Traumatic brain injury and psychogenic nonepileptic seizures

W. Curt LaFrance, Jr., M.D., M.P.H. †,*, Marie DeLucaº

† Department of Neurology and Comprehensive Epilepsy ProgramRhode Island Hospital, Brown Medical School

* Department of Psychiatry and Human Behavior, Brown Medical Schoolº Brown University, Providence, Rhode Island, USA

Partially funded by National Institute of Neurological Disorders and Stroke 5K23NS045902

Objective: We investigated the relationship between psychogenic nonepileptic seizures (PNES) and traumatic brain injuries (TBI). We hypothesized that TBI would be associated with more psychiatric comorbidities and disability in PNES than in patients with PNES without TBI.

Background:TBI has been shown to be a risk factor for PNES in several studies, but specifics of TBI have not been fully investigated. It is important to understand this relationship as a potential exacerbating factor in patients with PNES.

Design/Methods:PNES data were reviewed. TBI details were coded from neuropsychiatric evaluations. After excluding patients with incomplete injury histories, the final total population was 92. Chi-square and T-tests were performed on demographic, neurologic and psychiatric variables between the PNES with TBI and PNES without TBI populations.

Results:Of the 92 patients with PNES meeting inclusion criteria, 41 had a history of TBI. The PNES with TBI population had a higher mean age (p=0.0322), was less predominantly female (p=0.0390), and was more likely to receive disability (p=0.0110). Patients with both PNES and TBI were more likely to have major depressive disorder (p=0.0120), cluster B personality traits or disorders (p=0.0120), history of abuse (p=0.0400), and abnormal MRI results (p=0.0190) than patients with PNES without TBI.

Conclusions/Relevance:These results suggest a significant comorbidity between PNES and TBI. A history of TBI may increase the risk for psychiatric diagnoses and disability in patients with PNES. Further investigation into the nature of TBI in this population and contributions to PNES could be investigated in a prospective study to better understand risks, outcomes and brain-behavior mechanisms.

• Psychogenic nonepileptic seizures is a neuropsychiatric disorder characterized by seizures without epileptic activity on an EEG

• PNES is associated with histories of abuse, mood disorders, and other disorders

• Patients with comorbidities have a reduced quality of life• TBI may be a risk factor in patients with PNES

The purpose of this study was to further investigate the potential link between TBI and PNES and examine the differences in psychiatric comorbidities between patients with PNES only as compared to those with PNES and a history of TBI. We hypothesized that patients with TBI and PNES would have more psychiatric comorbidities and disability than in patients with PNES without TBI.

AbstractParticipants:Patients with PNES diagnosis confirmed through video EEG without epileptiform activityNeuropsychiatric evaluation (NPE) administered to each patient, including review of medical, social,

psychiatric and treatment history, and neurological and psychiatric examinationNPE reviewed for history of TBI using CDC and WHO criteria for TBI and mild TBI  Exclusion Criteria:Lack of confirmed PNES diagnosed by video EEG or of witnessed seizure with normal routine EEGAmbiguous history of TBI Incomplete descriptive History

Data Collection and Analysis:A database of demographic variables was created including gender, age, and disability status, and patient medical histories including monthly seizure frequency, Beck Depression Inventory score (BDI), Quality of life in Epilepsy score (QOLIE-31), and DSM-IV Axis I and II diagnoses TBI data. Specific focus was placed on mechanism of injury and severity of TBI. Data analysis using SAS included chi-square for categorical variables and paired t tests for continuous variables. Log transformation of seizure frequency was used to normalize the distribution. Comparisons between patients with PNES with TBI and PNES without TBI are described in the results section.

* No TBI n = 43, TBI n = 35

TBI appears to be a significant risk factor for PNES

Patients with PNES and TBI have a greater prevalence of comorbid psychiatric disorders than patients without TBI

Demographic differences may be a result of interaction between PNES and TBI demographics

TBI may add to the burden of illness in patients with PNES

Further exploration of the interaction between these two disorders could help with treatment, as new treatment options become available

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W. Curt LaFrance, Jr., MD, MPH Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903 USA William_LaFrance_Jr@Brown.edu

Methods

Introduction

References

Discussion

Contact Info

Results

 

No TBI TBI 

n=51 n =41      

Factors x¯ (sd) n (%) x¯ (sd) n (%)

Chi-Square value T P value

Age (years) 32.3725 15.614     38.9268 12.6281       -2.1754 0.0322Gender (female)     43 84.31     27 65.85 4.257   0.0390Receiving disability currently     12 23.53     20 48.78 6.389   0.0110

Mood disorders     26 50.98     29 70.73 3.688   0.0550Number of Mood Disorders 0.5294 0.5423     0.8049 0.6008       -2.3078 0.0233

Anxiety disorders     48 94.12     33 80.49 4.011   0.0450Number of Anxiety Disorders 1.8627 1.0396     1.6341 1.1991       0.9789 0.3303

Major Depressive Disorder     11 21.57     19 46.34 6.347   0.0120

Impulsivity (cluster B personality or traits)     10 19.61     18 43.90 6.336   0.0120

History of trauma/abuse     34 66.67     35 85.37 4.238   0.0400

Abnormal MRI of the brain (past or at enrollment)*

    11 25.58     18 51.43 5.519   0.0190

Table 1: Significant differences between patients with PNES and TBI and patients with PNES without TBI