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      Pitfalls in the diagnosis of new-onset frontal lobe seizures

      case-report

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          Abstract

          We reported the case of a young woman who received an antiepileptic drug after a first possible generalized tonic-clonic seizure with no clear inter-ictal epileptic paroxysms in the routine electroencephalogram. Her stereotypical movements decreased but did not disappear with treatment. Then a diagnosis of PNES was considered by neurologist after witnessing a stereotypical motor episode. While AED treatment was decreased and stopped, epileptic seizure frequency and severity increased with secondary generalized tonic-clonic seizures. Then she presented postictal psychotic features that combined with video-EEG findings led to the final diagnosis of new onset pre-frontal lobe epilepsy.

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          Psychogenic non-epileptic seizures--definition, etiology, treatment and prognostic issues: a critical review.

          In this review we systematically assess our currently available knowledge about psychogenic non-epileptic seizures (PNES) with an emphasis on the psychological mechanisms that underlie PNES, possibilities for psychological treatment as well as prognosis. Relevant studies were identified by searching the electronic databases. Case reports were not considered. 93 papers were identified; 65 of which were studies. An open non-randomized design, comparing patients with PNES to patients with epilepsy is the dominant design. A working definition for PNES is proposed. With respect to psychological etiology, a heterogeneous set of factors have been identified. Not all factors have a similar impact, though. On the basis of this review we propose a model with several factors that may interact in both the development and prolongation of PNES. These factors involve psychological etiology, vulnerability, shaping, as well as triggering and prolongation factors. A necessary first step of intervention in patients with PNES seems to be explaining the diagnosis with care. Although the evidence for the efficacy of additional treatment strategies is limited, variants of cognitive (behavioural) therapy showed to be the preferred type of treatment for most patients. The exact choice of treatment should be based on individual differences in the underlying factors. Outcome can be measured in terms of seizure occurrence (frequency, severity), but other measures might be of greater importance for the patient. Prognosis is unclear but studies consistently report that 1/3rd to 1/4th of the patients become chronic.
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            Delusions, illusions and hallucinations in epilepsy: 2. Complex phenomena and psychosis.

            In this second paper the clinical features and electrophysiological underpinnings of more complex psychotic states associated with epilepsy are reviewed. (a) Complex partial status epilepticus, in particular of temporal lobe origin, may result in mental states remarkably similar to those seen in the primary psychoses. This non-convulsive state is associated with prolonged epileptic discharges on intracranial stereoelectroencephalography (SEEG) in hippocampal and other mesial temporal structures, sometimes without abnormalities on the scalp EEG. Where hallucinatory or psychotic symptomatology does occurs, it can be considered an examples of an ictal psychosis. The phenomenology and electrophysiological features of this condition are reviewed. (b) Postictal psychosis is noted for its similarity to schizophrenia-like/paranoid and affective psychoses and there is convincing SEEG evidence that, for some cases at least, the psychosis is not in fact postictal but rather an ictal psychosis due to ongoing limbic seizure activity and a form of non-convulsive status epilepticus. It has been suggested that postictal psychosis should be divided into two sub-groups: the classical 'nuclear' postictal type and an atypical periictal type. (c) Interictal hallucinosis in epilepsy has been poorly studied, but is probably commoner than appreciated. To what extent it represents subclinical epileptic discharges (i.e. auras) is not known. It may interestingly also be associated with abnormal affective states in epilepsy. (d) The interictal psychosis of epilepsy is often indistinguishable from primary schizophrenia. It occurs more commonly in temporal lobe (limbic) epilepsy, in those with frequent seizures and only in patients with a long history of epilepsy (usually over 10 years). There is convincing SEEG evidence of frequent, semi-continuous and sometimes continuous epileptic activity in limbic structures at the time of psychotic and hallucinatory ideation and behaviour, suggesting that in some cases at least, the epileptic activity is the cause of the symptoms. Whether the psychosis is directly 'driven' by subclinical electrographic activity or is indirectly a consequence of function change induced by such activity is not clear. An intriguing question also arises as to whether similar electrophysiological changes could underpin psychosis in patients without epilepsy but evidence on this point is sparse. The effects of temporal lobe surgery on the psychoses of epilepsy are described and these might throw light on the mechanisms of epileptic psychosis. The principles of pharmacological therapy of epileptic hallucinosis and psychosis are outlined.
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              Clinical classification of psychogenic non-epileptic seizures based on video-EEG analysis and automatic clustering.

              Psychogenic non-epileptic seizures (PNES) or attacks consist of paroxysmal behavioural changes that resemble an epileptic seizure but are not associated with electrophysiological epileptic changes. They are caused by a psychopathological process and are primarily diagnosed on history and video-EEG. Clinical presentation comprises a wide range of symptoms and signs, which are individually neither totally specific nor sensitive, making positive diagnosis of PNES difficult. Consequently, PNES are often misdiagnosed as epilepsy. The aim of this study was to identify homogeneous groups of PNES based on specific combinations of clinical signs with a view to improving timely diagnosis.
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                Author and article information

                Contributors
                Journal
                Epilepsy Behav Case Rep
                Epilepsy Behav Case Rep
                Epilepsy & Behavior Case Reports
                Elsevier
                2213-3232
                28 November 2013
                2014
                28 November 2013
                : 2
                : 1-3
                Affiliations
                [a ]Service médico-psychologique régional, Metz, France
                [b ]Central Hospital of Nancy, Department of Neurology, Nancy Cedex, France
                [c ]University Hospital of Psychiatrie and Psychothérapie, Laxou, France
                [d ]CRAN, UMR 7039, CNRS, France
                [e ]Faculty of Medecine, University of Lorraine, Nancy, France
                Author notes
                [* ]Corresponding author at: Service médico-psychologique régional, 1 rue Seulhotte, 57 073 Metz, France. Fax: + 33 3 87 38 51 09. steph_bedes@ 123456yahoo.fr
                Article
                S2213-3232(13)00043-1
                10.1016/j.ebcr.2013.10.002
                4308027
                47cba475-7e25-46c8-8793-205ea8dc9847
                © 2013 . Published by Elsevier B.V.

                This is an open access article under the CC BY-NC-SA license (http://creativecommons.org/licenses/by-nc-sa/3.0/).

                History
                : 13 October 2013
                : 15 October 2013
                Categories
                Case Report

                frontal lobe epilepsy,psychogenic nonepileptic seizure,misdiagnosis

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