Neuropsychological performance and effort in patients with psychogenic non-epileptic seizures (PNES)
Abstract
Introduction: Multifactorial etiology has been identified that may underlie the development and occurrence of PNES: a history of abuse, post-traumatic stress disorder, malingering, mood and personality disorders, and cognitive impairment. Not all factors have the same type of impact.
A specific vulnerability may play a role in the development of PNES. Neuropsychological deficit or subtle neurological dysfunction has been found in patients with PNES (Fargo et al., 2000; Celik et al., 2015; Dworetzky & Baslet, 2017).
Prigatano et al. (2002) postulated a two-factor model: one factor is an emotional mechanism such as higher dissociation tendency in response to experiencing irresolvable situations that they cannot manage as adults; the second factor may be greater vulnerability of the brain for not tolerating conflict situations. Aims: The aim of this study is to evaluate cognitive performance and effort in patients diagnosed with PNES using RBANS Effort Index (EI).
We compared cognitive performance with control group. Materials and methods: 174 patients (125w/49m) with PNES were tested and followed one year after hospitalization in Epilepsy center, Na Homolce Hospital in Prague.
For the purpose of this study, patients were examined using RBANS (Czech research version) and the performance was compared with the control group (56w/48 m). Table 1.
Demographic variables Controls (104) Patients (174) Age 38.13 (13.4) 38.34 (13.24) Gender (56w/48 m) (125w/46m) Education (yrs) 15.57 (2.8) 11.9 (1.9) We also used semi-structured interview focused on the change in the frequency and severity of seizures, consumption of health care, change in subjective quality of life in respect to the seizures. Patients were also assessed by the semi-structured interview focused on the stressors in childhood, social learning and the stressors preceding seizures, and by emotional relationships in childhood questionnaire (Parental Bonding Instrument, Czech version); these results were not included in this study.
Results: We found significant differences in cognitive performance in patients' group in comparison with healthy controls in following domains - Immediate memory, Visuospatial/Constructional, Language, Attention, Delayed Memory and Total Scale (p<.001). The most reduced performance was in domains Attention and Delayed recall (below average).
Effort Index was significantly higher in PNES group and EI equal or higher than 3 was detected in 17.6% of patients with PNES. Detailed results are in the Table 3.
Table 2. Cognitive performance RBANS subtests and Index Scores controls patients group comparison MEAN SD Mean SD Mann-Whitney t.
List learning 31,24 3,840 27,83 5,463 0.000 Story memory 18,68 3,342 16,54 4,215 0.000 Figure copy 19,03 1,517 17,07 2,579 0.000 Line orientation 18,30 1,864 18,55 8,544 0,458 Picture naming 9,93 0,252 9,84 0,637 0,352 Semantic fluency 23,71 4,756 21,11 5,971 0,000 Digit span 10,39 2,266 8,67 2,058 0,000 Coding 52,01 11,318 38,78 13,522 0,000 List Recall 7,10 1,851 5,99 2,361 0,000 List Recognition 19,44 1,606 18,61 2,100 0,000 Story Recall 10,37 2,118 9,08 2,442 0,000 Figure Recall 16,36 3,441 13,65 4,011 0,000 Immediate Memory 102,14 13,479 91,94 17,459 0,000 Visuospatial/Constructional 106,27 15,055 94,50 16,892 0,000 Language 104,79 10,454 98,16 14,548 0,000 Attention 94,31 15,106 74,37 17,714 0,000 Delayed Memory 100,79 12,507 88,81 18,082 0,000 Total Scale 101,88 11,593 86,38 15,789 0,000 Effort index 0,32 1,026 1,20 2,022 0,000 Table 3. Effort index in patients with PNES Frequency Valid Percent Cumulative Percent 0 87 61,3 61,3 1 8 5,6 66,9 2 22 15,5 82,4 3 12 8,5 90,8 4 4 2,8 93,7 5 2 1,4 95,1 6 2 1,4 96,5 8 2 1,4 97,9 9 2 1,4 99,3 10 1 0,7 100,0 Total 142 100,0 Conclusions: Multifactorial approach in the understanding of pathogenesis of PNES is essential for correct diagnosis.
Integral part of neuropsychological assessment is evaluation of cognitive performance and effort in patients with PNES especially in patients suspected of insufficient effort or poor motivation. We consider RBANS Effort Index as useful screening method for detection of poor effort in PNES patients.
References: Celik, A. Ö., Kurt, P., Yener, G., Alkin, T., Öztura, I., Baklan, B. (2015). Comparison of Cognitive Impairment between Patients having Epilepsy and Psychogenic Nonepileptic Seizures.
Archives of Neuropsychiatry, 52, 163-168. Dworetzky, B.
A., Baslet, G. C. (2017).
Psychogenic nonepileptic seizures. Toward the integration of care.
New York: Oxford University Press. Fargo, J.D., Schefft, B.K., Szaflarski, J.P., Dulay, M.F., Testa, S.M., Privitera, M.D., & Yeh, H.S. (2004).
Accuracy of self-reported neuropsychological functioning in individuals with epileptic or psychogenic nonepileptic seizures. Epilepsy and Behavior, 5, 143-50.
Prigatano, G.P., Stonnington, C.M., & Fisher, R.S. (2002). Psychological factors in the genesis and management of nonepileptic seizures: clinical observations.
Epilepsy and Behavior, 3, 343-349. Schachter, S.
C., & LaFrance, W. C. (2010).
Gates and Rowan's Nonepileptic Seizures. Cambridge: Cambridge University Press.
Brown, R. J., & Reuber, M. (2016).
Psychological and psychiatric aspects of psychogenic non-epileptic seizures (PNES): A systematic review. Clinical Psychology Review, 45, 157-182.