Psychogenic Pseudosyncope: Diagnosis and Management Vidya Raj, Ama A. Rowe, Sheryl B. Fleisch, Sachin Y. Paranjape, Amir M. Arain, Stephen E. Nicolson PII: DOI: Reference:

S1566-0702(14)00063-0 doi: 10.1016/j.autneu.2014.05.003 AUTNEU 1653

To appear in:

Autonomic Neuroscience: Basic and Clinical

Received date: Revised date: Accepted date:

10 March 2014 25 April 2014 6 May 2014

Please cite this article as: Raj, Vidya, Rowe, Ama A., Fleisch, Sheryl B., Paranjape, Sachin Y., Arain, Amir M., Nicolson, Stephen E., Psychogenic Pseudosyncope: Diagnosis and Management, Autonomic Neuroscience: Basic and Clinical (2014), doi: 10.1016/j.autneu.2014.05.003

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ACCEPTED MANUSCRIPT Revised: April 23, 2014 Psychogenic Pseudosyncope: Diagnosis and Management Vidya Raj MB ChB (*), Ama A Rowe MD (*), Sheryl B Fleisch MD (*), Sachin Y Paranjape BS

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(), Amir M Arain MD (#), Stephen E Nicolson MD (*).

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Departments of Psychiatry (*), Medicine () and Neurology (#), Vanderbilt University,

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Author & Short Title: Raj – Pseudosyncope

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Nashville, Tennessee, USA.

Figures: 3

References: 44

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Tables: 0

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Keywords: Psychogenic pseudosyncope, conversion disorder, syncope, diagnosis, management.

Abstract: 217

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Word Counts: Total Manuscript: 5528

Corresponding Author & Address for Reprints: Vidya Raj MB ChB 1103 Oxford House, 1313 21st Avenue South, Nashville, TN, 37232, USA. Phone: 615-875-5838 Fax: 615-875-3450 Email: [email protected]

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ACCEPTED MANUSCRIPT Revised: April 23, 2014 ABSTRACT Psychogenic pseudosyncope (PPS) is the appearance of transient loss of consciousness

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(TLOC) in the absence of true loss of consciousness. Psychiatrically, most cases are classified as

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conversion disorder, which is hypothesized to represent the physical manifestation of internal stressors. The incidence of PPS is likely under-recognized and the disorder is under investigated

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in the unexplained syncope population, yet it can be diagnosed accurately with a focused history

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and confirmed with investigations including head-up tilt testing (HUTT), electroencephalogram (EEG; sometimes combined with video) or, in some centers, transcranial doppler (TCD). Patients

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are more likely to be young females with an increased number of episodes over the past 6 months. They frequently experience symptoms prior to their episodes including light-

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headedness, shortness of breath and tingling. Conversion disorder is associated with symptomatic chronicity, increased psychiatric and physical impairment, and diminished quality

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of life. Understanding the epidemiology, biological underpinnings and approach to diagnosis of PPS is important to improve the recognition of this disorder so that patients may be managed appropriately. The general treatment approach involves limiting unnecessary interventions, providing the patient with needed structure, and encouraging functionality. While there are no treatment data available for patients with PPS, studies in related conversion disorder populations supports the utility of psychotherapy. Psychotropic medications should be considered in patients with comorbid psychiatric disorders.

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ACCEPTED MANUSCRIPT Revised: April 23, 2014 INTRODUCTION Patients with psychogenic pseudosyncope (PPS) come to the attention of cardiologists,

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neurologists and primary care physicians, but the disorder is likely under recognized and

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underdiagnosed.(Tannemaat et al., 2013) It is likely that most cases of PPS represent conversion disorder. A recent systematic review of conversion disorder that included the closely related

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psychogenic non-epileptic seizures (PNES) showed a strong association with symptomatic

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chronicity, physical and psychological disability, impaired working status and impaired quality of life.(Gelauff, Stone, Edwards, & Carson, 2014) There is a paucity of literature available to

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guide clinicians who may feel uncomfortable in caring for these patients. We present a clinically

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DIAGNOSIS OF PPS

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focused review addressing the diagnosis and management of this disorder.

Classification and Prevalence of PPS PPS differs from syncope in that there is an appearance of loss of consciousness rather than true loss of consciousness. It is a subcategory of psychogenic transient loss of consciousness (TLOC), which also includes psychogenic non-epileptic seizures (PNES). Clinically, PPS differs from PNES by lacking the body movement that is characteristic of PNES.(Moya et al., 2009) There is very limited medical literature available on PPS compared with PNES.(van Dijk & Wieling, 2013) While the prevalence of PNES is estimated at 2-33 per 100,000 (Benbadis & Chichkova, 2006) and it accounts for up to approximately 30% of visits to epilepsy clinics, the prevalence of PPS in patients presenting for syncope evaluations has been reported to be 0-8%. It is likely that this represents an underestimation, particularly in populations enriched with

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ACCEPTED MANUSCRIPT Revised: April 23, 2014 unexplained syncope such as tertiary care syncope clinics.(Tannemaat et al., 2013; Benbadis & Chichkova, 2006; Iglesias et al., 2009) This is likely because the diagnosis of PPS is usually not

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actively investigated, unlike PNES.(Tannemaat et al., 2013)

Psychiatric Differential Diagnosis of PPS

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From a psychiatric perspective, PPS is classified as conversion disorder (also known as

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“functional neurological symptom disorder”). This diagnosis is made when a patient shows altered voluntary motor and/or sensory symptoms that are not consistent with known

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neurological or medical pathology.(American Psychiatric Association, 2013) Diagnostic and Statistical Manual of Mental Disorders V (DSM-V) criteria are as follows:

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A. One or more symptoms of altered voluntary motor or sensory function B. Clinical findings provide evidence of incompatibility between the symptom and

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recognized neurological or medical conditions C. The symptom or deficit is not better explained by another medical or mental disorder D. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation

Under DSM-V notation, PPS and PNES are further classified using the specifier “with attacks or seizures”. Note that the diagnostic criteria do not comment on level of consciousness, whether the patient is aware of the episodes, or whether specific stressors can be identified in the history. However, the identification of precipitating stressors can be helpful as conversion disorder frequently manifests following an acute trauma or stressful event.(Sadock & Sadock, 2008) A study of patients with PNES found that approximately 25% of them developed a

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ACCEPTED MANUSCRIPT Revised: April 23, 2014 different medically unexplained symptom over the next 6-12 months.(McKenzie, Oto, Graham, & Duncan, 2011) Clinically, the authors have personally observed patients with a well-

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established history of PPS go on to present with an alternative pseudo-neurological manifestation

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such as acute left-sided motor weakness without an underlying organic etiology. This has supported our clinical opinion that the majority of cases of PPS are likely to represent conversion

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disorder.

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Malingering is defined as the intentional production of false or grossly exaggerated physical or psychological symptoms motivated by external incentives such as financial gain or

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avoidance of responsibilities. Malingering patients are aware that they are producing their symptoms, while it is believed that patients with conversion disorder lack awareness that they are

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producing their symptoms.

PPS should also be differentiated from factitious disorder, where patients intentionally

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induce or aggravate illness not for secondary gain (as in malingering) but for the emotional care and attention they receive in the sick role. While not conscious of their motivation, patients with factitious disorder are aware that they are inducing or aggravating their symptoms. Patients with conversion disorder differ from both malingering and factitious patients in that they are not believed to intentionally produce their symptoms.(American Psychiatric Association, 2013; Escobar, 2009)

Neuroimaging Studies in Conversion Disorders Functional neuroimaging studies to investigate the neurobiological underpinnings of conversion disorder have supported the conclusion that patients are not simply feigning their symptoms (malingering or factitious disorder). For example, Spence et al. (Spence, Crimlisk,

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ACCEPTED MANUSCRIPT Revised: April 23, 2014 Cope, Ron, & Grasby, 2000) performed positron emission tomography (PET) studies on a small group of conversion patients with unilateral motor weakness and compared them with subjects

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feigning weakness while being asked to move a joystick. Reduced activity of the dorsolateral

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prefrontal cortex was present in the patients but not the comparison group who were feigning weakness. Activation in this brain region is associated with the planning of motor tasks,

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suggesting that this is impaired in patients with motor conversion symptoms but not

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malingerers.(Spence et al., 2000) Several studies have also shown altered activation of affective circuits in patients with conversion disorder. Exaggerated activation of affective brain regions

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was noted in response to being reminded of a traumatic memory in a patient with conversion disorder (functional right hemiparesis and hypoesthesia), even though the patient had selective

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amnesia for these memories.(Kanaan, Craig, Wessely, & David, 2007) Taken together, studies suggest that conversion disorder can be conceptualized as a syndrome of functional unawareness

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in which activation in specific brain regions is suppressed but the patient has diminished insight.(Perez, Barsky, Daffner, & Silbersweig, 2012) It should be acknowledged that these patterns of brain activation could be directly related to the manifestation of specific conversion symptoms rather than reflect underlying mechanisms applicable to conversion disorder. Psychiatrically, conversion disorder is hypothesized to represent a functional manifestation of psychological conflict of which the patient may have limited awareness.(Escobar, 2009)

Medical History in PPS The major clue to a potential diagnosis of PPS is a history that deviates from typical descriptions of syncope, such as episodes of apparent loss of consciousness lasting for greater than several minutes or occurring multiple times a day. One study found that episodes did not

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ACCEPTED MANUSCRIPT Revised: April 23, 2014 exceed one minute in their syncope patients compared with up to 14 minutes in their PPS group.(Tannemaat et al., 2013) Individuals with a diagnosis of PPS are more likely to be young

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women with an increased number of episodes in the six months prior to evaluation. Patients with

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PPS or vasovagal syncope have a higher likelihood of pre-episode symptoms such as lightheadedness, shortness of breath, palpitations, chest pain, and tingling compared to patients with

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other types of syncope.(Luzza et al., 2004; Iglesias et al., 2009) Furthermore, PPS patients

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almost always exhibit closed eyes during their episodes in contrast to syncope patients, whose eyes are often open and glassy. (Tannemaat et al., 2013) Thus, a history that is strongly

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consistent with PPS, including prolonged apparent TLOC occurring multiple times a day with closed eyes, is sufficient to make the clinical diagnosis. In practice, we have found that patients

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often require further investigations before accepting the diagnosis, and clinicians may feel

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uncomfortable delivering the diagnosis based on the history alone. Typically, the patient’s

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presentation conforms to their own theoretical understanding of medicine rather than what is anatomically and physiologically correct.(Escobar, 2009; Greenberg, Braun, & Cassem, 2008) Thus, it is clinically helpful to ask the patient for their own explanation of their symptoms.

Common Features of Conversion Disorder The estimated prevalence of conversion disorder was 50/100,000 in a community survey.(Akagi, 2001) It is even more commonly encountered in enriched populations such as neurology outpatient clinics, where a study found that 1 in 5 patients had symptoms not attributable to a neurological disorder.(Ewald, Rogne, Ewald, & Fink, 1994) Patients with conversion disorder are more likely to be female (2-10:1), from a lower socioeconomic background, less highly educated and from a rural rather than urban setting.(Sadock & Sadock,

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ACCEPTED MANUSCRIPT Revised: April 23, 2014 2008) A medically unexplained etiology is also more likely as the number of medically unexplained symptoms increases. Conversion disorder usually first presents prior to the age of 35

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years. Patients sometimes exhibit an unusually calm demeanor in the face of their apparent

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symptoms known as “la belle indifference”. The onset of conversion disorder frequently follows a traumatic event or occurs in the context of conflict, and is therefore believed to represent a

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physical manifestation of psychological distress. Patients themselves often have difficulties

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recognizing and expressing emotions, which is known as alexithymia. There is a high comorbidity with psychiatric illness, particularly major depressive disorder (MDD) and anxiety

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disorders. Approximately one third have a history of sexual abuse.(American Psychiatric Association, 2013; Escobar, 2009; Feinstein, 2011) Patients being assessed for unexplained

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syncope who meet these demographic criteria are therefore at increased risk of an underlying diagnosis of PPS. Indeed, one study found that patients with PPS were more likely to be young,

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female and experience pre-episode symptoms.(Iglesias et al., 2009)

Psychiatric Comorbidities with PPS In individuals with recurrent unexplained TLOC, approximately 31%-65% have comorbid psychiatric pathology (Kouakam et al., 2002; Linzer et al., 1992; Wiener, Shapiro, Chiu, & Grossman, 2013), with the most frequent disorders being MDD and generalized anxiety disorder (GAD).(Kapoor, Fortunato, Hanusa, & Schulberg, 1995) The presence of a psychiatric disorder correlates with increased risk of recurrent episodes of TLOC. One study found the one year recurrence of apparent TLOC was 26% with one co-morbid psychiatric disorder versus 50% with greater than two psychiatric disorders.(Kapoor et al., 1995; Kouakam et al., 2002) However, while this prevalence was significantly higher than in a comparison group of patients referred for

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ACCEPTED MANUSCRIPT Revised: April 23, 2014 arrhythmia evaluations, the presence of a psychiatric disorder is clearly not predictive of a

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diagnosis of PPS, which is much less common.(Linzer et al., 1990; Linzer et al., 1992)

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Prevalence of PPS in Unexplained Syncope

A naturalistic study of stepwise diagnostic testing in patients with unexplained syncope

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found that a cause was identified in 66% of cases, most commonly vasovagal syncope in 42% of

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cases. An arrhythmic etiology was found in only 6% of cases, while PPS was identified in 14% of cases. Hyperventilation testing provided a diagnosis in 49% followed by head-up tilt testing

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(HUTT), which provided a diagnosis in 38% of selected cases. While not specific, the study found that hyperventilation, which reproduces pre-episode symptoms, triggered a panic attack or

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“hysterical conversion” in 78% of patients ultimately diagnosed with PPS.(Iglesias et al., 2009) Another study found that this maneuver offered a 59% positive predictive value for a psychiatric

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diagnosis in this patient population.(Koenig, Linzer, Pontinen, & Divine, 1992) In another small prospective sample of 10 patients, approximately 90% of patients with recurrently unexplained TLOC were found to have electroencephalogram (EEG) specific findings consistent with PPS.(Benbadis & Chichkova, 2006)

Diagnostic Studies for PPS Patients and their relatives may bring home video recordings of the patient while experiencing an episode of apparent TLOC to show the clinician. We have found that pointing out key clinical features captured in the recording that support a diagnosis of PPS can be helpful in confirming the diagnosis to the patient.

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ACCEPTED MANUSCRIPT Revised: April 23, 2014 All tests confirming a diagnosis of PPS depend on documenting that the patient does not truly experience cerebral hypoperfusion or its downstream consequences (including hypotension,

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bradycardia, an abnormal EEG or clinical syncopal signs) during their apparent TLOC.

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Furthermore, patients with conversion disorder frequently share the characteristic of being suggestible, which can be used clinically to increase the likelihood of a patient experiencing an

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episode during testing.(Tannemaat et al., 2013; Escobar, 2009) Maneuvers identified by the

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patient as triggers of episodes may be used to provoke an episode. Indeed, one study found that placebo maneuvers can provoke an episode in 90% of patients with PPS.(Benbadis &

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Chichkova, 2006)

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The European Society of Cardiology considers the clinical suspicion of PPS to be an indication for HUTT. This test is of great utility in diagnosing PPS when the patient experiences

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an episode during the testing.(Moya et al., 2009) Sensitivity may approach 81%, as has been reported for the use of HUTT in patients with PNES. The key diagnostic features are an increase in heart rate and blood pressure starting before and continuing during the episode of apparent TLOC in PPS. This contrasts with the sharp decrease in heart rate and blood pressure observed before and during TLOC due to syncope [Figure 1].

Transcranial Doppler (TCD) ultrasound of the right middle cerebral artery can be of diagnostic utility when used with HUTT to investigate apparent TLOC because it shows cerebral blood flow velocity, and will thus additionally recognize cases of cerebral syncope that HUTT alone cannot identify. The key diagnostic feature of PPS is a normal TCD signal during an episode of apparent TLOC. Thus the TCD signal will continue to show a prominent dicrotic

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ACCEPTED MANUSCRIPT Revised: April 23, 2014 notch in mid-diastole and diastolic cerebral blood flow does not diminish (TCD velocity well above 0 cm/sec) during the episode [Figure 2]. This contrasts with narrowing of the TCD

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velocity wave during systole and early diastole, deepening of the dicrotic notch and onset of

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negligible diastolic cerebral flow (TCD velocity approaches 0 cm/sec) that is typical of an

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episode of syncope.(Raj & Sheldon, 2012)

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Like HUTT, video EEG monitoring is also a useful diagnostic tool when patients experience an episode during the monitoring. Similar to HUTT, activation techniques

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(hyperventilation, photic stimulation and verbal suggestion) are of utility to increase the likelihood of the patient experiencing a spell during the testing. The patient is typically seated or

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standing during the testing so that a typical episode can be easily recognized. The diagnosis of PPS is accurately made by noting the absence of EEG abnormalities before, during and

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following a typical spell. Background suppression (or “delta-wave slowing”), which is the characteristic hallmark of cerebral hypoperfusion, is absent during a PPS spell. Rather, normal alpha rhythm is maintained during the episode [Figure 3].(Benbadis & Chichkova, 2006)

It should be noted that a diagnosis of PPS does not exclude a comorbid diagnosis of syncope or seizures. In one study of patients positive for PPS on HUTT testing, 28% also had a syncopal event recorded.(Tannemaat et al., 2013)

MANAGEMENT OF PPS There are no formal studies on the treatment of PPS, which poses limitations on evidenced-based treatment recommendations. We present here a discussion of the literature on

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ACCEPTED MANUSCRIPT Revised: April 23, 2014 the treatment of PNES and conversion disorder combined with our own clinical approach to the

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management of PPS.

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General Approach to the PPS Patient

A small multicenter study of PNES patients showed that communication of the diagnosis

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alone is associated with a reduction in the median frequency of episodes during the next 6 months from 10 to 7.5, with 16% of patients remaining free of episodes during this

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timeframe.(Mayor et al., 2012) Thus the treatment of patients diagnosed with PPS should begin with a positive and non-judgmental discussion that their symptoms are not caused by an

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underlying organic problem.(Greenberg et al., 2008) We have found it helpful in practice to offer some examples of interactions between the mind and body that will help the patient

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understand how mental stress could cause the physical symptoms, such as the association of anxiety with tachycardia and gastrointestinal distress. Stressing that the spells are involuntary helps the patient to avoid feeling psychiatrically stigmatized or that they are “feigning” their symptoms. It is also best to refrain from in-depth psychological explanations as the PNES literature suggests that there is little improvement in the patient’s insight that their symptoms are psychologically influenced rather than physically influenced following appropriate investigations and diagnosis.(Mayor et al., 2012) The conversion disorder literature suggests that a main contact point with the medical system should be established. This is usually the family doctor or primary care physician (PCP), but in cases of PPS, a cardiologist or neurologist may be appropriate. Rather than handing their care over to a psychiatrist, the primary provider should maintain the direction of the patient’s 12

ACCEPTED MANUSCRIPT Revised: April 23, 2014 care to minimize iatrogenic harm and to avoid the patient feeling abandoned. The physician should provide regular follow-up appointments to encourage activity, improved functioning, and

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avoidance of bed rest as important goals. It is important that the patient knows they will continue

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to be seen regardless of whether their symptoms improve as the patient is typically invested in receiving medical care. Knowing that they will still be able to see their medical doctor can give

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the reluctant patient confidence to explore psychiatric treatment over time.(Greenberg et al.,

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2008)

Referral to Psychiatry

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Patients with conversion disorder most frequently experience comorbid mood disorders and anxiety disorders including GAD, panic disorder and post-traumatic stress disorder (PTSD).

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They are more likely to report a history of sexual or physical abuse.(Stonnington, Barry, & Fisher, 2006) A systematic review of patients with PNES found that 45-47% met current criteria for MDD and the lifetime prevalence was 50-80%. The prevalence of PTSD was reported to be 35-49%, panic disorder was ~20%, and GAD was noted in approximately 10% of patients.(Bowman, 1999) While treatment of these individual psychiatric disorders under a mental health professional can improve a patient’s mental health and functioning, it is less clear if they show similar improvements with a comorbid diagnosis of conversion disorder.(Stonnington et al., 2006) Most patients with conversion disorder do not follow up with mental health referrals.(Shapiro & Teasell, 2004) Due to their alexithymia (difficulty recognizing and expressing emotions) and strong focus on their somatic symptoms often to the exclusion of 13

ACCEPTED MANUSCRIPT Revised: April 23, 2014 psychological symptoms, they may actually report that their mood is fine even in the face of clear stressors.(Gulpek, Kelemence, Kesebir, & Bora, 2013) Referral to psychiatry is best

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phrased as a consultation with someone who can help the patient identify sources of stress and

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ways to improve their reaction to stress.(Greenberg et al., 2008) This improved stress response should theoretically lead to improvement in their physical symptoms.(Shapiro & Teasell, 2004;

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Greenberg et al., 2008)

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Psychotherapy for PPS

While little high quality data exists on optimal management, the treatment of choice for

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conversion disorder, including PNES, is psychotherapy. Multiple uncontrolled studies have found a reduction in the frequency of spells and reduced health service utilization in PNES

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patients who receive psychotherapy.(Martlew, Pulman, & Marson, 2014) Greater success in managing medically unexplained symptoms is achieved if the patient is actively involved and cooperative with the therapy.(Sharpe, Peveler, & Mayou, 1992; Henningsen, Zipfel, & Herzog, 2007)

While there is no consensus regarding the type of therapy that is of most benefit to patients with conversion disorder or PNES, most studies have used an individual therapy approach. Cognitive behavioral therapy (CBT) is a form of psychotherapy that addresses the relationship between a patient’s thoughts, feelings and associated behaviors, and has been consistently shown to be beneficial in the somatoform disorders populations.(LaFrance, Jr., Reuber, & Goldstein, 2013) In the only randomized clinical trial (RCT) to date of CBT in patients with PNES, patients received 12 individual sessions in a model that views non-epileptic 14

ACCEPTED MANUSCRIPT Revised: April 23, 2014 spells as an escape response to distressing cues. Techniques involved teaching relaxation skills, managing negative cognitions and avoidance behaviors, teaching techniques to manage non-

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epileptic spells, involving family members and preventing relapse. The study found that the CBT

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group was 3 times more likely to be free of spells at 3 and 6 months compared to the treatment as usual group, but this did not achieve statistical significance. Some improvement was also noted

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in measures of psychosocial functioning and health care utilization.(Goldstein et al., 2010)

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However, there are no data available on the long term efficacy of psychotherapy in PNES. In patients with medically unexplained symptoms, CBT can be an effective treatment option in

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reducing physical symptoms, psychological distress, and disability.(Kroenke & Swindle, 2000; Sumathipala, 2007) The likelihood of a better outcome may be increased by referral to a

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therapist knowledgeable about conversion disorder.(Stonnington et al., 2006) Psychodynamic psychotherapy focuses on linking current life experiences, emotions and

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actions with early life experiences, personality traits and prior relationships.(Hinson, Weinstein, Bernard, Leurgans, & Goetz, 2006) External symptoms are believed to be the manifestation of internal conflict, and psychodynamic oriented therapy is a useful approach to addressing the traumatic memories that are believed to result in conversion symptoms.(LaFrance, Jr. & Barry, 2005) While there are no RCTs of psychodynamic psychotherapy in patients with PNES, several studies indicated promising results in reducing the frequency of spells and health care utilization, reducing psychological distress, and improving quality of life and functionality in the short term.(Reuber, Burness, Howlett, Brazier, & Grunewald, 2007; Mayor, Howlett, Grunewald, & Reuber, 2010) One study found evidence of improvement that lasted a median of 50 months.(Mayor et al., 2010)

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ACCEPTED MANUSCRIPT Revised: April 23, 2014 Pharmacotherapy for PPS In clinical practice, the response of patients with conversion disorder to psychotropic

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medications is variable and can be disappointing. There are no RCTs studying the effects of

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psychotropic medications in patients with PPS.(Kroenke, 2007) A study of antidepressant

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medications in patients with chronic psychogenic movement disorder (a subtype of conversion disorder) found improvement in the movement disorder symptoms and psychiatric symptoms in

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patients who had comorbid depressive or anxiety disorders.(Voon & Lang, 2005). There is one

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RCT of antidepressant treatment in patients with PNES. This pilot study prescribed sertraline at doses of up to 200 mg or placebo for 12 weeks and found a non-significant trend toward a

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reduction in the number of non-epileptic spells in the sertraline group. There was no significant

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difference between the groups in secondary measures of psychiatric symptoms, quality of life,

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psychosocial functioning or family functioning.(LaFrance, Jr. et al., 2010) Taken together, these data suggest that selected patients with comorbid depressive or anxiety disorders are the most likely to benefit from psychotropic medications, but the utility in patients with conversion disorder, PNES or likely PPS alone is less certain.

CONCLUSIONS There is a paucity of literature available to guide clinicians on the diagnosis and management of PPS. PPS is currently underdiagnosed, which likely perpetuates under-treatment and worsens the prognosis. Data from the conversion disorder and PNES literature suggests that a diagnosis of PPS is associated with significant psychiatric and functional impairment, psychosocial dysfunction and disability. Most cases can be diagnosed with a focused history, 16

ACCEPTED MANUSCRIPT Revised: April 23, 2014 sometimes supplemented by home video footage of the episode of apparent TLOC. The diagnosis is frequently confirmed using tests that demonstrate that the patient does not truly

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experience cerebral hypoperfusion during their apparent TLOC. These tests include HUTT

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and/or TCD, and EEG.

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While clinicians often feel uncomfortable in managing non-organic disorders such as PPS, identifying these patients is important so that they can be managed appropriately and

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offered treatment that is likely to improve these outcomes. Although there is a lack of literature

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on treatment outcomes in patients with PPS, extrapolation from the conversion disorder and PNES literature suggests that psychotherapy, particularly CBT, is the treatment modality of

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choice. Psychotherapy is associated with a reduction in the frequency of episodes, improvements

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in psychosocial functioning and reduced health care utilization. Limited data on the utility of psychotropic medications in patients with PNES suggests they can be of some benefit in patients

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with comorbid depression and anxiety disorders. There is a great need for research investigating the utility of different treatment interventions in the PPS population in order to guide appropriate clinical management that will improve their prognosis.

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ACCEPTED MANUSCRIPT Revised: April 23, 2014 FIGURE LEGEND Figure 1

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Top Panel - Head-up tilt testing (HUTT) during an episode of neurally mediated syncope

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showing a sharp fall in blood pressure and heart rate starting before the tilt table was put down in response to loss of consciousness.

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Bottom Panel - HUTT recording during psychogenic pseudosyncope. Note that the blood

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pressure did not fall before the tilt table was returned to the supine position (during apparent loss

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of consciousness).

Figure 2

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Top Panel - Transcranial doppler (TCD) recording during an episode of neurally mediated

(asterisk).

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syncope. Note the marked reduction of blood flow during systole, and during early diastole

Bottom Panel - TCD recording during psychogenic pseudosyncope. Note the absence of a reduction of cerebral blood flow during diastole with maintenance of normal TCD waveform (asterisk).

Figure 3 Top Panel – Electroencephalogram (EEG) recording during an episode of cardioinhibitory neutrally mediated syncope. The first asterisk marks the onset of slowing of the EEG (channels 1-19) and the second asterisk marks flattening of the EEG. Also note the flattening of the electrocardiogram (EKG) tracing during the episode (channel 20).

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ACCEPTED MANUSCRIPT Revised: April 23, 2014 Bottom Panel - EEG recording during psychogenic pseudosyncope (PPS). Onset of the episode is marked with an asterisk. Note the maintenance of background alpha rhythm on the EEG

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recordings (channels 1-19) and absence of change in the EKG (channel 20) during the episode.

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ACCEPTED MANUSCRIPT Revised: April 23, 2014

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Most cases of psychogenic pseudosyncope (PPS) are probably conversion disorder PPS can be diagnosed with a focused history and confirmed with investigations Conversion disorder is associated with disability and poor quality of life There are no treatment data available for patients with PPS Studies in other conversion disorder subtypes supports the use of psychotherapy

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Psychogenic pseudosyncope: diagnosis and management.

Psychogenic pseudosyncope (PPS) is the appearance of transient loss of consciousness (TLOC) in the absence of true loss of consciousness. Psychiatrica...
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