Outcome of psychogenic seizures in children and adolescents compared with adults

Psychiatric disorders in patients with psychogenic non-epileptic seizures, with and without comorbid epilepsy

PURPOSE

The aim of this study is to describe similarities and differences in epidemiological, psychiatric and semiologic variables between patients with psychogenic none epileptic seizures (PNES) and comorbid epilepsy (mixed PNES), and patients with PNES without comorbid epilepsy (pure PNES).

RESULTS

Forty-three patients with PNES diagnosed by Video-EEG were included. Twenty-four had pure PNES, and ninteen mixed PNES. Female population, age, duration of PNES, psychiatric institutionalization, psychopharmacotherapy, dissociative disorders and posttraumatic stress disorder (PTSD), were significantly higher in the pure PNES patients. Suicide attempts, antiepileptic therapy, conversive, affective and personality disorders were frequent in both groups. In the analysis of seizure semiology, the total lack of responsiveness was significantly higher in the mixed PNES group.

CONCLUSIONS

Pure PNES patients showed similarities and differences in the psychiatric profile, with a greater prevalence of dissociative disorders and PTSD, factors related to psychiatric severity.

Nonepileptic seizures treatment workshop summary

In May 2005, an international, interdisciplinary group of researchers gathered in Bethesda, MD, USA, for a workshop to discuss the development of treatments for patients with nonepileptic seizures (NES). Specific subgroup topics that were covered included: pediatric NES; presenting the diagnosis of NES, outcome measures for NES trials; classification of NES subtypes; and pharmacological treatment approaches and psychotherapies. The intent was to develop specific research strategies that can be expanded to involve a large segment of the epilepsy and psychiatric treatment communities. Various projects have resulted from the workshop, including the initial development of a prospective randomized clinical trial for NES.

Risk factors for psychogenic nonepileptic seizures in children and adolescents with epilepsy

There is evidence that psychogenic nonepileptic seizures (PNES) remain underdiagnosed, especially in children and adolescents. Diagnosis of such events is even more difficult in patients that do have epilepsy, leading to delayed diagnosis and treatment and, consequently, iatrogenic complications. This study aimed to evaluate possible risk factors in children with epilepsy who had PNES. Seizures and epileptic syndromes were classified according to International League Against Epilepsy guidelines. Patients were evaluated with a structured psychiatric anamnesis and classified according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; Classification of Mental and Behavioral Disorders: Diagnostic Criteria for Research; and Schedule for Affective Disorders and Schizophrenia for School-Age Children--Epidemiological Version. Risk factors such as head trauma, physical, sexual and psychological abuse, and psychiatric diagnoses, among others, were investigated. Family history of epilepsy and psychiatric illness were detected by review of medical records and/or follow-up interviews. Gender was not a predictive factor, and although older children had a higher risk for PNES, younger children also presented truly psychogenic events mimicking epileptic seizures. The most common associated psychiatric diagnosis was depression. Family histories for epilepsy and psychiatric illness were a frequent finding. An inadequate family environment was more common than sexual or physical abuse. Current knowledge obtained from adults with PNES has been used to understand children with PNES. However, this study of children with epilepsy revealed some similarities and many differences. These features may help to identify predictive factors in a population in need of adequate diagnosis of and therapy for this long-lasting pathology.

Nonepileptic seizures: reframing the diagnosis

PROBLEM

Protocols for disclosing the diagnosis of psychological pseudoseizures have been developed. However, outcomes have not been carefully studied.

METHOD

Using a retrospective design, the investigators evaluated the outcomes by interviewing patients 2 years after diagnosis who received the diagnosis using a specific protocol.

FINDINGS

There was a reduction in symptoms demonstrated by reports of lessened intensity of events or actual reduction in the number of events in 86% of those interviewed.

CONCLUSION

This protocol proved helpful in the acceptance of the diagnosis and improved adherence to the treatment recommendations after disclosure of the diagnosis.

Frequency of secondary conversion symptoms in children with psychogenic nonepileptic seizures

We retrospectively identified 22 patients (19 were girls) with psychogenic nonepileptic seizures (NES) studied with video EEG telemetry over a 24-month period. A history of other conversion symptoms was identified in 11 of 22 patients. Symptoms were frequently neurological in nature. A strong association with depression and history of abuse was noted in children with multiple conversion manifestations. These NES patients with secondary conversion symptoms may require more intensive psychological therapy and be at risk for long-term pathology.

A study of nonepileptic seizures in an Indian population

OBJECTIVE

The goal of this study was to evaluate the background and the clinical profile of nonepileptic seizures (NESs) confirmed by short-term video encephalography (ST-VEEG) recording in an Indian population.

METHODS

Seventy-one patients with NESs were enrolled. A complete history was taken and the recorded event was reviewed to define the ictal events. Patients were divided into two groups, Group 1 with a paucity of movements and Group 2 with an excess of movement, and results were analyzed.

RESULTS

The mean age was 22.9 (9.6); there were 15 males (21.1%) and 56 females (78.9%). Twenty-four patients (33.8%) were receiving antiepileptic drugs. The majority of the patients (42, 59.1%) were students. All patients were amnesic for the event and were unresponsive during the event. The other characteristics were similar events in 98.6%, hyperventilation in 58 (81.7%). Forty-two patients (59.2%) were in Group 1 and 29 patients (40.8%) were in Group 2.

CONCLUSION

NES is a disease of the young and can affect the student or professional. A wrong diagnosis can result in inappropriate treatment. Awareness of this entity is critical to ensuring prompt diagnosis and early intervention.

Saline infusion: a diagnostic and therapeutic tool in nonepileptic attacks?

OBJECTIVE

Nonepileptic attacks (NEAs) pose diagnostic and therapeutic uncertainties. Prognosis is poor. Activation procedures like saline infusion have been used for diagnostic purposes.

METHOD

We reviewed 66 consecutive patients with a probable diagnosis of NEA. During the EEG an attempt was made to induce an attack with verbal suggestion and saline infusion. Patients were followed up with a postal or telephone questionnaire 4.5 years after the EEG.

RESULTS

Saline infusion with verbal suggestion induced in 41 of 66 patients a NEA, i.e., a positive test. Thirty-one patients were followed up. Attacks were reduced in 20 patients, of whom 12 were attack-free. More patients were attack-free at follow-up after a positive (7 of 16) in comparison to a negative (5 of 15) test.

CONCLUSION

A provocative test can be diagnostic in some patients with NEA. An early and firm diagnosis may lead to appropriate treatment and better outcome.

More controversies on the treatment of psychogenic pseudoseizures: an addendum

There is no shortage of controversies when it comes to psychogenic pseudoseizures (PPS). In this addendum to the Iriarte et al. paper [Epilepsy Behav 4 (2003) 354], I review some controversial issues related to the treatment of PPS. First, I advocate the point that our first goal of therapy is not to attempt to stop the occurrence of PPS, but to ensure that patients and families have accepted that they do not suffer from epilepsy, because the most frequent cause of morbidity and mortality seen in these patients is related to their misdiagnosis as epilepsy patients and the resultant aggressive treatment in intensive care units. Remission of PPS should be our second goal! The second controversial point pertains to how long neurologists should continue to follow up patients after a diagnosis of PPS is reached, and I suggest some parameters to be used in reaching such decision. In the third controversial issue, I review the lack of communication between neurologists and psychiatrists exemplified by the misinterpretation by psychiatrists of the diagnostic value of video-EEG-telemetry studies and resulting mixed messages given to patients and families by neurologists and psychiatrists. The fourth controversial point pertains to the criteria to discontinue antiepileptic drugs after a diagnosis of PPS has been established. Finally, I discuss the timing of introducing a psychogenic cause during the presentation of the diagnosis to patient and family.

Psychogenic nonepileptic seizures: review and update

The population incidence of psychogenic nonepileptic seizures (PNES) may be only 4% that of epilepsy, but many patients with PNES have a tendency to seek medical attention, and PNES make up a larger share of the workload of neurologists and emergency and general physicians. Although a great number of publications describe how PNES can be distinguished from epileptic seizures, it usually takes several years to arrive at this diagnosis, and three-quarters of patients (with no additional epilepsy) are treated with anticonvulsants initially. However, the management of PNES as epileptic seizures can lead to significant iatrogenic harm. Moreover, the failure to recognize the psychological cause of the disorder detracts from addressing associated psychopathology and enhances secondary somatization processes. This review provides an overview of studies of the diagnosis, etiology, treatment, and prognosis of PNES. Physicians should always consider PNES in the differential diagnosis of a seizure disorder. If a diagnosis of PNES is possible, or a diagnosis of epilepsy in doubt, a clear diagnostic categorization should be sought. This should involve the assessment of the patient by a physician versed in the diagnosis of seizure disorders and, in many cases, the documentation of a typical seizure by video-EEG. Outcome may be improved if the diagnosis is more actively sought, made earlier, and communicated more convincingly.

Outcome in psychogenic nonepileptic seizures: 1 to 10-year follow-up in 164 patients

Our knowledge of longer term outcome in psychogenic nonepileptic seizures (PNESs) patients is limited; we know less still about factors predicting prognosis. This study was intended to describe outcome in a large cohort and to identify predictive clinical and psychological factors to generate new ideas for treatment. One hundred sixty-four adult patients with PNESs (66.7%) responded to outcome, personality, and psychosymptomatology questionnaires (Dimensional Assessment of Personality Pathology-Basic Questionnaire [DAPP-BQ], Dissociative Experiences Scale, and Screening Test for Somatoform Symptoms) a mean of 11.9 years after manifestation and 4.1 years after diagnosis of PNES. Additional clinical data were retrieved from hospital records. The responses showed that 71.2% of patients continued to have seizures and 56.4% were dependent on social security. Dependence increased with follow-up. Outcome was better in patients with greater educational attainments, younger onset and diagnosis, attacks with less dramatic features, fewer additional somatoform complaints, and lower dissociation scores. Better outcome was associated with lower scores of the higher order personality dimensions "inhibitedness," "emotional dysregulation," and "compulsivity" but not "dissocial behavior" (DAPP-BQ). Outcome in PNESs is poor but variable. Clinical and personality factors can be used to provide an individualized prognosis. By generating a patient-specific profile, they show particular maladaptive traits or tendencies that can identify goals for psychological therapy.

Pseudostatus epilepticus in childhood

Pseudostatus epilepticus in childhood has not been well reported in the literature. We describe the clinical presentation and management of a 9-year-old child with well-controlled epilepsy who presented in a prolonged period of pseudoseizures. Intensive care management over a number of weeks with multiple high-dose antiepileptic drugs, anesthesia, and ventilation at a tertiary care pediatric center was performed before the diagnosis of pseudostatus epilepticus was made. Initiation of family counseling and behavior therapy after diagnosis of the nonepileptic nature of the protracted paroxysmal events with video telemetry in our pediatric epilepsy unit was followed by remission. The patient reported herein illustrates the risks of iatrogenic morbidity that may result from a delay in the diagnosis of pseudoseizures and pseudostatus epilepticus in childhood.

Intractable pediatric epilepsy: vagal nerve stimulation and the ketogenic diet

The KD has been proven an effective alternative epilepsy treatment in children refractory to standard anticonvulsants. Children to be placed on the diet must be carefully selected, monitored, and followed. The diet is to be regarded as a strict medical regimen and requires a comprehensive medical team approach in concert with intensive parental involvement. With better understanding of the scientific principles underlying brain ketosis, we should be able to optimize the KD to achieve even better results.

Treatment of nonepileptic seizures

Studies on nonepileptic seizures (NES) provide dichotomous data sets: extensive observational findings, but a paucity of controlled treatment data. Psychosocial stressors, whose full impact may lie outside a patient's awareness, often underlie NES. These stressors, along with patient's learned patterns of coping, may bring forth or potentiate comorbid psychiatric disorders. Patients with NES often have dysfunction in emotion regulation and family dynamics, as well as unemployment/disability. High percentages of comorbid disorders such as major depressive disorder, post-traumatic stress disorder, and cluster B personality with impulsivity (all disorders associated with serotonin system function) also exist in the NES population. The preliminary observational evidence suggests that specific psychotherapies and pharmacotherapy directed at comorbid conditions may be the most effective treatment for NES.

Conversion disorder in children and adolescents: a 4-year follow-up study

OBJECTIVE

To assess the outcome of conversion disorder in children and adolescents and to identify factors affecting the prognosis.

METHOD

Forty adolescents with conversion disorder were reevaluated 4 years after their initial interview. Changes in demographic and clinical data and the presence of any mood and anxiety disorders were recorded using the Structured Clinical Interview for DSM-IV Axis I Disorder (SCID-I). In addition, Beck Depression Inventory (BDI) and State-Trait Anxiety Inventory (STAI) were applied.

RESULTS

Thirty-four patients (85%) had completely recovered from their conversion symptoms and two patients had improved (5%), whereas only four (10%) were unchanged. Fourteen (35%) patients received the diagnosis of mood and/or anxiety disorder. Favourable outcome was associated with early diagnosis (P=.04) and good premorbid adjustment (P=.01).

CONCLUSION

Conversion disorder has a favourable outcome in children and adolescents. However, mood and/or anxiety disorders are encountered at a considerable rate in these patients even after recovery from conversion symptoms. Long clinical follow-up seems appropriate in children and adolescents with conversion disorder.

Treating patients with psychogenic non-epileptic seizures

While the diagnostic features of psychogenic non-epileptic seizures have been better characterized in recent years, comparatively little is written about management. This review provides guidance to clinicians involved in the treatment of patients with psychogenic non-epileptic seizures and generates ideas for future research. It summarizes the recent literature specifically dealing with the treatment of such seizures and draws on the wider psychiatric literature on effective treatments for patients with other medically unexplained symptoms.

Assessment of the utility of paediatric electroencephalography

Electroencephalography (EEG) is an important tool in investigating children with neurological disorders, particularly epilepsy. The objectives were to examine the relationship between clinical indications and EEG results, and assess the predictability of a normal result. 438 consecutive paediatric EEGs were included prospectively. One certified electroencephalographer (EEGer) reviewed EEG requisitions and recorded his prediction of a normal result. EEGs were reviewed separately and the relationship between the clinical indications and EEG abnormalities was recorded. The children's mean age was 5 years (SD 4.2). Paediatric neurologists ordered 32% of EEGs. The first EEG was studied in 65% of cases. Overall, 55% of the EEGs were abnormal. Repeat EEGs were twice as likely to be abnormal (95% CI 1.3-3, P= 0.001). Established epilepsy, using antiepileptic drugs, and sleep record, highly correlated with an abnormal result ( P< 0.0001). The EEGer predicted 26% of the EEGs to be normal. A normal EEG was correctly predicted in 97% of non-epileptic paroxysmal events, however, normalization of EEG was correctly predicted in only 54% of children with seizures. EEGs of 15 (3.4%) children with epilepsy revealed unexpected findings that completely changed their management. To conclude, a normal EEG is highly predictable in non-epileptic paroxysmal events. EEGs of children with epilepsy are not predictable and may yield unexpected results.

Nonepileptic seizures: an overview

Since before the time of Charcot, nonepileptic seizures (NES) have intrigued and perplexed physicians. With the advent of the electroencephalogram, particularly with the addition of continuous video monitoring, the diagnosis of NES has received increasing evaluation. Characteristic historical features and clinical signs of NES, coupled with new diagnostic techniques, have progressively refined our understanding of the disorder. The treatment of patients who have NES has received much less attention and the prognosis of these patients illustrates the need for a more comprehensive, systematic, and validated intervention. These issues are discussed with an emphasis on the need for future research.

Diagnóstico e tratamento de epilepsia e crises pseudoepilépticas psicogênicas associadas: relato de caso

Relatamos o caso de uma paciente de 26 anos em que é evidenciada a importância médica do diagnóstico diferencial entre epilepsia e crises pseudo-epilépticas psicogênicas (CPEP) e do seu tratamento. A paciente, uma professora desempregada, com crises desde os 13 anos, foi encaminhada ao PROJEPSI para diagnóstico e tratamento de CPEP. Seu diagnóstico inicial foi de epilepsia parcial sintomática por lesão tumoral cística em região occipto-temporal esquerda, associada a CPEP. Submetida a craniotomia occipital com ressecção de processo expansivo em região de istmo do cíngulo, evoluiu com persistência das CPEP. Submetida a tratamento psicológico integrado envolvendo técnicas de condicionamento operante, manejo de ansiedade, sugestão e orientação familiar, houve remissão completa das CPEP após 4 meses de tratamento. O caso apresentado demonstra a necessidade de múltiplos procedimentos diagnósticos e terapêuticos e a participação de equipe multidisciplinar especializada.

Clinical features and prognosis of nonepileptic seizures in a developing country

PURPOSE

To determine the predictive value of clinical features and medical history in patients with nonepileptic seizures (NESs).

METHODS

One hundred sixty-one consecutive ictal video-EEGs were reviewed, and 17 patients with 41 NESs identified. NES diagnosis was defined as paroxysmal behavioral changes suggestive of epileptic seizures recorded during video-EEC without any electrographic ictal activity. Clinical features, age, sex, coexisting epilepsy, associated psychiatric disorder, social and economic factors, delay in reaching the diagnosis of NES, previous treatment, and correlation with outcome on follow-up were examined.

RESULTS

The study population included 70% female patients with a mean age of 33 years. Mean duration of NESs before diagnosis was 9 years. Forty-one percent had coexisting epilepsy. The most frequent NES clinical features were tonic-clonic mimicking movements and fear/anxiety/hyperventilation. The most common psychiatric diagnosis was conversion disorder and dependent and borderline personality disorder. Seventy-three percent of patients with pure NESs received antiepileptic drugs (AEDs), and 63.5% of this group received new AEDs. Fifty-nine percent of the patients received psychological/psychiatric therapy. At follow-up, 23.5% were free of NESs.

CONCLUSIONS

All seizure-free patients had two good prognostic factors: having an independent lifestyle and the acceptance of the nonepileptic nature of the episodes. Video-EEG monitoring continues to be the diagnostic method to ensure accurate seizure classification. Establishing adequate health care programs to facilitate access to new technology in public hospitals as well as the implementation of continuous education programs for general practitioners and neurologists could eventually improve the diagnosis and treatment of patients with NESs.

Psychogenic non-epileptic seizures: management and prognosis

AIM

To determine the outcome and identify predictive factors in children with psychogenic non-epileptic seizures (PNES).

METHOD

The biographies of 35 children with PNES, attending a tertiary paediatric neurology centre, were reviewed.

RESULTS

Thirty five children attending the department between 1987 and 1997 were evaluated at a mean follow up of 4.6 years. The age range was 6-18 years. Twenty four were girls and 11 were boys. Eleven patients had a diagnosis of epilepsy with PNES, the remainder having PNES alone. Cause fell into four categories: a history of violence, abuse, or neglect; a high level of anxiety; dysfunctional family relationships; and attention seeking or avoidance behaviour. Management in all but five cases involved assessment and follow up by a child psychologist or child psychiatrist. The outcome was encouraging, with 66% of patients becoming PNES free. A further 23% have > 50% reduction in the frequency of PNES. Only two have had no reduction. Outcome was best in the group without epilepsy.

CONCLUSION

These results suggest that the prognosis of PNES is better in children than in adults, perhaps because causes are more likely to be external to the child, more easily identified, and more amenable to prompt intervention. The importance of good assessment, good communication, and a treatment plan that includes both symptom management and addressing the precipitating and perpetuating factors is emphasised.

Psychogenic seizures after head injury in children

A total of 148 patients with a history of probable seizure disorder were studied prospectively with long-term video electroencephalography over a 1-year period. Sixteen (11%) were identified with psychogenic seizures. Eleven (69%) of 16 were boys, with a mean age of 10.5 years. Seven (44%) of the 16 had an antecedent history of head injury prior to the development of these episodes; of these patients 85% were boys. Our results suggest that contrary to findings in the adult population, psychogenic seizures can be commonly seen in boys. The prevalence of antecedent head injury suggests that it is a notable risk factor in children as well as adults in the occurrence of psychogenic seizures.

A comprehensive profile of clinical, psychiatric, and psychosocial characteristics of patients with psychogenic nonepileptic seizures

PURPOSE

To attain a comprehensive profile of clinical, psychiatric and psychosocial characteristics of patients with psychogenic nonepileptic seizures (NESs), and to assess the relation of these factors to NES outcome.

METHODS

We administered a telephone-based structured questionnaire to 56 patients with NESs (16 male and 40 female patients; mean age, 35 years) at a mean follow-up time of 18 months after making the diagnosis of NES.

RESULTS

Mean age of NES onset was 28 years with a mean duration of 8 years. Episodes resolved in 29 (51.8%) cases, decreased in 24 (42.9%), persisted unchanged in two (3.6%), and increased in frequency in one (1.8%). Thirty (53.6%) patients, including 13 (44.8%) of patients whose NESs resolved, were rehospitalized for NESs or for other symptoms. Twenty-nine (51.8%) had significant depressive symptoms, 22 (39.3%) had suicidal ideation, and 11 (19.6%) attempted suicide [including 6 (21%) of the patients whose NESs resolved]. Believing the NES diagnosis was associated with resolution or improvement of NES frequency (p<0.029), whereas anger in response to receiving the diagnosis did not predict a poorer outcome. Patients' perceptions of having good health (p<0.02) and good occupational functioning (p<0.04) were highly correlated with NES resolution. Only patients whose episodes resolved were employed at the time of follow-up.

CONCLUSIONS

At a mean of 1.5 years, NES outcome was poor, with resolution in only half the group and with frequent rehospitalizations after NES diagnosis, even among patients whose NES resolved. Depressive symptoms, suicidal ideation, and suicide attempts were common. Believing the NES diagnosis and patient perceptions of having good health and good occupational functioning correlated well with NES resolution.

Non-epileptic attack disorder and clinical outcome: a pilot study

Of the total population admitted over a 12-month period to a tertiary referral epilepsy centre for assessment of their seizure disorder, a high percentage were diagnosed with non-epileptic attack disorder. A retrospective analysis of these patients revealed that although intensive therapy and support was offered during the period of admission, the long-term resources for further management post-discharge were inadequate and in some cases non-existent. The implications for patient satisfaction with the service being offered are discussed and a patient information booklet produced in response to the findings is available by writing to the first author (H.R.).

Retrospective analysis of the effects of psychotherapeutic interventions on outcomes of psychogenic nonepileptic seizures

PURPOSE

Uncertainty exists regarding the effectiveness of psychotherapy in patients with psychogenic nonepileptic seizures (PNES). We retrospectively reviewed the outcomes of therapeutic interventions in a cohort of patients with PNES.

METHODS

We identified patients with PNES by outpatient video-EEG (VEEG) between 1992 and 1996. We retrospectively analyzed the effects on outcomes of various types of interventions for PNES administered at random, using a structured interview and review of medical records. Patients with subjective events and severe psychosis were excluded. Patients who required inpatient monitoring because the outpatient VEEG was inconclusive were also excluded.

RESULTS

One hundred patients were diagnosed with PNES between 1992 and 1996: 61 patients completed the study. The average age was 43.3 years, and 90% were female. Nine (15%) had had PNES <1 year, and 7 (11%) had epilepsy. Eleven of 16 patients (68%) who received five or more counseling sessions, including showing the videotaped recording of the nonepileptic spell (13 of 16) by the comprehensive epilepsy program (CEP) psychotherapist had cessation (7 of 16) or reduction (4 of 16) of their episodes. Eleven of 15 patients (73%) who received only the feedback and care of their CEP neurologists had similar favorable outcome. Twelve of 25 patients (48%) who received counseling by a non-CEP psychotherapist or psychiatrist had cessation (10 of 25) or reduction (2 of 25) of episodes. Five patients who received no feedback or intervention had no improvement (4 of 5) or worsening (1 of 5) of the PNES.

CONCLUSIONS

Psychotherapy or feedback provided by CEP professionals with experience in epilepsy and PNES improves outcome and may be superior to other or no interventions.

Psychogenic nonepileptic seizures

Psychogenic nonepileptic seizures (NES) are commonly encountered in clinical practice, and they may pose difficult diagnostic problems. For appropriate evaluation and treatment of NES, a multidisciplinary team approach is needed; typically, a neurologist with expertise in epilepsy, a psychologist or psychiatrist, and a support staff should be involved. Psychogenic NES have no single initial clinical manifestation, and various etiologic factors may contribute to their development. Of importance, psychogenic NES are "real" seizures that may be as disabling as epileptic seizures. Most often, they occur on a subconscious level, and the patient may have no control over their occurrence. Precipitation or termination of a habitual seizure during video-electroencephalographic monitoring has often been used to distinguish NES from epileptic seizures, but the results can sometimes be misleading. Numerous additional diagnostic techniques can be used to assist in making the diagnosis. Treatment is based on the type of psychiatric disorder present. Favorable prognostic factors include being female and having an independent lifestyle, normal electroencephalographic findings, higher intelligence, and no prior psychotherapy.

Outcome after diagnosis of psychogenic nonepileptic seizures

Information regarding outcome in patients with psychogenic nonepileptic seizures (PNES) is limited. We attempted to contact 72 consecutive patients with PNES confirmed by video-EEG monitoring: 51 of 72 (71%) were reached a mean of 15 months (range 12-27 months) after diagnosis and agreed to answer a structured telephone questionnaire. The questionnaire assessed the number of PNES in the last 6 months, antiepileptic drug (AED) use, occupational status, global self-rating, and extent of psychotherapeutic treatments. PNES had ceased in 18 of 51 (35%), decreased > 80% in 21 of 51 (41%), and decreased < 80% in 12 of 51 (24%). Thirty-three of 51 (65%) were not taking AEDs. Occupational status improved in 20% and did not change in 75%. Overall, 29 of 51 (57%) rated themselves markedly improved and 15 of 51 (29%) rated themselves unchanged or worse. Persisting PNES were associated with longer duration of PNES before diagnosis (p < 0.02) and presence of additional psychiatric disease (p < 0.01). Persisting PNES were not associated with gender, presence of epileptic seizures, or extent of psychotherapeutic treatments after diagnosis. Placebo saline infusion had been administered in some patients to help precipitate PNES. This did not affect the number of psychotherapy visits or outcome. We conclude that PNES cease or significantly decrease in most patients, but occupational status does not improve as often. Earlier diagnosis may improve outcome.

Self-injury and incontinence in psychogenic seizures

Two patients who incurred significant injuries during psychogenic seizures prompted us to do a telephone survey of self-injury and incontinence in 102 consecutive patients diagnosed with psychogenic seizures by EEG-closed-circuit TV (EEG-CCTV) monitoring. Seventy-three patients (or a close family member or friend) were reached by telephone and responded to our survey. During typical attacks of psychogenic seizures, 40% reported injuries, 44% reporting tongue biting, and 44% reported urinary incontinence. Suicide attempts were reported by 32% and were more common in those with self-injury and urinary incontinence. We compared the results of patients with psychogenic seizures with those of 30 patients with refractory epilepsy documented by ictal recordings, using a similar telephone survey. Injuries of all types were more commonly reported by epilepsy patients. Burn injuries were reported only by patients with epilepsy. Suicide attempts were more commonly reported by the psychogenic seizure group. Self-injury and incontinence are commonly reported by psychogenic seizure patients. In view of their significant association with suicide attempts, they may indicate an underlying depression.

Supplementary sensorimotor area seizures in children and adolescents

RATIONALE

Some types of seizures in children may be difficult to recognize; the diagnosis of seizures arising near the mesial posterior frontal supplementary sensorimotor area (SSMA) may be especially challenging. Such seizures have been well described in adults, but few pediatric cases have been reported even though onset is typically in childhood.

METHODS

We studied 11 children and adolescents with SSMA seizures diagnosed by prolonged video electroencephalography (EEG).

RESULTS

Mean age at onset was 5.8 years, and diagnosis by video EEG was made at a mean age of 12 years. Children had at least borderline intelligence and few abnormal findings on neurologic examination. Seizures were typically brief, frequent, and predominantly nocturnal, with bilateral tonic posturing, gross proximal limb movements, and preserved consciousness. Magnetic resonance imaging showed normal findings or a superior or mesial posterior frontal tumor or cortical dysplasia. Routine EEG findings were usually normal, but prolonged EEG showed epileptiform discharges over the vertex. Seizure onset in the region of the SSMA was confirmed by subdural EEG in six patients who were studied for epilepsy surgery. Five patients had seizure-free outcome or worthwhile improvement after operation. Two nonoperated patients are seizure-free on antiepileptic medication, and three are undergoing surgical evaluation.

CONCLUSIONS

Diagnosis of SSMA seizures in children may be challenging because of unusual symptoms (bilateral tonic limb involvement with preserved consciousness) and frequently normal routine EEG findings. Video EEG may be necessary for diagnosis, and magnetic resonance imaging may reveal a focal lesion. Increased recognition of this seizure type in pediatric patients should lead to earlier diagnosis for optimal medical or surgical treatment.

Somatization in children and adolescents

OBJECTIVE

To review the empirical literature on somatization in the pediatric age group, emphasizing prevalence, influence on health care utilization, issues in the development of somatization, comorbidity with other psychiatric disorders, assessment, and treatment.

METHOD

One hundred nineteen studies and reports addressing medically unexplained somatic symptoms in children and adolescents were compiled via MEDLINE search and extensive cross-referencing. All available controlled studies were included, as were selected case reports and collections of cases. Selected citations from the adult literature were chosen for relevance to pediatric somatization.

RESULTS

Recurrent, medically unexplained physical symptoms are common in the pediatric age group, are often associated with other psychiatric symptoms, and may represent a common presentation of psychiatric disorder in the primary care setting. DSM-III-R-defined somatization disorder is rare, and pseudoneurological symptoms are unusual. Patients may be at risk for potentially dangerous, costly, and unnecessary medical investigations and treatments, and they may excessively utilize health care services.

CONCLUSION

Our current understanding of pediatric somatization and its consequences is limited. Collaboration between mental health professionals and primary health care providers is essential. Consistent terminology, developmentally appropriate classification, and systematic future research will be necessary for the development of successful prevention and treatment strategies.

Effective utilization of home-video recordings for the evaluation of paroxysmal events in pediatrics

In young children, differentiating seizures from nonepileptic "spells" by history alone can be difficult, even for the specialist. Nonepileptic spells may be psychogenic (rare in the young child) or physiologic in origin. Physiologic spells misidentified as epileptic may be treated with antiepileptic medication where none is needed. Recording spells on video provides a potentially valuable supplement to the clinical history in arriving at a correct diagnosis. In practice, however, most home-video recordings prove difficult to interpret. Simple instructions to parents on the manner in which spells should be recorded will greatly increase the usefulness of home-video recordings. A systemic analysis of precipitating factors and the evolution and resolution of the spell will very often exclude seizures. The widespread availability of home-video recordings provides the pediatrician with an opportunity to visually examine a child's spells, often avoiding unnecessary investigations and referrals and allowing the physician to more confidently offer reassurance to the parents.

Long-term EEG monitoring for difficult seizure problems

Long-term electroencephalographic (EEG) monitoring, initially popular in the form of 24-hour video-EEG telemetries developed for the evaluation of patients who were candidates for epilepsy surgery, is now possible in diverse configurations. Studies can be designed to evaluate a variety of diagnostic problems and can be individualized to address specific clinical questions for each patient. A great variety of severe epilepsies present in infancy and childhood with daily seizures, often presenting difficult diagnostic problems. Extending the benefits of long-term EEG monitoring to these patients early in the course of the epileptic process can be expected to result in more accurate diagnoses, more effective treatment, and improved prognoses. Long-term EEG monitoring is needed to improve our understanding of the nosology of infant epilepsy, which is incomplete.

Pseudoseizures (non epileptic attack disorder)--clinical management and outcome in 50 patients

The present report outlines the clinical management and outcome of 50 patients with pseudoseizures who, for practical reasons, are divided into acute and chronic groups. The former group, perhaps not surprisingly, fared better than the latter. Management consisted primarily of confrontation with the diagnosis with additional psychotherapy of various degrees of intensity. Overall, 46% of patients taking anticonvulsants either came off their medication or had it reduced. It was encouraging to observe that 76% of the 50 patients derived significant benefit for management with, on follow up, 80% of the acute group and 28% of the chronic group becoming seizure free and 34% of the latter group improving significantly. Early diagnosis and management are important in dealing with the problem of pseudoseizures and appear to produce a good outcome, associated, in general terms, with a less satisfactory outcome in those in whom the problem is chronic.

Nonepileptic paroxysmal events in childhood

Seizures are the most commonly occurring paroxysmal events of childhood. There are a large number of other disorders, however, that present with discrete attacks separated by symptom-free intervals. The differentiation of these conditions from seizures depends on a willingness to consider alternate diagnoses and a thorough review of the history of the events. Laboratory tests, and especially the electroencephalogram, are aids to diagnosis, but reliance on laboratory data has many pitfalls. The clinical features of the important nonepileptic paroxysmal disorders of childhood are reviewed.