We speak with W. Curt LaFrance Jr., MD, MPH, about functional (nonepileptic) seizures. We cover epidemiology, overlap and differences with regard to epilepsy, negative health outcomes, co-occurring psychological and neurological factors, an etiological framework, cognitive profiles, and treatment. We also discuss general overlap across neurology and psychiatry, as well as future directions in research on functional seizures.
A pdf of the transcript for this episode will be available soon.
If you’d like to receive APA-approved CE credit for listening to this episode, click here.
About Curt
Curt LaFrance Jr., MD, MPH, FAAN, FANPA, DFAPA, is director of neuropsychiatry and behavioral neurology at Rhode Island Hospital and professor of psychiatry and neurology at Brown University Warren Alpert Medical School. He is director of the VA Mind Brain Program, staff physician at the Providence Veterans Affairs Medical Center and clinical lead for the National TeleMental Health Center tele-seizures clinic. He studied at Wake Forest University (B.A. in Psychology), Medical College of Georgia (M.D.) and Brown University (MPH). He trained in Brown’s combined neurology/psychiatry residency and is double boarded. He has served on the Epilepsy Foundation Professional Advisory Board and has chaired task forces with the American Epilepsy Society and International League Against Epilepsy. He has received grants from EF, AES, the Matthew Siravo Memorial Foundation, Veterans Affairs and the Department of Defense, and a National Institute of Neurological Disorders and Stroke K23 Award. He directed the combined residency at Brown from 2012-19 and has served as research advisor or mentor to Brown undergraduates in neurobiology and psychology; residents in psychiatry, neurology and neuropsychiatry; and faculty. He trains clinicians around the country using distance supervision in treatment delivery for seizures, movement disorders, head injuries and somatic symptom disorders, based on a whole-person, integrative medicine bio-psycho-social-spiritual approach. His research focuses on developing new biomarkers and treatments for neuropsychiatric aspects of epilepsy, conversion (functional neurological) disorders and traumatic brain injury. His studies are published in neurology and psychiatry journals. He serves on journal editorial boards and is co-editor of the fourth edition of “Nonepileptic Seizures”, and co-author of “Taking Control of Your Seizures: Workbook” and “Taking Control of Your Seizures: Therapist Guide.” A goal of his work at Brown, nationally and internationally, has been to bridge neurology and psychiatry clinical practice and scientific research and to dissolve arbitrary boundaries between the two fields.
Resources
References
Asadi-Pooya, A. A. (2021). Incidence and prevalence of psychogenic nonepileptic seizures (functional seizures): A systematic review and an analytical study. International Journal of Neuroscience, 1–6. https://doi.org/10.1080/00207454.2021.1942870
Baslet, G. (2011). Psychogenic non-epileptic seizures: A model of their pathogenic mechanism. Seizure, 20(1), 1–13. https://doi.org/10.1016/j.seizure.2010.10.032
Baslet, G., Bajestan, S. N., Aybek, S., Modirrousta, M., Price, J., Cavanna, A., Perez, D. L., Lazarow, S. S., Raynor, G., Voon, V., Ducharme, S., & LaFrance, W. C. (2021). Evidence-Based Practice for the Clinical Assessment of Psychogenic Nonepileptic Seizures: A Report From the American Neuropsychiatric Association Committee on Research. The Journal of Neuropsychiatry and Clinical Neurosciences, 33(1), 27–42. https://doi.org/10.1176/appi.neuropsych.19120354
Baslet, G., Roiko, A., & Prensky, E. (2010). Heterogeneity in psychogenic nonepileptic seizures: Understanding the role of psychiatric and neurological factors. Epilepsy & Behavior, 17(2), 236–241. https://doi.org/10.1016/j.yebeh.2009.12.008
Baslet, G., Seshadri, A., Bermeo-Ovalle, A., Willment, K., & Myers, L. (2016). Psychogenic Non-epileptic Seizures: An Updated Primer. Psychosomatics, 57(1), 1–17. https://doi.org/10.1016/j.psym.2015.10.004
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. https://doi.org/10.1016/j.cpr.2016.01.003
Cáceres, C., Grau-López, L., Martínez, S., Mariscal, C., González-Fuxà, A., Jiménez, M., Ciurans, J., Gea, M., Fumanal, A., & Becerra, J. L. (2021). Psychogenic nonepileptic seizures: The effect of accurate diagnosis on cognition. Epilepsy & Behavior, 117, 107766. https://doi.org/10.1016/j.yebeh.2020.107766
Chen, D. K., Sharma, E., & LaFrance, W. C. (2017). Psychogenic Non-Epileptic Seizures. Current Neurology and Neuroscience Reports, 17(9), 71. https://doi.org/10.1007/s11910-017-0781-7
Dixit, R., Popescu, A., Bagić, A., Ghearing, G., & Hendrickson, R. (2013). Medical comorbidities in patients with psychogenic nonepileptic spells (PNES) referred for video-EEG monitoring. Epilepsy & Behavior, 28(2), 137–140. https://doi.org/10.1016/j.yebeh.2013.05.004
Dodrill, C. B. (2010). Use of Neuropsychological and Personality Testing to Identify Adults with Psychogenic Nonepileptic Seizures. In C. W. LaFrance & S. C. Schachter (Eds.), Gates and Rowan’s Nonepileptic Seizures (p. 14). Cambridge University Press.
Drane, D. L., & Locke, D. E. C. (2017). Mechanisms of Possible Neurocognitive Dysfunction (B. A. Dworetzky & G. C. Baslet, Eds.; Vol. 1). Oxford University Press. https://doi.org/10.1093/med/9780190265045.003.0005
Duncan, R., Razvi, S., & Mulhern, S. (2011). Newly presenting psychogenic nonepileptic seizures: Incidence, population characteristics, and early outcome from a prospective audit of a first seizure clinic. Epilepsy & Behavior, 20(2), 308–311. https://doi.org/10.1016/j.yebeh.2010.10.022
Fargo, J. D., Schefft, B. K., Szaflarski, J. P., Dulay, M. F., Marc Testa, S., Privitera, M. D., & Yeh, H.-S. (2004). Accuracy of self-reported neuropsychological functioning in individuals with epileptic or psychogenic nonepileptic seizures. Epilepsy & Behavior, 5(2), 143–150. https://doi.org/10.1016/j.yebeh.2003.11.023
Fiszman, A., Alves-Leon, S. V., Nunes, R. G., D‘Andrea, I., & Figueira, I. (2004). Traumatic events and posttraumatic stress disorder in patients with psychogenic nonepileptic seizures: A critical review. Epilepsy & Behavior, 5(6), 818–825. https://doi.org/10.1016/j.yebeh.2004.09.002
Goldstein, L. H., Robinson, E. J., Mellers, J. D. C., Stone, J., Carson, A., Reuber, M., Medford, N., McCrone, P., Murray, J., Richardson, M. P., Pilecka, I., Eastwood, C., Moore, M., Mosweu, I., Perdue, I., Landau, S., Chalder, T., Abe, A.-M., Adab, N., … Yogarajah, M. (2020). Cognitive behavioural therapy for adults with dissociative seizures (CODES): A pragmatic, multicentre, randomised controlled trial. The Lancet Psychiatry, 7(6), 491–505. https://doi.org/10.1016/S2215-0366(20)30128-0
Goldstein, L. H., Robinson, E. J., Chalder, T., Reuber, M., Medford, N., Stone, J., … & Landau, S. (2022). Six-month outcomes of the CODES randomised controlled trial of cognitive behavioural therapy for dissociative seizures: A secondary analysis. Seizure, 96, 128-136.
Goldstein, L. H., Robinson, E. J., Chalder, T., Stone, J., Reuber, M., Medford, N., … & Landau, S. (2022). Moderators of cognitive behavioural therapy treatment effects and predictors of outcome in the CODES randomised controlled trial for adults with dissociative seizures. Journal of Psychosomatic Research, 158, 110921.
Jennum, P., Ibsen, R., & Kjellberg, J. (2019a). Morbidity and mortality of nonepileptic seizures (NES): A controlled national study. Epilepsy & Behavior, 96, 229–233. https://doi.org/10.1016/j.yebeh.2019.03.016
Jennum, P., Ibsen, R., & Kjellberg, J. (2019b). Welfare consequences for people diagnosed with nonepileptic seizures: A matched nationwide study in Denmark. Epilepsy & Behavior, 98, 59–65. https://doi.org/10.1016/j.yebeh.2019.06.024
Karaaslan, Ö., & Hamamcı, M. (2020). Cognitive impairment profile differences in patients with psychogenic non-epileptic seizures and epilepsy patients with generalized seizures. Neurological Research, 42(3), 179–188. https://doi.org/10.1080/01616412.2020.1716468
Karakis, I., Montouris, G. D., Piperidou, C., Luciano, M. S., Meador, K. J., & Cole, A. J. (2014). Patient and caregiver quality of life in psychogenic non-epileptic seizures compared to epileptic seizures. Seizure, 23(1), 47–54. https://doi.org/10.1016/j.seizure.2013.09.011
LaFrance Jr, W. C., Baker, G. A., Duncan, R., Goldstein, L. H., & Reuber, M. (2013). Minimum requirements for the diagnosis of psychogenic nonepileptic seizures: a staged approach: a report from the International League Against Epilepsy Nonepileptic Seizures Task Force. Epilepsia, 54(11), 2005-2018.
LaFrance, W. C., Baird, G. L., Barry, J. J., Blum, A. S., Webb, A. F., Keitner, G. I., … & Szaflarski, J. P. (2014). Multicenter pilot treatment trial for psychogenic nonepileptic seizures: a randomized clinical trial. JAMA psychiatry, 71(9), 997-1005.
LaFrance, W. C., DeLuca, M., Machan, J. T., & Fava, J. L. (2013). Traumatic brain injury and psychogenic nonepileptic seizures yield worse outcomes. Epilepsia, 54(4), 718–725. https://doi.org/10.1111/epi.12053
LaFrance, W. C., Ho, W. L. N., Bhatla, A., Baird, G. L., Altalib, H. H., & Godleski, L. (2020). Treatment of psychogenic nonepileptic seizures (PNES) using video telehealth. Epilepsia, 61(11), 2572–2582. https://doi.org/10.1111/epi.16689
LaFrance, W. C., Keitner, G. I., Papandonatos, G. D., Blum, A. S., Machan, J. T., Ryan, C. E., & Miller, I. W. (2010). Pilot pharmacologic randomized controlled trial for psychogenic nonepileptic seizures. Neurology, 75(13), 1166-1173.
LaFrance Jr, W. C., Miller, I. W., Ryan, C. E., Blum, A. S., Solomon, D. A., Kelley, J. E., & Keitner, G. I. (2009). Cognitive behavioral therapy for psychogenic nonepileptic seizures. Epilepsy & Behavior, 14(4), 591-596.
McKenzie, P. S., Oto, M., Graham, C. D., & Duncan, R. (2016). Medically unexplained symptoms in patients with PNES: Do they explain poor employment outcome in patients with good seizure outcomes? Epilepsy & Behavior, 59, 9–12. https://doi.org/10.1016/j.yebeh.2016.03.027
Myers, L., Zeng, R., Perrine, K., Lancman, M., & Lancman, M. (2014). Cognitive differences between patients who have psychogenic nonepileptic seizures (PNESs) and posttraumatic stress disorder (PTSD) and patients who have PNESs without PTSD. Epilepsy & Behavior, 37, 82–86. https://doi.org/10.1016/j.yebeh.2014.06.009
O’Brien, F. M., Fortune, G. M., Dicker, P., O’Hanlon, E., Cassidy, E., Delanty, N., Garavan, H., & Murphy, K. C. (2015). Psychiatric and neuropsychological profiles of people with psychogenic nonepileptic seizures. Epilepsy & Behavior, 43, 39–45. https://doi.org/10.1016/j.yebeh.2014.11.012
Pick, S., Anderson, D. G., Asadi-Pooya, A. A., Aybek, S., Baslet, G., Bloem, B. R., Bradley-Westguard, A., Brown, R. J., Carson, A. J., Chalder, T., Damianova, M., David, A. S., Edwards, M. J., Epstein, S. A., Espay, A. J., Garcin, B., Goldstein, L. H., Hallett, M., Jankovic, J., … Nicholson, T. R. (2020). Outcome measurement in functional neurological disorder: A systematic review and recommendations. Journal of Neurology, Neurosurgery & Psychiatry, 91(6), 638–649. https://doi.org/10.1136/jnnp-2019-322180
Popkirov, S., Asadi-Pooya, A. A., Duncan, R., Gigineishvili, D., Hingray, C., Kanner, A. M., LaFrance, C. W., Pretorius, C., & Reuber, M. (2019). The aetiology of psychogenic non‐epileptic seizures: Risk factors and comorbidities. Epileptic Disord, 21(6), 529–547.
Popkirov, S., Carson, A. J., & Stone, J. (2018). Scared or scarred: Could ‘dissociogenic’ lesions predispose to nonepileptic seizures after head trauma? Seizure, 58, 127–132. https://doi.org/10.1016/j.seizure.2018.04.009
Prigatano, G. P., & Kirlin, K. A. (2009). Self-appraisal and objective assessment of cognitive and affective functioning in persons with epileptic and nonepileptic seizures. Epilepsy & Behavior, 14(2), 387–392. https://doi.org/10.1016/j.yebeh.2008.12.001
Salinsky, M., Parko, K., Rutecki, P., Boudreau, E., & Storzbach, D. (2016). Attributing seizures to TBI: Validation of a brief patient questionnaire. Epilepsy & Behavior, 57, 141–144. https://doi.org/10.1016/j.yebeh.2016.02.003
Salinsky, M., Rutecki, P., Parko, K., Goy, E., Storzbach, D., O’Neil, M., Binder, L., & Joos, S. (2018). Psychiatric comorbidity and traumatic brain injury attribution in patients with psychogenic nonepileptic or epileptic seizures: A multicenter study of US veterans. Epilepsia, 59(10), 1945–1953. https://doi.org/10.1111/epi.14542
Salinsky, M., Spencer, D., & Boudreau, E. (2011). Psychogenic nonepileptic seizures in US veterans. Neurology, 77, 945–950.
Salinsky, M., Storzbach, D., Goy, E., & Evrard, C. (2015). Traumatic Brain Injury and Psychogenic Seizures in Veterans. Journal of Head Trauma Rehabilitation, 30(1), E65–E70. https://doi.org/10.1097/HTR.0000000000000057
Sharma, A. A., Goodman, A. M., Allendorfer, J. B., Philip, N. S., Correia, S., LaFrance, W. C., & Szaflarski, J. P. (2022). Regional brain atrophy and aberrant cortical folding relate to anxiety and depression in patients with traumatic brain injury and psychogenic nonepileptic seizures. Epilepsia, 63(1), 222–236. https://doi.org/10.1111/epi.17109
Vanek, J., Prasko, J., Ociskova, M., Genzor, S., Holubova, M., Hodny, F., Nesnidal, V., Slepecky, M., Sova, M., & Minarikova, K. (2021). Sleep Disturbances in Patients with Nonepileptic Seizures. Nature and Science of Sleep, Volume 13, 209–218. https://doi.org/10.2147/NSS.S289190
Walsh, S., Levita, L., & Reuber, M. (2018). Comorbid depression and associated factors in PNES versus epilepsy: Systematic review and meta-analysis. Seizure, 60, 44–56. https://doi.org/10.1016/j.seizure.2018.05.014
Willment, K., Hill, M., Baslet, G., & Loring, D. W. (2015). Cognitive Impairment and Evaluation in Psychogenic Nonepileptic Seizures: An Integrated Cognitive-Emotional Approach. Clinical EEG and Neuroscience, 46(1), 42–53. https://doi.org/10.1177/1550059414566881
Ye, K., Foster, E., Johnstone, B., Carney, P., Velakoulis, D., O’Brien, T. J., Malpas, C. B., & Kwan, P. (2020). Factors associated with subjective cognitive function in epilepsy and psychogenic non-epileptic seizures. Epilepsy Research, 163, 106342. https://doi.org/10.1016/j.eplepsyres.2020.106342