Seizures, which are nonepileptic, have so far been understood as the body’s response to mental stressors such as anxiety and PTSD. However, a new study shows that functional seizures not caused by epilepsy are associated with structural changes in the brain that can be seen using MRI.
The findings, according to researchers, have the potential to lead to an earlier diagnosis of functional seizures, which are frequently misunderstood as epilepsy.
Just over 3 million Americans have epilepsy, which causes aberrant brain electrical activity that results in seizures. A smaller subset of persons also experiences non-epileptic seizures, also referred to as functional seizures, psychogenic seizures, nonepileptic seizures, or even the derogatory label pseudo seizures.
Using more than 650 clinical-grade MRIs, a team of researchers led by Michigan Medicine compared images from individuals who had functional seizures to those who did not have seizures but might have other mental health issues, such as melancholy and anxiety.
Patients with functional seizures had thinning in the superior temporal cortex
The superior temporal cortex, which affects one’s cognitive awareness and motor control, and the left occipital cortex, which oversees processing visual and other sensory data, were both thinner in patients with functional seizures, according to research published in Epilepsy & Behaviour. People with depression, anxiety, and obsessive-compulsive disorder (OCD) did not experience these changes.
“If we can figure out what brain changes make people have functional seizures, we can begin to look at how we can change that back,” said first author Wesley Kerr, M.D., Ph.D., a neurologist, and epileptologist at University of Michigan Health.
“Right now, the treatment for functional seizures is cognitive behavioural-informed therapy, but this therapy isn’t effective for everyone. We hope to find new ways to target treatments to help patients have fewer seizures and better quality of life.”
Finding them early enough is one of the difficulties in treating functional seizures. Before being properly diagnosed, most people with functional seizures receive average treatment for epilepsy for nine years.
According to Kerr, a clinical lecturer of neurology at the University of Michigan School of Medicine, this misdiagnosis can hurt patients. Future structural MRI tests might identify biomarkers that distinguish between the two diseases.
“During the years before people are accurately diagnosed with functional seizures, 80% of them were prescribed anti-seizure medications used to treat epilepsy,” he said. “Those medications have side effects, including fatigue and dizziness. These people can also come into the ER with prolonged seizures and end up being intubated and given high doses of medication, which can be lifesaving for someone with epilepsy but is both not needed and dangerous for functional seizures.”
To address the underlying psychological pressures that are overflowing and causing symptoms, psychotherapy is employed as a treatment for functional seizures.
Differentiating between epileptic and nonepileptic seizures
Although electrical irregularity is a certain sign of epilepsy, it might be difficult to distinguish the disease from a functioning seizure. In addition to diagnostic testing, doctors use a patient’s history of seizures to make an epilepsy diagnosis. If the seizures are epileptic, delaying treatment could result in death or irreversible brain damage.
“In those cases, people tend to give high doses of seizure medication if they are not sure,” Kerr said. “And around 10% of people who come in with what we think is status epilepticus are actually having prolonged functional seizures.”
Providers can perform an electroencephalogram, or EEG, which detects electrical signals in the brain, after learning about or witnessing a seizure. However, the EEGs of roughly 50% of individuals with known focal epilepsy are interpreted as normal.
“We would always like to have the EEG and MRI information to back up what we see in the patient clinically, but we still need to see the seizure to diagnose functional seizures reliably,” Kerr said.
“But once we diagnose someone with functional seizures, we can reduce the high health care utilization they have from coming into the ER often and having to pay a lot for anti-seizure medications to improve their quality of life. We do better when we can diagnose people with functional seizures earlier.”
MRI will continue playing a key role in improving the diagnosis and treatment of both conditions
MRI will continue to play a crucial role in advancing the diagnosis and management of both illnesses as researchers continue to examine the anatomical distinctions in changes to the brain between functional seizures and epilepsy.
“We know that early, accurate diagnosis of functional seizures is essential to starting treatment that will improve quality of life,” said co-author Nicholas J. Beimer, M.D., clinical assistant professor of neurology and psychiatry at U-M Medical School.
“This work is an example of how we can look more carefully at the tests we already perform, like a standard MRI of the brain, for subtle clues that lead us to the correct diagnosis. I look forward to how this research will be used to improve our diagnostic speed and accuracy so that we can get our patients with functional seizures to the right treatment sooner.”
Materials provided by Michigan Medicine – University of Michigan. Original written by Noah Fromson. Note: Content may be edited for style and length.
Wesley T. Kerr, Hiroyuki Tatekawa, John K. Lee, Amir H. Karimi, Siddhika S. Sreenivasan, Joseph O’Neill, Jena M. Smith, L. Brian Hickman, Ivanka Savic, Nilab Nasrullah, Randall Espinoza, Katherine Narr, Noriko Salamon, Nicholas J. Beimer, Lubomir M. Hadjiiski, Dawn S. Eliashiv, William C. Stacey, Jerome Engel, Jamie D. Feusner, John M. Stern. Clinical MRI morphological analysis of functional seizures compared to seizure-naïve and psychiatric controls. Epilepsy & Behaviour, 2022; 134: 108858 DOI: 10.1016/j.yebeh.2022.108858
Michigan Medicine – University of Michigan. “Functional, nonepileptic seizures show structural abnormalities in brain scans, study shows.” ScienceDaily. ScienceDaily, 25 October 2022. <www.sciencedaily.com/releases/2022/10/221025120129.htm>.
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