History of abuse and psychogenic nonepileptic seizures: A systematic review, 2021, Lloyd Jones and Rickards

Highlights

• PNES may be associated with a history of previous trauma/abuse.
• Abuse was more commonly reported in the PNES group than the epilepsy group.
• Future research should control for the effects of comorbid depression and anxiety in patients with PNES.

Abstract
Psychogenic nonepileptic seizures resemble epileptic seizures but lack the physiological basis of epileptic seizures. We conducted a systematic review to explore whether childhood abuse is a risk factor for subsequent development of PNES. We reviewed only papers with an epilepsy control group, which employed strict criteria for diagnosis of epilepsy and well-validated tools for assessing abuse history.

Odds ratios (ORs) for the different categories of childhood abuse and for childhood abuse as a whole were calculated where not previously available, and pooled ORs were calculated where suitable. In papers where OR could not be calculated data are presented as p values. Most Odds Ratios fell between 1.8 and 5.2 with relatively narrow confidence intervals. In 14 out of 18 calculations, 95% confidence intervals did not cross 1. This suggests that the chance of reporting abuse is higher in people with PNES than those with epilepsy and may be a causative factor in developing PNES. Several limitations of the data and directions for future study are discussed.

Paywall, https://www.seizure-journal.com/article/S1059-1311(21)00307-1/fulltext

 

All the studies in this review are retrospective studies, and all of them recruited their patient from specialist epilepsy clinics. They note in the discussion that another review found that the agreement between retrospective and prospective measures of trauma are poor. The leading view of PNES is as this thing that originates from trauma, it's likely that view has been pushed or suggested to them to some degree at specialist clinics. Adding the unreliability of retrospective measures of trauma, these results could be entirely due to suggestions being made to them at the clinics they attended that they have trauma in their past.

There could also be some bias from the fact that they're recruiting from PNES patients that regularly attend specialist clinics. The ones that don't continue to regularly attend may be less satisfied with the psychogenic approach and suggestions of trauma offered to them, so the sample could be biased from that.

 

I suspect that this is a similar situation to my recent Correspondence in Psychological Medicine regarding the 'link' between Fibromyalgia and lifetime stressors:
https://pubmed.ncbi.nlm.nih.gov/34085615/

Using retrospective reports in pain patients is likely to be highly misleading due to memory recall issues and perceptual matching and so forth.

Regarding NEAD I suspect that there is a subgroup of patients that may well benefit a lot from exploring past traumas BUT I would suggest this is approached delicately, with respect and only worthy of the time if this is likely to be a major factor in the patients condition. Not something that is assumed at the outset to be 'useful' 'curative' etc. Some of the methods used can be helpful for patients but do they help people to cope or do they reduce / eliminate attacks?

Early in Covid I responded to the CODES trial spin. This was unfortunately rejected as anything non-Covid was at the time. I suggested keeping objective outcome measures in such trials (David Perez was suggesting a move in future trials to subjective) and also the need for subgroups of patients.

 

This seems just like bullshit to me. Important to remember that the CODES study had null results in terms of reducing seizure frequency at end of trial--those who DIDN'T get the intervention had greater seizure reduction than those who did. https://www.virology.ws/2020/06/26/...-commentary-promotes-eminence-based-medicine/

 

I remember when there was a lot of argument about whether temporal epilepsy existed or not.

is very arrogant. Modern testing for epilepsy only looks at the top few centimetres of the brain who knows what is going on.

To say that childhood trauma is involved answers nothing. They offer no suggestion of how trauma as a child can affect the brain many years later.

It seems too obvious to state, but all types of seizures even psychogenic ones, must be generated by the brain unless the unspoken belief is that the patient is pretending.