Types of Seizures and Prevalence - Research Paper Example

Types of Seizures and Prevalence Defining Seizures A brain seizure is defined as an abrupt alteration in cortical electrical activity manifested clinically by a change in consciousness or by a motor, sensory, or behavioral symptom. Indicating the presence of neurological, physiological or psychological disorders seizures are characterized by time-limited alterations in behavior, motor activity, autonomic functioning, consciousness, or sensation (Lezak, 2004). Paroxysmal events overtly similar to epilepsy, but lacking any hyperexcitability and hypersynchronous discharge of neurons in the brain required for a diagnosis of ES, are defined as nonepileptic seizure (NES). While some NES reflect physiological disorders, including syncope, paroxysmal movement, or sleep disorders, NES seizures with psychological origins are defined as PNES (Benbadis, 2005). Types of Seizures and Prevalence Nonepileptic seizures (NESs) are stereotyped paroxysmal behavioral events that resemble and are mistakenly diagnosed as epilepsy. Unlike epileptic seizures, however, they are not correlated with abnormal electrical discharge in the brain. NESs can be divided into two groups: those that are organic in nature and those with a psychogenic origin. Organic NESs are defined by what they are not: they are seizures that are neither epileptic nor psychogenic. Organic NESs are most commonly due to cardiovascular illness, such as aortic stenosis, arrhythmias, cardiac syncope (fainting), and orthostatic hypotension. Other organic conditions often confused with NESs include transient cerebral ischemia, paroxysmal movement disorders, toxic or metabolic problems (i.e., drug toxicity and hypoglycemia), noncardiac hyperventilation attacks, parasomnias, and atypical complex migraine headache (Chabolla, Krahn, So, & Rummans, 1996). However, most NESs are psychogenic in origin (Chabolla et al., 1996). Nomenclature used to describe nonepileptic seizures of psychological origin includes pseudoseizures, psychogenic seizures, and hysterical seizures; they will be referred to here as psychogenic nonepileptic seizures (PNESs). The prevalence of PNESs is estimated to be in the range of 5 to 20% in outpatient epilepsy populations (Chabolla et al., 1996). Exact prevalence of the phenomenon is unknown, however, as prevalence estimates are based on populations in specialized epilepsy centers with varied diagnostic methods and criteria. At least three fourths of patients diagnosed with PNESs are women (Chabolla et al., 1996). Etiology Psychiatric Symptomatology and PNES Bowman (1993) examined the etiology and course of PNES in a sample of27 patients. Findings showed that the sample reported a high incidence of psychiatric symptoms: affective and dissociative disorders (85%) and posttraumatic stress disorder (33%). These findings were replicated by Bowman and Markand (1996) who investigated current and lifetime rates of psychiatric disorders in patients diagnosed with PNES. Participants (N=45) were interviewed regarding seizure activity and traumatic life experiences and were given various paper and pencil measures that examined psychosocial factors and behavioral tendencies. Seventy-eight percent of the sample was female; the mean age was 37.5 years and their mean duration of seizure activity was 8.3 years. Concurring with the previously high prevalence of psychiatric symptomatology in PNES patients, common current psychiatric diagnoses according to DSM-III-R included dissociative disorders (91 %) somatoform disorders (89%), affective disorders (64%), personality disorders (62%), post-traumatic stress disorder (49%) and other anxiety disorders (47%). Although a variety of psychiatric conditions have been documented in the literature (Bowman & Markand, 1996), conversion disorder is considered the most common cause of non-epileptic activity (Benbadis, 2005). Other conditions that can also be associated include mood disorders, anxiety disorders, dissociation, and malingering. Psychosocial Factors and PNES Literature in the area of family health has suggested that somatization (a disorder which is often used to label the incidence of non-epileptic events) may be determined by a family's response pattern to stressful situations (Wood, McDaniel, Burchfiel & Erba, 1998). A study conducted by Wood and associates (1998) compared families of patients with PNES and those of patients with epilepsy on anxiety, depression and somatization. Findings indicated that that the patient groups did not differ; however, family members of those with a diagnosis of PNES reported significantly more health problems, criticism, and distress than did the family members of those with epilepsy. The authors concluded that family members of those with PNES "are more troubled and may unwittingly contribute to psychogenic episodes through family distress, criticism, and tendencies to somatisize" (p. 435). Findings should be interpreted with caution as they were based on a sample of 18 participants (9 PNES and 9 epilepsy patients). Definite conclusions cannot be made due to this limitation. Berkhoff, Briellmann, Radanov, Donati and Hess (1998) investigated a variety of psychosocial factors (social modeling, developmental emotional stress, parent's tenderness toward patient, financial problems, physical abuse, parental divorce, and alcohol or substance abuse) in individuals diagnosed with PNES. No differences regarding previous functional disturbances, modeling, or developmental stressors were found. Sexual abuse was uncovered in two female patients, from a sample of ten. As with the previous study, results are sample specific and must be interpreted with caution due to the small sample. Neuropsychological Deficits and PNES Neuropsychological deficits have been associated with certain types of psychopathology. Patients with both Axis I and Axis II disorders have displayed impaired performance on cognitive tests. Axis I disorders related to specific cognitive deficits include major depression, which has been associated with deficits in cognitive set shifting, spatial working memory, visual memory, psychomotor speed, sustained effort and concentration, and memory and learning of demanding material (Burgess, 1992). Such findings have been interpreted as evidence that major psychological disorders can be conceptualized as neuropsychiatric conditions or syndromes that have associated cognitive changes. Cognitive impairments have also been demonstrated in studies of patients with personality disorders. People with borderline personality disorder have shown significant cognitive impairment on tasks requiring planning and sequencing (Burgess, 1992). Patients with "dramatic personalities" (histrionic, narcissistic, borderline, and antisocial types) were found to have deficits on tests of cognition and information processing, especially those requiring multi-step, multi-element associative operations (Burgess, 1992). Individuals with neurobehavioral impairments other than psychiatric disorders also may display social and behavioral disturbances. Patients with frontal lobe dysfunction frequently show decreased social concern, jocularity, facetiousness, boastfulness, irritability, coarseness, hyperkinesia, disinhibition, loss of social graces, inappropriate sexual advances, sexual exhibitionism, impulsiveness, restlessness, and grandiose delusions (Starkstein & Robinson, 1991). Children with attention deficit/hyperactivity disorder (ADHD) may display academic underachievement, disturbed peer relationships, and conduct problems or hostility towards adults. Another neurobehavioral syndrome, described by Rourke (1995), is nonverbal learning disability (NLD). According to Rourke, NLD arises from significant lesions in the right hemisphere or dysfunction of fibers accessing the right hemisphere. This syndrome involves academic as well as socioemotional and adaptive deficits, including deficits in adaption to novelty, social competence, emotional stability, and activity level (Rourke, 1995). These findings suggest that impairments of brain function and cognitive function can and do produce disorders of mood, social perception, and behavior. If cognition is impaired, one's ability to effectively cope with the environment is likely to be impaired as well. Certain cognitive deficits may significantly inhibit instrumental problem-solving skills that allow an individual to interact appropriately, obtain goals, and avoid aversive events. Therefore, such cognitive dysfunction could easily set the stage for PNES to be useful and more likely in these individuals. That is, PNES may represent a way for an individual without sufficient problem-solving skills to meet his or her needs. Treatment Modalities for PNES Galimberti and colleagues (2003) have suggested the use of psychological relaxation techniques in addition to psychotherapy given the high prevalence of elevated scores on scales of psychophysiological symptoms of distress. In addition, the development of effective management strategies is likely to require the collaboration of different professions due to the heterogenous nature of PNESs, the need for extensive follow-up and the range of possible therapeutic interventions. Lesser (2003) outlines 5 goals that should be the skeletal framework for PNES patients: acceptance, motivation, understanding, control, and consolidation. In addition, he suggests the use of counseling, psychotherapy, biofeedback, relaxation techniques, and medication. Further, dynamic psychotherapy and neuro feedback have also been documented as primary treatments of choice. While numerous recommendations for treatment have been provided (Lesser, 2003), the current treatment for PNES remains anecdotal. No controlled or large comparative trials have been successfully replicated utilizing a standard psychological intervention. Instead, the types of treatment examined have been sample specific and usually based on the resources available to the facility's treatment team. Although a multi­disciplinary approach is commonly utilized, specific components of the therapeutic programs differ widely between treatment facilities. Nevertheless, since this condition is considered to represent either a behavioral response to an emotional stressor or a chronic maladaptive behavior symptomatic of several psychiatric disorders, the literature has reached an agreement highly recommending the use of psychotherapy accompanied by an ongoing support system. Conclusion To date, there is no consensus in PNES literature regarding possible neuropsychological impairments, psychiatric conditions and prevalent personality characteristics. Conversely characteristics associated with poorer outcomes, such as problematic personality features, somatization and dissociative tendencies are enduring dispositions and unlikely to result in rapid changes. Thus, treatment should not only address personality characteristics which can be rigid, but the focus of the treatment should concentrate on the identification and management of stressors (interpersonal and environmental) that interact with personality vulnerabilities. References Benbadis, S. R (2005). The problem of psychogenic symptoms: is the psychiatric community in denial? Epilepsy & Behavior, 6: 9-14. Berkhoff, M., Briellmann, RS., Radanov, RP., Donati, F., Hess, C.W. (1998). Developmental background and outcome in patients with nonepileptic versus epileptic sezures: a controlled study. Epilepsia, 39(5): 463-469. Bowman, E.S. (1993). Etiology and clinical course of pseudo seizures. Relationship to trauma, depression, and dissociation. Psychosomatics, 34 (4): 333-342. Bowman, E.S. Markand, a.N. (1996). Psychodynamics and Psychiatric Diagnoses of pseudoseizures subjects. American Journal of Psychiatry, 153: 57-63. Burgess, J.W. (1992). Neurocognitive impairment in dramatic personalities: Histrionic, narcissistic, borderline, and antisocial disorders. Psychiatry Research, 42, 283-290. Chabolla, D.R. Krahn, L.E. So, E.L. & Rummans, T.A. (1996). Psychogenic non-epileptic seizures. Mayo Clinic Proceedings, 71(1), 493-500. Galimberti, C.A., Ratti, M.T., Marchioni, E., Manni, R., & Tartara, A. (2003). Patients with psychogenic nonepileptic seizures, alone or epilepsy-associated share a psychological profile distinct from that of epilepsy patients. Journal of Neurology, 250: 338-346. Lesser, RP. (2003). Treatment and Outcome of Psychogenic Non-epileptic Seizures. Epilepsy Currents, 3(6):198-200. Rourke, B.P. (1995). The NLD syndrome and the white matter model. In B.P. Rourke (Ed.), Syndrome of nonverbal learning disabilities: Neurodevelopmental manifestations (pp. 1-26). New York: The Guilford Press. Starkstein, S.E. & Robinson, R.G. (1991). The role of the frontal lobes in affective disorder following stroke. In H.S. Levin, H.M. Eisenberg & A.L Benton (Eds.), Frontal Lobe Function and Dysfunction (pp. 288-303). New York: Oxford University Press. Wood, B.L., McDaniel, S., Burchfiel, K., & Erba, G. (1998). Factors distinguishing families of patients with psychogenic seizures from families of epilepsy patients. Epilepsia, 39(4),432-437. Read More