Diurnal patterns and relationships between physiological and self-reported stress in patients with epilepsy and psychogenic non-epileptic seizures

Purpose: Patients with epilepsy and those with psychogenic non-epileptic seizures (PNES) experience high levels of stress and stress is one of the most frequently self-identified seizure precipitants. Although stress is a multifaceted phenomenon, few studies have systematically examined its different components in patients with seizures. The aim of this study was therefore to describe diurnal patterns of psychological and physiological measures of stress in patients with epilepsy and patients with PNES, and explore their relationships to each other in order to improve our understanding of the mechanisms underlying stress and seizure occurrence in these patients. Method: A range of stress markers including self-reported stress, salivary cortisol and heart rate variability (HRV) were explored in adult patients with refractory epilepsy (N = 22) and those with PNES (N = 23) undergoing three- to five-day video-telemetry. Results: A diurnal pattern was observed in the physiological measures, characterised by higher levels of physiological arousal in the mornings and lower levels at night in both patients with epilepsy and PNES. The physiological measures (cortisol and HRV) were associated with each other in patients with epilepsy, no close relationship was found with self-reported stress in either of the two patient groups. Conclusion: The findings contribute to and expand on previous studies of the patterns of stress in patients with seizures. The results also indicate a discrepancy between patients’ physiological responses and their subjective stress perceptions, suggesting that simple self-reports cannot be used as a proxy of physiological arousal in patients with seizures and stress. Stress in these patient groups should be studied using a combination of complementary measures

A conversation analytic intervention to help neurologists identify diagnostically relevant linguistic features in seizure patients’ talk

Recent Conversation Analytic work has revealed that there are systematic differences between the ways in which patients with epilepsy and patients with “psychogenic” non-epileptic seizures (NES) describe their seizure experiences. But these differences may not become apparent if patients are exposed to traditional fact-oriented questioning. This article describes a oneday intervention workshop, informed by Conversation Analysis, which was designed to help doctors change their history-taking style and solicit diagnostically useful narrative features. A comparison of video-recordings of 38 routine consultations before the intervention, and 20 consultations after it, showed that the intervention had the desired effect. Doctors' problem presentation solicitation changed, and the patient responses were better suited to revealing diagnostically-relevant features of their talk. Data in British English

Neurologists can identify diagnostic linguistic features during routine seizure clinic interactions: results of a one-day teaching intervention.

The diagnostic distinction between epilepsy and psychogenic nonepileptic seizures (PNES) can be challenging. Previous studies have demonstrated that experts in conversation analysis can identify linguistic and interactional features in transcripts and recordings of interviews with patients that reliably distinguish between epilepsy and PNES. In this study, ten senior neurology trainees took part in a one-day intervention workshop about linguistic and interactional differences in the conversation behavior of patients with epilepsy and those with PNES. Participants were familiarized with a 12-item questionnaire designed to capture their conversational observations immediately after talking to a patient with seizures. After the intervention, 55 initial outpatient visits of patients referred to seizure clinics were video and audio recorded. All medical diagnoses were confirmed two years after initial presentation on the basis of a chart review (including MRI and EEG findings) by a fully trained epilepsy expert. Postvisit questionnaires relating to patients confirmed to have epilepsy (n=20) or PNES (n=13) were analyzed. Doctors' mean responses to 6 of the 12 questions about linguistic and interactional observations differed significantly between the groups with epilepsy and PNES. Receiver operating curve analysis showed that a summation scale based on items demonstrating significant between-group differences correctly classified 81.8% of patients as having epilepsy or PNES. This study shows that a brief Conversation Analytic teaching intervention can enable neurologists to identify linguistic and interactional features supporting the differentiation of epilepsy and PNES as they take their patients' history in routine seizure clinic consultations, potentially improving diagnostic accuracy

The role of companions in outpatient seizure clinic interactions: a pilot study

Purpose This study explored contributions that patients' companions (seizure witnesses) make to interactions in the seizure clinic and whether the nature of the companions' interactional contributions can help with the differentiation of epilepsy and psychogenic nonepileptic seizures (PNES). Methods Conversation analysis methods were used to examine video recordings and transcripts of neurologists' interactions with patients referred to a specialist seizure clinic and their companions. Results The companions' behavior correlated with interactional features previously observed to distinguish patients with epilepsy from patients with PNES. Patients with PNES, but not those with epilepsy, tended to exhibit interactional resistance to the doctor's efforts to find out more about their seizure experiences and, thereby, encouraged greater interactional contribution from companions. Conclusion The contributions that companions make (in part, prompted by patient's interactional behavior) may provide additional diagnostic pointers in this clinical setting, and a number of candidate features that may help clinicians distinguish between epilepsy and PNES when the patient is accompanied by a seizure witness are described. However, companion contributions may limit the doctor's ability to identify linguistic and interactional features with previously demonstrated diagnostic potential in the conversational contributions made by patients themselves. To help offset potential diagnostic losses, doctors may need to explicitly discuss the role of the companion in the consultation when a seizure witness (or another companion) accompanies the patient

Response to Open Peer Commentaries on "Diagnosis By Television Documentary: Professional Responsibilities in Informal Encounters".

In presenting the situation of a health professional witnessing an instance of misdiagnosis and mistreatment in a television documentary, we hoped to stimulate discussion of the professional responsibilities of health workers in informal encounters in a rapidly changing environment comprising print, television, and more recently social media platforms. The commentaries on our article do not disappoint in this respect, providing insightful and sometimes challenging reactions to the position we outlined in response to our original case. In our reply here, we choose to focus on two themes running through all of the commentaries: (1) the distinction between axiological and deontic perspectives invoked by Salloch, and the open-endedness of the former that we see as crucial in addressing the constantly changing media landscape through which health workers may confront medical need; and (2) the role of institutional, structural, and social factors in constraining or enabling virtuous professional practice—suggesting perhaps a further need for health workers to take action directly against structural injustices that prevent them from fulfilling their professional responsibilities

The normativity of medical tests : Test ordering as a routine activity in ‘new problem’ consultations in secondary care

How does ordering a test fit into new-problem medical consultations? Robinson (2003) has shown that there are four main activities in new problem consultations in primary care (establishing the reason for the visit, gathering information, delivering a diagnosis, recommending treatment), but he speculates that other types of medical consultation may be organised differently. We show a key difference in new problem consultations in secondary care (neurology): clinicians and patients orient to test ordering as a normative activity. Our data come from 65 new problem consultations in two large neuroscience centres in the UK, in which tests were routinely ordered or, if not, their relevance was nonetheless handled by both parties. We argue that test ordering, despite being treatment-oriented, displaces treatment in the here-and-now. It thus serves as both bridge and barrier to accomplishing the overarching medical project. Data are in British English

Non-epileptic attack disorder: the importance of diagnosis and treatment

A 50-year-old woman was taken to hospital by emergency ambulance during her first seizure. She was admitted to hospital, treated with intravenous diazepam, diagnosed with epilepsy and started on antiepileptic drug (AED) therapy. This was ineffective so she was referred to a tertiary centre where she underwent video EEG and was diagnosed with non-epileptic attack disorder. Her experience of the diagnosis was positive; it allowed her to understand what was happening to her and to understand the link between her seizures, adverse childhood experiences and the death of her mother. She stopped taking AEDs and she was referred to a psychologist which led to a significant improvement in her functioning and quality of life. We present this case as a good example of the benefits of accurate diagnosis, clear explanation and access to specialist car

A multicenter evaluation of a brief manualized psychoeducation intervention for psychogenic nonepileptic seizures delivered by health professionals with limited experience in psychological treatment

Rationale The aim of this study was to add to our understanding of the impact of psychoeducation on patients' acceptance of the diagnosis of psychogenic nonepileptic seizures (PNESs), the frequency of their seizures, and their quality of life. The study also aimed to evaluate the effectiveness of brief manualized psychoeducation interventions for PNESs, delivered by a more diverse range of clinicians and in a wider range of treatment settings. Method The final sample consisted of 25 patients diagnosed with PNESs by a neurologist specializing in the treatment of seizure disorder and referred to the psychotherapy service. The study included patients from four centers, using a manualized psychoeducation intervention delivered over 4 sessions by specialist epilepsy nurses and assistant psychologists. All patients completed self-measure questionnaires for Seizure Frequency, Impaired Functioning (WSAS), Psychological Distress (CORE-OM), Illness Perception (BIPQ), Health-Related Quality of Life: general (ED-QOL) and epilepsy-specific (NewQOL-6D), Symptom Attribution, and patient's perception of usefulness and relevance of the intervention. All measures were collected at baseline and after the completion of the fourth session. Results All measures improved from baseline to postintervention, but this improvement was only significant for CORE-OM (p < .05) and BIPQ (p < .01). Out of the 25 patients who completed the intervention information, 6 out of 25 (24%) had been seizure-free for the past month, and an additional 6 out of 25 (24%) had achieved seizure frequency reduction. Consequently, upon completion of the intervention, 12 out of 25 patients (48%) were either seizure-free or experienced fewer seizures compared with the start of the intervention. Conclusion The evidence suggests that brief manualized psychoeducation intervention can reduce PNES frequency, improve the psychological distress, and have an effect on patients' illness perceptions that should help them engage with a more extended psychotherapy program if that was necessary. The intervention was carried out successfully by staff with relatively little training in delivering psychological interventions. Further controlled studies are required to provide proof of efficacy