Frequent Collapses

1. Frequent Collapses Mayur Bodani Department of Neuropsychiatry Kent & Medway NHS Partnership Trust

2. One for the Neurologists/Cardiologists

3. One for the Neuropsychiatrists Difference between Neurologists and Neuropsychatrists

4. Syncope Mimics • Acute intoxication (e.g., alcohol) • Seizures • Sleep disorders • Somatization disorder (psychogenic pseudo-syncope) • Trauma/concussion • Hypoglycemia • Hyperventilation • Very limited literature on PPS

5. Syncope Neurally-mediated reflex syndromes Orthostatic hypotension Cardiac arrhythmias Structural cardiovascular disease Disorders Mimicking Syncope With loss of consciousness, i.e., seizure disorders, concussion Without loss of consciousness, i.e., psychogenic “pseudo-syncope” PNES Both seem to have transient Loss of Consciousness (TLOC) Real or Apparent TLOC

6. How common? PPS in patients presenting for syncope evaluation 0 - 8% [Benbadis et al, 2006] (Not usually investigated) PNES 2 -3 per 100,000 30% of visits to epilepsy clinics Usually investigated

8. Psychiatric pseudosyncope vs. Syncope • S: Self-limited loss of consciousness and postural tone • S: Relatively rapid onset • PPS/S: Variable warning symptoms • PPS/S: Spontaneous, complete, and usually prompt recovery without medical or surgical intervention S: Underlying mechanism is transient global cerebral hypoperfusion.

9. PPS: ? Mechanism PPS = FND (DSM V) FND ‘diagnosis made when a patient shows altered voluntary motor and/or symptoms that are not consistent with known neurological or medical pathology’ (conversion disorder) Criteria DON’T • comment on level of consciousness • Whether the patient is aware of the episodes • or whether there are any specific stressors

10. Detailed Patient (Psychiatric) History • Circumstances of recent event • Eyewitness account of event • Symptoms at onset of event • Sequelae • Medications • Circumstances of more remote events • History of trauma Childhood + Later • Family history • Relational aspects • Past psychiatric history • Personality disorder • Self-harm • Substance use • Premorbid Personality

11. Deviations in the history → PPS • LOC • Frequency • Pre-episode symptoms • Patient and event characteristics: • young women • Closed eyes • Prolonged apparent LOC • Multiple episodes • Presentation conforms to own understanding of ‘medicine’ [Tell me how do you explain it?]

12. Exclude • Malingering ‘intentional production of false or grossly exaggerated physical or psychological symptoms motivated by external incentives such as financial gain or avoidance of responsibilities’ • Malingerers are aware they are producing their symptoms • Factitious Disorder ‘Patients intentionally induce or aggravate illness not for secondary gain but for emotional care and attention they receive in the sick role’ • Not conscious of their motivation • Aware they are inducing or aggravating their symptoms

13. Diagnostic Tests – Neuropsychiatrist needs the results • Ambulatory ECG • Holter monitoring • Event recorder • Head-Up Tilt (HUT) • EEG - Seizure • Neuroimaging: Head CT, Head MRI • So I can explain to the patient the basis of their diagnosis and why they are in a psychiatry clinic • Patients reluctant to accept diagnosis without investigations • Somatoform disorders

14. Psychiatric Objectives • Therapeutic alliance with the patient- rapport/ trust • Avoid collusion with their beliefs • Illuminate • Explain • Reassure • Show a path out • Feed

15. Reassurance? • No true cerebral hypoperfusion • Not life threatening • Avoids consumption of medical resources • Patients may bring home videos: • Diagnosis • Point out key clinical features • Suggestibility – communication of diagnosis • Positive and non-judgemental discussion • Involuntary nature of episodes

16. Features of conversion disorder • Prevalence 50/100000 (Akagi et al, 2001) • 1: 5 Neurology OPD (Ewald et al, 1994) • F > M ( 2 - 10: 1) • Lower SEC • Less well educated • Rural > urban (Sadock et al, 2008) • First onset < age 35 years • ‘’la belle indifference’’ • onset may follow trauma • or context of conflict

17. Psychiatric formulation Conversion is hypothesized to: • represent a functional manifestation • of psychological conflict • of which the patient may have limited awareness • Patients may have difficulties recognising and expressing emotions (alexithymic) Example: NHNN patient

18. Recurrent unexplained TLOC → 31% - 65% Co-morbidity • Depression • Anxiety disorder, GAD • PTSD • 1/3rd history of sexual abuse (Escobar et al, 2009) • Psychiatric disorder → increased risk of recurrent TLOC • 1 condition ↑ 1 year risk 26% • 2 conditions ↑ 1 year risk 50% (Kapoor et al, 1995)

19. Neuroimaging in conversion disorder • PET • Subjects – unilateral motor weakness (conversion) • Controls – Feigners • Result • Reduced activity DLPFC in subjects • Normal activity in controls • DLPFC • Planning motor tasks • Impaired in subjects with motor conversion symptoms • Normal activation in malingerers (Spence et al, 2000)

20. Affective brain networks in conversion • Exaggerated activation • Response to reminders of a traumatic memory • Functional right hemiparesis and hypoaesthesia • Conversion disorder is: • A syndrome of functional unawareness • Activation of specific brain regions is suppressed • Patient has diminished insight (Kanaan et al, 2007; Perez et al, 2012)

21. Psychiatric management • Refer • Consultation with someone who can help • Perhaps identify and improve reaction to stress • Offer medical FU – aids compliance with psychiatric management • Optimal management • No consensus on best therapy • CBT/Psychotherapy (knowledgeable in PPS) • Events as escapes to distressing cues • Relaxation techniques • Managing cognitions and avoidant behaviours • Treating co-morbid conditions

22. Thank you!