Kanner AM, Parra J, Frey M, Stebbins G, Pierre-Louis S, Iriarte J. Psychiatric and neu‐ rologic predictors of psychogenic pseudoseizure outcome. Neurology. 1999;53(5)

[75] Farias ST, Thieman C, Alsaadi TM. Psychogenic nonepileptic seizures: acute change in event frequency after presentation of the diagnosis. Epilepsy Behav. 2003;4(4)

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[77] Jirsch JD, Ahmed SN, Maximova K, Gross DW. Recognition of psychogenic nonepi‐ leptic seizures diminishes acute care utilization. Epilepsy Behav. 2011;22(2) 304-7. [78] LaFrance WC Jr, Alper K, Babcock D, Barry JJ, Benbadis S, Caplan R, Gates J, Jacobs M, Kanner A, Martin R, Rundhaugen L, Stewart R, Vert C; NES Treatment Workshop participants. Nonepileptic seizures treatment workshop summary. Epilepsy Behav.

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[97] O'Malley PG, Jackson JL, Santoro J, Tomkins G, Balden E, Kroenke K. Antidepressant therapy for unexplained symptoms and symptom syndromes. J Fam Pract. 1999;48(12) 980-90.

**Chapter 11**

**Quality of Life Issues in Epilepsy**

Additional information is available at the end of the chapter

ventions that may alleviate the burden of psychosocial problems.

**1.1. Epilepsy & psychosocial functioning**

There is overwhelming evidence that people with epilepsy (PWE) have a number of psycho‐ social difficulties which impact greatly on their quality of life [1]. To this end the chapter will summarise some definitive clinical features of the disorder and then go on to provide an overview of the types of psychosocial deficits that PWE experience and the influence of epilepsy related variables on these factors. The chapter will conclude by considering inter‐

The themes addressed in this chapter emerged from observing the symptoms and behaviours exhibited by patients with epilepsy who were attending a tertiary referral unit in the UK. The majority of patients have intractable epilepsy (difficult to manage seizures) and a number of these patients were being assessed to see if they were viable candidates for surgery. A recurring problem reported by epilepsy patients attending the unit was that they experienced a number of difficulties in relation to social functioning. Such difficulties have been evident in the wider epilepsy population where PWE often report difficulties such as low self-worth, stigma, social isolation, difficulties with interpersonal relationships and in gaining and maintaining em‐

In reviewing the literature it is evident that quality of life in PWE is determined by the interplay of a number of multifaceted biopsychosocial factors. Psychosocial factors include comorbid anxiety and depression, cognitive deficits, the impact of stigma, low self-esteem, reduced opportunities for social interaction, difficulties in both intimate and non-intimate relationships and employability [1-15]. The impact of these factors on the quality of life of people with epilepsy in relation to epilepsy related variables will be discussed throughout the chapter.

> © 2014 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Jane McCagh

**1. Introduction**

ployment [1].

http://dx.doi.org/10.5772/58689

### **Chapter 11**

## **Quality of Life Issues in Epilepsy**

Jane McCagh

[97] O'Malley PG, Jackson JL, Santoro J, Tomkins G, Balden E, Kroenke K. Antidepressant therapy for unexplained symptoms and symptom syndromes. J Fam Pract.

1999;48(12) 980-90.

224 Epilepsy Topics

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/58689

#### **1. Introduction**

There is overwhelming evidence that people with epilepsy (PWE) have a number of psycho‐ social difficulties which impact greatly on their quality of life [1]. To this end the chapter will summarise some definitive clinical features of the disorder and then go on to provide an overview of the types of psychosocial deficits that PWE experience and the influence of epilepsy related variables on these factors. The chapter will conclude by considering inter‐ ventions that may alleviate the burden of psychosocial problems.

#### **1.1. Epilepsy & psychosocial functioning**

The themes addressed in this chapter emerged from observing the symptoms and behaviours exhibited by patients with epilepsy who were attending a tertiary referral unit in the UK. The majority of patients have intractable epilepsy (difficult to manage seizures) and a number of these patients were being assessed to see if they were viable candidates for surgery. A recurring problem reported by epilepsy patients attending the unit was that they experienced a number of difficulties in relation to social functioning. Such difficulties have been evident in the wider epilepsy population where PWE often report difficulties such as low self-worth, stigma, social isolation, difficulties with interpersonal relationships and in gaining and maintaining em‐ ployment [1].

In reviewing the literature it is evident that quality of life in PWE is determined by the interplay of a number of multifaceted biopsychosocial factors. Psychosocial factors include comorbid anxiety and depression, cognitive deficits, the impact of stigma, low self-esteem, reduced opportunities for social interaction, difficulties in both intimate and non-intimate relationships and employability [1-15]. The impact of these factors on the quality of life of people with epilepsy in relation to epilepsy related variables will be discussed throughout the chapter.

© 2014 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **2. Epilepsy**

Epilepsy is the most common serious neurological disorder affecting people across the world with approximately 50 million people living with the condition [16]. The highest incidence and prevalence rates of epilepsy are in the early and later years of life. The largest majority of PWE (approx. 80%) live in developing countries with limited access to treatment [17]. This can be due to economic constraints but is most commonly a consequence of misconceptions about the origins of epilepsy. Some cultures believe that the condition is not organically based and therefore not treatable by medical intervention. Such misconceptions have been reflected historically where epilepsy was regarded as a 'sacred disease' representing possession by evil spirits or retribution by the gods.

Misconception, myths and stereotypes are still prevalent in media portrayals of epilepsy despite advances in education [32]. These misconceptions contribute to the psychosocial limitations and stigma experienced by PWE. The idea that epilepsy is defined by the symptoms of a tonic clonic seizure is often perpetuated by the media. Media portrayals are often mis‐ guided by ancient myths that see the person with epilepsy as being possessed by demons, frothing at the mouth, violent and in need of urgent medical care [32-33]. Consequently the media can hinder educating people about epilepsy by broadcasting inaccurate portrayals or misinformation [23]. Research suggests that misconceptions are more evident in individuals

Quality of Life Issues in Epilepsy http://dx.doi.org/10.5772/58689 227

Negative attitudes in society have created fear and stigma. The stigma of epilepsy can often be more debilitating for PWE than presenting symptoms. Subsequently individuals with epilepsy conceal their condition or are isolated within their family in an attempt to lessen the social stigma associated with the disorder and to increase marital prospects [2,12]. Psychosocial limitations in relation to employment and relationships are more likely to be a consequence of stigma in society than symptoms of epilepsy [23]. Withdrawing from society in order to reduce the experience of stigma can greatly impact on the quality of life of PWE by making them feel more socially isolated, have less social opportunities and smaller social support networks. This in turn can reduce their ability to cope with epilepsy. The uncertainty of having a seizure in public without warning can increase the likelihood of withdrawal. This is supported by research findings where fear of having a seizure and the uncertainty associated with epilepsy (such as if seizures will ever be controlled) were primary concerns of individuals living with the condition [7]. This uncertainty can increase vulnerability in social situations and greatly

The presence of stigma is complex and researchers have established two different types of stigma affecting PWE. Enacted stigma is when PWE experience discrimination because of their condition and felt stigma is apparent when PWE fear being subjected to enacted stigma [35]. Often there is a difference between the two, with felt stigma being more prevalent [36-37]. In a large cross cultural study of with over 5,000 participants, 51% of PWE felt stigma as a consequence of having the condition [3]. Perceived stigma is subjective and will differ across individuals. Felt stigma has been shown to depend on whether the individual feels that they have been discriminated against in the work place or constrained in their day to day life as a consequence of having epilepsy [38]. Personality, coping ability and the perceived impact of epilepsy in gaining and maintaining employment can greatly influence felt stigma [39] and increased time spent in education has been shown to reduce felt stigma [38]. The severity of the condition in early life has been found to impact on psychosocial sequalae and treatment

Felt and enacted stigma are influential in getting work and keeping it and stigma has far reaching consequences that impact upon interpersonal relationships, employability, health and quality of life [12; 41]. Children may feel stigma because they are subjected to an overprotective parental style which in turn may compromise their self-esteem when they

interventions at this stage can be effective in reducing felt stigma [12, 40].

who do not know someone with epilepsy [32].

impact on quality of life [1, 34].

are older [42-44].

Epilepsy is a complex disorder with many different seizure types and syndromes. An epileptic seizure is defined as 'a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain' [19, p 471]. Definitions of epilepsy often focus on the unprovoked and recurrent nature of seizures as not all individuals who experience a seizure will be given a diagnosis of epilepsy. Some individuals have a lower threshold to seizure activity [18]. Single isolated seizures and those which stem from systemic changes in the body, illness or an insult to the head do not constitute a diagnosis [20]. Epilepsy can often be comorbid with or caused by other neurological disorders such as cerebrovascular accidents, brain tumours, brain infection, congenital defects, exposure to toxic agents, degen‐ erative disorders, head injury and birth complications. The aetiology of epilepsy varies in accordance with age.

The remainder of the chapter will go on to discuss how epilepsy related variables interrelate with psychosocial factors and effect quality of life.

#### **3. Stigma & misconception**

Historical and media misrepresentations of epilepsy have been overwhelmingly negative and consequently the condition has been clouded by misunderstanding, superstition and discrimination present over many centuries and across different cultures. This in turn increases the experience of stigma in PWE. Contagion beliefs existed up until the 18th century and are still apparent in some African cultures [21-23]. Laws prohibiting marriage in both the UK (until 1970) and America (1956) have only been revoked in the past sixty years [23-24] and more recently over a third of PWE were refused one or more types of insur‐ ance in the UK [25]. Cross culturally the impact of stigma on PWE has caused them to be excluded from important social roles, under achieve in school, to find it more difficult to gain employment, have intimate relationships or maintain family relations [1, 21, 26-28]. Consequently negative attitudes and lack of family support render the individual as being more vulnerable to psychosocial difficulties [2]. Conversely recent research suggests that attitudes towards PWE have become more positive [29-31].

Misconception, myths and stereotypes are still prevalent in media portrayals of epilepsy despite advances in education [32]. These misconceptions contribute to the psychosocial limitations and stigma experienced by PWE. The idea that epilepsy is defined by the symptoms of a tonic clonic seizure is often perpetuated by the media. Media portrayals are often mis‐ guided by ancient myths that see the person with epilepsy as being possessed by demons, frothing at the mouth, violent and in need of urgent medical care [32-33]. Consequently the media can hinder educating people about epilepsy by broadcasting inaccurate portrayals or misinformation [23]. Research suggests that misconceptions are more evident in individuals who do not know someone with epilepsy [32].

**2. Epilepsy**

226 Epilepsy Topics

spirits or retribution by the gods.

accordance with age.

**3. Stigma & misconception**

with psychosocial factors and effect quality of life.

attitudes towards PWE have become more positive [29-31].

Epilepsy is the most common serious neurological disorder affecting people across the world with approximately 50 million people living with the condition [16]. The highest incidence and prevalence rates of epilepsy are in the early and later years of life. The largest majority of PWE (approx. 80%) live in developing countries with limited access to treatment [17]. This can be due to economic constraints but is most commonly a consequence of misconceptions about the origins of epilepsy. Some cultures believe that the condition is not organically based and therefore not treatable by medical intervention. Such misconceptions have been reflected historically where epilepsy was regarded as a 'sacred disease' representing possession by evil

Epilepsy is a complex disorder with many different seizure types and syndromes. An epileptic seizure is defined as 'a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain' [19, p 471]. Definitions of epilepsy often focus on the unprovoked and recurrent nature of seizures as not all individuals who experience a seizure will be given a diagnosis of epilepsy. Some individuals have a lower threshold to seizure activity [18]. Single isolated seizures and those which stem from systemic changes in the body, illness or an insult to the head do not constitute a diagnosis [20]. Epilepsy can often be comorbid with or caused by other neurological disorders such as cerebrovascular accidents, brain tumours, brain infection, congenital defects, exposure to toxic agents, degen‐ erative disorders, head injury and birth complications. The aetiology of epilepsy varies in

The remainder of the chapter will go on to discuss how epilepsy related variables interrelate

Historical and media misrepresentations of epilepsy have been overwhelmingly negative and consequently the condition has been clouded by misunderstanding, superstition and discrimination present over many centuries and across different cultures. This in turn increases the experience of stigma in PWE. Contagion beliefs existed up until the 18th century and are still apparent in some African cultures [21-23]. Laws prohibiting marriage in both the UK (until 1970) and America (1956) have only been revoked in the past sixty years [23-24] and more recently over a third of PWE were refused one or more types of insur‐ ance in the UK [25]. Cross culturally the impact of stigma on PWE has caused them to be excluded from important social roles, under achieve in school, to find it more difficult to gain employment, have intimate relationships or maintain family relations [1, 21, 26-28]. Consequently negative attitudes and lack of family support render the individual as being more vulnerable to psychosocial difficulties [2]. Conversely recent research suggests that Negative attitudes in society have created fear and stigma. The stigma of epilepsy can often be more debilitating for PWE than presenting symptoms. Subsequently individuals with epilepsy conceal their condition or are isolated within their family in an attempt to lessen the social stigma associated with the disorder and to increase marital prospects [2,12]. Psychosocial limitations in relation to employment and relationships are more likely to be a consequence of stigma in society than symptoms of epilepsy [23]. Withdrawing from society in order to reduce the experience of stigma can greatly impact on the quality of life of PWE by making them feel more socially isolated, have less social opportunities and smaller social support networks. This in turn can reduce their ability to cope with epilepsy. The uncertainty of having a seizure in public without warning can increase the likelihood of withdrawal. This is supported by research findings where fear of having a seizure and the uncertainty associated with epilepsy (such as if seizures will ever be controlled) were primary concerns of individuals living with the condition [7]. This uncertainty can increase vulnerability in social situations and greatly impact on quality of life [1, 34].

The presence of stigma is complex and researchers have established two different types of stigma affecting PWE. Enacted stigma is when PWE experience discrimination because of their condition and felt stigma is apparent when PWE fear being subjected to enacted stigma [35]. Often there is a difference between the two, with felt stigma being more prevalent [36-37]. In a large cross cultural study of with over 5,000 participants, 51% of PWE felt stigma as a consequence of having the condition [3]. Perceived stigma is subjective and will differ across individuals. Felt stigma has been shown to depend on whether the individual feels that they have been discriminated against in the work place or constrained in their day to day life as a consequence of having epilepsy [38]. Personality, coping ability and the perceived impact of epilepsy in gaining and maintaining employment can greatly influence felt stigma [39] and increased time spent in education has been shown to reduce felt stigma [38]. The severity of the condition in early life has been found to impact on psychosocial sequalae and treatment interventions at this stage can be effective in reducing felt stigma [12, 40].

Felt and enacted stigma are influential in getting work and keeping it and stigma has far reaching consequences that impact upon interpersonal relationships, employability, health and quality of life [12; 41]. Children may feel stigma because they are subjected to an overprotective parental style which in turn may compromise their self-esteem when they are older [42-44].

Particular clinical features of epilepsy can influence feelings of stigma and psychosocial functioning. Severe and frequent seizures, a chronic form of epilepsy and comorbidity of other conditions can increase psychosocial risk [2]. Becoming seizure free has been reported as the most important epilepsy related factor in relation to quality of life [45]. Seizure type, frequency, severity, age of onset and duration of epilepsy can greatly impact on stigma. PWE who experience more frequent seizures or whose seizures are not well controlled report more stigma, and tonic clonic seizures are more likely to induce stigma due to their dramatic nature and the attention they draw to the individual [3, 9].

may not improve. This can cause PWE to feel that they lack control over their life, can lower mood and heighten feelings of anxiety [6, 52-54]. This has been reflected in re‐ search where PWE demonstrate a lower sense of mastery in relation to healthy controls [55]. Seizure severity and frequency have been shown to be the most influential factors in deter‐ mining self-esteem and sense of mastery in PWE [61, 72]. Knowledge has been found to mediate the impact on self-esteem. Adolescents with more awareness of their condition report higher levels of self-esteem and educational interventions aimed at increasing knowledge have

Quality of Life Issues in Epilepsy http://dx.doi.org/10.5772/58689 229

Low self-esteem is commonly reported in PWE and is often mediated by employability, with those being unemployed reporting poorer self-esteem [4, 7, 9, 39, 74-76]. Research suggests that PWE with an increased sense of mastery are less likely to be affected by stigma and more likely to adhere to drug therapy [77]. Over protective parental styles can work to reduce a sense

Epilepsy has been shown to reduce opportunities for social interaction and PWE can isolate themselves for fear of having a seizure in public and the injury this may cause [7, 10]. Parents may have been over protective in early life which has impeded important independent living skills and confidence in social settings [2, 78]. PWE may also find it harder to gain employment and so are not afforded the same social networks as people without the condition. A reduction in social life has many confounding consequences in terms of social support. Social support can be a protective factor in aiding PWE to cope with living with a chronic condition. The opportunity to develop relationships and maintain them can be compromised and this is evident in the reduced marital status and likelihood of parenting a child in PWE [4, 7, 62, 79-81]. Seizure frequency and age of onset have been negatively related to marital status with those who have more frequent seizures and being younger at the age of onset being less likely

A research study investigated the employment, marital, social and educational status of 343 PWE [81]. The marital status of males and females over the age of twenty was much lower than that of the general population (males 33% compared to 65% and females 46% compared to 73%). Poor seizure control was indicative of people with poor social status. A similar disparity was found in another study where 42% of PWE in comparison to 71% without

Parental beliefs may be self-fulfilling, one study found that parents who believe their child will experience stigma and experience limitations reported more behavioural problems in their children than parents who did not hold such beliefs 82]. This study also found that children who report their parents as over controlling had more behavioural problems than children with epilepsy who did not. The authors concluded that seizure type and frequency did not predict behavioural problems but parents perceived stigma, perceived limitations and extent

of mastery and consequently make PWE less independent in adulthood [43].

been successful at enhancing self-esteem in PWE [72-73].

**6. Social factors: Social isolation and relationships**

to marry [9].

of control did.

epilepsy were married [4].

#### **4. Psychological factors: Anxiety and depression**

Both anxiety and depression are common comorbid features in PWE yet psychopathology is undertreated and underdiagnosed [17]. Forty to sixty percent of PWE display symptoms of depression and more than 40% present with anxiety [8, 46]. Depression is 4 to 5 times more likely in PWE than in the general population [16] and anxiety is the most common form of psychopathology reported [4, 9]. Suicide is also far more common in PWE than in the general population [47-48]. There is a reciprocal relationship between anxiety, depression and epilepsy such that those with anxiety and depression are more likely to experience epilepsy and those with epilepsy are more likely to experience anxiety and depression [46, 49-51]. The exact mechanism that underpins this relationship as yet is not fully understood.

Depression and seizure worry were found to be the most influential predictors of quality of life in people with intractable epilepsy [56]. Surgery has been shown to significantly reduce anxiety and increase quality of life in patients who have become seizure free [57]. Seizure related variables such as age of onset, seizure type, frequency, severity, duration, side effects of AED's, underlying aetiology and difficult to control seizures all impact on the prevalence of depression and anxiety [9, 11, 58-61].

Seizure activity in itself can be anxiety inducing especially if medial temporal lobe structures such as the amygdala are involved. Anxiety can occur before, during and after a seizure [46]. PWE may fear having a seizure which will in turn raise anxiety thresholds as will the associated stigma of having a seizure in public [7]. To this end PWE can often isolate themselves so as not to have a seizure at an inopportune moment [62]. Consequently social isolation is very common in PWE [2]. Increased feelings of anxiety and depression can be further compounded by reduced social opportunities, lack of social support, poor self-esteem, a reduced sense of mastery, stigma and discrimination, an overprotective parental style in childhood or voca‐ tional disability [35, 52-54, 63-70]. Self-esteem and sense of mastery have been inversely related to higher scores on measures of depression and anxiety in PWE [71].

#### **5. Dispositional factors: Self-esteem and sense of mastery**

Unpredictability is central to living with epilepsy. Individuals may not know when a seizure will occur and often have difficulty accepting living with a chronic condition that may or may not improve. This can cause PWE to feel that they lack control over their life, can lower mood and heighten feelings of anxiety [6, 52-54]. This has been reflected in re‐ search where PWE demonstrate a lower sense of mastery in relation to healthy controls [55].

Seizure severity and frequency have been shown to be the most influential factors in deter‐ mining self-esteem and sense of mastery in PWE [61, 72]. Knowledge has been found to mediate the impact on self-esteem. Adolescents with more awareness of their condition report higher levels of self-esteem and educational interventions aimed at increasing knowledge have been successful at enhancing self-esteem in PWE [72-73].

Low self-esteem is commonly reported in PWE and is often mediated by employability, with those being unemployed reporting poorer self-esteem [4, 7, 9, 39, 74-76]. Research suggests that PWE with an increased sense of mastery are less likely to be affected by stigma and more likely to adhere to drug therapy [77]. Over protective parental styles can work to reduce a sense of mastery and consequently make PWE less independent in adulthood [43].

#### **6. Social factors: Social isolation and relationships**

Particular clinical features of epilepsy can influence feelings of stigma and psychosocial functioning. Severe and frequent seizures, a chronic form of epilepsy and comorbidity of other conditions can increase psychosocial risk [2]. Becoming seizure free has been reported as the most important epilepsy related factor in relation to quality of life [45]. Seizure type, frequency, severity, age of onset and duration of epilepsy can greatly impact on stigma. PWE who experience more frequent seizures or whose seizures are not well controlled report more stigma, and tonic clonic seizures are more likely to induce stigma due to their dramatic nature

Both anxiety and depression are common comorbid features in PWE yet psychopathology is undertreated and underdiagnosed [17]. Forty to sixty percent of PWE display symptoms of depression and more than 40% present with anxiety [8, 46]. Depression is 4 to 5 times more likely in PWE than in the general population [16] and anxiety is the most common form of psychopathology reported [4, 9]. Suicide is also far more common in PWE than in the general population [47-48]. There is a reciprocal relationship between anxiety, depression and epilepsy such that those with anxiety and depression are more likely to experience epilepsy and those with epilepsy are more likely to experience anxiety and depression [46, 49-51]. The exact

Depression and seizure worry were found to be the most influential predictors of quality of life in people with intractable epilepsy [56]. Surgery has been shown to significantly reduce anxiety and increase quality of life in patients who have become seizure free [57]. Seizure related variables such as age of onset, seizure type, frequency, severity, duration, side effects of AED's, underlying aetiology and difficult to control seizures all impact on the prevalence

Seizure activity in itself can be anxiety inducing especially if medial temporal lobe structures such as the amygdala are involved. Anxiety can occur before, during and after a seizure [46]. PWE may fear having a seizure which will in turn raise anxiety thresholds as will the associated stigma of having a seizure in public [7]. To this end PWE can often isolate themselves so as not to have a seizure at an inopportune moment [62]. Consequently social isolation is very common in PWE [2]. Increased feelings of anxiety and depression can be further compounded by reduced social opportunities, lack of social support, poor self-esteem, a reduced sense of mastery, stigma and discrimination, an overprotective parental style in childhood or voca‐ tional disability [35, 52-54, 63-70]. Self-esteem and sense of mastery have been inversely related

Unpredictability is central to living with epilepsy. Individuals may not know when a seizure will occur and often have difficulty accepting living with a chronic condition that may or

and the attention they draw to the individual [3, 9].

228 Epilepsy Topics

of depression and anxiety [9, 11, 58-61].

**4. Psychological factors: Anxiety and depression**

mechanism that underpins this relationship as yet is not fully understood.

to higher scores on measures of depression and anxiety in PWE [71].

**5. Dispositional factors: Self-esteem and sense of mastery**

Epilepsy has been shown to reduce opportunities for social interaction and PWE can isolate themselves for fear of having a seizure in public and the injury this may cause [7, 10]. Parents may have been over protective in early life which has impeded important independent living skills and confidence in social settings [2, 78]. PWE may also find it harder to gain employment and so are not afforded the same social networks as people without the condition. A reduction in social life has many confounding consequences in terms of social support. Social support can be a protective factor in aiding PWE to cope with living with a chronic condition. The opportunity to develop relationships and maintain them can be compromised and this is evident in the reduced marital status and likelihood of parenting a child in PWE [4, 7, 62, 79-81]. Seizure frequency and age of onset have been negatively related to marital status with those who have more frequent seizures and being younger at the age of onset being less likely to marry [9].

A research study investigated the employment, marital, social and educational status of 343 PWE [81]. The marital status of males and females over the age of twenty was much lower than that of the general population (males 33% compared to 65% and females 46% compared to 73%). Poor seizure control was indicative of people with poor social status. A similar disparity was found in another study where 42% of PWE in comparison to 71% without epilepsy were married [4].

Parental beliefs may be self-fulfilling, one study found that parents who believe their child will experience stigma and experience limitations reported more behavioural problems in their children than parents who did not hold such beliefs 82]. This study also found that children who report their parents as over controlling had more behavioural problems than children with epilepsy who did not. The authors concluded that seizure type and frequency did not predict behavioural problems but parents perceived stigma, perceived limitations and extent of control did.

Young people with epilepsy report social isolation as the most influential factor in determining their quality of life and find it especially difficult to take part in social activities outside of their home environment and to make friends [62]. PWE find it very hard to develop friendships [2], perceived and enacted stigma, lower self-esteem, lack of employment and reduced social opportunities may well account for this.

who recruit PWE and in those who lose their jobs after diagnosis [44, 96]. Whilst the PWE may worry about being discriminated against in the workplace, employers also hold negative

Quality of Life Issues in Epilepsy http://dx.doi.org/10.5772/58689 231

The IBE Employment Commission [cited in 77] conducted a cross cultural study investigating factors that contributed to unemployment. PWE attributed their employment difficulties to; employers having stigmatised views, lack of self-worth, missing school and training, the uncertainty of whether epilepsy will cause a problem in the workplace and not getting the job they want. They felt that laws against discrimination, vocational assessment and epilepsy

Clearly improvements in diagnostic procedures and medical intervention will have important consequences for management, prognosis and psychosocial outcome of epilepsy and in turn improve quality of life. For example, seizure severity is the most influential clinical feature that impacts on felt stigma so seizure management is fundamental in reducing psychosocial consequences in relation to stigma. Two main avenues to increase quality of life in PWE are

Many of the psychosocial difficulties experienced by people with epilepsy stem from the society within which the individual lives which can determine how restricted they are as a consequence of their condition. Misconception about epilepsy is still prevalent in today's society and is influenced by inaccurate perceptions of the disorder. Such representations of epilepsy are disseminated by the media who perpetuate myths and stereotypes that conse‐ quently maintain stigma. Cultural differences in how epilepsy is perceived can influence whether PWE receive adequate treatment, the only way to resolve this is to educate society to

Felt stigma is reported to be the main obstacle for the individual with epilepsy and impacts greatly on social networks, relationships and employability. PWE who have developed efficient coping techniques, have high self-worth and foster more positive attitudes towards their condition are at less risk of psychosocial dysfunction [41, 99-103]. Therefore interventions that focus on increasing self-worth, developing effective coping strategies and positive cognition will help the individual accept their diagnosis, reduce psychosocial deficits and ultimately enhance quality of life. Cognitive behavioural therapy is likely to be particularly useful to this end and is also effective in managing the comorbid impact of anxiety and

Interventions that educate and integrate PWE more into society and increase social opportu‐ nity would reduce feelings of isolation and enhance coping strategies. Education both in schools and the wider community will help reduce stigma which in turn will enhance social prospects. The impact of education is apparent in adolescents with more knowledge about their condition who report higher levels of self-esteem [73]. Social anxiety has been related to

associations working together with employers would help solve the problem [77].

attitudes about employing PWE [97-98].

**8. Strategies to enhance quality of life**

increase understanding and reduce stigma.

depression which are common in PWE.

promoting attitude change in society and in the individual.

Epilepsy can have consequences for the whole family. There is an increased likelihood of mental health problems, stress, reduced social opportunities, marital problems and lower selfesteem in families of PWE [83]. Parental anxiety can also reduce quality of life in children with epilepsy and carers of PWE report being discontent due to reduced social and personal opportunities as a consequence of their role [84-85].

#### **7. Education & employment**

Children with epilepsy have been shown to underachieve at school in comparison to their peers and are more prone to educational difficulties [7, 34, 62]. These difficulties may arise as a consequence of a number of factors. Drug therapy and post ictal confusion may slow cognitive functioning and impact on children's capacity to learn. Children who experience absence seizures in class can often be mistaken for daydreaming, consequently they may not take in all the material taught to them or their attentiveness and behaviour in class may be misinterpreted by the teacher and result in adverse consequences. Children with more severe seizure types may miss time off school and may also be more prone to stigma if they have a seizure in class. Seizures can impair storage of learned information and consequently frequent seizures are more likely to interfere with educational progress [22].

PWE and those who have a history of epilepsy are prohibited by law from a variety of occupations [86]. Practices that discriminate against people with epilepsy are another major contributing factor to unemployment. Worldwide PWE are unemployed and underemployed in relation to the general population [23, 87]. Seizure related variables contribute to this, PWE who experience frequent seizures have less chance of employment and so do those who experience tonic clonic seizures [9, 88-89]. Adequate seizure control, early age of onset, stigma, side effects of AEDs, poor self-efficacy, poor social skills, education level, social isolation, cognitive deficits, negative attitudes of family members, employers and teachers have all been linked to unemployment and underemployment [90-95].

Internal work beliefs have been highlighted as an important factor in the successful inclusion of people with epilepsy into the workplace [91]. Self-worth, worry about safety at work, perceptions of the likelihood of injury in relation to self and others at work and attitudes of family members were primary factors in work status. A major barrier is stigma which in turn may lower self-worth and discourage PWE from seeking employment, conversely being part of the workforce is also likely to increase self-worth [62, 75 & 91]. As well as individual feelings of stigma, professional stigma may affect employability in the work place [97]. Perceptions of stigma in the workplace and experience of stigma have been found to be of a similar magnitude [40, 98]. Discrimination is apparent in relation to the availability of employment and employers who recruit PWE and in those who lose their jobs after diagnosis [44, 96]. Whilst the PWE may worry about being discriminated against in the workplace, employers also hold negative attitudes about employing PWE [97-98].

The IBE Employment Commission [cited in 77] conducted a cross cultural study investigating factors that contributed to unemployment. PWE attributed their employment difficulties to; employers having stigmatised views, lack of self-worth, missing school and training, the uncertainty of whether epilepsy will cause a problem in the workplace and not getting the job they want. They felt that laws against discrimination, vocational assessment and epilepsy associations working together with employers would help solve the problem [77].

#### **8. Strategies to enhance quality of life**

Young people with epilepsy report social isolation as the most influential factor in determining their quality of life and find it especially difficult to take part in social activities outside of their home environment and to make friends [62]. PWE find it very hard to develop friendships [2], perceived and enacted stigma, lower self-esteem, lack of employment and reduced social

Epilepsy can have consequences for the whole family. There is an increased likelihood of mental health problems, stress, reduced social opportunities, marital problems and lower selfesteem in families of PWE [83]. Parental anxiety can also reduce quality of life in children with epilepsy and carers of PWE report being discontent due to reduced social and personal

Children with epilepsy have been shown to underachieve at school in comparison to their peers and are more prone to educational difficulties [7, 34, 62]. These difficulties may arise as a consequence of a number of factors. Drug therapy and post ictal confusion may slow cognitive functioning and impact on children's capacity to learn. Children who experience absence seizures in class can often be mistaken for daydreaming, consequently they may not take in all the material taught to them or their attentiveness and behaviour in class may be misinterpreted by the teacher and result in adverse consequences. Children with more severe seizure types may miss time off school and may also be more prone to stigma if they have a seizure in class. Seizures can impair storage of learned information and consequently frequent

PWE and those who have a history of epilepsy are prohibited by law from a variety of occupations [86]. Practices that discriminate against people with epilepsy are another major contributing factor to unemployment. Worldwide PWE are unemployed and underemployed in relation to the general population [23, 87]. Seizure related variables contribute to this, PWE who experience frequent seizures have less chance of employment and so do those who experience tonic clonic seizures [9, 88-89]. Adequate seizure control, early age of onset, stigma, side effects of AEDs, poor self-efficacy, poor social skills, education level, social isolation, cognitive deficits, negative attitudes of family members, employers and teachers have all been

Internal work beliefs have been highlighted as an important factor in the successful inclusion of people with epilepsy into the workplace [91]. Self-worth, worry about safety at work, perceptions of the likelihood of injury in relation to self and others at work and attitudes of family members were primary factors in work status. A major barrier is stigma which in turn may lower self-worth and discourage PWE from seeking employment, conversely being part of the workforce is also likely to increase self-worth [62, 75 & 91]. As well as individual feelings of stigma, professional stigma may affect employability in the work place [97]. Perceptions of stigma in the workplace and experience of stigma have been found to be of a similar magnitude [40, 98]. Discrimination is apparent in relation to the availability of employment and employers

opportunities may well account for this.

230 Epilepsy Topics

**7. Education & employment**

opportunities as a consequence of their role [84-85].

seizures are more likely to interfere with educational progress [22].

linked to unemployment and underemployment [90-95].

Clearly improvements in diagnostic procedures and medical intervention will have important consequences for management, prognosis and psychosocial outcome of epilepsy and in turn improve quality of life. For example, seizure severity is the most influential clinical feature that impacts on felt stigma so seizure management is fundamental in reducing psychosocial consequences in relation to stigma. Two main avenues to increase quality of life in PWE are promoting attitude change in society and in the individual.

Many of the psychosocial difficulties experienced by people with epilepsy stem from the society within which the individual lives which can determine how restricted they are as a consequence of their condition. Misconception about epilepsy is still prevalent in today's society and is influenced by inaccurate perceptions of the disorder. Such representations of epilepsy are disseminated by the media who perpetuate myths and stereotypes that conse‐ quently maintain stigma. Cultural differences in how epilepsy is perceived can influence whether PWE receive adequate treatment, the only way to resolve this is to educate society to increase understanding and reduce stigma.

Felt stigma is reported to be the main obstacle for the individual with epilepsy and impacts greatly on social networks, relationships and employability. PWE who have developed efficient coping techniques, have high self-worth and foster more positive attitudes towards their condition are at less risk of psychosocial dysfunction [41, 99-103]. Therefore interventions that focus on increasing self-worth, developing effective coping strategies and positive cognition will help the individual accept their diagnosis, reduce psychosocial deficits and ultimately enhance quality of life. Cognitive behavioural therapy is likely to be particularly useful to this end and is also effective in managing the comorbid impact of anxiety and depression which are common in PWE.

Interventions that educate and integrate PWE more into society and increase social opportu‐ nity would reduce feelings of isolation and enhance coping strategies. Education both in schools and the wider community will help reduce stigma which in turn will enhance social prospects. The impact of education is apparent in adolescents with more knowledge about their condition who report higher levels of self-esteem [73]. Social anxiety has been related to knowledge of the condition such that PWE who have more knowledge are less likely to feel socially anxious [73]. Individual and family counselling may also work to enhance self-esteem in PWE [12].

Psychosocial factors are influenced by a number of clinical features of epilepsy such as seizure frequency, type and severity, duration of the condition, age of onset, aetiology and comorbid conditions. Seizure activity can impair cognitive dysfunction as can AED therapy. Memory deficits are the most commonly reported deficit and seizure activity can disrupt memory consolidation, learning and information storage which can interfere with academic progress consequently PWE may underachieve in education which in itself can reduce psychosocial

Quality of Life Issues in Epilepsy http://dx.doi.org/10.5772/58689 233

It is worth noting that many of the psychosocial difficulties discussed are pertinent to indi‐ viduals with intractable epilepsy where much of the research has been conducted as the severity of the disorder has more profound effects on psychosocial functioning so may not be

[1] McCagh J., Fisk J.E., Baker G.A. Epilepsy, psychosocial and cognitive functioning.

[2] Austin K. and deBoer H. Disruptions in social functioning and services facilitating adjustment for the child and adult. In: Engel Jr. J., Pedley, T.A. (eds.) Epilepsy: A

[3] Baker G A., Brooks J., Buck D., Jacoby A. The stigma of epilepsy: a European per‐

[4] Collings J. A. Psychosocial well-being and epilepsy: an empirical study. Epilepsia

[5] Corcoran R., Thompson P. Epilepsy and poor memory. Who complains and what do

[6] de Souza.E.A.P. and Salgado P.C.B. A psychosocial view of anxiety and depression

[7] Fisher R.S., Vickrey B.G., Gibson P., Hermann B., Penovich P., Scherer A. et al. The impact of epilepsy from the patient's perspective II: Views about therapy and health

they mean? British Journal of Clinical Psychology 1993; 32 199-208.

Comprehensive Textbook). Philadelphia: Lippincott-Raven; 1997 p2191–2201.

opportunities, employability and financial status.

relevant to all PWE [2].

Liverpool Hope University, England

Epilepsy Research, 2009; 86 1-14.

spective. Epilepsia 2000; 41 98–104.

in epilepsy. Epilepsy &Behavior 2006; 8 232-8.

care. Epilepsy Research 2000; 41 53–61.

1990; 31, 418-426.

**Author details**

Jane McCagh\*

**References**

Support groups for both the individual and their family can increase social support and facilitate coping strategies [104-105]. Educating families and PWE will enable better selfmanagement of the condition and reduce seizure activity which may be effective in reducing psychosocial sequalae and felt stigma. Non adherence to medication has been found to be the main reason for a seizure on PWE, also lack of awareness of the condition can increase felt stigma in PWE [106]. Stress also plays a significant role in seizure activity so stress management techniques may prove to be useful in aiding PWE to reduce seizure triggers.

Respite, social support groups and increased education for families of children with epilepsy would be useful in highlighting how parental behaviour can impact on the child [85]. This would help reduce the impact that parental anxiety and overprotectiveness can have on the self-esteem, independence and overall quality of life of the child now and in later life.

Vocational interventions could increase employability and confidence in dealing with epilepsy related issues in the work place especially in relation to disclosure of the disorder and how best to manage this. PWE report being very concerned and unsure about disclosing their condition when applying for jobs [107]. Role play may be useful in helping to increase the confidence of PWE in being able to disclose their condition and aid them in explaining to employers and colleagues what they should do in the event of a seizure [108]. This may have another added benefit by increasing feelings of control and sense of mastery in PWE and by encouraging positive coping strategies. Another strategy to improve employability is to make vocational training more available to PWE [97].

#### **9. Chapter summary**

This chapter has reviewed the main psychosocial difficulties PWE experience as consequence of epilepsy and its treatment. The main psychosocial issues stem from felt and enacted stigma which can reduce social opportunities in a number of ways. Stigma impacts on self-esteem, sense of control, the ability to gain and sustain employment, to form and maintain relationships and can increase feelings of social isolation. PWE may have a reduced sense of autonomy as a consequence of being exposed to over protective parental styles and underachieve in the education system due to ill health and absence. PWE are more commonly unemployed or underemployed than the general population which may well be a consequence of stigma or disruptions to academic engagement. This in turn can increase feelings of isolation which may also be compounded by the fear of having a seizure in public. Reduced autonomy and social opportunity can impact on building friendships and relationships which is evident in the reduced marital status of PWE in relation to the general public.

Psychiatric comorbidities such as anxiety and depression are often present in PWE, these can precede and be an outcome of having the condition and impinge on psychosocial outcomes.

Psychosocial factors are influenced by a number of clinical features of epilepsy such as seizure frequency, type and severity, duration of the condition, age of onset, aetiology and comorbid conditions. Seizure activity can impair cognitive dysfunction as can AED therapy. Memory deficits are the most commonly reported deficit and seizure activity can disrupt memory consolidation, learning and information storage which can interfere with academic progress consequently PWE may underachieve in education which in itself can reduce psychosocial opportunities, employability and financial status.

It is worth noting that many of the psychosocial difficulties discussed are pertinent to indi‐ viduals with intractable epilepsy where much of the research has been conducted as the severity of the disorder has more profound effects on psychosocial functioning so may not be relevant to all PWE [2].

#### **Author details**

Jane McCagh\*

knowledge of the condition such that PWE who have more knowledge are less likely to feel socially anxious [73]. Individual and family counselling may also work to enhance self-esteem

Support groups for both the individual and their family can increase social support and facilitate coping strategies [104-105]. Educating families and PWE will enable better selfmanagement of the condition and reduce seizure activity which may be effective in reducing psychosocial sequalae and felt stigma. Non adherence to medication has been found to be the main reason for a seizure on PWE, also lack of awareness of the condition can increase felt stigma in PWE [106]. Stress also plays a significant role in seizure activity so stress management

Respite, social support groups and increased education for families of children with epilepsy would be useful in highlighting how parental behaviour can impact on the child [85]. This would help reduce the impact that parental anxiety and overprotectiveness can have on the

Vocational interventions could increase employability and confidence in dealing with epilepsy related issues in the work place especially in relation to disclosure of the disorder and how best to manage this. PWE report being very concerned and unsure about disclosing their condition when applying for jobs [107]. Role play may be useful in helping to increase the confidence of PWE in being able to disclose their condition and aid them in explaining to employers and colleagues what they should do in the event of a seizure [108]. This may have another added benefit by increasing feelings of control and sense of mastery in PWE and by encouraging positive coping strategies. Another strategy to improve employability is to make

This chapter has reviewed the main psychosocial difficulties PWE experience as consequence of epilepsy and its treatment. The main psychosocial issues stem from felt and enacted stigma which can reduce social opportunities in a number of ways. Stigma impacts on self-esteem, sense of control, the ability to gain and sustain employment, to form and maintain relationships and can increase feelings of social isolation. PWE may have a reduced sense of autonomy as a consequence of being exposed to over protective parental styles and underachieve in the education system due to ill health and absence. PWE are more commonly unemployed or underemployed than the general population which may well be a consequence of stigma or disruptions to academic engagement. This in turn can increase feelings of isolation which may also be compounded by the fear of having a seizure in public. Reduced autonomy and social opportunity can impact on building friendships and relationships which is evident in the

Psychiatric comorbidities such as anxiety and depression are often present in PWE, these can precede and be an outcome of having the condition and impinge on psychosocial outcomes.

self-esteem, independence and overall quality of life of the child now and in later life.

techniques may prove to be useful in aiding PWE to reduce seizure triggers.

vocational training more available to PWE [97].

reduced marital status of PWE in relation to the general public.

**9. Chapter summary**

in PWE [12].

232 Epilepsy Topics

Liverpool Hope University, England

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[94] Thorbecke R., and Fraser R.T. The range of needs and services in vocational rehabili‐ tation. . In: Engel J. Jr., Pedley T.A. (eds.). Epilepsy: a comprehensive textbook Phila‐

[95] International League Against Epilepsy. Epidemiology. Epilepsia 2003; 44 (suppl. 6):

[96] Thompson P.J. and Oxley J. Socioeconomic accompaniments of severe epilepsy. Epi‐

[97] Hauser W.A. and Hesdorffer D.C. Epilepsy: frequency, causes and consequences.

[98] Bautista R.E.D. and Wludyka P. Factors associated with employment in epilepsy pa‐

[99] Cooper M. Epilepsy and employment: employer's attitudes. Seizure 1995; 4 193-9.

[100] Oosterhuis A. Coping with epilepsy: the effects of coping styles on self-perceived

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[81] Carlton-Ford S., Miller R., Mealeigh N., Sanchez N. The effects of perceived stigma and psychological over-control on the behavioural problems of children with epilep‐

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[103] Dilorio C., Shafer P.O., Letz R., Henry T.R., Schomer D.L., Yeager K. et al. Project EASE : a study to test a psychosocial model of epilepsy medication management. Ep‐ ilepsy & Behavior 2004; 5 926-36.

**Chapter 12**

**Marriage of Epileptic Patients**

Azra Alajbegovic, Jasminka Djelilović-Vranić,

Additional information is available at the end of the chapter

Epilepsy is a common syndrome. It occurs equally in all countries and in all nations represents

Human beings and their environment are constantly affecting each other, while under the term environment we include social, physical and economic milieu. The main need of people in general, as well as patients with epilepsy is to lead a normal life. The patient must be accepted as a whole person with the inevitable limitations imposed by the disease. Epileptic patients during their life are exposed to a series of related specific social relations from early childhood including relationships with parents, relationships during education, relation to vocational rehabilitation, the ability to drive, and for a variety of activities throughout life. Yet the oldest and biggest handicap is the dilemma of patients with epilepsy related to marriage and

The existence of the disease always results in response of the patients to disease, most often with non-psychotic character such as: mood disorders, certain personality changes that are closely related to relationship patient-society through the following parameters: public attitudes toward epilepsy, social situation of patients outside hospitals, rehabilitation of patients with epilepsy, education of patients and the immediate environment, the problems of vocational guidance, aspects of military doctrine, the ability to drive, ability to be involved in some sports, etc. Therefore, patients with epilepsy, to which is imposed the need "to live with epilepsy", often react with depression. Dominian et al (1963) found that depression is the

Depressive reactions are usually of reactive nature andmore often present in patients with temporal lobe epilepsy than in patients with other types of seizures. In addition to depression,

> © 2014 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

in response to the disease, also are seen neurotic syndromes and anxiety disorders.

most common psychiatric symptom in patients with epilepsy [3].

Salem Alajbegović and Lejla Alajbegović

a significant social and medical problem [1].

http://dx.doi.org/10.5772/58635

**1. Introduction**

parenthood [1,2].


### **Chapter 12**

## **Marriage of Epileptic Patients**

Azra Alajbegovic, Jasminka Djelilović-Vranić, Salem Alajbegović and Lejla Alajbegović

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/58635

#### **1. Introduction**

[103] Dilorio C., Shafer P.O., Letz R., Henry T.R., Schomer D.L., Yeager K. et al. Project EASE : a study to test a psychosocial model of epilepsy medication management. Ep‐

[104] Kobau R., Diloro C. Epilepsy self-management: a comparison of self-efficacy and out‐ come expectancy for medication adherence and lifestyle behaviours among people

[105] Kurtz L.F., Powell T.J. Three approaches to understanding groups. Social Work

[106] Trostle J.A., Hauser W.A., Sharbrough F.W. Psychological and social adjustment to

[107] Baker G.A. People with epilepsy: what do they know and understand, and how does this contribute to their perceived level of stigma? Epilepsy & Behavior 2002; 3 S26-32.

[108] Bishop M. Barriers to employment among people with epilepsy: Report of a focus

ilepsy & Behavior 2004; 5 926-36.

Groups 1987; 10 3 69-80.

240 Epilepsy Topics

with epilepsy. Epilepsy & Behavior 2004; 4 217-25.

epilepsy in Rochester, Minnesota. Neurology 1989; 36 633.

group. Journal of Vocational Rehabilitation 2002; 17 281-286.

Epilepsy is a common syndrome. It occurs equally in all countries and in all nations represents a significant social and medical problem [1].

Human beings and their environment are constantly affecting each other, while under the term environment we include social, physical and economic milieu. The main need of people in general, as well as patients with epilepsy is to lead a normal life. The patient must be accepted as a whole person with the inevitable limitations imposed by the disease. Epileptic patients during their life are exposed to a series of related specific social relations from early childhood including relationships with parents, relationships during education, relation to vocational rehabilitation, the ability to drive, and for a variety of activities throughout life. Yet the oldest and biggest handicap is the dilemma of patients with epilepsy related to marriage and parenthood [1,2].

The existence of the disease always results in response of the patients to disease, most often with non-psychotic character such as: mood disorders, certain personality changes that are closely related to relationship patient-society through the following parameters: public attitudes toward epilepsy, social situation of patients outside hospitals, rehabilitation of patients with epilepsy, education of patients and the immediate environment, the problems of vocational guidance, aspects of military doctrine, the ability to drive, ability to be involved in some sports, etc. Therefore, patients with epilepsy, to which is imposed the need "to live with epilepsy", often react with depression. Dominian et al (1963) found that depression is the most common psychiatric symptom in patients with epilepsy [3].

Depressive reactions are usually of reactive nature andmore often present in patients with temporal lobe epilepsy than in patients with other types of seizures. In addition to depression, in response to the disease, also are seen neurotic syndromes and anxiety disorders.

© 2014 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

These physiological changes in patients are the result of the complexity of psychosocial factors in relationship patient-environment, while is more significant relationship between the environment to disease and patient than relationship of patients to the disease [4,5].

Alstrom (1950) showed that eugenic laws which prohibited a patient suffering from epilepsy to marry and have children did not discouraged mentally healthy patients to marry and have children. Alstrom's study showed that the following parameters significantly reduce the

Marriage of Epileptic Patients http://dx.doi.org/10.5772/58635 243

**2.** Mental disorders related to the illness or incurred as a reaction to the disease in terms of

In the U.S., Lennox and Mchram in 1963 found that the specific nuptiality in patients with epilepsy is lower than in the general population, especially in patients whose seizures began before the age of ten. In Germany, the eugenic law was declared in 1935. Essen and Moler (1955) determined that the establishment of eugenic laws in Germany prevented patients to establish marital community, but did not significantly influence the fertility of women with

Andersen (1972) proved that for most patients with epilepsy hereditary factor is not higher than hereditary factor for other diseases that have a variety of factors in their emergence, such as diabetes considering that it in the same way predetermines marriage and parent‐ hood in patients with epilepsy as for those suffering from diabetes. In Quebec, where there were no eugenic laws that would affect the patients with epilepsy, there are few reports on the social conditions of people with epilepsy. Tomasi and Davidson (1949) found a low rate of married men (33%) among 160 patients. Pond and Gudmston (1966) found that the reduced rate of marriages of male patients compared to women with epilepsy in compari‐ son with the general population. At the Clinic of Neurology at Montreal Dansky Linda, Eva Andermann and Frederic Andermann (1978) found a reduced specific nuptiality in patients with epilepsy. Social handicap of men with epilepsy is higher because woman can stay in the house, living with their illness separated from the environment. A man has to deal with the problems of employment, to obtain the material basis for himself and his family. Therefore, the ability of men suffering from epilepsy to devise the marriage and to get married are significantly lower than in women with epilepsy as it is more unlikely that

It's common cohabitation of women with epilepsy, as well as the readiness of having children in these communities. The diversity of male and female pattern is partly conditioned by psychosocial factors, in part probably this has a background in often found and described disturbed sexuality of patients with epilepsy. After discontinuation of bromide therapy it was observed that many patients with temporal lobe epilepsy continue to have reduced sex drive in terms of hypopotence and impotence, as well that in patients with temporal lobe epilepsy after temporal lobectomy sexual activity and sexual interest is restored. In some patients is also described hyper sexuality, with other changes in the quality of sex drive like transsexu‐

**1.** Early onset of the seizures, seizures which began before the age of ten;

possibility of marriage and fertility:

epilepsy [7].

organic deterioration of mental function.

men with epilepsy will have offspring [14].

alism, fetishism and homosexuality [15,16,17].

In addition to responses to the disease that is of reactive character in patients with epilepsy, there is often "accompanying personality disorder" which is usually seen in patients with temporal lobe epilepsy. Changes which are encountered in this group of patients are: reduced ability to adapt, some "stickiness" in behavior, slowed thinking, redundancy in speech, formalism and pedantry, hypertrophic modesty, lability of mood and frequent hypochondria. In emergence of this specific personality profile are associated many factors: the occasional temporal lobe lesions, antiepileptic therapy, social and psychological impacts.

The specificity of the social status of people with epilepsy and attitude of the environment to the epilepsy can be best seen in the context of the attitude of the environment to some other, more serious and severe diseases with significantly greater disability than epilepsy and their better social acceptance than the acceptance of epilepsy. Such patients can, and sometimes do, discover the secret of their illness and from the knowledge of the disease have a certain social, material and other benefits [2,3].

On the other side the patient with epilepsy keeps the disease as "a shameful secret". Fear of seizures in public places restrains their freedom of thought and behavior which leads to avoidance of many life activities with suspicion in regard to marriage and parenthood. Family as a primary community is where the attitude of patients towards themselves, their illness and society is determined [6]. If the family accept the disease and makes an emotional basis for all life activities with frequent monitoring and the possibility of seizure control by medications a patient with epilepsy have a chance to lead a normal life with all its amenities [7].Kocijan-Hercegonja et al. examined the association between adverse psychosocial factors and varia‐ tions in the behavior of patients with epilepsy and found that the social status of the family is one of the most important factors in the forming of the personality, as well as the emergence of mental aberrations. Results showed that children with mental aberrations significantly more frequent originate from families from the countryside, from parents farmers and parents of low economic status [8].

The analysis showed that demographic factors: employment and education, as well as treatment with antiepileptic drugs, with accompanying depressive disorder are variables that are significantly associated with QOLIE-31 total score (p<0.01) which makes 64.8% of the variance in QOLIE-31 overall evaluation including seizure severity, comorbid depression and seizure frequency [5,6].

An important factor is the relationship of psychosocial environment and seizures.Reduction in the frequency of seizures can lead to better social adjustment, on the other hand better social opportunities can lead to a reduction in frequency of seizures [9,10,11]. Fear of the consequen‐ ces of seizures can by itself lead to lowering of the threshold for seizures [12,13].

In relation to marriage and parenthood better psychosocial adjustment in many ways increases the possibility of a patient suffering from epilepsy to get married and make the decision about the offspring [14].

Alstrom (1950) showed that eugenic laws which prohibited a patient suffering from epilepsy to marry and have children did not discouraged mentally healthy patients to marry and have children. Alstrom's study showed that the following parameters significantly reduce the possibility of marriage and fertility:

**1.** Early onset of the seizures, seizures which began before the age of ten;

These physiological changes in patients are the result of the complexity of psychosocial factors in relationship patient-environment, while is more significant relationship between the

In addition to responses to the disease that is of reactive character in patients with epilepsy, there is often "accompanying personality disorder" which is usually seen in patients with temporal lobe epilepsy. Changes which are encountered in this group of patients are: reduced ability to adapt, some "stickiness" in behavior, slowed thinking, redundancy in speech, formalism and pedantry, hypertrophic modesty, lability of mood and frequent hypochondria. In emergence of this specific personality profile are associated many factors: the occasional

The specificity of the social status of people with epilepsy and attitude of the environment to the epilepsy can be best seen in the context of the attitude of the environment to some other, more serious and severe diseases with significantly greater disability than epilepsy and their better social acceptance than the acceptance of epilepsy. Such patients can, and sometimes do, discover the secret of their illness and from the knowledge of the disease have a certain social,

On the other side the patient with epilepsy keeps the disease as "a shameful secret". Fear of seizures in public places restrains their freedom of thought and behavior which leads to avoidance of many life activities with suspicion in regard to marriage and parenthood. Family as a primary community is where the attitude of patients towards themselves, their illness and society is determined [6]. If the family accept the disease and makes an emotional basis for all life activities with frequent monitoring and the possibility of seizure control by medications a patient with epilepsy have a chance to lead a normal life with all its amenities [7].Kocijan-Hercegonja et al. examined the association between adverse psychosocial factors and varia‐ tions in the behavior of patients with epilepsy and found that the social status of the family is one of the most important factors in the forming of the personality, as well as the emergence of mental aberrations. Results showed that children with mental aberrations significantly more frequent originate from families from the countryside, from parents farmers and parents of

The analysis showed that demographic factors: employment and education, as well as treatment with antiepileptic drugs, with accompanying depressive disorder are variables that are significantly associated with QOLIE-31 total score (p<0.01) which makes 64.8% of the variance in QOLIE-31 overall evaluation including seizure severity, comorbid depression and

An important factor is the relationship of psychosocial environment and seizures.Reduction in the frequency of seizures can lead to better social adjustment, on the other hand better social opportunities can lead to a reduction in frequency of seizures [9,10,11]. Fear of the consequen‐

In relation to marriage and parenthood better psychosocial adjustment in many ways increases the possibility of a patient suffering from epilepsy to get married and make the decision about

ces of seizures can by itself lead to lowering of the threshold for seizures [12,13].

environment to disease and patient than relationship of patients to the disease [4,5].

temporal lobe lesions, antiepileptic therapy, social and psychological impacts.

material and other benefits [2,3].

242 Epilepsy Topics

low economic status [8].

seizure frequency [5,6].

the offspring [14].

**2.** Mental disorders related to the illness or incurred as a reaction to the disease in terms of organic deterioration of mental function.

In the U.S., Lennox and Mchram in 1963 found that the specific nuptiality in patients with epilepsy is lower than in the general population, especially in patients whose seizures began before the age of ten. In Germany, the eugenic law was declared in 1935. Essen and Moler (1955) determined that the establishment of eugenic laws in Germany prevented patients to establish marital community, but did not significantly influence the fertility of women with epilepsy [7].

Andersen (1972) proved that for most patients with epilepsy hereditary factor is not higher than hereditary factor for other diseases that have a variety of factors in their emergence, such as diabetes considering that it in the same way predetermines marriage and parent‐ hood in patients with epilepsy as for those suffering from diabetes. In Quebec, where there were no eugenic laws that would affect the patients with epilepsy, there are few reports on the social conditions of people with epilepsy. Tomasi and Davidson (1949) found a low rate of married men (33%) among 160 patients. Pond and Gudmston (1966) found that the reduced rate of marriages of male patients compared to women with epilepsy in compari‐ son with the general population. At the Clinic of Neurology at Montreal Dansky Linda, Eva Andermann and Frederic Andermann (1978) found a reduced specific nuptiality in patients with epilepsy. Social handicap of men with epilepsy is higher because woman can stay in the house, living with their illness separated from the environment. A man has to deal with the problems of employment, to obtain the material basis for himself and his family. Therefore, the ability of men suffering from epilepsy to devise the marriage and to get married are significantly lower than in women with epilepsy as it is more unlikely that men with epilepsy will have offspring [14].

It's common cohabitation of women with epilepsy, as well as the readiness of having children in these communities. The diversity of male and female pattern is partly conditioned by psychosocial factors, in part probably this has a background in often found and described disturbed sexuality of patients with epilepsy. After discontinuation of bromide therapy it was observed that many patients with temporal lobe epilepsy continue to have reduced sex drive in terms of hypopotence and impotence, as well that in patients with temporal lobe epilepsy after temporal lobectomy sexual activity and sexual interest is restored. In some patients is also described hyper sexuality, with other changes in the quality of sex drive like transsexu‐ alism, fetishism and homosexuality [15,16,17].

#### **2. Goal**

The goals of this research were:

**1.** Determine the marital status in the random sample of patients with epilepsy with special reference to the marriage in relation to the age when the illness started and determine how the future spouses were informed about the disease in cases when the disease occurred before marriage.

**ii.** Basic data on epilepsy

7. Type of seizures: primary generalized seizures (1), partial seizures

8. Specific heredity: mother (1), father (2), father's relatives (3),

(2), CNS infectious diseases (3), data on head

combined (5) 13. Neurology findings: with focal disturbances (1), without focal distur-

recorded (6) 16. Frequency of epi manifestation: daily (1), weekly (2), monthly (3), every couple months (4), annually (5), in several

unknown (9) 19. Therapeutic reactivity: good – without seizures (1), average – rare crises (2), poor – crises frequent as without therapy (3) 20. Family attitude: interested (1), not interested (2), denial

(3), unknown (4)

years (6), unknown (7) 17. Treatment: on regular basis (1), inordinately (2), not treated (3), unknown (4) 18. Therapy: barbiturates (1), hydantoins (2), barbiturates and hydantoins combined (3), diones (4), ethosuximid (5), Primidon (6), Tegretol (7), Hydanphen and Tegretol combined (8),

bances (2),unknown (3)

disturbances (6), unknown (7)

normal (4), unknown finding (5), unknown whether it was

(6)

12. Constitution: leptos (1), dysplastic (2), athletic (3), picnic (4),

14. Mental changes: personality changes (1), signs of organic psychosyndrome (2), neurotic disturbances (3), oligophrenic (4), psychoses (5), without mental

15. EEG finding: not recorded (1), focal specific changes (2), generalized specific changes (3),

9. Etiology: idiopathic (1), reliable data on birth trauma

10. First epileptic manifestation: at age of 11. Last epileptic manifestation: at age of

 with or without generalization (2), seizures with complex symptomatology (3), combined

seizures (4), unknown (5)

mother's relatives (4), unknown (6)

injury with or without loss of consciences (4), existence of so called "macro factors" (5), unknown 7

245

Marriage of Epileptic Patients http://dx.doi.org/10.5772/58635


#### **3. Material and methodology**

Material for our work represented a group of 98 patients suffering from idiopathic epilepsy with different epileptic manifestations that were treated on outpatient basis at the Neurology Clinic, Clinical Center of the University of Sarajevo. The diagnosis of epilepsy was certain, previously confirmed during clinical treatment. Patients were followed as outpatients for years through Dispensery for epilepsies. For each patient was made a special questionnaire with 40 questions to obtain targeted information about epilepsy, marriage and parenting.

#### **3.1. Marriage of epileptic patients**

II. BASIC DATA ON EPILEPSY


7

#### **ii.** Basic data on epilepsy

**2. Goal**

244 Epilepsy Topics

The goals of this research were:

**3. Material and methodology**

**3.1. Marriage of epileptic patients**

1. Last name, father's name, name

1. Sex: Male (1), Female (2) 2. Year of birth

6. Employment duration

II. BASIC DATA ON EPILEPSY

3. Place of residence (ZIP code and address)

2. Place of birth

**i.** Basic patient data <sup>6</sup>

before marriage.

epilepsy.

**1.** Determine the marital status in the random sample of patients with epilepsy with special reference to the marriage in relation to the age when the illness started and determine how the future spouses were informed about the disease in cases when the disease occurred

**2.** Determine the difference in relation to marriage status between men and women with

**3.** Determine correlations between significant social parameters of marriage and epilepsy as well as patient's profession, marital status, level of education, also marital status according to EEG findings, marital status according to the therapeutic responsiveness, marriage duration according to the type of epileptic events, marriage duration according to therapeutic responsiveness, duration of marriage according to the psychological changes.

Material for our work represented a group of 98 patients suffering from idiopathic epilepsy with different epileptic manifestations that were treated on outpatient basis at the Neurology Clinic, Clinical Center of the University of Sarajevo. The diagnosis of epilepsy was certain, previously confirmed during clinical treatment. Patients were followed as outpatients for years through Dispensery for epilepsies. For each patient was made a special questionnaire with 40

questions to obtain targeted information about epilepsy, marriage and parenting.

3. Education: without formal education (1), grammar school (2), high school

4. Profession: workman (1), craftsman (2), clerk (3), farmer

5. Employed: in profession (1), other workplace (2), unknown (3)

(3), higher (4), college (5), unknown (6)

 (4), pupil (5), student (6), retired (7), housewife (8), unknown (9)


#### **iii.** Marriage 8

III MARRIAGE


**FREQUENCY OF EPI**

TOTAL

MARRIED

SINGLE

OTHER

**AGE OF FIRST EPI EVENT**

**TOTAL ALL PATIENTS**

**Table 2.** Frequency epi events and marital status

**Table 3.** Average age of patients when they had first epi event

**Table 4.** Age of first epi event and patient marital status

**TOTAL**

TOTAL 100 100% 65 100% 24 100% 11 100% 1. Daily 10 100% 6 92% 1 42% 3 273% 2. Weekly 14 140% 5 77% 7 292% 2 182% 3. Monthly 21 210% 19 292% 1 41% 1 91% 4. Every couple months 19 190% 12 185% 5 208% 2 182% 5. Annual 8 80% 5 77% 3 125% - - 6. Several years 27 270% 17 262% 7 292% 3 272% 7. Unknown 1 10% 1 15% - - - -

**MARITAL STATUS Gender No. of patients Average age of first EPI**

**MARITAL STATUS MARRIED SINGLE OTHER**

**event, years**

*MARITAL STATUS* **MARRIED SINGLE OTHER**

Total 98 25.1 12.98 Male 52 26.9 13.77 Female 46 23.1 11.71

Total 63 27.7 11.63 Male 37 28.2 11.80 Female 26 27.0 11.56

Total 24 14.0 6.38 Male 11 13.7 6.31 Female 13 14.2 6.69

Total 11 34.1 15.81 Male 4 50.3 7.95 Female 7 24.9 11.05

TOTAL 100 100% 65 100% 24 100% 11 100% 1. 0 – 9 yrs. 11 11.0% 2 3.1% 8 33.3% 1 9.1% 2. 10 – 19 yrs. 31 31.0% 17 26.2% 12 50.0% 2 18.2% 3. 20 – 29 yrs. 25 25.0% 19 29.2% 4 16.7% 2 18.2% 4. 30 – 39 yrs. 11 11.0% 10 15.4% - - 1 9.1% 5. over 40 yrs. 20 20.0% 15 23.1% - - 5 45.4% 6. Unknown 2 2.0% 2 3.0% - - - -

**Standard deviation (S.D.)**

Marriage of Epileptic Patients http://dx.doi.org/10.5772/58635 247

**EVENTS**

After data collection we performed the statistical analysis.

After data collection we performed the statistical analysis.

#### **4. Results**

RESULTS The results are presented in tabular form.


**Table 1.** Average age when patient got married according to age of the first epi event


**Table 2.** Frequency epi events and marital status

**iii.** Marriage 8

246 Epilepsy Topics

III MARRIAGE

23. Age of marriage:

21. Marital status: married (1), single (2), divorced (3), widowed (4),

mental disorder (4), unknown

have epilepsy: yes (1),

28. Duration of marriage: in years:

RESULTS

**4. Results**

TABLE 1.

(5) 27. Did the spouse mothers or fathers relatives or parents

no (2), unknown (3)

29. Emotional relationships in marriage: harmonious (1), average (2), poor (3), unknown (4) 30. Household members: only married couple (1), with children (2), with parents (3), single (4), unknown (5)

After data collection we performed the statistical analysis.

**Table 1.** Average age when patient got married according to age of the first epi event

After data collection we performed the statistical analysis.

AVERAGE AGE WHEN PATIENT GOT MARRIED ACCORDING TO AGE OF THE FIRST EPI EVENT

**(S.D.)**

**AGE OF FIRST EPI EVENT Average age when patient got married Standard deviation**

Under 20 years 21.2 yrs. 2.95 20 – 29 years 22.5 yrs. 3.70 30 – 39 years 23.0 yrs. 3.69 40 and older 25.0 yrs. 7.36

The results are presented in tabular form.

The results are presented in tabular form.

(6) 22. Previous marriages: one (1), two (2), three (3), extramarital

24. Marriage: before illness is diagnosed (1), after the illness was diagnosed (2) 25. Spouse knew about the disease: yes (1), no (2), unknown (3) 26. Spouse: health (1), have epilepsy (2), organic somatic or neurology patient (3), suffers from some other

extramarital community (5), unknown

community (4), unknown (5)


**Table 3.** Average age of patients when they had first epi event


**Table 4.** Age of first epi event and patient marital status


**Frequency of epi seizures TOTAL**

**Table 8.** Frequency of epileptic events

2. Partial seizure with or without

3. Seizures with complex symptomatology

generalization

**Type of epi events TOTAL**

**Table 9.** Marriage duration and type of epi events

when they had first epileptic event.

this group at average age of 27.4±5.47 years.

*Marriage duration in years*

*Marriage duration in years*

**0 - 1 2 - 6 7 – 11 12 – 16 17 and**

7 12 - - 4 -

10 3 - 1 - 6 -

**more**

Marriage of Epileptic Patients http://dx.doi.org/10.5772/58635

**more**

**Unknown**

**Unknown**

249

**0 – 1 2 – 6 7 - 11 12 - 16 17 and**

TOTAL 75 11 9 10 5 37 3

TOTAL 75 11 9 10 5 37 3

1. Primary generalized seizures 42 3 5 7 5 20 2

4.Combined seizures 14 4 2 2 - 5 1 5. Unknown 2 - - - -2-

The difference between the average age of the first epileptic event between married [27.7] and total bachelors/unmarried (14 years) was statistically highly significant. Value of t-test is: t=7.00, p<0.01. The result shows that the unmarried were significantly younger than married

The difference between men and women, depending on the average age of life where they had

T-test of the difference significance between the average age of men and women in the group of married is t=0.463, and is not significant. In the group of bachelors/unmarried in the total sample, we had 24 (24%) patients with a mean age of 31.8±13.11 years. There was 11 men in

first epileptic seizuredwas not significant withthe value of t-test t=1.506.

1. Daily 9 4 - 113 - 2. Weekly 6 2 - - - 4 - 3. Monthly 20 1 3 3 2 9 2 4. Every couple months 14 2 1 3 - 8 - 5. Annual 5 - - 1 - 4 - 6. Several years 20 2 5 2 2 8 1 7. Unknown 1 - - - - 1 -

**Table 5.** Sample according to gender and marital status


**Table 6.** Average age of the patients according to gender an marital status


**Table 7.** Age of first epi event and years when patient got married


**Table 8.** Frequency of epileptic events

**MARITAL STATUS**

248 Epilepsy Topics

TOTAL

MARRIED

SINGLE

OTHER

**Table 5.** Sample according to gender and marital status

**MARITAL STATUS Gender N Average age in years**

**Table 6.** Average age of the patients according to gender an marital status

**Table 7.** Age of first epi event and years when patient got married

**TOTAL Male Female N % N % N %**

> **Standard deviation (S.D.)**

**up to 22 years 23 -27 years 28 years and older**

**Student t test of differenceamong average age of men and women**

> Significant at p < 0.01

TOTAL 100 100 53 100 47 100

Total 100 39.1 11.18 t = 0.171 Male 53 39.0 11.30 not significant

Total 65 41.2 9.31 t = 0.463 Male 38 40.8 9.76 not significant

Total 24 31.8 11.13 t = 2.021

Female 47 39.4 11.05

Female 27 41.9 8.63

Male 11 27.4 5.47 Female 13 35.5 13.16

Total 11 43.9 14.36 Male 4 54.0 8.39 Female 7 38.1 13.88

YEARS 75 100 43 57,3 25 33,3 7 9,4

0 – 9 years 3 100 2 66,7 1 33,3 - - 10 – 19 years 19 100 12 63,2 7 36,8 - - 20 – 29 years 20 100 12 60,0 6 30,0 2 10,0 30 – 39 years 11 100 6 54,5 4 36,4 1 9,1 40 and older 20 100 10 50,0 6 30,0 4 20,0 Unknown 2 100 1 50,0 1 50,0 - -

**Age of first epi event TOTAL** *Age when got married*

1. MARRIED 65 65.0 38 71.7 27 57.5 2. SINGLE 24 24.0 11 20.8 13 27.7 3. DIVORCED 9 9.0 4 7.5 5 10.6 4. WIDOWED 1 1.0 - - 1 2.1 5. UNKNOWN 1 1.0 - - 1 2.1


**Table 9.** Marriage duration and type of epi events

The difference between the average age of the first epileptic event between married [27.7] and total bachelors/unmarried (14 years) was statistically highly significant. Value of t-test is: t=7.00, p<0.01. The result shows that the unmarried were significantly younger than married when they had first epileptic event.

The difference between men and women, depending on the average age of life where they had first epileptic seizuredwas not significant withthe value of t-test t=1.506.

T-test of the difference significance between the average age of men and women in the group of married is t=0.463, and is not significant. In the group of bachelors/unmarried in the total sample, we had 24 (24%) patients with a mean age of 31.8±13.11 years. There was 11 men in this group at average age of 27.4±5.47 years.

Significance of the difference between the average age of men and women in a group of bachelors/unmarried measured by Student's t test show result of t=2.021 which was significant at the level p<0.01.

Also, there is no significant difference in the average duration of marriage between patients with primary generalized seizures and patients with seizures of complex symptomatology

Marriage of Epileptic Patients http://dx.doi.org/10.5772/58635 251

The difference between patients with primary generalized seizures and patients with com‐

Progress in medicine over the last century has been accompanied by advances in social and human attitudes in relation to man in general, while it is especially pronounced in some groups

The main motive for taking care of these patients is functioning of whole personality which implies besides proper diagnosis, treatment and therapy,also complete social rehabilitation of these patients. It should be noted that "living with epilepsy" means to live with a series of restrictions aimed at protecting these patients. It first refers to the sphere of education, relationship to the patient, education, career choice, limitations in daily life that the disease

Advice whether the patient with epilepsy should get married or not depends solely on individual decisions. Regardless of epilepsy form the spouse must be informed about the disease and be familiar with it, and make a decision about marrying a person who has epilepsy. It is best that future spouse meet with the doctor who treated his/hers future spouse, and that with enough patience doctor informboth the patient as well as the future spouse on the character of the disease and the limitations that it brings, the possible situations in which they may found themselves, with a special emphasis on providing accurate and useful information

The existence of laws which was prohibiting marriage to patient with epilepsy has shown that the establishment of such legislation did not discourage mentally healthy patients to marry

Alstrom (1950) proved that in spite of eugenic laws patients with epilepsy get married in Sweden. Lennox and Mchram (1963) found that in the U.S., patients with epilepsy more rarely

Goodmsson (1965) presented the results made in Iceland on marriage of patients with epilepsy and low rate of marriages in patients where the seizures began early in life, in which the

In our sample, we had 100 respondents, 65 married, 24 unmarried/single, 9 divorced, 1

bined seizures is significant, but at a lower level of reliability, t=1.908, p<0.10.

of patients, for example, in patients who have epilepsy [18].

in terms of genetic factors [21,22,23].

get married in relation to the general population [14].

widowed and one whose marital status was unknown.

In the group of married we had 38 men and 27 women.

seizures were frequent and when personality changes occurred [18].

and have children [14].

inevitably brings and restrictions on marriage and parenthood [19,20].

(Value of t-test is: t=0.768)

**5. Discussion**

The difference between the average age of the married (41.2 years) and a group of bachelors/ unmarried (31.8 years) was statistically highly significant, or group of bachelors/unmarried was significantly younger than the group of married. Value of t-test is: t=3.716, at the confidence level of p=0.01.

We tested the difference between marital status and age at which respondents first had epileptic manifestation in life and came to the result that these differences were highly significant (χ2 test values: 18.801, p <0.01).

Based on the above data we tested the difference between men and women according to "marital status", the difference is not statistically significant (χ2 test value is 0.920), which means that between men and women there is no significant difference according to marital status.

We tested the difference between married and unmarried according to the type of epileptic manifestations which was statistically significant. The value of χ2 test is: χ2=9.313, p<0.05, DF=3)

The difference between men and women according to the type of epileptic manifestations was not significant. The value ofχ2 test was 3.839, DF=3.

The test of significance between specific focal EEG changes in relation to marital status between married and unmarried is 1.008 which was not significant.

Contingency test between EEG generalized specifically altered and marital status was 0.341 which is also not significant.

According to the results of all three groups of respondents, regardless of marital status, the largest number of patients have generalized specifically altered EEG findings. Testing the significance of differences between married and unmarried according to the proportion of patients with generalized specifically altered EEG findings indicated that the difference was not statistically significant. Value of Sudent's t-test is: t=1.008. Thus there is no significant difference in the proportion of patients with focal specifically altered EEG findings. Value of t-test is: t=0.341.

Having in this manner calculated average duration of marriage in relation to the type of epileptic manifestations, we tested the significance of differences in the average duration of marriage of patients with primary generalized seizures (type 1) in relation to other types of epileptic events by Student's t-test and came to the following results:

The difference in the average duration of the marriage between patients with primary generalized seizures (17.4 years) and patients with partial seizures with or without generali‐ zation (13.9 years) was not statistically significant (t-test value is: t=0.850).

Also, there is no significant difference in the average duration of marriage between patients with primary generalized seizures and patients with seizures of complex symptomatology (Value of t-test is: t=0.768)

The difference between patients with primary generalized seizures and patients with com‐ bined seizures is significant, but at a lower level of reliability, t=1.908, p<0.10.

#### **5. Discussion**

Significance of the difference between the average age of men and women in a group of bachelors/unmarried measured by Student's t test show result of t=2.021 which was significant

The difference between the average age of the married (41.2 years) and a group of bachelors/ unmarried (31.8 years) was statistically highly significant, or group of bachelors/unmarried was significantly younger than the group of married. Value of t-test is: t=3.716, at the confidence

We tested the difference between marital status and age at which respondents first had epileptic manifestation in life and came to the result that these differences were highly

Based on the above data we tested the difference between men and women according to "marital status", the difference is not statistically significant (χ2 test value is 0.920), which means that between men and women there is no significant difference according to marital

We tested the difference between married and unmarried according to the type of epileptic manifestations which was statistically significant. The value of χ2 test is: χ2=9.313, p<0.05,

The difference between men and women according to the type of epileptic manifestations was

The test of significance between specific focal EEG changes in relation to marital status between

Contingency test between EEG generalized specifically altered and marital status was 0.341

According to the results of all three groups of respondents, regardless of marital status, the largest number of patients have generalized specifically altered EEG findings. Testing the significance of differences between married and unmarried according to the proportion of patients with generalized specifically altered EEG findings indicated that the difference was not statistically significant. Value of Sudent's t-test is: t=1.008. Thus there is no significant difference in the proportion of patients with focal specifically altered EEG findings. Value of

Having in this manner calculated average duration of marriage in relation to the type of epileptic manifestations, we tested the significance of differences in the average duration of marriage of patients with primary generalized seizures (type 1) in relation to other types of

The difference in the average duration of the marriage between patients with primary generalized seizures (17.4 years) and patients with partial seizures with or without generali‐

epileptic events by Student's t-test and came to the following results:

zation (13.9 years) was not statistically significant (t-test value is: t=0.850).

at the level p<0.01.

250 Epilepsy Topics

level of p=0.01.

status.

DF=3)

significant (χ2 test values: 18.801, p <0.01).

not significant. The value ofχ2 test was 3.839, DF=3.

which is also not significant.

t-test is: t=0.341.

married and unmarried is 1.008 which was not significant.

Progress in medicine over the last century has been accompanied by advances in social and human attitudes in relation to man in general, while it is especially pronounced in some groups of patients, for example, in patients who have epilepsy [18].

The main motive for taking care of these patients is functioning of whole personality which implies besides proper diagnosis, treatment and therapy,also complete social rehabilitation of these patients. It should be noted that "living with epilepsy" means to live with a series of restrictions aimed at protecting these patients. It first refers to the sphere of education, relationship to the patient, education, career choice, limitations in daily life that the disease inevitably brings and restrictions on marriage and parenthood [19,20].

Advice whether the patient with epilepsy should get married or not depends solely on individual decisions. Regardless of epilepsy form the spouse must be informed about the disease and be familiar with it, and make a decision about marrying a person who has epilepsy. It is best that future spouse meet with the doctor who treated his/hers future spouse, and that with enough patience doctor informboth the patient as well as the future spouse on the character of the disease and the limitations that it brings, the possible situations in which they may found themselves, with a special emphasis on providing accurate and useful information in terms of genetic factors [21,22,23].

The existence of laws which was prohibiting marriage to patient with epilepsy has shown that the establishment of such legislation did not discourage mentally healthy patients to marry and have children [14].

Alstrom (1950) proved that in spite of eugenic laws patients with epilepsy get married in Sweden. Lennox and Mchram (1963) found that in the U.S., patients with epilepsy more rarely get married in relation to the general population [14].

Goodmsson (1965) presented the results made in Iceland on marriage of patients with epilepsy and low rate of marriages in patients where the seizures began early in life, in which the seizures were frequent and when personality changes occurred [18].

In our sample, we had 100 respondents, 65 married, 24 unmarried/single, 9 divorced, 1 widowed and one whose marital status was unknown.

In the group of married we had 38 men and 27 women.

Kantardzic et al (1990) on a sample of 5076 respondents, obtained results that differ from ours. In that study 64.4% of the sample were unmarried/single, 13.9% married, 2.3% divorced, 28% widowers, 10.1% in common law marriage and 8.8% unknown [24,25].

Number of patients with the disease onset in the first decade of life in our sample is so small that these results could not be compared with the results of Dansky, Andermann

Marriage of Epileptic Patients http://dx.doi.org/10.5772/58635 253

For patients with onset of the seizures in the second decade of life the men had significantly reduced specific nuptiality, their ratio was 47% of expected. In our sample of 19 patients which had a first epileptic manifestation in the second decade of life, married was all 19 respondents after age of 22 years, so after the first epileptic event. First epileptic event after age of 20 in our sample had 51 patients, 38 is married before 22 years of age, 16 at the age from 23-27 years and

In our study, we came to the conclusion that there is a significant difference in the average age of the respondents at age when they get married and age of the first epileptic event. The linear correlation coefficient between the age of the first occurrence of epileptic event and age of marriage amounts to 0.435 and means that for the possibility of marriage an important parameter is the absence or presence of disease. So there is a significant correlation between

Dansky and Andermann (1980) determined that in patients with the first seizure after 20 years

Our results also show that there is a significant difference between the average age of a total number of married (41.2 years) compared to the average age of the total number of unmarried,

Gudmuston (1966) stated that male patients more rarely get married. Dansky andAndermann (1980) showed that the difference between male and female patients is equal. Our results agree with the results of the Dansky and Andermann considering that the difference between men and women according to marital status was not statistically significant, with chi square value for this parameter of 0.920. These results can be explained by significant advances in medicine and epileptology in general, and the changes of attitudes towards patients with epilepsy who do not show mental changes in terms of alteration of personality within nosology entity or the

Thus, from the current results and literature we have data that women get married more often, or those patients in whom the first epileptic event occurred after 20 years of age, or to say,

In our sample, we had 53 men and 47 women. The average age of men was 39.0 years and of

We had 38 married men, with a mean age of 40.8 years, and 27 married women, with a mean

Dansky and Andermann (1980) tested 100 patients with epilepsy. The average age of the male patients in their sample was 39.3±1.7 years and average age of female was 42.3±1.6 years.

of age specific nuptiality is not much different than the general population [14].

or the group of unmarried was significantly younger than the group of married.

age of marriage and the occurrence of the first epileptic event.

disease with consequent changes in personality [14,18].

before the first epileptic event [30,31].

women 39.4 years.

age of 41.9 years.

andAndeemann [14,3].

7 after age of 28 years.

The diversity of the results can be explained by the fact that Kantardzic and associates conducted a wide social study at the territory of the Republic of Bosnia and Herzegovina, and that sample covered all age populations of patients in all regions including residents of the Institute for the mentally retarded. In our sample, we had patients who have good social adjustment in relation to the disease and whose treatment trough the Dispensary for epilepsy was aimed at increasing the quality of life and social adaptation [24,25].

Our results agree with the results of Schupf and Ottman (1996) which in their study on 863 patients treated by voluntary organizations in cooperation with Neurological Clinic in Montreal, presented findings that male respondents were more likely to be married than women. It should be noted that all subjects in study by Schupf and Ottman were mar‐ ried [26,27].

In respect of occupation among a group of married we had 75 patients: 26 laborers, 4 craftsmen, 20 clerks, 16 retirees and 8 housewives.

According to Kantardzic and colleagues (1990) on a sample of 7698 respondents in the highest percentage wererepresented students, then laborers, followed by housewives, craftsmen and clerks [24,25].

Also this difference in results can be explained by the size and sample specificity in our study and study conducted by Kantardzic and associates (1990).

In relation to marriage in our results we should indicate that more than half of the respondents were married before the age of 22 years. The exceptions were clerks who entered into marriage after age of 22 years.

Dansky Linda, Anderman Eva and Frederic Andermann (1980) examined the marital status of epileptic patients and fertility of women with epilepsy compared with the fertility of women whose husbands suffering from epilepsy and obtain the results that were previously described in the literature: there is a direct correlation between marital status and age when the first epileptic event in life occurred, and as the first epileptic event occurs later in life the chance that such a person get married and remains in marriage is higher. [14]

Their results are as follows: if the seizures began in the first decade of life the married status among male patients was reduced to 32% from expected with a very significant difference. In the female sample the same authors also found reduced specific nuptiality directly related to the age of forstepileptic event occurrence by 58% from expected, which is also important [28,29].

In our sample, we had only 3 patients with the occurrence of the first epileptic event in the first decade of life, of which 2 got married before 22 years of age, and one at age from 23-27 years.

Number of patients with the disease onset in the first decade of life in our sample is so small that these results could not be compared with the results of Dansky, Andermann andAndeemann [14,3].

Kantardzic et al (1990) on a sample of 5076 respondents, obtained results that differ from ours. In that study 64.4% of the sample were unmarried/single, 13.9% married, 2.3% divorced, 28%

The diversity of the results can be explained by the fact that Kantardzic and associates conducted a wide social study at the territory of the Republic of Bosnia and Herzegovina, and that sample covered all age populations of patients in all regions including residents of the Institute for the mentally retarded. In our sample, we had patients who have good social adjustment in relation to the disease and whose treatment trough the Dispensary for epilepsy

Our results agree with the results of Schupf and Ottman (1996) which in their study on 863 patients treated by voluntary organizations in cooperation with Neurological Clinic in Montreal, presented findings that male respondents were more likely to be married than women. It should be noted that all subjects in study by Schupf and Ottman were mar‐

In respect of occupation among a group of married we had 75 patients: 26 laborers, 4 craftsmen,

According to Kantardzic and colleagues (1990) on a sample of 7698 respondents in the highest percentage wererepresented students, then laborers, followed by housewives, craftsmen and

Also this difference in results can be explained by the size and sample specificity in our study

In relation to marriage in our results we should indicate that more than half of the respondents were married before the age of 22 years. The exceptions were clerks who entered into marriage

Dansky Linda, Anderman Eva and Frederic Andermann (1980) examined the marital status of epileptic patients and fertility of women with epilepsy compared with the fertility of women whose husbands suffering from epilepsy and obtain the results that were previously described in the literature: there is a direct correlation between marital status and age when the first epileptic event in life occurred, and as the first epileptic event occurs later in life the chance

Their results are as follows: if the seizures began in the first decade of life the married status among male patients was reduced to 32% from expected with a very significant difference. In the female sample the same authors also found reduced specific nuptiality directly related to the age of forstepileptic event occurrence by 58% from expected, which

In our sample, we had only 3 patients with the occurrence of the first epileptic event in the first decade of life, of which 2 got married before 22 years of age, and one at age from

widowers, 10.1% in common law marriage and 8.8% unknown [24,25].

was aimed at increasing the quality of life and social adaptation [24,25].

ried [26,27].

252 Epilepsy Topics

clerks [24,25].

after age of 22 years.

is also important [28,29].

23-27 years.

20 clerks, 16 retirees and 8 housewives.

and study conducted by Kantardzic and associates (1990).

that such a person get married and remains in marriage is higher. [14]

For patients with onset of the seizures in the second decade of life the men had significantly reduced specific nuptiality, their ratio was 47% of expected. In our sample of 19 patients which had a first epileptic manifestation in the second decade of life, married was all 19 respondents after age of 22 years, so after the first epileptic event. First epileptic event after age of 20 in our sample had 51 patients, 38 is married before 22 years of age, 16 at the age from 23-27 years and 7 after age of 28 years.

In our study, we came to the conclusion that there is a significant difference in the average age of the respondents at age when they get married and age of the first epileptic event. The linear correlation coefficient between the age of the first occurrence of epileptic event and age of marriage amounts to 0.435 and means that for the possibility of marriage an important parameter is the absence or presence of disease. So there is a significant correlation between age of marriage and the occurrence of the first epileptic event.

Dansky and Andermann (1980) determined that in patients with the first seizure after 20 years of age specific nuptiality is not much different than the general population [14].

Our results also show that there is a significant difference between the average age of a total number of married (41.2 years) compared to the average age of the total number of unmarried, or the group of unmarried was significantly younger than the group of married.

Gudmuston (1966) stated that male patients more rarely get married. Dansky andAndermann (1980) showed that the difference between male and female patients is equal. Our results agree with the results of the Dansky and Andermann considering that the difference between men and women according to marital status was not statistically significant, with chi square value for this parameter of 0.920. These results can be explained by significant advances in medicine and epileptology in general, and the changes of attitudes towards patients with epilepsy who do not show mental changes in terms of alteration of personality within nosology entity or the disease with consequent changes in personality [14,18].

Thus, from the current results and literature we have data that women get married more often, or those patients in whom the first epileptic event occurred after 20 years of age, or to say, before the first epileptic event [30,31].

In our sample, we had 53 men and 47 women. The average age of men was 39.0 years and of women 39.4 years.

We had 38 married men, with a mean age of 40.8 years, and 27 married women, with a mean age of 41.9 years.

Dansky and Andermann (1980) tested 100 patients with epilepsy. The average age of the male patients in their sample was 39.3±1.7 years and average age of female was 42.3±1.6 years.

Our results in relation to the age of the male and female patients are comparable with the sample from study conducted by Dansky andAndermann (1980) at the Neurological Clinic in Montreal [14].

I.

II. Generalized seizures:

IV. Unclassified seizures.

14.3 years.

literature were not found.

**a.** Partial seizures with simple symptomatology. **b.** Partial seizures with complex symptomatology. **c.** Partial seizures with secondary generalization.

**a.** Generalized seizures without local onset, **b.** Generalized seizures with local onset.

III. Unilateral or predominantly unilateral seizure

12%, combined seizures 25% and unknown in 2%.

In our study we use the following classification of seizures: primary generalized seizures 51%, partial seizures with or without generalization 10%, seizures with complex symptomatology

Marriage of Epileptic Patients http://dx.doi.org/10.5772/58635 255

According to the results of Jears (1975) from the Clinical Center in Ljubljana on a sample of 525 children-aged between 3 and 15 years, using the division on focal and generalized seizures

Our results agree with the results of Kantardzic and associates who on a sample of 250 patients from the territory of Sarajevo, Tuzla, Mostar and Livno (1990) found that most respondents had generalized seizures, followed by partial with complex symptomatology, then partial

In relation to marriage in our sample of 65 respondents more were married (65.0%) compared to unmarried (35%). 38 patients had generalized seizures, 7 partial seizures with simple symptomatology. Our result was also that the group of unmarried had in much larger number

Study by Schupf and Ottman (1996) on a sample of 863 patients treated by voluntary organi‐ zations in cooperation with the Clinic of Neurology in Montreal showed partial onset in 82%

These authors state in their discussion diversity compared with previous studies. Weber also states that specific nuptiality in the group of patients with epilepsy with partial seizures is higher than in group suffering from generalized seizures. The average duration of marriage in 40 patients with primary generalized seizures was 17.4 years, patients with partial seizures with or without generalization 13.9 and patients with seizures of complex symptomatology

Our conclusion is that the type of epileptic event does not affect the duration of the marriage, which we did not compared with the results from other authors as these results in the available

In relation to EEG results significance of difference between married and unmarried according to proportions of generalized specifically altered EEG, and the results of difference significance

there was 31.3% cases of generalized epilepsy and 68.7% of focal epilepsy.

seizures with simple symptomatology and combined seizures.

of cases 41.7% the combined seizures than married 15.4%.

of patients, which is different compared to our study.

In our sample, as well as in a sample from comparative literature there is no significant difference between the average agebetween genders.

In relation to the etiology the recent division into genuine (idiopathic, cryptogenic) and symptomatic is already largely abandoned. Epilepsy in many ways is idiopathic while the genuine epilepsy can manifest if the hereditary tendency is influenced by some other symptomatology. Basically pathophysiological cause of epilepsy unclude all that can overcome the polarization balance in groups of nerve cells located at the main afferentefferent pathways of the brain. On inherited tendencies, level of maturity, location, size, and material cells in focus depends on whether one cause will initiate the crisis-epileptic form of seizure, or a single disorder of polarization balance will cause the second and so on, until the first primarily functional, and then structurally "biochemical focus" does not lead to such balance disorder of irritant and inhibitory processes in the brain that are clinically manifested as epilepsy [32,33,34].

In the group of exogenous factors in our study, we considered:

Birth trauma (reliable data), infectious diseases of the CNS, head injury with or without loss of consciousness, and the existence of "macro factors". Positive heredity in epilepsy in our sample was present in 6.88% of patients, negative in 54 and unknown in 16 patients.

Our results in relation to specific heredity agree with results from the literature: In case of petit mal 15.3%, 2.6% in case of psychomotor epilepsy (Lennox), 3% (Gastaut), Gibbs 4.5%.

Jears et al. (1975) at the Children's Hospital in Ljubljana found among 525 patients positive specific heredity in 12.98%. Jears and associates had sample of 809 children between 3 and 15 years of age. In our sample the youngest patient was 17 years old, the oldest 53 and the positive result of a specific heredity is considered to be in accordance with results from the literature [22,30].

Hajnsek (1980) presented the results of the age group from 20-50 years in testing the etiology of epilepsy on a sample of 572 patients and came to the following results: trauma 40.7%, 35.4% of unknown etiology, inflammatory CNS processes 11.4%. Positive heredity for epilepsy in his study was 10%.

In our sample we found: trauma 6% (tested reliable data of birth trauma), infectious CNS diseases 6%, and head injury with or without loss of consciousness 17% and 58% with unknown data. Positive heredity in the total sample was 13% and among married 8.8%.

We can conclude that our results agree with the results of Hajnsek, while certain differences can be explained by age variations of the samples.

Classification of epilepsy is an open problem. International classification of diseases in the latest version from the 1981 simplifies the main categories of epilepsy into a) generalized and b) partial seizures. Hercegovac (1976) deepened earlier given classification by Gastaut (1969) which divided epileptic events into the following groups:

I.

Our results in relation to the age of the male and female patients are comparable with the sample from study conducted by Dansky andAndermann (1980) at the Neurological Clinic in

In our sample, as well as in a sample from comparative literature there is no significant

In relation to the etiology the recent division into genuine (idiopathic, cryptogenic) and symptomatic is already largely abandoned. Epilepsy in many ways is idiopathic while the genuine epilepsy can manifest if the hereditary tendency is influenced by some other symptomatology. Basically pathophysiological cause of epilepsy unclude all that can overcome the polarization balance in groups of nerve cells located at the main afferentefferent pathways of the brain. On inherited tendencies, level of maturity, location, size, and material cells in focus depends on whether one cause will initiate the crisis-epileptic form of seizure, or a single disorder of polarization balance will cause the second and so on, until the first primarily functional, and then structurally "biochemical focus" does not lead to such balance disorder of irritant and inhibitory processes in the brain that are

Birth trauma (reliable data), infectious diseases of the CNS, head injury with or without loss of consciousness, and the existence of "macro factors". Positive heredity in epilepsy in our

Our results in relation to specific heredity agree with results from the literature: In case of petit

Jears et al. (1975) at the Children's Hospital in Ljubljana found among 525 patients positive specific heredity in 12.98%. Jears and associates had sample of 809 children between 3 and 15 years of age. In our sample the youngest patient was 17 years old, the oldest 53 and the positive result of a specific heredity is considered to be in accordance with results from the

Hajnsek (1980) presented the results of the age group from 20-50 years in testing the etiology of epilepsy on a sample of 572 patients and came to the following results: trauma 40.7%, 35.4% of unknown etiology, inflammatory CNS processes 11.4%. Positive heredity for epilepsy in his

In our sample we found: trauma 6% (tested reliable data of birth trauma), infectious CNS diseases 6%, and head injury with or without loss of consciousness 17% and 58% with unknown data. Positive heredity in the total sample was 13% and among married 8.8%.

We can conclude that our results agree with the results of Hajnsek, while certain differences

Classification of epilepsy is an open problem. International classification of diseases in the latest version from the 1981 simplifies the main categories of epilepsy into a) generalized and b) partial seizures. Hercegovac (1976) deepened earlier given classification by Gastaut (1969)

sample was present in 6.88% of patients, negative in 54 and unknown in 16 patients.

mal 15.3%, 2.6% in case of psychomotor epilepsy (Lennox), 3% (Gastaut), Gibbs 4.5%.

difference between the average agebetween genders.

clinically manifested as epilepsy [32,33,34].

can be explained by age variations of the samples.

which divided epileptic events into the following groups:

In the group of exogenous factors in our study, we considered:

Montreal [14].

254 Epilepsy Topics

literature [22,30].

study was 10%.


II. Generalized seizures:


IV. Unclassified seizures.

In our study we use the following classification of seizures: primary generalized seizures 51%, partial seizures with or without generalization 10%, seizures with complex symptomatology 12%, combined seizures 25% and unknown in 2%.

According to the results of Jears (1975) from the Clinical Center in Ljubljana on a sample of 525 children-aged between 3 and 15 years, using the division on focal and generalized seizures there was 31.3% cases of generalized epilepsy and 68.7% of focal epilepsy.

Our results agree with the results of Kantardzic and associates who on a sample of 250 patients from the territory of Sarajevo, Tuzla, Mostar and Livno (1990) found that most respondents had generalized seizures, followed by partial with complex symptomatology, then partial seizures with simple symptomatology and combined seizures.

In relation to marriage in our sample of 65 respondents more were married (65.0%) compared to unmarried (35%). 38 patients had generalized seizures, 7 partial seizures with simple symptomatology. Our result was also that the group of unmarried had in much larger number of cases 41.7% the combined seizures than married 15.4%.

Study by Schupf and Ottman (1996) on a sample of 863 patients treated by voluntary organi‐ zations in cooperation with the Clinic of Neurology in Montreal showed partial onset in 82% of patients, which is different compared to our study.

These authors state in their discussion diversity compared with previous studies. Weber also states that specific nuptiality in the group of patients with epilepsy with partial seizures is higher than in group suffering from generalized seizures. The average duration of marriage in 40 patients with primary generalized seizures was 17.4 years, patients with partial seizures with or without generalization 13.9 and patients with seizures of complex symptomatology 14.3 years.

Our conclusion is that the type of epileptic event does not affect the duration of the marriage, which we did not compared with the results from other authors as these results in the available literature were not found.

In relation to EEG results significance of difference between married and unmarried according to proportions of generalized specifically altered EEG, and the results of difference significance between married and unmarried according to specific proportions of focal EEG changes in terms of the absence of statistical significance, we also did not compare with the earlier studies because for us such results in the literature were not known.

(1984) fromMausdley and Kings College Hospital, which have proven that the intellectual deterioration as the ultimate outcome of epilepsy occurs much less frequently than previously thought at the beginning of the 20th century. Trough comparative results we can say that the mental deterioration occurs in a certain number of patients, but not in majority of cases, as previously thought. In both studies it was concluded that the mental deterioration occurs more frequently in men than women. This can be explained by the long history of the disease in terms of early onset of the seizures, poor therapeutic reactivity and the possible effects of antiepileptic drugs, especially barbitone and diphetoin. Confirmation of toxic effects on mental functioning of AEDs have was proven Thomson and Trimbler, De Niegri et al., Andrewes et

Marriage of Epileptic Patients http://dx.doi.org/10.5772/58635 257

In our sample, we had 21 patients without mental changes, 14 men and 7 women. In relation to marrital status 14 respondents in this group was married with different marriage duration.

These results can be correlated with good psychosocial functioning of patients on which there are many studies: Salajpal and Ristovic (1986) have shown an adverse effect of some social factors in the course of the disease and psychological status: poverty, deficient education within the family, poor emotional family relationships, duration of conflict family situations

In the same context Kocijan-Hercegonja (1986) and colleagues have concluded that the social status of the family is the most important factor in forming the patient's personality, and for

Loewenson et al (1980) in terms of socioeconomic status, interviewed 298 patients: all was older than 18 years and none of them was mentally retarded. The average duration of disease was 15 years at mean age of 30 years. The results were: There was no significant correlation between marital status, employment, good income with the frequency of seizures, type of seizures and

All respondents without psychiatric disorders in our sample were of good social status. Seventeen respondents who were married had a harmonious relationship with the spouse.

Slodnjak et al (1986) evaluated the overall psychosocial functioning of patients with epilepsy and found poor prognosis in 26% of boys and only 7% girls. Our result agrees with the result of Slodnjak et al (1986), the women in our sample had more disorders of mental sub normality

Our results on mental changes depending on the marriage duration are the following: mental changes have occurred after 12 or more years of marriage in 64.7% of cases: neurotic disorders

Our results in terms of the correlation between the marriage duration and psychological changes can be explained by multiple factors: disease factors, factor of antiepileptic therapy, psychosocial dynamics factor in marriage not related to the disease, problems that marriage brings in relation to the provision of the financial basis for the family as a whole and the like.

al., Calandre et al., Thompson and Trimble [14].

with an aggressive and rejecting attitude towards the patient [27].

the presence or absence of psychological changes in patient [22].

psychological problems of reactive nature [24,25].

without disorder of psychosocial functioning [30].

71% and 21.4% was without problems.

Understanding the neurological aspects of epilepsy significantly improved during last decades. Psychiatric aspects have for many years been neglected. Lately in the project to improve the quality of life of patients with epilepsy more attention is focused on the psycho‐ logical aspects of life of patients in order to achieve better social functioning and good social reintegration.

Quality of life of patients with epilepsy was one of the leading topics of the 29th Congress on Epilepsy (Tokyo 1995] and the Second European Congress of epileptologists (Hague 1996).

The most important contribution in this regard was the European Quality of Life study conducted on 5000 adult patients in 15 European countries. The study collected clinical and demographic data on psychosocial functioning. Survey was filled by the patients. The questions focused on: types of seizures, the frequency of seizures, injuries related to the seizures, the side effects of anti-epileptic therapy, problems in social functioning in relation to the family, workplace and the environment in general. Results are as follows: 1/5 of the respondents felt that the seizures are not under good control, 1/3 considered to have frequent seizures. The most common side effects of antiepileptic drugs that patients listed were: fatigue, memory problems and focusing difficulties. In our country in the last two years special attention is given.in light of the global trend of epileptology psychological changes,to patients with epilepsy. Gavranovic (1996) and associates all psychological changes within epilepsy divided into two large groups:


According to Kantardzic (1997) study on the prevalence of conduct disorder shows that these disorders occurs in 12-95% of cases and depends on the study population. They are lowest in the normal population, in schools and general practice (12-23%), in the out-patient clinics for epilepsy 50% and 95% in inpatient psychiatric hospitals [24,25].

In our sample psychological changes that have been investigated are: character changes 4%, signs of organic mental disorder 23%, neurotic disorders 37%, 13% oligophrenic, without psychiatric disorders 21%, unknown 2% and 0% of psychosis.

Neurotic reaction in our sample occurred in 37% of patients, twice as often is present neurotic reactions among women with epilepsy than in men. Our result is comparable with some results from the literature like ones by Currie and colleagues, Betts, Ramesch et al., Fenton and colleagues, and Bingley [12].

Signs of organic mental disorder we found in 23 patients, 17 were in the group of married, 16 men and 7 women. Our results are compatible with the results of Broxn and Abeyasinghe (1984) fromMausdley and Kings College Hospital, which have proven that the intellectual deterioration as the ultimate outcome of epilepsy occurs much less frequently than previously thought at the beginning of the 20th century. Trough comparative results we can say that the mental deterioration occurs in a certain number of patients, but not in majority of cases, as previously thought. In both studies it was concluded that the mental deterioration occurs more frequently in men than women. This can be explained by the long history of the disease in terms of early onset of the seizures, poor therapeutic reactivity and the possible effects of antiepileptic drugs, especially barbitone and diphetoin. Confirmation of toxic effects on mental functioning of AEDs have was proven Thomson and Trimbler, De Niegri et al., Andrewes et al., Calandre et al., Thompson and Trimble [14].

between married and unmarried according to specific proportions of focal EEG changes in terms of the absence of statistical significance, we also did not compare with the earlier studies

Understanding the neurological aspects of epilepsy significantly improved during last decades. Psychiatric aspects have for many years been neglected. Lately in the project to improve the quality of life of patients with epilepsy more attention is focused on the psycho‐ logical aspects of life of patients in order to achieve better social functioning and good social

Quality of life of patients with epilepsy was one of the leading topics of the 29th Congress on Epilepsy (Tokyo 1995] and the Second European Congress of epileptologists (Hague 1996).

The most important contribution in this regard was the European Quality of Life study conducted on 5000 adult patients in 15 European countries. The study collected clinical and demographic data on psychosocial functioning. Survey was filled by the patients. The questions focused on: types of seizures, the frequency of seizures, injuries related to the seizures, the side effects of anti-epileptic therapy, problems in social functioning in relation to the family, workplace and the environment in general. Results are as follows: 1/5 of the respondents felt that the seizures are not under good control, 1/3 considered to have frequent seizures. The most common side effects of antiepileptic drugs that patients listed were: fatigue, memory problems and focusing difficulties. In our country in the last two years special attention is given.in light of the global trend of epileptology psychological changes,to patients with epilepsy. Gavranovic (1996) and associates all psychological changes within epilepsy

**1.** Epilepsy and intellectual functions (mental retardation, cognitive disorders, dementia or

**2.** Psychiatric disorders (epilepsy personality changes, psychosis, vacillating moods-

According to Kantardzic (1997) study on the prevalence of conduct disorder shows that these disorders occurs in 12-95% of cases and depends on the study population. They are lowest in the normal population, in schools and general practice (12-23%), in the out-patient clinics for

In our sample psychological changes that have been investigated are: character changes 4%, signs of organic mental disorder 23%, neurotic disorders 37%, 13% oligophrenic, without

Neurotic reaction in our sample occurred in 37% of patients, twice as often is present neurotic reactions among women with epilepsy than in men. Our result is comparable with some results from the literature like ones by Currie and colleagues, Betts, Ramesch et al., Fenton and

Signs of organic mental disorder we found in 23 patients, 17 were in the group of married, 16 men and 7 women. Our results are compatible with the results of Broxn and Abeyasinghe

because for us such results in the literature were not known.

reintegration.

256 Epilepsy Topics

divided into two large groups:

psychosindrome) and;

colleagues, and Bingley [12].

dysphoria, depression, psychoreactive disorders).

epilepsy 50% and 95% in inpatient psychiatric hospitals [24,25].

psychiatric disorders 21%, unknown 2% and 0% of psychosis.

In our sample, we had 21 patients without mental changes, 14 men and 7 women. In relation to marrital status 14 respondents in this group was married with different marriage duration.

These results can be correlated with good psychosocial functioning of patients on which there are many studies: Salajpal and Ristovic (1986) have shown an adverse effect of some social factors in the course of the disease and psychological status: poverty, deficient education within the family, poor emotional family relationships, duration of conflict family situations with an aggressive and rejecting attitude towards the patient [27].

In the same context Kocijan-Hercegonja (1986) and colleagues have concluded that the social status of the family is the most important factor in forming the patient's personality, and for the presence or absence of psychological changes in patient [22].

Loewenson et al (1980) in terms of socioeconomic status, interviewed 298 patients: all was older than 18 years and none of them was mentally retarded. The average duration of disease was 15 years at mean age of 30 years. The results were: There was no significant correlation between marital status, employment, good income with the frequency of seizures, type of seizures and psychological problems of reactive nature [24,25].

All respondents without psychiatric disorders in our sample were of good social status. Seventeen respondents who were married had a harmonious relationship with the spouse.

Slodnjak et al (1986) evaluated the overall psychosocial functioning of patients with epilepsy and found poor prognosis in 26% of boys and only 7% girls. Our result agrees with the result of Slodnjak et al (1986), the women in our sample had more disorders of mental sub normality without disorder of psychosocial functioning [30].

Our results on mental changes depending on the marriage duration are the following: mental changes have occurred after 12 or more years of marriage in 64.7% of cases: neurotic disorders 71% and 21.4% was without problems.

Our results in terms of the correlation between the marriage duration and psychological changes can be explained by multiple factors: disease factors, factor of antiepileptic therapy, psychosocial dynamics factor in marriage not related to the disease, problems that marriage brings in relation to the provision of the financial basis for the family as a whole and the like. In relation to gender differences in psychological problems that we found, they also may be explained by the above-mentioned factors that we discussed, as well as socio cultural specific factors of the environment and climate of our respondents.

In our sample we found the following therapeutic reactivity: 27% of our patients had one seizure in several years, 19 every couple of months, 8 once per year, 21 once a month, 14 weekly and 10 daily seizures, so complete or very satisfactory therapeutic reactivity was found in 54%

Marriage of Epileptic Patients http://dx.doi.org/10.5772/58635 259

Remission rates of patients with different types of seizures in the literature varies: in patients with tonic seizures,they vary according to Gavranovic (1988) from 60-80%, according to

Satisfactory therapeutic reactivity in our sample we found in 54% of patients which is consis‐

In relation to marrital status in our sample we had the following results: the group of married and group of unmarried in approximately same percentage had epileptic events during few years before the study, while a group of unmarried usually have weekly frequency of seizures

Comparison of therapeutic responsiveness in relation to marriage we did not conducted

Explanation for better therapeutic responsiveness of married in our sample we can find in following facts: our sample was respondents from the Dispensary for treatment of epilepsy, so the patients who in previous period were treated and whose social status (employed in the profession 55, at another job 8) requested functionality within the job, environment and family. The purpose of their treatment through the Dispensary is "best possible therapeutic reactivity" in relation to the type of disease, EEG changes, disease duration, age and choice of antiepileptic

Our results in terms of patient's employment patients agree with the results of Kantardzic and associates (1990) as they found the overall employment rate of 43.2% (28% in the profession

Hydanphen received 61 patients, 4 patients were taking barbiturates, Tegretol 9, 22 combina‐

**1.** Epilepsy affects the possibility of marriage and is in the direct correlation with the age at

**2.** Early occurrence of the disease reduces the possibility of entering into marriage, if the disease occurs later in life chances of conceiving marriage are significantly higher.

which the first epileptic event occurred and the type of the epileptic event.

**3.** Patients who are married have less frequent epileptic seizures.

Sofijanov (1982) remission rate as simple absence seizures is 70-80% [24,25].

because in the available literature we did not find such results [31,32].

of our respondents.

tent with those authors.

(29.2%).

drugs.

and 15.2%at another job).

**6. Conclusion**

tions of Tegretol and Phenobarbitone.

When we talk about psychological changes in our patients we must emphasize the fact that we tested those patients who had been treated through the Dispensary for epilepsy, and that the triage of these patients in terms of nonpsychotic disorders by sample selection was already made.

Our results on psychological changes agree with the other results from the literature. Accord‐ ing Pekovic (1990) neurotic problems are encountered in 32% of patients, character personality disorders in 22%, signs of organic mental disorder at an early form in 15% and 32% of respondents had no psychological disorders. Our results are parallel with this.

In relation to treatment there are strict principles with the aim of successful treatment. According to Gavranovic (1988) principles of epilepsy treatment are:


In our sample we found the following therapeutic reactivity: 27% of our patients had one seizure in several years, 19 every couple of months, 8 once per year, 21 once a month, 14 weekly and 10 daily seizures, so complete or very satisfactory therapeutic reactivity was found in 54% of our respondents.

Remission rates of patients with different types of seizures in the literature varies: in patients with tonic seizures,they vary according to Gavranovic (1988) from 60-80%, according to Sofijanov (1982) remission rate as simple absence seizures is 70-80% [24,25].

Satisfactory therapeutic reactivity in our sample we found in 54% of patients which is consis‐ tent with those authors.

In relation to marrital status in our sample we had the following results: the group of married and group of unmarried in approximately same percentage had epileptic events during few years before the study, while a group of unmarried usually have weekly frequency of seizures (29.2%).

Comparison of therapeutic responsiveness in relation to marriage we did not conducted because in the available literature we did not find such results [31,32].

Explanation for better therapeutic responsiveness of married in our sample we can find in following facts: our sample was respondents from the Dispensary for treatment of epilepsy, so the patients who in previous period were treated and whose social status (employed in the profession 55, at another job 8) requested functionality within the job, environment and family. The purpose of their treatment through the Dispensary is "best possible therapeutic reactivity" in relation to the type of disease, EEG changes, disease duration, age and choice of antiepileptic drugs.

Our results in terms of patient's employment patients agree with the results of Kantardzic and associates (1990) as they found the overall employment rate of 43.2% (28% in the profession and 15.2%at another job).

Hydanphen received 61 patients, 4 patients were taking barbiturates, Tegretol 9, 22 combina‐ tions of Tegretol and Phenobarbitone.

#### **6. Conclusion**

In relation to gender differences in psychological problems that we found, they also may be explained by the above-mentioned factors that we discussed, as well as socio cultural specific

When we talk about psychological changes in our patients we must emphasize the fact that we tested those patients who had been treated through the Dispensary for epilepsy, and that the triage of these patients in terms of nonpsychotic disorders by sample selection was already

Our results on psychological changes agree with the other results from the literature. Accord‐ ing Pekovic (1990) neurotic problems are encountered in 32% of patients, character personality disorders in 22%, signs of organic mental disorder at an early form in 15% and 32% of

In relation to treatment there are strict principles with the aim of successful treatment.

**2.** When the diagnosis is certain the treatment should be started as soon as possible because is well-known fact that the neurons damage by repeated seizures is much more severe

**3.** Treatment should always begin with monotherapywhilepolytherapy should be avoided. Reynolds et al (1976, 1981) reported that 80% of seizures can be treated by monotherapy. When introducing AEDs start with small doses. Each patient is an individual in terms of treatment and the determination of AEDs dose is highly complex depending on: type of seizure, seizure frequency, age, general condition, individual drug tolerance, the envi‐ ronment and the attitude of the environment in relation to the disease and socioeconomic

**4.** Selection of antiepileptic drugs depends on the type of epileptic manifestations. Partial seizures with elementary symptomatology and generalized seizures are treated with phenobarbitone, carbamazepine, and diphenyl-hydantoin. Partial complex seizures are the most common drug-resistant seizures, they are treated with carbamazepine, diphenylhydantoin and primidone. In case of generalized non convulsive seizures of simple type the drug of choice is ethosuccimide, then sodium valproate, or these two drugs in

**5.** In refractory cases when we are forced to use polytherapy we must respect the principle: never combine identical antiepileptics, avoid combinations of toxic drugs, the choice of antiepileptic drugs and its concentration should be within the therapeutic dose spectrum.

**6.** It is necessary to control the drug tolerance which in clinical practice means to control the

**7.** A special task is to educate patients in terms of knowledge about the disease and precip‐ itating factors of potential seizures such as: reduced sleep, alcohol use, stress, hormonal

skin, lymph nodes, liver, spleen, mental state and possible ataxia.

respondents had no psychological disorders. Our results are parallel with this.

According to Gavranovic (1988) principles of epilepsy treatment are:

**1.** Diagnosis of epilepsy must be reliable.

than by other factors.

factors.

combination.

changes.

factors of the environment and climate of our respondents.

made.

258 Epilepsy Topics


#### **Author details**

Azra Alajbegovic1 , Jasminka Djelilović-Vranić<sup>1</sup> , Salem Alajbegović<sup>2</sup> and Lejla Alajbegović<sup>3</sup>

1 Neurology Clinic, Clinical Center of Sarajevo University, Sarajevo, Bosnia and Herzegovina

[11] Baker GA, Smith DF, Dewey M, Jacoby A, Chadwick DW. The initial development of healt-related quality of life model as an outcome measure in epilepsy.Epilepsy Res

Marriage of Epileptic Patients http://dx.doi.org/10.5772/58635 261

[12] Betts TA. Depression, anxiety and epilepsy.Reynolds EH, Trimble MR, eds. epilep‐

[13] Britten N, Morgan K, Fenwick PBC, Britten H. Epilepsy and handicap from birth to

[14] Dansky LV, Andermann E, Andermann F. Mariageet fertility in epilepticpatients. Ep‐

[15] Dodrill CB, Batzek LW. Patterns of Psychosocial Problems in Chronic Epilepsy-acta‐

[16] Ercegovac D, Savić Č, Mitrović D. Psihosocijalniaspektiepilepsije. X Jugoslovenski‐

[17] Goodridge D, Shorvon SD. Epileptic seizures in a population of 6ooo:Treatment and

[18] Gudmunsson G. Epilepsy in Iceland.A clinical and epidemiological investigation.Ac‐

[19] Hauser WA, Hersdorffer DA. Epilepsy: frequency, causes and conse-quences. Epilep‐

[20] Jacoby A, Baker GA, Smith DF, Dewey M, Chadwick DW. Measuring the impact ofe‐

[21] Jacoby A, Graham Jones S, Baker GA, RatoffR,HaynesJ,Chadvick DW. A general

[23] Jensen P, Jensen SB, Sorenson PS, et al. Sexual dysfunction in male and female pa‐ tients with epilepsy: A study of 86 patients Arch Sex Behavior 1990;19:1-14.

[24] KantardićDž, et al. Epilepsija-analizasociomedicinskihpokazatelja u grupiod 4071 pa‐

[25] KantardžićDž, Gavranović M, Jovanović M. Socijalna traumau provokacijiepileptič‐

[26] Reproduction Among Individuals with Idiopathic (Cryptogenic Epilepsy) Risk Fac‐ tors for Reduced Fertility in Marriage Epilepsia 37 (9): 833-840,1996 Nicole Scupl and

[27] Salajpal T. RisovićDž. Utjecajpsihosocijalnihfaktoranatokepilepsije-Soc.Psihijatrija 15

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2 Cantonal Hospital Zenica,Zenica, Bosnia and Herzegovina

3 Berlin-Chemie Sarajevo, Representative office Bosnia and Herzegovina, Germany

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**Author details**

260 Epilepsy Topics

Azra Alajbegovic1

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1 Neurology Clinic, Clinical Center of Sarajevo University, Sarajevo, Bosnia and Herzegovina

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262 Epilepsy Topics

Marta J Morrell and Gregory T GuldnerEpilepsia 37 (12) 1204-1210.1996.

## *Edited by Mark D. Holmes*

An international group of recognised experts has contributed to this volume to discuss a variety of topics on epilepsy. The subject matter is diverse, including new concepts in brain circuitry involved in seizure generation, a discussion on reflex epilepsy, reviews and updates on juvenile myoclonic epilepsy, the role of EEG in epilepsy evaluation, the novel possibility of employing scalp EEG for seizure prediction, the roles of vagus nerve stimulation and other neuromodulatory therapies, non-epileptic seizures, and, no less important, some of the psychosocial issues that confront the patient and his or her family. This volume is not a comprehensive overview of the entire field of epilepsy, but each discussion is focused and will be valuable to both investigators and practitioners.

Epilepsy Topics

Epilepsy Topics

*Edited by Mark D. Holmes*

Photo by Ralwel / iStock