Psychogenic Nonepileptic Seizures

The author, a healthy, left-handed, male medical writer with no epileptic disorder, was 37 years old when he inadvertently triggered an elaborate sequence of phosphene light-visions while he was trying to use his meditation skills to relax enough to fall asleep during early morning hours. He'd previously acquired a substantial sleep deficit, a condition associated with hyperexcitable cortical neurons. A reverse-engineering analysis of the phosphene characteristics—shapes, colors, movements, timing intervals and serial order—suggests new and otherwise unavailable insights about events taking place inside complex structures located deep in the brain which are difficult to monitor using the imaging technologies currently available. The analysis suggests several hypotheses: (1) that the altered state of consciousness called " empty mind " meditation, a state called turiya in Hindu mysticism and dhyana in Buddhist mysticism, is induced by the meditator's activation of synchronous sleep rhythms that would normally be associated with stage 2 and stage 3 non-rapid-eye-movement sleep; (2) that the author's pre-existing condition of sleep deprivation and hyperexcitable cortical neurons triggered a destabilization of sleep rhythm oscillators, generating spike-wave complexes and cortical fast-runs; (3) that the hypersynchrony in thalamocortical circuits drove a slow build-up of rhythmical discharges in the hippocampi which eventually triggered paroxysmal discharges in the left hippocampus; and, (4) that the hippocampal seizure evolved into a bilateral temporolimbic seizure with an ecstatic aura. These images may help neuroscientists design new experiments related to sleep, mental imagery, meditation, dissociation, hypnotic analgesia and psychogenic nonepileptic seizures.

The meanings of many metaphors used to describe luminous visions in the Rig Veda (RV) remain elusive or ambiguous despite years of expert hermeneutical exegesis. In this series of papers, we classify the metaphors used to describe luminous visions into sets based on certain abstract characteristics (shapes, colors, movements, order of appearance), then show how these metaphor-sets can be matched with remarkable precision, image by image, to a sequence of internally-generated light sensations ('phosphenes') induced by meditation. These meditation-induced phosphenes can also evolve in longer and more elaborate sequences if the subjects practice meditation while in a sleep-deprived condition. A sleep deficit increases the risk of subclinical seizures emerging at sleep onset - and the paroxysmal activity generates further evolution of the phosphene imagery. In the first paper of this three-part series, we document the parallels between the meditation-induced phosphenes and two types of luminous visions described in the RV - the Asvins' radiant, three-wheeled chariot and the flamearrows
of Agni. In the second paper, we analyze metaphors used to describe the
visions of Soma and Indra and show that there is a close match between these luminous visions and paroxysmal phosphenes. Based on the extensive parallels revealed by our comparison, we conclude that the metaphors for luminous visions in the RV were meant to refer to the same visual content as appears in the meditation-induced visions
described by the author, and that, despite years of poetic embellishment, the eulogists' choice of metaphors suggests a much more empirically-oriented attempt to describe visionary experience than has hitherto been suspected. This hypothesis about the meaning of luminous visions in the RV has important implications for several issues debated by Vedic scholars, including: (1) the identity of the original soma plant; (2) the
influence of shamanic practices in the creation of the Vedic myths, and (3) the extent of the continuities between the visionary experiences described in the RV and those described in the Upanishads and in the many yoga meditation texts in the Hindu, Tantric, and Tibetan-Buddhist traditions.

How is creativity related to health and mental illness? What is the relationship between the nature of the unconscious and the predisposition to both creativity and mental illness? These questions are explored with reference to research on: creativity, imagination and primary process thinking, intuition and unconscious processes, dream sleep, and aspects of schizophrenia. A positive model of mental health that sees creativity as an aspect of self-realisation is outlined in terms of homeostasis and the importance of information flow between neuropsychological systems. The role of executive function and attention in controlling information flow between the cerebellar unconscious and the cerebral conscious is noted, with reference to

Clinicians making medical diagnoses explaining presentations with transient loss of consciousness are faced with the complex task of having to distinguish between epileptic and (dissociative) non-epileptic seizures and rely heavily on patients' verbal accounts in this process. In this paper we summarise a series of four studies using different techniques to analyse talk between 21 patients with seizures and a neurologist, with the aim of describing conversational profiles typically associated with a medical diagnosis of epilepsy or nonepileptic seizures. The methods employed included conversation analysis, metaphor analysis and content analysis. This summary focuses on the way in which these qualitative methods had to be adapted in order to contribute to the diagnostic process and how quantitative methods were used to explore the differential diagnostic potential of the qualitative findings. In our discussion we consider some of the challenges of combining qualitative and quantitative approaches to talk-in-interaction, whilst recognizing the remarkable benefits the combination of these approaches has for clinical practice.

In this paper, I will discuss issues relating to narrative identity and its construction.
    I will focus on my own concerns when writing a memoir about my experiences of living with seizures – and similar ones as described by writer Siri Hustvedt in The Shaking Woman and Lauren Slater in Lying: A Metaphorical Memoir. Hence, my paper will explore the double bind of at once attempting to create a convincing narrative identity within a text whilst at the same time describing an experience which fragments the self.
      I will begin by discussing general issues around writing memoir. How do we shape the past? What do we do when we can’t remember? Do we ‘find our voice’ or do we choose a narrative identity – who, or what, is the ‘me’ I create throughout time within the text?
    I will go on to examine the process of writing about my own seizures, including different diagnoses I’ve received – medical, psychological and spiritual – and how these very different, and often conflicting, languages mirror the distinct ways of approaching writing about the subject.
    Then I will explore how, in their writing about seizures, Siri Hustvedt and Lauren Slater investigate notions of narrative identity. I will argue that, ultimately, the seizures described in their texts mimic the impossibility of creating a completely authentic narrative self. Slater, in particular, challenges the ability of memoir to tell the truth of our lives and of our selves, writing “There is only one kind of memoir I can see to write and that’s a slippery, playful, impish, exasperating text, shaped, if it could be, like a question mark.”

Management of psychogenic nonepileptic seizures (PNES) requires collaboration among and between health care professionals. Although criteria are established for diagnosis of PNES, miscommunication between neurologists, primary care providers, and mental health professionals may occur if the clinical impression is not clearly articulated. We extracted progress notes from the Department of Veterans Affairs (VA) electronic health record (EHR) nationally to study veterans who were evaluated for PNES. Of the 750 patients being worked up for PNES, the majority of patients did not meet criteria for PNES (64.6%). Of those who were thought to suffer from PNES, 147 (19.6%) met International League Against Epilepsy (ILAE) criteria for documented PNES, 14 (1.9%) for clinically established PNES, and 104 (13.9%) for probable or possible PNES. Neurologists tended to use ambiguous language, such as "thought to be" or "suggestive of" to describe their impressions of patients over...

Recent conversation analytic work has revealed that there are systematic differences between the ways in which patients with epilepsy and patients with “psychogenic” nonepileptic seizures describe their seizure experiences. But these differences may not become apparent if patients are exposed to traditional fact-oriented questioning. This article describes a one-day intervention workshop, informed by conversation analysis, which was designed to help doctors change their questioning 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 are in British English.

Objective: To demonstrate that the semiology of human bilateral tonic motor seizures evolves intra-ictally and that their full description should comprise this evolution.

Method: We scrutinized sequential tonic phenomena of bilateral motor seizures as recorded by video-EEG telemetry among 15 adult patients investigated because of intractable epilepsy. Seizures were divided into sequential stages, each defined as a tonic motor posture maintained for at least three seconds. As posture reflects joint involvement and its principally flexor or extension contour, results are expressed by joints as opposed to patients. Only the first seizure of each patient meeting all criteria are included. All four limbs had to be involved for three consecutive stages for inclusion. Two authors (SB, WB) each independently assessed ictal evolution, rare discordances (rare werer esolved by mutual review.   

Results: The tonic motor component of each of 15 seizures evolved intra-ictally.  More joints were involved in seizure stages two and three than in stage one, except cephalic version, which occurred principally in, stage one. Involvement of joints became more bilaterally symmetrical as seizures evolved. Joint flexion evolved to extension far more commonly than conversely.

Significance: Our data suggest that any study describing tonic motor semiology must indicate at what point in seizure evolution the observations were made. Its findings will sharpen ictal history taking: lay persons’ observations may better reflect ictal evolution if sequence is emphasized. We interpret these findings as reflecting increasing reticulospinal tract involvement as the seizure proceeds.

ALFONSO MARTÍNEZ-TABOAS1; GISELA G. JIMÉNEZ COLÓN; MARIANETTE COLÓN LABOY; CHRISTIAN J. GONZÁLEZ JIMÉNEZ; MIGUEL TORRES NARVÁEZ; YEIRA M. VALDEZ PIMENTEL (UNIVERSIDAD CARLOS ALBIZU, Recinto de San Juan, Puerto Rico) RESUMEN Las convulsiones psicógenas no-epilépticas (CPNE) son parecidas a las convulsiones de tipo epiléptico, lo que suele traer mucha confusión al momento de ofrecer un diagnóstico diferencial. La diferencia medular radica en que las CPNE no son producidas por anomalías electrocorticales, y sí por factores psico-emocionales. En el presente artículo, presentamos una revisión actualizada del tema, con énfasis en aspectos fenomenológicos, de diagnóstico y de curso clínico. Para ilustrar la complejidad de las CPNE, presentamos varias viñetas clínicas que se basan en la experiencia del primer autor con más de 100 pacientes con CPNE. De nuestra revisión se desprende que las CPNE se relacionan a un menoscabo y a un deterioro marcado generalizado psicosocial. Esta situación se agrava cuando típicamente pasan años antes de ofrecerse el diagnóstico correcto. Asimismo, estudios retrospectivos y prospectivos documentan el punto de que típicamente más del 50% de estos pacientes presentan un historial previo de abuso físico, emocional y sexual. Al respecto, se presenta un modelo multicausal/multifactorial para dar cuenta de las variables que predisponen, precipitan y perpetúan la aparición de las CPNE. PALABRAS CLAVE: Eventos no-epilépticos, disociación somatoforme, inducción de convulsiones, experiencias de abuso infantil, epilepsia. ABSTRACT Psychogenic nonepileptic seizures (PNES) are likely to be confused with epileptic seizures. The main difference is that PNES are not produced by anomalous electrical brain discharges, but by emotional and psychological dysfunctions. In the present article, we present an empirical and conceptual update on PNES, emphasizing the phenomenological, diagnostic and natural course of the disorder. To illustrate the clinical complexity of PNES, we present several clinical vignettes. We conclude that PNES are related to psychosocial burden and to impairment in several important areas of living. This situation is aggravated when the research literature indicate that many PNES patients are misdiagnosed with epilepsy and do not receive adequate psychological/psychiatric care. Furthermore, patients with PNES typically report high rates of a wide plethora of abusive childhood experiences. Lastly, we present a biopsychosocial conceptual framework to understand the emergence of this disorder.

There has been a growing interest in the use of antiepileptic drugs
(AEDs) for neuroprotection, and in the possible role of AEDs in
disease modification (i.e., antiepileptogenesis). Increased
understanding of the mechanisms underlying brain injury has led
to advances in the study of neuroprotection. However, defining the
clinical paradigm and selecting appropriate outcomes to detect
neuroprotective effects present challenges to clinicians studying
the neuroprotective properties of drugs. Established AEDs, such as
phenytoin, phenobarbital, and carbamazepine, have shown
neuroprotective activity in an ischemic/hypoxic model of neuronal
injury. Animal model studies also have suggested that newer
AEDs, such as levetiracetam, topiramate, and zonisamide, may
have neuroprotective or antiepileptogenic properties. However, the
prevention of epileptogenesis by an AED has yet to be
demonstrated in clinical trials. The future of neuroprotection may
involve established and newer AEDs, as well as other compounds,
such as immunophilins, caspase inhibitors, endocannabinoids, and
antioxidants.