Stoyan Popkirov

University Hospital Essen | UK Essen · Clinic for Neurology

Psychogenic non‐epileptic seizures (PNES), also known as dissociative seizures, are paroxysms of altered subjective experience, involuntary movements and reduced self‐control that can resemble epileptic seizures, but have distinct clinical characteristics and a complex neuropsychiatric aetiology. They are common, accounting for over 10% of seizure...

Objective To determine the epidemiology of prolonged psychogenic non-epileptic seizures (pPNES) misdiagnosed as status epilepticus, as well as the risks associated with non-indicated treatment. Methods We performed an individual patient data analysis from the Rapid Anticonvulsant Medication Prior to Arrival Trial (RAMPART) and the Established Stat...

Functional neurological disorder (FND) reflects impairments in brain networks leading to distressing motor, sensory, and/or cognitive symptoms that demonstrate positive clinical signs on examination incongruent with other conditions. A central issue in historical and contemporary formulations of FND has been the mechanistic and etiological role of...

Background Dissociative seizures, also known as functional or psychogenic non-epileptic seizures, account for 11%–27% of all emergency seizure presentations. Misdiagnosis as epileptic seizures is common and leads to ineffective and potentially harmful treatment escalations. We assess the potential for diagnostic improvement at different stages of e...

Introduction Dissociative seizures often occur in the context of dysregulated affective arousal and entail dissociative symptoms such as a disintegration of bodily awareness. However, the interplay between affective arousal and changes in interoceptive processing at the onset of dissociative seizures is not well understood. Methods Using retrospec...

Objective. Dissociative seizures are paroxysmal disruptions of awareness and behavioural control in the context of affective arousal. Alterations in stress-related endocrine function have been demonstrated, but the timescale of dissociation suggests that the central locus coeruleus (LC) noradrenergic system is likely pivotal. Here, we investigate w...

Introduction Illness perception refers to patients’ subjective representations and appraisals of somatic and mental symptoms. These are relevant for self-management and outcome. In clinical practice, patients with functional neurological disorder (FND) often encounter a fragmented biomedical attitude, which leaves them without clear concepts. In th...

Background Current proposed criteria for functional cognitive disorder (FCD) have not been externally validated. We sought to analyse the current perspectives of cognitive specialists in the diagnosis and management of FCD in comparison with neurodegenerative conditions. Methods International experts in cognitive disorders were invited to assess s...

Functional movement disorders are not uncommon in neurological consultations, hospitals and emergency departments. Although the disorder can usually be recognized clinically, the communication of the diagnosis is often unsatisfactory. Those affected are indirectly accused of a lack of insight or openness but it is often the doctors who fail to form...

Introduction: Somatic Symptom Disorder (SSD) as introduced by the DSM-5 is characterized by chronic somatic symptoms not fully explained by underlying pathology and accompanied by psychological factors, the diagnostic B-criteria. These cognitive, affective, and behavioral disturbances are related to increased attention to somatic symptoms. However,...

Psychological stress is the most commonly self‐reported precursor of epileptic seizures. However, retrospective and prospective studies remain inconclusive in this regard. Here, we explored whether seizures would be preceded by significant changes in reported stressors or resource utilization. This study is based on high‐frequency time series throu...

Introduction: Metacognition provides a lens through which individuals experience, interpret, and respond to their affective states and behaviour; it might thus influence complex neuropsychiatric conditions such as functional seizures – events characterized by states of heightened affective arousal and the disinhibition of prepotent behaviour. In th...

Dissociative seizures often occur in the context of dysregulated affective arousal and entail dissociative symptoms such as a disintegration of bodily awareness. However, the interplay between affective arousal and changes in interoceptive processing at the onset of dissociative seizures is not well understood. Using routine data obtained from vide...

Purpose of Review When persistent postural-perceptual dizziness (PPPD) entered the diagnostic nomenclature in 2017, treatment options were adopted from its predecessors, including use of vestibular rehabilitation, psychotherapy, and serotonin reuptake inhibitors. Individualised treatment may require additional interventions to cover the full range...

ZUSAMMENFASSUNG Die Diagnose einer funktionellen Bewegungsstörung sollte innerhalb neurologischer Behandlungsstrukturen anschlussfähig vermittelt werden. Erfahrungsgemäß gelingt dies am besten, wenn spezifische Untersuchungszeichen, aus denen sich neben der Diagnose auch Störungsmodell und Therapieprinzipien ableiten lassen, demonstriert und reflek...

The legitimacy of an illness is often determined by our understanding of the underlying disorder. In this essay, Stoyan Popkirov considers what this means for our approach to functional neurological disorders such as dissociative.

Background Misdiagnosis of seizure-like events (SLE) in emergency situations is common. Here, we evaluate whether a single, video-based lesson highlighting distinguishing semiological features can improve the diagnostic accuracy of emergency physicians for epileptic seizures (ES), psychogenic non-epileptic seizures (PNES) and syncopes (SY). Method...

Background Anxiety disorders remain undiagnosed in routine clinical practice in up to two thirds of affected patients with epilepsy despite their significant impact on medical and psychosocial outcomes. The study objective was to translate and validate the German 8-item “brief Epilepsy Anxiety Survey Instrument” (brEASI) to facilitate effective scr...

Within stress-diathesis models, adverse life experiences (ALEs) increase the susceptibility to functional neurological symptoms through neuroplasticity effects. We aimed to characterize potential genetic influences on this relationship in 20 patients with functional seizures. Questionnaires, structural MRIs and Allen Human Brain Atlas gene expressi...

Objective: This study aimed to illuminate potential gene expression influences in neuroanatomical variation related to adverse life experiences (ALEs) and functional neurological symptom severity in patients with functional seizures. Background: ALEs increase the susceptibility to psychopathologies, likely through neurodevelopmental and genetic eff...

Neurocognitive screening instruments usually require printed sheets and additional accessories, and can be unsuitable for low-threshold use during ward rounds or emergency workup, especially in patients with motor impairments. Here, we test the utility of a newly developed neuropsychology pocketcard set for point-of-care testing. For aphasia and ne...

Background: Dissociative seizures (DS) are a common subtype of functional neurological disorder (FND) with an incompletely understood pathophysiology. Here, gray matter variations and their relationship to clinical features were investigated. Methods: Forty-eight patients with DS without neurological comorbidities and 43 matched clinical control...

The biopsychosocial model was defined by George L. Engel to propose a holistic approach to patient care. Through this model, physicians can understand patients in their context to aid the development of tailored, individualized treatment plans that consider relevant biological, psychological, and social-cultural-spiritual factors impacting health a...

Zusammenfassung Von Kriegszitterern zu Teenies mit TikTok-Tics – funktionelle Bewegungsstörungen galten lange als motorischer Ausdruck seelischer Turbulenzen. Tatsächlich werden psychodynamische Modelle jedoch zunehmend durch neurophysiologische Erkenntnisse ergänzt, sodass die Kombination von Psychotherapie mit spezialisierter Physiotherapie an Be...

Objective: Adverse life experiences (ALEs) increase the susceptibility to functional (somatoform/dissociative) symptoms, likely through neurodevelopmental effects. This analysis aimed to illuminate potential genetic influences in neuroanatomical variation related to functional symptoms and ALEs in patients with functional seizures. Methods: Questio...

Objective To compare self-reported outcomes, clinical trajectory and utility of baseline questionnaire responses in predicting prognosis in functional and recognised pathophysiological neurological disorders. Methods Baseline data on 2581 patients included health-related quality of life, psychological and physical symptoms, illness perceptions, co...

Background: Anxiety and depression remain underdiagnosed in routine clinical practice in up to two thirds of epilepsy patients despite significant impact on medical and psychosocial outcome. Barriers to adequate mental health care for epilepsy and/or psychogenic non-epileptic seizures (PNES) include a lack of integrated mental health specialists an...

Smartphone videos can be an important diagnostic tool in the differential diagnosis of seizure-like events. The aim of this review is to present the relevance and hurdles of smartphone videos in the differential diagnosis of ictal events based on a literature review and expert opinions. Challenges arise primarily in ensuring sufficient quality of t...

Background: Consensus criteria for autoimmune limbic encephalitis (ALE) allow for a diagnosis even without neural antibodies (Abs), but it remains unclear which clinical features should prompt neural Ab screening in temporal lobe epilepsy patients. Methods: We identified 47 patients from a tertiary epilepsy center with mediotemporal lobe seizure...

Purpose: To identify variations in white matter tract integrity related to behavioural control in response to emotional stimuli in patients with dissociative seizures (DS) and healthy controls (HC), and examine associations with illness characteristics and psychological trauma history. Methods: Twenty DS patients and 20 HC completed an emotional...

Background Patients with borderline personality disorder (BPD) experience difficulties in emotional awareness (alexithymia), and often develop dissociative symptoms, which may reflect broader deficits in interoceptive awareness. Whether this is associated with alterations in cortical processing of interoception is currently unknown. Methods We uti...

Objective: Functional movement and seizure disorders are still widely misunderstood and receive little public and academic attention. This is in stark contrast to their high prevalence and levels of associated disability. In an exploratory observational study, the authors examined whether the relative lack of media coverage of functional neurologic...

Background: Nociplastic pain has been recently introduced as a third mechanistic descriptor of pain arising primarily from alterations of neural processing, in contrast to pain due to tissue damage leading to nociceptor activation (nociceptive) or due to lesion or disease of the somatosensory nervous system (neuropathic). It is characterized by hy...

Functional neurological (conversion) disorder (FND) is a prevalent and disabling condition at the intersection of neurology and psychiatry. Advances have been made in elucidating an emerging pathophysiology for motor FND, as well as in identifying evidenced-based physiotherapy and psychotherapy treatments. Despite these gains, important elements of...

Patienten mit funktionellen neurologischen Störungen erleben in der Praxis oft, dass ihre Probleme nicht ernst genommen werden. Doch groß angelegte Studien und aktuelle neurowissenschaftliche Erkenntnisse lassen dieses vernachlässigte Teilgebiet der Neurologie in neuem Licht erscheinen. -------------------------------> Access PDF here: https://www....

Objective To determine the utility of suggestive seizure induction for inpatient work‐up of suspected psychogenic nonepileptic seizures (PNES). Methods Prospective study of epilepsy center inpatient admissions with suspected PNES. Patients were randomized to undergo suggestive induction first (group A) and then, if necessary, long‐term video–elect...

Funktionelle Sehstörungen können grob in Visusstörungen, Gesichtsfeldeinschränkungen, Augenbewegungsstörungen und Empfindungsstörung eingeteilt werden. Sie fallen üblicherweise in das Arbeitsgebiet der Augenheilkunde, sodass in diesem Kapitel vorrangig Symptome und Untersuchungstechniken aus dem neurologischen Alltag beschrieben werden. Konkret wer...

Funktionelle neurologische Störungen sind weder vorgetäuscht noch eingebildet. Da sie aber in ihrer Ausprägung teilweise den Krankheitsvorstellungen der Betroffenen entsprechen und anhand ihrer klinischen Unstimmigkeit und Umkehrbarkeit diagnostiziert werden, kann die Unterscheidung zur Simulation und der artifiziellen Störungen einerseits und zur...

Die Behandlung funktioneller neurologischer Störungen sollte niederschwellig und interdisziplinär erfolgen, wobei verschiedene Therapiemodalitäten wie Psychotherapie, Physiotherapie und Ergotherapie zum Einsatz kommen. Das Engagement des Neurologen sollte nicht abrupt mit der Diagnosemitteilung enden. Eine Behandlung kann je nach den individuellen...

Dissoziative Anfälle sind plötzlich auftretende und zeitlich begrenzte Störungen der Wahrnehmung und der Bewegungskontrolle, die äußerlich anderen neurologischen Paroxysmen wie epileptischen Anfällen oder Synkopen ähneln können. Allerdings liegt dissoziativen Anfällen weder eine neuronale Hypersynchronisation noch eine zerebrale Minderdurchblutung...

Neben dem nozizeptiven und neuropathischen Schmerz wurde kürzlich der sogenannte noziplastische Schmerz beschrieben, dem eine funktionelle Störung der zentralen Schmerzwahrnehmung zugrunde liegt. Als primäre chronische Schmerzsyndrome werden Krankheitszustände bezeichnet, die in erster Linie durch noziplastische Schmerzen charakterisiert sind und k...

Als Placebo-Effekt werden positive Veränderungen der empfundenen oder tatsächlichen Körperfunktion bezeichnet, die ausschließlich durch körpereigene Mechanismen als Reaktion auf eine medizinische Prozedur vermittelt werden. Negative Veränderungen werden als Nocebo-Effekt beschrieben. Der Einsatz von Placebo bei funktionellen neurologischen Störunge...

Funktionelle Störungen des Hörens gehören zum Arbeitsfeld der Hals-Nasen-Ohren-Heilkunde und führen nur selten zu neurologischen Vorstellungen. In diesem Kapitel werden folgende Themen in Kürze besprochen: funktioneller Hörverlust, die auditive Verarbeitungs- und Wahrnehmungsstörung, Hyperakusis, Phonophobie, Misophonie, Tinnitus, das Brummton-Phän...

Der phobische Schwankschwindel wurde kürzlich mit anderen funktionellen Schwindelsyndromen zusammengeführt und neu als Persistent postural-perceptual dizziness (PPPD) definiert. Bei diesem Schwindelsyndrom handelt es sich um eine chronische Fehlanpassung der Haltungskontrolle und Störung der multisensorischen Integration nach einem auslösenden Schw...

In diesem Kapitel werden funktionelle Gedächtnis- und Konzentrationsstörungen, wie sie in Gedächtnissprechstunden häufig anzutreffen sind, sowie die seltenere dissoziative Amnesie besprochen. Bei der funktionellen kognitiven Störung im engeren Sinne handelt es sich um eine chronische Störung der Aufmerksamkeitskontrolle und des Gedächtnisabrufs, di...

Funktionelle neurologische Störungen sorgen im klinischen Alltag oft für Verunsicherung. Unvollständige oder veraltete Krankheitsvorstellungen lassen Zweifel an der Authentizität der Symptome, deren Behandlungsbedürftigkeit sowie der klinischen Zuständigkeit aufkommen. Ein moderner, ganzheitlicher Blick auf diese Störungsbilder erlaubt jedoch einen...

Funktionelle neurologische Störungen werden heutzutage in einem biopsychosozialen Modell verstanden. In letzter Zeit konnten komplexe bildgebende oder elektrophysiologische Methoden zunehmend neurobiologische Aspekte beleuchten. Diese Entwicklung darf jedoch nicht dazu führen, den Einfluss sozialer Interaktion sowie sprachlicher und kultureller Sin...

Die verbale Kommunikationsfähigkeit kann auf unterschiedlichen Ebenen der Stimm- und Sprachproduktion gestört sein. Wenn die Symptomatik nicht auf strukturelle Schäden zurückzuführen ist, spricht man von einer nicht-organischen, psychogenen oder funktionellen Störung. Im neurologischen Arbeitsfeld können akute funktionelle Sprech- und Sprachstörung...

In diesem Kapitel wird ein kurzer, historischer Abriss der Erklärungsmodelle für funktionelle neurologische Störungen sowie deren Bezug zu modernen Entstehungstheorien, neurowissenschaftlichen Erkenntnissen und klinischen Konzepten dargestellt. Bereits in der ersten großen Studie zur Hysterie von Pierre Briquet wurde die Bedeutung emotionaler Belas...

In diesem Kapitel wird eine Auswahl polysymptomatischer Syndrome besprochen, die im neurologischen und neurorehabilitativen Kontext relevant sind. Alle hier besprochenen Syndrome sind Gegenstand kontroverser Debatten. Konkret werden chronische Beschwerden nach Gehirnerschütterung oder Schleudertrauma; das chronische Erschöpfungssyndrom; Syndrome de...

Funktionelle Bewegungsstörungen umfassen persistierende und paroxysmale, hyper- und hypokinetische Funktionsstörungen der Willkürmotorik. Häufige Ausprägungsformen sind Tremor, Dystonien, Myoklonien und Gangstörungen. Seltener kommt es zu Parkinson- und Tic-artigen Störungen. In diesem Kapitel werden spezielle Untersuchungstechniken und charakteris...

Die Diagnose einer funktionellen neurologischen Störung basiert auf der Erkennung spezifischer Charakteristika des Störungsbildes sowie dem Nachweis positiver klinischer Zeichen. In der Gesprächsführung und Anamnese müssen einige krankheitsspezifische und interaktionelle Besonderheiten berücksichtigt werden. Apparative Zusatzdiagnostik sollte nicht...

Als funktionelle Parese wird eine lokalisierte Schwäche beschrieben, die nicht auf eine strukturelle Veränderung im motorischen System zurückzuführen ist, sondern auf eine Funktionsstörung der willkürlichen Bewegungskontrolle. Analog dazu können auch im somatosensiblen System nicht strukturell-bedingte Veränderungen der bewussten Wahrnehmung auftre...

Objectives This International League Against Epilepsy (ILAE) Report: (a) summarizes the literature about “driving and psychogenic nonepileptic seizures (PNES)”; (b) presents the views of international experts; and (c) proposes an approach to assessing the ability of persons with PNES (PwPNES) to drive. Methods Phase 1: Systematic literature review...

Objectives We aimed to identify existing outcome measures for functional neurological disorder (FND), to inform the development of recommendations and to guide future research on FND outcomes. Methods A systematic review was conducted to identify existing FND-specific outcome measures and the most common measurement domains and measures in previou...

Background Many patients with brain tumours exhibit mild to severe (neuro)cognitive impairments at some point during the course of the disease. Social cognition, as an instance of higher-order cognitive functioning, specifically enables initiation and maintenance of appropriate social interactions. For individuals being confronted with the diagnosi...

Dieses Buch bietet eine Übersicht über ein vernachlässigtes Gebiet der Neurologie: Funktionelle Störungen bedingen jeden sechsten Praxisbesuch und etwa 10% der Notfälle und stationären Aufnahmen an neurologischen Kliniken. Dennoch sorgen sie oft für diagnostische Verunsicherung und therapeutische Ratlosigkeit. Praxisnah und evidenzbasiert erläutert...

To the Editor In a secondary analysis of the New Approach Rivaroxaban Inhibition of Factor Xa in a Global Trial Versus ASA to Prevent Embolism in Embolic Stroke of Undetermined Source trial, Healey and colleagues¹ determined that for patients with embolic stroke of undetermined source and left atrial enlargement rivaroxaban treatment was associated...

Background: Dissociative seizures (DS) are brief episodes of disrupted awareness and behavioural control that may resemble epileptic seizures. They are thought to arise in the context of impaired emotion processing and disinhibition. In a multi-perspective neuropsychological study, we aim to assess specific metacognitive traits and behavioural fea...

Background: Dissociative seizures (DS) are thought to arise in the context of impaired emotion processing and disinhibition. Still, despite a wealth of theoretical considerations and pathophysiological models, experimental behavioural evidence of these critical affective and cognitive underpinnings of dissociative seizures is still scarce. In a mul...

Objective: Functional movement and seizure disorders are still widely misunderstood and receive little public and academic attention. This is in stark contrast to their high prevalence and levels of associated disability. In an exploratory observational study, the authors examined whether the relative lack of media coverage of functional neurologic...

Cardiac embolism is presumed to cause a significant portion of cryptogenic strokes. Transesophageal echocardiography may detect intracardiac thrombi, but this remains a rare finding, possibly because remnant clots dissolve spontaneously or following thrombolysis. Cardiac imaging within cerebral CT angiography might offer an alternative method for t...

Dissoziative Anfälle sind in ihrer Ätiologie noch nicht vollständig verstanden. Als Schlüsselpunkte in der Krankheitsentstehung werden in aktuellen Modellen unter anderem Veränderungen in Emotionserkennen und Emotionsverarbeitung hervorgehoben; insbesondere sind hohe Alexithymie-Werte bei Patienten mit dissoziativen Anfällen typisch. Alexithymie be...

There have been many articles highlighting differences and similarities between complex regional pain syndrome (CRPS) and functional neurological disorders (FND) but until now the discussions have often been adversarial with an erroneous focus on malingering and a view of FND as ‘all in the mind’. However, understanding of the nature, frequency and...

Purpose of review Persistent postural-perceptual dizziness (PPPD) is a newly defined disorder of functional dizziness that in the International Classification of Diseases in its 11th revision (ICD-11) supersedes phobic postural vertigo and chronic subjective dizziness. Despite efforts to unify the diagnosis of functional (somatoform) dizziness, pat...

To the Editor In a report on 21 US diplomatic staff who became unwell in Cuba,¹ the authors rejected the possibility of a functional neurological disorder as the etiology. We disagree. The accompanying Editorial pointed out that functional neurological disorders are genuine and not malingering.² Patients with functional disorders typically pass cog...

In terminally ill patients, paroxysmal or episodic changes of consciousness, movements and behavior are frequent. Due to ambiguous appearance, the correct diagnosis of epileptic seizures (ES) and non-epileptic events (NEE) is often difficult. Treatment is frequently complicated by the underlying condition, and an approach indicated in healthier pat...

Background The aim of this study was to identify the prevalence of sleep disorders and measure the objective sleep quality in patients with seizure disorders. Methods Patients admitted for video electroencephalography monitoring were prospectively recruited and polysomnography was performed on the third night of monitoring. Results Four out of 44...

Dissociative seizures are a common and often elusive differential diagnosis in epilepsy centers. Considering their high prevalence, long diagnostic delays, and disappointing rates of treatment response, scientific research dedicated to dissociative seizures is surprisingly scarce. In order to chart the scientific landscape of dissociative seizures...

There are so many nice infographics and posters on various neurological disorders, I thought I'd make some for the chronically neglected FND/PNES researchers and patients out there. Powerpoint files available on request if interested in tweaking the content.

Objective To report the clinical characteristics of 12 patients with limbic encephalitis (LE) who were antibody‐negative after a comprehensive immunological study. Methods Review of clinical records of 163 patients with LE. Immunohistochemistry on rat brain, cultured neurons, and cell‐based assays were used to identify neuronal autoantibodies. Pat...

A history of head injury is common in patients with psychogenic nonepileptic seizures (PNES). This association has so far been interpreted as either spurious or psychologically mediated. Biased recall and misattribution could foster illness beliefs about brain damage that promote symptom production. Furthermore, the emotional impact of head injury...

Previous studies have suggested that alexithymia may be related to impairments in automatic emotion processing. While it is well established that alexithymia is highly prevalent in individuals with borderline personality disorder (BPD), it is unknown whether this is reflected by an altered automatic processing of emotional stimuli. In the present s...

Frontal EEG asymmetry (FEA) has been studied as both state and trait parameter in emotion regulation and affective disorders. Its significance in borderline personality disorder (BPD) remains largely unknown. Twenty-six BPD patients and 26 healthy controls underwent EEG before and after mood induction using aversive images. A slight but significant...

Persistent postural-perceptual dizziness (PPPD) is a newly defined diagnostic syndrome that unifies key features of chronic subjective dizziness, phobic postural vertigo and related disorders. It describes a common chronic dysfunction of the vestibular system and brain that produces persistent dizziness, non-spinning vertigo and/or unsteadiness. Th...

Highlights Limbic encephalitis with antibodies against glutamic acid decarboxylase can occur in patients with latent autoimmune diabetes of the adult. Autoimmune encephalitis should be considered when patients with autoimmune diabetes present with seizures and memory impairment.

Background Frontal EEG asymmetry is a widely studied correlate of emotion processing and psychopathology. Recent research suggests that frontal EEG asymmetry during resting state is related to approach/withdrawal motivation and is also found in affective disorders such as major depressive disorder. Patients with borderline personality disorder (BPD...

Plenary talk on Functional Cognitive Disorders

Psychogenic nonepileptic seizures (PNES) can remain undiagnosed for many years, leading to unnecessary medication and delayed treatment. A recent report by the International League Against Epilepsy Nonepileptic Seizures Task Force recommends a staged approach to the diagnosis of PNES (LaFrance, et al., 2013). We aimed to investigate its practical u...

Purpose Survivors of viral encephalitis can develop refractory epilepsy and hippocampal sclerosis. Both the initial infectious insult and the secondary effects of recurrent seizures have been implicated in chronic disease progression. Recently, post-infectious autoimmunity, involved in acute relapses, has also been proposed as a pathomechanism for...

Onconeural antibodies are associated with cancer and paraneoplastic encephalitis. While their pathogenic role is still largely unknown, their high diagnostic value is undisputed. In this study we describe the discovery of a novel target of autoimmunity in an index case of paraneoplastic encephalitis associated with urogenital cancer. A 75-year-old...