key: cord-0729472-6w67e82f authors: Asadi-Pooya, Ali A.; Trinka, Eugen; Hingray, Coraline; Fawaz, Ahmad; Karakis, Ioannis; Kishk, Nirmeen A.; Farazdaghi, Mohsen; Höfler, Julia; Tarrada, Alexis; Ashkanani, Abdulaziz; Risman, Aida; Rizk, Haytham title: An international study of the effects of the COVID-19 pandemic on characteristics of functional seizures date: 2021-12-29 journal: Epilepsy Behav DOI: 10.1016/j.yebeh.2021.108530 sha: 167b6916cb46ca631abe8be7431a0e31910e187d doc_id: 729472 cord_uid: 6w67e82f OBJECTIVE: We investigated whether the COVID-19 pandemic has affected the clinical characteristics of patients with functional seizure (FS) (at the time of diagnosis) in a large multicenter international study. METHODS: This was a retrospective study. We investigated all patients with FS, who were admitted at the epilepsy monitoring units at six centers in the world: 1. Shiraz, Iran; 2. Salzburg, Austria; 3. Nancy, France; 4. Atlanta, USA; 5. Kuwait City, Kuwait; and 6. Cairo, Egypt. Patients were studied during two time periods: admitted in 2018-2019 (pre-COVID era) and 2020-2021 (COVID era). RESULTS: Three hundred and twenty-six patients were studied. Two hundred and twenty-four (68.7%) patients were diagnosed before and 102 (31.3%) persons during the COVID-19 pandemic. Only, a history of family dysfunction was significantly associated with the COVID-19 pandemic era (Odds Ratio: 1.925, 95% Confidence Interval: 1.099-3.371; p = 0.022). A low level of education might also be associated with FS during the COVID-19 pandemic, at least in some cultures (e.g., the Middle-East). CONCLUSION: The COVID-19 pandemic has not affected the clinical characteristics of patients with FS (at the time of diagnosis). However, a history of family dysfunction was significantly more frequently associated with FS during the COVID-19 pandemic. Multiagency integration of law enforcement responses, social services, and social awareness are recommended to address family dysfunction and domestic violence and support the victims during this pandemic. We thank Shiraz University of Medical Sciences. Ali A. Asadi-Pooya, M.D.: study design, data collection, statistical analyses, and manuscript preparation. Others: data collection and manuscript preparation. None of the authors listed on the manuscript are employed by a government agency. All are academicians. None of the authors are submitting this manuscript as an official representative or on behalf of the government. Functional seizures (FS), also known as dissociative seizures (DS) or psychogenic nonepileptic seizures (PNES), are often associated with psychological problems [1] [2] [3] . Previous studies have shown a higher prevalence of psychopathologies in patients with FS compared to patients with epilepsy 4 . On the other hand, semiology of FS may be associated with the co-existing neuropsychiatric conditions in these patients. For example, patients with akinetic FS may have fewer co-existing neuropsychiatric problems compared with those who have motor FS [5] [6] [7] . While the underlying pathomechanisms of FS are not fully understood yet, some precipitating factors (e.g., relationship difficulties, natural disasters, job loss) may occur over days to months before the onset of FS 1 . Since late 2019, the world has been experiencing a catastrophic and deadly pandemic of severe acute respiratory syndrome coronavirus-2 [Coronavirus disease 2019 (COVID-19)] 8 . This virus is highly contagious and has a high potential for person to person transmission. This deadly outbreak has caused more than five million deaths, massive job losses, various psychiatric problems, and increasing numbers of relationship difficulties worldwide (all of which may be considered as potential precipitating factors for FS) [9] [10] [11] [12] . Therefore, it is plausible to consider this pandemic as a potentially significant factor that may affect the characteristics of FS. In a previous study, at one of the centers involved in the current study, we observed that patients diagnosed during the COVID-19 pandemic less frequently had generalized motor FS and had higher seizure frequencies. In addition, FS were inversely associated with the education level as a trend during the COVID-19 pandemic 13 . However, this was a single center study with a limited number of patients during the COVID-19 pandemic (24 persons). In the current study, we investigated whether the COVID-19 pandemic has affected the clinical characteristics of patients with FS in a large multicenter international study. Considering the magnitude of the global impacts of the COVID-19 pandemic and also the prevalence and importance of FS 14 , it was important to reproduce the previous study in a larger international multicenter study. Changes in the characteristics of FS have never been studied during other widespread societal traumas / events, to the best of our knowledge. This unique occasion (of COVID-19 pandemic) may have provided an enlightening window for research into the associated factors of FS on a global scale. This was a retrospective study. We investigated all patients with a new diagnosis of FS, who were admitted at the epilepsy monitoring units at six centers in the world: 1. Shiraz, Iran; 2. We extracted all the relevant demographic and clinical data from our databases. These included: (i) the demographic characteristics: sex, age at onset, age, duration of illness, marital status, and education level; (ii) the functional seizures characteristics: FS frequency, semiology of FS including aura, loss of responsiveness (LOR), generalized motor seizures, urinary incontinence with FS, prolonged seizures (> 10 minutes), and ictal injury; and (iii) the associated risk factors: a family history of seizures, a history of physical abuse (i.e., corporal punishment or any physical injury resulted from aggressive behavior towards the patient), a history of sexual abuse (i.e., rape), a history of family dysfunction (i.e., divorce, significant family disputes, single parent), a history of medical comorbidities (self-declared), a history of known psychiatric comorbidities (taking psychiatric drugs), and epilepsy comorbidity (based on the clinical history and the results of the video-EEG monitoring). All the data were collected by an epileptologist in an interview with the patient and their care-givers. Kolmogorov-Smirnov normality test was performed. Values were presented as mean ± confidence intervals (CIs) were estimated. A p value (2-sided) less than 0.05 was considered as significant. We investigated the factors in association with the COVID-19 pandemic era in univariate analyses. Variables that had a p < 0.2 in univariate analyses were analyzed in a binary logistic regression analysis model. The Institutional Review Boards of each center approved this study. The data are confidential and will not be shared. Three hundred and twenty-six patients were studied. Patients were recruited from six centers: In the current study, we observed that a history of family dysfunction was significantly more frequently associated with FS during the COVID-19 pandemic. Otherwise, the clinical and semiological characteristics of patients with FS were similar between patients who were diagnosed before the pandemic compared with those who received the diagnosis during the pandemic. Therefore, we can conclude that while this deadly outbreak has caused significant stress for everyone 9-12 , it has not affected the characteristics of FS significantly. A low level of education might also be associated with FS during the COVID-19 pandemic, at least in some cultures (e.g., the Middle-East in the current study). Previous studies suggest that learning problems are a risk factor for the development of FS in children and adults 19, 20 . This study may not represent the full spectrum of patients with FS; the mildest disease forms may not be referred to busy university clinics and therefore, the possibility of selection bias exists. Furthermore, in patients with FS, often some time passes between the onset and the diagnosis. While we can explore and discuss the differences of the characteristic of FS at the time of the diagnosis in the current study, we cannot ascertain any differences at the onset of the disease. The pandemic, at least in some cultures (e.g., the Middle-East). Interquartile range (IQR). Some data were missing. 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