Psychogenic seizures: video telemetry observations in 27 patients

Scoping review and expert-based consensus recommendations for assessment and management of psychogenic non-epileptic (functional) seizures (PNES) in children: A report from the Pediatric Psychiatric Issues Task Force of the International League Against Epilepsy

Limited guidance exists regarding the assessment and management of psychogenic non-epileptic seizures (PNES) in children. Our aim was to develop consensus-based recommendations to fill this gap. The members of the International League Against Epilepsy (ILAE) Task Force on Pediatric Psychiatric Issues conducted a scoping review adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-SR) standards. This was supplemented with a Delphi process sent to pediatric PNES experts. Consensus was defined as ≥80% agreement. The systematic search identified 77 studies, the majority (55%) of which were retrospective (only one randomized clinical trial). The primary means of PNES identification was video electroencephalography (vEEG) in 84% of studies. Better outcome was associated with access to counseling/psychological intervention. Children with PNES have more frequent psychiatric disorders than controls. The Delphi resulted in 22 recommendations: Assessment-There was consensus on the importance of (1) taking a comprehensive developmental history; (2) obtaining a description of the events; (3) asking about potential stressors; (4) the need to use vEEG if available parent, self, and school reports and video recordings can contribute to a "probable" diagnosis; and (5) that invasive provocation techniques or deceit should not be employed. Management-There was consensus about the (1) need for a professional with expertise in epilepsy to remain involved for a period after PNES diagnosis; (2) provision of appropriate educational materials to the child and caregivers; and (3) that the decision on treatment modality for PNES in children should consider the child's age, cognitive ability, and family factors. Comorbidities-There was consensus that all children with PNES should be screened for mental health and neurodevelopmental difficulties. Recommendations to facilitate the assessment and management of PNES in children were developed. Future directions to fill knowledge gaps were proposed.

Pediatric psychogenic non-epileptic seizures: A retrospective observational cohort study at a quaternary center

BACKGROUND

Psychogenic non-epileptic seizures (PNES) represent a common functional disorder in the pediatric population. We aimed to characterize pediatric PNES by describing their clinical characteristics, PNES semiologies, and healthcare pathway towards and after diagnosis.

MATERIAL AND METHODS

This was a retrospective, observational chart review of pediatric patients aged 6 to 18 years admitted between December 2020 and December 2021 for spell classification or suspected PNES. Psychogenic non-epileptic seizure diagnosis was made by the capture of a typical event on video electroencephalogram (vEEG). We used descriptive statistics to summarize demographic and clinical characteristics.

RESULTS

We included 26 patients (18 females, 69.2%) with a mean age (SD) of 13.9 (2.5) years. Pre-morbid neurologic and psychiatric conditions included: epilepsy (23.1%), migraine (46.2%), mild traumatic brain injury (26.9%), anxiety (57.7%), ADHD (34.6%), and depression (30.8%). Six patients (23.1%) had a prior diagnosis of PNES. 14 patients (53.8%) presented with convulsive, and 6 (23.1%) each with non-convulsive and mixed PNES. Patients were seen by a range of providers prior to diagnosis including ED providers (50%), neurologists (53.8%), pediatricians (34.6%), and psychology/psychiatry (11.5%). Emergency department evaluation occurred for 13 patients (50%) on 15 occasions, and six (23.1%) were admitted to the hospital. The median (p25-p75) time from PNES onset to presentation and diagnosis at our institution was 3.5 (1.5-6.2) and 4.1 (3-7) months, respectively. A total of 33 events from the 26 patients were captured on vEEG. The most frequent semiologies in our cohort were rhythmic motor (27.3%) followed by equal frequency (18.2%) of complex motor and dialeptic. Eighteen patients (69.2%) were followed after the PNES diagnosis, for a median (p25-p75) of 17.3 months (6.3-21) with variable outcome.

CONCLUSION

Pediatric PNES has female predominance and often presents with comorbid psychosocial stressors and psychiatric conditions. High clinical suspicion and early recognition are crucial to decrease healthcare utilization and establish timely diagnosis and treatment.

Paroxysmal Nonepileptic Events in a Pediatric Epilepsy Clinic

Aims:

We aimed to study the frequency, age, and gender distribution of paroxysmal nonepileptic events (PNEs) in children referred to epilepsy clinic with the diagnosis of epilepsy. We also evaluated the therapeutic implications of correct diagnosis and co-existence of true epilepsy in this population.

Settings and Design:

All new patients below 18 years attending the Pediatric epilepsy out-patient clinic of PD Hinduja hospital over 6 months were evaluated.

Materials and Methods:

Patients with history of paroxysmal events characterized by abrupt changes in consciousness or behavior or movement were included. They were assessed on description of events aided by recorded videos. If the diagnosis was not confirmed by this preliminary evaluation, further investigations were advised.

Statistical Analysis Used:

Chi-square/Fisher’s exact test was used to analyze differences between categorical variables and Kruskal–Wallis test between continuous variables. The data were analyzed by SAS University Edition. All significance tests were two-tailed with α <0.05.

Results:

Two hundred new patients presenting with paroxysmal events were enrolled over 6 months. After diagnoses, 19% of these children had PNEs, 80% had epileptic events, and 1% remained undiagnosed. Common nonepileptic events seen were physiological in patients below 5 years and psychogenic in older children. Thirty-four percent of patients with PNEs were on anti-epileptic drugs (AEDs). After confirming nonepileptic attacks, only 2.6% patients needed AEDs for coexisting epilepsy which was statistically significant (P < 0.001) change in treatment.

Conclusions:

Epilepsy mimics are common in children and are often misdiagnosed causing undue stress. Correct diagnosis leads to a drastic change in management like withdrawal of drugs, commencing new treatment if needed, and appropriate referrals.

Incidence rates and characteristics of pediatric onset psychogenic nonepileptic seizures

BACKGROUND

Pediatric onset psychogenic nonepileptic seizures (PNES) is a highly disabling disorder and potentially misdiagnosed as epilepsy. Still, knowledge regarding PNES in children and adolescents is limited and data on both incidence and characteristics are scarce. This study investigated the incidence rate (IR) and clinical characteristics of pediatric onset PNES, including possible differences when having comorbid epilepsy.

METHODS

A population-based study of children and adolescents aged 5-17 years with an incident diagnosis of PNES in the Danish healthcare registries between 1996 and 2014. In total, 386 children and adolescents were included after assessment of diagnostic validity using medical record data.

RESULTS

The IR increased during the study period with the maximum IR observed in 2014 (7.4 per 100,000 person-years). A history of both neurologic and psychiatric problems as well as negative life events was identified. Comorbid epilepsy was confirmed for 55 cases (14.2%) and was associated with intellectual disabilities, school support and prolonged delay in PNES diagnosis.

CONCLUSIONS

PNES are increasingly diagnosed in children and adolescents, and the clinical profile of both neurologic and psychiatric health problems underscores the need for collaborative pediatric and mental healthcare. These findings provide important information for future healthcare planning in this area.

IMPACT

This nationwide study is the first to report population-based incidence rates of pediatric onset PNES documenting markedly increasing incidence rates between 1996 and 2014. A history of both neurologic and psychiatric problems as well as negative life events was identified for pediatric onset PNES. Comorbid epileptic seizures were associated with intellectual disabilities, school support and prolonged delay in PNES diagnosis. The clinical profile of both neurologic and psychiatric health problems underscores the need for collaborative pediatric and mental healthcare. The increasing number of children and adolescents diagnosed with PNES is important information for future healthcare planning in this area.

Risk Factors for Diagnostic Delay in Psychogenic Nonepileptic Seizures Among Children and Adolescents

BACKGROUND

This study aims to analyze a series of pediatric patients with psychogenic nonepileptic seizures (PNES) to establish the diagnostic gap and possible risk factors for the delayed diagnosis in this age group.

METHODS

We evaluated all children with PNES documented by video electroencephalography. None had a previous diagnosis of PNES. In total, we included 53 children (interquartile range: seven to 17 years; mean age 12.81 years [S.D. 3.15]; 60.4% girls) who underwent a protocol consisting of neurological and psychiatric interviews.

RESULTS

The average time between seizure onset and referral was 17.76 months (interquartile range: 0.5 to 48 months; S.D. ± 12.62). Earlier age of onset correlated with a later diagnosis (P < 0.001). The late referral group also presented with a history of psychological abuse (P = 0.018).

CONCLUSION

Youth with PNES represent a diagnostic challenge. Identification of children at risk might lead to earlier diagnosis of PNES.

Conversion disorder in a preschool age girl

This article reports a case of a 5-year-old girl with clinical manifestations of a conversion disorder. Children presenting with a conversion disorder very often have multiple investigations and more than two-thirds of them are admitted to the hospital. This case illustrates the necessity of adapting, from the outset, a multidisciplinary approach to diagnosis and management, which helps in providing an explanatory model that takes into account stressors, factors within the child and the family, and aids in planning an appropriate psychotherapeutic intervention based on the child’s and family’s needs.

Psychogenic Paroxysmal Nonepileptic Events in Children: A Review

BACKGROUND

Paroxysmal nonepileptic events are common in children. Events with a psychological basis, historically referred to as pseudoseizures, are a large subset of paroxysmal nonepileptic events.

METHODS

A review of the relevant pediatric and adult literature was performed.

RESULTS

It was found that these events have many semioloigc features similar to epileptic events and can be challenging to correctly identify. The use of a detailed history in combination with video encephalography and knowledge of psychogenic paroxysmal nonepileptic events will facilitate making the correct diagnosis. Paroxysmal nonepileptic events are important to identify as comorbid disorders such as depression, anxiety disorder, family discord, and school issues are frequent. In addition, prior sexual, emotional, and/or physical abuse may be present.

CONCLUSIONS

Pediatric patients with paroxysmal nonepileptic events need to be recognized in order to avoid unnecessary antiepileptic drugs and emergency department or hospital visits and to facilitate appropriate psychological intervention to address the underlying etiologies. This review will focus on evaluation and identification of paroxysmal nonepileptic events, in addition to reviewing the various comorbidities, effective treatments, and outcomes for pediatric patients. The key differences between pediatric and adult patients with paroxysmal nonepileptic events are addressed.

Paroxysmal non-epileptic events in infants and toddlers: A phenomenologic analysis

AIM

The aim of this study was to analyze in detail the clinical phenomenology of paroxysmal non-epileptic events (PNEE) in infants and toddlers.

METHODS

We studied all children aged ≤2 years who were diagnosed with PNEE based on video-electroencephalographic (VEEG) recordings. We analyzed the following four clinical domains of each clinical event: (i) motor manifestations (body/limb jerking, complex motor, and asymmetric limb posturing); (ii) oral/vocal (crying, vocalization, sighing); (iii) behavioral change (arrest of activity, staring); (iv) and autonomic (facial flushing, breath holding).

RESULTS

Thirty-one of 81 (38.3%) infants and toddlers had 38 PNEE recorded during the study period (12 girls and 19 boys, mean age 10.5 months). The predominant clinical features were as follows: motor in 26/38 events, oral/verbal in 14/38 events, behavioral in 11/38 events, and autonomic in 8/38 events. Epileptic seizures and PNEE coexisted in four children (12.9%). Seventeen children (54.8%) had one or more risk factors suggestive of epilepsy. Twelve children (38.7%) had a normal neurologic examination, 10 (32.3%) had developmental delay, and eight (25.8%) had a family history of epilepsy or seizures.

CONCLUSION

VEEG recorded PNEE in nearly 40% of 81 infants and toddlers referred for unclear paroxysmal events in our cohort. Non-epileptic staring spells and benign sleep myoclonus were the most common events recorded, followed by shuddering attacks and infantile masturbation. In addition, greater than one-half of the infants and toddlers had risk factors, raising a concern for epilepsy in the family and prompting the VEEG evaluation, suggesting that paroxysmal non-epileptic seizures may frequently coexist in young children with epilepsy.

Functional relapses in pediatric multiple sclerosis

Multiple sclerosis in children is characterized by more frequent relapses than in adult patients. Diagnosing and treating youth with multiple sclerosis present a number of challenges including differentiating organic relapses from functional symptoms. However, there is no literature describing coexistence of functionality in pediatric multiple sclerosis. Here, we report 2 cases in which inconsistency between clinical history, physical examination, imaging, and atypical disease progression led to suspicion of functional relapses. The purpose of this study is to raise awareness of functional relapses, as prompt recognition can prevent overtreatment and iatrogenic risks in children and adolescents with multiple sclerosis. Underlying psychiatric issues also need to be addressed.

Children with psychogenic non-epileptic seizures (PNES): a detailed semiologic analysis and modified new classification

PURPOSE

To analyze children with psychogenic non epileptic seizures and propose a modified new classification.

METHODS

This retrospective analysis included 56 children aged <18 years (M:F=26:30; mean age: 12.3±4.0 years) diagnosed PNES on video-EEG monitoring. The semiological characteristics like pattern of bodily movements, emotional signs, stereotypy, ictal vocalization, responsiveness, delay in diagnosis etc. were recorded. We analyzed our data as per previous adult classifications and proposed a modified classification.

RESULTS

There were 190 recorded attacks (range: 1-9, median: 3) recorded. The age at onset of PNES was 8.9±4.1 years (range: 0.4-15.8 years; median: 9 years), age at diagnosis: 11.9±4.1 years (range: 2-17; median: 12.0 years), delay in diagnosis: 3.2±3.7 years (range: 0-15; median: 2.0 years). Anxiety disorder was seen in 9 (16.1%), stress in 6 (10.7%) children. Flexion/extension bodily movements were seen in 40 (70.1%), negative emotional signs in 17 (30.4%) and tremors in 14 (25%) cases. Thirty-three (58.9%) patients diagnosed as having true seizures initially and were on anti-epileptic drugs (AEDs), 14 patients (25.0%) initially diagnosed of PNES which remained unchanged after VEEG, nine patients (16.1%) had both PNES and true seizures. Twenty-six (46.4%) of our patients into the existing classifications. We then classified our patients into categories of a modified new classification: Hypermotor: 13 (23.2%), partial motor: 8 (14.3%), affective/emotional behaviour phenomena: 2 (3.6%), dialeptic: 8 (14.3%), 'aura': 3 (5.4%), mixed: 22 (39.3%).

CONCLUSION

Incorrect diagnosis of epilepsy leads to unnecessary drug treatment. A detailed analysis of semiology and classification helps in early diagnosis of PNES. A modified systematic classification of PNES is proposed which would help in better standardization of PNES.

Health-related quality of life in adolescents with psychogenic nonepileptic seizures

The aim of this study was to evaluate the health-related quality of life (HRQoL) in adolescents with psychogenic nonepileptic seizures (PNESs) and to identify factors affecting the quality of life in these patients. Thirty-four adolescents with PNESs were compared to 30 adolescents without any psychiatric disorder. The Schedule for Affective Disorders and Schizophrenia for School-Age Children, Present and Lifetime Version (K-SADS-PL) was applied to determine comorbid psychiatric disorders in the study group and to rule out any psychiatric disorder in the control group. The Pediatric Quality-of-Life Inventory (PedsQL) was used to assess the HRQoL. Physical HRQoL and psychosocial HRQoL, including emotional and school functioning, were found to be significantly lower in adolescents with PNESs. In the group with PNESs, the physical HRQoL and total HRQoL of adolescents with somatoform disorders other than PNESs and the emotional functioning of adolescents with major depressive disorder were worse than those of the adolescents without these comorbid psychiatric disorders. Seizure frequency and the duration of symptoms were not correlated with HRQoL scores. Treatment strategies in adolescents with PNESs should regard comorbid unexplained somatic symptoms and psychiatric disorders in addition to the reduction or cessation of seizures.

Parental ranking of terms describing nonepileptic events

Paroxysmal nonepileptic events of psychogenic etiology in children and adolescents are common. Patients and their parents are often confused by the terminology used to describe these events. This can lead to frustration and may result in the failure to obtain the necessary nonpharmacologic treatment. Various terms are used to describe such events, some of which might be considered offensive to some individuals. Surveys from 146 parents or guardians of patients identified from a general pediatric clinic, a general neurology clinic, and a pediatric epilepsy monitoring unit were completed with the aim of determining which words and phrases were least offensive. It was determined that nonepileptic events, functional seizures, and nonepileptic attack disorder were the least offensive labels; whereas "it is all in his or her head," hysterical seizures, and psychogenic seizures were the most offensive terms. This is the only study of its type in the pediatric population. Although each child and family requires individualized communication, we hope that this article will provide useful information to guide the practicing pediatric neurologist in informing families that their children are having events of nonepileptic etiology.

Semiology of psychogenic nonepileptic seizures: age-related differences

The few studies addressing semiology of psychogenic nonepileptic seizures (PNES) in children showed that this group differs from adults, considering the classical signs described. Our study with systematic assessment provides a direct comparison of the classical signs of psychogenic nonepileptic seizures (PNESs) in children and adults in order to establish the usefulness of the most important signs described for adults in children. Video-EEG recordings of patients with PNESs from 2006 to 2011 were analyzed. Twenty-five signs were selected as the most prevalent in literature, and their presence was evaluated. Events were categorized as either of the following: catatonic, major motor, minor motor, and subjective (Griffith et al., 2007 [11]). One hundred and fifteen patients were included; 63.5% were adults, 73.2% were females, and 14.4% had epilepsy. Adults presented more ictal eye closure (p=0.006), convulsions lasting >2 min (p<0.001), postictal speech change (p=0.021), vocalization during the "tonic-clonic" phase (p=0.005), and pelvic thrust movement (p=0.035). Biting the tip or side of the tongue and opisthotonos were rare and only present in adults. As for the semiological categories, major motor activity was the main feature in adults, and minor motor activity was more prevalent among children (52.9% and 38.1%, respectively; p=0.01). Our data showed that research about the distinct ictal features of PNESs, such as minor motor events that are more typical in children, is likely to be useful in promoting earlier recognition of PNESs in this population.

Childhood paroxysmal nonepileptic events

We aimed to determine the types and clinical characteristics of paroxysmal nonepileptic events (PNEs) in children. During a 13-year period, 765 patients underwent long-term video-EEG monitoring, and 95 (12.4%) of them were identified to have PNEs. The most common diagnoses were conversion disorder, parasomnias, staring spells, movement disorders, and hypnic jerks. Paroxysmal nonepileptic events originated from physiologic or organic (43.2%) and psychogenic (56.8%) causes. Mean delay in diagnosis was 3.1 years. Mean ages at diagnosis were 8.8 and 13.8 years in physiologic or organic and psychogenic groups, respectively. A marked female predominance was seen in the psychogenic group, whereas males slightly predominated in the physiologic or organic group. In the physiologic or organic group, events were less frequent, longer in duration, and commonly manifested as subtle motor activity, whereas subtle and prominent motor activities were encountered equally in both groups. Concomitant epilepsy was present in 10.5% of the patients. Differences in clinical characteristics may be helpful in differentiating physiologic or organic PNEs in children from psychogenic PNEs.

Depression and epilepsy, pain and psychogenic non-epileptic seizures: clinical and therapeutic perspectives

The clinical manifestations of depression in people with epilepsy (PWE) are pleomorphic, often associated with anxiety symptoms and anxiety disorders. The ongoing debate of whether the clinical presentation of depression in PWE is unique to this neurologic disorder is reviewed. Comorbid depression can impact the recruitment of PWE for pharmacologic trials with antiepileptic drugs (AEDs). Yet, the impact of depression on the response of the seizure disorder to pharmacotherapy with AEDs and its impact on worse adverse events may bias the interpretation of the trial findings, particularly when depressed patients are included in the AED trials. PWE have a greater suicidal risk than the general population. This risk is mediated by multiple factors, and recent data from the FDA have imputed a potential pathogenic role to all AEDs. The recognition of patients at risk is reviewed. Yet, the validity of the FDA data has been questioned, and the status of this controversial question is analyzed. As in the case of epilepsy, depression and pain syndromes have a relatively high comorbidity. The negative impact of depression on pain is reminiscent of that of depression in PWE; furthermore, the high comorbidity may be also associated with the existence of common pathogenic mechanisms. Neurologists and in particular, epileptologists establish the diagnosis of psychogenic non-epileptic seizures (PNES) in whom a comorbid depressive disorder is very often identified. The role of depression in the course of PNES and its treatment are discussed. Scarce data are available on the treatment of depression in PWE. Thus, clinicians have had to adopt data from patients with primary depressive disorders. We outline a consensus strategy on the identification and treatment of depressive disorders in adult and pediatric patients with epilepsy.

A detailed semiologic analysis of childhood psychogenic nonepileptic seizures

PURPOSE

Psychogenic nonepileptic seizure (PNES) is an important differential diagnostic problem in patients with or without epilepsy. There are many studies that have analyzed PNES in adults; currently, however, there is no systematic assessment of purely childhood PNES semiology. Our study based on a large pediatric video-electroencephalography (EEG) monitoring (VEM) cohort, provides a detailed analysis of childhood PNES and assesses the usability of the current classification system described in adults.

METHODS

Medical and video-EEG records of 568 consecutive children (younger than 18 years) who underwent video-EEG monitoring (VEM) at our hospital were reviewed. Aura, type of movement, anatomic distribution, synchrony, symmetry, eye movement, responsiveness, vocalization, hyperventilation, vegetative and emotional signs, presence of eyewitness, and duration of the event were recorded among children with the diagnosis of PNES. We also compared our data with those of earlier adult studies.

KEY FINDINGS

Seventy-five archived PNES of 27 children (21 girls; age 8-18 years) were reanalyzed. Nine children (33%) had the diagnosis of epilepsy currently or in the past. Mean age at the time of PNES onset was 11.6 (standard deviation 3.2) years. Mean duration of PNES was longer (269 s) compared to seizures of the epileptic group (83 s; p = 0.002). Eyewitnesses (mostly parents) were present in 89% of cases. Eighty percent of PNES had an abrupt start, with 68% also ending abruptly. In only 15% of events were the patients eyes closed at the beginning of the attack. Patients were unresponsive in 34%. The most frequent motor sign was tremor (25%) with the upper, rather than lower limbs more frequently involved. Pelvic thrusting was seen in only two attacks. Emotional-mostly negative-signs were observed during 32 PNES (43%). Based on Seneviratne et al.'s classification, 18 events (24%) were classified as rhythmic motor PNES, only half the frequency of that previously described in adults. No hypermotor PNES was found. The frequency of complex motor PNES (13%) and mixed PNES (4%) showed similar frequency in children as in adults. Dialeptic PNES was found more frequently among younger children. All PNES belonged to the same semiologic type in 23 patients (85%).

SIGNIFICANCE

Because homogeneity of PNES within a patient was high in the pediatric population, we found it useful to classify PNES into different semiologic categories. Dialeptic PNES seems to be more frequent among younger children. Tremor is the most frequent motor sign and usually accompanied by preserved responsiveness in childhood. Negative emotion is commonly seen in pediatric PNES, but pelvic thrusting is a rare phenomenon. We, therefore, suggest a modification of the present classification system in which PNES with motor activity is divided into minor and major motor PNES, and the latter group is subdivided into synchron rhythmic motor and asynchron motor PNES. We believe that our study, a detailed analysis on the semiology and classification of purely childhood PNES might assist the early and precise diagnosis of nonepileptic paroxysmal events.

A structured questionnaire predicts if convulsions are epileptic or nonepileptic

OBJECTIVE

Therapy for convulsive seizures is usually initiated on the basis of clinical assessment, without video/EEG confirmation, but a nonepileptic origin may eventually be demonstrated. This study evaluates the diagnostic value of a witness-questionnaire in distinguishing between convulsive epileptic seizures (CES) and convulsive nonepileptic seizures (CNES).

METHODS

We prospectively identified all adult patients admitted for video/EEG evaluation of convulsive attacks and interviewed the "best" witness using 12 questions on ictal and postictal features.

RESULTS

Video/EEG diagnosed CES in 19 and CNES in 26 patients. The predictive accuracy of the questionnaire was 84.4%. Six features were strong predictors of CNES diagnosis: ictal eye closure, presence of side-to-side movements, prolonged seizure duration, and three postictal breathing features (not loud, shallow, no snoring).

CONCLUSION

A structured witness questionnaire distinguishes CES and CNES and will help in selecting patients for early video/EEG evaluation and rapid initiation of appropriate therapy.

Nonepileptic Seizures in Children

PURPOSE

To determine if the clinical characteristics of nonepileptic seizures (NES) are different in children younger than 13 years age as compared to adolescents.

METHODS

Retrospective review of medical records and video-EEGs (VEEG) of all patients with NES confirmed on VEEG monitoring was performed.

RESULTS

Sixty-eight (3.5%) of 1,967 patients monitored with VEEG had a clinical diagnosis of NES. Fifty-nine of 68 patients had their habitual event recorded. Mean age at the time of the VEEG diagnosis was 13 years 4 months. Twenty-two patients were less than 13 years (group A) and 37 were 13 years and older (group B). The male to female ratio was equal in group A, with female predominance seen in group B. NES commonly manifested as subtle motor activity in group A (p < 0.01) and prominent motor activity in group B (p < 0.001). Difficulties at school, family discord, and interpersonal conflicts, were frequent stressors in both groups. Sexual abuse was the least frequent. Depression was more common in group B; cognitive dysfunction (p < 0.001) and epilepsy (p < 0.01) were more common in group A.

CONCLUSIONS

Differences in clinical semiology and predisposing factors may help identify young children and adolescents who might be at risk for the development of NES.

Conversion disorder in Australian pediatric practice

OBJECTIVES

To describe the incidence and clinical features of children presenting to Australian child health specialists with conversion disorder.

METHOD

Active, national surveillance of conversion disorder in children younger than 16 years of age during 2002 and 2003.

RESULTS

A total of 194 children were reported on. The average age was 11.8 years; 23% were younger than 10 years of age. Presentations were complex, with 55% presenting with multiple conversion symptoms. The most common presentations were disturbance of voluntary motor function (64%), sensory symptoms (24%), pseudoseizure (23%), and respiratory problems (14%). Hospital admission was required for 70%, with an average stay of 10.2 days. Antecedent stressors were also reported in 62% and a history of mental health concerns in 42%, with 14% of children taking psychotropic medications for comorbid anxiety or depression. The incidence of conversion disorder in Australian specialist child health practice is estimated to be between 2.3 and 4.2/100,000.

CONCLUSIONS

Conversion disorder is associated with a significant burden for the child, family, and the health system. This study emphasizes the comorbidity with anxiety, depression, and symptoms of pain and fatigue. It also highlights the potential impact of "commonplace" stressors such as family conflict and children's loss of attachment figures.

Psychogenic status epilepticus in children

Epilepsy features, psychiatric profile, psychosocial factors, and outcome are described for six children (three males) aged 5-15 years (mean 12.1) with psychogenic status epilepticus (PSE), i.e., prolonged or repetitive psychogenic seizures (PSs), >30 minutes, simulating status epilepticus. They had epilepsy, they were on chronic anticonvulsants (ACVs), and some had other neurological deficits. All received intravenous and/or rectal ACVs prior to suspicion of PSE. PSE was confirmed via video/EEG, demonstrating no epileptogenic activity during alleged seizures. Provocation and placebo therapy techniques were used in two. Psychiatric assessment identified comorbid disorders such as depression, anxiety disorder, obsessive-compulsive disorder, obsessive-compulsive symptoms, and posttraumatic stress disorder. Psychosocial stressors were almost ubiquitous. Psychiatric intervention included psychotherapy, family therapy, and medical treatment in one patient. Outcome was monitored for an average of 3.6 years (3-5 years). PSE did not recur. PSs recurred in three. Psychiatric comorbidity improved in four, who accepted psychiatric intervention and whose epilepsy also improved. In conclusion, the occurrence of PSE in children and adolescents with epilepsy is stressed. Prompt diagnosis was often missed in the acute care setting, and this carries important implications for iatrogenic complications. PSE diagnosis resulted in identification and management of comorbid psychiatric disorders. This was probably important in reducing the predominating anxiety and affective disorders in most patients as well as PSE recurrence. Epilepsy severity and associated deficits were most likely important factors in determining outcome.

Psychogenic movement disorders in two children

Two schoolboys with diagnostic criteria for psychogenic movement disorder (PMD) are described: one with bizarre tremor of the right hand and a very slow and cautious gait, another with exaggerated trunk sway and collapses during standing and walking.

Paroxysmal nonepileptic events in children and adolescents

OBJECTIVE

Paroxysmal nonepileptic events (PNEs) are frequently encountered in children and adolescents; however, there is little information concerning the relative frequency of various types of these disorders. We report our experience with PNEs in a group of children and adolescents who underwent prolonged video-electroencephalographic monitoring.

METHODS

During a 6-year period, 883 patients were monitored in the Pediatric Epilepsy Monitoring Unit and 134 patients (15.2%) were documented to have PNEs on the basis of a typical spell recorded during monitoring. Their hospital charts were reviewed and videotapes of these events were analyzed.

RESULTS

Patients were divided into 3 age groups: 1) the Infant, Toddler, and Preschool Group (2 months-5 years) that comprised 26 patients. The most common diagnoses were stereotyped movements, hypnic jerks, parasomnias, and Sandifer syndrome. Concomitant epilepsy was present in 12 patients (46%). 2) The School-Age Group (5-12 years) consisted of 61 patients. The most frequent diagnoses were conversion disorder (psychogenic seizures), inattention or daydreaming, stereotyped movements, hypnic jerks, and paroxysmal movement disorders. Fifteen patients (25%) had concomitant epilepsy. 3) The Adolescent Group (12-18 years) consisted of 48 patients, of whom 40 patients (83%) were diagnosed with conversion disorder. Nine patients (19%) had concomitant epilepsy.

CONCLUSIONS

In our patients with PNEs, conversion disorder was seen in children >5 years old and its frequency increased with age, becoming the most common type of PNEs among adolescents. In adolescents, conversion disorder was more common in females, whereas males predominated in the school-aged group. Concomitant epilepsy with nonepileptic events occurred in all 3 age groups to a varying extent.

Psychogene Lähmungen im Kindes- und Jugendalter

Zusammenfassung: Am Beispiel vorliegender klinischer Studien aus der Literatur werden die Charakteristika der psychogenen Lähmung im Kindes- und Jugendalter erarbeitet. Anhand einer Übersicht wird zunächst der Wandel in der diagnostischen Einordnung der psychogenen Lähmung von der ICD-6 bis zur ICD-10 dargestellt. Weiterhin werden die epidemiologischen Daten aus der Literatur referiert. Die psychogene Lähmung bei Kindern und Jugendlichen zeigt innerhalb der dissoziativen Störungen in dieser Altersgruppe eine charakteristische Alters- und Geschlechtsverteilung, sowie eine gute Prognose. Eine besondere Rolle für die Genese der psychogenen Lähmungen und Gangstörungen spielen invasive iatrogene diagnostische und therapeutische Eingriffe, körperliche Traumata, Infekterkrankungen und Modellerkrankungen.

Psychiatric Manifestations of Epilepsy in Children and Adolescents

There is a high incidence of psychiatric difficulties in children and adolescents with epilepsy. The severity and range of the problems that exist are broad. In pseudoseizures, which may coexist with true epileptic seizures, the primary problem is psychiatric. Optimal management of children and adolescents with epilepsy involves a team approach, or at least a multidisciplinary effort, with close coordination between neurologist, primary health care provider, mental health professional, psychologist, educational specialist, and other providers (eg, physical therapist), depending on the associated features and particular case. Because many children and adolescents with epilepsy ultimately will be taking psychotropic medication and because of their psychiatric difficulties, a knowledge of interactions between anticonvulsants and psychotropic medication is crucial.

Nonepileptic seizure outcome varies by type of spell and duration of illness

PURPOSE

To determine whether differences in clinical manifestations of psychogenic nonepileptic events are associated with differences in outcome and whether the length of illness before diagnosis correlates with outcome.

METHODS

We reviewed ictal videotapes and EEGs in 85 patients diagnosed with exclusively nonepileptic psychogenic seizures during inpatient CCTV-EEG monitoring at the University of Michigan between June 1994 and December 1996. They were classified into groups of similar ictal behaviors. Fifty-seven of these patients were available to respond to a follow-up telephone survey about their condition 2-4 years after discharge. We examined demographics, baseline EEG abnormalities, and outcome of treatment interventions. We also evaluated whether interventions were more likely to succeed if patients were diagnosed early in the course of the illness.

RESULTS

We found that the largest groups consisted of patients with motionless unresponsiveness ("catatonic," n = 19) and asynchronous motor movements with impaired responsiveness ("thrashing," n = 19). Infrequent signs included tremor, automatisms, subjective events with amnesia, and intermittent behaviors. There was a higher incidence of baseline EEG abnormalities in the thrashing group (31%) than in the catatonic group (0%). There was a higher incidence of complete remission of spells in the catatonic group (53%) than in the thrashing group (21%). Patients who had a more recent onset of seizures (most often within 1 year) were much more likely to have remission of spells after diagnosis.

CONCLUSIONS

Classification of nonepileptic seizures is useful in predicting outcome and may be valuable in further investigation of this complex set of disorders.