Traumatic brain injury and psychogenic nonepileptic seizures
W. Curt LaFrance, Jr., M.D., M.P.H. †,*, Marie DeLucaº
† Department
of Neurology and Comprehensive Epilepsy Program
Rhode Island Hospital, Brown Medical School
* Department of Psychiatry and Human Behavior, Brown Medical School
º Brown University, Providence, Rhode Island, USA
Partially funded by National Institute of Neurological Disorders and Stroke 5K23NS045902
Abstract
Methods
Discussion
Objective:
We investigated the relationship between psychogenic
nonepileptic seizures (PNES) and traumatic brain injuries
(TBI). We hypothesized that TBI would be associated with
more psychiatric comorbidities and disability in PNES than in
patients with PNES without TBI.
Participants:
Patients with PNES diagnosis confirmed through video EEG without epileptiform activity
Neuropsychiatric evaluation (NPE) administered to each patient, including review of medical, social,
psychiatric and treatment history, and neurological and psychiatric examination
NPE reviewed for history of TBI using CDC and WHO criteria for TBI and mild TBI
Background:
TBI has been shown to be a risk factor for PNES in several
studies, but specifics of TBI have not been fully investigated.
It is important to understand this relationship as a potential
exacerbating factor in patients with PNES.
Exclusion Criteria:
Lack of confirmed PNES diagnosed by video EEG or of witnessed seizure with normal routine EEG
Ambiguous history of TBI
Incomplete descriptive History
Design/Methods:
PNES data were reviewed. TBI details were coded from
neuropsychiatric evaluations. After excluding patients with
incomplete injury histories, the final total population was 92.
Chi-square and T-tests were performed on demographic,
neurologic and psychiatric variables between the PNES with
TBI and PNES without TBI populations.
Data Collection and Analysis:
A database of demographic variables was created including gender, age, and disability status, and patient
medical histories including monthly seizure frequency, Beck Depression Inventory score (BDI), Quality of
life in Epilepsy score (QOLIE-31), and DSM-IV Axis I and II diagnoses TBI data. Specific focus was placed
on mechanism of injury and severity of TBI. Data analysis using SAS included chi-square for categorical
variables and paired t tests for continuous variables. Log transformation of seizure frequency was used to
normalize the distribution. Comparisons between patients with PNES with TBI and PNES without TBI are
described in the results section.
Results:
Of the 92 patients with PNES meeting inclusion criteria, 41
had a history of TBI. The PNES with TBI population had a
higher mean age (p=0.0322), was less predominantly female
(p=0.0390), and was more likely to receive disability
(p=0.0110). Patients with both PNES and TBI were more
likely to have major depressive disorder (p=0.0120), cluster
B personality traits or disorders (p=0.0120), history of abuse
(p=0.0400), and abnormal MRI results (p=0.0190) than
patients with PNES without TBI.
Conclusions/Relevance:
These results suggest a significant comorbidity between
PNES and TBI. A history of TBI may increase the risk for
psychiatric diagnoses and disability in patients with PNES.
Further investigation into the nature of TBI in this population
and contributions to PNES could be investigated in a
prospective study to better understand risks, outcomes and
brain-behavior mechanisms.
Introduction
•
•
•
•
Psychogenic nonepileptic seizures is a neuropsychiatric
disorder characterized by seizures without epileptic
activity on an EEG
PNES is associated with histories of abuse, mood
disorders, and other disorders
Patients with comorbidities have a reduced quality of life
TBI may be a risk factor in patients with PNES
The purpose of this study was to further investigate the
potential link between TBI and PNES and examine the
differences in psychiatric comorbidities between patients
with PNES only as compared to those with PNES and a
history of TBI. We hypothesized that patients with TBI and
PNES would have more psychiatric comorbidities and
disability than in patients with PNES without TBI.
Results
Patients with PNES and TBI have a greater
prevalence of comorbid psychiatric disorders
than patients without TBI
Demographic differences may be a result of
interaction between PNES and TBI
demographics
TBI may add to the burden of illness in patients
with PNES
Further exploration of the interaction between
these two disorders could help with treatment,
as new treatment options become available
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Table 1: Significant differences between
patients with PNES and TBI and patients
with PNES without TBI
No TBI
n=51
Factors
Age (years)
Gender (female)
Receiving disability
currently
Mood disorders
Number of Mood
Disorders
Anxiety disorders
Number of Anxiety
Disorders
Major Depressive
Disorder
Impulsivity (cluster B
personality or traits)
History of
trauma/abuse
Abnormal MRI of the
brain (past or at
enrollment)*
 TBI appears to be a significant risk factor for
PNES
x¯
32.3725
(sd)
15.614
TBI
n =41
n
43
84.31
27
65.85
4.257
P value
0.0322
0.0390
12
23.53
20
48.78
6.389
0.0110
26
0.5294
* No TBI n = 43, TBI n = 35
x¯
38.9268
(sd)
12.6281
50.98
0.5423
70.73
T
-2.1754
3.688
0.0550
-2.3078
33
1.6341
(%)
0.6008
94.12
1.0396
n
29
0.8049
48
1.8627
(%)
ChiSquare
value
80.49
4.011
1.1991
0.0233
0.0450
0.9789
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0.3303
11
21.57
19
46.34
6.347
0.0120
10
19.61
18
43.90
6.336
0.0120
34
66.67
35
85.37
4.238
0.0400
11
25.58
18
51.43
5.519
0.0190
Contact Info
W. Curt LaFrance, Jr., MD, MPH
Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903 USA
William_LaFrance_Jr@Brown.edu